Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health (World Psychiatric Association)

Psychiatrists and Traditional Healers

Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

Psychiatrists and Traditional Healers Unwitting Partners in Global Mental Health

Editors

Mario Incayawar, MD, MSC Director, Runajambi – Institute for the Study of Quichua Culture and Health, Otavalo, Ecuador

Ronald Wintrob, MD Clinical Professor of Psychiatry and Human Behavior, Warren Alpert School of Medicine, Brown University, Providence, RI, USA

Lise Bouchard, PhD Director of Research, Runajambi – Institute for the Study of Quichua Culture and Health, Otavalo, Ecuador Honorary Editor

Goffredo Bartocci, MD Istituto Italiano Igiene Mentale Transculturale, Rome, Italy

A John Wiley & Sons, Ltd., Publication

This edition first published 2009 Ó 2009 John Wiley & Sons, Ltd Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing. Registered office John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Other Editorial Offices 9600 Garsington Road, Oxford, OX4 2DQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data Psychiatrist and traditional healers : unwitting partners in global mental health / [edited by] Mario Incayawar, Ronald Wintrob, Lise Bouchard. p. ; cm. Includes bibliographical references and index. ISBN 978-0-470-51683-6 (cloth : alk. paper) 1. Psychiatry, Transcultural. 2. Healers. I. Incayawar, Mario. II. Wintrob, Ronald. III. Bouchard, Lise. IV. World Psychiatric Association. [DNLM: 1. Mental Disorders—therapy. 2. Cross-Cultural Comparison. 3. Medicine, Traditional. 4. Psychiatry. 5. Religion and Psychology. WM 400 P973494 2009] RC455.4.E8P79 2009 616.89—dc22 2008044729 A catalogue record for this book is available from the British Library. ISBN 978-0-470-51683-6 Set in 10/12 Times by Integra Software Services Pvt. Ltd, Pondicherry, India Printed in Singapore by Markono Print Media Pte. Ltd First Impression 2009 Cover image of traditional healer and Quichua woman courtesy of Mario Incayawar

Contents Foreword by Raymond H. Prince

xi

Foreword by Goffredo Bartocci

xiii

Salutation by Juan E. Mezzich

xv

Preface

xvii

Contributors

xix

1

Overview: Looking Toward the Future of Shared Knowledge and Healing Practices

1

Ronald Wintrob 1.1 1.2 1.3 1.4 1.5

2

Introductory Remarks Complementary and Alternative Medicine The US National Center for Complementary and Alternative Medicine Botanicals, Biological Products and their Commercial Development The Medical, Medicinal and Botanical Knowledge and the Intellectual Property Rights of Indigenous Peoples 1.6 Supernatural Determinism, Faith Healing and Exorcism 1.7 Faith Healing 1.8 Curanderismo and Candomble 1.9 Toward the Integration of Medical and Traditional Healing; Case Examples from the Americas 1.10 Concluding Comments

2 2 2 3

8 11

Legitimacy and Contextual Issues in Traditional Lakota Sioux Healing

13

3 4 5 7

Jeffrey A. Henderson 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8

Introduction Definitions Research on Indigenous Healing in the Americas Traditional Lakota Sioux Healing Renewed Interest in Traditional Medicine Rephrasing a Typical Question Issues with Legitimacy Reimbursement for Traditional Healing Services in the United States: What are we Getting Ourselves into? Conclusion References

13 15 15 16 16 17 18 20 21 22

vi

3

CONTENTS

Doctor-Patient Relationship in Psychiatry: Traditional Approaches in India Versus Western Approaches

25

Vijoy K. Varma and Nitin Gupta

4

3.1 Introduction 3.2 Psychotherapy: Definitions and Common Concepts 3.3 Western Models of the Doctor-Patient Relationship 3.4 Traditional Models of the Doctor-Patient Relationship 3.5 Psycho-Cultural Variables Relevant to the Doctor-Patient Relationship Conclusion

25 26 27 28 29 35

South American Indigenous Knowledge of Psychotropics

37

Sioui Maldonado Bouchard

5

4.1 Introduction 4.2 Definitions 4.3 Three Indigenous Peoples’ Medicinal Plants: Quinine, Coca and Ayahuasca 4.4 Legal Issues Conclusion Notes References

37 38 39 41 49 49 50

Psychiatric Case Identification Skills of Yachactaita (Quichua Healers of the Andes)

53

Mario Incayawar

6

5.1 Introduction 5.2 The Quichua People 5.3 Research Methods 5.4 Comparison of Quichua and Western Diagnosis 5.5 The Western Clinical Diagnosis 5.6 Diagnostic Ability of Yachactaitas 5.7 Traditional Healers’ Diagnostic Abilities in Other Societies 5.8 Clinical, Research and Health Policy Implications Conclusion Acknowledgment References

53 54 55 56 60 61 62 62 63 64 64

A Western Psychiatrist among the Shuar People of Ecuador

67

Joan Obiols-Llandrich 6.1 Introduction 6.2 The Shuar Culture 6.3 Shuar Hallucinogenic Use 6.4 The Survey 6.5 Previous Research in the Shuar Area 6.6 First Steps in the Shuar Territory: Collaborating as a Psychiatrist 6.7 Witchcraft and Disease 6.8 The Wishin (the Shuar Shaman) 6.9 The Natem Experience Conclusion References

67 68 69 69 70 71 72 72 74 76 76

CONTENTS

7

vii

The Awakening of Collaboration between Quichua Healers and Psychiatrists in the Andes

79

Lise Bouchard

8

7.1 Introduction 7.2 Pervasive Social Exclusion 7.3 Health Disparities and Health Care Inequities 7.4 The Quichua Response: Jambihuasi 7.5 Going Further: The Foundation of Runajambi Conclusion Notes References

79 80 80 81 88 90 90 91

Factors Associated with Use of Traditional Healers in American Indians and Alaska Natives

93

Jeffrey A. Henderson 8.1 Introduction 8.2 How we Assessed Traditional Healer Use 8.3 Results – Scope of Traditional Healer Use 8.4 Discussion Acknowledgments References

9

Re-Kindling the Fire – Healing Historical Trauma in Native American Prison Inmates

94 94 97 100 105 105

107

L. Tyler Barlowe and Karuna R. Thompson 9.1 9.2 9.3 9.4 9.5

Imprisonment and My Life as a Spiritual Advisor A Snaphot of Life in an American Prison Holocaust of Aboriginal Native American Peoples Native Americans in the Oregon State Prison System Historical Trauma and Traditional Native American Methods of Healing 9.6 Native American Healing Programs Within the Oregon Department of Corrections 9.7 Dignity, Identity and Redemption 9.8 Personal Comments from Inmates References

10 American Indian Healers and Psychiatrists

107 108 109 110 112 115 117 119 120

123

Jay H. Shore, James H. Shore and Spero M. Manson 10.1 10.2 10.3 10.4

Introduction American Indian Veterans, Psychiatrists and Traditional Healers: Background American Indian Veterans, Psychiatrists and Traditional Healers: Southwest Tribes American Indian Veterans, Psychiatrists and Traditional Healers: Northern Plains Tribe

123 125 125 127

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CONTENTS 10.5 Discussion Note References

11 Mental Health in Contemporary China

129 132 132

135

Xudong Zhao 11.1 The Medical Care System and Mental Health Services in China 11.2 Difficulties Facing Mental Health Professionals 11.3 Help-Seeking Behaviors of Chinese Patients 11.4 Distinguishing Among Types of ‘Traditional Chinese Medicine’ 11.5 Psychotherapeutic and Communicative Aspects of TCM 11.6 Folk Healers in China Conclusions Acknowledgments References

136 137 138 141 142 145 146 147 148

12 Health-Seeking Behavior for Psychiatric Disorders in North India 149 Antti Pakaslahti 12.1 Introduction 12.2 Orientation to the Temples and the Healing Tradition 12.3 The Network of Healers in Balaji 12.4 Background and Help-Seeking Pathways of Patients 12.5 On Symptoms and Diagnoses of Patients from Two Perspectives 12.6 Three Accounts of Help-Seeking 12.7 Summing up for Future Research Notes References

13 Anxiety, Acceptance and Japanese Healing

149 150 152 153 156 158 161 163 164

167

Fumitaka Noda 13.1 Introduction 13.2 Japanese Psychology 13.3 Japanese Anxiety 13.4 The Religious Climate of Japan 13.5 Local Treatment (Morita Therapy) 13.6 Coexistence with Traditional Healers 13.7 Healing and Salvation Acknowledgment Note References

14 Dissatisfied Seekers: Efficacy in Traditional Healing of Neuropsychiatric Disorders in Bali

167 168 169 170 172 173 176 177 177 177

179

Robert B. Lemelson 14.1 14.2

Introduction Obsessive Compulsive Disorder and Tourette’s Syndrome

179 180

CONTENTS

ix

14.3

Traditional Healing of Neuropsychiatric Disorders: Meaning and the Issue of Efficacy 14.4 Introduction to Balinese Traditional Healing Systems 14.5 Broad Philosophical Organizing Features of Balinese Healing 14.6 Does the Meaning Making of Traditional Healing Play a Role in Reducing Symptoms and Suffering in Neuropsychiatric Disorders? Conclusion Notes References

15 Islamic Religious and Traditional Healers’ Contributions to Mental Health and Well-being

181 183 184 190 193 193 194

197

M. Fakhr El-Islam 15.1 Introduction 15.2 Mental Health and Moslem Identity 15.3 The Islamic Religion in Everyday Mental Life 15.4 Islamic Self-Help Therapy by Prayer 15.5 Islamic Religion as a Background Yardstick in Mental Health 15.6 The Relationship Between Psychiatrists and Religious Healers 15.7 Traditional Healing Practices in the Islamic World Conclusion References

16 Bringing Together Indigenous and Western Medicine in South Africa: A University Initiative

197 198 199 199 200 201 202 204 205

207

Dan L Mkize 16.1 Introduction 16.2 The Inception of Western Medical Systems 16.3 Prospects for a New African Health Care System 16.4 The African Health Care System 16.5 Objectives of the African Health Care System (AHCS) 16.6 Resources 16.7 Stakeholders 16.8 Networks 16.9 Work Plan 16.10 Challenges Conclusion References Appendix

17 Globalization and Mental Health Traditional Medicine in Pathways to Care in the United Kingdom

208 208 210 211 211 212 212 212 212 213 213 213 213

215

Ajoy Thachil and Dinesh Bhugra 17.1 17.2 17.3

Introduction Migration, Mental Health and Traditional Medicine Traditional Medicine and Pathways to Mental Health Care

215 216 217

x

CONTENTS 17.4

Complementary and Alternative Medicine – Relevance and Collaboration Conclusion References

18 Psychotherapy or Religious Healing?

223 225 226

229

Micol Ascoli 18.1 Introduction 18.2 The Charismatic Theoretical Approach to Illness 18.3 Therapeutic Factors in Catholic Charismatic Religious Healing 18.4 Discussion Notes References Bibliography

19 Maori Knowledge and Medical Science

229 230 232 233 235 236 236

237

Mason Durie 19.1 Introduction 19.2 Traditional Healing in Contemporary New Zealand 19.3 The Structure of Maori Healing Process 19.4 Indigenous Knowledge and Science 19.5 Indigenous Healing and Biomedicine 19.6 Indigenous Healing Contributions to Global Mental Health 19.7 Exploring the Interface 19.8 Impacts References

237 238 240 241 242 243 245 247 248

20 Future Partnerships in Global Mental Health – Foreseeing the Encounter of Psychiatrists and Traditional Healers

251

Mario Incayawar 20.1 The Global Burden of Mental Illness 20.2 Needless Suffering 20.3 Medical Workforce Shortage and Allocation of Funds 20.4 Unveiling Traditional Healers’ Contributions 20.5 Foreseeing Future Partnerships Acknowledgment References

Index

251 253 253 254 257 258 258

261

Foreword by Raymond H. Prince

I feel highly honored to write a few words of introduction for this book. I congratulate the authors for their timely contributions to the burgeoning field of traditional healing practices. It is worthy of note that in 1976, the World Health Organization (WHO) officially recognized the potential value of traditional practitioners and folk healers to deliver health care. At that time, they reported that up to 80 percent of the world’s population relies upon traditional medicine, chiefly herbal medicines (Foster and Johnson, 2006). Contributors to this volume include commentators upon the traditional healing practices of India, Ecuador, New Zealand, Japan, Egypt, China, South Africa and America. These studies represent a considerable advance in positive attitudes towards traditional healers compared with the period of my studies of Yoruba healers (1957–58, 1962–63). Western-trained psychiatrists then paid little attention to non-Western trained practitioners. Indigenous healers were regarded as ‘witch doctors’. But as a government psychiatrist, I was called upon to see all civil servants who had recovered from psychiatric disorders, in order to certify them as well enough to return to work. I began to see a whole series of patients, who described obvious psychotic episodes and had been treated by traditional healers. It became clear that their treatments, whatever they were, were as efficacious as my own! How did they do this? My first clue came from a male nurse working at my hospital. He confided to me that his father was a traditional healer who specialized in the treatment of psychoses. He also told me that the potion his father used produced the same parkinsonism-like side effects that chlorpromazine produced! This was in 1958. It will be recalled that the major tranquilizers, both Rauwolfia and chlorpromazine were introduced into Western psychiatry in about 1954. Rauwolfia was derived from the indigenous medicine of India. My nurse’s observations suggested that the Yoruba healers had their own brand of tranquilizer. These considerations led me to spend the last two weeks of my first tour in Nigeria with this nurse’s father, Chief Jimo Adetona. I bribed one of Adetona’s workers to bring me a branch of the tree that Adetona used for his medicine. On my way home from Nigeria, I took this specimen to an expert in botany (and in Linnaeus), Professor W.T. Stearn at the British Museum. He identified the plant as Rauwolfia vomitoria, the plant from which reserpine is extracted. He also showed me an interesting volume, The Useful Plants of West Tropical Africa, pointing out particularly the line ‘In Nigeria it is given for convulsions in children. A concoction of the root can be used as a sedative for maniacal symptoms, inducing several hours sleep.’

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FOREWORD BY RAYMOND H. PRINCE

It is interesting that Chief Adetona had told me that some years previously, he had taken his medicine to England to treat a psychotic Nigerian official there. He showed me his 1925 passport! If British physicians had paid more attention to Chief Adetona’s powerful antipsychotic potion, we in the West could have had the tranquilizing drugs a quarter century earlier! Raymond H. Prince, M.D. M.Sc. Emeritus Professor of Psychiatry McGill University, Montreal, Canada

REFERENCES Foster, S and Johnson, R.L. 2006, Desk Reference to Nature’s Medicine, National Geographic. Prince, R. 1974, Careers in Transcultural Psychiatry: a personal view. Volume IV, Number 2. Career Directions: Careers in Transcultural Psychiatry. Sandoz Pharmaceuticals.

Foreword by Goffredo Bartocci

I well remember meeting Mario Incayawar during a pause of the very memorable WPA TPS (World Psychiatric Association Transcultural Psychiatry Section) – SSPC Joint Meeting in Providence in October 2004. Profs Tseng and Wintrob were with us to discuss Mario’s and my intention to organise a conference in Quito on a quite intriguing topic: ‘What are the overt differences and the hidden similarities between the psychotherapies performed by traditional healers in South America and by conventional psychiatrists in the rest of the world?’ As WPA TPS Chair, I had the pleasure to have already had preliminary correspondence with Dr. Incayawar, aimed at identifying the Runajambi Institute for the Study of Quichua Culture and Health as the local organiser for the conference. Thus, the task of the meeting in Providence was to formulate the details of this new event in the history of transcultural psychiatry. As a matter of fact, Dr. Incayawar’s proposal to go deeper into the relationship between traditional medicine and conventional modern psychiatry had deeply attracted my attention, considering my longstanding interest in the powerful attitude of traditional healers in rapidly curing such kinds of mental disturbances which in the West often undergo lengthy psychoanalytic treatment. What a striking difference between the respective approaches! In addition, I had already published several papers on contemporary Roman Catholic stigmatic healers in southern Italy, raising the question of the medical interpretation of how ‘vital forces’ are representing a metaphoric mediator between the natural world, human agency and the super-human. It is not necessary to tell you the result of my meeting with Dr Incayawar in Providence, since you see in these pages its best result: a book collecting the contributions of many distinguished authors who have addressed this topic in depth. I wish great success for this book that has a special meaning to me. Goffredo Bartocci, M.D. Past Chair and Honorary Advisor WPA TPS President-elect, World Association of Cultural Psychiatry, USA (Honolulu)

Salutation by Juan E. Mezzich

I am pleased to extend a warm salutation to the volume on Psychiatrists and Traditional Healers edited by Drs. Mario Incayawar, Ronald Wintrob and Lise Bouchard with Goffredo Bartocci as honorary editor. These colleagues are distinguished members of the World Psychiatric Association’s Section of Transcultural Psychiatry and therefore their contribution represents an opportunity for institutional celebration. This is specially pertinent given the importance and timeliness of the book in today’s world. As proclaimed by Dr. Gro Brundtland, former WHO Director General, there is no health without mental health. At the same time, we increasingly realize the value of a comprehensive concept of health to substantiate understanding of ill-health and the positive aspects of health to undertake effectively clinical care, prevention and health promotion. Within such a broad framework, it is crucial for both the care of individual patients and for public health to consider pointedly what traditional medicine has to offer. The need for such consideration has led to the emergence of the concepts of complementary and integrative medicine as attempts to harmonize conventional or scientific medicine and traditional medicine in the increasingly interactive world in which we live. Furthermore, WPA’s initiative on Person-centered Psychiatry and Medicine makes highly relevant the consideration of efforts to contextualize the understanding of health and the implementation of health care. For all the above reasons, it is a pleasure for me to welcome this important volume and to commend it to the attention of all psychiatrists and health professionals across the world. Professor Juan E. Mezzich President of the World Psychiatric Association, 2005–2008

Preface

As we embark on a new century and millennium, sophisticated and scientifically based psychiatric, psychological and rehabilitative services are expanding throughout the world. Almost every country is committed to improving the mental health of their communities, through the cogent use of advances in neuroscience, behavioral medicine, and community mental health. However, most of the world’s population, who live in developing countries, has limited access to medical care (including psychiatric care), according to the World Health Report, 2001, of the World Health Organization. It is estimated that up to 85 percent of the world’s population relies on traditional healers and medicines to meet their health care needs. The World Health Organization, in its Traditional Medicine Strategy 2002–2005, notes that in Uganda, for example, the ratio of traditional healers to population is 1:200. This contrasts dramatically with the availability of biomedically trained health professionals, for which the ratio is 1:20 000. In certain regions of the world such as in the Andes of South America, there are no psychiatric or mental health services available to the Indigenous Peoples. They therefore rely completely on traditional healers, family and community support to cope with their mental health problems and relieve their psychological distress. This volume focuses on the significant contribution of traditional healers to the wellbeing of most of the world’s population and highlights the role of these unintended partners in global mental health. The origin of this book could probably be traced to the work of a small group of Quichua (Inca) people and friends who created an innovative health care initiative called Jambihuasi, in Otavalo, a renowned Quichua handicraft market town in the highlands of Ecuador, in the 1980s. They realized that traditional Quichua healers could be, contrary to the common belief of local health officials, effective partners in the effort to improve the health status of the Quichua communities of the Andes – the most impoverished and neglected people in the country. Later, with the creation of the Runajambi Institute, the first Quichua health research group, and the development of a research program that aimed to understand the nature and efficacy of traditional healers’ work, the idea of this book took form. We approached the Transcultural Psychiatry Section of the World Psychiatric Association (WPA-TPS) in 2001, and we felt that WPA-TPS supported our objectives and projects. This book is the natural development of a unique international conference titled ‘Psychiatrists and Healers: Unwitting Partners – A Challenge for Transcultural Psychiatry in Times of Globalization,’ held in May, 2005 in Quito, Ecuador. This conference was co-sponsored by the Runajambi Institute and the Transcultural Psychiatry Section of the World Psychiatric Association. We made a significant effort to cover important regions of the world. Eight presentations given at the conference in Quito were selected to be included in the book, namely those authored by Micol Ascoli, Jeffrey Henderson, Sioui Maldonado Bouchard, Dan L. Mkize,

xviii

PREFACE

Mario Incayawar, Joan Obiols-Llandrich, and Vijoy Varma. The remaining 13 chapters are original contributions of recognized world experts, including Tyler Barlowe, Dinesh Bhugra, Lise Bouchard, Mason Durie, Mario Incayawar, Spero M. Manson, Jay H. Shore, James Shore, Antti Pakaslahti, Fumitaka Noda, Robert B. Lemelson, M. Fakhr El-Islam, Ajoy Thachil, Karuna R. Thompson, Ron Wintrob, and Xudong Zhao. Moreover, all the chapters have been carefully revised/rewritten or newly prepared to fit with the goals and scope of this book. The contributors came from Andorra, Canada (Quebec), China, Egypt, Finland, Japan, Italy, South Africa, India, United Kingdom, USA, the Maori (New Zealand), and the Quichua, Modoc/Klamath, and Sioux Lakota Nations of South and North America. This book presents original research data, clinical experiences, case vignettes, and pilot psychiatric collaborative programs between traditional healers and psychiatrists in countries around the world. All chapters highlight, in one way or another, the unanticipated and often unrecognized contribution of traditional healers and traditional psychiatric knowledge to global mental health. It is hoped that the material in this volume will be useful to clinicians, researchers, community mental health practitioners, educators, and mental health policy makers. Many colleagues and friends generously contributed to this book. I am deeply grateful to Dr. Ronald Wintrob, Chair of the World Psychiatric Association – Transcultural Psychiatry Section for his unconditional and enthusiastic support and friendship. I also wish to thank Professor Helen Herrman, Secretary for Publications of the World Psychiatric Association, for including this volume in the WPA-sponsored series and for introducing us to our publisher, Wiley-Blackwell. The encouragement and support we received from Dr. Joan Marsh, Associate Publishing Director, Ms. Fiona Woods, Project Editor, and Ms. Robyn Lyons, Publishing Assistant, and Robert Hambrook, Content Editor, is greatly appreciated. With their flexible and highly professional assistance, they have greatly facilitated the successful completion of our book. I also want to express my gratitude to the John Simon Guggenheim Memorial Foundation for its generous 2006 fellowship that helped me in the editing of this book and the conducting of my research on the diagnostic skills of traditional healers in the Andes. My deep and heartfelt appreciation goes to our contributors. Without their outstanding work, this book would not have been prepared. Our patients from the most remote Andean communities and yours, as well as traditional healers from around the world provided the impetus and motivation for this book. We hope that this volume helps nurturing, between psychiatrists and traditional healers, collaborations that benefit current and future patients everywhere. MARIO INCAYAWAR, M.D., M.Sc., D.E.S.S. Director Runajambi (Institute for the Study of Quichua Culture and Health) Otavalo, Ecuador February 11, 2009

Contributors

Micol Ascoli, M.D. Consultant Psychiatrist, East London NHS Foundation Trust, London, UK L. Tyler Barlowe, M.S. Counselor/Case Manager, United Auburn Indian Community Dinesh Bhugra, MBBS, MRCPsych, M.Phil., M.Sc., M.A., FRCPsych, Ph.D. Professor of Mental Health & Cultural Diversity, Section of Cultural Psychiatry, Health Services and Population Research Department, Institute of Psychiatry, King’s College, London, UK Lise Bouchard, Ph.D. Director of Research, Runajambi – Institute for the Study of Quichua Culture and Health, Otavalo, Ecuador Sioui Maldonado Bouchard, B.Sc., M.Sc. (in progress) Universite´ de Montre´al, Montre´al, Canada; Research Assistant, Runajambi – Institute for the Study of Quichua Culture and Health, Otavalo, Ecuador Mason Durie, M.D. Psychiatrist and Professor of Maori Research and Development, Massey University, Palmerston North, New Zealand M. Fakhr El-Islam, M.D., FRCP, FRCPsych Academic Consultant, Behman Hospital, Helwan, Cairo, Egypt Nitin Gupta, M.D. South Staffordshire and Shropshire, Healthcare NHS Foundation Trust, Burton on Trent, Staffordshire, UK Jeffrey A. Henderson, M.D., M.P.H. Black Hills Center for American Indian Health, Rapid City, SD, USA Mario Incayawar, M.D., M.Sc. Director, Runajambi – Institute for the Study of Quichua Culture and Health, Otavalo, Ecuador; Former Henry R. Luce, Professor in Brain, Mind and Medicine: Cross-Cultural Perspectives, Pitzer, Claremont McKenna, and Harvey Mudd Colleges, California, USA.

xx

CONTRIBUTORS

Robert B. Lemelson, Ph.D. Research Anthropologist, Semel Institute of Neuroscience, UCLA, California, USA Spero M. Manson, Ph.D. University of Colorado Denver, Department of Psychiatry, American Indian and Alaska Native Programs, Aurora, Colorado, USA Dan L. Mkize, MB ChB, DCH, MFGP, DFM, M Med(Psych) Professor of Psychiatry, Nelson Mandela School of Medicine, Univeristy of KwaZuluNatal, Durban, South Africa Fumitaka Noda, M.D., Ph.D. Professor of Phychiatry, Department of Human Welfare, Faculty of Human Studies, Taisho University, Tokyo, Japan; Adjunct Professor, University of British Columbia, Vancouver, Canada Joan Obiols-Llandrich, M.D., Ph.D. Psychiatrist and Anthropologist, Director Mental Health Services, Andorra; Professor of Mental Health, University of Andorra Antti Pakaslahti, M.D., Ph.D. Adjunct Professor of Transcultural Psychiatry, School of Public Health, University of Tampere, Finland James H. Shore, M.D. University of Colorado Denver, Department of Psychiatry, American Indian and Alaska Native Programs, Aurora, Colorado, USA Jay H. Shore, M.D., M.P.H. University of Colorado Denver, Department of Psychiatry, American Indian and Alaska Native Programs, Aurora, Colorado, USA Ajoy Thachil, MBBS, MRCPsych Walport Academic Clinical Fellow, Section of Cultural Psychiatry, Health Services and Population Research Department, Institute of Psychiatry, King’s College, London, UK Karuna R. Thompson, M.A. Doctoral Candidate, Department of Religious Studies, University of the West, Rosemead, CA Vijoy K. Varma, M.D., D.M.P., M.Sc., FRCPsych, FAMS Indiana University School of Medicine, Indianapolis, IN, USA Ronald Wintrob, M.D. WPA-Transcultural Psychiatry Section, Warren Alpert School of Medicine, Brown University, Providence, RI, USA Xudong Zhao, Dr., Med. Professor of Psychiatry, Department of Psychosomatic Medicine, Tongji University Medical School, Shanghai, China

World Psychiatric Association Evidence and Experience in Psychiatry Series Series Editor: Helen Herrman (2005 - ) WPA Secretary for Publications, University of Melbourne, Australia The Evidence & Experience in Psychiatry series, launched in 1999, offers unique insights into both investigation and practice in mental health. Developed and commissioned by the World Psychiatric Association, the books address controversial issues in clinical psychiatry and integrate research evidence and clinical experience to provide a stimulating overview of the field. Focused on common psychiatric disorders, each volume follows the same format: systematic review of the available research evidence followed by multiple commentaries written by clinicians of different orientations and from different countries. Each includes coverage of diagnosis, management, pharma and psycho- therapies, and social and economic issues. The series provides insights that will prove invaluable to psychiatrists, psychologists, mental health nurses and policy makers. Depressive Disorders, 3e Edited by Helen Herrman, Mario Maj and Norman Sartorius ISBN: 978-0-470-98720-9 Substance Abuse Edited by Hamid Ghodse, Helen Herrman, Mario Maj and Norman Sartorius ISBN: 978-0-470-74510-6 Schizophrenia 2e Edited by Mario Maj, Norman Sartorius ISBN: 978-0-470-84964-4 Dementia 2e Edited by Mario Maj, Norman Sartorius ISBN: 978-0-470-84963-7 Obsessive-Compulsive Disorders 2e Edited by Mario Maj, Norman Sartorius, Ahmed Okasha, Joseph Zohar ISBN: 978-0-470-84966-8 Bipolar Disorders Edited by Mario Maj, Hagop S Akiskal, Juan Jose´ L´opez-Ibor, Norman Sartorius ISBN: 978-0-471-56037-1 Eating Disorders Edited by Mario Maj, Kathrine Halmi, Juan Jose´ L´opez-Ibor, Norman Sartorius ISBN: 978-0-470-84865-4 Phobias Edited by Mario Maj, Hagop S Akiskal, Juan Jose´ L´opez-Ibor, Ahmed Okasha ISBN: 978-0-470-85833-2 Personality Disorders Edited by Mario Maj, Hagop S Akiskal, Juan E Mezzich ISBN: 978-0-470-09036-7 Somatoform Disorders Edited by Mario Maj, Hagop S Akiskal, Juan E Mezzich, Ahmed Okasha ISBN: 978-0-470-01612-1

Other World Psychiatric Association Titles Series Editor (2005 - ): Helen Herrman, WPA Secretary for Publications, University of Melbourne, Australia Special Populations The Mental Health of Children and Adolescents: an area of global neglect Edited by Helmut Remschmidt, Barry Nurcombe, Myron L. Belfer, Norman Sartorius and Ahmed Okasha ISBN: 978-0-470-51245-6 Contemporary Topics in Women’s Mental Health: global perspectives in a changing society Edited by Prabha S. Chandra, Helen Herrman, Marianne Kastrup, Marta Rondon, Unaiza Niaz, Ahmed Okasha, Jane Fisher ISBN: 978-0-470-75411-5 Families and Mental Disorders Edited by Norman Sartorius, Julian Leff, Juan Jose´ L´opez-Ibor, Mario Maj, Ahmed Okasha ISBN: 978-0-470-02382-2 Disasters and Mental Health Edited by Juan Jose´ L´opez-Ibor, George Christodoulou, Mario Maj, Norman Sartorius, Ahmed Okasha ISBN: 978-0-470-02123-1 Approaches to Practice and Research Psychiatric Diagnosis: challenges and prospects Edited by Ihsan M. Salloum and Juan E. Mezzich ISBN: 978-0-470-72569-6 Recovery in Mental Health: reshaping scientific and clinical responsibilities By Michaela Amering and Margit Schmolke ISBN: 978-0-470-99796-3 Handbook of Service User Involvement in Mental Health Research Edited by Jan Wallcraft, Beate Schrank and Michaela Amering ISBN: 978-0-470-99795-6 Psychiatry and Religion: beyond boundaries Edited by Peter J Verhagen, Herman M van Praag, Juan Jose´ L´opez-Ibor, John Cox, Driss Moussaoui ISBN: 978-0-470-69471-8 Psychiatric Diagnosis and Classification Edited by Mario Maj, Wolfgang Gaebel, Juan Jose´ L´opez-Ibor, Norman Sartorius ISBN: 978-0-471-49681-6 Psychiatry in Society Edited by Norman Sartorius, Wolfgang Gaebel, Juan Jose´ L´opez-Ibor, Mario Maj ISBN: 978-0-471-49682-3 Psychiatry as a Neuroscience Edited by Juan Jose´ L´opez-Ibor, Mario Maj, Norman Sartorius ISBN: 978-0-471-49656-4 Early Detection and Management of Mental Disorders Edited by Mario Maj, Juan Jose´ L´opez-Ibor, Norman Sartorius, Mitsumoto Sato, Ahmed Okasha ISBN: 978-0-470-01083-9 Also available in electronic editions only, through Wiley Online Library: WPA Anthology of Italian Language Psychiatric Texts WPA Anthology of Spanish Language Psychiatric Texts WPA Anthology of French Language Psychiatric Texts

CHAPTER 1

Overview: Looking Toward the Future of Shared Knowledge and Healing Practices Ronald Wintrob WPA-Transcultural Psychiatry Section, Warren Alpert School of Medicine, Brown University, Providence, RI, USA

Abstract Medicine has made outstanding advances over the past 50 years in understanding the biology of the disease process at the level of organs and cells and genes, leading to a vast array of effective new treatments. But for all its success in these areas, medicine cannot answer the two fundamental questions most people ask about the misfortune of becoming ill: why me, and why now? These are questions that relate to every society’s beliefs about cosmology; about how the world works, and why it works the way it does. These are the larger questions about the relationship between man and nature, and man and the supernatural, and the search for harmony in relations between the natural and the supernatural worlds. The chapters in this volume address these large questions, referring to societies around the world. In this overview chapter, consideration is directed first to issues of man and nature; to past and contemporary beliefs and practices about the healing powers of plants and their derivative biologically active compounds. The focus of this section is on the field now called ‘complementary and alternative medicine’. This subject leads to a consideration of the medical knowledge of indigenous populations around the world; knowledge that includes both medicinal effects of local plants and healing practices developed over many centuries by indigenous peoples. Discussion is included of the intellectual property rights of indigenous peoples to their accrued medical knowledge. The chapter continues with discussion of the relationship between the natural and the supernatural worlds, specifically concerning beliefs about the causes of illness and its treatment. This involves the central issue of supernatural determinism in illness and its outcome. It involves beliefs and practices about healing of illness through participation in religious rituals. Examples of Christian faith healing rituals are cited, as are examples of Hindu and Muslim religious healing practices. In the last section of the overview chapter, the focus is directed toward contemporary efforts to integrate aspects of traditional healing beliefs and practices, among indigenous peoples in North and South America, with medical and psychiatric treatment programs. The

Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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THE FUTURE OF SHARED KNOWLEDGE AND HEALING PRACTICES implications of such integrated approaches for improving the effectiveness of treatment and decreasing resistance to treatment are pointed out, with reference to chapters in this volume that offer detailed descriptions of landmark efforts of this type.

1.1

INTRODUCTORY REMARKS

Doctors, and that certainly includes psychiatrists, think of themselves as clinicians whose diagnostic and treatment decisions are ‘evidence-based’; and that evidence is ‘scientific’. Other clinicians in the mental health disciplines of psychology, social work and nursing share that perspective. What follows from that shared perspective is great skepticism about what clinicians regard as unscientific, scientifically unproven and ‘faith-based’ treatments for medical and psychiatric disorders.

1.2

COMPLEMENTARY AND ALTERNATIVE MEDICINE

It therefore comes as a surprise to clinicians who have been trained and ‘enculturated’ in the scientific method and evidence-based medicine, that such a large proportion of the world’s population does not share their firm commitment to those principles, but instead believes in and practices a wide variety of what is now called ‘complementary and alternative medicine’. And this belief and practice in complementary and alternative medicine is by no means limited to people living in areas remote from access to contemporary scientific institutions and medical facilities. It is one of the paradoxes of the well-recognized advance of the acceptance of the accomplishments of both science and medicine that there is growing skepticism about their benefits, and growing worry about the human and environmental costs of the advances and accomplishments of science and medicine. It is a further paradox that it is in just those countries characterized by the highest levels of median education and income, that there has been the most rapid growth in complementary and alternative medicine during the past 25 years. Such is the case in the United States, where the National Institutes of Health, through a study conducted in 2004 by its National Center for Complementary and Alternative Medicine, estimated that complementary and alternative treatments are being used by some 60 million Americans, comprising 20% of the national population and one third of all US adults. These treatments are being used as therapies for conditions and illnesses of all degrees of severity and complexity, including cancer and AIDS, hypertension and ulcerative colitis, asthma and depression, stress reduction and counteracting the physical and psychological effects of aging. Indeed, office visits to providers of complementary and alternative medicine are estimated to outnumber visits to primary care physicians, and may soon outnumber visits to all physicians. Annual expenditures by Americans on complementary and alternative medicine are estimated at $40 billion.

1.3

THE US NATIONAL CENTER FOR COMPLEMENTARY AND ALTERNATIVE MEDICINE

Even though it has been well known for hundreds, if not thousands of years, that belief in the efficacy of herbal treatments, as well as incantations and prayers, has been widely

THE INTELLECTUAL PROPERTY RIGHTS OF INDIGENOUS PEOPLES

3

accepted and practiced by the world’s cultures, it was not until 1998 that the US National Center for Complementary and Alternative Medicine was inaugurated. It is the US government’s lead agency for scientific research on complementary and alternative medicine, and one of the 27 institutes and centers that make up the National Institutes of Health, established over a century ago. The National Center for Complementary and Alternative Medicine defines its subject as ‘a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine’. The Center’s mission is; (i) to explore complementary and alternative healing practices in the context of rigorous science, (ii) to train complementary and alternative medicine researchers, and (iii) to disseminate authoritative information to the public and professionals, in order to help the public and health professionals understand which complementary and alternative medicine therapies have been proven to be safe and effective. In 2008, its funding was over $120 million.

1.4

BOTANICALS, BIOLOGICAL PRODUCTS AND THEIR COMMERCIAL DEVELOPMENT

In the United States, Canada and many European countries, the names of compounds once considered exotic, such as ginseng, ginkgo biloba, St John’s Wort (hypericum perforatum) and aloe vera are now familiar, and widely used as treatments for a vast range of conditions and illnesses. Natural plant substances alone are estimated to generate more than $75 billion in annual sales for the world’s pharmaceutical industry, in addition to some $20 billion in ‘herbal supplement’ sales. The well-established therapeutic effectiveness of a very large number of commerciallydeveloped drugs should not obscure two related issues of fundamental importance; first, that for every drug of proven effectiveness, there are many others being widely administered for the same or similar disorders that have no such proven effectiveness, and second, that the vast profits that can be derived from sales of pharmaceutical products can and do impinge on a variety of ethical issues affecting intellectual property rights and the cultural integrity of cultural groups and other identifiable groups of people around the world.

1.5

THE MEDICAL, MEDICINAL AND BOTANICAL KNOWLEDGE AND THE INTELLECTUAL PROPERTY RIGHTS OF INDIGENOUS PEOPLES

The issue of the intellectual property rights of indigenous peoples, specifically in relation to the use of their medical, medicinal and botanical knowledge, developed over centuries, is addressed in this book in the unique analysis by Sioui Maldonado Bouchard. Using the cultural case example of the Quichua peoples of the Andean highlands region of South America, she describes the traditional as well as the contemporary uses of the anti-pyretic and anti-malarial compounds derived from the bark of the Andean cinchona tree, as well as the analgesic and related effects of the traditional and contemporary use of coca leaves, also grown and used in the Andes for many centuries. Maldonado Bouchard then compellingly relates the intellectual property rights of indigenous peoples concerning their medicinal and botanical knowledge, to the complex

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THE FUTURE OF SHARED KNOWLEDGE AND HEALING PRACTICES

subject of patent laws; laws that have had the effect of preventing indigenous peoples, like the Quichua peoples of the Andes, from earning some of the enormous profits that have come from the worldwide commercial development and patenting of drugs for the treatment of fever and pain. The search for other medicinally useful, and profitable, botanicals in the Andean highlands continues today. One example is the tropane alkaloids derived from an Andean plant that is used to enable ophthalmologists to dilate the pupil for efficient eye examination. Identification of the active compounds contained in botanical and other biological products that can be used as the basic components of patentable and commercially marketable pharmaceuticals can generate millions and even billions of dollars in profits. Studies sponsored by the United Nations University in recent years have estimated that more than 60% of all cancer drugs approved by the US Food and Drug Administration have come from such discoveries. In light of those incentives, and the risks they engender in overlooking and denying the claims of indigenous groups to the benefits of their medical, medicinal and botanical knowledge, the United Nations has become more active over the last two decades, in giving legal recognition to and ensuring the intellectual property rights of the world’s indigenous populations. Maca is a small, whitish root vegetable that grows in the Peruvian Andes. Indigenous Quichuas of the Andes have used it for centuries as a stimulant to increase energy and enhance sex drive. Preliminary laboratory studies of its pharmacological properties have supported the findings of increased stamina, as well as increased volume and motility in sperm counts, and also reduced risk of prostate cancer. In the past 10 years, Peruvian, American and European investors have cultivated and harvested commercial quantities of maca, extracted its active compounds, obtained US patents for them, and marketed them as medicinals and health supplements, resulting in revenues of over $200 million in 2007. Realizing the economic scale of the commercial development of indigenous Peruvian plants such as maca, the Peruvian government has recently started to protest the commercial exploitation of its national botanical, biological and medicinal heritage; although the Peruvian government is not doing so on behalf of its indigenous Andean peoples. In another chapter in this volume, Dan Mkize describes the landmark efforts of the Nelson Mandela School of Medicine in Durban, South Africa, where he is Professor of Psychiatry, to work out a set of legal and ethical guidelines for the recognition and commercial development of indigenous South African peoples’ medical, medicinal and botanical knowledge, in collaboration with the medical school. The same agreement gives explicit recognition to indigenous medical knowledge and healing practices, according legal status, previously unrecognized, to their practitioners, and inaugurating courses of study of indigenous healing methods for students of medicine and related health professions. Collaborative research enterprises, guaranteeing equitable sharing of benefits, are also envisioned in this landmark agreement.

1.6

SUPERNATURAL DETERMINISM, FAITH HEALING AND EXORCISM

Physicians and other scientists investigating the causes of illness, disease and organ pathology have had outstanding success in explaining many of the biological and some of the social and psychological factors responsible for illness and manifest disease

FAITH HEALING

5

processes; that is, in explicating the ‘how’ of illness. But those successes have not been able to explain the individualistic, fortuitous or random nature of illness. This is the ‘why’ of illness: why has misfortune, in the form of illness, affected a given person or their family, and not others in their extended family and community, and why has their illness befallen them at that particular time, and not at some other time. Physicians and other scientists do not like to be confronted by these questions, because they cannot provide answers that will reassure their patients, patients’ families, or themselves. These questions are regarded as philosophical, speculative, conjectural; impossible to answer with assurance or accuracy, therefore better to avoid the subject completely. Nonetheless, these questions are in the minds of most people who encounter misfortune of any kind, including illness, disease and death; and have been so since the dawn of human thought. Answers to questions such as these have formed a fundamental component of religious faith, in which misfortune, illness and death are explained by supernatural determination. It follows from this explanatory framework that healing requires prayer, atonement for transgressions, divine intervention and forgiveness, and exorcism of malign spirits. Healing requires restoring harmony between the natural world of humans and the supernatural and spirit world. In an article titled ‘Faith and Healing’, published recently in the New York Times (NYT; 27 January 2008), Jerome Groopman, an academic physician at Harvard Medical School, described one of his patients, a woman with breast cancer, then in remission following intensive medical treatment. Cost-cutting at work was making her feel tense, anxious and angry. She expressed the worry that the stress she was experiencing would ‘weaken her immune system’, resulting in the recurrence of her cancer. Being a believer in complementary and alternative medicine, she was attempting to cope with these stressful circumstances by doing yoga exercises regularly, drinking green tea and ‘visualizing her blood cells on patrol and in combat against any recurrence of tumor cells’. In addition she was continuing to take prescribed hormone blockers to prevent recurrence of her tumor. How could Dr Groopman, or any of us, assess the effectiveness of each individual component of her treatment, or their combined effect on her treatment and prognosis? He could not, and neither could we. But we would probably acknowledge that they all played some part in her treatment and in her recovery from breast cancer.

1.7

FAITH HEALING

The surge of interest in alternative healing beliefs and practices over the past several decades in the world’s ‘developed’ countries, as the case example of Dr Groopman’s patient illustrates, has by no means been limited to people who lack access to contemporary medical facilities and practitioners. It affects all social classes, immigrants as well as those who have lived in their home countries for generations. It reflects currents of contemporary skepticism and disappointment with the promises of science, including medicine, to effect cures of diseases that have defied cures and continue to take a huge toll on lives and well-being in all societies. It also reflects the never-ending search for explanation of suffering and misfortune, believed by many millions of people to relate to divine intervention or God’s will, or to malign spirits, the placing of spells, malign magic, sorcery and witchcraft.

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THE FUTURE OF SHARED KNOWLEDGE AND HEALING PRACTICES

Faith healing beliefs and practices have been studied by cultural anthropologists and by cultural psychiatrists for decades, in countries all over the world. In the United States, it has been practiced for over a century, and in other countries for many centuries. In the United States faith healing has been encountered mainly among fundamentalist Christian groups, and has been most closely studied in rural Appalachian communities. But that concentration of studies in Appalachian communities obscures the reality that faith healing is practiced throughout the country, in both urban and rural settings. In recent years there has been increasing evidence of the blending of ‘Western’ and ‘Eastern’ beliefs about supernatural intervention and faith healing; blending some aspects of Christian, Buddhist and Hindu traditions and practices related to causation of illness and its treatment through religious ritual performance. Fundamentalist Christian faith healing rituals in the United States have certain characteristic features. They include the central role of a charismatic church leader/healer, intense ritual activity involving both healer and congregation, often involving musical accompaniment of instruments, chanting and singing, occurring in an emotionally charged atmosphere, and ‘testimonials’ by leader and congregants, affirming the power of ‘the Holy Spirit’ to ease suffering and to heal both spirit and body. There is believed to be evidence of direct communication with the Holy Spirit in faith healing ceremonies. Such evidence is provided by the leader/healer, as well as some congregants, entering into trance and possession by the Holy Spirit, by ‘speaking in tongues’ (glossolalia), and by the ‘laying on of hands’ in healing. Christian faith healing congregations exist in well over 100 countries throughout the world, involving some 100 million adherents. In this volume, Micol Ascoli gives a detailed account of Roman Catholic charismatic faith healing that she has been studying for several years in Italy and in the United Kingdom. In Italy, it is a movement called ‘Renewal in the Spirit’ that is officially approved and sanctioned by the church hierarchy and has been growing over the past 30 years. Ascoli points out that the Catholic conceptualization of illness involves several complex strands. Illness can represent a means of spiritual purification, an occasion for demonstrating hope and charity, a manifestation of God’s will, testimony of God’s healing power and triumph over evil. There is also representation of illness as punishment for sins, which the sufferer must acknowledge and overcome in order to be healed. Ascoli describes the therapeutic factors in Catholic faith healing rituals that are demonstrated by the charisma, or ‘gifts’ of the leader, called the ‘animator’ to prophesy, to ‘speak in tongues’, and to communicate to the congregation in such a way that they will more clearly comprehend the fundamental truths of their religious faith; thereby enabling them to; ‘break free from negative forces, including illness, if God so wishes’. Having described the process of Catholic charismatic faith healing ritual performance, she compares that religious-based group healing ritual with the healing ritual performance of individual psychotherapy conducted in psychotherapists’ offices in Italy and the United Kingdom. There are many countries in the world where faith healing rituals have been practiced for centuries, even millennia; particularly in Asia. In this volume, the chapter by Vijoy Varma, formerly Professor of Psychiatry in Chandigarh, India, addresses some of the issues raised by Ascoli, both about spiritual healing and its comparison with psychotherapy, in the culturally and religiously complex context of Indian society. In another chapter, Xudong Zhao, an experienced cultural psychiatrist and Professor of Psychiatry at Tongji University

CURANDERISMO AND CANDOMBLE

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Medical School in Shanghai, describes the wide range of beliefs and practices related to both scientific and ‘alternative and complementary’ healing in contemporary China. Fumitaka Noda, Professor of Psychiatry at Taisho University in Tokyo, has contributed a carefully detailed chapter about beliefs concerning mental illness and the varieties of secular and religious healing techniques that are characteristic of both Japanese and Okinawan cultures. In another chapter, Antti Pakaslahti, Associate Professor of Transcultural Psychiatry at the University of Tampere in Finland, who has conducted research for many years on religious healing rituals at Hindu temple complexes in Rajasthan, in northern India, carefully points out that such healing ceremonies are often conducted for the families of people who live in urban settings, such as New Delhi, and who have tertiary level academic backgrounds; that religious healing is not at all limited to those living in rural areas and having limited education. Pakaslahti emphasizes the flourishing activities of healing ritual practices at well-known Hindu temple compounds in northern India, where many supplicants come for help with problems clearly related to contemporary job and family stressors of urban living. In his chapter, Fakr El-Islam, a senior consultant psychiatrist from Cairo, who has extensive experience as clinician, teacher and investigator in several countries in the Middle East, describes traditional Islamic beliefs in Egypt and other Arab countries related to mental illness, and Islamic influences, both direct and indirect, on treatment and rehabilitation of emotional turmoil.

1.8

CURANDERISMO AND CANDOMBLE

During the past four decades there has been a rapidly increasing surge of migrants from the Caribbean and Latin America to the United States. Their numbers have surged from less than 10 million in 1970, to over 35 million in 2000 and 43 million in 2006, representing 14.6% of the total US population. More than 50% of that surge is comprised of migrants from Mexico. There are substantial numbers coming from Central and South American countries, as well as from the Caribbean, particularly Cuba, the Dominican Republic and Haiti. These migrants have brought with them rich and complex cultural traditions about health, illness and the relief of suffering and misfortune, including suffering believed to be caused by malign magic. Those traditions include santeria, voodoo and espiritismo from the Caribbean, and ‘curanderismo’, common to many cultural groups from Mexico, Central and South America. Curanderismo involves beliefs and healing practices related to ‘mal puesto’, witchcraft; ‘mal de ojo’, evil eye; ‘susto’, soul fright or soul loss, and ‘envidada’, envy or jealousy. There are four levels of intervention that are believed to relieve these afflictions; material; such as herbal, psychological, psychosocial and spiritual. There are readily evident similarities between the ingestion and rubbing on of herbal preparations in curanderismo and the types of ‘complementary and alternative’ procedures described earlier in this chapter. And the similarities to fundamentalist Christian faith healing and exorcism in the United States and Europe should be equally evident. In Brazil, as well as in its neighboring countries in South America, the number of adherents to the alternative beliefs and ritual healing practices of Candomble and Umbanda is in the many millions. They are syncretic spiritual movements, combining

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THE FUTURE OF SHARED KNOWLEDGE AND HEALING PRACTICES

Catholic cosmology with beliefs in a pantheon of gods derived from sub-Saharan, mainly West African tribal beliefs, transmuted via slave population experiences in the Caribbean, in Brazil and in other South American countries. The supplicants in Candomble rituals appeal to the gods or Orishas, through the spirits of four main intermediaries, all identified as former slaves, who are represented during the ritual prayer and healing performances by the principal male and female officiators and their numerous assistants. Intense drumming and chanting, as well as burning of incense and candles is part of the ritual performance. As in Christian faith healing rituals, the presence and intervention of the Orishas is believed to be demonstrated by the dramatic appearance of trance in several of the assistants, and their possession by the Orishas is evidenced by their speaking in tongues and showing agitated and frenetic behavior. Other assistants monitor those possessed, to avoid injury to them or the supplicants, some of whom also experience trance and possession during the course of the ceremonies. As the trance state subsides, those possessed are cared for, ritually bathed and dressed in the robes and decoration indicative of the gods and spirits that possessed them. The healing ritual is completed by the principal male and female officiators, called the ‘mother and father’ of the congregation, interpreting the messages from the gods and offering counsel to supplicants and to the whole congregation. The most common issues for which the gods’ help is sought are mistrust and infidelity, financial reversal, family turmoil, school failure, alcohol and drug abuse, intra-familial violence, and physical and psychiatric illness.

1.9

TOWARD THE INTEGRATION OF MEDICAL AND TRADITIONAL HEALING; CASE EXAMPLES FROM THE AMERICAS

Indigenous peoples’ cosmology, as well as their beliefs in illness causation and healing practices are most clearly manifest in the activities of indigenous healers. Candomble and Umbanda are one such example from the Americas. Another example, and one that is a principal theme of this volume, is the more effective diagnosis and treatment of the psychosocial distress of people living in predominantly indigenous rural communities, as well as in urban enclaves. Keeping the focus on South America, two chapters in this book directly address the theme of how the large Quichua population living in villages throughout the Andean highlands of Ecuador, and by extension, the equally large indigenous populations in Peru, Bolivia and Colombia as well, could get better access to health and mental health services. This is a very much bigger and more complex issue than getting the respective national and regional governments to provide clinical facilities and the services of physicians and related health professional staff in Andean communities. It has everything to do with the indigenous population achieving legal, medical and social equality, and the recognition of their inherent dignity as the first and continuous human settlers of those countries, whose heritage goes back centuries and millennia. Some of these over-arching issues are discussed in the chapters by Mario Incayawar and Lise Bouchard of the Runajambi Institute for the Study of Quichua Culture and Health. Both authors describe the toxic atmosphere of prejudice, exploitation, exclusion and repression that has characterized the relations between the indigenous population and the settler and ruling classes of the Andes for centuries. That legacy of discrimination has

INTEGRATION OF MEDICAL AND TRADITIONAL HEALING

9

resulted in the suppression of indigenous medical knowledge and healing practices, along with the harassment and punishment of the traditional healers themselves. Despite those measures, the traditions and the practitioners persisted through the centuries, and are beginning to get some recognition. Incayawar gives the results of his study of the ability of yachactaitas, traditional Quichua healers, to diagnose conditions that a Western-trained psychiatrist would also diagnose as being indicative of psychiatric illness. Ten yachactaitas took part in the identification of 50 patients suffering from symptoms the Quichua healers called llaqui, a condition that has four types of symptom clusters, derived primarily from their putative causes; being victimized by malign spirits, or sadness and distress caused by adverse life events. The clinical evaluation of these patients indicated that they were suffering from both psychiatric and medical disorders. Eighty-two per cent of patients met the criteria for depressive disorders. None of the patients suffering from llaqui were considered healthy either in bio-medical or psychiatric terms. Incayawar’s data indicate that even though their conceptual frameworks of illness causation are different from psychiatrists, yachactaitas are quite capable of recognizing emotional distress and diagnosable psychiatric disorders in their Quichua patients. Given this population’s almost complete lack of access to psychiatric treatment, utilizing yachactaitas’ skills could help alleviate some of the emotional distress and related physical symptoms in this population. In discussing the significance of these findings, Incayawar points out that if there was a paradigm shift of attitude, Quichua communities in the Andes could once again be served by Quichua healers who share their worldview. If yachactaitas could be incorporated into the health service system that provides medical and psychiatric care for people of the Andes, and could work collaboratively with medically-trained personnel, mutual respect and mutual learning could result, ultimately reducing inter-ethnic tensions and improving the well-being of all the region’s inhabitants. That idealistic vision raises the question of whether such an attempt to integrate traditional healing beliefs and practices with contemporary medical approaches has been made in other places in the Americas. And it has. This volume includes several chapters that address this issue in the United States. In their chapter exploring the history and current efforts at closer integration of traditional healing beliefs and practices with medical and psychiatric approaches in the United States, Jay Shore, James Shore and Spero Manson, from the University of Colorado, note that the literature on this subject emphasizes two broad themes. The first is that large numbers of American Indians, belonging to tribes throughout the country, ascribe to traditional beliefs about illness and healing practices, and make use of them when they or their families are ill and traditional healers and healing methods are accessible to them. The second theme is that there have been a considerable number of attempts to integrate some aspects of traditional beliefs and practices into standard medical approaches to diagnosis and treatment of medical and psychiatric illness in Native American populations. One such example is Jilek-Aall’s development of a technique, in her work with the Northwest coastal Salish Indians, to incorporate traditional Salish myths in facilitating the process of psychotherapy. Another approach to the integration of the two healing systems is in the collaboration between individual physicians and/or psychiatrists and individual traditional healers, in the treatment of a given patient or patient population seeking treatment in a clinic or in a community. This approach involves giving individuals and communities access to both traditional treatments and medical/psychiatric treatments, on an equal basis,

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THE FUTURE OF SHARED KNOWLEDGE AND HEALING PRACTICES

encouraging their open choice of either or both forms of treatment, without prejudice and respecting the benefits of both forms of treatment. Shore, Shore and Manson point out that in a large epidemiological study of Northern Plains and of Southwestern tribes, a highly significant percentage of subjects made use of traditional healing practices. Among those who experienced behavioral disorders, over 40% had made use of some kind of traditional healing in the previous year. About 25% of subjects in this study who had used standard medical/psychiatric services for treatment of emotional problems, had also been treated by traditional healers. In a separate study of American Indians living in urban areas and receiving medical treatment at a primary care clinic, it was found that 70% of subjects were also making use of traditional healing practices. This was especially true of subjects who had alcohol use problems and a history of exposure to traumatic events. Furthermore, among urban-living Native Americans who obtained treatment from both medical facilities and traditional healers, the majority rated their healers’ advice more highly than their physicians’. Only a small minority of subjects informed their physicians that they were simultaneously getting treatment from traditional healers; indicating a distressing lack of coordination and collaboration between physicians and healers, and contributing to mutually negative perceptions of the others’ approaches to treatment. Shore, Shore and Manson’s chapter describes the results of two types of collaboration in the treatment of Native American Vietnam war veterans from two tribes; one in the Southwest and the other from the Northern Plains, that illustrate the processes by which traditional healers and psychiatrists can work together. The Southwest example involves the implementation of a formal system of consultation between medical/psychiatric services offered to Southwest Indian veterans by the Veterans Health Administration and by Southwestern traditional healers. Both forms of treatment were endorsed by and paid for by the Veterans Health Administration; making this a landmark accomplishment and a model for future collaboration and integration of services that recognizes the cultural uniqueness of given population groups. It is, therefore, a compelling illustration of the concept of ‘cultural competence’ put into practice. In the ‘American Indian Vietnam Veterans Project’, the prevalence of post-traumatic stress disorder among veterans of the two tribes was measured, and found to be significantly higher than for non-Indian Vietnam veterans. It was determined that 77% of Indian veterans had a diagnosable psychiatric disorder, but only about 15% had received psychiatric treatment in the previous six months. About 10% had seen a traditional healer during the previous six months. The investigators found that participation in tribal ceremonies and traditional healing rituals, both before and after their military service, was strongly associated with a lower risk of post-traumatic stress disorder in these veterans, as well as with less severe symptoms and shorter duration of acute symptoms of post-traumatic stress disorder. Moreover, Indian veterans who sought traditional forms of treatment were less likely to seek medical/psychiatric services for emotional/psychiatric disorders and needed less medical/psychiatric treatment when they did seek it. These findings of the mental health benefits of traditional healing methods for veterans of these two Indian tribes led to the adoption of a contractual agreement between the Veterans Health Administration and traditional healers of the two tribes, that ensured there would be reimbursement for traditional healing methods. This agreement has been in effect for ten years now.

CONCLUDING COMMENTS

11

Another approach to collaboration and consultation between physicians/psychiatrists and traditional healers, described in this chapter, involves the use of live interactive videoconferencing technology to connect psychiatric personnel at the University of Colorado with American Indian veterans living in rural reservation communities. This technology has been progressively extended, so that treatment is now being offered to twelve Northern Plains tribes. The details of collaborative and consultative arrangements between the psychiatrists and the tribal authorities, and between the psychiatrists and the traditional healers of each tribe, are delineated in the chapter. Two chapters by Jeffrey Henderson, physician-epidemiologist of the Black Hill Center for American Indian Health, in South Dakota, address similar issues of the integration of traditional Native American healing techniques with medical treatment, respecting the rights of Native American communities and patients to choose the treatment methods they believe will be most helpful to them.

1.10

CONCLUDING COMMENTS

What distinguishes traditional healing from medical treatment is the strong emphasis on spiritual healing as an inseparable component of all healing; healing that has as its objective the relief of intra-familial, interpersonal and communal stressors at the same time and on an equal level of importance as the relief of the symptoms of physical illness. Whether the healing occurs in India, Canada, Brazil or the United Kingdom, China or the United States, the results are better when there is a shared understanding of the causes of the illness between treatment providers and patients, their families and community members, and when there is agreement on the cultural appropriateness of the methods of treatment provided. Many examples are included in this volume of both the intentional and the unwitting, unplanned and unintended collaboration of biomedical and traditional healing, including the benefits and the problems such collaboration can generate. Where it has been possible for mutual understanding and respect to characterize the collaborative efforts of traditional healers and physicians to relieve the emotional and physical suffering of illness, there have been advances in knowledge and greater satisfaction with treatment. The chapters of this book are a contribution to furthering this mutual respect and understanding between alternative approaches to healing in all societies.

CHAPTER 2

Legitimacy and Contextual Issues in Traditional Lakota Sioux Healing Jeffrey A. Henderson Black Hills Center for American Indian Health, Rapid City, SD, USA

Abstract Disclaimer: The views expressed are solely those of the author and do not necessarily reflect those of the US Department of Health and Human Services or the World Health Organization. For decades developing countries have struggled and coped unevenly with the issue of the interface between traditional indigenous medical systems and the dominant biomedical system. All too often the traditional system and its practitioners are subordinated to the biomedical system, both purposefully as well as inadvertently. These situations have been accelerated and fuelled by the World Health Organization’s drive toward a Primary Health Care model beginning in the 1970s, and subsequent efforts to institutionalize traditional healers and commoditize traditional knowledge. Ironically, while China, India and Africa have been grappling with these interface issues for decades, this dialogue has only recently emerged in the United States. The author approaches these issues from a Weberian standpoint, and shows how the differing forms of legitimacy derived by traditional medicine and biomedicine complicate even egalitarian attempts at cooperation between the two, often resulting in further marginalization of the traditional system. Lessons to be learned from the situation are examined, and then linked to the situation in the United States. While in many areas of the world the situation is deep-rooted, the opportunity still exists in the United States to advocate for an equal footing to exist for traditional healing vis-a`-vis biomedicine.

2.1

INTRODUCTION

At the dawn of the twenty-first century, in the Western world and the United States in particular, the use of complementary and alternative medicine (CAM) is booming (Eisenberg et al., 1998, Vincent and Furnham, 1997). What attracts people to it is its

Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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holistic approach to health and disease, which is more congruent with patients’ expectations and needs (Astin, 1998). At the same time frustration and disillusionment with the way allopathic medical services are provided are increasing. In 2004, the total out-ofpocket expenditures incurred by US patients in CAM treatment were estimated at $40 billion. In this context, structured research efforts on complementary and alternative medicine, as well as their funding, have been growing steadily. Understandably, the scientific community is interested in documenting CAM therapeutic safety, efficacy, effectiveness and validity (Walach et al., 2002). A neglected aspect of the increasing popularity of CAM is its impact on nonWestern societies (Numrich, 2005; Struthers and Nichols, 2004). Many healing techniques, herbs and animal products are imported to the Americas and are being integrated as exotic alternative medicines (Napolitano and Flores, 2003; Tyler, 2000). Some traditional practitioners are leaving their countries and coming to the United States as immigrants (Reiff et al., 2003). Therefore, the question of cultural appropriation by an economically powerful society needs to be raised. In addition, very rich and complex, non-Western traditional healing systems are being merged into one single label, namely ‘complementary and alternative medicine’ (Saunders, 2003). Important implications derive from the use of CAM concepts for referring to the traditional healing systems of the Indigenous peoples of the Americas, such as perpetuation of colonialist or paternalistic research agendas promulgated within Indigenous communities (Fink, 2002). The traditional healing practices of the Indigenous peoples of the Americas and, indeed, the world, have been subject to well over a century of scrutiny, primarily anthropological and biomedical. These practices have also been subjected to malevolent influences, including purposeful assimilation, annihilation, censure and research. Further, as Waldram (2000) points out, much of the research into traditional healing practices has often been characterized by vagueness, bias, insensitivity and the application of inappropriate methods. In many cases the source of these difficulties is the lack of Indigenous researchers’ and communities’ involvement in the conceptualization, design, implementation, conduct and interpretation of the research, or a combination of these factors in the research process; for too long, investigation of Indigenous healers and traditional medicine has stemmed from an ‘etic’, or outsider’s perspective, when more of an ‘emic’, or insiders’ orientation, is what has been needed. It is therefore somewhat ironic that for much of the past century, and especially since the 1970s, academics, governments, international entities such as the World Health Organization, non-governmental organizations and many others have intensely debated the issue of integration and/or collaboration between traditional Indigenous healing systems and Western, biomedical systems. This question has been and continues to be dealt with from China and India to sub-Saharan Africa, to North and South America. A common feature of the majority of these efforts has been an effort to marginalize and subordinate the Indigenous healing system to the biomedical system, often inadvertent if not intentional. In this chapter the author, a Lakota Sioux physician and epidemiologist, will place the traditional healing practices of the Lakota Sioux of the Northern Plains of the United States within this larger context. From this vantage point some closely related contextual issues may be examined, allowing for key impediments in such integration/collaboration efforts to be explored and discussed.

RESEARCH ON INDIGENOUS HEALING IN THE AMERICAS

2.2

15

DEFINITIONS

2.2.1 Traditional Medicine Traditional medicine is a collective term used to describe the systems of medicine and healing that were developed before scientific medicine, largely by Indigenous peoples, and that are still in use today. Inherent in this definition is the notion that a traditional medicine system derives from language, behaviors and beliefs; that is the culture of the people with whom the system is associated (Ataudo, 1985). The World Health Organization (2000) defines traditional medicine as follows: Traditional medicine is the sum total of the knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.

2.2.2 Complementary and Alternative Medicine Complementary and alternative medicine consists of therapies that have been created more recently and generally by individuals or small groups of clinicians or scientists, often in opposition to Western biomedicine (Cardini et al., 2006). The World Health Organization (2000) has also described complementary and alternative medicine. The terms ‘complementary medicine’ or ‘alternative medicine’ are used interchangeably with traditional medicine in some countries. They refer to a broad set of health care practices that are not part of that country’s own tradition and are not integrated into the dominant health care system.

2.3

RESEARCH ON INDIGENOUS HEALING IN THE AMERICAS

Ethnographic research on Indigenous healing and healers in America is abundant (Aberle and Moore, 1991; Bastien, 1987; Csordas, 2000; Jilek, 1982; Kiev, 1964; Maddox, 1977; Merkur, 1985; Miller, 1992; Robinson, 1979). As Maldonado has pointed out (2001), research on this subject has most often covered aspects of the therapeutic process, ranging from descriptions of the multiple roles of healers to the study of their mental status, doctorhealer collaborations between healers and physicians/scientists, to descriptions of patients seeking healers’ services. It is worth noting that until recently these studies have been conducted almost entirely by Western, non-Indigenous researchers who are frequently viewed as outsiders with personal career and financial interests as their paramount concerns, and with little commitment to solving Indigenous peoples’ health problems (Boyer, 1961; Kim and Kwok, 1998; Martinek, 1999; Silverman, 1967). Studies performed by Indigenous researchers trying to understand health issues and healing practices from within their respective cultures have been infrequent and badly needed. The situation is slowly changing, however. Over the last several decades, and especially in the past ten years, American Indian researchers have significantly contributed to our understanding of the nature of disease, illness prevalence, risk and protective factors, and

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LEGITIMACY AND CONTEXTUAL ISSUES

culturally adapted preventive intervention strategies that work for American Indian communities. Their culturally sensitive epidemiological and clinical work has been important and often invaluable (Duran and Duran, 1995; Garroutte et al., 2003; Henderson et al., 2004; Manson, 1982; Manson et al., 1985; Roubideaux et al., 2004; Roubidoux et al., 1998).

2.4

TRADITIONAL LAKOTA SIOUX HEALING

The Indigenous peoples of the Americas have developed and used their rich and diverse traditional medicine systems for millennia. The widespread use of these systems has continued even during the last five centuries of contact with European cultures. In the last century biomedicine has exerted a major influence on North American Indigenous peoples (Rhoades, 2000). In South Dakota, the traditional healing practices of the Lakota Sioux have survived and are experiencing a contemporary renaissance, particularly since passage of the American Indian Religious Freedom Act in 1978 (American Indian Religious Freedom Act of 1978). A common trait of the Indigenous peoples of the Americas is that they frequently use both traditional and Western medicine at the same time (Rhoades, 2000; Young, 1988). The traditional healing system of the Lakota Sioux is fairly typical of most traditional healing systems in that a holistic view of health and wellness is subscribed to, with disease felt to stem from an imbalance within the patient-client. This imbalance between people’s physical, emotional and spiritual aspects can have multiple causes, including physical injury, taboo violation, various other types of misbehavior, spirit loss, and sorcery or conjuring. There are a variety of traditional healers among the Lakota, though fewer today than in the past. Regardless of their type, they all view themselves as ‘mediums’ through which the sacred spirits effect the healing. In the present day a distinction is generally made between healers that operate more or less exclusively in the realm of the spirits, or Wicasa Wakan (literally, ‘holy man’), and healers who use plant and/or animal-based medicines, or Pejuta Wicasa (literally, ‘medicine man’). The author is currently conducting an ethnographic study with traditional Lakota healers of both types, underscoring the contemporary distinction. However, simply said there are several different subtypes of Wicasa Wakan, classified according to their specialization, including several kinds of ‘curers’, ‘performers’, conjurers and magicians, and prophets (Lame Deer and Erdoes, 1992; Powers, 1992; Walker et al., 1980). Many healers are specialists who practice only one of these subtypes. However, a Wicasa Wakan, when referred to specifically instead of generically, is generally considered the most advanced form of traditional Lakota healer (Lame Deer and Erdoes, 1972, 1992), as they are able to perform most of the rituals and ceremonies associated with these various subtypes, and can often heal with herbs like a Pejuta Wicasa.

2.5

RENEWED INTEREST IN TRADITIONAL MEDICINE

In the late 1970s the World Health Organization (WHO) became very interested in traditional medicine, particularly with regard to the manpower reserve which traditional providers represented relative to the WHO’s big drive toward an international Primary

REPHRASING A TYPICAL QUESTION

17

Health Care model. In 1978, at the historic International Conference on Primary Health Care, held in Alma-Ata, USSR, the WHO recommended that governments place high priority on the use of traditional medicine practitioners and traditional birth attendants, and incorporate proven traditional remedies into the contemporary, biomedical setting. WHO and the Pan American Health Organization (PAHO) have maintained an optimistic and respectful attitude toward traditional medical systems in the Americas, despite the fact that many Latin American countries largely ignored WHO’s recommendations. For the last 20 years both WHO and PAHO have recommended that countries integrate traditional medicines in their respective national health care systems. The WHO Strategy for Traditional Medicine for 2002–2005 is largely focused on the safety, efficacy and quality of traditional healing practices worldwide (World Health Organization, 2002). The primary objectives of this Strategy, not yet superseded, are to encourage and support countries in their efforts to: (i) integrate traditional medicine within national health care systems; (ii) promote the safety, efficacy and quality of traditional medicine; (iii) increase the availability and affordability of traditional medicine for poor populations; and (iv) promote therapeutically sound use of appropriate traditional medicine by providers and consumers. The first of these goals, that of the integration of traditional medicine with national health systems (i.e. regulation), has received a lot of thoughtful analysis and commentary, especially in Africa, China, India and New Zealand. In sub-Saharan Africa, this dialogue has been propelled ahead because of the impact of the HIV/AIDS epidemic (Green et al., 1995; Homsy et al., 2004; Kaboru et al., 2006; Kayombo et al., 2007). More recently, concerns over the exploitative nature of ethnopharmacology have fuelled debate (Mgbeoji, 2006).

2.6

REPHRASING A TYPICAL QUESTION

Most prior attempts to integrate traditional medicine with allopathic approaches have primarily asked the question thus: What aspects of traditional medical systems should we incorporate into the biomedical setting? One can appreciate in the way that this question is phrased that the traditional medical system is being placed in a subordinate position to the biomedical system, implicitly questioning the traditional system’s legitimacy. Another core assumption implicit in this question relates to the conviction that biomedicine is right, that it is ‘scientific’ and highly reliable, and applicable to all people. Traditional healers, similarly, can also sense these fundamental biases. As the dominant paradigm for health care in much of the world, biomedicine can certainly survive having this question rephrased: What aspects of biomedicine should be accepted or allowed into the realm of traditional healing systems? One can now easily appreciate in the way this question is worded the legitimation and validation of traditional medicine. I used a PowerPoint presentation to present this concept in 1998, in a Medical Grand Rounds presentation at the Mayo Clinic, in Rochester, Minnesota (Henderson, 1998). To say that this discussion went over the heads of most of the 500+ faculty, fellows and students in the lecture hall that morning would be a gross understatement. Imagine my surprise, then, when after my talk I was enthusiastically approached by a group of 20–40 doctors and students, nearly all of whom were persons of color and most of whom were foreign-born. For them the relevance of these questions was very clear in their home countries.

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LEGITIMACY AND CONTEXTUAL ISSUES

The essential question is twofold: what is the nature of the integration that is to take place, and by whose standards will we judge the systems being integrated? Or, alternatively, we might discard altogether the notion of integration and focus instead on collaboration. At any rate, numerous scholars have pointed out that traditional medicine and biomedical systems are fundamentally different systems that cannot and should not be directly compared (Fan, 2003; Fink, 2002; Tangwa 2007). As discussed below, I contend that an essential component of the fundamental differences between traditional medicine systems and biomedicine is that each derives its legitimacy from different orientations. To sum up the topic of rephrasing a typical question, I am pleased to see that several authors have more recently taken up the ‘integration’ issue. Very recently, both Tangwa (2007) and van Bogaert (2007) echoed the question while debunking a blanket negation of African traditional healing by Nyika (2007) in the context of HIV/AIDS. Tangwa sums up the situation thus: Shisong hospital (and there are many similar Western style hospitals in the same region) is, of course, only one possible face of Western scientific medicine in the African context. Other possible faces look quite unattractive, conjuring up the spectre of a complete takeover of peoples’ lives and healthcare by a powerful, self-righteous system, the building pillars/underpinnings of which include colonization, exploitation and monopoly, and putting healthcare beyond the reach of the vast majority of the people.

Fan and Holliday (2007), too, address this essential question when discussing the situation in China: Against those who take the dominance of MSM (mainstream medicine) for granted, we argue that in order to develop an appropriate integrative system for MSM and TM (traditional medicine), it is first necessary to explore two fundamental questions. Which medicine should be emphasized? Whose medical standard should be adopted?

2.7

ISSUES WITH LEGITIMACY

MacCormack (1981) was apparently the first scholar to directly relate the classic Weberian Theory of Legitimate Rule to traditional medical systems, an analytic approach that I find especially compelling. The influential German political economist and sociologist, Maximilian Carl Emil Weber, established the classic theory of legitimate rule (Mommsen, 1989). Weber theorized that there exist three types of legitimacy: charismatic, traditional and rational-legal. Charismatic legitimacy derives primarily from the personality and leadership qualities (i.e. charisma) of the individual, traditional legitimacy from time-honored tradition, and rational-legal legitimacy through rule-making that is applied administratively and judicially to all members of the group. Weber theorized each type as a pure type existing only in certain societies, but acknowledged that in practice most leaders derive their legitimacy through a combination of these pure types. Weber goes on to describe that charismatic authority is unstable over time, while traditional authority is subject to challenge and revolution (Bendix, 1977). Thus, Weber theorized that over time there is an inevitable shift toward a rational-legal authority type in most societies. Herein

ISSUES WITH LEGITIMACY

19

lay several important observations for traditional medicine practitioners, systems and advocates. Firstly, government and biomedicine, each predicated upon a rational-legal form of legitimacy, represent ‘official knowledge’. In most settings this has been and frequently continues to be contrasted with traditional or ‘unofficial’ practices. When these two domains first interact or interface, and often for a long time thereafter, the former will generally know little about, or even disavow, knowledge of the latter. This stance serves to further ensure the legitimacy of biomedicine while simultaneously marginalizing traditional practices and practitioners. The relatively recent post-colonial dynamic in many African countries and elsewhere has been to perpetuate this situation when the new post-colonial government largely adopted and continued much of the colonial-era legal framework. South Africa, despite having gained its independence from Britain in 1910, and having overthrown apartheid in 1990, followed by Nelson Mandela’s election as president in 1994, only legalized the practice of its traditional healers in August, 2004. The ‘legalization’ of traditional healing implies in some sense its legitimization (and institutionalization), and as Fassin and Fassin point out ‘he who legitimates gets renewed legitimacy himself’ (1988, p.355). An example of this corollary would be the academic or fringe biomedical practitioner who receives funding to document and/or catalog traditional practices, and in so doing realizes personal acclaim, career advancement and subsequent renewed legitimacy in the eyes of his peers/department/ institution/agency. Both government and biomedicine are very experienced in creating new forms of legitimacy, which in turn produce new authorities for legitimation. An example of this would be the new governmental unit created to register, oversee, train and/or carry out a certification process for newly legalized traditional healers. Nearly all countries that are recognized to have Indigenous populations today, have such oversight bodies for traditional healing, many created long ago. In the United States there are numerous examples of this dynamic in the biomedical field, including the US Preventive Services Task Force (Anon.), which promulgates ‘evidence-based’ clinical guidelines on the use of many types of preventive services; the Joint Commission on Accreditation of Hospital Organizations (Anon.), the now-dominant accreditation body for multiple aspects of the health care delivery enterprise; and the numerous peer-review organizations that were created by Medicare in the 1980s (Dettmann, 1995). Lest we lose sight of the traditional healers in this discussion, it should be pointed out that not all the actors in this play necessarily have something to gain with a change in legitimacy status. The widely acclaimed, venerable old traditional healer has little need for rationallegal legitimacy. Indeed, her/his efforts to go in this direction may jeopardize her/his traditionally legitimate standing in her/his community. Similarly, the longstanding, highly-esteemed Dean of Medicine at the medical school has no need to strive for traditional legitimacy. Conversely, charlatan traditional healers, who by definition have little inherent traditional legitimacy, potentially have a lot to gain by a change in the rules. For example, a new certification process for traditional healers, ideally requiring some measure of literacy and numeracy skills, might be just the thing that charlatans, often with some formal education, would seek in order to establish or extend their foothold in the traditional healing structure. Alternatively, and to much the same effect vis-a`-vis the charlatans, the

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LEGITIMACY AND CONTEXTUAL ISSUES

venerable traditional healer might simply refuse to play by these new sets of rules. Bichmann (1979, p.178) long ago summed up the crux of the matter: Therefore ‘integration of traditional healers’ in modern health services is considered to be possible only after initial training and under permanent supervision. Programmes of ‘integration’ of traditional and cosmopolitan medicine, as it were, are intended for the establishment of the superiority of cosmopolitan medicine by supervising the activities of traditional practitioners. Not all of these are prepared to accept this: on the contrary, the social status of a traditional healer within their given culture is in most cases likely to be higher than the one they can achieve through recognition by the public health administration and their integration into the national health system as an ‘auxiliary’!

Traditional Lakota Sioux healers derive all or most of their legitimacy through traditional means (Crow Dog and Erdoes, 1995; Lame Deer and Erdoes, 1992; Mohatt and Eagle Elk, 2000). They are generally lifelong members of their communities, their work and its efficacy has been witnessed and acknowledged in their communities over time, and they most often have had their special talent passed to them through a patrilineal line. It is certainly the case that with respect to their actual practice of traditional medicine, there is little or no legitimacy derived through rational-legal means. They have not passed a standardized examination pertaining to their healing art, nor obtained a licensure certificate that hangs on their wall, nor received a provider code for reimbursement, nor applied for a license in order to dispense therapies. Yet, there are clearly legitimate traditional Lakota healers, just as there are also charlatans. Indeed, as previously noted it is often the case that the charlatans do have some rational-legal manifestations of their supposed legitimacy.

2.8

REIMBURSEMENT FOR TRADITIONAL HEALING SERVICES IN THE UNITED STATES: WHAT ARE WE GETTING OURSELVES INTO?

An examination of the role that legitimacy plays in the ever-changing tapestry that is the interface between traditional healing and biomedicine in the United States is important for policy, as well as health promotion/disease prevention-related reasons. In April 1998, the US Veterans Administration developed a policy whereby Navajo veterans could be reimbursed for care they received from Navajo traditional healers for specified conditions (Donovan, 1998). This policy is being closely watched and evaluated by other third-party payors, among them the Indian Health Service, which for the past decade has been facilitating regional dialogues with traditional healers about a variety of issues, including reimbursement. While the Veterans Administration moves forward and the Indian Health Service watches, the states of New Mexico and Arizona have been providing reimbursement for traditional healing services as part of their victim reparation programs (U.S. Indian healers ‘‘cheaper’’ than psychological therapy, 2001). Officials of these programs believe that these services are effective, but primarily they note they are utilized for very limited durations – the majority of case-episodes are for a single encounter – and are less expensive than lengthy, traditional psychological treatments. Even Health Canada’s Medical Services Branch in the province of Ontario has been providing reimbursement for several years for traditional healing services delivered at one of thirteen designated ‘Aboriginal Health Access Centres’ across Ontario

CONCLUSION

21

(Ontario Aboriginal Health Advocacy Initiative (OAHAI) Resource Manual: Traditional Healers, 1999). To understand the potential magnitude of this issue it should be noted that reimbursement for traditional healing was also discussed by the Centers for Medicare & Medicaid Services in its consultation meetings with Tribes during 1999 (American Indian and Alaska Native beneficiaries: current issues and news, 2000). As has been seen with a variety of so-called complementary and alternative therapies, reimbursement dramatically increases accessibility. There is evidence to suggest this would occur with respect to traditional healing. A 2001 study of mental health service utilization by reservation-based American Indian veterans in two tribes revealed that use of both traditional American Indian and mainstream medical services was common (Gurley et al., 2001). Overall, the veterans used both types of services much less for mental health problems than for physical health problems. IHS facilities were equally available to both tribes, but Veterans Administration services were available more readily to one of them. Within the tribe with less access to Veterans Administration services, more traditional healing services were both available and used, so that overall, similar amounts of care were received. Though this scenario did not involve payment coverage for traditional healing, an instructive point is raised. It is the minority of the approximately 560 federally-recognized tribes that have managed to preserve some degree of their traditional healing practices. To the extent that third-party coverage for traditional healing practices becomes realized, geographic, rather than financial, barriers to access will become a more prominent issue. Add to this the fact that many Federal agencies are keen to evaluate the efficacy of traditional therapies, including the National Institutes of Health, along with academic institutions and third-party payors, and it becomes easy to predict that the issue of traditional healer use by American Indians/Alaska Natives will be one of growing, not receding, importance. Third, several states, including Florida, are categorizing American Indian traditional healing within their faith-based organizational structure and/or initiatives. Florida in particular, through the Substance Abuse & Mental Health Services Administration’s Access to Recovery initiative, has considered under what circumstances it would reimburse traditional healers for care provided (LaCour and Daigle). However, a prominent set of questions arise when exploring the possibility of reimbursement for traditional healing practices. Though different states and third-party payors have slightly different versions of these questions, they revolve around whether traditional healing practices and providers have been standardized, credentialed and quantified for reimbursement purposes. As an example, an Access to Recovery-eligible provider requires standards and quantifiable units of care. Thus, a myriad of issues is raised with respect to traditional healing including legitimacy and, by extension, charlatanism; the ability of state and other third-party payors to treat these sensitive practices with cultural competence and flexibility within the rules; the role of tribes in an era of increasing self-governance over health affairs; and the extent to which non-federally recognized tribes may benefit. These and related issues are prime candidates for future consideration and research.

CONCLUSION Traditional healing systems have not only survived, but in some cases have been rejuvenated, even in the United States, one of the world’s most developed countries. When considering the interface of traditional healing systems and biomedicine, the very nature

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LEGITIMACY AND CONTEXTUAL ISSUES

and structure of the dialogue itself is of great importance. Many of the issues that relate to this interface, and discussions of ‘integration’ or ‘collaboration’, which are frequently cast in terms of ‘power’ relationships, can be seen to emanate from a conflict between each system’s underlying sources of legitimacy. Both biomedicine and traditional medicine systems coexist within the pluralistic structure that is our ‘medical system’. In the process of legitimation, we need to be conscious of the needs, motives and profits of all the different actors, especially where the rational-legal legitimation of traditional healers is concerned. While this chapter has not focused on an examination of the many actual examples of how this collaboration may be realized, for better and for worse, our ultimate goal might remain essentially unchanged from that first espoused by MacCormack (1981, p.428) over 25 years ago: This model has suggested a solution which maintains both traditional and Westernized medical systems in a symbiotic relationship where the two are loosely linked and neither controls the other. One continues its emphasis on technological methods for successful curing of certain complaints, and the other continues to follow traditional – but changing – wisdom in restoring a sense of well being to whole people in social groups.

REFERENCES Aberle, D.F. and Moore, H.C. (1991) The Peyote Religion Among the Navaho, University of Oklahoma Press, Norman. American Indian and Alaska Native beneficiaries: Current issues and news 2000, Centers for Medicare & Medicaid Services, Available at: http://www.cms.hhs.gov/aian/summiss.asp [Accessed 26 August 2004]. American Indian Religious Freedom Act of 1978. 42 USC 1996 (orig. Public Law 95–341, August 11, 1978). Astin, J.A. (1998) Why patients use alternative medicine: results of a national study. JAMA, 279, 1548–53. Ataudo, E.S. (1985) Traditional medicine and biopsychosocial fulfillment in African health. Soc Sci Med, 21, 1345–7. Bastien, J.W. (1987) Healers of the Andes: Kallawaya Herbalists and Their Medicinal Plants, University of Utah Press, Salt Lake City. Bendix, R. (1977) Max Weber: an Intellectual Portrait, University of California Press, Berkeley. Bichmann, W. (1979) Primary health care and traditional medicine: considering the background of changing health care concepts in Africa. Soc Sci Med [B], 13, 175–82. Boyer, L.B. (1961) Remarks on the personality of shamans. Psychoanalytic Study of Society, 2, 233–54. Cardini, F., Wade, C., Regalia, A.L. et al. (2006) Clinical research in traditional medicine: priorities and methods. Complem Therap Med, 14, 282–7. Crow Dog, L. and Erdoes, R. (1995) Crow Dog: Four Generations of Sioux Medicine Men, HarperCollins Publishers, New York. Csordas, T.J. (2000) The Navajo healing project. Med Anthropol Q, 14, 463–75. Dettmann, F.G. (1995) The origins and evolution of peer review organizations. Jt Comm J Qual Improv, 21, 322–4. Dine´ Bureau. VA to expand coverage for traditional ceremonies (2006) The Gallup Independent. http://www.gallupindependent.com/2006/jun/061906vatrdcrm.html. Donovan, B. (1998) VA gives Navajo care the OK. The Arizona Republic, April 8, Special. Duran, E. and Duran, B. (1995) Native American Postcolonial Psychology, State University of New York Press, Albany, NY.

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Eisenberg, D.M., Davis, R.B., Ettner, S.L. et al. (1998) Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA, 280, 1569–75. Fan, R. (2003) Modern western science as a standard for traditional Chinese medicine: a critical appraisal. J Law Med Ethics, 31, 213–1. Fan, R. and Holliday, I. (2007) Which medicine? Whose standard? Critical reflections on medical integration in china. J Med Ethics, 33, 454–61. Fassin, D. and Fassin, E. (1988) Traditional medicine and the stakes of legitimation in Senegal. Soc Sci Med, 27, 353–7. Fink, S. (2002) International efforts spotlight traditional, complementary, and alternative medicine. Am J Public Health, 92, 1734–9. Garroutte, E.M., Goldberg, J., Beals, J. et al. (2003) Spirituality and attempted suicide among American Indians. Soc Sci Med, 56, 1571–9. Green, E.C., Zokwe, B. and Dupree, J.D. (1995) The experience of an AIDS prevention program focused on South African traditional healers. Soc Sci Med, 40, 503–15. Gurley, D., Novins, D.K., Jones, M.C. et al. (2001) Comparative use of biomedical services and traditional healing options by American Indian veterans. Psychiatry Serv, 52, 68–74. Henderson, J.A. (1998) The healing journey: Perspectives on traditional healing. Presented at Medical Grand Rounds at The Mayo Clinic, February 1998, Rochester, MN. Henderson, P.N., Rhoades, D., Henderson, J.A. et al. (2004) Smoking cessation and its determinants among older American Indians: the strong heart study. Ethn Dis, 14, 274–9. Homsy, J., King, R., Tenywa, J. et al. (2004) Defining minimum standards of practice for incorporating African traditional medicine into HIV/AIDS prevention, care, and support: a regional initiative in eastern and southern Africa. J Altern Complement Med, 10, 905–10. Jilek, W. (1982) Indian Healing Shamanic Ceremonialism in the Pacific Northwest Today, Hancock House, Surrey, BC, Blaine, WT. Kaboru, B.B., Falkenberg, T., Ndubani, P. et al. (2006) Can biomedical and traditional health care providers work together? Zambian practitioners’ experiences and attitudes towards collaboration in relation to STIs and HIV/AIDS care: a cross-sectional study. Hum Res Health, 4, 16. Kayombo, E.J., Uiso, F.C., Mbwambo, Z.H. et al. (2007) Experience of initiating collaboration of traditional healers in managing HIV and AIDS in Tanzania. J Ethnobiol Ethnomed, 3, 6. Kiev, A. (1964) Magic, Faith, and Healing; Studies in Primitive Psychiatry Today, Free Press of Glencoe, New York. Kim, C. and Kwok, Y.S. (1998) Navajo use of native healers. Arch Intern Med, 158, 2245–9. LaCour, J. and Daigle, J. Outreach to Faith-Based Organizations: Access to Recovery Regional Technical Assistance, DHHS/Substance Abuse & Mental Health Services Administration. A presentation available on-line at: http://atr.samhsa.gov/downloads/elig_prov_LaCourDaigle.pdf [Accessed 26 August 2004]. Lame Deer, A.F. and Erdoes, R. (1992) Gift of Power: The Life and Teachings of a Lakota Medicine Man, Bear & Co, Santa Fe, NM. Lame Deer, J.F. and Erdoes, R. (1972) Lame Deer, Seeker of Visions, Simon and Schuster, New York. MacCormack, C.P. (1981) Health care and the concept of legitimacy. Soc Sci Med [B], 15, 423–8. Maddox, J.L. (1977) The Medicine Man: A Sociological Study of the Character and Evolution of Shamanism, AMS Press, New York. Maldonado, M.G. (2001) Are Yachactaitas (quichua healers) good diagnosticians? WPA-TPS Newsletter, 19 (2), 11–3. Manson, S.M. (ed.) (1982) New Directions in Prevention Among American Indian and Alaska Native Communities, Oregon Health Sciences University, Portland. Manson, S.M., Shore, J.H. and Bloom, J.D. (1985) The depressive experience in American Indian communities: A challenge for psychiatric theory and diagnosis, in Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder, (ed. A. Kleinman) University of California Press, Berkeley. Martinek, C.R. (1999) Collaborating with native healers. Adv Nurse Pract, 7, 84. Merkur, D. (1985) Becoming Half Hidden: Shamanism and Initiation Among the Inuit, Almqvist & Wiksell International, Stockholm.

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Metraux, A. (1949) Religion and shamanism, in Handbook of South American Indians – the Comparative Ethnology of South American Indians, 5th edn (ed. J.H. Steward) United States Government Printing Office, Washington, DC. Mgbeoji, I. (2006) Global Biopiracy: Patents, Plants and Indigenous Knowledge, UBC Press, Vancouver. Miller, J. (1992) Native healing in Puget Sound. Caduceus, 8, 1–15. Mohatt, G.V. and Eagle Elk, J. (2000) The Price of a Gift: A Lakota Healer’s Story, University of Nebraska Press, Lincoln. Mommsen, W.J. (1989) The Political and Social Theory of Max Weber: Collected Essays, University of Chicago Press, Chicago. Napolitano, V. and Flores, G.M. (2003) Complementary medicine: cosmopolitan and popular knowledge, and transcultural translations – cases from urban Mexico. Theory Culture Society, 20, 79–95. Numrich, D.P. (2005) Complementary and alternative medicine in America’s ‘two Buddhisms’, in Religion and Healing in America, (eds L. Barnes and S. Sered) Oxford University Press, London. Nyika, A. (2007) Ethical and regulatory issues surrounding African traditional medicine in the context of HIV/AIDS. Dev World Bioeth, 7, 25–34. Ontario Aboriginal Health Advocacy Initiative (OAHAI) Resource Manual: Traditional Healers 1999, Ontario Federation of Indian Friendship Centres. Available at: http://www.ofifc.org/ oahai/acrobatfiles/tradhlth.pdf [Accessed 26 August 2004]. Powers, W.K. (1992) Sacred Language: The Nature of Supernatural Discourse in Lakota, University of Oklahoma Press, Norman. Reiff, M., O’Connor, B., Kronenberg, F. et al. (2003) Ethnomedicine in the urban environment: Dominican healers in New York City. Hum Org, 62, 12–26. Rhoades, E.R. (2000) American Indian Health: Innovations in Health Care, Promotion, and Policy, Johns Hopkins University Press, Baltimore. Robinson, S.S. (1979) Toward an Understanding of Kofan Shamanism, Cornell University, New York. Roubideaux, Y., Buchwald, D., Beals, J. et al. (2004) Measuring the quality of diabetes care for older American Indians and Alaska natives. Am J Public Health, 94, 60–5. Roubidoux, M.A., Kaur, J.S. and Giroux, J. (1998) Mammographic findings and family history risk for breast cancer in American Indian women. Cancer, 83, 1830–2. Saunders, P.R. (2003) Complementary and alternative medicine in Canada: what is the future? HealthCarePapers, 3, 43–9. Silverman, J. (1967) Shamans and acute schizophrenia. Am Anthrop, 69, 21–31. Struthers, R. and Nichols, L.A. (2004) Utilization of complementary and alternative medicine among racial and ethnic minority populations: implications for reducing health disparities. Annu Rev Nurs Res, 22, 285–313. Tangwa, G.B. (2007) How not to compare western scientific medicine with African traditional medicine. Dev World Bioeth, 7, 41–4. Tyler, L. (2003) Understanding Alternative Medicine New Health Paths in America, Haworth Herbal Press, Binghamton, NY. van Bogaert, D.K. (2007) Ethical considerations in African traditional medicine: a response to Nyika. Dev World Bioeth, 7, 35–40. Vincent, C. and Furnham, A. (1997) Complementary Medicine: A Research Perspective, Wiley, Chichester. Walach, H., Jonas, W.B. and Lewith, G.T. (2003) The role of outcomes research in evaluating complementary and alternative medicine. Altern Ther Health Med, 8, 88–95. Waldram, J.B. (2000) The efficacy of traditional medicine: current theoretical and methodological issues. Med Anthropol Q, 14, 603–25. Walker, J.R., DeMallie, R.J. and Jahner, E. (1980) Lakota Belief and Ritual, University of Nebraska Press, Lincoln. Young, T.K. (1988) Health Care and Cultural Change: The Indian Experience in the Central SubArctic, University of Toronto Press, Toronto.

CHAPTER 3

Doctor-Patient Relationship in Psychiatry: Traditional Approaches in India Versus Western Approaches Vijoy K. Varma Indiana University School of Medicine, Indianapolis, IN, USA

Nitin Gupta South Staffordshire and Shropshire, Healthcare NHS Foundation Trust, Burton on Trent, Staffordshire, UK

Abstract Modern clinical psychiatry has emerged from central Europe at the Victorian epoch and it imbibed the cultural ethos and norms of that context. Health care is conceived to address specific needs and the doctor-patient relationship follows European and North American norms based on formality, distance between individuals, confidentiality, etc. In contrast to the West, in traditional societies all relationships are multi-dimensional and the doctor is viewed as a guide who will help in the person’s total growth and not just in the narrow confines of illness. Examining the psycho-cultural variables relevant to the doctor-patient relationship, this chapter compares the Western doctor-patient relationship to the one found in traditional societies like India. It concludes by underlining the importance of gaining knowledge of cross-cultural differences in the doctor-patient relationship, so that various cultures can benefit from each other’s models and experiences. Words of comfort, skilfully administered, are the oldest therapy known to man. Louis Nizer, American trial lawyer, in ‘‘My Life in Court’’, (1961)

3.1

INTRODUCTION

For millennia, traditional healers have been providing therapy for the mentally ill. Although Western-trained psychiatrists have supplanted and formalized their work, it has been Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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pointed out that the traditional healers may have been just as effective. One of the important aspects of healing practices is how patients and healers relate to each other. This chapter discusses and compares the doctor-patient relationship in a traditional approach as practiced in India, and what developed as the formal Western-model of psychotherapy. Modern clinical psychiatry developed, along with psychoanalysis and psychotherapy, at a particular epoch in history in a certain part of the world. The setting was central Europe and the age Victorian. It was subsequently extrapolated to North America, and only much later to other parts of the globe. As such, it imbibed the cultural ethos and norms and the social mores and organization of the era and the place of its inception. The doctor-patient relationship also developed from the social and professional relationships current at the time and place. It took from the European and North American norms. Particularly, it derived from a social relationship, based on formality, distance between individuals, individual autonomy with self-rights and prerogatives, and the cultural concept of confidentiality. Health care became formalized and professionalized to address only the specific needs. The doctor-patient relationship varies from culture to culture. At least to a certain extent, it derives from social inter-relationships in the society. Some societies have a more informal, open system of social interactions than others. Almost by definition, the traditional societies of the developing countries have a more informal, open system in which individuals feel freer to interact with each other. Social relationships are easier, freer. On the other hand, in the developed societies of the West, interpersonal relationships are more fixed and formalized. As opposed to the West, in the traditional societies of Asia and Africa, all relationships are multi-dimensional, serving a myriad of functions. The same applies to the doctorpatient relationship. The doctor has been and remains a friend, philosopher and guide, a wise person, a village elder and a benevolent senior, but also a surrogate family member. His objective is to help in all possible ways, in total growth, development and actualization, and not just in the narrow confines of the illness. Before we come to the doctor-patient relationship, a few general issues need to be discussed. In this chapter, we are discussing the doctor-patient relationship in the context of psychotherapy in particular. As such, we need to understand psychotherapy, and its transcultural underpinning.

3.2

PSYCHOTHERAPY: DEFINITIONS AND COMMON CONCEPTS

Psychotherapy has been defined in numerous ways. Probably the most popular and widely used definition is by Wolberg (1967). He defines psychotherapy as ‘the treatment by psychological means, of problems of an emotional nature, in which a trained person deliberately establishes a professional relationship with the patient with the object of removing, modifying or retarding existing symptoms, of mediating disturbed patterns of behaviour and, of promoting positive personality growth and development’ (Wolberg, 1967). Certain other definitions of psychotherapy, relevant for our topic, are as follows: ‘For a very simple, simplistic definition, one can say that psychotherapy is the utilization of psychological measures in the treatment of sick people’ (Romano, 1947). ‘Psychotherapy may be defined as the treatment of emotional and personality problems and disorders by psychological means’ (Kolb, 1968).

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‘Psychotherapy is a form of help in which a trained, socially sanctioned healer tries to relieve a sufferer’s distress by facilitating certain changes in the feelings, attitudes and behaviour, through the performance of certain activities with him’ (Frank, 1961). It is obvious, going by the above definitions, that there is a wide agreement that psychotherapy relates to psychological, as opposed to organic, methods of treatment. Again, it is addressed to problems of an emotional or psychological nature. However, in the transcultural perspective, it seems that there are still differences in who can be a therapist – his qualifications and calling – and the degree to which the relationship is structured and deliberate. The definitions differ from each other in terms of deliberateness of the therapeutic interaction, training and equipment of the therapist, and the objectives: whether only for treatment of an illness and/or for personality growth and self-actualization (viz. ancient Indian concepts).

3.3

WESTERN MODELS OF THE DOCTOR-PATIENT RELATIONSHIP

In the conventional Western model of psychotherapy the doctor-patient relationship is purely professional. A professional relationship is one which is engaged in for a specific clearly defined objective. The defined objective is the removal of the symptoms and morbidity resulting from a psychiatric illness. Of course, the objective could also include improving the well-being and social effectiveness of the patient. As opposed to the Western model, the healer-patient relationship in traditional societies is seldom limited as a purely professional one. In traditional societies, the doctor-patient relationship more closely approaches the primary group, filial relationship, with the patient’s dependency needs playing a greater role, demanding a more assertive, caring and empathic role for the doctor. It is an all-encompassing relationship approaching that seen in a primary group. It often involves the therapist assuming a number of filial roles, as a family elder and advisor. The therapist is often viewed as a parent or as a respected uncle. He/she assumes the powers and prerogatives as such and is accordingly given respect due to that station in the society. Sometimes the patient also views the therapist as a younger sibling or even a child, if that fulfils some emotional need. A primary group or filial relationship is one in which each member relates to every other in a myriad of possible ways. All family relationships are of this nature. For example, in the father-son relationship, the duties and responsibilities of the father are not clearly circumscribed, are never limited. He is supposed to do all that is needed from time to time.

3.3.1 Psychotherapy as a Contractual Relationship Karl Menninger has given a beautiful example of a professional ‘contractual’ relationship, the barber-client relationship. A barber is also a professional, whose only identified role is to give a haircut or a shave. The client enters into a ‘contract’ with the barber. The client approaches the barber, cooperates in the process and pays. The barber gives the haircut/ shave. He may, and often does, also provide the neighborhood gossip, but that is not the basic and defined purpose. You do not go to the barber just for the gossip. Any professional relationship is a formal relationship, with both parties maintaining specific social positions. Between a doctor and his/her patient, there exists a significant

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social distance. As opposed to this, members of a primary group maintain an informal relationship, which could vary depending on the immediate situation and need. For example, the father can alternate between being strict and tolerant. In traditional societies, the ‘professional relationship’ tends to strongly encompass the dimension of ‘filial relationship’, thereby not having the clear-cut boundaries that would be expected in the Western model. One other aspect of Western social order – and psychotherapy – is its emphasis on confidentiality. All that transpires remains a secret between the therapist and the patient. Lately, in the West, increasingly rigorous rules and guidelines have been implemented. In traditional societies, the concept of confidentiality has been different. The senior author (VKV) remembers that as a child in India, it was clearly conveyed to him that a person should not have secrets. If you have secrets, it appeared that you had something to hide. One of the principles of Mahatma Gandhi was that a person should not have secrets; it extolled virtues of complete transparency.

3.4

TRADITIONAL MODELS OF THE DOCTOR-PATIENT RELATIONSHIP

In India, as in many traditional societies and third world countries, there are a large number of persons who can be categorized as faith healers or religious healers. Their approach and treatment can be called psychological, in the larger context. They do treat psychiatric illnesses. Can we call it psychotherapy? Torrey (1972a, b) has pointed out the significant similarities between Western psychotherapy and faith healing. He has underscored that, in spite of apparent differences in the technique, the core therapeutic ingredients are remarkably similar. Wittkower and Warnes (1974) have commented on similarities between psychotherapies as practiced around the world. The similarities are particularly in: 1) an intense emotional and confiding relationship between the therapist and the patient, and 2) that they share a worldview. Lately, the therapeutic role of the interpersonal relationship has been brought into sharper focus in the therapeutic process. Frank (1968) and Abroms (1968) have emphasized the role of persuasion as a therapeutic ingredient. ‘We must assume that most, if not all, psychiatric patients are influenced to some extent by the demand character of the therapy situation and the implicit or explicit expectation of the therapist. . . .’ (Frank, 1968). Psychotherapy has had a long history and tradition in many Eastern traditional societies. This includes India where psychotherapy has been linked with Buddhist traditions. In the same way, cultures like those in ancient China, Korea and Japan have also had a long tradition in psychotherapy. Many of these approaches have been taken from Buddhism which originated in India and subsequently was transported to many countries in East and South Asia. At the same time, ancient Hindu traditions have largely influenced many countries and cultures in South-East Asia, including Thailand, Sri Lanka, Indonesia and others. However, as opposed to the Western model of psychotherapy, the Indian model has not been meant only, or even principally, as a method of treatment of sick people. As such, it did not follow a narrow medical model. On the other hand, psychotherapy was considered a part of and one of several mechanisms to guide people into the right path. It was intended to help them develop into mature adults attuned to the totality of social and moral values and

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mores and capable of realizing their full human potential. As such, it was practiced in a guru-chela (teacher-pupil) relationship, a paradigm of preceptorship. The methodology of psychotherapy was not only limited to talking about one’s illness or problems, but also to promote values that would contribute to the development of a better individual. Accordingly, emphasis was given to such things as a good code of conduct, being pious, one’s lifestyle (i.e. in manasa, vachha, karmanaa – in what we think, we say and do). The process of psychotherapy was not so much dialectical ‘where truth was reached or approached by debate between patient and therapist or within the heart of the patient’, but was more of a situation where truth was revealed by the patient and accepted by the patient. Some of the subsequent developments historically related to such goals as self-realization and self-actualization. It, thus, addressed our unique human needs and the goal of achieving full human potential. Traditional therapeutic approaches would be better for traditional cultures because of being culture-consistent. In many countries they are better accepted. Many such treatments are self-administered and cost-effective. In their landmark study, Varma and Ghosh (1976) found that the Indian psychotherapist had a relatively more active role than the Western counterpart: suggesting, sympathizing, manipulating the environment, teaching and reassuring. Indian psychotherapists also suggested departures from the Western model; pleading for greater flexibility, greater activity on the part of the psychotherapist, and greater use of suggestion and reassurances.

3.5

PSYCHO-CULTURAL VARIABLES RELEVANT TO THE DOCTOR-PATIENT RELATIONSHIP

3.5.1 Dependence Versus Autonomy In the Western context, psychotherapy is viewed as an interaction between two autonomous adults. Autonomy is much extolled as a personality variable. In psychotherapy, both the patient and the therapist are viewed as autonomous parties, responsible for their own decisions and conduct. Although socially different, they are both at about equal levels in terms of their responsibilities. Both the patient and the therapist are viewed as fully responsible for their acts. Although limited by the illness, and by its effects on their perceptions, emotions and interpersonal relations, the patient is still held accountable for their actions. The patient may be provided a full opportunity to examine their feelings and a course of action; they are still personally responsible for their actions. As compared to Western societies, it has been pointed out that the individual in traditional societies in the East develops a greater amount of dependence on the social milieu (Neki, 1976; Varma, 1985a; Varma, 1985b; Varma, 1988). It has been said that the Eastern man in developing countries is more dependent and less autonomous. In actual practice, in traditional Eastern societies, the child is more dependent on their parents. As they grow up, there is a greater amount of inter-dependence on peers. The interdependence continues between siblings, spouse, friends and co-workers. However, when the person becomes old and less able to look after their own needs they become, in turn, dependent on their children. Why does this occur? It may be hypothesized that in traditional Eastern societies, there is less clear compartmentalization of roles and responsibilities. In both personal and

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professional lives, a person is generally expected to be able to switch/modify their roles as the situation requires. Another explanation could be that in traditional societies (like India), a child grows up in a family where co-existence and co-dependence of functioning (especially at personal levels) with other family members is expected and probably the norm. Hence, even on achieving cognitive maturity or adult functioning, the person is not able to fully demarcate their ‘self’ from others, leading to possible lack of clear demarcation (and consequent blurring) of ego boundaries. On the other hand, the social inter-relationships in the technological advanced countries of the West are more characterized by individual autonomy ‘This is me and this is my body bounded by my epidermis. Everything within the layer of epidermis is me and I have, or I should have, complete control over it, over its needs, wishes and desires. I should assume full responsibility over my desires, emotions and actions. Just like I take full responsibility over myself, everybody should take full responsibility for himself or herself’. As such, the Western person develops with a keener sense of their individuality, rights, prerogatives and responsibilities. The Western model of psychotherapy places high emphasis on personal autonomy and responsibility. Accordingly, it needs to be examined how far such therapy could be applied to less autonomous and more dependant personalities and what modifications are required to adapt it to traditional societies. Beck (1987) suggested two dimensions of personality, sociotropy and autonomy (cited by Sato and McCann, 2007). His concept of sociotropy is virtually identical to our concept of dependence. Sociotropy includes – beliefs, behavioral dispositions and attitudes that draw an individual to attend to and depend on others for personal satisfaction. Sociotropic individuals emphasize inter-personal interactions involving relatedness, intimacy, empathy, approval, affection, protection, guidance and help. On the other hand, autonomy is considered to be a combination of beliefs, behavioral dispositions and attitudes that draw an individual to invest in oneself for one’s own uniqueness, mastery over one’s bodily functioning and control over one’s environment. Autonomous individuals emphasize individuality, self-reliance, personal achievements and a sense of power to do what one wants. Although we have, for the sake of simplicity and better understanding, clearly demarcated autonomy and dependence, these are relative. It needs to be recognized that societies are constantly changing. In a traditional society like India, autonomy-proneness is probably a more understandable concept in urban populations whereas dependency-proneness is probably more relevant in the rural population. Hence, one may find that the dynamics (or concepts) related to autonomy and dependence may present in a more mixed than a purist picture.

3.5.2 Psychological Sophistication Psychotherapy is mainly a verbal exercise. It is often referred to as ‘talk therapy’. In the actual process, words influence emotions and operate through it. The emotional infrastructure of the patient gets converted into a verbal supra-structure which then communicates with the therapist. The verbal response of the therapist again gets sent back from the patient’s verbal supra-structure to the emotional infrastructure to bring about the emotional change. It thus requires verbal fluency psychological sophistication, and introspective ability. Over the last 100 years or so, there has been a large increase in the West in what can be called ‘psychological sophistication’. Although hard to exactly define, psychological

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sophistication may relate to understanding such things as – personality, symptoms, illness and treatment – in psychological terms. That understanding has taken us away from the ‘physical and concrete’ to the ‘psychological and subtle’. Much of this understanding is probably dependent on the key concepts of psychoanalysis such as the concepts of the unconscious, drives and motivation. We have defined ‘psychological sophistication’ as ‘the ability to understand one’s emotions and actions, conflicts and difficulties in intra-psychic rather and environmental terms’ (Varma, 1985a). To illustrate, if a young man wants to marry a young woman and is detracted or prevented from doing so by the family, is the conflict in the social milieu or within his own mind? In other words, is this a conflict between him and other individuals or within his own mind, between his desires and his conscience? It is obvious that a relatively high degree of psychological sophistication is essential to the process of psychotherapy. The conflicts need to be translated into psychological concepts and terms to be dealt with in psychotherapy. To illustrate, if the patient views the causes of their difficulties in external terms such as ghosts and spirits rather than in terms of intra-psychic conflicts, psychotherapy cannot be successful. The increasing psychological sophistication in the West is also manifest in literature, art and folklore. Key concepts of psychoanalysis have become commonplace and are widely used by the population. Psychoanalysis has not permeated the traditional societies of the East to the same extent. The Eastern mind continues to try to understand causation and conflicts in physical and concrete terms.

3.5.3 Introspective and Verbal Ability Introspection is a key requirement for Western psychotherapy. It is an ability to look within, to contemplate and reflect. Introspection combined with verbal ability is what is necessary for the patient to participate effectively in psychotherapy. The process of psychotherapy may be a direct function of the combined effect of these two variables. Psychotherapy requires the ability to introspect, reflect and verbalize, and there may well be cross-cultural differences in it. As psychotherapy operated at the level of the verbal supra-structure that represents the emotional infrastructure, the ability to translate the latter into the former is a must (Varma, 1985a). However, the cross-cultural differences in this must be taken into account. In traditional societies like India patients tend, to varying degrees, to have a strong magico-religious belief system. To illustrate, if the patient continues to view the root of their psychological problems as being mystical (such as ghosts, spirits, etc.) or puts them down to explanatory religious beliefs, then the Western model of psychotherapy cannot be very successful (Varma, 1985a). This may be attributed to the traditional patient’s mind being orientated in a physical/concrete manner and also viewing conflicts to be metaphysical or mystical (as stated above) (Varma, 1985a). To the layman, psychotherapy is called the ‘talking cure’. The patient needs to express his symptoms and concerns in words and then communicate it to the therapist again in words. The therapist also has to convey back their assessment in words. At the level of both the patient and therapist, there is an inter-change between the emotional infra-structure and the verbal supra-structure. However, the communication between the two is largely inwards as opposed to emotions or physical actions.

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Some patients may have a difficulty in translating emotions into words. They may know how they are feeling but they may not be able to find suitable words to express it. Of course, we all know that words cannot express the full range of emotions. Don’t we often say, at the height of emotions, ‘I have no words to express what I feel’.

3.5.4 Need for Confidentiality and the Nature of the Dyadic Relationship Western culture places greater emphasis on the need for confidentiality. Perhaps it is related to the concept of autonomy and personal rights and prerogatives. One’s secrets are nobody else’s business. In Western culture, idle curiosity about things which do not relate to one is not appreciated. Furthermore with decreasing family size, matters are generally shared between fewer and fewer people. On the other hand, in the open-system societies of the East, confidentiality is not valued. On the contrary, confidentiality is frowned upon. Confidentiality seems to indicate that one has something to hide. A person’s life should be transparent and an open book. Of course perhaps there is no one who does not have secrets, but it is not seen as a right. In a WHO survey on the use of illegal drugs, there was a question: ‘If you had used cannabis, would you have said so in this questionnaire?’ When we asked this question in India, this absolutely baffled the respondents. They could not understand the meaning of this question. Of course, if the person had used cannabis, they would have said ‘yes’ to the question. The person could not fathom that they had a right not to disclose everything. One other aspect of the need for confidentiality in psychiatry and psychotherapy relates to the role of the family in clinical assessment and therapeutic interviews. In the traditional society, the patient may not only not mind discussing their illness in front of friends and family members, but may welcome the opportunity. In traditional societies, such confidentiality issues are probably not that relevant or not too much emphasis is placed on issues related to sharing information with immediate family members. It may be pertinent to mention here that immediate family members in the traditional societies include – spouse, parents and children, and that sharing (or discussing) personal information with them is not an exception, if not a fixed norm. Accordingly, the age-old dictum of confidentiality may not be applicable in certain societies.

3.5.5 Personal Responsibility and Decision-Making Western psychotherapy views the patient as a relatively responsible adult and assumes that they are finally responsible for their own decisions and actions (Varma, 1985a). The therapeutic process may give the patient insight which may help them to arrive at a more rational and mature decision. For example, the therapeutic process may make them aware of the idiosyncrasies in their personality and style and may suggest an adaptive change. In that sense, the patient is viewed as a responsible adult. However, the therapist usually does not direct the patient to take a particular course of action. The achievement of insight is such that it appears as a self-discovery to the patient. As such, the patient must assume full responsibility for their decisions and actions (Varma, 1985a). In Eastern traditional societies, the expectations of the patient may be different. They may be happier to play a dependant or an immature role and expect to be told in definitive

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and practical terms what is wrong and what they need to do. The patient may be more hesitant to arrive at and exercise their own choices. Accordingly, in traditional societies, the differences in the decision-making process must be taken into account. It thus requires a departure from the Western model of psychotherapy. The patient’s lack of assertiveness may also be exploited to a more clearly assertive role by the therapist.

3.5.6 Nature of Guilt and Shame Western societies are more familiar with ‘guilt culture’. In a ‘guilt culture’, if I believe that I did it (something wrong) I am expected to feel guilty regardless of whether I did it and even if other people believe that I did not. But, if I did not do it and other people believe that I did it, I have to protest my innocence and fight the accusation. On the other hand in a ‘shame’ culture, if I did it and other people believe that I did not do it, ‘no one knows, so I am not shamed’. But, if other people believe that I did it and I believe that I did not do it, ‘I am shamed and dishonored by their belief’. Benedict (1946, reprinted 1967) concluded that in ‘guilt cultures’ your actions reflect on you and that ethics and truth are universal, whereas in ‘shame cultures’ your actions reflect on others and ethics and truth are situational. The differences are between, ‘you are bad; what you did was wrong’ and ‘people laugh at you’ (Varma, in press). ‘Shame’ comes from other people pointing a finger at you, from social disapproval. You feel ashamed if other people do so, or if you think that they will do so. ‘Shame’ depends upon the social milieu. On the other hand, ‘guilt’ comes from within. It comes from a more internalized super-ego. You feel guilty even though nobody points a finger at you. In the context of mental illness, numerous workers have said that the so-called traditional cultures are relatively free of ‘guilt’ and they show more of ‘shame’ (Varma, 1982). The senior author (VKV) has also suggested that the guilt-proneness of the Judeo-Christian religions may be on account of ‘subscribing to the view that man was created in sin and hence attempts to absolve him from such sin (Christ died for our sins, saving one’s soul, concept of damnation, etc.), [whereas] the Eastern religions do not subscribe to guilt as a necessary prerequisite to human existence’ (Varma, 1985a). The senior author (VKV) has also pointed out that perhaps, ‘in case of the Indian patient, the guilt feeling may be related to certain values other than those important in the western culture and maybe thought to be based sometimes on misdeeds of an earlier birth’ (Varma, 1982).

3.5.7 Religious and Socio-Cultural Belief System Religious and philosophical belief systems are relevant for understanding symptoms, coping mechanisms and illness. They should also be taken into account in psychotherapy. Beliefs such as those related to sin, fatalism and reincarnation can affect psychopathology and the conduct of psychotherapy. Guilt may span across several successive ‘births’. At the same time the concepts of ‘karma’ and ‘sanskara’ may mitigate one’s responsibility for wrong-doing and for one’s station in life. People often have a misconception about the dual concepts of ‘karma’ and ‘sanskara’. ‘Karma’ is basically one’s fate. ‘Sanskara’ is the sum total of everything that the person is. The concept of ‘sanskara’ is basically a genetic concept. ‘Sanskara’ is determined not only

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by the physical and biological components of the person but also by his/her thoughts and deeds. The concepts of ‘karma’ and ‘sanskara’ can be utilized favorably in psychotherapy. ‘Karma’, by assigning part of the responsibility to the deeds of the previous birth can assuage the mind of part of the guilt and distress.

3.5.8 Patient’s Expectations What the patient expects out of therapy may influence the conduct and outcome of psychotherapy. Possibly on account of his/her dependency needs, the Eastern patient approaches the psychotherapeutic situation with a high degree of faith, trust and expectation and is better able to assume a subordinate relationship with the therapist. Such expectations can be favorably exploited to enhance therapeutic goals and may favorably influence treatment outcome (Varma, 1985a).

3.5.9 Social Distance Between the Patient and the Therapist All societies around the world are hierarchically stratified. People in different social strata enjoy different grades of social status, power and prestige. Societies are differentially stratified. The Western model of psychotherapy is predicated upon the model in which social distances are minimized. In other words, the patient and the therapist come together almost as social equals. They, of course, can come from widely diverse social classes but the hierarchical distance is deliberately minimized or underplayed. However, traditional Eastern societies are more accepting of the social distance between the therapist and patient. Not only does the patient accept their inferior position, but the social distance between therapist and patient can be put to therapeutic use by the therapist. Probably an extreme example of the above could be the concept of ‘shraddha’ (reverence) that operates in the traditional cultures between patients and their therapists (doctors). This is probably a concept parallel to the one proposed in the ‘Guru-Chela’ relationship. Any person going to the therapist (doctor) tends to view them with a certain degree of reverence and suggestions/advice by the therapist are listened to with seriousness and can contribute to the therapeutic process. During this interaction, this ‘shraddha’ (reverence) contributes to the accelerated therapeutic learning for the patient, and hence can be seen to be utilized therapeutically by the doctor.

3.5.10 Rule of Abstinence One of the major concepts of psychotherapy relates to not what it is, but what it should not be. Psychotherapy is a professional relationship but at the same time it should not become an informal or a social relationship. In Western psychotherapy, the rules of abstinence are clearly marked. Western psychotherapy specifically prohibits any business, financial, physical, romantic or sexual relationship between the therapist and the patient, usually for a good reason. However, this prohibition often goes to the extreme barring even simple

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social interaction. For example, it becomes embarrassing when the patient and the therapist come face to face in a common social situation, for example a wedding of a family of a mutual friend. Traditional psychotherapy does not prohibit such simple social interchange between patients and therapists. One other aspect that is related to the rule of abstinence is extolling the virtues of the therapist who is expected to remain an anonymous figure. In other words, the patient should know only the name of the therapist and such general attributes as gender and marital status. Other aspects, such as the therapist’s personal attributes and belief systems should remain unknown to the patient. The idea is that the therapist remains an unknown figure who the patient can conceptualize and mold according to their needs. However, in traditional psychotherapies it is not unusual for a lot more to be known about the therapist. In traditional societies, it is not unusual that patients and therapists know a lot more about each other. Being a generally more ‘open’ society with greater transparency, people generally know a lot more about each other. Since traditional societies also have a longer history and rootedness, it is not uncommon that details of the lives of many of its members are common knowledge. For example, if you just gave the senior author (VKV) the name of an Indian, he can guess a lot about them: the part of the country they belong to, the caste, perhaps the occupation and social status. In traditional societies, there is often a richer network of interactions. It is not unusual that the patient and the therapist come face to face at such situations as weddings, funerals, etc. Caste is a major preoccupation in a country like India. People are generally curious about the caste of someone they come across. Caste determines, to a large extent, the occupation (that was the main purpose of the division into castes or ‘varnas’), and socioeconomic status. Marriages being determined largely on the basis of the caste, it also determines the social network of a person. It is common knowledge that the respective caste determines the choice of a therapist.

CONCLUSION An optimal relationship between the patient and the healer is crucial to treatment. In the context of psychotherapy, the relationship needs to be such as to facilitate the patient to express themselves fully and to accept help from the therapist. The doctor-patient relationship varies across cultures. As opposed to the purely professional relationship in the technologically developed countries of the West, in traditional, developing societies, it approximates a primary group, filial model. The relationship is patterned after a number of socio-cultural variables, such as autonomy-dependence, ego boundaries, patient’s decision-making, need for confidentiality, social distance between doctor and patient, religious belief system, etc. Psychotherapy needs to be consistent with and the doctor-patient relationship patterned after these social and cultural realities.

REFERENCES Abroms, G.M. (1968) Persuasion in psychotherapy. American Journal of Psychiatry, 124, 1212. Beck, A.T. (1987) Cognitive models of depression. Journal of Cognitive Psychotherapy International Quarterly, 1, 5–37.

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Benedict, R. (1946, reprinted 1967) The Chrysanthemum and the Sword, Routledge and Kegan Paul, London. Frank, J.D. (1961) Persuasion and Healing: A Comparative Study of Psychotherapy, Johns Hopkins, Baltimore, p. 114. Frank, J.D. (1968) Recent American research in psychotherapy. British Journal of Medical Psychology, 41, 5. Kolb, L.C. (1968) Noyes’ Modern Clinical Psychiatry, Saunders, Philadelphia (Indian edition by Oxford and IBH, 1970) p. 546. Neki, J.S. (1976) An examination of cultural relativism of dependence as a dynamic of social and therapeutic relationship. I. Socio-developmental. British Journal of Medical Psychology, 9, 1–10. Nizer, L. (1961) My Life in Court, Pyramid Books, New York, p. 244. Romano, J. (1947) Psychotherapy, in Teaching Psychotherapeutic Medicine (ed. H.L. Witmer) The Commonwealth Fund, New York and Harvard University, Cambridge, MA, p. 122. Sato, T. and McCann, D. (2007) Sociotropy-autonomy and interpersonal problems. Depression and Anxiety, 24, 153–62. Torrey, E.F. (1972a) What western psychotherapists can learn from witchdoctors. American Journal of Orthopsychiatry, 42, 69. Torrey, E.F. (1972b) The Mind Game: Witchdoctors and Psychiatrists, Emerson Hall, New York. Varma, V.K. (1982) Present state of psychotherapy in India. Indian Journal of Psychiatry, 24, 209–26. Varma, V.K. (1985a) Psychosocial and cultural variables relevant to psychotherapy in the developing countries, in Psychiatry: The State of the Art, Vol. 4: Psychotherapy, Psychosomatic Medicine (ed. P. Pichot) Plenum Press, New York, pp. 159–65. Varma, V.K. (1985b) The Indian mind and psychopathology. Integrative Psychiatry, 3, pp. 290–6. Varma, V.K. (1988) Culture, personality and psychotherapy. International Journal of Social Psychiatry, 34, 142–9. Varma, V.K. Cultural psychodynamics and suicidal behaviour, in Handbook of Suicide Behaviour (ed. A. Shrivastava) Royal College of Psychiatrists, London (in press). Varma, V.K. and Ghosh, A. (1976) Psychotherapy as practised by the Indian Psychiatrists. Indian Journal of Psychiatry, 18, 177–86. Wittkower, E.D. and Warnes, H. (1974) Cultural aspects of psychotherapy. American Journal of Psychotherapy, 28, 566. Wolberg, L.R. (1967) The Technique of Psychotherapy, Grune & Stratton, New York, p. 3.

CHAPTER 4

South American Indigenous Knowledge of Psychotropics The Need for Culturally Adapted Intellectual Property Rights Sioui Maldonado Bouchard Research Assistant, Runajambi Institute (Ecuador) Master’s student in Psychology, Universite´ de Montre´al (Canada)

Abstract Indigenous people have contributed greatly to the advancement of science with their knowledge of medicine. Unfortunately they have not received appropriate recognition for it. Intellectual property rights of indigenous people in this field have been neglected, and current intellectual property laws make it nearly impossible for indigenous people to claim property over their knowledge. It is here demonstrated that the status quo regarding intellectual property laws is not acceptable. Three study cases are put forward as examples in which the intellectual property rights of indigenous people have been grossly overlooked. The text concludes by suggesting the gains that would ensue from modified and improved laws in this regard for society at large.

4.1

INTRODUCTION

Regardless of whether Western medicine and indigenous medicine work together voluntarily or not, the knowledge exchange between them has had important impacts. In 1990, worldwide sales of all pharmaceuticals amounted to $130 billion, $32 billion of which was based upon indigenous medicines (Lassonde, 2003). Plants are an important part of indigenous medicine, and also of Western medicine. Prescriptions given in US pharmacies from 1959 to 1980 were analyzed, and it was found that 25% of these contained plant extracts or derivatives and also contained at least 119 chemical substances from 90 plant species. Moreover, 74% of these drugs were the result of isolating active substances from plants used by indigenous people (Gurib-Fakim, 2006). For example, local anesthesia was first made possible with the psychotropic cocaine, derived from the coca leaves used by South American indigenous people. Malarial fevers could finally be appeased thanks to the quinine found in cinchona bark used by the Incans of Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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the Andes. Inducing muscle paralysis in surgery was at last feasible with curare, used as a muscle relaxant by South American indigenous peoples. Breast cancer treatments were improved tremendously with the advent of tamoxifen,1 an active ingredient of the Pacific yew Taxus used by the Nuxa´lk Nation [Bella Coola tribe] of British Columbia (Canada) for lung ailments (Gurib-Fakim, 2006). Historically, little or no recognition has been given to the indigenous people for the contribution their knowledge has made to the advance of Western medicine. Yet thanks to the indigenous medicinal knowledge passed down from one generation of healers to the next, Western scientists were able to work directly on relevant plants, and did not have to go through the long trial-and-error process of trying to find a plant useful to the treatment of a given disease. Shaman Pharmaceutical, for example was based on this fact: consulting indigenous peoples, bio-prospectors can increase their success ratio from 1 out of 10 000 to 1 out of 2 (Bierer, Carlson and King, 2006). They worked closely with indigenous healers to identify plants of medicinal use. This eliminated the need to test tens of thousands of plant species; they were able to focus on chemically separating the active ingredient of the plants, and understanding the chemical structure of this entity. This chapter aims to demonstrate that indigenous peoples’ knowledge in general and indigenous healers’ medicinal knowledge in particular needs to be given recognition as an important human achievement. According to the United Nations Development Program and the World Trade Organization, 80% of the world’s population depends on indigenous knowledge to meet their medicinal needs (Lassonde, 2003). Acknowledgement of indigenous peoples’ contributions to mankind should also take an appropriate legal form. This would ensure that indigenous peoples’ knowledge is not exploited, that indigenous people retain ownership of their collective knowledge, and that they receive proper compensation for others’ use of that cultural knowledge. This has not yet been achieved. Current intellectual property laws are modeled after Western philosophy’s concept of property rights. Using currently accepted intellectual property laws, it is nearly impossible for indigenous peoples to argue for legal recognition of their intellectual property rights over their culturally-shared medicinal knowledge. This chapter will first define important terms, and then describe three specific examples of indigenous medicinal knowledge – quinine, coca and ayahuasca, two of which (coca and ayahuasca) have known psychotropic properties. The second part of this chapter will deal with the legal aspects of indigenous intellectual property rights in general and indigenous medicinal knowledge in particular. Current intellectual property laws will be described, as well as how they become problematic when dealing with indigenous healers’ medicinal knowledge. Reasons why legal and economical recognition of indigenous peoples’ knowledge have not been achieved will be presented. The intellectual property rights problems pertaining to the three examples of indigenous medicinal knowledge (quinine, coca and ayahuasca) will then be illustrated. The chapter will conclude with a discussion of both the general benefits that recognition of indigenous healers’ medicinal knowledge would bring to mankind, and the specific benefits it would bring to the indigenous peoples concerned.

4.2

DEFINITIONS

4.2.1 Indigenous People Various definitions for the term ‘indigenous’ exist. In the following text, we will use the working definition of the United Nations Working Group on Indigenous Populations.

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Indigenous populations are composed of existing descendents of the people who originally inhabited the present territory of a country (or countries), wholly or partially, at the time when persons of a different culture or ethnic origin arrived there from other parts of the world and overcame them, either by direct conquest, settlement, or other means, and reduced them to a nondominant group within their home regions or territory (Swazo, 2005).

It must be stressed that this is only a working definition. We believe that the identity of an indigenous person should not depend on the presence of a history of colonization and nondominance.

4.2.2 Indigenous Knowledge By indigenous knowledge, we mean any and all knowledge held individually or collectively by members of indigenous populations. Beyond this definition, indigenous knowledge is described by many as knowledge directly functional in long-term survival of a specific group of people. In this text, we refer specifically to one type of indigenous knowledge, that is indigenous medicinal knowledge. The term indigenous medicinal knowledge will be used here as a synonym for traditional medicine, as defined by the World Health Organization in 2000: . . . the sum total of the knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health, as well as in the prevention, diagnosis, improvement or treatment of physical and mental illnesses (WHO, 2000).

4.3

THREE INDIGENOUS PEOPLES’ MEDICINAL PLANTS: QUININE, COCA AND AYAHUASCA

The indigenous people of the South American continent have contributed to the advancement of the sciences and the arts in multiple ways. Among them are many of the world’s staple foods as well as numerous medicinal plants. For instance, potatoes, maize, beans, tomatoes, cacao, peanuts and yams were all selectively cultivated and consumed by South American indigenous peoples prior to the arrival of Europeans. Also, medicinal plants such as American ginseng, golden seal, quinine, ayahuasca, curare and coca have played an important role in Western medical treatments (Forbes, 1997). Yet there currently exists no form of recognition of, or remuneration to indigenous peoples for their knowledge of the agricultural and medical uses of these plants. We here give a brief description of the traditional and current uses by indigenous people of three specific plants.

4.3.1 Quinine Traditional Use Quinine is the alkaloid found in the bark of cinchona (also called quinaquina) trees, constituting an important anti malarial drug. The tree is native to the Andes, found from

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Venezuela to Bolivia. Quinine from cinchona bark was used to treat malarial symptoms before the disease was identified in Western medicine (Gilani and Atta ur, 2005). The Incas knew it was effective in the treatment of muscle aches and fever. Their use of quinine was an empirical one (Kaufman and Ru´veda, 2005). Quinine was known and used by indigenous people of the Andes for centuries before the arrival of Europeans (AGN, 1931).

Current Use Quinine is still among the most effective anti-malarial treatments (Meshnick, 1997). Synthetic drugs are now also used (such as Chloroquine and Mefloquine), but these can cause serious side effects, and also resistance is developed, and thus quinine remains a preferred treatment in many cases.

4.3.2 Coca Traditional Use Coca, from the plant Erythroxylum coca var. coca and Erythroxylum novogranatense var. truxillense, has been used by the indigenous peoples of the highlands of South America for more than 2000 years (Sgan, 1998). Pre-Columbian use of coca was common. Its use is reflected in ceramics and figurines found in archeological sites in Venezuela, Colombia, Bolivia, Ecuador, Peru, Chile and Argentina. Using radioimmunoassay and gas chromatography/mass spectrometry, coca has been detected in mummies from Peru, Bolivia and Chile. The earliest detection of coca was made in two Alto Ramirez mummies from Northern Chile. Carbon-14 dating determined them to be from 2900 to 2700 years BP (before present.) (Rivera et al., 2005). The traditional Incan uses of coca were mainly health-related. It was used by healers directly on the cranial wound during trepanation2 as a local anesthetic (Sgan, 1998). It was also used in powder or plaster form on skin ulcers and wounds. In addition, it was used to manage pain. It was infused in tea to appease gastrointestinal pains and it was chewed to relieve toothache, sore throat and abdominal pain. It was used as a means to preserve strength, curb hunger and mask thirst. Coca was also used in religious rituals. When the Spaniards came to South America, they added to the uses of coca, giving daily doses of coca to Incan laborers as a means of increasing their work output. Today, coca chewing is common among impoverished highland peasants of South America (Naranjo, 1981).

Current Use In the medical field, coca has proven extremely useful. Because of cocaine’s rapid absorption across mucous membranes, otolaryngologists use cocaine during surgery as an anesthetic, and as a vasoconstrictor of nasal and laryngeal mucous membranes. Cocaine is also used as local anesthetic during endoscopies and in ophthalmology, to determine the presence of Horner’s syndrome (Sgan, 1998).

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4.3.3 Ayahuasca Traditional Use Traditional use of the plant Ayahuasca (Quichua term for ‘vine of the evils’) goes back thousands of years. Until today, the beverage made from Ayahuasca was used in religious rituals for its hallucinogenic properties. Use of Ayahuasca has its origin among the Quichua of the Amazon Basin (McKenna, 2004). It has been used to diagnose illnesses, to aid in prophecies, as a preventive measure against evil-doers, to train traditional healers, and to achieve religious ecstasy (de Rios and Grob, 2005). Ayahuasca is a beverage made from the mixture of two plant species of Banisteriopsis caapi and Psychotria viridis. The hallucinogenic properties of Ayahuasca are due to the reversible inhibitors of type-A monoamine oxidase (MAO) such as harmine and harmaline, contained in Baristeriopsis caapi, which, by inhibiting the type-A MAO, allow the activity of N, N-dimethyltryptamine contained in the leaves of Psychotria viridis (Callaway et al., 1999). Ayahuasca’s hallucinogenic properties cause dream-like states, as well as enhanced introspective attention. Physiological effects of Ayahuasca include nausea, increased heart rate, increased frontal and paralimbic activation (Riba et al., 2006), and an increased number of binding sites in the platelets of regular Ayahuasca drinkers (Callaway et al., 1994). More precisely, N, N-dimethyltryptamine and the type-A MAO increase central and peripheral serotonergic activity and facilitate N, N-dimethyltryptamine activity (Callaway et al., 1999).

Current Use Today, Quichua traditional healers in the Amazon Basin continue to use the Ayahuasca in their religious and healing ceremonies. The concoction is only used under a healer’s supervision. The drink has profound religious significance for the indigenous people concerned. However, use has now spread to mestizo3 groups of Ecuador, Peru, Venezuela, Colombia and Brazil. There is also today confirmed use of Ayahuasca as a hallucinogenic in Spain and the United States (de Rios and Grob, 2005).

4.4

LEGAL ISSUES

4.4.1 Current Situation Respect for intellectual property is of primordial importance in Western society, both in the arts and the sciences. Intellectual property rights are conceptualized as protecting due ownership rights of those concerned, but also, perhaps most critically, to promote the development of new ideas, inventions and discoveries (Fecteau, 2001), by providing recognition and ownership rights to those who contribute to the advancement of the sciences or the arts. Current Western intellectual property rights firmly base their eligibility criteria on the logic of Locke and Hettinger. John Locke, an English empiricist philosopher, considered

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individuals to have property rights over knowledge to which they had contributed labor and effort. Hettinger, a contemporary philosopher, views the implementation of intellectual property rights as necessary in cases in which such rights promote further intellectual outputs (Townley, 2002). These ideologies advocate assigning intellectual property rights on medicinal knowledge of indigenous people to Western scientists based on the following reasoning: since the Western scientist put labor into understanding the traditional indigenous knowledge, and, that prior to this effort, the traditional knowledge was unknown to Western society, then, the Western scientist has indeed contributed a new form of knowledge to which he is entitled ownership. A variety of legal concepts exist to protect and/or recognize intellectual property rights. They include trade secrets, patents, sui generis systems, customary laws, tailor-made contracts and specific protective laws, such as the Plant Variety Protection laws (Timmermans, 2003). The most influential in matters of intellectual property rights is the patent system. The patent system works very well within Western society. Indeed, its purpose and requirements fit well with the nature of Western science and art. It recognizes and rewards individuals for new, unique work, never before seen in one’s country, nor published elsewhere. It works very well to grant intellectual property rights to holders of Western scientific knowledge. The purpose of patents is ‘to promote the progress of science and useful arts’ (Fecteau, 2001). The patent system achieves this by granting the patent applicant exclusive commercial rights over his invention or discovery for a fixed period of time. In return, he must disclose the invention/discovery. By restricting the short-term access to inventions/discoveries and granting individual applicants temporal ownership of the inventions/discoveries, the patent system functions as an incentive to further invention and discovery. In the long-term, the patent system contributes to the progress of society by providing a database where discoveries and inventions are registered.

Patent Criteria Patents function within the borders of a sovereign nation. In this chapter, we limit our review to US laws. Patents must be acquired within each country in which intellectual property rights are desired for a particular invention or discovery (X). In the United States, X must meet three criteria in order to be granted a patent by the US Patent Office: (i) novelty, (ii) non-obviousness and (iii) utility. The novelty criterion requires X to be new. This means that there must be no prior art involving X. US Patent law recognizes four possible types of prior art: (i) prior knowledge of X in the United States, (ii) prior use of X in the United States, (iii) prior patent of X in any country and (iv) printed publication of X in any country (Fecteau, 2001). Importantly, foreign prior use or knowledge is not recognized as prior art, unless its use or knowledge is published prior to patent request in the United States. The non-obviousness criterion requires that X not be obvious to someone with ordinary skill in the particular art. Here too, obviousness to a person in a foreign country is not deemed relevant, and does not impede granting of patent in the United States. It must be noted, further, that just what constitutes ‘a skill in the particular art’ is often interpreted narrowly. Thus, for example a healer’s knowledge of a medicinal plant and its beneficial effects will not necessarily be considered to be prior art to the knowledge of the chemical

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composition of the active components in the medicinal plant, even though the former was essential to the determination of the latter (Wiser, 1999). As will be seen in the following section, this puts indigenous healers’ medicinal knowledge in an evident position of disadvantage, making it difficult to defend indigenous intellectual property rights and to fight patents over plants requested by scientists and companies. The utility criterion requires X to be useful. This criterion is rarely a problem for patent applicants. The concept of utility is broadly interpreted, and truly only demands that the discovery or invention have at least some kind of trivial use, and that it cause no harm; that is that it have no illegal or immoral purpose.

Problematic Aspects of Indigenous Medicinal Knowledge Under Current Intellectual Property Rights Indigenous knowledge, as defined earlier in the chapter, is most often communal, intra- and inter-generational, often subjective, directly functional in long-term survival, and usually transmitted through oral tradition among indigenous healers (Dutfield, 2001). It involves biodiversity, for the knowledge is often of animals and medicinal plants. For these reasons, many have come to consider indigenous healers’ medicinal knowledge to be an integral part of biodiversity (Gepts, 2004) and to treat indigenous knowledge as common heritage of mankind (Soejarto et al., 2005). This tendency has also been encountered amongst those advocating for the property rights of indigenous peoples. Until the 1970s, the concept of Common Heritage of Mankind was thus the principal policy towards biodiversity and indigenous medicinal knowledge protection. On the surface, it seemed a good solution. However, this proposes that indigenous medicinal knowledge, considered as Common Heritage of Mankind, should not be the property of any individual or group (Trotti, 2001). Common Heritage of Mankind made it very difficult for indigenous people to acquire property rights over their indigenous medicinal knowledge (Godshall, 2003). The current measures of intellectual property rights were conceived with the Western notion of property and knowledge in mind. This is so much so, that intellectual property rights often send the message that indigenous knowledge should be considered as part of the public domain. In the making of policies, there are three main conceptual views on the nature of knowledge categories (view one and two are most prevalent): (i) that there are two types of knowledge – that in the public domain, and that in the private domain, protected by intellectual property rights (Timmermans, 2003); (ii) that there is knowledge in the public domain, but also two types of private domain knowledge – that protected by intellectual property rights, and that protected by customary law (Dutfield, 2000); and (iii) that there exists three types of knowledge: (a) public domain knowledge, (b) community knowledge and (c) private domain knowledge. In the first two views, indigenous medicinal knowledge will easily fall into the public domain knowledge type, which prevents anyone, indigenous people included, from obtaining intellectual property rights over the knowledge. The third view, importantly, stresses that knowledge shared by a group does not make it public domain knowledge, but rather community knowledge (Gupta, Gabrielsen and Ferguson, 2005). Indigenous medicinal knowledge should most often fit within this community knowledge category.

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The Clash between Current Intellectual Property Rights and Indigenous Medicinal Knowledge Many fundamental differences between indigenous medicinal knowledge and Western intellectual property rights make it difficult for these two to work together. Here we will look more closely at these differences and their implications, and we will conclude with possible solutions for reconciliation in a cross-cultural perspective. The terms indigenous knowledge, indigenous medicinal knowledge and even indigenous people are ambiguous. Various definitions for each of these terms exist, and there is not agreement about what exactly should constitute each of these three terms (Godshall, 2003). These definitional ambiguities alone make it difficult to meet the required legal standard to prove that indigenous knowledge is knowledge. We will take a look at the domino effect that this creates. The first problem is to prove that indigenous medicinal knowledge should be considered as knowledge. Indigenous knowledge is often considered to be subjugated knowledge and as such, is disqualified as inferior knowledge (Swazo, 2005). However, even when indigenous medicinal knowledge is recognized as knowledge, other problems arise. As stated earlier, a basic ‘rule of the game’ is that intellectual property rights are granted to elements of which no prior use or knowledge exists. Because indigenous medicinal knowledge is often communally held knowledge, it is difficult to establish that the indigenous medicinal knowledge is not already in the public domain. Indeed, as stated earlier, the two following views about knowledge types are prevalent: (i) that there are two types of knowledge: that in the public domain, and that in the private domain, and (ii) that there is knowledge in the public domain, but also two types of private domain knowledge: that protected by intellectual property rights, and that protected by customary law. Even when the indigenous medicinal knowledge is proven not to be, as of yet, part of the public domain, arguing that it should not automatically become part of the public domain becomes the next challenge. At this point, it is necessary to argue that the indigenous knowledge being communal, it should be under the authority of the communities concerned. It then becomes necessary to prove that there exist specific communal ownership concepts within the indigenous community which apply to the indigenous medicinal knowledge in question. Intellectual property rights defenders must show that there are authority figures within the indigenous communities, such as traditional healers and tribal elders, and that these authority figures have the right to determine the conditions under which access is to be granted to the indigenous medicinal knowledge under consideration. Succeeding to demonstrate that indigenous communities have the authority to decide how and to whom their knowledge is to be disclosed depends on demonstrating that indigenous medicinal knowledge is different from Western knowledge; that it has its own criteria of belongingness, its own rules and purposes, and that indigenous medicinal knowledge ‘has the right’ to be protected by intellectual property rights which suit its nature, just as current intellectual property rights suit the nature of Western knowledge. In summary, the obstacles to the legal recognition of indigenous medicinal knowledge are the following: (i) one must prove that indigenous medicinal knowledge is knowledge, (ii) one must prove that indigenous medicinal knowledge is not part, and should not become part, of the public domain, (iii) one must show that authority figures in indigenous communities are present and that they must be granted control over their indigenous

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medicinal knowledge, (iv) one must demonstrate that granting communities control over their indigenous medicinal knowledge implies the creation of intellectual property rights that allow such proceedings, and that applying intellectual property rights to indigenous knowledge is no more of a concession than applying the current intellectual property rights to Western knowledge. The fundamental problem here seems to be, then, a problem of paradigms. A continuous challenge throughout this process is to keep in mind that just as indigenous medicinal knowledge is a culturally-adapted construct, so is Western knowledge. And that just as indigenous medicinal knowledge defenders seek to formulate policies and laws that can fit the nature of indigenous medicinal knowledge, so have current intellectual property rights been modeled according to the nature of Western knowledge. In seeking to provide equal chances of intellectual property rights both to Western and indigenous knowledge, it is of primordial importance to keep in mind that all products of a society are influenced by its culture, its ‘worldview’.

Actions Taken to Date Some significant actions to protect indigenous medicinal knowledge have been taken. The Convention on Biological Diversity, enacted in December 1993, recognized that biological and genetic resources should be the property of a given party, a statement that contradicts the Common Heritage of Mankind position that biological and genetic resources can be used by everyone. Moreover, the Convention on Biological Diversity acknowledges the contribution of the medicinal knowledge of indigenous healers to Western science, and calls for intellectual property rights to be put into practice for the indigenous people concerned. The Convention on Biological Diversity has been ratified by 179 countries and the European Union; in these countries, companies can no longer, in theory, harvest bio-resources without acknowledging indigenous ownership. It is worth noting that the United States has not participated in the convention (Gurib-Fakim, 2006). The weakness of the Convention on Biological Diversity is that it only proposes a new view, but does not have the authority to impose international rules or standards. Intellectual property rights are the responsibility of each sovereign nation, and thus, nations agreeing to the Convention on Biological Diversity are free to determine how they wish to apply its principles. This is problematic, given that indigenous peoples are not the politically dominant groups in their countries (Swazo, 2005). More often than not, their governments are not sincerely concerned with the indigenous peoples; let alone their intellectual property rights, and thus the principles of the Convention on Biological Diversity are not likely to be enforced. Or, should they be, the national governments are likely to take ownership of the economic benefits gained, leaving the indigenous people as empty-handed as before. The Trade-Related Aspects of the Intellectual Property Rights Agreement partly solves this problem of lack of international standards. Trade-Related Aspects of Intellectual Property Rights Agreement is the Annex 1C of the Marrakesh Agreement Establishing the World Trade Organization, adopted in 1994 (WTO, 1994). The Trade-Related Aspects of Intellectual Property Rights Agreement made intellectual property part of international trade law. This obliges all nations to follow international standards with respect to intellectual property, as determined by the World Trade Organization. It stipulates that patents must be available for all inventions, as long as they meet patent criteria within the country

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concerned. However, not much in the Trade-Related Aspects of Intellectual Property Rights Agreement refers to indigenous intellectual property rights. Indeed, attempts to include indigenous intellectual property rights often meet objections (IITC, 2002). Again, when a patent is requested for indigenous healers’ medicinal knowledge, this knowledge, which is most often communal, does not meet the patent criteria (Timmermans, 2003). This is because the patent criteria have not been modified to include the nature of indigenous knowledge. Some advances have been made by indigenous groups and non-governmental organizations. Currently, some aspects of indigenous intellectual property rights are taken into consideration by the World Trade Organization and the World Intellectual Property Organization. Indigenous peoples’ rights to intellectual property rights have been recognized, as has been the contribution of their indigenous medicinal knowledge to Western medicine. Nonetheless, further modifications of intellectual property law need to be made to include indigenous knowledge.

4.4.2 The Specific Cases of Quinine, Coca and Ayahuasca; Intellectual Property Rights Issues Examples of problems that arise from the inadequacy of status quo intellectual property rights will be demonstrated in this section, by looking at the three plants described earlier as examples of medicinal plants used by indigenous peoples. The first case to be discussed is that of the Cinchona bark, whose alkaloid quinine is used to treat malaria. The second is the case of the psychotropic coca. It is here presented as an example of past intellectual appropriation of indigenous healers’ medicinal knowledge which has gone unresolved. The last case is that of the psychotropic ayahuasca. Ayahuasca is presented as an example of a resolved case of intellectual property appropriation, albeit with problems.

Quinine – Legal Issues Cinchona ledgeriana, the botanical name of the plant which contains quinine, speaks of its past. According to the historical account, the countess of Chinchona (Spain), very ill with fever during a trip to South America, was prescribed Cinchona (quinaquina in the Quichua language) by Incas, which cured her fever. The Englishman Charles Ledger is then said to have ‘discovered’ the most effective type of Cinchona for the treatment of malaria. Less well known is Manuel Incra Mamani, who had the knowledge and expertise to identify the variety of plants and trees which Ledger was hoping to find (Rocco, 2003). Mamani helped Ledger select the plants and trees richest in quinine, thirteen times richer than the ordinary Cinchona ledgeriana tree in Bolivia (Allen, 1989). Manuel Incra Mamani was a young Inca man from the region of Loxa (Loja), Ecuador. Also, during World War II, the United States obtained large quantities of quinaquina bark (nearly 6 million kilograms) from Ecuador. In this instance too, Quichua plant experts assisted in the collection of the quinaquina bark (Rainey, 1946). Their help went unacknowledged. No recognition or payment has ever been given to the indigenous people who helped Europeans treat malaria. In the case of quinine, the main problem for indigenous people in trying to obtain legal intellectual property rights is that undocumented knowledge held

LEGAL ISSUES

47

abroad is not recognized by the US’ patent laws. Moreover, even when it is recognized, it is extremely difficult for it to be considered as state of the art knowledge that should disqualify a patent claim related to that knowledge. In 1995, Lord Hoffman of the British House of Lords asserted that a single entity can have several definitions depending on the perspective of the person making the definition (Dutfield, 2001). For this reason, it should not be the case that only one definition for an entity is considered valid. To illustrate his assertion, Lord Hoffman used the case of quinine. He argued the following: The Amazonian Indians have known for centuries that cinchona bark can be used to treat malarial and other fevers [. . .]. Does the Indian know about quinine? My Lords, under the description of a quality of the bark which makes it useful for treating fevers, he obviously does. I do not think it matters that he chooses to label it in animistic rather than chemical terms. [. . .] If shown pills of quinine sulphate, he would not associate them with the cinchona bark. [. . .] And he certainly would not know about the artificially synthesized alkaloid.

Although the indigenous people do not have the knowledge of quinine as a molecule or a chemical formula, they have another type of knowledge that is just as valid. When determining whether a proposed entity is patentable or not, it seems that prior art, although of another kind, should be considered as such and should have the capability to disqualify a patent candidate on grounds of lack of novelty (Dutfield, 2001).

Coca – Legal Issues The use of coca as a local anesthetic was known by the indigenous people of the Andean region prior to the arrival of the Europeans. It is clear that the indigenous healers’ knowledge of the medicinal properties of cocaine greatly contributed to the later use of cocaine in Western medicine (Eunice, 1947). Yet no remuneration or recognition has been given to the indigenous people concerned. Current law concerning intellectual property rights makes it difficult for remuneration or recognition to be given. It is difficult to argue the case for coca, because the problem of identifying an individual or a group owner of the knowledge about this plant arises. In cases like this, adoption of a First Nations Intellectual Property Act could be a solution. This act could be adopted as an amendment to the North American Free Trade Agreement, or as separate legislation in each country. For many indigenous peoples’ inventions and knowledge, it is not possible to designate ownership to one person, one group or even one nation. Jack Forbes, professor of Native American studies at the University of California, Davis, has proposed that the First Nation Intellectual Property Act stipulate that royalties must be paid for the use of indigenous peoples’ inventions and products, and that these royalties be deposited in a First Nations International Bank. This bank, a non-profit corporation, would be controlled by an Indigenous Board of Trustees, which would determine the use of these funds (Forbes, 1997). Such a system could be used in South America and Central America as well.

Ayahuasca – Legal Issues In 1986, US entrepreneur Loren Miller obtained a patent on a variety of Banisteriopsis caapi, also called Ayahuasca, used to make the Ayahuasca beverage. He named it Da Vine. In 1994, the Coordinating Body of Indigenous Organizations of the Amazon Basin

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(COICA, Ecuador) learned of Miller’s patent. They found it absurd, given that the plant has been known and used by indigenous people of the Amazon for centuries. In 1999, the Center for International Environmental Law filed a request for reexamination on behalf of Coordinating Body of Indigenous Organizations of the Amazon Basin and the Amazon Coalition. The Center for International Environmental Law argued that: (i) Da Vine is neither new nor distinct, and thus violates the novelty requirement under the Patent Act; (ii) Da Vine is found in an uncultivated state and thus violates the Plant Patent Act, which prohibits patenting these plants; (iii) Da Vine is a sacred plant to indigenous people (i.e. it is used as part of religious rituals) and thus granting a patent on it constitutes an immoral action, a violation of the utility criterion under the Patent Act. On May 28, 1999, the US Patent and Trade Office granted the reexamination request. However, it did not grant the reexamination because of the Center for International Environmental Law’s argument that Amazonian people’s knowledge of the plant nullified Miller’s patent. The Patent and Trade Office granted reexamination because in its request, the Center for International Environmental Law mentioned that Da Vine was similar in physical appearance to another B. caapi plant found in a US herbarium collection. It was this B. caapi specimen found in the herbarium collection of the Field Museum of Chicago which nullified Miller’s patent. It must be pointed out that the Patent and Trade Office’s grounds for re-examination of the Miller Patent avoided the question of whether the knowledge of the use of a plant by generations of indigenous peoples should constitute prior art under the patent rules. It also failed to address the question of whether patenting a plant sacred to indigenous people should be considered immoral, and thus a violation of the utility criterion. The US Patent and Trade Office thus revoked Miller’s patent on very narrow grounds – Miller’s patent violated the novelty criterion under the Patent Act, because Banisteriopsis caapi specimen were described on herbarium sheets in the Field Museum of Chicago (35 USC x 102 (b)) over one year prior to the patent request. Although COICA was successful in obtaining a patent revocation, this case did not initiate a debate on the need for changes in the current intellectual property rights laws. Furthermore, the Patent and Trade Office stated that the Center for International Environmental Law’s grounds for patent revocation were invalid. The Center for International Environmental Law’s argument of novelty violation due to prior indigenous knowledge of Da Vine was not valid, because it did not fall into any of the four categories of prior art under US Patent law (see Table 4.1).

Table 4.1 The three criteria a discovery/invention (X) must meet to be granted a patent in the United States. Criteria

Implications

Novelty

. . . . . . .

Non-obviousness Utility

No prior knowledge of X in the United States No prior use of X in the United States No prior patent of X in any country No printed publications of X in any country That X is not obvious to someone with ordinary skill in the particular art. That the discovery or invention has at least some kind of trivial use That it causes no harm; that is, that it has no illegal or immoral purpose.

NOTES

49

It seems reasonable to argue that the Patent and Trade Office’s failure to review the pertinence of the Patent Act criteria in this indigenous knowledge case demonstrates a clear cultural bias. The three criteria were not questioned; they were considered to be objective and neutral requirements to grant patents. This constitutes in itself a cultural bias, for the criteria of the Patent Act are inevitably culturally determined criteria; criteria produced within the Western paradigm.

CONCLUSION Intellectual property protection has increased in many areas in recent decades. Yet, as regards indigenous intellectual property protection, not much progress has been achieved. Too often, indigenous intellectual property is considered similar or equal to public domain. What is needed is general acceptance that all laws and norms are culturally-constructed, and thus, that laws be enacted to protect indigenous knowledge as property, in the same way that laws protect intellectual property for other nations. In 1993, the Julayinbul Statement on Indigenous Intellectual Property Rights adopted in Australia concerning indigenous peoples’ intellectual property rights stated the following: . . . Indigenous Peoples and Nations also declare that we are capable of managing our intellectual property ourselves, but are willing to share it with all humanity provided that our fundamental rights to define and control this property are recognized by the international community (Hunter and Jones, 2004).

Ensuring that intellectual property rights are applied to indigenous medicinal knowledge would allow indigenous populations to derive, from the use that others make of their indigenous medicinal knowledge, financial benefits which are sorely needed in many indigenous communities that have experienced centuries of colonization and exploitation. If indigenous people were fairly recognized and compensated for the contributions their indigenous medicinal knowledge have made to Western medicine, they would be more likely to participate in Western scientists’ search for new medicinal products. In the longrun, indigenous people holding medicinal knowledge could work in partnership with Western scientists to create new drugs that could benefit people everywhere. Moreover, should indigenous people be granted rightful compensation for their contribution to Western medicine, poverty levels could be reduced in indigenous communities.

NOTES 1. Interestingly, tamoxifen is also currently under scrutiny as a drug to treat manic symptoms in bipolar disorder patients – it is, up to now, the only selective protein kinase C inhibitor known to be able to cross the blood-brain barrier. Zarate, C.A. Jr., et al. (2007). 2. Trepanation was a type of skull surgery performed by Incans. Specific holes were made in the skull, as part of treatment for headaches, cranial fractures and mental illness. Coca was used by the Incan healers to anesthetize the cranial wound and alleviate the patient from pain during the trepanation procedure. Sgan, S.L. (1998). 3. Mestizos, in Latin America, are the dominant group. They are of both Spanish and Indigenous descent, but they shun their indigenous roots and seek to identify themselves as being solely of European descent.

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REFERENCES AGN (1931) The tercentenary of the first recognized use of cinchona bark by Europeans. Canadian Medical Association Journal, 24 (2), 280–1. Allen, D.E. (1989) The life of Charles Ledger (1818–1905): alpacas and quinine. Medical History, 33 (3), 388–9. Bierer, D.E., Carlson, T.J. and King, S.R. (2006) Shaman Pharmaceuticals: Integrating Indigenous Knowledge, Tropical Medicinal Plants, Medicine, Modern Science and Reciprocity into a Novel Drug Discovery Approach, Network Science Corporation, Saluda, NC, [Online] Available at: http://www.netsci.org/Science/Special/feature11.html Callaway, J.C., Airaksinen, M.M., McKenna, D.J. et al. (1994) Platelet serotonin uptake sites increased in drinkers of ayahuasca. Psychopharmacology, 116 (3), 385–7. Callaway, J.C., McKenna, D.J., Grob, C.S. et al. (1999) Pharmacokinetics of hoasca alkaloids in healthy humans. Journal of Ethnopharmacology, 65 (3), 243–56. de Rios, M.D. and Grob, C.S. (2005) Ayahuasca use in cross-cultural perspective. Journal of Psychoactive Drugs, 37 (2), 119–21. Dutfield, G. (2000) The public and private domains: intellectual property rights in traditional knowledge. Science Communication, 21 (3), 274–95. Dutfield, G. (2001) TRIPS-related aspects of traditional knowledge. Case Western Reserve Journal of International Law, 33 (2), 233–75. Eunice, M.M. (1947) Coca, divine plants of the incas. Anaesthesia, 2 (1), 4–12. Fecteau, L.M. (2001) The ayahuasca patent revocation: raising questions about current U.S. patent policy. Boston College Third World Law Journal, 21 (69), 69–104. Forbes, J.D. (1997) Intellectual property rights of Indigenous peoples, Windspeaker 14 (11):3(sup) [Online] Available at http://www.ammsa.com/classroom/CLASS3Intelligence.html Gepts, P. (2004) Who owns biodiversity, and how should the owners be compensated? Plant Physiology, 134 (4), 1295–307. Gilani, A.H. and Atta ur, R. (2005) Trends in ethnopharmacology. Journal of Ethnopharmacology, 100 (1–2), 43–9. Godshall, L.E. (2003) Making space for indigenous intellectual property rights under current international environmental law. Georgetown International Environmental Law Review, 15 (3), 497–530. Gupta, R., Gabrielsen, B. and Ferguson, S.M. (2005) Nature’s medicines: traditional knowledge and intellectual property management. Current Drug Technologies, 2, 203–19. Gurib-Fakim, A. (2006) Medicinal plants: traditions of yesterday and drugs of tomorrow. Molecular Aspects of Medicine, 27 (1), 1–93. Hunter, J. and Jones, C. (2004) Bioprospecting and Indigenous Knowledge in Australia: Valuing Indigenous Spiritual Knowledge and its Implications for Integrated Legal Regimes, Indigenous Knowledge and Bioprospecting, Macquarie University, Sydney, Australia. IITC (2002) Summary of the Informal Intersessional Consultations: Geneva 16–19 September 2002. Kaufman, T.S. and Ru´veda, E.A. (2005) The quest for quinine: those who won the battles and those who won the war. Angewandte Chemie International Edition, 44 (6), 854–85. Lassonde, M.C. (2003) The protection of indigenous medicinal knowledge in international intellectual property law, Institute of Comparative Law, Law Faculty, McGill University, Montreal. McKenna, D.J. (2004) Clinical investigations of the therapeutic potential of ayahuasca: rationale and regulatory challenges. Pharmacology & Therapeutics, 102 (2), 111–29. Meshnick, S.R. (1997) Why does quinine still work after 350 years of use? Parasitology Today, 13 (3), 89–90. Naranjo, P. (1981) Social function of coca in pre-Columbian America. Journal of Ethnopharmacology, 3 (2–3), 161–72. Rainey, F. (1946) Quinine hunters in Ecuador, National Geographic Magazine 539, 341–63. Riba, J., Romero, S., Grasa, E. et al. (2006) Increased frontal and paralimbic activation following ayahuasca, the pan-Amazonian inebriant. Psychopharmacology, 186 (1), 93–8.

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Rivera, M.A., Aufderheide, A.C., Cartmell, L.W. (2005) Antiquity of coca-leaf chewing in the south central Andes: a 3,000 year archaeological record of coca-leaf chewing from northern Chile. Journal of Psychoactive Drugs, 37 (4), 455–8. Rocco, F. (2003) The Miraculous Fever-Tree: Malaria and the Quest for a Cure That Changed the World, HarperCollins, London. Sgan, S.L. (1998) Therapeutic uses for cocaine: a historical review. Pharos of Alpha Omega Alpha Honor Medical Society, 61 (1), 23–8. Soejarto, D.D., Fong, H.H.S., Tan, G.T. et al. (2005) Ethnobotany/ethnopharmacology and mass bioprospecting: issues on intellectual property and benefit-sharing. Journal of Ethnopharmacology, 100 (1–2), 15–22. Swazo, N.K. (2005) Research integrity and rights of indigenous peoples: appropriating foucault’s critique of knowledge/power. Studies in History and Philosophy of Biological and Biomedical Sciences, 36 (3), 568–84. Timmermans, K. (2003) Intellectual property rights and traditional medicine: policy dilemmas at the interface. Social Science & Medicine, 57 (4), 745–56. Townley, C. (2002) Intellectual property and indigenous knowledge. Philosophy and Public Policy Quarterly, 22 (4), 21–6. Trotti, J.L. (2001) Compensation versus colonization: a common heritage approach to the use of indigenous medicine in developing western pharmaceuticals. Food and Drug Law Journal, 56 (3), 367–82. WHO (2000) General guidelines for methodologies on research and evaluation of traditional medicine, World Health Organization, Geneva. Wiser, G.M. (1999) PTO Rejection of the ‘Ayahuasca’ patent claim: background and analysis, Center for International Environmental Law. [Online] Available at: http://www.ciel.org/Biodiversity/ ptorejection.html WTO (1994) Agreement on Trade-Related Aspects of Intellectual Property Rights, Geneva. Zarate, Jr. C.A., Singh, J.B., Carlson, P.J. et al. (2007) Efficacy of a protein kinase C inhibitor (tamoxifen) in the treatment of acute mania: a pilot study. Bipolar Disorders, 9, 561–70.

CHAPTER 5

Psychiatric Case Identification Skills of Yachactaita (Quichua Healers of the Andes) Mario Incayawar Director, Runajambi – Institute for the Study of Quichua Culture and Health, Otavalo, Ecuador

Abstract Interest in traditional healers is increasing around the world. However, little attention has been paid to the diagnostic work performed by them. The aim of this exploratory study is twofold; (i) to examine the emic views of llaqui, a widespread Quichua illness category and (ii) to determine if llaqui patients are suffering from medical or psychiatric disorders, and in so doing document the diagnostic abilities of yachactaita (Quichua healers of the Andes). For over 18 months, ten yachactaita participated in the identification of 50 patients suffering from llaqui. The clinical evaluation of these patients indicated that they were suffering from both psychiatric and medical disorders. Eighty-two percent of patients met the DSM III-R criteria for depressive disorders; 44% for somatoform disorders; and 40% for anxiety disorders. None of the patients suffering from llaqui were considered healthy either in bio-medical or psychiatric terms. This study shows that yachactaita are capable of identifying psychiatric cases in their communities.

5.1

INTRODUCTION

Traditional healers and physicians were omnipresent in my life experience. Yachaitaita, Quichua traditional healers in the Andes, were highly respected by relatives, friends and the community. Physicians, on the other hand, were both respected and feared. I have vivid memories from my childhood, of both yachactaita and physicians trying to alleviate and treat the many ailments from which my mother chronically suffered. In the family, we all had high expectations of both practitioners. Equally vivid are my memories of Latino Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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(Ecuador) teachers at elementary and high school, and later at medical school, warning us and at times joking about the primitive, non-scientific and dangerous nature of yachactaita’s practices. As the first son in our family and in the entire Quichua community to go to high school and then to medical school, I always wondered whether yachactaita’s efforts were beneficial or deleterious for patients, including my own mother. Four years after completing my medical training, I was able to explore the yachactaita’s work in some detail. The observations reported in this chapter derive from my research on a widespread Quichua illness category called llaqui. The study was part of my Master’s thesis research at McGill University. Llaqui was not recognized by the latino physicians and professors at my medical school in Quito, Ecuador in the 1980. They regarded it as a superstitious belief of ignorant Indians, a condition of no legitimate clinical significance. Their bias prevented them from recognizing that many thousands, if not millions of Quichua people were suffering from this condition. Some were dying, and many preferred to die in their homes and refused to go to the local hospitals, where their beliefs about illness were often ridiculed, or they were mistreated by racist medical staff. Doctors often diagnosed parasitic diseases, malnutrition, or various gastrointestinal conditions and prescribed analgesics, vitamins or anti-parasitic medications. A widespread condition affecting the Quichuas of the Andes called llaqui, as well as the treatment provided for it by yachactaita practitioners were summarily rejected by the local medical establishment. This is a snapshot of the failures of the dominant biomedical health system in the Andes. Traditional healers have been the subject of study for over a century (Bogoras, 1907). There are numerous research reports from around the world describing traditional healers and their therapeutic practices. Research on this subject covers many aspects, ranging from the social, religious and political roles of healers to the study of their mental status, physician-healer collaboration, treatment efficacy and the characteristics of patients seeking healers’ services (Me´traux, 1949; Boyer, 1961; Silverman, 1967; Kleinman and Sung, 1979; Kleinman and Gale, 1982; Kim and Kwok, 1998; Martinek, 1999). In the Americas, Amerindian healers and their healing methods have been studied extensively, particularly by social science researchers (Maddox, 1923; Jilek and Jilek-Aall, 1978; Robinson, 1979; Kleinman, 1980; Jilek, 1982; Bastien, 1987; Merkur, 1992). They have focused on treatment methods used by traditional healers and on their therapeutic efficacy. However, an important gap in knowledge exists about the diagnostic abilities of traditional healers. Our knowledge is particularly limited to issues related to, for example how healers make a diagnosis, the diagnostic criteria used and their reliability as diagnosticians. This chapter explores some elements of yachactaita’s diagnostic abilities and how well they identify psychiatrically ill patients in the community.

5.2

THE QUICHUA PEOPLE

The Quichuas constitute an Amerindian nation that once made up a large proportion of the Tawantinsuyu, the Inca Confederation, which at its height included present-day Bolivia, Ecuador and Peru, as well as parts of Argentina, Chile and Colombia. In the sixteenth century, Spanish armies invaded and subjugated the Confederation and instigated a regime of domination and exploitation which still persists today, despite the national

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55

independence from Spain gained by those countries in the nineteenth century. Within Ecuador, for example the ruling latino group (people of mixed Spanish and Quichua ancestry who identify themselves as white Westerners and repudiate their Amerindian roots) have replaced the Spaniards as exploiters of the Quichua people. In present-day post-colonial Ecuadorian political structure there is a caste-like social stratification that marginalizes indigenous peoples, and supports institutionalized racism (Casagrande, 1981). This persistent oppression and subjugation has transformed the Amerindians into one of the most impoverished and dispossessed peoples in the world; a distinctive sociopolitical condition of the indigenous people often called the Fourth World (Berger, 1991). The colonial and post-colonial oppression has also been harmful for healers, as they have been victims of witch-hunting campaigns organized by the Catholic Church, the military and the State (Kubler, 1963). Until recently, yachactaita were persecuted, imprisoned and sometimes tortured by the police, who would accuse them of practicing medicine illegally. As a young physician, I witnessed these abuses and spent years, working in the northern highlands of Ecuador, for the liberation of healers and prevention of their imprisonment without trial.

5.3

RESEARCH METHODS

This exploratory case series descriptive study was conducted in Otavalo, in the province of Imbabura, Ecuador. It is part of a larger study entitled ‘Llaqui and Depression: Exploration of a Quichua (Ecuador) Folk Illness Cluster’. The ten participating healers came from three rural Quichua villages. They drew patients from the surrounding areas. The ‘convenience sample’ of 50 patients suffering from llaqui was identified and selected by yachactaita during a period of 18 months. Of the 53 patients who agreed to participate in the study, three refused to continue and were not included in the analyses. We were not able to have a control group for this study. After having given a complete description of the study to the participants, a culturally appropriate family-based and community-based informed consent was obtained. Each of the 50 patients was referred to a physician and psychiatrist by the collaborating healers. Each patient was invited to visit, or was brought by an assistant to the physician’s office located in the town of Otavalo, in order to establish a Western medical and/or psychiatric diagnosis. Each received (i) a structured interview, using the Quichua Questionnaire on the Nature of llaqui; (ii) a medical evaluation, including personal and medical history and physical examination; (iii) laboratory tests, including blood, stool and urine, and x-ray; (iv) a psychiatric evaluation and diagnosis, using the DSM III-R criteria (American Psychiatric Association, 1987); and (v) a Quichua version of the Zung Self-Rating Depression Scale (Zung, 1965). The Zung scale was orally administered by a research assistant, due to the limited formal education of our study participants. The Quichua Questionnaire on the Nature of Llaqui, was prepared in Quichua, and was tested and pretested twice with ten Quichua volunteers. The Zung Scale was translated from English to Spanish and back-translated to English; then it was translated from Spanish to Quichua and back-translated to Spanish. Finally the Quichua version of the Zung scale was tested and pretested with ten Quichua volunteers in order to check the clarity of the questions and the translation accuracy. Our categorical data were analyzed with basic descriptive statistics.

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5.4

PSYCHIATRIC CASE IDENTIFICATION SKILLS OF YACHACTAITA

COMPARISON OF QUICHUA AND WESTERN DIAGNOSIS

The great majority of our patients (94%) reported living in rural villages of the Otavalo area. Most of them were peasant-farmers, artisans and housewives. Fifty-six percent were illiterate, and an additional 34% did not complete elementary school. Our sample was comprised of 54% male and 46% female subjects. Seventy percent of them were married. Almost half the participants (46%) were between 15 to 44 years old. Two sets of data related to Quichua and Western diagnoses are presented. Having the two sets at hand facilitates the comparison of the diagnostic work of Quichua traditional healers and biomedically trained physicians. The main purpose of the comparison is to verify the case identification ability of yachactaita. In this chapter, we do not intend to use the data to document whether or not the Quichua illness category llaqui is equivalent to a particular psychiatric disorder.

5.4.1 The Quichua Diagnosis The Quichua themselves, and yachactaita in particular, identify llaqui as a cluster of four illness sub-categories, namely mancharishca, wairashca, shungu nanay and rurashca. Llaqui is a complex illness category defining a symptom (sadness), the name of an illness, life events and a causal factor of illness. It is essential to recognize the low importance of symptom configuration as a criterion for defining llaqui and its subcategories among the Quichua. Rather, attributed causal factors, either natural or supernatural, play a primary role in defining illness categories. For the frequencies of llaqui sub-categories, see Table 5.1. Table 5.1 Quichua illness diagnoses (N ¼ 50). Illness Sub-Categorya Victim of sorcery (Rurashca) Victim of malign spirits (Mancharishca-Wairashca) Heart pain-shattered heart (Shungu Nanay)

Percentage 64 34 14

a

More than one diagnosis per patient.

For brevity, the two first sub-categories can be merged into one that could be translated as ‘victim of malign spirits’. According to the Quichua, mancharishca or wairashca is a condition resulting from a sudden fright and approaching ‘bad places’. The patient is believed to be under attack by natural spirits or spirits under human control that can damage the patient’s body or spirit. Patients suffering from mancharishca, or wairashca present, from the Quichua point of view, a wide variety of physical and psychological symptoms. In biomedical terms, the condition resembles infectious diseases or certain organic conditions. The third sub-category, shungu nanay (heart pain or shattered heart) is believed to result from adverse life events and from sorcery. From the Questionnaire on the Nature of Llaqui, it is observed that among the Quichuas, land disputes, family conflicts and the death of a relative are the most stressful life events. Quichua people consider epigastric pain and

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57

convulsion-like episodes as key symptoms, or pathognomonic symptoms of shungu nanay. This condition resembles the symptomatology of anxiety and depressive disorders. The fourth sub-category, rurashca (victim of sorcery) is believed to result from the aggression of malign spirits under human control, usually a healer, or by physical or visual contact with materials used in the treatment of sorcery, including plants, food, animals and clothes. Rurashca is the most frequent llaqui sub-category, affecting 64% of our sample. Co-morbidity is not rare; patients can suffer from one or more illness categories simultaneously.

CASE VIGNETTE # 1 Mrs MJ is 26 years old, and the mother of five children (including one who died). She is illiterate, a housewife and has been married for six years. She lives in a small Quichua village near Otavalo, and is a Quichua monolingual. She came to our office accompanied by three family members and her yachactaita, complaining about severe pain in the shungu, the epigastrium and part of the anterior thorax, which radiated towards the lower dorsal and lumbar areas. The pain began suddenly seven days earlier, while she was preparing food, and the pain was severe. She described it as knifelike. For five days, the pain was present most of the time, with relief of about five minutes each 30–60 minutes. The pain resulted in her crying a lot, experiencing headaches, vomiting, perspiring profusely and having palpitation, fever, anorexia, fatigue and excessive sleep. She thought she was going to die. She was extremely worried about the uncertain future her children would be confronted with if she were to eventually die. Mrs MJ told us the pain had subsided following the yachactaita’s intervention, two days earlier. However, the pain had recurred because, she said, she had consumed hot water before coming to our office for the medical consultation. Further questioning revealed she was very sad, had lost interest in everything and only wants to sleep. She cries easily and frequently, and she thinks that the severity of her illness will lead to her death. She is extremely fearful about being the target of sorcery, and insists that she is sick due to the sorcery inflicted on her by her envious neighbors. Mrs MJ communicated clearly, but she spoke slowly and cried easily during the interview. Her mood was depressed and anxious. She was not fully aware of the time and day and her concentration was poor. However, abstract reasoning, memory and grasp of information were intact. She was well informed about her condition in Quichua terms and was actively seeking help, indicating intact judgment and insight. When asked about recent life events, she gave a detailed description of problems within the family and the community she lived in. Two weeks earlier, her alcoholic husband had an altercation with a neighbor, which resulted in this neighbor sustaining a minor head injury. Mrs MJ’s husband was subsequently arrested and imprisoned, and while she was alone at home, the relatives of the injured person came to her home and insulted her, threatening her with sorcery. She felt deeply humiliated and fearful, and she cried inconsolably for several days. There had been friction between the two families prior to the incident that led to her husband’s arrest. Mrs MJ’s husband had inherited a small piece of land from his adoptive father. Mrs MJ and her husband

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(CONTINUED) managed to build a house on this land. However, with the argument that they were not taking good care of the land, the adoptive father dispossessed them of their land and house. The neighbor who had been involved in the altercation with Mrs MJ’s husband was a friend of his adoptive father. This man became an enemy and told Mrs MJ and her husband that they would be the targets of sorcery. According to Mrs MJ, it was during this land dispute that she dreamed of the police coming to their house, tying her hands and taking her to prison. She had also dreamed of frightening and dark water springs, small lakes, and streams. She had woken in a panic. Two days later, her husband was arrested and sent to prison, and her current illness episode started. Mrs MJ is an only child who was abandoned by her father when she was two years old. Her mother died when she was three. Her aunt adopted her, and according to the patient, her childhood years were healthy and happy. It is worth noting that her two cousins went to school, but she did not. She was put in charge of domestic work, and took care of the family’s animals. Today, she realizes the unfair treatment she received from her adoptive parents. When she was 15, she went to Quito, the capital city, to work as a domestic servant. At 18, she met the man who is now her husband. Her life in her first years of marriage could not have been more frightening. Her husband beat her frequently and threatened to kill her. He was equally brutal whether drunk or sober. The reason for his beatings was that she was an orphan, and had no inherited land. After years of enduring the situation on her own, her aunt and female neighbors learned of the abuse, and confronted her husband. He became less abusive toward Mrs MJ, but accused her of having children who were not his own. These accusations and humiliations were almost unbearable for Mrs MJ. She separated from her husband a couple of times for short periods, and on one occasion she went to court for a formal divorce. During this time her fourth child died. Currently, the marriage is going quite well, but both are worried about their ability to keep their land and house. They feel rejected by their neighbors and the community; they feel intensely socially isolated. Mrs MJ mentioned that she has suffered from shungu nanay (heart pain or shattered heart) since childhood. She has had at least four episodes per year, each episode lasting about one month. ‘Life has not been easy, and I was often times hit by the illness’, she said. Interestingly, the illness disappeared during the first two years of marriage, and reappeared when she was applying for divorce. Mrs MJ is familiar with the use of several plants for the treatment of shungu nanay, and she mentioned that she had, in the past, taken some pills for relief of pain and sadness (one she recalled was aspirin). The yachactaita made the diagnosis of shungu nanay. The patient and relatives seemed satisfied with the healer’s diagnosis, as they constantly used this label for referring to her illness experience. Western clinical diagnosis: Pain Disorder Associated with Psychological Factors, Chronic (code 307.80) and Major Depression, recurrent (296.33), and Parasitosis; Psychosocial stressors: threatened with sorcery, removed from house and land; GAF current 45, GAF past year 55; Zung Depression score 75 (severe).

COMPARISON OF QUICHUA AND WESTERN DIAGNOSIS

CASE VIGNETTE # 2 Mrs JC was 50 years old, married, and mother of nine children. She was born in a remote village in the Otavalo region of Ecuador and completed three years of elementary school. She spent most of her life as a housewife, doing some agricultural work, and as a textile weaver. Mrs JC came to our office in company of her yachactaita (Quichua healer), who had given her the Quichua diagnosis of rurashca (victim of sorcery). For two weeks, she had suffered severe headaches, cough, fever and muscular pain. She told us that she was very thirsty and weak, and that other family members were suffering from the same symptoms. We found normal vital signs, throat redness and obstruction of the left auditory canal with cerumen. Suspecting a common cold, she was advised to take liquids in the form of herbal infusions and soup. Her ears were washed thoroughly and she was recommended to come back in a week. One week later, her flu symptoms had receded but she returned with a severe pain in the upper chest, right anterior axillar line that prevented her from breathing deeply and talking. The pain radiated to all the chest area and arms. The pain started after her usual agricultural activity two days earlier. Following our invitation to discuss her feelings about her illness experience, Mrs JC mentioned that two days earlier, she had encountered several lizards on the road and believed they were powerful evil spirits that were now causing her pain; a condition she identified as wairashca (victim of malign spirits). She believed she was extremely vulnerable to wairashca because she was being attacked with sorcery, rurashca. The fact that her pregnant pig (of important local value) was sick and one cow had died recently, had made her suspect that she was a victim of sorcery. For the past three years, Mrs JC had been constantly worried about her farm animals. She cried a lot and her hands were shaky. She told us she was deeply worried that all her animals would eventually die and she would, accordingly, lapse into extreme poverty. She was sad most of the day and almost every day. She felt tired, sleepy and had no energy to work. Her appetite had decreased and she had lost weight. Mrs JC mentioned that she had suffered from back pain, worries and sadness since her youth. Conditions such as wairashca , shungu nanai (heart pain) and rurashca had afflicted her most of her life, although lately her condition had become more severe. Mrs JC had had difficult relationships with family and neighbors throughout her life. When she was seven years old, she saw her father die while harvesting crops. Her mother died when she was 15 years old. The older of her two sisters was never kind to her, and sometimes berated her severely. According to Mrs JC, her neighbors were hostile and violent. On one occasion, a neighbor family had accused her of stealing potatoes and she had been beaten by a male member of that family. After that incident, the neighbor family started using portions of her property to feed their farm animals and cultivate their corn. The same neighbors accused her family of stealing a cow. She was arrested and sent to prison. Sadly, the hostile neighbors were relatives of her husband. Mrs JC believed her neighbors were envious people. She explained they were envious because despite being an orphan, she worked hard, managed to build a house and buy a piece of land, and was able to save some money. She now strongly believed her

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(CONTINUED) neighbors were attacking her with sorcery, and consequently, her pigs, sheep, goats, cows and chickens were dying. She believed that even the destruction of her new house in an earthquake was caused by sorcery. The yachactaita treating her confirmed that family members were trying to make her sick or cause her to die by means of powerful sorcery. The yachactaita made the diagnosis of rurashca. Western clinical diagnosis: Undifferentiated Somatoform Disorder (code 300.82); Generalized Anxiety Disorder (300.02); and Major Depression, Recurrent with Culturally Mood-Congruent Psychotic Features; and Parasitosis; Psychosocial stressors: land disputes, unfair imprisonment, conflict with neighbors and family, livestock death; GAF current 45, GAF past year 55; Zung depression score 68 (severe). Note: It was a challenge to determine that our patient had delusions of being the victim of sorcery. This is a culturally common theme among the Quichua, but the healer and myself found it quite disruptive and deviant (in number, severity and content) from the local Quichua standards. Even the earthquake was sorcery directed to her. The patient’s convictions made members of the patient’s family feel uncomfortable and made the healer (who is knowledgeable about the distinctions between normal and abnormal in Quichua culture) express she was clearly deviant. Therefore, we decided that her persecutory ideas were delusional.

5.5

THE WESTERN CLINICAL DIAGNOSIS

The medical, psychiatric and psychometric evaluations of the same 50 llaqui patients reveal the high frequency of depressive disorders and parasitic and infectious diseases among them. Eighty-two percent of patients met the DSM III-R criteria for depressive disorders; 44% for somatoform disorders; and 40% for anxiety disorders. Over 80% of them were also suffering from infectious and parasitic diseases. None of the patients suffering from llaqui were considered normal in Western medical or psychiatric terms. Patients had more than one condition simultaneously, and co-morbidity with somatoform disorders and anxiety disorders was frequent. The Zung scores, reflecting the severity of depression, were consistent with the psychiatric diagnoses. All patients in Table 5.2 Western psychiatric diagnoses (N ¼ 50). Diagnosesa Depressive Disorders Somatoform Disorders Anxiety Disorders Psychological Factors Affecting a Physical Condition Adjustment Disorder a

Percentage

Zungb

82 44 40 26

65 63 59 62

10

54

Mean 2.2 diagnoses per patient. The Zung depression scale scores are the mean of the entire diagnostic category.

b

DIAGNOSTIC ABILITY OF YACHACTAITAS

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Table 5.3 Western medical diagnoses (N ¼50). Diagnosesa Parasitic and infectious diseases Ophthalmologic diseases Anemia Neurological diseases Protein-calorie malnutrition

Percentage 80 18 14 10 10

a

Mean 1.58 diagnoses per patient.

our sample received some type of psychiatric diagnosis and most of them also suffered from physical diseases. Clearly, our 50 llaqui patients were sick and in need of medical and psychiatric care, see Table 5.2 and 5.3.

5.6

DIAGNOSTIC ABILITY OF YACHACTAITAS

Patients suffering from llaqui when evaluated medically and psychiatrically by a Quichua biomedically trained doctor, were found to be suffering from serious psychiatric disorders and medical conditions. All 50 Quichua patients identified by yachactaita as suffering from llaqui met the DSM-III-R criteria for several psychiatric disorders, including depressive, anxiety and somatoform disorders. In addition, the Quichua version of the Zung Self Rating Depression Scale also showed consistent scores of depressive symptoms in the severe range. The triangulation (multiple evaluative tools and approaches) used in the design of this study enhanced the validity of the findings and contributed to the robustness of their interpretation. None of the patients suffering from llaqui were found to be completely normal in either biomedical or psychiatric terms. Our llaqui patients were acutely ill and in need of medical and psychiatric care. The findings of this study show that both the biomedically trained doctor and the yachactaita are identifying patients as acutely symptomatic. There is a high degree of concordance in the diagnostic work of the physician and the Quichua healers. The Quichua healers, using supernatural and life events notions of causation, are able to identify psychiatrically ill people. The criteria (related to social, community, psychological and familial dimensions), that yachactaita use to evaluate their patients and the means they use to arrive at a diagnosis need to be elucidated by further research. The author is currently addressing this issue in a study entitled ‘Understanding the Diagnostic Skills of yachactaita (Quichua healers of the Andes)’. This exploratory study is part of a larger study on llaqui and depression among the Quichua in the Andes (Maldonado, 1992). It was not specifically designed to assess the diagnostic abilities of Quichua traditional healers. Nevertheless, the findings of the study reported in this chapter are a first detailed report about the diagnostic abilities of yachactaita. A short report has been published recently (Incayawar, 2008).

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5.7

PSYCHIATRIC CASE IDENTIFICATION SKILLS OF YACHACTAITA

TRADITIONAL HEALERS’ DIAGNOSTIC ABILITIES IN OTHER SOCIETIES

Our findings reported in this chapter are consistent with studies of the diagnostic skills of traditional healers conducted in other cultural settings. Beiser, in his study in Senegal of 32 Serer patients suffering from ‘illness of the spirit’, found that what is considered disordered behavior by the Serer was also recognized as deviant behavior by him, as a psychiatrist. Beiser concluded that the Serer have identified patterns of behavior that resemble many psychiatric syndromes (Beiser et al., 1972). Westermeyer’s study of 36 patients in Laos suffering from the indigenous category ba (crazy, insane) and three patients affected by sia chit (nervous breakdown, nervous problem) shows a similar result. Four clinicians performed clinical evaluations, using ten psychometric scales, and spending ten to 15 hours with each patient. The clinical and psychometric scores showed serious psychopathology among the ba patients. Westermeyer concluded that ‘Lao villagers, mostly illiterate and living in a society without psychiatrists, are able to recognize psychosis with a high degree of reliability vis-a`-vis experienced clinicians’ (Westermeyer and Zimmerman, 1981). Interestingly, Jones’s qualitative study among the Maori in New Zealand found similarities in the overall diagnostic approaches used by traditional healers and biomedically trained Western physicians. Similar to Western diagnosticians, Maori traditional healers consider diagnosis important in their work. However, diagnosis was not always needed in order to start treatment. Maori’s diagnostic work included history taking, doing a physical examination and performing an ‘extraordinary observation’ which involved a spiritual examination, analogous to further examination done by physicians when they use laboratory examinations and x-rays (Jones, 2000).

5.8

CLINICAL, RESEARCH AND HEALTH POLICY IMPLICATIONS

Realizing the apparent connection between the Quichua illness llaqui and Western psychiatric categories, as well as the psychiatric diagnostic skills of yachactaitas, have important clinical, research and health policy implications. This new perspective could translate in improved quality in the mental health care provided for the indigenous peoples of the Andes. Substantial changes in psychiatric clinical practice will inevitably follow the recognition of yachactaitas’ diagnostic abilities. Traditional healers would become professional partners capable of helping improve the mental health of patients in the clinical setting or the national public health scene. Thousands of traditional healers in the Andes are already identifying patients and providing culturally meaningful treatments. Their work could be introduced in hospitals, clinics and doctors’ offices where patients (with Quichua, Latino, Black and other ethno-cultural backgrounds) could benefit from biomedical and Quichua medical interventions. Psychiatric patients and families in the Andes (regardless of ethnicity) are used to seeking services from both medical systems. What will change with the professional recognition of yachactaitas’ clinical skills is that patients will now find within the hospitals and clinics a familiar health professional, namely the traditional healer. The collaboration of biomedically-trained doctors and yachactaitas in providing psychiatric care would result in better diagnosis of psychosocial stressors and biomedical conditions,

CONCLUSION

63

increased patients’ and relatives’ satisfaction, better adherence to treatment plans and ultimately better outcomes. However, the details of what clinical realm pertains to each type of practitioner, what its constraints are, etc., remains to be determined. Twenty years ago, we initiated an innovative medical service called Jambihuasi, in Otavalo, Ecuador. The initiative proposed to work in a model that included biomedical doctors and traditional healers sharing a unique space (the clinic) but keeping separate offices. Consultations concerning diagnosis and treatments were encouraged, and referrals to specialists located in urban centers were done regularly. The model proved successful. The local community accepted it well. It also helped the medical community gain local acceptance of traditional healers. More information about this Quichua initiative is offered in the chapter in this book by Dr Lise Bouchard. If mental health researchers and health policy makers accept that yachactaitas are skilful diagnosticians, we can anticipate two important effects in psychiatric research. It will open up a rich field for inquiry concerning inter-rater and intra-rater reliability studies of healers as diagnosticians, comparative studies of cross-cultural diagnosis (Quichua and Western) and studies of treatment safety and efficacy, to name a few. Furthermore, the diagnostic skills of traditional healers and their high level of acceptance in their communities make them ideal partners to conduct community-based psychiatric research. Their diagnostic abilities could be very useful for screening purposes. Indigenous communities, including the Quichua, are quite suspicious about the motives of Western psychiatric researchers. Their suspicious attitude is consistent with centuries of colonization and exploitation, which often times jeopardizes valuable psychiatric research among indigenous people. Traditional healers could become ideal research partners and cultural brokers that will greatly facilitate the design and implementation of scientific research. Finally, countries with a sizeable number of skilled traditional healers, such as the Andean countries in South America, need to reconsider their assumptions about their human resources for providing health care. Mental health planners and mental health policy makers could gain impact by adopting a more inclusive approach working with clinically skilled traditional healers. Mental health policies that make rational use of traditional healers in the workforce could benefit millions of people living in rural communities. This is especially true for countries such as Ecuador, which have very great health and mental health disparities between latino and Quichua segments of the population. These are Andean countries negligent and incapable of serving rural communities in general and the indigenous peoples communities in particular (Incayawar, 2007). In addition, with the participation of traditional healers in national health programs, the available and future national health care services could benefit greatly from the trust and prestige enjoyed by traditional healers. The current health services could gain acceptance by the Quichua communities and patients who often times refuse to seek care in hospitals and clinics and sometimes prefer to die at home rather than be treated in hospitals with culturally alien clinical staff.

CONCLUSION Our exploratory study on the diagnostic work of yachactaita (Quichua healers) indicates that they are able to identify psychiatric cases in the community. Although conclusions on yachactaita diagnostic abilities are still tentative, due to methodological limitations, it

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remains an intriguing finding. At the very least, the findings reported in this chapter make it more difficult to simply dismiss the concept of traditional healers having diagnostic and clinical acumen. If Western oriented health practitioners seriously questioned their assumptions about indigenous healers being primitive or fake practitioners, there would be greater potential for fruitful collaboration. It is worth mentioning that healers in many societies hold Western doctors in high esteem and they are quite willing to collaborate (Hewson, 1998). Such collaboration has been hindered by the biases of Western-trained practitioners. Our report challenges the Ecuadorian medical community view of healers as charlatans, and instead highlights their potential role in favorably influencing clinical practice, psychiatric research and health policy in the Andean region.

ACKNOWLEDGMENT This study was funded in part by a John Simon Guggenheim Memorial Foundation Fellowship in 2006 and in part by Fonds FCAR No. 892027-1, Quebec, Canada. I would like to thank Sioui Maldonado Bouchard for her assistance in reviewing the English usage. My deepest gratitude goes to Ronald Wintrob, MD, for his insightful and useful comments.

REFERENCES American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders DSM-III-R, 3rd revised edn, American Psychiatric Association, Washington, DC. Bastien, J.W. (1987) Healers of the Andes – Kallawaya Herbalists and Their Medicinal Plants, University of Utah Press, Salt Lake City. Beiser, M., Ravel, J.L., Collomb, C. and Egelhoff, C. (1972) Assessing psychiatric disorder among the serer of Senegal. The Journal of Nervous and Mental Disease, 154, 141–51. Berger, T.R. (1991) A Long and Terrible Shadow – White Values, Native Rights in the Americas, 1492–1992, Vancouver, Douglas & McIntyre. Bogoras, W. (1907) The Chukchee. American Museum of Natural History, New York. Boyer, L.B. (1961) Remarks on the personality of shamans. Psychoanalytic Study of Society, 2, 233–54. Casagrande, J.B. (1981) Strategies for survival: the Indians of highland Ecuador, in Cultural Transformations and Ethnicity in Modern Ecuador (ed. N.E. Whitten) University of Illinois Press, Urbana, pp. 260–77. Hewson, M.G. (1998) Traditional healers in southern Africa. Annals of Internal Medicine, 128 (12 Pt 1), 1029–34. Incayawar, M. (2007) Indigenous peoples of South America – inequalities in mental health care, in Culture and Mental Health – a Comprehensive Textbook (eds K. Bhui and D. Bhugra) Hodder Arnold, London, UK, pp. 185–90. Incayawar, M. (2008) Efficacy of Quichua healers as psychiatric diagnosticians. The British Journal of Psychiatry, 192 (5), 390–1. Jilek, W.G. (1982) Indian Healing – Shamanic Ceremonialism in the Pacific Northwest Today, Hancock House, Surrey, BC. Jilek, W.G. and Jilek-Aall, L. (1978) Psychiatrist and his shaman colleague: cross-cultural collaboration with traditional Amerindian therapists. Journal of Operational Psychiatry, 9, 32–9. Jones, R. (2000) Diagnosis in traditional Maori healing: a contemporary urban clinic. Pacific Health Dialog: A Publication of the Pacific Basin Officers Training Program and the Fiji School of Medicine, 7 (1), 17–24. Kim, C. and Kwok, Y.S. (1998) Navajo use of native healers. Archives of Internal Medicine, 158 (20), 2245–9.

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Kleinman, A. (1980) Patients and Healers in the Context of Culture – an Exploration of the Borderland Between Anthropology, Medicine, and Psychiatry, University of California Press, Berkeley. Kleinman, A. and Gale, J.L. (1982) Patients treated by physicians and folk healers: a comparative outcome study in Taiwan. Culture, Medicine and Psychiatry, 6 (4), 405–23. Kleinman, A. and Sung, L.H. (1979) Why do indigenous practitioners successfully heal? Social Science and Medicine [Medical Anthropology], 13B (1), 7–26. Kubler, G. (1963) The Quechua in the colonial world, in Handbook of South American Indians (ed. J.H. Steward), Cooper Square, New York, pp. 331–410. Maddox, J.L. (1923) The Medicine Man – a Sociological Study of the Character and Evolution of Shamanism, The Macmillan Company, New York. Maldonado, M.G. (1992) Llaqui Et De´pression; Une Etude Exploratoire Chez Les Quichuas (Equateur), MSc., Department of Psychiatry, McGill University, Montreal. Martinek, C.R. (1999) Collaborating with native healers. Advance for Nurse Practitioners, 7 (4), p. 84. Merkur, D. (1992) Becoming Half Hidden: Shamanism and Initiation Among the Inuit, Garland, New York. Me´traux, A. (1949) Religion and shamanism, in Handbook of South American Indians – the Comparative Ethnology of South American Indians (ed. J.H. Steward) United States Government Printing Office, Washington, DC, pp. 559–99. Robinson, S.S. (1979) Toward an Understanding of Kofa´n Shamanism, Ph.D., Cornell University, New York. Silverman, J. (1967) Shamans and acute schizophrenia. American Anthropologist, 69, 21–31. Westermeyer, J. and Zimmerman, R. (1981) Lao folk diagnoses for mental disorder: comparison with psychiatric diagnosis and assessment with psychiatric rating scales. Medical Anthropology, 5, 425–43. Zung, W.W.K. (1965) A self-rating depression scale. Arch Gen Psychiatry, 12, 63–70.

CHAPTER 6

A Western Psychiatrist among the Shuar People of Ecuador Exploring the Role of Healers in Mental Health Joan Obiols-Llandrich Psychiatrist and Anthropologist, Director Mental Health Services, Andorra; Professor of Mental Health, University of Andorra

Abstract The Shuar people live in the Upper Amazon area of Ecuador. Partially acculturated, most of the population, living in small settlements in the middle of the Amazon forest, maintain their traditional culture, including their healing system. As in other traditional societies, witchcraft tends to be the main explanation for illness, and the healers, wishin in Shuar language, are in charge of manipulating the energies imputed to healing or harming individuals in Shuar communities. They use a variety of healing techniques, although the best known is the use of a hallucinogenic compound called natem (or ayahuasca – meaning ‘the devil’s rope’ in Quichua). The Shuar explanatory model of illness is described, based on fieldwork by the author among the Shuar people. Some personal experiences in providing Western medicine among the Shuar are presented.

6.1

INTRODUCTION

Some years ago, as a member of a multidisciplinary team, I had the opportunity to visit the Amazonian region to study some psychiatric practices of the Shuar – known regionally by the pejorative term Jibaros. My study focused on the healing ceremonies that used vegetal hallucinogenic beverages. The project was led by an anthropologist, Josep M. Fericgla, who had extensive experience in the study of modified states of consciousness in different cultures. He had previously done fieldwork among the Shuar people in the area where we stayed, and had prior contact with several healers. An ethnomusicologist, Josep Martı´, was also part of the team. He concentrated on the study of the ritual chants sung by the healers during their healing ceremonies.

Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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A WESTERN PSYCHIATRIST AMONG THE SHUAR PEOPLE OF ECUADOR

As a cultural psychiatrist, I was interested in observing the healing ceremonies in order to become familiar with the explanatory model for diseases used by the Shuar healers. In addition, I had the opportunity to make some observations on the prevalence of mental diseases among the Shuar (Obiols, 2001). Another psychiatrist, Jorge Atala and a psychologist, Mireia Recasens, took care of this new aspect of the project that allowed us to draw some – provisional – conclusions on the prevalence of mental illness among the Shuar. Since we were particularly interested in the use of hallucinogenic compounds, the project included studying its effects on EEG brain activity. A very simple, portable two-channel EEG recorder was used. As frequently happens with this kind of anthropological fieldwork, the time I spent among the Shuar represented a milestone in my life. Beyond the scientific work developed, I benefited from the personal contacts I made, the life experiences I encountered and the personal experience as a whole. In this anthropological study, the participant observation method was used, including both emic and etic perspectives. In some of the ceremonies we had direct experience with hallucinogenic beverages. We tried to go beyond a pure, supposedly objective, description of the healing ritual, by experiencing it in a subjective, direct way. We were aware that the meaning of the experience was very different for the Shuar individual, who shared a different cultural belief system compared to ours, no matter how sympathetic we felt towards the Shuar culture.

6.2

THE SHUAR CULTURE

The Shuar community is an indigenous population of the Amazonian rain forest region of Ecuador, in South America. The Shuar population numbers about 45 000, although the exact number is not known and might be as high as 60 000. They are considered the most numerous and powerful community of the five that form the great Jibaro family: the Shuar themselves, the Achuar, the Huambissa or Aguaruna, the Kantuash and the Patukmei Shuar. They live on the western side of the Andes, in a tropical forest region between the Pastaza and Santiago rivers. Their territory mostly belongs to the southern forests of Ecuador, as well as a small northern area of Peru. They mainly live from hunting, collecting fruits and roots and from some cultivation of vegetables, and continue to maintain their traditional way of life and social structure. Part of the Shuar population lives in the borderline area of the forest and has been under intense acculturative stress due to increasing contact with the ‘colon’ (mestizo) population: the Spanish word mestizo, is derived from the Latin for the mixture of European and indigenous people. The Shuar people have had to struggle to survive culturally and economically. Life in the rain forest has become harder to sustain as hunting and fishing are much less productive than decades before. Deforestation is severely impacting their living conditions and ultimately forcing them to migrate and settle in mestizo villages or cities. The result is a profound change of the traditional culture that might now be considered to be in grave danger of being lost. Mestizo settlers are coming from many parts of Ecuador looking for new opportunities. Many Shuar people, through contact with the Spanish-speaking settlers, have learned Spanish. In this regard, the work of the Italian and Spanish Salesian missionaries has been crucial in the assimilatory practices in the region. However, the majority of Shuar people continue to speak their own language.

THE SURVEY

69

A cultural practice has been mentioned earlier and is far from disappearing. It refers to the heavy consumption of several hallucinogenic beverages reputed for their curative characteristics.

6.3

SHUAR HALLUCINOGENIC USE

The Shuar use a very powerful compound called maikiwua. It is made from different species of the Brugmansia plant. They are very close to the Datura. Both have been widely employed by many indigenous peoples in North and South America (Schultes, 1994). The Shuar prepare several different kinds of maikiwua according to the different intended uses, such as having visions for adults, having visions for children, for dogs, to cure bone fractures, among others. The maikiwua might be highly toxic and have continuing effects (lasting more than two days) (Mader, 1999). The Brugmansia are known for containing the tropane alkaloids atropine, scopolamine and hyoscyamine, which can induce anticholinergic toxicity. Initial symptoms include dry skin, blurred vision, tachycardia and urinary retention, followed sometimes by fever, confusion, agitation, seizures, coma and even death. (Wagner and Keim, 2007) Besides maikiwua, the more famous of these hallucinogenic compounds is natem (in the Shuar language) also known as ayahuasca (the Quichua term) outside their territory. The name natem refers to a liana, Banisteriosis Caapi, from the Malpighia family, containing beta-carbolines alkaloids like harmine, tetrahydro-harmine and harmaline, known to have a MAOI (mono-amine-oxydase inhibitor) action. The hallucinogenic property comes, in fact, from other plants; Diplopterys Cabrerana or Psychotria Viridis, leaves containing DMT (dimethyl tryptamine). Interestingly enough, DMT is known to be a powerful hallucinogenic agent, but it is almost inactive when taken alone and orally. It is the combination with the beta-carbolines and their MAOI action that permits DMT to fully exert its action (McKenna, Towers, and Abbott 1984). It is significant that such a combination was found by the Amazonian indigenous peoples, if we consider that more than 30 000 different vegetal species exist in this area. A mixture purely by chance is highly unlikely. The Shuar healer controls the elaboration of the natem compound and during healing ceremonies will consume the beverage himself and sometimes administer it to their patients. The visionary experience will allow them to diagnose patients, as well as make predictions about the future. It is common, then, for Shuar people to resort to natem when confronted with important decisions in their life, such as deciding whom to marry, for example. Another attributed virtue of natem ingestion is to enable people to foresee events taking place far away in place and possibly also in time. Spirits are believed to mediate those amazing visionary powers. This visionary world is for Shuar people the real one. Conversely, the day-to-day experience, without the natem (or maikiwua) influence, is considered the unreal world.

6.4

THE SURVEY

The goal of our study was to determine the extent of ayahuasca use and other substances, including the alcoholic beverage called mamma made of fermented yuca (mandioca), I present the results from the survey made about the consumption of these compounds (Atala et al., 1995). The sample was comprised of patients attending a small mobile primary

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health care clinic in the communities of Sevilla Don Bosco, San Juan Bosco, Uunt Chiwas, San Luis, Uunt Paastas and Yaupi. All people older than 15 years were asked to participate. Nobody refused to participate in the survey. One hundred and thirteen questionnaires were considered valid. A Shuar assistant read the questions, as illiteracy is very high. Seventy-six percent of the respondents were female and 33% were males. This gender difference could be explained because many males were away; hunting or fishing at the time our team offered the free clinic. The mean age was 36.8 years (Standard Deviation: (SD) 15.5) for men and 34.0 (SD: 14.2) for women. All individuals were familiar with drinking the alcoholic beverage mamma. Eighty-two percent had consumed natem, maikiwua or both. There was a high correlation in the consumption of both hallucinogenic compounds. Men consumed more drugs than women: 46% of men had consumed maikiwua five or more times, as compared to 11% of women. The percentages for natem were 57 and 8, respectively. A bias might exist, as it was not possible to build in a random sample in a controlled way, but the results probably reflect the average use of the compounds among the Shuar population. Ayahuasca or natem is not exclusively used by the Shuar people. Many Amazonian indigenous peoples have been using it for centuries and it has also gained wide popularity and use outside the Shuar area. In Brazil, among the non-indigenous population, the consumption of ayahuasca has been linked to some syncretic religious cults. More than 20 different churches have developed: the Santo Daime or the Uniao do Vegetal, among others. They organize group ceremonies in which small doses of ayahuasca, as a ritual communion, are distributed. This kind of use has found its way to the USA and Europe, among what has been called ‘new age cults’ or ‘neo-shamanic’ circles.

6.5

PREVIOUS RESEARCH IN THE SHUAR AREA

The Shuar culture has been subject to substantial study among anthropologists. A review of the available information was conducted in order to combine this previous knowledge with the findings of the present research. The material presented comes from the author’s fieldwork in the 1990s in the area of Macas, in the province of Morona Santiago, particularly the villages of Uunt Paastas and Utungush. I had the opportunity to be present during several shamanic ceremonies and to interview several shamans, as well as people treated by them and their families. A classical anthropological monograph about the Shuar derived from the fieldwork by Karsten between 1916 and 1929. (Karsten, 1935). Much of Karsten’s description is still valid today. Another important source of information is the work of the American anthropologist Michael Harner (Harner, 1972; Harner, 1973). He became so interested in the use of the hallucinogenic compounds of the Shuar, and was so impressed by his own experiences, that he became one of the pioneers of ‘neo-shamanism’ in the USA (Harner, 1980). The mythological perspective is well covered by the German anthropologist Elke Mader (Mader, 1999). From an emic perspective, we also have some works on the shamanic world of the Shuar written by Shuar writers (Chinkim, Petsain and Jimpikit, 1987; Antun and Chiriap, 1991). Finally, the director of the research project described in this chapter, Josep M Fericgla, has spent several years among the Shuar and published several reports (Fericgla, 1994; Fericgla, 1997).

FIRST STEPS IN THE SHUAR TERRITORY

6.6

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FIRST STEPS IN THE SHUAR TERRITORY: COLLABORATING AS A PSYCHIATRIST

The long drive from Quito brought us to a village of about 2000 inhabitants at the time, in the Amazonian area. The people of the study village are mostly ‘colonos’, mestizo people who have come from other areas of Ecuador to settle in the Shuar territory. It is impressive to find there an enormous Catholic church, built with expensive materials. The size and the richness of this building goes far beyond what one would expect in a place where poverty is predominant. At the same time, it is a clear symbol of colonialism exerted by the Ecuadorian government and the Catholic Church, and a sad symbol of the acculturative stress process endured by the Shuar. Education, medical assistance and other social services are available through the missionaries, but at the cost of accepting the Catholic religion. I was introduced to Dr A, a physician from urban Ecuador, who had been living for years in this remote area. His extroverted and enthusiastic personality helped him to be accepted by all the different segments of the population. So, it was with pleasure that I accepted his invitation to share his consultation time. For some days, I sat at his side, seeing how skilful he was at interviewing his patients, both mestizo and Shuar. Usually his patients were not reluctant to explain some alternative therapeutic methods they have used. I was surprised how often many patients had tried to treat their ailments through the use of maikiwua applied locally. Its use is not free of side effects, and one of the cases we saw was a young woman presenting a unilateral pupil dilatation provoked by an accidental maikiwua drop when she was preparing it to cure an ill animal. Dr A was eager to have my advice about many of his patients whom he considered quite rightly as suffering from psychiatric disorders, something very usual in primary health care. I was happy to help him. In the beginning, I was somewhat worried that the cultural distance might represent a problem in my understanding of the psychiatric symptoms expressed by patients. But, I was struck by the fact that, far from finding such cultural barriers, I was able to notice the expression of suffering through well known symptoms of anxiety and depression, not so different from what I was used to seeing in Spain; for example, somatization expressed through physical pain, discomfort in many bodily regions and psychological conflict. While psychiatrists are aware of these idioms of distress, it was not so easy to make this understandable to most patients presenting somatic symptoms. Dr A was conscious of the problem and provided good advice to his patients, along with benzodiazepine medication. He was relieved to learn that he was treating his patients appropriately. Nevertheless, I was even more surprised to notice, in the following weeks, in the forest, in the small Shuar communities where we stayed, that, again, I heard about the same problems. To begin with, Shuar people living in the depth of the forest, in places that took a whole day’s walk through the jungle to arrive there, seemed quite familiar with what a psychiatrist was. It must be said that, although living in isolated areas, the Shuar sometimes leave their villages to visit members of their families living in more Western oriented villages, trade at the regional markets and are aware of what is going on, including watching some television and other urban activities. So the role of a psychiatrist was not unknown for most of them. After a few days of building trust and confidence in my presence in their village, I was discreetly approached by some individuals worried about their life problems. Of the six people who consulted me, five were females and one was male. The description of their problems sounded familiar to me, as they were not essentially different from the problems

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I had been treating for almost 20 years in my psychiatric practice in Spain. Unfaithful husbands were quite a common complaint, as well as disrespectful husbands, and sometimes physically abusive ones. The complaints sometimes extended to the person’s teenage sons and daughters, who were not courteous and respectful enough toward their mothers. Family conflicts of all kinds were mentioned, especially strained relations with the motherin-law. In one case, if available, I would even have prescribed an antidepressant, as the symptoms, after a pathological mourning, were severe enough to justify it. However, I was only able to listen and give some advice, trying to make it culturally appropriate. One man who consulted me, a shaman himself, complained about the jealousy of his wife as a problem he felt unable to cope with. Far from my initial research plans, I found myself practicing as a psychiatrist and learning a great deal from the experience. My unexpected patients were respectful and grateful at the same time. I felt somewhat as if they considered me a sort of Western shaman and maybe this consideration had motivated them to seek my help. I felt grateful, too, for the trust they placed in me, opening their hearts to a stranger and accepting my advice. Maybe this was a first step in the unwitting partnership between psychiatrists and healers, in this case by sharing the patients, as the shaman in the community was well aware of these consultations. My overall impression was that human beings, beyond their undeniable cultural differences, tend to express their psychological distress in quite similar ways.

6.7

WITCHCRAFT AND DISEASE

For the Shuar people, the possibility of witchcraft is ever-present and is the main explanation for most diseases and non-violent deaths. The roots of witchcraft, as in many other cultures, seem to be envy. This feeling is very common and might develop inside the family itself, among rival families due to some previous conflict, among neighbors, among shamans as one might envy some magic powers from another shaman, etc. Witchcraft encompasses a set of beliefs and behaviors, so it is linked to religious beliefs, implying the belief in something or somebody stronger or more powerful. At the same time, witchcraft is a social fact, strongly embedded in individual and group behavior as a way of interpreting and justifying all sorts of misfortunes, losses and illness experiences that occur in life. And, of course, it is also a psychological conviction: many Shuar people have supposedly died after being convinced that they were witchcraft victims and not finding magic power through a Shuar shaman strong enough to counteract the effects of witchcraft. The theory of illness among the Shuar is mainly psychological, because they consider a person becomes ill when their soul is ill. This illness might be caused simply by the individual fearing some potential enemy. Therefore, to solve the problem, the sick person needs the help of somebody powerful enough to remove the witchcraft or ‘malign magic’, namely the Shuar shaman, the wishin.

6.8

THE WISHIN (THE SHUAR SHAMAN)

The term wishin means, in Shuar, shaman, the man (women can be wishin, but infrequently) with power, capable of diagnosing and then mobilizing, through precise and complex rituals, the supernatural strengths required to produce healing. Among the more acculturated Shuar, the Spanish term curandero is also used.

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73

In order to develop their powers the wishin has to endure an initiation process. When somebody is interested in developing this condition, they have to ask a known wishin to fulfill the role of mentor. The master can be a family member or somebody else. This knowledge has to be paid for, with money or some material goods. The process is a long one and requires long fasting periods, isolation in some particular places, sexual abstinence for a time, drinking the natem, learning to control the ‘magical arrows’, the tsentsak, little by little, learning to sing the anent, and many other aspects, so that the candidate acquires the magical powers that will allow them, in the end, to become a full wishin. The Shuar distinguish two different types of wishin. One is the tsuakratin, the good healers, who are well respected within the Shuar community. Shuar society strongly trusts the tsuakratin, and people share the explanatory model about the origin of illness – witchcraft – and about the ritual needed to remove it. When an ill individual is fully confident of their healer’s supernatural power, things are much easier. The other type of healer is the wawekratin, or evil healer. The wawekratin, instead of curing and helping, is believed to cause the witchcraft rendering people ill. So people are afraid of them and they have important social influence through the fear they evoke from their neighbors. Some of them might not be known as such, as they hide their condition in order to be more effective. It is believed that they often do their evil deeds just for the pleasure of it. But, sometimes they are paid by some person who wants to exact revenge on somebody in the community. There is a strong rivalry between the two types of wishin. Both use similar methods, as they are able to control the tsentsak or ‘magical arrows’ that are believed to engender illness. The wawekratin, the evil healer, after a period of fasting, will drink the hallucinogenic natem, at night, as well as sniff tobacco juice and, after this preparation, will be ready to ‘throw the magical arrows’ causing disease to the victim. The arrows are, of course, metaphorical, not real material objects. This is done by blowing or sometimes by looking at somebody: the real evil eye. In fact, the tsentsak are considered some sort of auxiliary spirits related to different trees or animals and there are many kinds of them of different strength; some are believed to be so powerful that there is no cure, while others might harm people in a minor and reversible way. The good wishin, the tsuakratin, in order to cure, will fast during the day, then sniff tobacco juice and consume natem during the night. They will be ready then to make the diagnosis about the location and the number of tsentsak their patient has in their body. The wishin might see some brilliant small lights signifying the presence of the tsentsak. They will then proceed to suck them out of the victim’s body and vomit them up. Ritual chanting or anent also plays an important role in the healing process, as the shaman will invoke many natural spirits to help. The word anent means request, chant and sorrow. Every Shuar might have some anent of their own intended to favor some aspect of their life. It might be learned while dreaming, transmitted by some elder of the family or simply stolen from another person. For this reason, the Shuar tend to sing them at a very low volume or, even, silently, to avoid their being stolen. The shaman might also be able to determine the person responsible for the witchcraft, so that the patient and the family might take revenge. It must be said that usually the ritual sessions can take the whole night during which time the patient is not alone, but accompanied by the entire family. The session can end with counselling and advice given by the shaman. It is, certainly, something very close to the Western concept of psychotherapy. The individual usually feels much better after the ritual but, sometimes, the witchcraft is thought to be so powerful that more sessions are needed. Sometimes the patient ultimately does not

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recover, meaning that the wawekratin has been more powerful than the tsuakratin and cure is not possible. The explanatory model of illness among the Shuar people is related to the models accepted in many other cultures where witchcraft seems to be the main etiological explanation. Shamanistic healing is also related to the kinds of healing found not only in neighboring areas but in very distant places. It is remarkable how, even submitted to the acculturative stress process, the Shuar people continue to maintain their medical system and their own explanatory models for illness.

6.9

THE NATEM EXPERIENCE

Psychiatry has a long history of interest in modified (or altered) states of consciousness (MSC) induced by hallucinogens. We can trace this interest back to the French ‘alienist’ Jacques-Joseph Moreau de Tours, in the XIX century, who described some of the seminal ideas that generated research in this field. Moreau de Tours can be considered a pioneer of transcultural psychiatry as, after traveling through Egypt and the Middle East, he became interested in the use of hashish. He was responsible for spreading the use of this drug among a circle of artists and intellectuals in Paris. He undertook research on the psychological and somatic effects of hashish and published a well-documented report (Moreau de Tours, 1845/1970), still worth reading. He said, ‘I’m against anybody who pretends to talk about hashish effects if he does not speak in his own name and if he does not act after a sufficiently repeated use’. With this sentence, Moreau de Tours advocates self-experience as a method of getting to know the effects of hallucinogenic substances. Obviously, any external observer in this field, however refined their methods might be, will have a limited knowledge of the experience. Instead, an individual submitted to the action of this kind of substances and having the mental experience will give a rather different view. In some way, the proposal of Moreau de Tours means completing a full external description – an etic vision –, with an internal one – an emic vision. Only linking one to the other represents a genuine approach to the MSC. The intention of Moreau de Tours was to go deeply into knowledge about mental disease: ‘I have seen in hashish, or better said in its action on moral faculties, a powerful means, unique to explore the field of mental pathogenesis’. He was creating in that way the modern concept of ‘model psychosis’: the experimental reproduction of a mental state, the closest possible to the most altered states of mind. In psychiatric research, a line has persisted in the sense of self-experiencing to mimic short-term psychotic states, in order to better understand those peculiar cognitive and perceptual states. Albert Hoffman, synthesizer of psilocybin and LSD, and a world authority on hallucinogens, recommended its use for mental health professionals as a method by which to understand their patients (Hoffman, personal communication, 1997). Cultural anthropology has endorsed participant observation as a method leading in this same direction. For many anthropologists there is a long tradition of personal involvement in many of the rituals and ceremonies described. So, as a cultural psychiatrist, I was willing, not to stay on the edge of the natem ritual, but to have a direct experience. I took the compound twice while in the Amazon (and on several other occasions later). I was not naive regarding hallucinogens. In Mexico, in Huautla de Jimenez, I had taken the ‘honguitos’, the Psylocibes mushroom, a tradition among the Mazatecan Indians, on two occasions. In my

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training years as a psychiatrist I had taken LSD several times and also mescaline. At the Psychiatry department of the University of Barcelona, where I did my training in the 1970s, LSD, mescaline and psilocybin had been used experimentally during the 1950s and 1960s and there was a substantial experience in its use (Gonza´lez Monclu´s, 1996). So, going through the hallucinogenic experience was not new for me. The setting, of course, was quite impressive: at night, inside a jea, the shuar palm hut, in the middle of the Amazon forest, after a whole day fasting and sniffing tobacco juice and feeling fully confident about the knowledge and ability of the shuar shaman to control the session. In any event, on both occasions, I must confess I felt a little disappointed, as the experience was not as intense as I had expected. It had nothing to do with the sort of transcendental trip experienced by Harner among the Conibos with the same compound (Harner, 1980). To describe such an experience through words is very difficult. Years ago, Ludwig (1966) managed to systematize – quite correctly, in my opinion – what would be the major aspects describing what a MSC might represent. The summary of his proposal is:

 thought alterations: – predominance of archaic views; – less distinction between cause and effect; – cognitive ambivalence;

    

alteration of temporal sensation; loss of control with a tendency to disinhibition; change in emotional expressivity toward affective extremes; changes in body image; perceptual distortions; changes in meaning: increased intensity of subjective experiences and external clues. This provokes feelings of insight and ‘revelation of truth’ leading to intense conviction;  sense of the ineffable: the essence is not communicable;  sense of getting younger or being reborn;  hyper-suggestibility. Practically all those items were perceived by me during the natem experience, but, in a ‘low profile’. I remember some perceptual distortions like an intense hum coming and going. The Shuar call it in Spanish ‘el avi´on’ (the plane), and I had been told about this possibility. I also noticed a variety of small colored figures vanishing into the night, but nothing about big animal visions like snakes or jaguars, typically described by others. I remember in particular, the first time, the presence of paranoid thoughts referring to some persons, not Shuar people, that we had met during the preceding days. Surprisingly enough, these paranoid sensations seemed, later on, to be confirmed. The problem with the natem preparation is that the final chemical composition is highly variable, due to changes in the alkaloid content of the plants used in its preparation and other factors (Riba and Barbanoj, 2000). It is well known that psychiatry during the 1950s and 1960s produced an impressive amount of literature about the effects of hallucinogens (Obiols, 2000). The therapeutic effects of these substances seemed to work in two ways: the psycholitic therapy and the psychedelic therapy (Abramson, 1967). This was abruptly ended in the mid 1960s after an uncontrolled spreading of these substances among the ‘counter-culture’ circles caused social alarm. It is probably unfair for scientific research, the present status of hallucinogens

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that makes the continuation of previous work very difficult. Several groups, in the USA, in Russia, in Switzerland, in Spain and in Germany try to continue the research, but have encountered great legal and financial difficulties. I see in this field, the research on the therapeutic possibilities of the hallucinogens or the use of them to produce model psychosis and acquire a deeper knowledge about its psychopathology, another possibility of partnership between psychiatrists and shamans. I have received information from some colleagues who have tried to undertake studies in the field, some collaborative work with local healers, specifically using ayahuasca. The French physician Jacques Mabit has been working for years at the Takiwasi center created by him in the early 1990s, in the Amazonian area of Peru. He has specialized in addiction treatment, with good results. A more recent experience is being undertaken in Brazil by a Catalan psychiatrist, Josep Maria Fabregas. He opened a center, the Instituto de Etnopsicologia Amazonica Aplicada, in Parattorasso, Pauni, in the state of Amazonas, in Brazil, for the same purpose, and is also getting good outcomes in addicted patients with a long history of previous failures in rehabilitation. In both cases, ayahuasca seems to induce, through the impact of the hallucinogenic experience, the kind of intense internal change needed to abandon drug use. An open mind is obviously required. Both anthropology and cultural psychiatry, have produced enough scientific material to build bridges with the archaic, millenary, traditional knowledge of the shamans. I am sure the results could surprise all of us.

CONCLUSION There is an exciting field of potential collaboration among healers and psychiatrists in many areas. Particularly in the domain of the therapeutic use of hallucinogenic compounds, it would be unfortunate to abandon such a promising field. Shamans from many countries around the world have accumulated extensive knowledge about the use of hallucinogens and have mastered the control of modified states of consciousness. If we recall that in the middle of the last century academic psychiatry had developed a quite successful approach to treating a number of psychiatric conditions such as alcoholism, obsessive compulsive disorder, personality disorders, among others with hallucinogenic drugs, it is obvious that a common effort of collaboration in this field could be very productive. For such an endeavor, many walls of mutual lack of understanding need to crumble and many legal difficulties need to be overcome as well. So, even if the future perspective seems exhilarating, the way forward is not easy and a deep cultural change will be required, especially in academic psychiatry.

REFERENCES Abramson, H.A. (ed.) (1967) The Use of LSD in Psychotherapy and Alcoholism, The Bobbs-Merril Company, Indianapolis. Antun, R.Y. and Chiriap, V.H. (1991) Tsentsak. La Experiencia Chama´nica En El Pueblo Shuar, Ediciones Abya–Yala, Quito. Atala, J., Obiols, J., Haro, J.M. and Fericgla, J.M. (1995) Poster, Search for the Causes of Psychiatric Disorders: Epidemiological Approaches Symposium, New York. Chinkim, L., Petsain, R. and Jimpikit, J. (1987) El Tigre Y La Anaconda, Ediciones Abya-Yala, Quito. Fericgla, J.M. (1994) Els Jivaros, Cac¸adors De Somnis, Edicions La Campana, Barcelona.

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Fericgla, J.M. (1997) Al Trasluz De La Ayahuasca, Los Libros de la Liebre de Marzo, Barcelona. Gonza´lez Monclu´s, E. (1996) Mescalina, psilocibina y LSD-25 como inductores de psicosis experimentales, in Alucin´ogenos (eds L. San, M. Gutie´rrez and M. Casas), Ediciones en Neurociencias, Barcelona. Harner, M. (1972) The Jivaro: People of the Sacred Waterfalls, Doubleday/Natural History Press, New York. Harner, M. (1973) The sound of rushing water, in Hallucinogens and Shamanism (ed. M. Harner), Oxford University Press, London, Oxford and New York. Harner, M. (1980) The Way of the Shaman: a Guide to Power and Healing, Harper & Row, New York. Karsten, R. (1935) The Head Hunters of Western Amazonas, Societas Scientiarum Fennica, Helsingfors. Ludwig, A. (1966) Altered states of consciousness. Archives of General Psychiatry, 15, 225–34. Mader, E. (1999) Metamorfosis Del Poder. Persona, Mito Y Visi´on En La Sociedad Shuar Y Achuar, Ediciones Abya-Yala, Quito. McKenna, D.J., Towers, G.H.N. and Abbott, F. (1984) Monoamine oxidase inhibitors in South American hallucinogenic plants: tryptamines and beta-carboline constituents of ayahuasca. Journal of Ethnopharmacology, 10, 195. Moreau de Tours, J.J. (1845/1970) Du Haschich Et De L’alie´nation Mentale, Fortin et Masson/ SEMP, Paris. Obiols, J. (2000) Alucin´ogenos: de la Psicolisis terape´utica al ‘‘bad trip, in Los ente´ogenos y la ciencia (ed. J.M. Fericgla), Ediciones Abya Yala, Quito. Obiols, J. (2001) Impressions of a western psychiatrist among the Shuar of Upper Amazonia, World Psychiatric Association Regional Meeting, Antalya (Turkey). Riba, J. and Barbanoj, M. (2000) Disen˜o de un estudio clı`nico con ayahuasca, in Los Ente´ogenos Y La Ciencia (ed. J.M. Fericgla), Ediciones Abya Yala, Quito. Schultes, R.E. (1994) El campo virgen en la investigaci´on de las plantas psicoactivas, in Plantas Chamanismo Y Estados De Conciencia (ed. J.M. Fericgla), Los Libros de La Liebre de Marzo, Barcelona. Wagner, R.A. and Keim, S.M. (2007) Plant poisoning, Alkaloids-Tropane, Available at: www.emedicine.com/emerg/topic438.htm.

CHAPTER 7

The Awakening of Collaboration between Quichua Healers and Psychiatrists in the Andes Lise Bouchard Director of Research, Runajambi Institute for the Study of Quichua Culture and Health, Otavalo, Ecuador

To the memory of Mr Alberto Cacuango; a great Quichua community leader and health advocate who died from tuberculosis in 1998, at age 39.

Abstract The indigenous people of the Andes do not receive conventional psychiatric care. They rely almost completely on traditional healers to cope with their suffering and mental illness. In this chapter, we describe a project intended to combine Quichua traditional medicine and Western medicine in the Andean region of South America. In 1984, an innovative Quichua health project started in the highlands of Imbabura, a northern province of Ecuador. Jambihuasi (Health Care House) proposed to bring yachactaitas (Quichua traditional healers) and Western trained medical doctors to work together and offer integrative health care services for the indigenous population of the mountain villages of the region. Runajambi (Institute for the Study of Quichua Culture and Health) was founded in 1990 as a health research institution devoted to the improvement of the physical and mental health of the Quichua people. We present these initiatives as one model of an approach to reversing the current neglect of mental health care services among Amerindian communities in the countries of South America.

7.1

INTRODUCTION

The Quichua people (Incas) are considered one of the world’s great and ancient civilizations. Their architectural, cultural, agricultural and linguistic legacies among others, are still evident today. However, the Quichuas rarely reach the public international arena with news other than their extreme poverty, illiteracy, high mortality and morbidity rates, and other negative descriptors. Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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The indigenous peoples are viewed as needing full assistance to solve their socioeconomic and health problems, which are massive (PAHO and WHO, 1994; World Bank, 2006). This population is neglected by national and regional governments’ health authorities and very few programs focus on improving the health status of the Quichua people. Twenty-five years ago, a new kind of health initiative was developed by the Quichua people themselves, in the northern Ecuadorian province of Imbabura. Jambihuasi (Health Care House) and Runajambi – Institute for the Study of Quichua Culture and Health are the result of a lengthy process of maturation that emerged in the heart of the Andes from the vision of a young Quichua physician. This chapter describes both an innovative health care program called Jambihuasi and the course of action that led to its creation as a community-based, culturally adapted health care service, and the creation of the first Quichua health research institute of Ecuador, Runajambi. This project is presented as an excellent example of Quichua people’s drive and ability to formulate original health care solutions, and to contribute valuable experiences to the fields of community health, rural and community psychiatry and mental health of indigenous peoples.

7.2

PERVASIVE SOCIAL EXCLUSION

The Quichuas once made up a large proportion of the Tahuantinsuyu (the Inca confederation), which at its peak included present-day Bolivia, Ecuador and Peru, and parts of Argentina, Chile and Colombia. At the end of the fifteenth century, the Spaniards invaded and subdued the Tahuantinsuyu. When Atahualpa, the last Incan emperor, was assassinated, the Quichuas lost their political power, which passed into the hands of the Spanish invaders. The Spaniards established the feudal system of their European native land with a tax and debt inheritance regime. Soon the Quichuas were enslaved and forced to work for the Spanish Crown in agriculture, mining, weaving, etc. This was the beginning of centuries of exploitation, marginalization and oppression. Later, at the beginning of the nineteenth century, as a result of wars of independence, many countries emerged. They formed what is now Latin America. For the Quichua people, the Independence of Andean countries did not mean liberation, but rather a change of oppressors. Within Ecuador, for example the latinos (locally called mestizos – mixed Spaniard and Quichua who identify themselves as white Westerners and repudiate their Amerindian roots) replaced the Spaniards as subjugators. The present day post-colonial social conditions and the political integration of the Quichuas in the Ecuadorian structure has been characterized as ‘exploitative integration’ (Weinstock, 1973), in which there is a caste-like social stratification and racism is institutionalized (Casagrande, 1981). There are no reliable statistics about the number of Quichuas in the total population of Ecuador. For example, the national census of 2001 did not include questions about ethnicity, making it difficult to have reliable data on the indigenous population in Ecuador. Curiously enough, the official number used by the government in the 1980s was around 40%, whereas now it varies between 10 and 20%. Indigenous peoples’ organizations estimate that they comprise around 40% of the total population.

7.3

HEALTH DISPARITIES AND HEALTH CARE INEQUITIES

Throughout the Americas, health indicators (where they exist) consistently show widespread poverty and health status poorer for the Amerindian population than those of the

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non-Amerindian populations (PAHO and WHO, 1994). The World Bank estimates that the infant mortality rate in the indigenous communities of Ecuador is double that of the general population; 105 per 1000 live births among indigenous people, compared with 51 per 1000 for non-indigenous people (World Bank, 2006). The Quichuas also have a much higher incidence of infectious diseases, such as gastroenteritis, tuberculosis, diphtheria, respiratory problems, infectious hepatitis and meningitis, as well as diabetes, goiter, malnutrition, etc. than of the general population. The problems of alcohol use and abuse, alcohol-related violence and injuries, suicide, anxiety, depressive, and somatoform disorders, child abuse and neglect, etc. are perhaps dramatically higher among indigenous peoples (Incayawar, 2007). In the rural areas of Ecuador, where the majority of the Quichua population lives, health care services are scarce and inefficient. Even where public community health centers exist, they often remain closed and deserted during official operating hours. In most towns and cities, there are public hospitals, but they are avoided by the Quichuas because they fear being abused and mistreated by hospital administrative and clinical staff alike.

7.3.1 Mental Health Services A report by the Pan-American Health Organization published in 1986 shows that mental health services in Latin America are underdeveloped and that this situation particularly affects the indigenous communities, which are suffering from severe poverty, marginalization and exclusion. In addition, little support has been provided to traditional community health services (PAHO, 1998). Ecuador is no exception. There are approximately 600 psychiatrists for a national population of 13 million. The vast majority of them are located in the major cities of Quito, Guayaquil and Cuenca, and services are offered only in Spanish. Very few psychiatrists or psychologists work in the provincial public hospitals or private clinics, and they are nonexistent in the rural areas. In most midsize towns, there are no psychiatrists at all. This is the case for Otavalo, a town of 45 000 people. There are no psychiatrists, psychologists or mental health social workers serving Quichua and other indigenous communities in Ecuador, a country where it is estimated that 5.2 million indigenous people live.

7.4

THE QUICHUA RESPONSE: JAMBIHUASI

The Quichua communities have used their own traditional medicine system for centuries. Yachactaitas (Quichua healers) continue to provide care and guidance today, as they have for centuries. With the intention of overcoming the pervasive barrier to access to Western-oriented health care services, the Jambihuasi project (a mental/physical health care facility) was created in the early 1980s. In 1982, two Quichuas, a man and a woman, graduated for the first time from an Ecuadorian medical school. One of them, Dr Mario Incayawar (aka Dr Mario G. Maldonado)1 began to formulate a new way of providing adequate health care and to facilitate access to available biomedical services for the Quichua communities in the region. He began treating patients in rural communities in his native province of Imbabura. By doing so, he became increasingly aware of the central role yachactaitas

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played in the traditional Quichua health care system and the maintenance of health/mental health status of the Quichua population. In 1983, Dr Incayawar started planning a Quichua culturally-adapted medical center that would bring together, under the same roof, Quichua healers and Western-trained physicians. He spent several months preparing a proposal titled: preventive medicine for the Quichuas of Otavalo which he presented to the Ministry of Health in Quito. Despite the interest it generated in some officials, no action was taken by health authorities. The project was heading for failure, victim of the bureaucratic apathy and the fear of creating ‘one state within another’ as one high ranking Ecuadorian health official declared. Nonetheless, Dr Incayawar kept on searching for new avenues to make the Preventive medicine for the Quichuas of Otavalo project come to life. He sent it to the Canadian non-governmental organization of social solidarity called De´veloppement et paix which agreed to finance it. Accordingly, in 1984, Jambihuasi (Health Care House) was inaugurated.2

7.4.1 The Jambihuasi Mission The goal of Jambihuasi was to combine Quichua and Western medicine, and to offer integrated and community-based health care services and health education to Quichua people. A second goal was to collect data about Quichua traditional medicine knowledge; namely medicinal plants used in the province of Imbabura. The Jambihuasi headquarters were located in the town of Otavalo, with extensions in two small Quichua communities of the region, Huacsara and Huairapungu.

7.4.2 The Founding Protagonists The first step was to find collaborators; people who were trained in health care, communications, etc. The search to create a team began. This task was a difficult one since there are only a handful of trained Quichua health professionals even today. I well remember going to visit potential collaborators all over the province of Imbabura and in the neighboring provinces as well. From the beginning, the project received support from Mr Alberto Cacuango a leader of the Quichua community of Punguhuaicu. We contacted Dr Mercedes Guaja´n, the first female Quichua doctor in Ecuador who graduated in the same class as Dr Incayawar. She agreed to join the team. Yachactaitas Jose´ Manuel Montalvo and Jose´ Manuel C´ordova became the official Quichua traditional healers of Jambihuasi. Two dentists, Dr Nancy Nu´n˜ez from Quito, and Dr Lena Te´gner, a dentist from Sweden, working as a volunteer in Quito, also joined the project. Three young Quichuas helped in the communication and health education department: Germa´n Muenala, a recent graduate from the school of journalism, and Roberto Conejo, a graphic artist. Mercedes Cachihuango did the secretary tasks. Finally, Herna´n Basantes and I were in charge of the herbarium of medicinal plants (Figure 7.1).

7.4.3 The First Integrative Community-Based Clinic The first clinic was established in Huacsara, a few miles north of Otavalo. This was a poor community which totally lacked public health services. At that time, there was no running

THE QUICHUA RESPONSE: JAMBIHUASI

Figure 7.1

83

Dr Mercedes Guaja´n, the first Quichua female doctor of Ecuador.

water, electricity or telephone. There, Quichua peasants lived from farming, owned only small plots of land and few animals. The community built and made available a small room where Dr Incayawar was able to treat patients once a week. The visit of the Western trained Quichua physician helped to improve the health condition of the community, and on some occasions, to save the lives of some patients whose families considered them to be untreatable. For example, the Jambihuasi doctor once cured an eightyear-old boy who was suffering from a streptococcal pyoderma and enormous abscesses of the right forearm and leg. Convinced that there was nothing else that could be done, the boy’s extended family had moved him outside the house under a small shelter, and with resignation, was waiting for him to die. They did not want to take him to the hospital in Otavalo because they thought that hospitals were a place where Quichua people were mistreated, where people went to die.3 When they heard that a Quichua physician was visiting the village, they came to see him. He examined the boy, whose left arm and leg were severely swollen and had an enormous abscess filled with pus. He surgically drained the abscess and administered intramuscular penicillin. Eight days later the boy had recovered. With this kind of spectacular recovery, the service rapidly became very popular and each week, the physician had a larger number of patients waiting for him (Figure 7.2).

7.4.4 Getting Established in Otavalo To better understand the impact and celebrity gained with the establishment of Jambihuasi in Otavalo, it is worth considering some historical details regarding the town. At the beginning of the colonial era, around the seventeenth century, Otavalo was converted into an administrative center of the region, with the presence of officials of the Spanish Crown and of the Catholic Church, and became the symbol of the occupation

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Figure 7.2 A patient at the Jambihuasi clinic of Huacsara.

(Phelan, 1967). Otavalo thereby became a hostile and discriminatory environment for the Quichuas. Until the 1960s, Quichuas were forbidden to enter the parks of the town. This privilege, like many others, was reserved for mestizos, the dominant group. Quichuas who dared to defy this rule were sanctioned by municipal police, who would confiscate a piece of their clothing. To reclaim their belongings the Quichuas would have to clean the streets of the town for a week or more. Until the 1980s, Otavalo was inhabited almost exclusively by mestizos. Therefore, it was considered by them to be a ‘whites or civilized only’ town. Very few Quichua families had settled in town before the 1960s. Those who did were mostly handicraft merchants and artisans who had earned some money working in Quito, the capital city, or in the neighboring country, Colombia. Some of them had then come back to Imbabura and founded small textile enterprises in Otavalo. Gradually, they became a model of success for the Quichuas of the region, and by the end of the 1990s, many began to dedicate themselves to the handicraft business and to sell their products all over the world (Meisch, 2002). This has now become the main economic activity of the Quichuas of the Otavalo region. With their emerging economic success, many Quichuas of surrounding communities have begun to buy houses in town, and over time, more and more Quichua families have become established in Otavalo. Nowadays, the ethnic composition of Otavalo is largely inverted and it is considered a Quichua town. In 1984, then, at the beginning of Jambihuasi, Otavalo was still a mestizo town, hostile to the presence of the Quichuas. In that context, the establishment of a Quichua-run health center stood out in the eyes of the population.

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7.4.5 Unusual Integrated Quichua/Western Health Care Center Traditional healers are often perceived merely as a useful resource for expanding public health programs based on Western medicine. That is, there is no interest in a reciprocal exploration of what they know about their communities’ health. For example, a 1995 World Health Organization manual on the use of traditional practitioners as primary health providers made 13 key recommendations, none of which suggested learning about the indigenous health systems of these practitioners (Kiesser, McFadden and Belliard, 2006). From the beginning, Jambihuasi offered combined Quichua and Western health care services. The patient had the choice. The way the service was implemented was as follows: the patient would come to the clinic and ask to see either the yachactaita (Quichua traditional healer) or the Western trained doctor. The chosen practitioner would examine the patient, make a diagnosis and propose a treatment plan. If they judged it necessary, they would consult with the other practitioner. When deemed necessary, the physician and the healer would consult each other and examine the case together, in order to reach the most appropriate treatment possible. It is worth noting that this procedure was greatly appreciated by the patients and their family members who came to Jambihuasi. We observed that patients and their families chose their practitioners according to the kind of illness they felt they had, using the Quichua categories of illness classification. There is a continuum of Quichua illnesses such as mancharishca (victim of malign spirits caused by a sudden fright), huairashca (victim of malign spirits caused by approaching bad places), etc., at one end, sprains and bruises in the middle, and chronic and acute diseases such as cancer, diabetes or schizophrenia at the other end. When they thought they had a Quichua illness, they would ask to see the yachactaita (Quichua healer). When they had a serious injury or when they felt they had a chronic or acute disease, they would ask to see a physician. Sometimes, they would ask to see both sequentially or at the same time; because they considered the illness to be treatable by both. If they were unsatisfied with the results they would go to see the other practitioner. The health-seeking behavior was the same regarding mental disorders. Patients and their families would seek the help of the healer to relieve Quichua illnesses and ask to see a physician to treat acute mental disorders such as an acute psychotic episode. This is an example of medical pluralism in the Andes. As stated by Kiesser, McFadden and Belliard: ‘Medical pluralism is what we practice when given the freedom to do so’ (2006: 225) (Table 7.1). Table 7.1

Quichua pathways to health care.

Quichua illnesses

Mild conditions

Chronic and Acute Diseases

+

+

+

Quichua Traditional Medicine

Quichua Traditional Medicine or Biomedical System

Biomedical System

If treatment is unsatisfactory

If treatment is unsatisfactory

+

+

Biomedical System

Quichua Traditional Medicine

Quichua illnesses: mancharishca (victim of malign spirits caused by a sudden fright), huairashca (victim of malign spirits caused by approaching bad places), rurashca (witchcraft), shungu nanai (shattered heart), etc. Mild conditions: sprains, bruises, etc. Chronic and acute diseases: cancer, diabetes, physical trauma, schizophrenia, acute psychotic episode, etc.

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In addition to clinical work, the Jambihuasi team conducted health education and promotion. That included activities in Quichua communities such as courses and presentation of movies on hygiene and diseases. Moreover, because of the increasing level of trust the population had in the Jambihuasi, it was also able to conduct vaccination campaigns for children in the Quichua communities, where until then, the Ministry of Health had failed, due to local resistance and suspiciousness of the motives of government officials. Concerned with the necessity of improving the quality of mental and physical health care provided to the indigenous communities of South America, in 1985, the Jambihuasi organized the ‘First International Seminar on Indigenous Health and States’ Policies’ with the sponsorship of the Pan-American Health Organization. Delegates from indigenous organizations in Ecuador, Colombia and Peru gathered in Otavalo to discuss the need to promote collaborative work between Western trained physicians and traditional healers (Figure 7.3).

7.4.6 The Quichua Community Response to Jambihuasi The services offered by Jambihuasi not only filled a gap, but also brought to the region a new model of health care. For the first time, it provided the Quichua population with culturally-adapted care that was provided in a culturally respectful, empathetic and welcoming environment. Quichua patients and their families greatly appreciated it. Soon people from the surrounding Quichua rural communities, and from the town, came to

Figure 7.3 Demonstration in favor of Quichua culturally adapted health care services in Otavalo, Ecuador.

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receive Quichua/Western integrated health care. To our surprise, some mestizo people began to also seek health care at Jambihuasi. By word of mouth, Jambihuasi gained prestige for its special character. As a result, Quichua communities started asking for the establishment of a Jambihuasi clinic in their villages. The physician, healer and dentist began visiting two more communities once a week. In both communities, like in many others, access to the Ecuadorian medical care system had been difficult until then, because of the lack of adequate infrastructure, as well as the physical and cultural distance between clinic personnel and the target patient population. The first rural service offered by Jambihuasi was in Huairapungu, an isolated community without any basic services, located in the moorlands, about an hour and a half by car from Otavalo. There was no drinking water, electricity, telephone, school or health care services. At that time, the only road leading to this settlement was almost impassable without a jeep during the rainy season. No public transportation was available and people had to walk to Otavalo or rely on the good will of the rare drivers passing by who would take them to town in their trucks. With the help of Mr Alberto Cacuango, Jambihuasi also started giving services in Punguhuaicu, a village close to Ibarra, the capital of the province. It was another poor Quichua community lacking basic services, whose people worked as servants at haciendas (large estates of feudal characteristics, one of them owned by a former president of Ecuador, Galo Plaza).

7.4.7 Health Officials’ and Local Physicians’ Reactions The health authorities of the province of Imbabura literally woke up one morning to see that the opening of Jambihuasi was a reality. They were intrigued by this health center; the first Quichua health institution in town. They kept an eye on it out of curiosity, but never intervened in its operation. Somehow, Jambihuasi earned their respect. Three reasons probably account for this: (i) because they had not been asked to contribute funds to its establishment; (ii) the director was a Western trained Quichua physician; and (iii) because they had not been consulted at any time during the process that led to its implementation. They felt they had no right to intervene. Also, they knew, vaguely, that there had been some discussions held between the Jambihuasi team and their superiors at the Ministry of Health in Quito. They also may have realized that their system did not extend services to the Quichua people and felt that Jambihuasi would take a burden off their shoulders. Mestizo physicians, on the other hand, were amazed by the creation of this new, modern looking clinic. They did not react to the fact that the people who were occupying a central position in the clinic were the traditional healers – the same people whom they generally considered to be charlatans or fringe doctors, the same people whom they viewed as a threat to public health. The Mestizo doctors simply remained attentive to its development from afar.

7.4.8 The Political Turbulence After two years of functioning, Jambihuasi triggered the interest of some leaders of InrujtaFici; a Quichua peasants leftist political organization with which Jambihuasi had been

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collaborating. A faction of them tried to take control of the health center. Although they were peasants with no training in health matters, they claimed to capable of managing the center, and even to perform medical procedures. They began campaigning in the surrounding Quichua communities, with the argument that the center was the property of the true poor Quichua peasants, and convinced a number of people that they should take over Jambihuasi by any means necessary. Other communities, like Punguhuaicu and Huairapungu, who had hosted the rural Jambihuasi branches, remained loyal to Jambihuasi’s leadership. To avoid imminent and possibly violent confrontation between Quichua communities, Dr Incayawar decided to officially hand over Jambihuasi to InrujtaFici in a public ceremony presided over by a lawyer.4

7.5

GOING FURTHER: THE FOUNDATION OF RUNAJAMBI

The experience of Jambihuasi proved to be a valuable but limited project. We realized at this point that confronted by the needs of millions of Quichuas in the country, working on a one-to-one basis with patients was rewarding, but frustratingly limited at the same time. Something had to be done to bring improvements in health status at the population level. The main idea that emerged in those days was to develop a research program on Quichua health that could be beneficial and have a far reaching impact in the long run. The idea of creating a research institute on Quichua culture and health gained solidity. It culminated in the creation, in 1990, of Runajambi (literally: Medicine of the Quichua people) Institute for the Study of Quichua Culture and Health.

7.5.1 The Mission of the Runajambi Institute Runajambi was created to contribute to the development of Quichua society in general, and to the improvement of Quichua health in particular. The main idea is to promote excellence in health research related to the study of the Quichuas’ health and medicine, that could be of practical and direct benefit to the patients and the Quichua communities in which they lived. Runajambi is interested in studies that can contribute to a better understanding of Quichua medicine, health status and the relationship between Quichua culture and health. Its goal is to identify priority areas of study that address physical and mental health problems of the Quichuas. Also, it strongly encourages multidisciplinary studies that explore the influence of culture and social forces in health, disease and treatment responses. It has a particular interest in the potential of collaboration between traditional healers and Western trained doctors to deliver culturally-adapted medical and psychiatric services. The scientific inquiry of the efficacy of Quichua medicine treatments and the validity/reliability of Quichua diagnostic methods are other topics of scientific interest and study. One task of Runajambi is to assist in the design and development of primary prevention programs targeting the physical and mental health needs of the Quichuas and other First Nations of the Andes. It also participates in the development of culturally-sensitive and culturally-adapted health care programs. Runajambi provides the necessary medical and technical assistance to the First Nations communities and organizations in their search for practical solutions to their health problems and promotes the First Nations’ control over

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their own health service programs. Finally, it disseminates the results of research and experiences gained from working with the First Nations of the Andes and other regions of the world.

7.5.2 The Achievements Until now, Runajambi has carried out studies related to Quichua psychiatry, mental health, cross-cultural doctor-patient relationship and also examined themes in other areas of Quichua culture such as language acquisition and maintenance. Runajambi is also interested in developing collaborative research with other indigenous nations. In this perspective, it has carried out two studies in California: one on healing practices among Native Americans of the region and another about traditional knowledge of Medicinal Plants of the Tongva People (www.runajambi.org/tongva) (Figure 7.4). With the aim of bringing awareness on Quichua and indigenous health related themes, Runajambi participated in several symposia on health and culture organized by indigenous

´ Figure 7.4 Dr Mario Incayawar and Mr Jose´ Manuel Cordova, yachactaita (Quichua healer) conducting a research on llaqui (depression-anxiety) together.

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health organizations in the USA as well as in international congresses. It has also organized conferences on subjects such as: Healer-Physician Collaborations in the Americas: The Indigenous Peoples’ Experience that was held at the Claremont Colleges, California, in April 2004. This meeting brought together Amerindian researchers and interested faculty and students. It provided the most up-to-date exposure to innovative interdisciplinary research and initiatives on healer-physician collaboration in the Americas. It focused on the achievements of the indigenous and Western medical systems collaborative endeavors for the improvement of physical and mental health of the indigenous peoples of the Americas. Moreover, keeping in mind the importance of encouraging collaboration between Western trained psychiatrists and traditional healers, in May 2005 Runajambi was the host and organizer of the international conference of the Transcultural Psychiatric Section of the World Psychiatric Association, held in Quito, Ecuador. Transcultural psychiatrists of all continents met to discuss the theme of the unexpected partnership of psychiatrists and traditional healers in countries around the world. They also had the opportunity to observe treatment performed by yachactaitas (Quichua traditional healers). That meeting was the foundation upon which the present book has been built.

CONCLUSION Since the founding of Jambihuasi in the 1980s, not much has changed regarding the mental and physical health services offered by the Ministry of Health to Quichua people in Ecuador. More than a quarter of a century after the graduation of the first two Quichua physicians in the country, only three more have been trained in Western medicine. There are now five physicians, and there is only one psychiatrist among them. There have been no governmental measures taken to support young Quichuas to study medicine. The vast majority of Quichua people continue to rely mainly on the care offered by their trusted traditional healers. Since there are no public mental health services available in indigenous communities, the Quichuas continue to consult yachactaitas for treatment. In this context, the recognition of the yachactaitas and their integration in a culturally-sensitive health care system is important to improve the health status of the Quichua population. The case of Jambihuasi and Runajambi, presented in this chapter, constitute an innovative indigenous health care model to help overcome the physical and mental health care neglect among Amerindian communities in Latin America. In poor countries where resources are scarce and indigenous people suffer discrimination and neglect, the promotion of collaboration between traditional healers and psychiatrists could be a valuable part of the solution to the health problems that plague this vulnerable population.

NOTES 1. Quichua cultural practices of acknowledgment and recognition call for citing people’s and place’s names. This is in part a reaction to centuries of anonymity and marginalization of Quichuas in Ecuadorian society, as well as in the scientific arena. In this chapter, we will follow the Quichua cultural practices and thus names of people and place will be cited. 2. Contrary to what has been reported in previous publications (Droz, 1997; Hinrichsen, 1999; Mignone et al., 2007), Jambihuasi was created in 1984 by Dr Mario Incayawar (aka Dr Mario G. Maldonado)

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3. Still, today, many Quichuas share this opinion and are reluctant to go to the hospitals. They say they would rather die at home than go to a hospital. 4. Amazingly, the integration of Maori’s healing practice and Western medicine services (see Dr Mason Durie’s chapter in this book) was beginning on the other side of the world almost at the same time that we created Jambihuasi in Otavalo. Fortunately for them, they received more support in New Zealand.

REFERENCES Casagrande, J.B. (1981) Strategies for survival: the Indians of highland Ecuador, in Cultural Transformations and Ethnicity in Modern Ecuador (ed. N.E. Whitten), University of Illinois Press, Urbana, pp. 260–77. Droz, Y. (1997) Jambihuasi: une tentative d’inte´gration de deux pratiques me´dicales a` Otavalo, Equateur. Socie´te´ Suisse Des Ame´ricanistes, 61, 91–8. Hinrichsen, D. (1999) Taking health to the High Sierra. Millennium trailblazers 4: Jambi Huasi. People & the Planet, 8 (4), 21–2. Incayawar, M. (2007) Indigenous peoples of South America – inequalities in mental health care, in Culture and Mental Health – A Comprehensive Textbook (eds K. Bhui and D. Bhugra), Hodder Arnold, London, UK, pp. 185–90. Kiesser, M., McFadden, J. and Belliard, J.C. (2006) An interdisciplinary view of medical pluralism among Mexican-Americans. Journal of Interprofessional Care, 20 (3), 223–34. Meisch, L. (2002) Andean Entrepreneurs: Otavalo Merchants and Musicians in the Global Arena, University of Texas Press, Austin, Texas. Mignone, J., Bartlett, J., O’Neil, J. and Orchard, T. (2007) Best practices in intercultural health: five case studies in Latin America. Journal of Ethnobiology and Ethnomedicine, 3, p. 31. PAHO (1998) 10. Programas Y Servicios De Salud Mental En Comunidades Indı´genas, Grupo De Trabajo, Pan American Health Organization; World Health Organization, Washington, DC, p. 10. PAHO & WHO (1994) Health Conditions in the AMERICAs, 1st edn, Pan American Health Organization, Pan American Sanitary Bureau, Regional Office of the World Health Organization, Washington, DC. Phelan, J.L. (1967) The Kingdom of Quito in the Seventeenth Century: Bureaucratic Politics in the Spanish Empire, University of Wisconsin Press, Madison. Weinstock, S. (1973) The Adaptation of Otavalo Indians to Urban and Industrial Life in Quito Ecuador, PhD, Cornell University. World Bank (2006) Ecuador-Highlights. Available at http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/LACEXT/ECUADOREXTN/0,contentMDK:20505836menuPK:325138 pagePK:141137piPK:141127theSitePK:325116,00.html.

CHAPTER 8

Factors Associated with Use of Traditional Healers in American Indians and Alaska Natives* Implications for Future Research and Policy Jeffrey A. Henderson** Black Hills Center for American Indian Health, Rapid City, SD, USA

Abstract Not much is known about factors that may influence the use of traditional healers among American Indians and Alaska Natives, and systematically collected data on this issue is nearly non-existent. However, in 1987–1988 the National Medical Expenditure Survey II included a random probability sample of about 2000 American Indian/Alaska Native households. Data was collected on traditional healer use. The overall prevalence of traditional healer use in this cohort was 4.9%, while females and those older than 36 years exhibited higher prevalence use rates. In the multivariate analysis controlling for age, sex and family income, English as a second language, education beyond twelfth grade, participation in native social occasions, chronic disease count and disability bed-days were significantly related to traditional healer use. Aside from associated factors, the very low prevalence of use of traditional healers by this cohort deserves explanation, with particular attention being given to the implications for future research and policy.

* Disclaimer: The views expressed are those of the author and do not necessarily reflect those of the Indian Health Service. ** This research was supported in part by a grant ‘Native Elder Research Center’ to the University of Colorado Health Sciences Center (Dr Manson) from the National Institute of Aging (Grant No. 5 P30 AG15292).

Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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8.1

FACTORS ASSOCIATED WITH USE OF TRADITIONAL HEALERS

INTRODUCTION

The past decade has seen increasing interest, both academic and political, in ‘alternative’, or ‘complementary’ medical practices (Burg, Hatch and Neims, 1998; Eisenberg et al., 1998; Kaptchuk and Eisenberg, 1998). It is now recognized that a large number of Americans use alternative medical resources and third-party payers are increasingly providing reimbursement for these services. Indeed, the National Institutes of Health recognized this phenomenon with the creation of the Office of Alternative Medicine in 1987 (Jacobs, 1995). While recognition of alternative medicine in the United States is belated, Indians in North America have a long history of traditional medical practices that predates modern allopathic medicine. The American Indian and Alaska Native populations of North America, as a result of interactions with the federal government, were exposed relatively recently to allopathic medicine, the dominant medical system in the United States; thus emerged an interface or medical pluralism between traditional and allopathic healing modalities within the American Indian and Alaska Native populations. Relatively little is known about health care utilization among American Indians and Alaska Natives. While there have been several reports of service utilization among urban American Indians (DeGeynt, 1973; Fuchs and Bashshur, 1975; Taylor, 1988; Waldram, 1990; Grossman et al., 1994; Marbella et al., 1998; Buchwald, Beals and Manson, 2000), including use of traditional medicine modalities, data reflecting the use of traditional healers among reservation-based American Indians is sparse (Kim and Kwok, 1998; Gurley et al., 2001; Novins et al., 2004). This chapter presents a study of traditional healer use in the American Indian and Alaska Native population using data from the Survey of American Indians and Alaska Natives, conducted in 1987 as part of the then-larger National Medical Expenditure Survey II. These large, population-based surveys were designed to capture extensive information concerning health care utilization and expenditures, insurance coverage and health status (Edwards and Berlin, 1989; Harper, 1991). However, the Survey of American Indians and Alaska Natives (alternately referred to as ‘Survey’) is unique in that American Indian and Alaska Native respondents were probed regarding their use of traditional Indian medicine practitioners during 1987. In this chapter we describe the use of traditional medicine as well as examine a set of demographic, clinical and cultural factors that were associated with the use of traditional healers. We close with a discussion of the implications of these findings for the delivery of health care services, the planning of public health initiatives and future research concerning the health care of American Indians and Alaska Natives.

8.2

HOW WE ASSESSED TRADITIONAL HEALER USE

8.2.1 Sample Design and Characteristics The data are derived from the 1987 Survey of American Indians and Alaska Natives, a survey of approximately 2000 households located on or near American Indian and Alaska

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Native communities with at least one household member eligible for care through locallyavailable Indian Health Service facilities. Funded by the Indian Health Service, an agency within the United States Public Health Service responsible for providing health care to eligible American Indians and Alaska Natives, the Survey was designed to provide comprehensive information on the use and sources of payment for health services, as well as insurance coverage, of the civilian non-institutionalized population eligible for Indian Health Service care. The Survey represented a targeted oversampling within the second National Medical Expenditure Survey, conducted by the Center for General Health Services Intramural Research, Agency for Health Care Policy and Research. The National Medical Expenditure Survey employed a household survey format in which each family was interviewed four times at four-month intervals to obtain information about the family’s health and health care utilization during calendar year 1987. The Survey of American Indians and Alaska Natives, varying slightly from the National Medical Expenditure Survey, consisted of three core interviews (i.e. ‘rounds’) at five-to-six-month intervals. Additionally, at the request of the Indian Health Service, several culturally unique questions were added to the core interview. The Survey trained local American Indian/Alaska Native community members as the interviewers.

8.2.2 Measurement of Traditional Healer Use The data that are the subject of these analyses center on the questions addressing the use of traditional medicine practitioners by the Survey of American Indians and Alaska Natives respondents. As part of the central questionnaire administered in each round, adult participants were probed regarding their use of medical providers, including traditional healers. Specifically, participants were asked: ‘In order to get as complete a picture as possible of all sources of health care, we would also like to ask about the use of traditional medicine. Since (REF. DATE), has anyone in the family had a physical health problem for which you consulted someone who practices traditional medicine?’ (Edwards and Berlin, 1989). If a respondent answered ‘yes’ to this screening question this triggered a more detailed, discrete booklet on traditional medicine use to be filled out. This booklet, the data from which was not available to us, queried the type of traditional practitioner consulted, this practitioner’s specialty, the condition(s) consulted for (which now were now not limited to exclusively physical conditions), consultation location, and type, amount and form of payment made for the consultation. Multiple records could arise when a given individual either used more than one type of traditional practitioner in any one round, or if that individual consulted with a traditional provider (whether the same or different) in more than one round. Hence, we culled duplicate records from among those individuals who had, in fact, reported use of a traditional medicine practitioner during calendar year 1987. In such instances the earliest report was retained. This study looks at only 3018 of the 4455 adults who answered the above question about traditional healer use on at least one round, and for whom a complete caserecord was present for all pertinent variables. Children were screened out owing to an inability to gauge their autonomy with respect to use of a traditional healer and to lessen recall bias to at least some extent.

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8.2.3 Measurement of Demographic, Clinical and Cultural Factors The Survey of American Indians and Alaska Natives Round 1 core interview was the source of the age, sex and education variables used in this analysis. Age was ascertained during each round and for this analysis age as of the final round was chosen. Education was coded as highest grade of schooling completed from persons 17 and older, with the value 18 representing six or more years of schooling beyond high school. Vocational/technical training was not included in the tally of schooling. Three income-level variables are provided for in the Survey, annual family income, annual person-level income and a poverty status variable corresponding to the family income variable. In brief, after producing valid data for each of 26 sources of income for the entire sample of 7533 persons in the Survey, an aggregate income measure was constructed for each person by summing over each of the income sources. A family income variable was created by summing over the total income of each member of the person’s family. The person’s family income was then compared with the official poverty threshold for 1987 for the appropriate family size to create the poverty status variable for the dataset. Employment status was obtained for all persons age 16 or older at the time of the Survey of American Indians and Alaska Natives interview in each round. Information about employment status and different types of jobs held by sampled persons was collected in Sections B (disability days) and S (employment) of the central questionnaire during each round of the National Medical Expenditure Survey. From these data an employment variable was constructed that described whether a person had worked for at least one week during the reporting period. From this variable it could be ascertained whether a participant had worked at any time during 1987 or was unemployed throughout. The clinical characteristics (excluding disability days), including usual source of care, were obtained through the use of an adult self-administered questionnaire and access to care supplement mailed to households prior to the round two interview. Data were only reported for the 5695 persons who responded for their entire period of 1987 eligibility and responded to a minimum set of items in the self-administered questionnaire and access to care supplement, and who were at least one year of age as of 31 December 1987. These data included the 3018 adults included in this analysis for whom a complete case-record was available for all pertinent variables. Disability days were ascertained in Section B of the National Medical Expenditure Survey central interview in each round of Survey of American Indians and Alaska Natives and included the following information for each disability period: beginning and end dates of the period and/or the actual number of disability days between these dates. Two of four disability days’ measures are reported in this analysis: total work-loss days and total bed-days. These aggregate annual measures were constructed by summing across all rounds of the Survey in which the respondent was eligible. The cultural characteristics reported in this chapter were collected from several sources. The nature of language in which the interview was conducted was captured during the central questionnaire in each round. The nature of the respondent’s language preferences was ascertained through the access to care supplement that is noted above. Finally, the social occasions variables (attends, participates) were ascertained during a short traditional activities module incorporated into the adult self-administered questionnaire, also described above.

RESULTS – SCOPE OF TRADITIONAL HEALER USE

97

8.2.4 Analysis Strategy The prevalence of traditional medicine use was examined for each of the demographic, clinical and cultural factors. Statistical testing compared differences in prevalences using the chi-square analyses. Multivariate analysis simultaneously examined the effects of demographic, clinical and cultural factors using logistic regression analysis. Age, education (range 0–18), annual family income, self-reported health (response range 1–4) and chronic disease score (range 0–9) were allowed to enter the model as continuous variables. All other variables were dichotomized as 0 versus 1. Multivariate factor adjusted odds ratios were obtained along with 95% confidence intervals. All statistical analyses were performed using SPSS/PC Version 10.0.4 statistical software (SPSS, 1998).

8.3

RESULTS – SCOPE OF TRADITIONAL HEALER USE

Table 8.1 shows the prevalence of traditional healer use for physical health problems by selected demographic characteristics of the Survey of American Indians and Alaska Natives population Table 8.1 Prevalence of traditional healer use according to demographic characteristics of adult Survey of American Indians and Alaska Natives participants (n ¼ 3018). Used TIMa (n ¼ 149)

No TIM (n ¼ 2869)

Prevalence (%)

Age (at end of last round) 18–36 yr 37–98 yr

54 95

1494 1375

3.49 6.46

Sex Female Male

88 61

1505 1364

5.52 4.28

Annual individual income  $4, 236 $4, 237

78 71

1415 1454

5.22 4.66

Annual family income  $14, 755  $14, 756

88 61

1472 1397

5.64 4.18

Poverty status (at end of last round) Poor/near poor Low/med/high income

86 63

1465 1404

5.54 4.29

Educational status 512th grade 12th grade >12th grade

83 27 39

1290 1054 525

6.05 2.50 6.91

Employment status Employed during any round Unemployed throughout

75 74

1734 1135

4.15 6.12

Demographic Factors

a

TIM ¼ Traditional Indian Medicine.

p value .000

.115

.471

.062

.113

.000

.014

98

FACTORS ASSOCIATED WITH USE OF TRADITIONAL HEALERS

Overall, 149 (4.9%) adults reported using a traditional health practitioner for a physical health problem at least once during 1987. These individuals were more likely to be female. There was a modest trend toward lower personal and family income and poor/near poor poverty status for users of traditional medicine. Significant differences in education were found with those both less well educated and with advanced education more likely to have consulted a traditional healer. Unemployment throughout the reporting period was also associated with traditional healer use. Table 8.2 shows the prevalence of traditional healer use for physical health problems for selected clinical and cultural characteristics of the Survey of American Indians and Alaska Natives population No differences were seen with respect to usual source of care. However, users of traditional medicine were significantly more likely to have poorer self-rated health than non-users. While there were no significant differences between users and non-users of traditional medicine in terms of diabetes status, any chronic disease or chronic disease score, Table 8.2 reveals that adults reporting any symptom or minor complaint were more likely to have used a traditional healer. Traditional medicine users were also significantly more likely to speak English as a second language, to have spent one or more half days disabled in bed (excluding days spent in the hospital) and to have participated in native social occasions (vs. attended) during the study timeframe. Table 8.2 Prevalence of traditional healer use according to clinical and cultural characteristics of adult survey of American Indians and Alaska Natives participants (n ¼ 3018). Clinical and cultural factors Usual source of care Yes No Self-reported health status Excellent Good Fair Poor History of diabetes mellitus Yes No Any chronic diseasea Yes No Chronic disease score 0 1 or 2 3–9 Any symptomb Yes No Any minor complaintC Yes No

Used TIM (n ¼149)

No TIM (n ¼ 2869)

Prevalence (%)

135 14

2589 280

4.96 4.76

18 74 47 10

568 1463 718 120

3.07 4.81 6.14 7.69

20 129

275 2594

6.78 4.74

63 86

1044 1825

5.69 4.50

86 47 16

1825 788 256

4.50 5.63 5.88

86 63

1288 1581

6.26 3.83

87 62

1328 1541

6.15 3.87

p value 0.884

0.031

0.124

0.146

0.342

0.002

0.004

RESULTS – SCOPE OF TRADITIONAL HEALER USE No. of disability bed daysd None 1–4 5 or more English is primary language Yes No Attends native social occasions Yes No Participates in social occasions Yes No

99 0.000

76 32 41

2168 385 316

3.39 7.67 11.48

29 120

1739 1130

1.64 9.60

89 60

1508 1361

5.57 4.22

46 103

515 2354

8.20 4.19

0.000

0.087

0.000

a Stroke, cancer, heart attack, gall bladder, hypertension, hardening of the arteries, rheumatism, emphysema, arthritis, diabetes, heart disease. b Fatigue, swollen joints, weight loss, indigestion, fever, bleeding, abdominal pain, skin rash, shortness of breath. c Hemorrhoids, hay fever, sinus problems, acne, backache, varicose veins, headache. d Excludes days spent in hospital.

Table 8.3 Multivariate analysis of the influence of clinical and cultural factors on use of a traditional healer in calendar year 1987 odds ratios and 96% confidence intervals. Clinical and Cultural Factorsa Clinical Factors Chronic disease count Any symptom Any minor complaint No disability bed days 1–4 disability bed days 5 or more disability bed days Self-rated health Cultural Factors English as a second language Participates in traditional social occasions

Odds Ratio

95% C.I.

1.2 1.1 1.4 1.0 2.3 3.4 1.1

1.0, 1.4 0.7, 1.6 0.9, 2.0 — 1.4, 3.6 2.2, 5.4 0.9, 1.4

5.8 2.0

3.8, 8.9 1.4, 3.0

a Adjusted for age, sex, income, and poverty and employment status. Chronic disease count and self-rated health status entered the model as continuous variables.

Table 8.3 reveals results of the multivariate analysis, expressed as odds ratios for the use of a traditional healer After controlling for other predictors in the model, English as a second language, number of half days disabled in bed, education beyond twelfth grade (not displayed in table) and participation in American Indian social occasions were all associated with use of traditional medicine. Individuals who used a traditional healer were 5.8 times more likely to have English as a second language than non-users. Also, users were 2.6 times more likely to have a greater than twelfth grade educational level than non-users. This is followed in the educational hierarchy by a trend toward low educational level, in which users were 1.5 times more likely to have a less than twelfth grade educational level than non-users. Additionally, users were 2.3 times more likely to have spent 1–4 days disabled (from work, school or ability to

100

FACTORS ASSOCIATED WITH USE OF TRADITIONAL HEALERS

carry on usual activities) in bed than non-users, and 3.4 times more likely if five or more such disability bed-days were experienced. Finally, users were twice as likely to participate in native social occasions (celebrations, pow-wows, etc.) than non-users, and 1.2 times more likely to experience a chronic disease.

8.4

DISCUSSION

This study is the first investigation of the use of traditional healers in a population-based sample of American Indians and Alaska Natives living on or near reservations. How an individual decides which treatment option to employ has been a subject of intense investigation over the years (Prochaska and DiClemente, 1984; Coons et al., 1989; Weinstein, Rothman and Sutton, 1998). Aside from the nature of the ailment it is widely accepted that culture greatly influences such decisions (Chrisman and Johnson, 1990; Payer, 1990; Helman, 1994; Landy, 1977; Buchwald, Beals and Manson, 2000). The availability and accessibility of a particular treatment resource is important, but the acceptability of the resource may be an equal or even greater factor (Heggenhougen and Shore, 1986). If a treatment option does not adequately fulfil an individual’s need to understand the illness process, if the setting of the option does not place one at ease, or if the option cannot be communicated well it is not likely to be used. While this study cannot address treatmentseeking behavior directly, it does contribute to a more complete picture of health careseeking behavior of American Indians and Alaska Natives.

8.4.1 Clinical and Cultural Factors Associated with the Use of Traditional Healers This study reveals several factors associated with the use of traditional healers among American Indian and Alaska Native adults. One of the strongest associations was observed for the use of English as a second language. Native language fluency is an indicator of traditionalism (Deyo, Diehl, Hazuda and Stern, 1985; Hazuda, Stern and Haffner, 1988), thus it should come as no surprise that our study participants who were most likely to have used a traditional healer were also those fluent in their native language. The number of days spent disabled in bed at any point during 1987 was significantly associated with traditional healer use. Additionally, chronic disease count revealed a weak association in the final multivariate model, while the strength of the association with any symptom and any minor complaint was diminished. Finally, participation in native social occasions (as opposed to ‘attends’) reveals itself to be a strong independent factor associated with the use of a traditional healer. This finding points to the considerable heterogeneity in cultural practices among American Indians and Alaska Natives living on reservations. While the list of occasions queried for in the Survey is quite general (‘. . . celebrations, pow-wows, and other such social occasions.’), the actual act of participation (as opposed to attendance) identified those respondents who were much more likely to use a traditional healer during the reporting period. Future studies looking at cultural factors among American Indians and Alaska Natives, particularly those focused on health care-seeking behavior, would do well to query for both attendance and active participation in more finely described native activities.

DISCUSSION

101

The results of this study differ from previously reported utilization patterns of traditional healers by urban-dwelling American Indians. That only 4.9% of Survey participants reported the use of a traditional healer contrasts sharply with the 30–50% figures found for urban Indians dwelling in San Francisco, Milwaukee and Seattle. It also is divergent with the 62% rate of traditional healer use for reservation-based Navajo, and the approximately 30% overall use by a large cohort of primarily reservation-based American Indians from two tribes in the Southwest and Northern Plains (Novins et al., 2004). A 1973 survey by the Urban Indian Health Board of San Francisco provided the first report of traditional medicine utilization patterns among urban-dwelling American Indians and Alaska Natives (Taylor, 1988). Twenty-eight percent of families in this study reported at least one family member who had used some form of traditional medicine during the five-year period preceding the interview. This figure rose to 43% among those families who had been in the city less than one year. This study also noted an association between increased use and both the presence of a specific health problem and hospitalization. Additionally, marked tribal variation in use was observed, as were associations with native language fluency, social visitation patterns, a preference for living on reservations and a weak trend for increasing income and education. A 1987 study at the Milwaukee Urban Indian Health Clinic revealed a 38% utilization rate of traditional healers by clinic attendees during an unspecified timeframe, and 86% who stated they would consider seeing one in the future (Marbella et al., 1998). Patients 40 years of age and older were significantly more likely to have utilized a traditional healer than those younger. The most common reasons given for use were spiritual, intended more for health maintenance than for treatment of a specified condition. A more recent study (1995–1996) at the Seattle Indian Health Board revealed that 65% of respondents reported using some form of traditional medicine to treat illness or maintain health in the preceding year (Buchwald, Beals and Manson, 2000). Ninety-six percent of respondents indicated an interest in using such practices to varying degrees if more generally available. Significantly associated with use were being male, poorer functioning (as measured by the Medical Outcomes Study Short Form-6), self-identification as ‘Native’ and associated ways, presence of back pain, history of assault or physical injury by a relative, excessive drinking and feeling depressed for two or more weeks during the past year. There were no differences noted in use based on the number of medical problems or medications being used. A study conducted from 1997–1999 and reported by Novins et al. (2004) described the use of biomedical and traditional healing options among a reservation-based sample of 2595 American Indian adolescents and adults ages 15–57 randomly selected to represent two tribes living on or near their rural reservations in the Southwest and Northern Plains, respectively. In addition to describing overall higher traditional healer use for the Southwest sample for both physical (23 vs. 8.4%) and psychiatric (7.8 vs. 3.2%) problems, they document that overall traditional healing provided a greater proportion of care for psychiatric than physical health problems. A 1998 study on the Navajo reservation reported that 62% of adult Navajos had used native healers and 39% used native healers on a regular basis (Kim and Kwok, 1998). This cross-sectional study took place in an ambulatory clinic setting among a convenience sample of 300 consecutive patients seen. Users were not able to be distinguished from nonusers by age, education, income, fluency in English, identification of a primary provider or compliance.

102

FACTORS ASSOCIATED WITH USE OF TRADITIONAL HEALERS

Finally, a 2001 comparative study of biomedical and traditional healing options by reservation-based American Indian military veterans in two tribes revealed that use of both traditional American Indian and mainstream medical services was markedly apparent (Gurley et al., 2001). Overall, while the veterans used all services much less for mental health problems than for physical health problems, Southwest veterans specifically used traditional healing significantly more than biomedicine for mental health and drug/alcohol problems. Indian Health Service facilities were equally available to both tribes, but United States Department of Veterans Affairs services were available more readily to one of them. Within the tribe with less access to Veterans Affairs services, more traditional healing services were used, so that similar amounts of care were received.

8.4.2 Why the Low Reported Use of Traditional Healers in this Study? The diversity of findings amongst the various studies of American Indian and Alaska Native use of traditional medicine is likely due to differences in wording, the sampling source, use and placement of questions within the survey instrument, and the relative power differentials between participants and researchers, including interviewers. The most obvious explanation for the differences observed are due to the fact that the screening question used to query participants in the Survey of American Indians and Alaska Natives specifically asked about ‘physical health problems’ and, therefore, made it nearly impossible to discriminate between traditional healer use for physical versus mental, spiritual or preventive reasons. Though open-ended questions (i.e. not just framed in terms of a physical health problem) were used in the subsequent traditional medicine booklet which was used to follow-up ‘yes’ responses to the screening question, it is likely that the majority of participants who might have used traditional healers for exclusively mental, spiritual or preventive reasons were already screened out. This is likely very significant for, as detailed above, most prior studies of American Indian use of traditional healing have reported greater use for purposes other than for discrete physical health problems. Differences in the setting may also partly explain the low rate of reported traditional healer use by our sample. Data for the Survey of American Indians and Alaska Natives were obtained using a population-based and primarily in-household survey questionnaire. This differs from most of the previous utilization studies conducted among American Indians and Alaska Natives, which derived data from clinic-based samples. This is particularly salient for the use of traditional medicine since these prior studies identified the participants at allopathic health care settings. This may generate selection biases that make the findings from these studies difficult to interpret. Individuals seeking care at medical clinics, including urban Indian health care clinics, do so primarily because they are ill. Additionally, clinic attendees are more likely to bear a larger chronic disease burden including psychological illness (Wilson, Civic and Glass, 1995). Hence, the factors likely to be associated with the use of traditional healing practices occur more frequently and with greater intensity among American Indians and Alaska Natives seeking health care. This explanation argues strongly for pursuing these kinds of questions through larger community-based studies of American Indians and Alaska Natives. A failure to pre-test the questionnaire may also have influenced our findings. The Survey of American Indians and Alaska Natives was a targeted oversampling of a special population based upon the National Medical Expenditure Survey of 1987. This larger effort

DISCUSSION

103

afforded the Indian Health Service an opportunity to obtain data on health care utilization and expenditures. Though the entire National Medical Expenditure Survey instrument was employed, several changes were made: (i) the number of rounds of interviewing was reduced from four to three and (ii) traditional activities of this unique population, including utilization of traditional healers, received select attention. These modifications led to revisions of the National Medical Expenditure Survey instrument for application in the Survey of American Indians and Alaska Natives. Unfortunately, there was not sufficient time to pilot the questions. Another difference with previous studies is that participants in the studies of urban American Indians and Alaska Natives had more formal education than participants in the Survey of American Indians and Alaska Natives. These urban American Indians and Alaska Natives may have had a better understanding of the questions being asked. The issues of language fluency, literacy and educational level all need to be carefully considered in future research. Other important issues relate to the differing timeframes employed and the kind of question(s) used. Respondents in San Francisco were queried about their use of traditional medicine within the preceding five years versus the one-year interval used in the Survey of American Indians and Alaska Natives. While Seattle respondents were also asked about their use of traditional medicine during the preceding year, the timeframe for traditional healer use among Milwaukee and Navajo respondents is not known. In both Seattle and Milwaukee, however, respondents were asked about such use not only for the treatment of a specific illness, but also for maintenance of health (i.e. prevention). As previously noted, this contrasts with the respondents of the Survey, who were initially screened about their household’s use of traditional healing practices only in the context of treatment of a physical health problem. In addition to issues related to sampling timeframes, the design of the survey instrument is also relevant. In the Survey of American Indians and Alaska Natives the traditional activities questions were grouped together on the adult self-administered questionnaire, while the traditional healer utilization questions stood alone, falling in the face-to-face interview directly after questions inquiring about allopathic health care utilization. It has been shown that under certain conditions individuals disclose more sensitive information in response to anonymous self-administered questionnaires as opposed to face-to-face interviews (Lucas et al., 1977; Skinner and Allen 1983). Survey participants were perhaps reticent to share information as sensitive as the utilization of traditional healers. To the extent that a dearth of information exists regarding survey approaches among American Indians and Alaska Natives, this situation represents an area of potential valuable future study, both to document the impact of a method effect as well as to describe what types of formats better serve these kinds of inquiries. Despite the fact that the majority of interviewers for the Survey of American Indians and Alaska Natives were trained American Indian/Alaska community members, participants were certain to be aware that the Federal government sponsored the survey. In the aftermath of the Wounded Knee massacre of 1890, the Federal government banned the performance of traditional ceremonies by American Indians and Alaska Natives, including traditional healing. It was not until 1978, when Congress passed the American Indian Religious Freedom Act that American Indians and Alaska Natives were legally allowed to practice many facets of their native spirituality, including traditional healing (American Indian Religious Freedom Act of 1978). It is well-known, however, that during this nearly

104

FACTORS ASSOCIATED WITH USE OF TRADITIONAL HEALERS

100-year interim traditional healing did not die out, but went underground, pursued in secret and beyond detection. As a consequence, many American Indians and Alaska Natives remain reticent to share such experiences. Even today traditional healing in many reservation communities largely avoids easy scrutiny. A final point concerning the dataset used for this study should be expanded upon, and that is the obvious fact that the data is now more than 20 years old. While longitudinal data shows that use of complementary and alternative medicine by the general US population continues to rise, our dataset cannot say whether the same dynamic may be or has occurred with respect to traditional healer use by American Indians/Alaska Natives. Indeed, I know of no dataset that could address this issue. Nonetheless, nearly all the previous studies reviewed underscore the fact that use of traditional healing is driven by availability and accessibility far more than for need. As a result, we would expect to see significant variation in traditional healer use over time across American Indian/Alaska Native communities, including urban areas. So, too, we should be concerned about the continued viability and accessibility of traditional healing in many Native communities as majority culture influences advance, healers pass to the spirit world with few or no apprentices, and dialogues (and consequences) about ‘integration’ and ‘collaboration’ move forward.

8.4.3 Impacts on Health Policy Understanding the nature, extent and function of traditional healing in Native communities is an important task, for matters of policy as well as health improvement. First, in April 1998, the Department of Veterans Affairs signed an agreement with a Southwest tribe whereby reimbursement may be made for care provided to eligible American Indian and Alaska Native veterans for specified conditions treated by traditional healers (Donovan, 1998; Shore, Shore and Manson, 2008). This policy, recently expanded (VA to expand coverage for traditional ceremonies, 2006), is being closely watched and evaluated by other third-party payers, among them the Indian Health Service, who in the late 1990s facilitated regional dialogues with traditional healers concerning a variety of issues, including reimbursement. However, it should be noted that while Indian Health Service encourages the use of traditional medicine and in some instances provides the physical context for this to happen (e.g. the traditional hogan within the Chinle Indian Health Service hospital), it has still largely held at arms-length the issue of reimbursement. Second, as Indian Health Service beneficiaries fall under increasing managed care penetration, particularly as States pursue Medicaid waivers (Noren, Kindig and Sprenger, 1998; Wellever, Hill and Casey, 1998), the nature and extent of health care utilization becomes an issue of paramount importance. Add to this the fact that many Federal agencies, academic institutions and third-party payers are keen to evaluate the efficacy of traditional therapies, and it becomes easy to predict that the issue of utilization of traditional healers will be one of growing, not receding, specter. Finally, American Indians and Alaska Natives today manifest exceedingly poor health when measured along virtually every health parameter compared to the United States allraces figures (Indian Health Service, 1997). The eventual improvement of the health status of American Indians and Alaska Natives will need to maximize every facet of the

REFERENCES

105

medical pluralism model that represents their health care environment. The traditional healing traditions of American Indians and Alaska Natives have survived a tremendous assault over the past century. These traditions are part of an eventual solution to the current epidemic of disease and illness in American Indian and Alaska Native communities. In this regard, the continued utilization of traditional healers, perhaps even the enhancement of such, will prove a pivotal issue in the relatively near future.

ACKNOWLEDGMENTS The author wishes to thank Jack Goldberg for his review of this chapter and technical assistance, and Spero Manson and Dedra Buchwald for their helpful comments. Noel Chrisman, David Grossman and Sharyne Shiu-Thornton are also acknowledged for their contributions toward this project. Finally, the statistical assistance of Alan Cheadle, Jan Beals, Paula Espinoza and Dorothy Rhoades is gratefully appreciated. This research was supported in part by a grant ‘Native Elder Research Center’ to the University of Colorado Health Sciences Center (Dr Manson) from the National Institute of Aging (Grant No. 5 P30 AG15292).

REFERENCES American Indian Religious Freedom Act of 1978 42 USC 1996 (orig. Public Law 95-341, August 11, 1978). Buchwald, D., Beals, J. and Manson, S.M. (2000) Use of traditional health practices among native Americans in a primary care setting. Medical Care, 38, 1191–9. Burg, M.A., Hatch, R.L. and Neims, A.H. (1998) Lifetime use of alternative therapy: a study of Florida residents. Southern Medical Journal, 91, 1126–31. Chrisman, N.J. and Johnson, T.M. (1990) Clinically applied anthropology, in Medical Anthropology: Contemporary Theory and Method (eds T. Johnson and C. Sargent), Praeger, New York. Coons, S.J., McGhan, W.F. and Bootman, J.L. (1989) Self-care practices of college students. Journal of American College Health: J of ACH, 37, 170–3. DeGeynt, W. (1973) Health behavior and health needs of urban Indians in Minneapolis. Health Services Reports, 88, 360–6. Deyo, R.A., Diehl, A.K., Hazuda, H. and Stern, M.P. (1985) A simple language-based acculturation scale for Mexican Americans: validation and application to health care research. American Journal of Public Health, 75, 51–5. Dine´ Bureau. VA to expand coverage for traditional ceremonies (2006) The gallup independent, June 19. http://www.gallupindependent.com/2006/jun/061906vatrdcrm.html. Donovan, B. (1998) VA gives Navajo care the OK. The Arizona Republic, April 8, Special. Edwards, W. and Berlin, M. (1989) Questionnaires and Data Collection Methods for the Household Survey and the Survey of American Indians and Alaska Natives, Department of Health and Human Services/Public Health Service, Rockville. Eisenberg, D.M., Davis, R.B., Ettner, S.L. et al. (1998) Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. Journal of the American Medical Association, 280, 1569–75. Fuchs, M. and Bashshur, R. (1975) Use of traditional Indian medicine among urban native Americans. Medical Care, 13, 915–27. Grossman, D.C., Krieger, J.W., Sugarman, J.R. and Forquera, R.A. (1994) Health status of urban American Indians and Alaska natives. A population-based study. Journal of the American Medical Association, 271, 845–50.

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Gurley, D., Novins, D.K., Jones, M.C. et al. (2001) Comparative use of biomedical services and traditional healing options by American Indian veterans. Psychiatric Services, 52, 68–74. Harper, T. (1991) Survey of American Indians and Alaska Natives: Final Methodology Report. U.S. Public Health Service, Rockville. Hazuda, H.P., Stern, M.P. and Haffner, S.M. (1988) Acculturation and assimilation among Mexican Americans: scales and population-based data. Social Science Quarterly, 69, 687–705. Heggenhougen, H.K. and Shore, L. (1986) Cultural components of behavioural epidemiology: implications for primary health care. Social Science and Medicine, 22, 1235–45. Helman, C. (1994) Culture, Health, and Illness: An Introduction for Health Professionals, Butterworth Heineman, Oxford and Boston. Indian Health Service (1997) Trends in Indian Health – 1997, Department of Health and Human Services, Rockville. Jacobs, J.J. (1995) Building bridges between two worlds: the NIH’s office of alternative medicine. Academic Medicine: Journal of the Association of American Medical Colleges, 70, 40–1. Kaptchuk, T.J. and Eisenberg, D.M. (1998) The persuasive appeal of alternative medicine. Annals of Internal Medicine, 129, 1061–5. Kim, C. and Kwok, Y.S. (1998) Navajo use of native healers. Archives of Internal Medicine, 158, 2245–9. Landy, D. (1977) Culture, Disease, and Healing: Studies in Medical Anthropology, Macmillan, New York. Lucas, R.W., Mullin, P.J., Luna, C.B. and McInroy, D.C. (1977) Psychiatrists and a computer as interrogators of patients with alcohol-related illnesses: a comparison. The British Journal of Psychiatry: The Journal of Mental Science, 131, 160–7. Marbella, A.M., Harris, M.C., Diehr, S. and Ignace, G. (1998) Use of native American healers among native American patients in an urban native American health center. Archives of Family Medicine, 7, 182–5. Noren, J., Kindig, D. and Sprenger, A. (1998) Challenges to native American health care. Public Health Reports, 113, 22–33. Novins, D.K., Beals, J., Moore, L.A. et al. (2004) Use of biomedical services and traditional healing options among American Indians: sociodemographic correlates, spirituality, and ethnic identity. Medical Care, 42, 670–9. Payer, L. (1990) Medicine and Culture: Notions of Health and Sickness in Britain, the U.S., France, and West Germany, V. Gollancz, London. Prochaska, J.O. and DiClemente, C.C. (1984) Self change processes, self efficacy and decisional balance across five stages of smoking cessation. Progress in Clinical Biological Research, 156, 131–40. Shore, J.H., Shore, J.H. and Manson, S.M. (2008) American Indian Healers and Psychiatrists: Building Alliances, in Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health (ed. M. Incayawar), John Wiley & Sons, Inc., Indianapolis. Skinner, H.A. and Allen, B.A. (1983) Does the computer make a difference? Computerized versus face-to-face versus self-report assessment of alcohol, drug, and tobacco use. Journal of Consulting and Clinical Psychology, 51, 267–75. SPSS (1998) SPSS for PC Version 10.0.4, SPSS, Inc, Chicago. Taylor, T.L. (1988) Health problems and use of services at two urban American Indian clinics. Public Health Reports, 103, 88–95. Waldram, J.B. (1990) Access to traditional medicine in a western Canadian city. Medical Anthropology, 12, 325–48. Weinstein, N.D., Rothman, A.J. and Sutton, S.R. (1998) Stage theories of health behavior: conceptual and methodological issues. Health Psychology: Official Journal of the Division of Health Psychology, American Psychological, 17, 290–9. Wellever, A., Hill, G. and Casey, M. (1998) Commentary: medicaid reform issues affecting the Indian health care system. American Journal of Public Health, 88, 193–5. Wilson, C., Civic, D. and Glass, D. (1995) Prevalence and correlates of depressive syndromes among adults visiting an Indian health service primary care clinic. American Indian and Alaska Native Mental Health Research (Monographic Series), 6, 1–12.

CHAPTER 9

Re-Kindling the Fire – Healing Historical Trauma in Native American Prison Inmates L. Tyler Barlowe Counselor / Case Manager, United Auburn Indian Community

Karuna R. Thompson Doctoral Candidate, Department of Religious Studies, University of the West, Rosemead, CA

Abstract Using recent work to describe historical trauma as well as structural factors among colonized peoples as a background, this chapter discusses the healing and liberational effects of Indigenous Spiritual Practices for incarcerated peoples. This chapter also explores the hypotheses that there is not only a re-kindling of interest in spiritual healing practices within institutional settings – there is also an expanding awareness of the need for a blending of Western Medical Models of healing with Traditional Indigenous Healing and Liberating Practices within the global community.

9.1

IMPRISONMENT AND MY LIFE AS A SPIRITUAL ADVISOR

I will begin this chapter by sharing a little about myself to let folks know that I do have personal experience of the subject matter contained in this piece. I’m not comfortable with writing, but I believe in what Mario Incayawar is doing. Earth based people who have experienced colonization have the right and obligation to tell their own story in their own words – free from censorship and misinterpretation. I believe that the level of imitation, assimilation and acculturation to/of European behaviors and attitudes which has occurred in the Americas has adversely affected original inhabitants of the Western hemisphere and that the blending of European influenced Western Medical Models with traditional Native American healing practices is necessary to liberate/heal the effects of a blitzkrieg assault on the Western hemisphere. Peoples anywhere on the earth who were colonized still have access to their precolonial knowledge systems which kept them spiritually, mentally and physically healthy for centuries. It is our indigenous duty and responsibility – where ever we are in the land – to restore this knowledge by whatever means to our individual nations, communities and families. Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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I am a 61-year-old Native American indigenous to the Western Hemisphere. I was raised on a reservation in Oregon; one of many reservations which were terminated by US government decision in the 1950s. Three different tribes shared that reservation. Termination was a destructive federal policy which began to develop in the late 1940s and eventually led to the termination of the education, health, economic and other benefits of over 100 federal recognized tribes nationwide. My grandparents raised me on a farming ranch until about 14 years old. I spent time in reservation school, Catholic boarding school, juvenile homes, reform school, jails and prisons. In 1977, I was released from an Oregon prison (my second term) and earned a full pardon from the governor in 1992. A resolution was adopted by the Klamath Tribes in 1999 recognizing me as a spiritual leader. I earned a BS in Applied Psychology at the Oregon Institute of Technology (OIT) in 2001 and a MS in Psychology at the University of Oregon in 2003. I was a volunteer for the Oregon Department of Corrections (ODOC) religious service section for about 12 years and was eventually hired as a full time chaplain in 2003 at the same prison where I was once a prisoner. As a volunteer and chaplain I conducted traditional Native American spiritual ceremonies at most of Oregon’s 13 correctional facilities, including the women’s prison. I am no longer working for the ODOC but I do have a volunteer card and continue to facilitate traditional ceremonies in Oregon prisons. Today I work as a Health & Wellness Counsellor/Case Manager for a Rancheria in northern California. My ancestors fought the US army in a war on the California/Oregon border in 1872–3; on my mother’s side my great grandfather and great-great grandfather fought side by side against the army. My great-great grandfather was one of two leaders ‘hung by the neck’ after the war ended. On my father’s side I am also distantly related to the other leader who was also ‘hung by the neck’ at wars end; two other warriors were also executed and two more were sentenced to life in prison on Alcatraz Island. Immediate family members of the four warriors who were hung as well as members of all three tribes were forced to watch the hangings. Army and newspaper reports indicate that my great-great grandfather struggled for more than twenty minutes before he died – with family members watching. The remaining Native combatants were removed to Oklahoma; survivors were allowed to return to Oregon in 1910, although some chose to remain in Oklahoma. The man who I called Grandpa, the man who raised me and had a great deal of influence on my life was not my paternal grandfather; his father also fought in the war, was removed to Oklahoma and finally was allowed to come home to Oregon in 1910, bringing his family with him.

9.2

A SNAPHOT OF LIFE IN AN AMERICAN PRISON

Consider the stereotypical image which most folks have of prison. Of those images which is most frightening to you personally? Imagine having undergone the humiliation of being arrested, booked and thrown in a jail cell. They stripped you naked at intake and also stripped you of pride and dignity, dehumanized you and turned you into a number. Don’t forget that number, or your cell number and location, wander into an unauthorized area here and the punishments are severe. Your race/ethnicity or gang-affiliation dictates where you fit in on the yard and in the dining hall. Don’t get out of bounds. Racial issues are the primary cause of ‘incidents’ in prison; stay close to your kind. As time goes on your wife/husband finds someone else, your kids call someone else dad and begin to hate you for deserting them; no letters, no phone calls, no visits for years. You try to act tough and say things like ‘I don’t want

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them to see me like this anyway’ or ‘it don’t mean s---’. You begin to feel like it’s all for the best when you begin to believe that you are truly worthless and deserve what’s happening to you. Then you’re a real ‘con’ and other cons become your family and you’re closer to them than you ever were to anyone else including your biological family. You live with them every minute of every day, day after day, year after year. You know more about them and them about you than anyone else alive. You know who is a fool and who has integrity, courage, wisdom and you feel valued for the first time in your life. And then all of a sudden your time is up and you get out. You are not free but you are out of prison. You end up in a room about the same size as a prison cell with a job you hate; they take most of your wages for rent and past fines. You’re ashamed and feel guilty that you got out and left your friends behind in the prison; you miss those guys but at the same time you know that they are laughing and making bets as to how soon you will come back. That same familiar feeling of worthlessness and selfloathing rides down on you there in the dark. You feel like you don’t deserve anything good or decent or real and the illusion of freedom is more frightening than the specter of prison and this can scare you home – to prison.

9.3

HOLOCAUST OF ABORIGINAL NATIVE AMERICAN PEOPLES

These days it seems almost rude to detract from the Jewish Holocaust by bringing to light the fact that another and larger holocaust exists. Of course I am referring to the American holocaust that was and continues to be perpetrated against indigenous peoples of the Western Hemisphere. No holocaust or act of genocide should ever be forgotten or diluted by calling it a civil war or ethnic cleansing. There are differing opinions as to the number of indigenous peoples inhabiting Turtle Island (North America) at the time Columbus washed ashore. Pre-Columbian numbers vary as historians and anthropologists’ opinions change with ‘new’ discoveries. Estimates vary from between 12 and 112 million in 1492. ‘Twaddle about imaginary millions’, scoffed one Smithsonian expert reflecting the prevailing view that Indians were too incompetent to have ever reached large numbers, (Lord, 1997). The land base in the United States was 2 000 000 000 acres; the number of Native peoples declined to about 250 000 by 1900 and the land base was diminished to 140 000 000 acres. Today there are approximately 2.5 million people identifying themselves as Native American, and the land base is about 50 000 000 acres (as cited in Ball, 1998; Unpublished doctoral dissertation). Of course these numbers are not empirical, they are fluctuating snapshots and are presented here to give an idea of the effects of colonization and to act as evidence. Genocide has been defined in Article II of the United Nations Convention on Genocide (UNCG), 1948 as: any of the following acts committed with intent to destroy, in whole or in part, a national, ethnic, racial or religious group, such as:

 killing members of the group;  causing serious bodily or mental harm to members of the group;  deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part;

 imposing measures intended to prevent births within the group;  forcibly transferring children of the group to another group.

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History itself testifies to the fact that each of these violations has happened repeatedly in regard to the indigenous inhabitants of the Western Hemisphere through European style warfare, population decimation due to imported disease, relocation, reservation, paper genocide, forced sterilization, boarding schools, missionaries and adoption of Native children by non-native families. As immigrants moved across America each encounter with Native people provided an opportunity to refine their skills at destroying indigenous cultures. In an interview in 1994 (as cited in Allison, 1994; unpublished doctoral dissertation) one elder stated ‘They slaughtered even the old people; killed the little children. That’s how they treated the Indians; kill even the kids’. This is in reference to the slaughter of an entire native village called Dokdokwas at the hands of white vigilantes led by the famous ‘Indian Fighter’ Kit Carson (Fremont, 1949). It turned out that they not only attacked the wrong village but the wrong tribe as well; still over 40 men, women and children were killed and burned. In the same interview another elder recorded ‘And like when they had the Modoc war; they killed a lot of little Indian children. Killed the little children. That’s awful, init [isn’t it]? Sometime I feel like, I. . .feel mean’ (as cited in Ball, 1998; Unpublished doctoral dissertation). These acts are not only war crimes but are also crimes against humanity. Stories of these historically traumatic events passed down through the generations can have an effect not only on the descendents of the victims but also on the descendents of the perpetrators. These painful histories must be faced if healing is to occur. Much discrimination and racist attitudes have their origin in these still festering wounds.

9.4

NATIVE AMERICANS IN THE OREGON STATE PRISON SYSTEM

States all across America are building increasing numbers of prisons which fill even before they are completed. More laws and acts are being passed which criminalize and pathologize increasing numbers of behaviors which in turn insures a continued economic growth potential for the prison industrial complex. We must maintain a conscious awareness of the historical potential for states’ political use/abuse of social institutions. This is further complicated for Native Americans. Native Americans are living in an ‘occupied’ country. This means that the laws of the dominant society are often not recognized by Natives as meaningful or having legitimate application to indigenous values and ways of life. Breaking these ‘laws’ can be experienced as an expression of indigenous solidarity and of support and honoring of the family members and ancestors who fought colonization and continue to struggle for validation of the traditional ways of living. Going to prison can be a way of maintaining personal identity as ‘Native American’. For many young people who have not had access to traditional ways of life as they were raised, these acts of resistance may be their only connection to their ancestors and making meaning of ‘the way things are’. There was a time when young people would have ‘rights of passage’ (puberty ceremonies) after which they would be recognized as responsible young adults and full participants in the function of community, clan, tribe and nation. As traditional ways are lost young people have increasingly limited means of learning the ways of their ancestors and developing a legitimate and safe way of entering the community as healthy productive members. Where there are not legitimate ways of being young people create their own rights of passage. These often

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include meaningless violence and surviving a prison sentence becomes a warped right of passage. The lack of meaning and connection lead to a sense of despair and many youth ask the question ‘Who am I, what am I?’ This despair leads to many forms of drug and alcohol abuse which leads to ‘crime’. As Dr Tom Ball says, ‘Society creates the crime; the individual simply carries it out’ (personal communication, 8 September 2001). There are approximately 47 000 Native Americans in Oregon today; the Oregon Department of Corrections (ODOC) inmate population profile claims there were 266 inmates identifying themselves as Native American incarcerated on 1 March 2007, 35 of whom are females. This information is gathered from Oregon inmates during the initial prison intake process and is unreliable to say the least. The number of women under correctional supervision has increased substantially in recent years. At year-end 2005, for example 107 518 women were incarcerated in state or federal prisons nationwide, and over 950 000 female offenders were on probation (Glaze and Bonczar, 2006). Over the past several years, the annual rate of incarceration for women has outpaced that for men, and in 2005 the number of women serving state or federal prison sentences increased 2.6%, while the number of male prisoners increased 1.9% (Harrison and Beck, 2005). Consequently, the proportion of women in state and federal correctional institutions increased to an all time high of 7% in 2005 (Harrison and Beck, 2005). This has an important impact on Native American children. Even though Native Americans make up less than 2% of the population in Oregon (1.4%) more than 12% of the 16 000 children in the Oregon foster care system are Native American. At any given time, 400 Native American children are in foster care in Oregon. In a recent parenting project carried out in Oregon’s women prison, Coffee Creek Correctional Facility (CCCF), 198 women participated. The project was carried out by a nationally known social research organization located in Eugene, Oregon. Of the 198 participants, 14 self reported as Native American women, 26 self reported multi-racial, 4 self reported other, 20 self reported African American, 17 self reported Hispanic/Latino and 117 self reported as White. Less than half of the reported 35 Native American female inmates at CCCF participated in the parenting project; these parenting programs are carried out in the male institutions as well and also reflect minimal participation on the part of Native inmates. Most interventions, whether in a school, prison or hospital have very little impact on or interest for marginalized peoples. Western interventions – tests and measurements – seldom if ever include people living in depressed areas such as ghettos, barrios and reservations in the development of the tool and the mostly white assistants carrying out the work may not have the real life experience needed to have a meaningful effect with these populations. This leads to lack of participation by those who may benefit the most. Negative stereotypes, a lack of political clout and culture bound behaviors are seldom acknowledged when developing programs in the correctional system. Quoted in Faith (1993); ‘Put at its baldest, there is an equation for being drunk, Indian and in prison. Like many stereotypes, this one has a dark underside. It reveals a view of native people as uncivilized and without a coherent social or moral order. The stereotype prevents us from seeing Native people as equals. The fact that the stereotypical view of Native people is no longer reflected in official government policy does not negate its power in the popular imagination and its influence in shaping decisions of the police, prosecutors, judges and prison officials’.

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9.5

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HISTORICAL TRAUMA AND TRADITIONAL NATIVE AMERICAN METHODS OF HEALING

My grandmother used to say ‘musen’t do that’ (you must not do that), what she meant was you don’t do anything to get the attention of the white folks. Her father who fought in the Modoc war, told her the same thing. After the Modocs surrendered they were chained and taken back to Fort Klamath, Oregon in US army wagons escorted by soldiers and civilian volunteers. Along the way other civilians approached the caravan and began shooting into the wagons full of chained Modocs; the US soldiers did nothing to prevent this attack, they only moved out of the way. Grandma’s father told her that every time the Modoc captives would move and try to get out of the line of fire the assault would focus on this movement and those people trying to save themselves were shot. To get attention from any entity also means that the resulting consequences of that attention must be dealt with. This can be the attention of the police, social workers, doctors, psychiatrists, psychologists, preachers, teachers, coaches, welfare workers and bosses. The intergenerational effect of this could be an unwillingness or discomfort or inability to accept positive attention for doing positive things. Many Natives grow up in communities where the attention received is mostly negative and we learn how to deal with it through role models and personal experiences. Positive attention is different for folks who have a history of being taken advantage of; it makes you uncertain, confused and paranoid. Someone pats you on the back and compliments you or tries to give you something; your first thought may be ‘what’s this fool want now?’ Many tribal youth are very good at sports or academics in high school and as a result may ultimately be the recipients of positive attention in the form of college scholarships. College can be frightening; it can be so intimidating that it scares you home; the fear can be fear of success as much as fear of failure. Dysfunctional community and family life may be hard for a young person, but surviving in a college/university town is a cold and lonely challenge, like living with a snake with constant expectations of being bitten. It’s easy to be scared home, especially when there is little or no family/social support. Indigenous culture/language evolved in relation to natural environmental conditions; instinctive cultural evolution is about abstracting meaning from the natural environment and creating ways of being which harmonize with nature. With European contact the natural instinctive evolutionary process was interrupted. Survival mechanisms which were in place and functional 500 years ago – for the most part – are not appropriate in today’s ‘tech-no-logic’ environmental realities. Science has made an enemy of nature – anthropocentrism. Almost everything we do today to survive destroys the natural environment in some way; every time the toilet is flushed between three and seven gallons of fresh water is dumped into the sewer system. Water is the sacred blood of mother earth and nothing can survive without water. Instinctively we know this, but at the same time we are impelled to participate in unnatural self-destructive behaviors which can cause a deep sense of confusion, shame and anxiety. We may come to believe that we no longer deserve to participate in traditional healing – cultural appropriate ceremonies. Because we drive and have a TV in nearly every room does not mean that we should neglect our spiritual obligations to nature and self. The ceremonies and especially the songs which kept us healthy and sane for centuries are still there and are still effective. Our environment has changed as well as the challenges of living in today’s realities. Today we are not threatened

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by starvation because the salmon run was small or the deer herd didn’t migrate or the roots and berries didn’t grow as abundantly as usual. But the songs and ceremonies which took care of us then will take care of us now. That is a cultural lag that can also be a cultural lead. Threats to our communities today; domestic violence, drug and alcohol abuse, gang violence, can all be impacted by ceremony. One of the things that young Natives say today is ‘I don’t know who I am’ or ‘I don’t know what I am’. One of the songs which we use in ceremony asks that very question and is a song which was used to help folks through times of self-doubt for hundreds/thousands of years and is still effective today for any age group. There are many more healing songs and rituals which can and should be used where appropriate. Although there has been much research conducted on Native Americans on almost every topic, it is only recently that an increasing number of Native American researchers and scholars have argued for the primacy of unresolved trauma as a determinant of negative health and psychosocial outcomes in Native American communities (Duran and Duran, 1995; Brave Heart and DeBruyn, 1998; Duran et al., 1998;). Only lately has research with Native Americans been acknowledged and not always in a positive light. Historically most research was conducted by white scientists and anthropologists who were/are insensitive and unaware of the underlying value and influence of Native culture. According to Smith (1999), the word itself, ‘research’, is probably one of the dirtiest words in the indigenous world’s vocabulary . . . it stirs up silence, it conjures up bad memories, it raises a smile that is knowing and distrustful . . . indigenous people even write poetry about it. Many nonIndian researchers think that they have the authority, power and entitlement to gather information by whatever methods, no matter how aggressive or unprincipled. This arrogant behavior leads to suspicion, avoidance and mistrust of all researchers on the part of Native Americans. The application and study of Native American spirituality and traditional Native American methods of healing is gaining increased attention in such areas as alcohol and/ or other drug (AOD) treatment facilities, prisons and in the social services. There exists a huge volume of literature in corrections on effective Western medical methods of treatment but only a small amount of literature on the role of Native American traditional healing techniques. Duran and Duran (1995) argued that, as a starting point, interventions must acknowledge the historical trauma experienced by Native Americans and must carefully examine how this trauma relates to the current issues faced by Native American individuals and communities alike. This means that care providers, therapists and so on must be aware of the histories of individuals, families, clans, communities, tribes and nations in relation to the effects of colonization. Understanding colonization in the Americas is incomplete without awareness of the intergenerational effects of colonization on Native American communities. The intergenerational transference of the intense emotions expressed by tribal members is the point; consciously or unconsciously we impress our values/beliefs onto the next generation as former generations impressed their views onto us. The traditional ceremonies that were in place in the past to filter out the potential destructiveness of such extreme emotions must be reintroduced into native cultural healing practices. Moreover, these ceremonies must be facilitated by competent knowledgeable Native healers who understand the need to tailor ritual to meet specific need. Survival tools of a specific culture must evolve to meet contemporary challenges facing that culture. This is a time for evolving mechanisms which highlight and celebrate the resilience of our peoples. After all, our societies did not completely collapse; things may have gotten chaotic for

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awhile, we may have even been significantly influenced by the colonist culture imposed on us but we are still here, our numbers are growing and our spirituality has not been totally destroyed by Western religion or metrospirituality. Pre-Columbian cultures and languages evolved in a natural way, adapting to environmental changes and influenced by actively living life. Since 1492, our indigenous cultures seem to have stopped redefining themselves in an instinctive way and began accepting the definitions and categories projected onto us by the colonizer. Out of their ignorance and intolerance they defined, reinvented and categorized nearly everything in the Western hemisphere – and we imitate the illusion, the false image. We are not Indians although we will fight each other over who is ‘more’ Indian than another. Each nation of Indigenous Native Americans has its own name and identity, but sometimes we forget or maybe get ashamed of ourselves. It takes courage to be who you really are; especially in a civilization where reinventing yourself with a new face and personality through plastic surgery and legal/illegal cosmetic psychopharmacology has become the norm. Five hundred years of traumatic oppressive colonial policies at the hands of European immigrants has resulted in the near destruction of many Native American cultures and traditions (First Nations Website, 7 September 2002; Washburn, 1971; Hammerschlag, 1982; Thornton, 1987; Echo-Hawk, 1993; Harjo, 1993; Mieder, 1995 The circle Archives: available online, accessed 8 December 2002; Duran et al., 1998; Brave Heart and DeBruyn, 1998; Tafoya and Del Vecchio, 1996). Many of the problems that we face today are a result of not being given the time and access to resources to resolve the trauma. Many of the behaviors which put tribal members behind bars may be a knee jerk reaction to the atrocities which our ancestors have endured for hundreds of years. Awareness is primary; awareness of personal origin, who exactly are you, who are your ancestors, where did they live, how did they live, how did they die, where are they buried, what did they endure and what did you inherit from them? If spirituality and tradition were our parents most of us would be orphans. By far the most catastrophically destructive experience in relation to traditional Native American parenting skills was the boarding school era which spanned approximately one hundred years from 1850 to 1950 (Manson et al., 1996; Marr, Available online, Accessed 7 September 2002; Morrissette, 1994; The Circle Archives, Available online, Accessed 8 December 2002; Terry, Available online, Accessed 7 September 2002; Smith, 1999; Freire, 1999; Duran and Duran, 1995). From about the same time; the mid 1880s to the 1960s participation in Native American spiritual ceremonies was criminalized. This regulation did not stop the ceremonies, but only drove them underground. Denial of adaptive, self-protective survival mechanisms effectively created outlaws out of ceremony participants. Facilitation of Native spiritual ceremonies should be done by authentic tribal members who are knowledgeable and experienced in conducting rituals. We are born out of the suffering of our ancestors. Trying to live in this reality as Native people is a shock; especially when we realize that our cultures and languages have been marginalized, trivialized and devalued. Our parents, grandparents, great-grandparents and great-great grandparents are all survivors, as are we. What our ancestors endured in order to survive is unimaginable; enduring the feeling of shame, the loss of dignity, the confusion and the guilt for having allowed certain things to happen to friends and relatives to insure their personal continued existence is a remarkable example of resilience. They lived with that survivors’ guilt down through the generations; we are descendant survivors, we are the evidence; evidence of a crime committed against the Indigenous Inhabitants of the Western Hemisphere. This America is a crime scene. Some may say that our ancestors

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passed only guilt and shame on to us, and this might be somewhat true. In order to free ourselves from guilt and shame each individual must decide for themselves whose baggage to carry and how far to carry it. Whatever, we are the ones who must find ways to deal with it. Some of the young Indians today, at times, cannot understand why their parents are unable to teach them the native languages, rituals and traditions that they think all indigenous people should know and understand. In restoring harmony between parents and children, it is imperative that the children eventually learn about their parents emotional pain . . . many Native young people are unaware of their parents devastating history . . . parents are fearful that their children will disrespect them since they did not rebel or fight back. What needs to be monitored closely during this process, however, is the young person’s desire to defend and seek revenge on behalf of his or her parents. . . . (Morrissette, 1994).

Five hundred years of genocide and abusive colonialism have left deep scars. Guilt and shame unconsciously or consciously internalized by the ancestors of today’s Native inmates may have some causative relation to their criminal/anti-social behaviors. Intergenerational oppression and lateral oppression go hand in hand; what we learn through our experiences in life we tend to pass on to our children and can result in hate, anger, rage and racism. Historical events may have an unconscious effect but recent crises may be consciously suppressed. Either way, stress and anxiety may result in leading to attempts at selfmedication through alcohol and drug abuse. These feelings directed towards an image that Natives carry as representative of America are the effects of colonialism. Colonialism, genocide and holocaust would not be a growing concern and interest today if it were not for the effects. What is passed on to Native youth in place of traditional wisdom can/may be no more than the symptom or effect of the colonial de-dignification of our ancestors. When dignity, honor and pride are stripped away by whatever means and self-redemption is denied/prevented for generations it is no wonder that our youth are angry and confused. Effects of the de-spiritualization and dehumanization of Native peoples and the de-spiritualization of the environment continue to fuel the resentment and play a decisive role in the continuation of negative behaviors among colonized peoples.

9.6

NATIVE AMERICAN HEALING PROGRAMS WITHIN THE OREGON DEPARTMENT OF CORRECTIONS

Re-kindling the spark of spirituality which has endured generations of genocide and tending the resulting fire will begin resolution of the effects of historical trauma. Tending a fire and bringing it to its full potential is very much like nurturing a child. If too many people aggressively attempt to tend a fire it will take much longer to reach its full potential – if it ever does. Many things are involved in the building of a good fire; what kind of wood, dry or green, kindling, environmental conditions such as wind direction and weather all must be taken into account. If fire tenders steal fire from one side to start the other, chances are the fire will never burn. Same with a child, what must be done, what must be present to create conditions which will temper and meld a child to its full potential? If caregivers provide confusing information (fuel) to the child the footing needed for positive growth may never be there and the child may never mature. Puberty ceremonies (rights of passage)

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took the child away from the parents and placed them with folks who would have a more clear perspective of the child’s true abilities and capabilities. Parents on the other hand may see things in their kids which are not really there. Parents tend to overprotect their children and place blame for shortcomings on others; teachers, peers, police and so on. Many prisoners are still dependent on their parents, especially ‘m-others’ to support them while they are incarcerated. Steps must be taken to help individuals become aware of immature dependencies and realize that they can learn to tend their own fire and burn off the debris of historical trauma. Some of the debris colonized peoples carry is invented identity, misplaced values, gender role confusion/reversal, emotional illiteracy and labels such as lazy, drunken and so on Many traditional cultures believe that ‘bad medicine’ can be thrown into others. Some cultures believe that spirits or demons exist and can be internalized by unsuspecting and unprotected individuals. These entities take on a more meaningful image when compared to the challenges presented in modern society. Senseless violence, greed and a sense of entitlement are spells cast over societies worldwide. Entities such as these become the demons internalized by acculturated peoples. Remembering history – white Europeans coming to this country were themselves colonized and oppressed at some point in their past. They too were forced to turn from their birthright and cultural heritage. The only difference was their skin color; they were white-skinned and even if they were oppressed in Europe they could use their skin color to attain privilege in America and in turn oppress those who were not white. Part of that oppression is labelling; labels can take on a life of their own and labelled behaviors can become demonic when internalized. If a people are told over and over, generation after generation, that they are lazy, dumb, ugly, drunken, violent, killers, robbers, predators, junkies and so on pretty soon they are going to start living up to that label. Those labels are the demons internalized by oppressed people. And white-skinned Americans are the ones creating and casting the demon label/spells. What you sow, so shall you reap. If a person is at the bottom of the barrel any label will provide an identity and make them unique. Even negative attention is better than no attention. One thing we do in prison ceremony is encourage individual participants to express themselves. We want them to know that their feelings and thoughts, hopes and dreams are important and worth hearing. What we do – in a traditional sense – is help them build a basket; a basket that will hold those hopes, dreams and good intentions. Here is a story. Once there was young Native woman who was well known for her ability to dig roots. She was very fast and could clear a field faster than anyone else. But there was a hole in her basket and all the roots would fall out as soon as she put them in. When she tried to fix the hole it would be there again as soon as she put anything in the basket. Finally she was able to fix the hole, but only by using material that the basket was not initially made from. She had to use different material to make the basket useable. During the various traditional ceremonies we provide in prisons, we can help participants to build a basket to hold their hopes and dreams and good intentions when they get out. The problem is that sooner or later a hole appears and all the good stuff falls out. Using traditional material to patch the basket – at times – just doesn’t seem to work. We need to use something else to fix our basket just like the young woman did. To deal with the symptoms of historical trauma and the internalization and imitation of created mis-labels we need to include Western methods (material) of healing along with our culturally specific traditional (material) methods. Modern Westerners may feel alone and ache for ‘something’ they cannot name. To understand the current terrain of ‘indigenous psychology’ one must understand the history. It is important in reviewing the history to take it in the context of survival, not victim. That

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any peoples could withstand the violence inflicted by colonial policy, practice and culture is a testament to the profound strength and resilience of the traditional healing practices native to colonized lands. Native Americans have not completely turned their backs on their birthright and heritage; we do not deny or try to escape who we are.

9.7

DIGNITY, IDENTITY AND REDEMPTION

Imprisonment has been a continuation of indigenous experience throughout history, ‘isolate and seclude’. Through this practice and others, people are separated from their families and cultures and systematically ‘broken’ of any personal will or ambition to carry their culture and language into the future. On the side of the oppressor, as talked about by Bruno Bettelhiem in The Informed Heart, his reflections of being a prisoner in a Nazi war camp, prisons are simply an ‘efficient’ way of handling large groups of people. When we are able to think of people not as people, but as numbers/objects and principles that need management, and inflicting violence of all kinds becomes possible, this is what is meant by ‘efficiency’. This could also be perceived as structural violence, which is present in some fashion in most institutional settings where denial of basic needs and intimidation can fuel hate crimes and racial conflicts. In the late 1970s and early 1980s, as colonized indigenous peoples around the world were starting the long journey of reclamation of traditional values and voices, awareness dawned regarding the number of youths and adults who were incarcerated. In New Zealand in particular, among the indigenous Maori people over 80% of their male youths were in juvenile facilities (Hayden, 2001). This was creating a huge crisis in the social fabric of the community. At the core of Maori values is a very extensive extended family system; the ‘nuclear’ family which European peoples are accustomed to is quite unfamiliar. As the community reflected on the crisis they realized that the conventional/European justice system was not serving their children nor the families. A similar process has taken place for Canada’s First Nations peoples as well. In a position paper created by an Ojibwa tribe they state the issue with simple clarity: The use of judgment and punishment actually works against the healing process. An already unbalanced person is moved further out of balance. What the threat of incarceration does do is keep people from coming forward and taking responsibility for the hurt they are causing. It reinforces the silence, and therefore promotes, rather than breaks, the cycle of violence that exists. In reality, rather than making the community a safer place, the threat of jail places the community more at risk. (Ross, 1996) As a community they chose to return to traditional forms of ‘harmony and balance’ rather than ‘justice’. Justice in Euro-Christian terms focuses on retribution and retaliation rather than healing the harms and confusion in the individual and community. This change in approach, focusing on healing, has not only impacted the children in the Maori and First Nations communities but has transformed the face of Western justice in total – giving birth to the Restorative Justice movement. The Maori peoples created what has come to be known as ‘Family Group Conferencing’ and the Ojibwa peoples created a similar healing approach known as ‘Community Holistic Circle Healing’. Central to both of these models is the focus on healing for individuals, family and community. Often when people think of harmony they think of all parties being in agreement. This is not the intention of harmony in this context. Here it represents the idea that each person has

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a place and a purpose. When people lose a sense of place and meaning we become disoriented and harmful to one another. The colonization process has deliberately and systematically stripped indigenous peoples of their traditional social/gender roles and in so doing has removed their sense of purpose and meaning for living. Further, colonial societies have laws that do not belong to the tribes they govern and often directly in conflict with traditional ways and values. One example of this is the outlawing of traditional ceremonies here in the United States. Mixing these truths with the reality of historical trauma carried by colonized peoples, prison for many is simply an inevitable expression of what might be called colonial trauma syndrome. To bring back balance and harmony to individuals in prison all of these concerns must be addressed. This includes not only the offender but the victim/s and the community. Often it is not only the offender or family that is out of balance, but it is the whole community that needs to care for something. Everyone needs to be responsible and redeemable to one another. Redemption in this context requires a meaningful, obvious and public sacrifice; this sacrifice may be as simple as being allowed an opportunity for self-expression in a ceremonial setting or as serious as committing to a more intense four-day Sun Dance, for example. As a culture we are comfortable with convicting/blaming a single offender; we as a community, town or nation do not want to look at what we may have done collectively to contribute to the situation in which this person has found themselves. After several years attempting to develop a ‘healing conference’ to be held within the walls of the Maximum Security Oregon State Prison (OSP) the conference became a reality for five days in April, 2007. This healing conference was an opportunity to expose male prison inmates to information and innovative interventions which they may never have experienced otherwise. We are hopeful that a similar conference will be allowed for the Native American women at CCCF in the near future. At the conclusion of the conference the Protestant Chaplain assigned to the institution was so impressed by the event that he has extended a standing invitation to the Native American community to hold a conference or similar event annually in this facility. Four Native American PhDs together with other Native people who work with domestic violence, restorative justice, Fetal Alcohol Syndrome/Fetal Alcohol Effect (FAS/FAE), and alcohol recovery presented over the five day conference. Dr Tom Ball, from the University of Oregon opened the conference with a presentation on Historical Trauma; Dr John Spence of Portland State University presented on Traditional Approaches to Healing and the implications of this healing with historical trauma. Dr Allison Ball from the University of Oregon Child and Family Center & Alethea Barlowe, along with Danita Herrera, Project Coordinator – Parent Child Study – Oregon Social Learning Center (OSLC) focused on parenting, Bob Ryan, Multnomah County Oregon – Mental Health & Addiction Services Division, shared views on alcohol/drug recovery from an Indigenous Recovery perspective. Tawna Sanchez and Andulia White Elk, representing the Native American Youth And Family Center put forth views on domestic violence, Suzanne Kuerschner, MEd, National Indian Child Welfare Association, Northwest Portland Indian Health Board offered insight into Fetal Alcohol Syndrome (FAS) and related neuron-developmental disorders. An intensive full day workshop focusing on Traditional Ceremonial Recovery Strategies was conducted by Warm Springs tribal members Guy Wallulatum and Patrick Mitchell. The agenda of this conference reflects what is needed in every prison for the healing of Native Americans; through combining intensive interventions like this conference with traditional ceremonies,

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incarcerated people can build the strength to face their past, tell their stories and bringing healing to themselves, their families and the larger community. A personal or family genogram is one method of creating and realizing one’s own journey through the effects of colonization. Following back through personal and family traumatic events will bring realization that we have a right to be angry, but more importantly we have a responsibility and duty to use that anger spirit in a positive way. We can’t continue pouting, blaming and throwing tantrums; we must use that anger spirit in an honorable way and shed light where it’s needed to reveal a righteous path to liberation. Survival is an instinctive process, but Natives seem to have allowed the intellect to interfere with a natural instinctive evolution and we second guess our spiritdriven gut feeling. Whose intellect is it, whose intelligence, whose language, definitions and categories are we allowing ourselves to be dependent on and directed by? In ceremony we help ourselves and others to get past the shame and guilt of having allowed ourselves to deteriorate so far. Sometimes we do things that are so unspeakable there is no way to redeem ourselves. No way to apologize, no way to go home, no home to go to, no way to express ourselves. But even with all that we still have a responsibility and duty to do the best we can; we are warriors, warrior men and warrior women. Warriors do these five things; they provide, protect, nurture, make things happen and do it as peacefully as possible. . . . . prisoners indicate that Native American culture and religious practices have helped encourage a law-abiding lifestyle, prohibiting the use of alcohol and drugs among inmates. Grobsmith (1994)

9.8

PERSONAL COMMENTS FROM INMATES

If I didn’t go to prison I really don’t know where I’d be today!!! The guys from the Lakota Club I wrote to were a lot of help spiritually and helped me to know myself as well as the books that I read from Native authors. I thought being Native was being tough and drinking as much alcohol as I could. That is what was going on at the time I was growing up. When I got out I started drinking again and I hit someone with a cue stick when I was sober in the bar, I realized then that this just wasn’t for me anymore. Sharron. To this day my days are a constant struggle with the feeling of unworthiness. I became more frozen, harder, tougher, and a callous began to grow around my heart; a kind of emotional flak jacket that blunted the blows and sting of living by bells and rules designed to control the actions of us from the time we woke up in the morning to the time we went to bed at night. Ganndi. There is so much that ceremony does. I guess it is more important in prison because you are trying to better yourself and strive for more than you have had before. Getting involved with your culture, prior to coming here most people didn’t know anything about their culture, their reservation, their language. It gives you more confidence in who you are. When other people ask you who you are and where you are from and if you know your language, if you can’t answer that it is hard for you and the other person. Once you learn these things it develops you as a person. Tigger.

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Ceremony opened doors for me. Made me feel like I was connected when I wasn’t really feeling I belonged anyplace. Taught me to open up and I learned a different kind of communication. Stu. I was released 7/25/07 and have been to Dorothy’s home and sweat-lodge on four occasions. I thank the Creator for those people who have given me the gifts and the opportunity to learn a better way of life. Sweat-lodge provided a window into my thought process which affirmed the value I have for family, community, and self. Jim. This way of life has been pulling at my heart my whole life. My mother hears me sing these sacred songs and speak of the sacred ceremonies. She cries and tells me that her Daddy would be very proud of me. Shawn.

REFERENCES Allison, J. (1994), The Cultural Landscape of the Klamath, Modoc, and Yahooskin Peoples: Spirit, nature, History. Prepared for the Klamath Tribes, is fulfillment of National Historic Preservation Grants to Indian tribes & Alaska Natives, Grant #41-92-NA-411, as cited in Ball 1998, unpublished doctoral dissertation. Ball, T.J. (1998), Prevalence Rates of Full and Partial PTSD and Lifetime Trauma in Sample of Adult Members of an American Indian Tribe. Unpublished doctoral dissertation, University of Oregon, Eugene. Brave Heart, M.Y.H. and DeBruyn, L.M. (1998) The American Indian holocaust: Healing unresolved grief. American Indian & Alaska Native Mental Health Research, 8 (2), 60–82. Duran, E. and Duran, B. (1995) Native American Postcolonial Psychology, SUNY Press, New York. Duran, E., Duran, B., Brave Heart, M.Y.H. and Yellow Horse-Davis, S. (1998) Healing the American Indian soul wound. International Handbook of Multigenerational Legacies of Trauma, Plenum Press, New York. Echo-Hawk, W.R. (1993) Native American religious liberty: Five hundred years after Columbus. American Indian Culture and Research Journal, 17 (3), 33–5. Faith, K. (1993) Unruly Women the Politics of Confinement and Resistance, Press Gang Publisher, Vancouver, British Columbia, Canada. Freire, P. (1999) Pedagogy of the Oppressed, The Continuum Publishing Company, New York. Fremont, J.C. (1949) Memoirs, Tippin & Streeper. 30th Congress, 2nd Session, House misc. doc. 5. Howes F 366, Washington DC. Glaze, L.E. and Bonczar, T.P. (2006) Probation and Parole in the United States, US Dept of Justice, Bureau of Justice Statistics, United States. Grobsmith, E. (1994) Indians in Prison: Incarcerated Native Americans, University of Nebraska. Hammerschlag, C.A. (1982) American Indian disenfranchisement: Its impact on health and health care. White Cloud Journal, 2 (4), 32–6. Harjo, S.S. (1993) The American Indian experience, Family Ethnicity: Strength in Diversity. Sage Publications, Inc, Thousand Oaks, CA, pp. 199–207. Harrison, P.M. and Beck, A.J. (2005) Prisoners in 2004, US Dept of Justice, Bureau of Justice Statistics, Washington DC. Hayden, A. (2001) Restorative Conferencing Manual of Aotearoa New Zealand, Department for Courts, Wellington. Lord, L. (1997) One of the few certainties: the indian populations of north and south america suffered a catastrophic collapse after 1492. Copyright U.S News & World Report, Inc. All rights reserved. Manson, S., Beals, J., O’Nell, T. et al. (1996) Wounded spirits ailing hearts PTSD and related disorders among American Indians: trauma and the American Indian. Ethnocultural Aspects of Post-Traumatic Stress Disorders: Issues, Research, and Clinical Applications. American Psychological Association, Washington, DC, pp. 255–281.

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Morrissette, P.J. (1994) The holocaust of first nation people: Residual effects on parenting and treatment implications. Contemporary Family Therapy, 16 (5), 381–392. Human Sciences Press, Inc., 381–392. Ross, R. (1996) Returning to the Teachings: Exploring Aboriginal Teachings, Penguin Canada. Smith, L.T. (1999) Decolonizing Methodologies: Research and Indigenous Peoples, Zed Books Ltd, New York. Tafoya, N. and Del Vecchio, A. (1996) Back to the future: An examination of the Native American holocaust experience. Ethnicity and Family Therapy (2nd edn). pp. 45–54. The Circle Archives. Historical trauma response. [Online] Available at: http://www.thecirclenews.org/archives/221covere.html. Terry, F. Naming the Indians. (1897) American Monthly Review of Reviews 15 Mar, 1897, pp. 301–307. [Online] Available at: http://etext.lib.virginia.edu/etcbin/toccer-new2?id=TerName. sgm&images=images/ Thornton, R. (1987) American Indian Holocaust and Survival: A Population History Since 1492, University of Oklahoma Press, Norman, OK. Washburn, W.E. (1971) Red Man’s Land White Man’s Law, University of Oklahoma Press, Norman and London.GG

CHAPTER 10

American Indian Healers and Psychiatrists Building Alliances Jay H. Shore, James H. Shore and Spero M. Manson University of Colorado Denver, Department of Psychiatry, American Indian and Alaska Native Programs, Aurora, Colorado, USA

Abstract The traditional beliefs and practices of North American Indians offer benefits for mental health in this population. There is an important but limited historical body of knowledge on collaboration between North American Indian healers and psychiatrists. Two recent collaborations in the treatment of Indian veterans in the US southwest and northern plains states illustrate the process by which traditional healers and psychiatrists can work together. The southwest example describes the creation and implementation of a formal system of consultation and reimbursement between health services offered by the US Veterans Health Administration and southwestern healers. An account is then given of both formal and informal consultation between psychiatrists and northern plains medicine men during the course of treatment of Indian veterans. The chapter concludes by offering a set of guidelines for psychiatrists who wish to collaborate and consult with American Indian traditional healers.

10.1

INTRODUCTION

Traditional healing practices of North American Indians predate the field of psychiatry, the modern foundation of which emerged early in the twentieth century. The relative stability of traditional healing practices contrasts with enormous changes Western psychiatry experienced over the previous century. For American Indians who seek mental health treatment from Western medical services, additional access to Native healing traditions offers many potential benefits. Conversely, incorporating traditional medicine from the patient’s community may be a critical determinant of their treatment by a psychiatrist or other mental health provider. Effective collaboration between these practitioners can be challenging. Yet, this process can be as important to the care of a patient as the treatment Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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itself. The purpose of this chapter is to describe collaborations between psychiatrists and North American Indian healers and to present a set of guidelines and model for collaboration to facilitate such care. A growing body of literature has examined American Indian patients’ use of biomedical and traditional healing services, demonstrating high rates of help-seeking from both sources of care across a diverse range of tribes and settings (Buchwald, Beals and Manson, 2000; Gurley et al., 2001; Kim and Kwok, 1998; Marbella et al., 1998; Novins et al., 2004; Zubek, 1994). These studies have revealed that biomedical services and traditional healing are used both independently and in combination with one another (Novins et al., 2004). A large epidemiological study involving a sample comprised of northern plains and southwestern tribes observed that a significant percentage of American Indians use traditional healing practices (Novins et al., 2004; Gurley et al., 2001; Beals et al., 2005b). This was true especially of participants who suffered from behavioral disorders: 34–49% in the past year (Beals et al., 2005a). Indeed, 16–32% of users of biomedical services for emotional problems also had seen a traditional healer (Novins et al., 2004). A separate study of urban American Indians in primary care also found high rates of traditional healing practices usage (70%), the likelihood of which was associated with alcohol use and a history of exposure to traumatic events (Buchwald, Beals and Manson, 2000). Although these studies document the phenomenon of dual use, there have been no published studies of the collaboration or coordination of care between biomedical services and traditional healing. A study among urban American Indian patients revealed that of the considerable number (38%) of patients who saw Indian healers, the majority (62%) rated their healer’s advice higher than their physician’s. Only a small minority (15%) informed their physicians that they were seeing a traditional healer (Kim and Kwok, 1998). Distressingly, these findings indicate a lack of collaboration and coordination of care. An important, but limited historical body of knowledge on collaboration between North American Indian healers and psychiatrists focused on case and program descriptions (Shore, 1977). This early work began in the southwest, and is reflected in the Leightons’ writings about the psychotherapeutic aspects of Navajo religion (Leighton and Leighton, 1941). Bergman extended this perspective in his studies of the use of peyote within the context of the Native American Church (Bergman, 1971). He then turned to preserving Navajo healing methods by supporting a school for medicine men (Bergman, 1973). Albaugh and Anderson participated in the development of an alcohol treatment program for the southern Cheyenne and Arapaho which offered patients culturally responsive therapy, including the option to participate in peyote meetings (Albaugh and Anderson, 1974). In Canada, Jilek worked to better understand the use of spirit power as psychotherapy among the Salish Indians (Jilek and Todd, 1974) and Jilek-Aall developed a technique to incorporate traditional Indian myths to facilitate psychotherapy (Jilek-Aall, 1976). Shore’s work with North American Plateau tribes showed how their Whipper Man tradition – an indigenous form of social control – reinforced extended family community responsibility for child care and led to the development of a tribally sponsored group home (Shore and Nicholls, 1975). More recent work has underscored the importance of integrating traditional cultural elements into psychiatric care for American Indians. Examples include traditional cultural elements in alcohol and posttraumatic stress disorder (PTSD) in-patient programs (Fisher, Lankford and Galea, 1996; Naquin, Trojan, O’Neil and Manson, 2006; Scurfield, 1995) and developing culturally targeted psychotherapy techniques (Robbins, 2001).

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In summary, the relevant literature is characterized by two important themes. The first documents the importance of traditional healing practices and their use by American Indian patients. The second describes specific case- and program-consultations between psychiatrists and traditional healers, with special emphasis on incorporating elements of traditional healing into Western mental health practice. Noticeably absent is a discussion of how psychiatrists might foster such collaboration in their clinical practices. This chapter presents two recent collaborations from the authors’ work to illustrate the process by which traditional healers and psychiatrists can work effectively together. These collaborations inform a set of guidelines and a model for collaborative care.

10.2

AMERICAN INDIAN VETERANS, PSYCHIATRISTS AND TRADITIONAL HEALERS: BACKGROUND

The collaborations described in this section involve psychiatric treatment of American Indian veterans. A brief background is presented here on American Indian veteran mental health issues and veterans’ use of traditional healing services. The American Indian Vietnam Veterans Project (AIVVP) examined the prevalence of post-traumatic stress disorder (PTSD) among American Indian Vietnam veterans from two tribes, and found rates of PTSD (31% current, 59% lifetime) (National Center for Post-Traumatic Stress Disorder and the National Center for American Indian and Alaska Native Mental Health Research, 1996; Gurley et al., 2001; Beals et al., 2002) significantly higher for Indian veterans than their white veteran counterparts. These findings were partly explained by greater combat exposure among American Indian veterans (Beals et al., 2002). While 77% of the Indian veterans sample had a diagnosed psychiatric disorder, only 11–21% had received psychiatric treatment services in the past six months; 52–83% of these services were provided by the Department of Veterans Affairs (VA) (Gurley et al., 2001). In the AIVVP, 5–19% of veterans reported seeing a traditional healer for behavioral health problems (Gurley et al., 2001). Over the past decade there have been several efforts within the VA to incorporate and integrate traditional healing practices into treatment for American Indian veterans. Many of these efforts have centered on integration of aspects of traditional culture into PTSD treatment. Scurfield described the efforts at the American Lake VA PTSD Treatment programs to add culturally specific elements to their treatment program, which included building a sweat lodge on hospital grounds, using an American Indian spiritual advisor, and promoting attendance at pow-wows (Scurfield, 1995). Since then multiple VA programs, particularly in the northern plains and southwest, have sought to reproduce these initiatives, although no published data is available regarding the success of these efforts.

10.3

AMERICAN INDIAN VETERANS, PSYCHIATRISTS AND TRADITIONAL HEALERS: SOUTHWEST TRIBES

As mentioned above, the AIVVP replicated the National Vietnam Veterans Readjustment Study (Kulka et al., 1990) The samples consisted of male Vietnam theater veterans

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drawn from the formal membership of two large tribes, one located in the northern plains, the other in the southwest (Beals et al., 2002).1 Of the men identified as Vietnam veterans, only those then living on or near their reservation were selected for interview. Rates for locating selected participants exceeded 90% in both the northern plains and southwest communities. Once located, more than 90% of the selected veterans agreed to participate. Using a two-stage design, the study conducted computer-assisted lay interviews with these men to learn about their individual experiences before, during, and after the Vietnam War. A total of 621 lay interviews were completed. Several hundred clinical re-interviews were conducted with selected subsamples using the Structured Clinical Interview for DSM Disorders (SCID) (APA, 1994). The lay interview included an extensive section on health care utilization, covering both biomedical and traditional healing resources (Gurley et al., 2001; Novins et al., 2004). Questions regarding the latter were influenced by key informants and focus groups representing private, tribal, state and federal health providers who practiced on or near the participating communities. Respondents were queried about the extent, frequency, and duration of their participation in specific tribal ceremonies and healing rituals, about the costs – monetary and non-monetary – associated with participation, and about their perceptions of the outcomes, namely their satisfaction with, as well as their assessment of the effectiveness of the treatment they received. The southwest tribe had been particularly adamant about the importance of gathering this information with respect to their veterans’ use of traditional healing resources. Their leadership felt that these men often sought help from local healers and benefited from participation in the ceremonies and rituals practiced by them. The results of the study supported these assumptions. Specifically, participation in tribal ceremonies and healing rituals, before and after military service, was strongly associated with a lower risk of PTSD, and with a less severe as well as a shorter course of the illness. Moreover, veterans who sought help through such traditional means were less likely to seek biomedical care for emotional and psychological problems and needed less help of this nature if they did seek it. These findings applied to veterans from both tribes. Citing this data, leaders of the southwest tribe subsequently advocated for VA reimbursement of traditional healing provided to veterans by members of their local medicine men’s association. In April, 1998, the tribe and the VA signed a memorandum of agreement to this effect. The agreement was accompanied by a payment schedule which lists 13 ceremonies eligible for reimbursement and the applicable charges, ranging from $50 to $750 per procedure. In practice, the veteran seeks approval from the tribal Department of Veterans’ Affairs for the performance of a given ceremony by an eligible healer. Once approved and the ritual performed, an invoice is presented to the Department and the veteran is reimbursed accordingly. Of special note is that the veteran first pays the costs; the healer is not reimbursed separately by the agency. This arrangement explicitly acknowledges the importance of the patient-healer relationship, and symbolically reinforces their mutual obligations to one another: a lesson perhaps relevant to much of the Western world of medicine. That memorandum of agreement is still in effect, nearly a decade later.

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10.4

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AMERICAN INDIAN VETERANS, PSYCHIATRISTS AND TRADITIONAL HEALERS: NORTHERN PLAINS TRIBE

The University of Colorado at Denver and Health Sciences Center’s American Indian and Alaska Native Programs, in partnership with the US Department of Veterans Affairs, in 2001–2002 began implementing a series of mental health clinics for American Indian veterans. These clinics use live interactive videoconferencing, referred to here as telepsychiatry, to link psychiatric providers in Denver with American Indian veterans on remote rural reservations in the northern plains states. Nine clinics currently offer treatment for mental health problems, in the form of medication management as well as individual, family and group psychotherapy, provided to 12 different tribes. More detailed descriptions of these clinics can be found in a series of articles describing program development, implementation and clinical issues (Shore and Manson, 2004a; Shore and Manson, 2004b; Shore and Manson, 2005; Shore et al., 2006). Since the clinics’ inception, providing culturally appropriate care has been an important focus of these services. A number of elements within the clinic structure contribute to achieving this goal. Examples include using clinicians trained and experienced in cultural psychiatry, community consultation on the overall structure of the clinics, collaboration with local traditional healers and hiring local American Indian veterans to serve as tribal/ telehealth outreach workers. The telehealth outreach workers have several key functions: reaching out to prospective patients, running the clinic at the reservation site, serving as a community liaison and providing access to the local network of traditional healers. These clinics have developed both informal and formal collaborations with traditional healers in the reservation communities in which they are located. Informal collaborative arrangements typically begin during the initial phase of development and implementation. At this point in time, the clinic psychiatrist makes multiple trips to the community to establish the clinic structure and protocols. They become familiar with the community through a series of meetings with key local organizations (e.g. Tribal Council, local mental health services). Capitalizing on the community relationships/network of the telehealth outreach worker, the psychiatrist attends local community events such as pow-wows and sweat lodges. This participation often brings the psychiatrist into contact with local traditional healers and allows the psychiatrist to demonstrate interest in and initiate a dialogue about traditional activities in the community. At this stage the psychiatrist must strike an appropriate balance between showing respectful curiosity and interest in traditional healing, yet avoiding intrusive inquires about topics consider sacred and privileged information for tribal members or traditional healers. Guidance from the telehealth outreach worker helps the clinic psychiatrist to successfully handle these culturally sensitive issues. Once the initial relationship has been established, the psychiatrist continues to build the relationship with the traditional healers through discussions and meetings. In the telepsychiatry clinics these further meetings have been held both in-person and through videoconferencing. The telehealth outreach worker continues to provide direction to the psychiatrist on how to interact with the healers. For example, among many tribes of the northern plains, tobacco is offered as a sign of respect. The telehealth outreach worker often provides advice about the timing and manner in which this should be done with a healer.

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Also, if a psychiatrist is invited to participate in a sweat lodge ceremony, it is often culturally appropriate to bring a gift for the healer. The actual gift varies by tribe and healer. Active case collaboration occurs in several ways. The psychiatrist and healer will discuss general models and philosophies of care and exchange questions about perspectives on specific symptoms and treatments. The psychiatrist or healer may consult one another about a specific case. For example, a psychiatrist might encounter a case where a patient reports seeing visions of the deceased. The psychiatrist may contact the healer and ask how the healer would interpret these symptoms, their cultural meaning and appropriate treatment. Finally the healer or psychiatrist may refer patients to one another. In our telepsychiatry clinics, the most common referral to healers has been for sweat lodge ceremonies for veterans with PTSD. Criteria for identifying patients appropriate for such referrals are discussed in the next section. Psychiatrists in the clinics have found that sweat lodge ceremonies not only ameliorate the psychological and physical symptoms of PTSD, but also address the spiritual distress that can arise from experiencing a traumatic event. Patient consent is obtained prior to a clinic psychiatrist entering into direct case discussions and collaboration with a healer. Another process by which collaboration with traditional healers occurs in the clinic is directly through the patient. The psychiatrists in these clinics conduct a cultural assessment of patients that includes review of tribal languages spoken, spiritual history, attitude towards traditional healing practices and past treatment by traditional healers. For patients who endorse an interest in or history of working with traditional healers, the psychiatrist further discusses the treatment options related to traditional healing that can address the patient’s current mental health issues. Traditional healing may then become part of the treatment plan along with prescribed psychiatric medications and other therapy. The psychiatrist checks periodically with the patient about the status, progress and results of the traditional healing process. In these instances the psychiatrist may or may not directly contact the traditional healer who is working with the patient. Through active inquiry the psychiatrist provides support for engagement and use of traditional healing practices. Through a patient, the psychiatrist may be asked at times to participate in a traditional healing practice, such as a talking circle, smudging ceremony or a sweat lodge. This connection through the patient often provides an entre´e for the psychiatrist into a community’s traditional healing network. A recent case reports describes cultural elements in clinical care and collaboration with traditional healers in these clinics (Shore and Manson, 2004b). The talking circle, smudging ceremony and sweat lodge are all forms of traditional healing practices that are common in the northern plains. In a talking circle participants gather in a circle and a ceremonial object (e.g. talking stick, feather) is passed between members. Only when an individual is holding the object is it their turn to talk. This process facilitates the expression and addressing of community and individual issues. Smudging is a ritual purification ceremony in which native herbs, usually sweet grass, cedar or sage, are burned and then an individual brushes the smoke over the body. The sweat lodge ceremony also has components of a ritual of purification and involves the use of a lodge composed of natural materials (traditionally willow branches and buffalo hide robes). Within the sweat lodge water and super heated rocks are used to create the heat and steam for the sweat. Various types of healing and purification ceremonies are conducted by a sweat leader, typically a medicine man. There is growing evidence of the emotional, physical and spiritual benefits of the sweat lodge for patients (Schiff and Moore, 2006).

DISCUSSION

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In addition to the informal collaboration described above, several of these clinics have instituted more formal collaborative arrangements between the healers and the VA. In the latter instance, as the clinics were being developed, initial discussions were held among the VA, tribal councils, veterans’ leadership in the communities, and locally recognized traditional healers. A list of traditional healers interested in working with veterans was generated, together with a list of common traditional practices (e.g. smudging, sweats, talking circles). Veterans interested in receiving these treatments inform their VA provider of this interest. The VA provider then generates a consult within the VA system. This consult is assigned to the healer, who is reimbursed for materials associated with the traditional treatment (e.g. the cost of a cord of wood for a fire to heat the rocks used in a sweat lodge ceremony). This more formal collaborative arrangement reaffirms the VA’s efforts to provide culturally appropriate care and, where this program has been implemented, furthers rapport between the tribes and the VA. Our experience has shown that formal collaboration is not successful if the informal collaboration and networks between the telepsychiatry clinics and healers are not well established. This type of arrangement is not possible or appropriate for all communities, and needs to be discussed and agreed upon in advance by the multiple organizations with a stake in these matters. Additional concerns about how this relationship may affect the traditional healers in the community warrant discussion as well (e.g. introducing a reimbursement mechanism into the traditional healing process). Ultimately the decision to proceed with more formal collaborative arrangements rests with the local healers and their community.

10.5

DISCUSSION

The examples presented here from work with American Indian veterans illustrate both the process and importance of collaboration between psychiatrists and healers. Two major lines of advocacy promote the use of traditional healers with American Indian populations. The first is drawn from recent discussions of the cultural competency literature which argues for ‘individualized medicine’ (Anderson et al., 2003). This line of reasoning argues that patients should have access to and receive care that is appropriate, consistent and adapted to their cultural beliefs and practices. The second line of reasoning springs from traditional healing practices. Psychiatry as a science targets the brain or ‘psyche’ in its attempt to relieve psychological and emotional distress. American Indian traditional healing practices revolve around a holistic approach to addressing the mind, body and spirit or the biological, psychological and spiritual contexts of patients’ problems. This holistic approach, in the authors’ experience, is strongly emphasized by both patients and practitioners of traditional healing. It has particular relevance in the treatment of disorders related to trauma, where traumatic events can cause changes in a patient’s biology and psychology as well as cause significant spiritual anguish as a patient seeks to understand the causes and meaning behind traumatic events and their aftermath (Fontana and Rosenheck, 2004; Fallot and Heckman, 2005). Table 10.1 presents recommendations and guidelines for psychiatrists interested in collaborating with traditional healers. This begins with the psychiatrist developing background knowledge of the traditional beliefs and practices in the community in which they work. This baseline knowledge should extend beyond simply learning about traditional healing practices

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Table 10.1 Guidelines for psychiatrists interested in collaborating with American Indian traditional healers.

 Develop background knowledge of the traditional beliefs and practices in the community in which they are working.

 Actively seek an opportunity for collaboration. This may come through clinical care, employment or personal relationships.

 Become a serious student of healing practices of the American Indian culture the clinician is working with.  Develop a trusting relationship with a community member who has knowledge of traditional healing practices, and is connected with a network of healers in the community.  Identify collaboration as major goal of ongoing relationships.

and encompass wider knowledge about a particular tribe’s history and culture. This information can be obtained from a variety of sources including readings, but more importantly, from community site visits which allow participation in community events such as pow-wows, sweats, conversations with community members and direct observation. For psychiatrists wishing to collaborate with traditional healers, the responsibility rests with them to initiate the process. These opportunities may arise in various forms, as described in the case examples, and typically emerge through patient as well as community contacts. A psychiatrist may have the good fortune to begin working in a system with existing, formal collaborative relationships with traditional healers, as described in the case examples. They should not, however, assume that because there is a pre-established collaborative arrangement no further effort on their part is necessary. The authors’ experience has demonstrated that ultimately such collaborations are based on specific, wellnurtured relationships and networks established between the psychiatrist, community healers and patients. Psychiatrists desiring such collaboration must become serious students of the healing practices used in the local community, gradually accumulating knowledge about these practices in an appropriate and respectful manner. In doing so, the psychiatrist seeks sufficient knowledge of traditional healing practices to hold informed discussions with patients, healers and community members (e.g. patients’ families). This knowledge aids the psychiatrist in both better understanding the cultural context of a patient’s illness as well as allowing them to make informed referrals. The psychiatrist may be invited to participate in traditional healing activities (e.g. attend a sweat lodge ceremony held for a patient). As appropriate, the psychiatrist should strongly consider accepting such an invitation. But boundary issues may emerge, should be anticipated, and will warrant careful thought. Here the psychiatrist has a responsibility for clarity in their own mind about respective roles and obligations, as well as for communicating these expectations to patients and other healers. As discussed in the case examples, a trusting relationship with a community member who has knowledge of traditional healing practices, and connections to a network of healers in the community are key elements in collaboration. This person does not have to be a healer; indeed, there can be advantages to having a non-healer as a community facilitator. For example, a non-healer facilitator may provide wider access to the healing practices and healers in a community than a healer who is seen to be part of specific network within that community. Finally collaboration should be identified by the psychiatrist as a major goal of any ongoing relationship, both with individual healers and the community at large.

DISCUSSION

131 Traditional Healer • •

Willingness to Collaborate Experience with Collaboration and western medical model

Community and System Issue

Formal and/or informal collaboration

Patient • • •

Traditional background (language, previous use) Experience with western medical model Willingness to discuss issues with psychiatrist

Figure 10.1

Psychiatrist • • •

Willingness to collaborate Ability to facilitate dialogue Knowledge and experience with traditional healing practices

Model for process of collaboration between AI healers and psychiatrists.

Figure 10.1 depicts a model to describe the process of collaboration among American Indian healers, psychiatrists and their shared patients. The model also lists factors associated with each participant that may affect collaboration. A critical one is the willingness of each to engage in collaboration. Key determinants of this are the parties’ knowledge of each others’ treatment systems and past experience with these systems. Greater knowledge and positive past experiences and outcomes will increase willingness of all parties to collaborate. Patient appropriateness for traditional healing services is also an important component of this. Psychiatrists working with American Indian patients should perform a cultural assessment as part of their initial clinical evaluation. Clinicians should work from a systemized model when completing the cultural assessment, such as the DSM-IV cultural formulation, but should be aware of the potential limitations of this model in American Indian populations (APA, 1994; Novins et al., 1997). Generally, patients from more traditional backgrounds who have experience with traditional healing may be more willing to enter a discussion about collaboration with traditional practices. This does not mean that American Indian patients from less traditional backgrounds may not also benefit from and share an interest in traditional practices. It is important to discuss with all American Indian patients their willingness and desire to engage in traditional healing practices. Many patients who may not identify themselves as having strong traditional cultural beliefs express interest in pursuing such options. The ability to create a collaborative treatment arrangement depends heavily on the ability of the psychiatrist to foster a dialogue about these issues with both patients and healers. Overlaying these interactions are the systems of care and host communities; they mediate the possibilities and promises of collaboration. How collaborations are established and structured (e.g. formal vs. informal), the history of the relationship between systems of care (e.g. VA and a specific tribe, past attempts), and the process within a specific community (e.g. community expectations regarding traditional healing, willingness/ desire to involve non-community members) all impact the process. While the individual

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relationships in this triad are critical, a psychiatrist also must be attentive to the larger system and community issues. The timeline for this process is highly variable and depends on the participants. The guidelines in Table 10.1 suggest the steps a psychiatrist should follow in developing collaborations with traditional healers. The psychiatrist should be aware that traditional healing practices do not adhere necessarily to a rigid or inflexible time schedule. Traditional events unfold at a culturally determined pace rather than being driven by a specific appointment on a scheduling calendar. The collaboration between psychiatrists and American Indian healers is a crucial and rich area in mental health treatment. Unfortunately, much of the information available to guide one is anecdotal and descriptive in nature. The approach and guidelines presented here are offered with the hope of generating further collaboration, discussion and refinement. Important next steps include furthering discussions with indigenous communities about how best to obtain evidence of the effectiveness of traditional healing practices, and carefully documenting models of collaboration between psychiatrists, healers and their patients.

NOTE 1. In our work with American Indian groups, maintenance of community confidentiality is as important as that of individual confidentiality. Therefore, in this chapter, general cultural descriptors are used rather than specific tribal names (Norton and Manson, 1996).

REFERENCES Albaugh, B.J. and Anderson, P.O. (1974) Peyote in the treatment of alcoholism among American Indians. The American Journal of Psychiatry, 131, 1247–50. Anderson, L.M., Scrimshaw, S.C., Fullilove, M.T. et al. (2003) Culturally competent healthcare systems. A systematic review. American Journal of Preventive Medicine, 24, 68–79. APA (1994) Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, Washington, DC. Beals, J., Manson, S.M., Shore, J.H. et al. (2002) The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: Disparities and context. Journal of Traumatic Stress, 15, 89–97. Beals, J., Manson, S.M., Whitesell, N.R. et al. (2005a) Prevalence of DSM-IV disorders and attendant help-seeking in two American Indian reservation populations. Archives of General Psychiatry, 62, 99–108. Beals, J., Novins, D.K., Whitesell, N.R. et al. (2005b) Prevalence of mental disorders and utilization of mental health services in two American Indian reservation populations: mental health disparities in a national context. The American Journal of Psychiatry, 162, 1723–32. Bergman, R.L. (1971) Navajo peyote use: Its apparent safety. The American Journal of Psychiatry, 128, 695–9. Bergman, R.L. (1973) A school for medicine men. The American Journal of Psychiatry, 130, 663–6. Buchwald, D., Beals, J. and Manson, S.M. (2000) Use of traditional health practices among Native Americans in a primary care setting. Medical Care, 38, 1191–9. Fallot, R.D. and Heckman, J.P. (2005) Religious/spiritual coping among women trauma survivors with mental health and substance use disorders. The Journal of Behavioral Health Services & Research, 32, 215–6.

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Fisher, D.G., Lankford, B.A. and Galea, R.P. (1996) Therapeutic community retention among Alaska natives. Akeela house. Journal of Substance Abuse Treatment, 13, 265–71. Fontana, A. and Rosenheck, R. (2004) Trauma, change in strength of religious faith, and mental health service use among veterans treated for PTSD. The Journal of Nervous and Mental Disease, 192, 579–84. Gurley, D., Novins, D.K., Jones, M.C. et al. (2001) Comparative use of biomedical services and traditional healing options by American Indian veterans. Psychiatric Services, 52, 68–74. Jilek-Aall, L. (1976) The western psychiatrist and his non-western clientele. Transcultural experiences of relevance to psychotherapy with Canadian Indian patients. Canadian Psychiatric Association Journal, 21, 353–9. Jilek, W.G. and Todd, N. (1974) Witchdoctors succeed where doctors fail: Psychotherapy among Coast Salish Indians. Canadian Psychiatric Association Journal, 19, 351–6. Kim, C. and Kwok, Y.S. (1998) Navajo use of native healers. Archives of Internal Medicine, 158, 2245–9. Kulka, R.A., Schlenger, W.E., Fairbank, J.A. et al. (1990) Trauma and the Vietnam War Generation, Brunner/Mazel, New York. Leighton, A.H. and Leighton, D.C. (1941) Elements of psychotherapy. Psychiatry, 4, 515–23. Marbella, A.M., Harris, M.C., Diehr, S. et al. (1998) Use of native American healers among Native American patients in an urban Native American health center. Archives of Family Medicine, 7, 182–5. Naquin, V., Trojan, J., O’Neil, G. and Manson, S.M. (2006) The therapeutic village of care: an Alaska native alcohol treatment model. Therapeutic Communities, 27, 105–21. National Center for Post-Traumatic Stress Disorder and the National Center for American Indian and Alaska Native Mental Health Research (1996). Matsunaga Vietnam Veterans Project. White River Junction, VT. Norton, I.M. and Manson, S.M. (1996) Research in American Indian and Alaska native communities: Navigating the cultural universe of values and process. Journal of Consulting and Clinical Psychology, 64, 856–60. Novins, D.K., Beals, J., Moore, L. et al. (2004) Use of biomedical services and traditional healing options among American Indians: Sociodemographic correlates, spirituality, and ethnic identity. Medical Care, 42, 670–9. Novins, D.K., Bechtold, D.W., Sack, W.H. et al. (1997) The DSM-IV outline for cultural formulation: a critical demonstration with American Indian children. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1244–51. Robbins, R. (2001) The dream catcher meditation: a therapeutic technique used with American Indian adolescents. American Indian and Alaska Native Mental Health Research: Journal of the National Center, 10, 51–65. Schiff, J.W. and Moore, K. (2006) The impact of the sweat lodge ceremony on dimensions of wellbeing. American Indian and Alaska Native Mental Health Research: Journal of the National Center, 13, 48–69. Scurfield, R.M. (1995) Healing the warrior: admission of two American Indian war-veteran cohort groups to a specialized inpatient PTSD unit. American Indian and Alaska Native Mental Health Research: Journal of the National Center, 6, 1–22. Shore, J.H. (1977) Non-traditional therapies for American Indians. White Cloud Center Newsletter. Shore, J.H. and Manson, S. (2004a) Telepsychiatric care of American Indian veterans with post-traumatic stress disorder: bridging gaps in geography, organizations, and culture. Telemedicine Journal: The Official Journal of the American Telemedicine Association, 10, S64–69. Shore, J.H. and Manson, S.M. (2004b) The American Indian veteran and posttraumatic stress disorder: a telehealth assessment and formulation. Culture, Medicine and Psychiatry, 28, 231–43. Shore, J.H. and Manson, S.M. (2005) A developmental model for rural telepsychiatry. Psychiatric Services, 56, 976–80.

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Shore, J.H. and Nicholls, W.M. (1975) Indian children and tribal group homes: new interpretations of the whipper man. The American Journal of Psychiatry, 132, 454–6. Shore, J.H., Savin, D.M., Novins, D. and Manson, S.M. (2006) Cultural aspects of telepsychiatry. Journal of Telemedicine and Telecare, 12, 116–21. Zubek, E.M. (1994) Traditional native healing. Alternative or adjunct to modern medicine? Canadian Family Physician Me´decin De Famille Canadien, 40, 1923–31.

CHAPTER 11

Mental Health in Contemporary China Struggles and Contributions of Psychiatrists and Traditional Healers Xudong Zhao* Professor of Psychiatry, Department of Psychosomatic Medicine, Tongji University Medical School, Shanghai, China

Abstract China is a country with great cultural diversity and a long history of medical care delivery. Before Western medicine was introduced to China, there were no specialized mental health services such as psychiatry and psychotherapy. Compared to non-psychiatric physicians and practitioners of Traditional Chinese Medicine (TCM), psychiatrists and psychologists play a relatively minor role for most help-seekers in China. Due to complicated interactions between health care systems, the law, culture and economics, the parties involved (including patients, psychiatrists, psychologists, non-psychiatric physicians and TCM physicians) have formed strategies to navigate the huge market of medical care. The author systematically analyzes these dynamics in order to illustrate the difficulties facing Chinese mental health workers, and discusses some points of congruence and contention between Western mental health and more traditional forms of healing in contemporary China.

* The author of this chapter is a psychiatrist who has been trained in transcultural psychiatry in China in the 1980s and then in family therapy in Heidelberg, Germany from 1990 to 1993. He discussed various kinds of healers in Chinese society from a systemic perspective in his dissertation, entitled ‘The introduction of systemic family therapy into China as a cultural project’ (Zhao, 2002), in order to illustrate the roles being played by various healers in the complex social context of contemporary Chinese society, so that the professional staff who wanted to apply Western therapeutic techniques in China could understand their possible roles in such a large and diverse medical and cultural system. In this chapter, the author discusses similar issues, with updated data after 16 years of rapid social change in China.

Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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THE MEDICAL CARE SYSTEM AND MENTAL HEALTH SERVICES IN CHINA

China has been changing rapidly for about 60 years, especially since the Opening and Reform Policy was launched in 1978 after the Cultural Revolution. Since 1949, China’s official health care system has been based on modern Western medicine. With low financial investment and high cost-effectiveness, China has achieved outstanding results, considering the meager medical resources available. Some key health indices ranked very high among developing countries, and some are even comparable to that of industrialized countries. For example, in 2005, the neonatal mortality rate was 0.75% in urban areas, and 1.47% in rural areas (Ministry of Health of PRC, 2007, p. 191), and life expectancy for urban and rural residents was 73.0 (Ministry of Health, 2008), while life expectancy for residents in Shanghai was 80.97 in 2006 (Municipal Health Bureau of Shanghai, 2007). Despite the many advances in public health and biological medicine since 1949, psychiatry and clinical psychology have remained low priorities and have relatively little influence on Chinese society. Since China is still a developing country, funding of general medical services and payment of general medical service personnel remains low compared with developed countries and funding of mental health services and personnel is even further behind. An epidemiological survey conducted in 1982 showed a huge gap between service provision and demand. The researchers found that the prevalence rate of neurosis in the community was 2.22%, while the prevalence rate of psychotic disorders and other mental illnesses was 1.27% (Zhang, 1986). The numbers of patients exceeded the service provision capacity of the mental health professional staff. It was estimated that there were less than 10 000 psychiatrists in all of China at that time (1982). In 1990, there were still only 11 893 psychiatrists in the whole country, accounting for only 1.1% of all Western medicine practitioners (Yang, 1994). Among these psychiatrists, only half of them received university-level education (He, Zhu and Zhang, 2002). To make matters worse, few medical school graduates are willing to get involved with mental health work due to fear of stigma, which will be discussed further below. However, changes have taken place recently at the national level, and mental health has been gaining more attention from government officials. The milestone marking this political attitude shift is marked by the Resolution about some critical issues by constructing a harmonious society, published by the Central Committee of the Chinese Communist Party on 10 November 2006. This constitutes the first time that the Party addressed human psychological issues in its official documents. The resolution states that the Party would be attentive to promoting the psychological harmony of the people. Perhaps due to these changes, in 2007, the number of psychiatrists in China has increased to 19 000 (Mental Health Bureau of the State Health Ministry, 2007); an increase of nearly 40% since 1990. Despite some progress, there is still a huge gap between Chinese and international standards. Furthermore, the advances do not benefit the population evenly, due to China’s enormous size and diversity. Most psychiatrists who have received higher education work within institutions, especially medical schools and hospitals in large and medium-sized cities. This leaves mental health delivery very limited in the vast rural areas, where 80% of the Chinese population lives.

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Cultural differences among ethnic groups bring further complexity to the medical service system. China has 56 ethnic nationalities of various populations. Ninety-two percent of the Chinese national populations are ethnically Han, while the other 8% are people of 55 minority nationalities living in all parts of China, sharing respective sub-cultures (Jiang, 2006). Due to the profound socio-cultural diversity among the ethnicities, there are different beliefs and practices regarding health, illness and mental health. This means that beyond the cultural barriers between Western mental health and Chinese patients, discussed below, there also exist sub-cultural differences within China itself.

11.2

DIFFICULTIES FACING MENTAL HEALTH PROFESSIONALS

Beyond the problems of availability and distribution of personnel and medical services, another barrier to mental health service provision involves the difficulties facing mental health workers. These include stigma toward and devaluation of their profession, problematic aspects of the doctor-patient relationship, and low level of payment for personnel providing psychotherapy services. Due to the general stigma toward mental illness, very few medical graduates have been willing to work in mental health fields. A large number of graduates have been assigned to mental health work against their will. Therefore they were not highly motivated and often experience secondary stigma. The situation has been improving since the reform policies of the 1980s. However, changes have differed across the mental health professions. Interestingly, the general public in China finds the word ‘psychologist’ quite mysterious and appealing, because psychologists are so rare in China. The majority of the population has never met a psychologist, and psychology is not yet an official health professional category. As a result, many people believe that psychologists can read peoples’ minds, infer their past life history and maybe predict their future as well. On the other hand, although psychiatrists are also scarce in China, the profession is seldom regarded as a positive and mysterious entity, but rather is viewed as strange and frightening. If someone introduces themselves as a psychiatrist, the audience often shows their surprise, and might consider it a joke. However, if it is added that they are a doctor at a psychiatric department, and one who performs psychotherapy, the audience will show admiration and respect. The author has encountered this awkward situation many times. It is fascinating and worth serious investigation, as it relates to the larger web of complications and obstacles facing the mental health field in China. Aside from stigma, another difficulty facing psychologists – particularly clinical psychologists – is the devaluation of their profession. In the 1960s, psychology was viewed as a pseudo-science; therefore, it was outlawed altogether during the Cultural Revolution and eliminated from many academic curricula. More recent disregard for clinical psychology stems from a shallow and biased understanding of psychotherapy by doctors trained in the biomedical model. However, there is some truth to the stereotype, in the sense that there is an ongoing lack of adequate training for clinical psychologists, and prior to 2008, there had been no official licensing system regulating the quality of psychotherapy services in China. In order to shorten the distance between the general public and mental health services, psychotherapy needs to be strengthened as a professional discipline. However, there remains a shortage of systematic psychotherapy theories and corresponding operational

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techniques in China. Until now, Western psychotherapy theories have been used in fragmented ways, and sometimes in a biased and uninformed manner. Nonetheless, some recent attempts by psychiatrists to develop indigenous forms of psychotherapy in China hold promise for their future clinical application. In the clinical setting, psychotherapists face another dilemma. Traditionally, being a ‘good doctor’ in China involves a particular relationship in which the doctor is kind and sympathetic toward the patient, yet maintains an authoritative role. The doctor and patient are not viewed as equals. A ‘good’ doctor is expected to act as a stern yet benevolent authority figure. In some ways, these types of doctors play a psychologically supportive role, since many patients and their family members feel respected in and prefer this type of doctorpatient relationship. They are comforted by the guidance and even the criticism given by these experts, and accept the cultural role of doctors as almsgivers, educators and judges. However, there are two problems with this dynamic. First, it can lead to cases of pseudocompliance, in which patients feign understanding and acceptance of the doctors’ opinions, but in fact do not comprehend or do not agree with them. Nonetheless, they do not verbalize their doubts, in order to avoid causing their doctors to ‘lose face’. The more experienced doctors are aware of this kind of pseudo-compliance through non-verbal signals. However, many inexperienced doctors do not sense it, as their enthusiasm clouds their perspective of the situation, and they are often the last to know that their treatment efforts aren’t effective at all. The second problem with the culturally accepted model of the doctor-patient relationship is that it is not a sufficient substitute for psychotherapy, yet is used to undermine the validity of actual psychotherapeutic treatment. Since providing advice about many aspects of a patient’s life is a common practice among Chinese doctors, both doctors and patients often cast doubt on the efficacy of talk therapy as the sole source of healing, and mental health professionals often feel the need to prescribe medication at the end of a clinical interaction. Of course, another reason for drug prescription is very practical; no prescription, no charges. Many physicians are critical of psychologists due to their inability to bring financial benefit to the hospital through prescribing drugs that the hospital provides to patients at some profit to the hospital. With dramatic transformation of China’s society and culture, there is a need for developing new models to supplement the dominant model of the authoritarian physician-patient relationship. Later in this chapter, the author describes some insight he has gained from the ways TCM practitioners and folk therapists communicate with patients.

11.3

HELP-SEEKING BEHAVIORS OF CHINESE PATIENTS

When dealing with health care systems, the categories Chinese patients use to determine what kind of help to seek differ from the Western division between mental and physical health. Rather, the acute-chronic differentiation tends to be more culturally salient. If one suffers from acute, infectious or surgical diseases, one will visit Western medicine practitioners without any hesitation. However, if one is suffering or recovering from chronic diseases, one is more likely to visit TCM practitioners, or regard TCM therapy (or other folk therapies) as important supplementary treatments. The latter is quite common with regard to treatment for mental illness. Unless a patient is facing acute and severe mental health problems, Western mental health care is an unlikely choice for Chinese patients.

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Why do patients with ‘chronic’ illness cast doubt on Western medicine, including Western mental health? This is an issue related with cultural affinity and cultural barriers of medical and psychological techniques. The Chinese like to accept biological and material interventions based on so-called ‘hard sciences and technology’. But in case of chronic illness, such ‘hard sciences and technology’ don’t work well, so that there is large space to use various other material or non-material methods for the patients who are often eager for any promising treatment. Thus, TCM or other folk therapies, as familiar practices for them, are more likely to be their preferred options. In clinical practice, we can observe how people utilize medical resources from five perspectives noted below, and then we can assess whether the cultural affinity for any particular therapeutic technique is high or low relative to a certain disease, and whether the cultural barrier these techniques confront is strong or weak. (1) Time (when, how long and how often): This refers to the stage of illness at which the patient seeks help. For example, do they seek preventative care prior to the manifestation of any symptoms, or only when symptoms arise, or seek treatment only when the disease has progressed to a very serious stage? In addition, it also refers to treatment compliance and continuity; specifically to the frequency and duration of contact between medical staff and patients after the therapeutic relationship has been established. (2) Place (where): The place where one seeks treatment. If there is something wrong with one’s health, will one go to the public hospital, the outpatient clinic, the doctor’s own home, religious organizations or some other place? (3) People (whom): From whom does the patient seek help. Some possibilities include professional Western physicians, TCM practitioners, poorly trained herbalists, ‘witch doctors’, family members and friends, employers and those who engage in ideological and political work. (4) Means (how): The means through which one seeks for help and the patient’s attitude toward treatment. What do they hope to receive; chemical, physical, psychological or supernatural intervention? Does one hope to keep it secret or seek help publicly? How to pay the bill – is there a need to give presents or hong bao (money wrapped in a red envelop) to doctors? Is there any need for a middleman? (5) Reason (for what, why): First, the reason for choosing a particular method of care is impacted by the nature and category of the problem. This, in turn, gives rise to the need for help (for what?). For example, does the patient suffer from an acute and serious disease, trauma, chronic somatic disorder or psychological problems? Second, the patient’s reasoning is influenced by the charisma, quality of service, and reputation of treatment providers (why?). Even if patients know that a certain treatment is suitable for a certain kind of disease, are they willing to receive such a treatment from that particular doctor and/or from that particular hospital? This aspect – the reason for choosing a particular treatment provider and setting – is the key component affecting the other four. Behind the patient’s reason, we can find its deeper explanatory roots, their ‘medical beliefs’. Frankly, from these five perspectives, there is no user-friendly interface between people with psychological problems and Western mental health institutions in China. Although there is a huge need for psychotherapy and counselling, a large number of Chinese

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patients are prone to express their psychological conflicts, trauma and frustration through somatic symptoms. For this ‘somatization tendency’, there are two explanations. First, some of the patients or clients have received very little formal education, so they have trouble describing or expressing the complexity of their feelings or emotional experiences through language. Second, due to social and cultural factors such as maintaining social relationships, ‘fear of losing face’, and fear of being misunderstood or discriminated against, many people don’t want to describe or express their psychological or interpersonal problems. This avoidance of discussing psychological problems is not unfounded, as many people treat those with physical illnesses quite differently than those with mental disorders. While patients with physical illnesses are well taken care of, patients who reveal their interpersonal and psychological problems are often stigmatized and avoided. Reasons behind this include the nurturing methods of Chinese families that are overprotective and low in differentiation, as well as the emphasis on the corresponding relationships between psychological activities and body organs in TCM discourse. In TCM, there exist seven emotions, each corresponding to a specific organ. An emotion can either nurture or hurt its corresponding organ. In spoken Chinese, people describe their emotional state through metaphors of body organs or functions. For instance, people often say, ‘This problem is a big headache for me’, or ‘I am so angry that I feel a sharp pain in my belly’. Interestingly, and for quite similar reasons, the diagnosis of ‘neurasthenia’ in the category of neurosis is an exception, because the word ‘neurasthenia’ is made up of ‘neuro’, a derivative of nerve, and ‘asthenia’, which means ‘weakening of the brain’. This word does not hold connotations of psychiatric or psychological problems. Thus, patients don’t reject this diagnosis. On the contrary, although there is adequate scientific evidence of biological disturbances underlying mental illnesses, the general population usually does not regard mental disorders as body-related or somatic; they still believe that most mental illnesses are purely psychological, not real. With the above discussions as context, the following is a summary of where Chinese patients with psychological problems are likely to seek help, depending on the nature of their distress: (1) Mentally ill patients with obvious disorganized behavior will be sent to psychiatric hospitals. But there are still many patients who have never been diagnosed and treated due to lack of access to psychiatric facilities or due to poverty. (2) Patients with neurosis and most patients with depression are often diagnosed with neurasthenia, autonomic nervous disorders or other somatic illnesses. Most of them seek treatment from internal medicine doctors or other non-psychiatric physicians. At times, doctors regard these patients as overly talkative, fussy and difficult-to-dealwith people, or even consider that the ‘patients are faking illness’. In that case, the patients will be shuffled throughout the medical system, ignored or discharged. (3) People who are facing life stress, crisis or suffering from emotional distress without somatic complaints mainly need psychological counseling or psychotherapy. However, many – including medical professionals – believe that these services are beyond the doctor’s job responsibilities and are a waste of their time without extra financial reward. Therefore, the clients have nowhere to seek help from. If they are lucky, these clients or patients will find doctors from counseling clinics within larger hospitals or counselors from social service institutions and receive informal relief and

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guidance from them. When some doctors from non-psychiatric health departments suggest that clients should be transferred to psychiatric departments, these clients will express doubt and hostility toward such a suggestion. (4) All patients or clients mentioned above are likely to seek help from doctors who practice TCM. From 1994 to 1996, in the hospital where the author has worked, the number of TCM in-patients who sought consultation from the psychiatry department was the highest among all hospital departments. In-patients from the TCM department who received consultation accounted for 2% of the total in-patients of the TCM department during this period of time. (Zhao, Xu and Bai, 1998). This shows that the TCM department admitted a large number of patients with symptoms of mental illness and overlapped with the psychiatric department, because these patients were the most obviously mentally disturbed patients, who were easily identified by the TCM doctors.

11.4

DISTINGUISHING AMONG TYPES OF ‘TRADITIONAL CHINESE MEDICINE’

Traditional healing is a very unique part of China’s health care system. As the ‘mainstream medicine’ in China, TCM has a very long history and consists of very complex components in both theories and practices. But it is very difficult to make a generalized comment about TCM, because there are ‘non-mainstream healers’ who like to utilize TCM’s name, but whose practices are not regulated by law. Therefore, before we discuss the psychotherapeutic effects of TCM techniques in detail, we should distinguish and define different types of ‘TCM’. The author distinguishes three categories of traditional healing: (1) Orthodox TCM, which has official status and is protected by law. These TCM physicians have certificates or licenses and work in public or private institutions. Medical insurance covers most costs for services offered by TCM physicians. (2) Folk herbalists. These are the people who have no systematic training for TCM, therefore have no officially acknowledged status and have no officially designated or recognized places to practice. But they always claim that they are TCM practitioners. In recent years, their activities have been gradually banned in the cities and in developed areas by means of strict licensing examinations. (3) ‘Magic witch doctors’. These people can be easily distinguished from the other two categories mentioned above, because they work mainly in various ‘non-material’ ways in the sense that they use supernatural terminology, interpretations and corresponding rituals to treat their clients. Legally, they can readily be listed as practicing ‘superstitious activities’ and banned or punished. The work of these three kinds of practitioners overlaps, but still differs from one another. Given the huge number of Chinese people who need psychological help, and given the relatively small number of Western-oriented medical practitioners to treat them, it is apparent that the three categories of TCM ‘doctors’ should play an enormous role in the provision of psychological help to the Chinese population. However, until now, this has been a neglected topic that has lacked systemic research.

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PSYCHOTHERAPEUTIC AND COMMUNICATIVE ASPECTS OF TCM

In contrast to the various problems discussed above with applying Western mental health care in the Chinese context, a look at TCM provides an alternative model for addressing the same issues, as well as insights for future areas of improvement and integration. TCM in China has enjoyed an officially recognized position and the government’s support. Based on the foundation of a complete theoretical system, TCM has been applied to a variety of areas and has achieved a renowned reputation among the general public. At the same time, there has been a formal education system that passes on TCM knowledge from one generation to the next. A large number of research institutions and medical staff have been engaged in TCM. It was estimated that there were nearly 500 000 TCM practitioners in 1949. In 1990, there were 500 000 nationally recognized TCM practitioners in China (Ministry of Health of PRC, 1991). In 2003, the number remained nearly the same, but some people claimed that only 300 000 TCM physicians can work in the pure traditional way, while the others have been ‘Westernized’ (Jiang and Zha, 2006). If there exist misunderstandings, prejudice or discrimination against TCM, they often originate from practitioners of Western medicine who have been trained in medical schools to practice modern medicine, since Chinese medicine and Western medicine don’t share many common grounds with each other from the perspectives of both theory and practice. Since the 1950s, the government has spared no effort to combine Chinese medicine and Western medicine. In fact, this initiative stopped at the material level, which means that attention has been paid to interpret the efficacy of TCM through modern technology that is relying on the so-called ‘reductionistic- analytic thinking or paradigm’. The philosophical and anthropological foundations of TCM that emphasize holistic perspective have been ignored. The author believes that the philosophical and anthropological foundations of TCM are critically important, and can be used as a bridge to make psychotherapy much more effective and beneficial for many patients. In the ancient classic books and documents of TCM, there are no systematic theories about psychiatry and medical psychology. However, we can easily recognize rich psychological thought in the Yin-Yang theory, the theory of five elements, the viscera theory, and traditional Chinese diagnostics and therapeutics. Benefiting from the protective policies of the government since the 1950s, there have been special sections in TCM books dedicated to psychiatry or textbooks written by famous psychiatrists aiming to introduce these thoughts to professional Western medicine practitioners. Unfortunately, some of the Western practitioners don’t place much emphasis importance on this content. The famous book entitled Psychology of TCM, written by Wang Miqu is highly recommended. In this book, Wang chose a large number of theoretical arguments and clinical cases from voluminous ancient books on TCM and grouped them in a systematic way, according to the theoretical framework of modern psychology (Wang, 1985). Several cross-disciplinary journals, such as Medicine and Philosophy, serve as a platform for high-level discussion of the principles and interconnections between TCM and modern psychology. The attraction of TCM in the eyes of the general public comes partly from the ‘holistic’ care it can provide to patients, although the patients are never fully aware of this benefit.

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When patients go to see doctors who practice TCM, the experience makes them feel like they are entering a comfort zone. There, the patients not only can feel protected, secure, relaxed, and receive guidance and explanations for their life troubles, but can also avoid directly disclosing embarrassing issues related to mental health problems. This is because a good TCM practitioner can show his willingness to enter into a relationship characterized by sympathy and understanding, and at the same time, he can use jargon that seems to be unrelated to the current situations on the surface, but is suitable for addressing the internal life of the patients below the surface of conscious awareness. This kind of indirect communication resonates with the Taoist interpersonal relationship model, which advocates keeping people at arm’s length, and when dealing with interpersonal relationships, it’s better to address them in an emotionally neutral and detached manner. When TCM practitioners conduct diagnoses, they place emphasis on ‘utilizing their hearts’. On one hand, it refers to the features regarding education, cultivation and mentality inside the TCM practitioners, and on the other hand, it refers to various psychological factors related to the present condition of the patients. As a healer, one should try to comprehend how others feel by putting oneself into the other’s shoes; you should let your spirit meet the other’s spirit in order to establish a harmonious, natural and trusting relationship. Through four methods of diagnosis (i.e. observing, listening, questioning and pulse-taking to assess patients’ conditions based on their verbal and non-verbal expressions, movements and gestures, appearance of the tongue and quality of their pulse and so on which contrast with the Western methods of inspection, auscultation, palpation, percussion and interrogation), the experienced TCM practitioners can understand the psychological implications of many symptoms related to certain diseases. When reading cases compiled by Wang Miqu, one finds that many ancient TCM practitioners show astounding ‘intuition’ when dealing with patients. They could quickly and easily recognize the socio-psychological background and conflicts from which the patients suffer, although they neither interrogate the patients for details nor give direct comments and explanations. They carefully choose professional jargon to analyze the causative mechanisms of patients’ illnesses and their ‘dynamic characteristics’; for example the imbalance between Yin and Yang, Five Elements restraining and reinforcing each other, liver Qi stagnation and so on and then prescribe drugs according to these inferences and explain the efficacy of these prescribed drugs accordingly. In contemporary times, laudable TCM physicians are still practicing in those ways with their patients. During these processes, the TCM practitioners use specialized discourse that is very sophisticated, profound, metaphorical and abstract. Although the discussion is kept at a general level, they hold symbolic and implicit meanings. Even if most of the patients can’t understand the full meaning of the TCM practitioners’ messages, they are nonetheless convinced of the validity of those messages because they are being delivered by wise TCM practitioners in a very cordial manner. People comprehend something through their ‘feelings’. They don’t necessarily analyze the literal meaning of each word. This kind of ‘reframing’ method with Chinese characteristics is aligned with the patients’ ‘inner map’, as it better fits Chinese epistemology and cultural norms of communicating with the outside world. Another characteristic that distinguishes TCM from Western medicine is the dynamic nature of its diagnoses. Beyond taking into consideration the dynamic relationships among various factors when analyzing pathological phenomena, the actual diagnoses for the patients remain flexible, rather than having a fixed label. TCM doesn’t fully adopt the

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concept of categorizing different disease entities as Western medicine does. TCM places more emphasis on comprehending the ‘syndromes’, or xiang, holistically. Xiang in TCM is always changing. The patient could get different diagnoses on different days by the same physician. Therefore, a patient’s prognosis depends on the interactions of numerous internal and external factors, rather than the impersonal and long-lasting ‘sentence’ characteristic of the Western diagnostic process. Corresponding to the dynamic TCM diagnoses, therapeutic techniques of TCM are also flexible and constantly changing. The TCM practitioners prescribe different drugs to different patients, and are ready to make adjustments at any moment according to the conditions of the same patient at different stages of the illness. Every component of the prescription is carefully selected according to the ‘principal-assisting-adjuvant-guiding (PAAG)’-order with decreasing weight of importance. Originally, PAAG-order resembled the ruling order of the human society, namely, the order of the emperor and his ministers, adjuvants and common people. The specific usage and efficacy of each component in treating the patient is explained accordingly. And the adjustments of dosage as well as the changes in the number of components are fully aligned with different TCM diagnoses. The efficacy of such a treatment method derives not only from the materials constituting the drugs, but also incorporates processes such as examining, analyzing, diagnosing, explaining and prescribing. Sometimes the drugs are just placebos; however, behavior and communication can enormously magnify the efficacy of these placebos. Under such situations, drugs are indispensable tools for enhancing the effects of psychotherapy among Chinese people, who are famous for advocating ‘pragmatic rationality’ over empty talk. No matter how wonderful the theory is, a material medium is needed, even if the theory is not necessarily linked to the materials used. In terms of neurotic disorders, there are some cases showing that the diseases can only be successfully treated through verbal communication, without prescribing any drugs. In Wang Miqu’s book, he mentioned one such case. An intellectual named Mr Dong felt unsettled and anxious all day long. When he went to bed at night, he felt his soul fly away from his body. He couldn’t fall asleep. Even when he did fall asleep, he would wake up, feeling startled from nightmares he had recurrently. Many doctors felt like they were at their wits end when attempting to treat his illness. Once a doctor called Xu asked him how his previous doctors had treated his illness. Mr Dong answered that the other doctors all said there was something wrong with his heart. Xu reframed the problems. He gave Mr Dong the following opinions: his pulse showed that it was his liver that was under attack from some external hazards. There was nothing wrong with his heart. His liver was where his soul inhabited. However, the soul was always unsettled and liked wandering around outside his body. Under normal conditions, the liver should be stronger than external hazards. It could attract the soul back and keep it in the body. Then one could go to bed and fall asleep. However, now, Mr Dong’s liver was under attack by some external hazards. Therefore the soul couldn’t go back home; (the soul was absent from its dwelling.) Although he lay in bed, his soul was still wandering in the atmosphere. In addition, the liver would be affected by the wrathful emotions, which could explain that although he didn’t show any anger, his illness still worsened. After hearing these comments, Mr Dong felt extremely encouraged. He told Dr Xu that he had never before heard anything that bore any resemblance to what Dr Xu said. Although he didn’t receive any prescribed drugs, his persistent pains were completely eliminated.

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Hypnotherapy techniques have been documented in TCM long ago, which can be considered a pure form of psychotherapy. In the Inner Canon of Huangdi (Yellow Emperor), there is content dedicated to discussing the theoretical and practical issues on ‘Moving Essence and Transmuting Qi’. In ancient times, people adopted a technique called ‘Zhu You’, which means that therapists used language and behavior (dancing included) to mobilize patients in order to distract them and break up the vicious cycle of distorted cognitions and emotions, and other symptoms. Hua Tuo is one of the greatest doctors in China’s history. History books have recorded his treatment techniques, including cases in which he mobilized emotional factors to conduct psychotherapy. For example, when Hua Tuo treated a senior general, he forced this officer to get enraged. After his diagnosis, he deliberately asked for a lot of money and hid himself. He even wrote a letter to humiliate this patient. In his rage, the patient issued an order to hunt down Hua Tuo and then sentenced him to death. By doing this, the patient vented his depression and conflict and felt much better after that. A doctor named Li Jian’an in Qing Dynasty also adopted such a technique to treat the phobia of an intellectual. He knew that the intellectual loved saving face. Therefore, Dr Li read an article written by this intellectual aloud, in a disrespectful manner, just outside his room. Enraged, this patient rushed out of his room, which he had not left for a very long period of time, just to see with his own eyes who had dared to desecrate his cherished writings. These two cases are reminiscent of the Western therapeutic technique of utilization, advocated by the famous American hypno-therapist, Dr Milton Erickson. From this section, we can see that TCM should neither be regarded as an outdated discipline far away from our modern life, nor simply be analyzed by its tangible components. Modern doctors and psychotherapists must consider the national culture in which TCM is deeply rooted, and how the ability to address a patient’s interpersonal relationships and psychological characteristics in a culturally appropriate manner impacts the efficacy of healing.

11.6

FOLK HEALERS IN CHINA

Aside from TCM, there are other forms of folk healing that play various roles in Chinese society (see Table 11.1). While these folk therapists are not officially recognized, they are nonetheless a very appealing option for many, particularly for those with less access to education. Some of these folk therapies involve mass movements such as the ‘Qigong fever’ of the 1980s–1990s. Analyzing potential reasons for the popularity of such a phenomenon can help us explore some of the barriers currently facing Western mental health care from a different perspective. For instance, in the case of Qigong fever, the popularity of the movement might have related to the massive unmet demand for mental health service. The movement was able to capitalize on the low level of individualization and high level of ‘superman worship’ among the Chinese, a wish for lost traditions, the great prestige attributed to science and scientific knowledge, and references to the traditional health-maintaining philosophy of ethical character cultivation to gain momentum and mass following. This provides an interesting contrast with the resistance to and suspicion of Western mental health practices in the Chinese context, as discussed above.

146 Table 11.1

Healer type

MENTAL HEALTH IN CONTEMPORARY CHINA Other forms of folk healing in Chinese society.

Herbalists

Religious healers (e.g. necromancers, wizards, witches and Feng-shui masters)

‘Modern’ folk healers (e.g. Qigong Fever of 1980s–1990s)

Healing techniques

Material techniques (e.g. drugs, medical equipment)

Fortune-telling, handwriting analysis, physiognomy, palm-reading

Physical and mental exercises; use of religious concepts; possible (ab)use of hypnosis

Claims

Magical therapies; secret ancestral formulas; scientifically proven methods; cures for diseases beyond scope of Western medicine; cures for sexually transmitted diseases

Removing bad fate; counteracting evil spirits; compensating for doubts or past mistakes; repairing relationships with ancestors; comforting wrathful gods or ‘heaven’

Heal chronic diseases untreatable by Western medicine; incorporates modern scientific theory

Locales

Street stalls

Healer’s home, patients’ home, streets, parks

Counseling clinics with named as research institutes; stadiums, convention centers, public squares, parks

Legality

Not officially recognized, but tolerated by government and not heavily regulated

Forbidden by government as ‘superstitious activities’

Utilizing legal vacuum; at the boundary of laws and political taboos, often forbidden and punished

Potential benefits

Mostly work psychologically due to placebo effects; sometimes effective biologically

Accessible to rural, poor and culturally diverse populations; provides psychological comfort for patients

Filling a socio-cultural void

Potential problems

False claims for personal profit; chemically toxic

Exaggeration of negative situations, creating self-fulfilling prophecies; cheating for money

Collective hysteria; social control driven by economic greed

CONCLUSIONS Until now, we have discussed an issue in a full chapter that seems to have no direct relevance to the operations of specific clinical techniques such as drug treatments and psychotherapy. But as a matter of fact, this kind of discussion is of critical importance for how we act when we treat different types of patients and their families. The author believes that the ‘Dao’ (or ‘Tao’), that is the way, to pursue one’s knowledge often goes beyond the

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aimed knowledge. The Taoist perspective holds that the relationships between our intended target and its surroundings are not always apparent. For instance, the method of treatment goes beyond the articulated techniques. ‘Mental health’ issues are only a small part of human psychological, biological and social processes. Thus, in order to solve a mental health problem, we need to understand the patient in their own context. A mature therapist must have a considerable understanding and experience of the patient’s socio-cultural environment in order to heal effectively. While many Chinese mental health professionals share similar cultural backgrounds as their patients, they often overlook the potential benefits of this unspoken knowledge to their work. This neglect can be observed in two forms. On one hand, some people are so enthusiastic for the development and prioritization of biological medicine that they look down upon the role of psychotherapy, not to mention cultural issues. On the other hand, the colleagues who are practicing psychotherapy have focused too much on the application of Western approaches in China, without having learned sufficiently from our own traditional culture. As noted previously, there are many psychological components of TCM that might shed light on Chinese mental health treatment if appropriately integrated. Furthermore, both biological psychiatrists and psychotherapists in China have ignored the culturally conditioned features of the psyche and behavior of the contemporary Chinese, leaving no user-friendly interface with Western mental health care, as discussed earlier. In order for psychiatry and psychotherapy to play a bigger role in the struggle against mental health problems, it is necessary for professionals to consider the importance of cultural awareness to their work. Systemic training for mental health professionals should address their relationship with the broader context of the therapeutic enterprise in a holistic way, so that they can grasp the territories and rules of the game, namely, the obstacles and possibilities facing them. Most of the phenomena we have discussed in this chapter are actually very commonplace. However, if we observe these phenomena from a different or holistic view, we will gain new perspectives that can help address current problems and improve the quality of care in the future. I hope the reflections discussed in this chapter can be inspiring for Chinese mental health professionals to promote such awareness, because mental health care does not only consist of ‘hard science and technology’, but is an enterprise encompassing many social, cultural, economic and psychological factors. For colleagues outside of China, this chapter intends to serve as a window to an aspect of the colorful complexities of healing practices in China, which could stimulate academic curiosity. Hopefully, the readers can see that the psychological and physical suffering of human beings can be seen and dealt with in many ways. Due to the richness and diversity of the cultures of various nationalities in the world, it is improper to believe that we need only one universal solution for all their troubles.

ACKNOWLEDGMENTS It was an unforgettable experience for me to write this chapter, because I had difficulty expressing my thoughts on these complicated issues in English. I had to utilize help from many other colleagues. I’d like to thank Dr Ronald Wintrob and Dr Mario Incayawar for their professional suggestions. Especially, I want to express my sincere thanks to Ms Emily

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Ng for her very generous help. As a bilingual cultural anthropology researcher who is interested in medical anthropology, she has corrected this chapter carefully and re-written some parts of it. Without these valuable aids, it would be impossible to imagine that this chapter could have reached its current state.

REFERENCES He, Y.L., Zhu, Z.Q. and Zhang, M.Y. (2002) A survey on mental health professionals in mental health institutes. Shanghai Archives of Psychiatry, 14 (B12), 19–22. Jiang, R. (2006) The changes in the population distribution of Chinese minorities and analysis on its inducement. Heilongjiang National Series, 1, 46–50. Jiang, L.S. and Zha, Q. (2006) Concerns about the human resource tendency of TCM practitioners. Jiangxi Journal of Traditional Chinese Medicine, 37 (3), 1–1. Zhang. (1986) The coordination group for epidemiological study of 12 provinces and cities. Analysis of the results and methodology of the epidemiological study on mental disorders in 12 provinces and cities. Chinese Journal of Psychiatry, 19, 65–9. Ministry of Health of PRC (1991) Health Yearbook of China, People’s Publishing House of Health, Beijing. Ministry of Health of PRC (2007) Mortality rate of children under 5-year and maternal mortality rate in surveillance region, in Health Yearbook of China, People’s Publishing House of Health, Beijing, p. 191. Ministry of Health (2008) Briefing: The development of health protection in China 2003–2007, Available at: http://www.moh.gov.cn 2008-01-15, Municipal Health Bureau of Shanghai (2007) Medical and health information of Shanghai in 2006, Available at: http: www.wsj.sh.gov.on Mental Health Bureau of the Ministry of Health of PRC (2007) Trends of Mental Health Service in China. Official report for the National Annual Meeting of Psychiatry, Shanghai. Wang, M. (1985) Psychology in Traditional Chinese Medicine, Publishing House for Sciences and Technology Tianjin, Tianjin. Yang, D.S. (1994) The development of psychiatry in China. Shanghai Archives of Psychiatry, 6 (4), 190–3. Zhang, W.X. (1986) The national coordination group of epidemiological research on mental illnesses within 12 provinces and cities. Journal of Medical Research, (6), 187–8. Zhao, X.D. (2002) Die Einfu¨hrung Systemischer Familientherapie in China Als Ein Kulturelles Projekt, Verlag fu¨r Wissenschaft und Bildung, Berlin. Zhao, X.D., Xu, X.F. and Bai, Y. (1998) A retrospective analysis of 411 psychiatric consultations in a general hospital. Chinese Journal of Psychiatry, 31 (4), 231–3.

CHAPTER 12

Health-Seeking Behavior for Psychiatric Disorders in North India An Exploration of Medical Pluralism Antti Pakaslahti MD, PhD Adjunct Professor of Transcultural Psychiatry, School of Public Health, University of Tampere, Finland

Abstract In low-income countries where community-based psychiatric services are still scarce, mental health resources are available from traditional practitioners, often little known to official psychiatry. In the culturally rich and medically pluralistic societies of India, these include both secular codified medicines and varieties of oral religious healing traditions. This chapter, based on over a decade of field research, explores the healing tradition at the increasingly popular Hindu temples of Balaji in Rajasthan, 270km from Delhi, in North India. They do not cater only to local treatment needs. Help-seeking for mental disorders, culturally known as ‘spirit illness’, is cross-regional, interstate and occasionally transnational (Hindus from Nepal, from United Kingdom and United States). The majority of patients is literate, urban and has had prior consultations with allopathic doctors. The pilgrimage setting of the temples is non-stigmatizing and a large network of healers offers specialized professional help for the suffering and their families. The idiom of spirit illness functions as a culturally relevant discourse for therapeutic communication and intervention. Traditional healing in North Indian medical pluralism appears as a widely used secondary option for those who suffer from mental disorders.

12.1

INTRODUCTION

In many parts of the world, traditional healers provide a wide range of community mental health resources (e.g. Kleinman, 1980; Desjarlais et al., 1995: pp. 51–4; Leslie, 1998). This is not limited to low-income countries. They may work also in Western metropolises with Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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large immigrant communities, often unknown to official psychiatry (Dein and Sembhi, 2001; Bhugra et al., 2004). In the culturally rich and medically pluralistic societies of India, traditional healers are widely heterogeneous as to orientations and practices. They include practitioners of the secular codified medical systems (Ayurveda, Unani, Siddha) and those working in religious settings (Hindu, Muslim, Christian) (Neki, 1973; Carstairs and Kapur, 1973; Kakar, 1982; Kapur, 1979; de Sousa and de Sousa, 1984; Skultans, 1987; Pfleiderer, 1988; Freed and Freed 1993; Jadhav, 1995; Campion and Bhugra, 1997; Carrin, 1999; Halliburton, 2004; Kapur, 2004; Cohen, 2005; Sebastia, 2007). The majority of psychiatric patients in contemporary India would appear to seek help from religious varieties of traditional healing. Modern psychiatric services are increasingly available in India, but these still suffer from serious manpower limitations, hospital-based models and uneven geographical distribution (Weiss et al., 2001; Varma and Wig, 2002; Agarval et al., 2004). In 2005, there were four psychiatrists per million population in India, compared with over 100 psychiatrists per million population in Europe (Gangolli et al., 2005). Help-seekers alternate between traditional and modern help-providers according to availability of options, experienced efficacy, cultural preferences and economic factors (Kleinman, 1980: pp. 188–9; Channabasavanna et al., 1993; Campion and Bhugra, 1997; Weiss et al., 1986, 1988; Leslie, 1998; Chadda et al., 2001). Halliburton (2004) found that in medically pluralistic settings psychiatric patients could find a suitable treatment, a ‘fit’, equally in modern psychiatry, Ayurvedic healing and religious shrines. Raguram et al. (2002) observed significant improvement of patients in a healing shrine in South India. Campion and Bhugra (1997) estimated that in order to successfully plan and deliver psychiatric services in India, it is important that the role of traditional healers be established, clarified and understood. Recently, Kapur (2004) noted that the abundant and flourishing community-based resources of the traditional type have still been largely ignored in psychiatric research. This chapter explores aspects of help-seeking from the temples and healers of Balaji, Mehndipur,1 in Rajasthan, 270km southwest of Delhi. The temples have a wide reputation for providing help to those who suffer from illnesses associated with spirits (bhu¯t-pret) and mental disorders (Satija et al., 1981; Kakar, 1982, 53–88; Satija and Nathawat, 1984, 119–60; Seeberg, 1992; Pakaslahti, 1996, 1998, 2000, 2004, 2005, 2006, 2008; Dwyer, 2003; F. Smith, 2006, 114–19; Lutgendorf, 2007, 262–70). Mental disorders are expressed in culturally congenial spirit concepts, some of which have been widespread in India since ancient times (Weiss, 1977; F. Smith, 2006). Help-seeking will be examined in several perspectives: cultural context, healers as a network of specialized help providers, patient characteristics, prior help-seeking pathways, symptoms and diagnoses (Western and indigenous) and three case studies. The author – fluent in Hindi – has conducted field research trips in Balaji for over a decade.

12.2

ORIENTATION TO THE TEMPLES AND THE HEALING TRADITION

An exploration of help-seeking in a healing tradition distant from our own needs to start with an overview of the material and cultural settings in which it is embedded. The small temple town of Mehndipur, nestled in a fertile valley between hills of the Arawalli range in Rajasthan, is a flourishing Hindu pilgrimage and help-seeking site. Easily

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reached from many directions, throughout the year it draws a brisk daily influx of pilgrims and help-seeking families from far and wide, especially from the capital area. Tens of thousands participate in its spring and autumn festivals. Growing affluence shows everywhere: renovated temples, modernized services for pilgrims, sumptuous new guesthouses. Among the many temples of the locality, the principal attraction is the valley’s freshly embellished main temple, dedicated to Balaji, a common Rajasthani designation of the very popular pan-Indian Monkey God Hanuman. By extension, the town of Mehndipur itself is usually simply called Balaji.2 The majority of pilgrims and help-seekers also visit a series of temples located on a hilltop next to the valley. There are along with the temples of Hanuman, a veritable array of shrines for Shiva, Bhairav, mother goddesses, various folk deities3 and from last year even one for Parshvanath, a Jain deity. Pilgrim manuals sold in the market claim a thousand year history to the Balaii main temple and its priestly lineage. According to them, its idol of Hanuman was found there ‘long ago’ as a natural rock formation in the epic pose of a healer flying across the sky to succor the suffering. In popular Rajasthan temples prestige-enhancing myths of divine origin and immemorial priestly lineages are not rare (Lutgendorf, 2007, 250–1). Although historical accounts or archive studies of the Mehndipur temples are not available, interview data from well informed elder locals and pilgrims suggest that the Balaji temple was, less than a hundred years ago, a minor rural shrine with a marginal healing cult in a roadless village.4 The present shrines on the adjoining hills did not exist, but had replaced by or been added to older holy sites, not uncommon on hilltops of the region.5 The fame of Mehndipur started to grow only after an outside Brahmin priest Ganeshpuri, a celibate scholar, had established himself there in the early half of the last century as a caretaker of the Balaji idol.6 He proved a dynamic religious innovator and a charismatic healer who raised Balaji into a regionally important pilgrimage and healing centre. Since his death in 1974, at the age of 82 (Seeberg, 1992), the growth of Balaji has continued phenomenally. He is worshipped as a saint by pilgrims, patients and today’s healers at his burial shrine (sama¯dhi) is adorned by his larger-than-life statue. The current hagiographic temple web site (www.balajimehandipur.org) shows him almost as an equal in the divine company of the Monkey God and local helping deities.7 Apart from local dynamics, the rise of Mehndipur has profited from greatly facilitated communications, successful publicity and the general ascendency of the Monkey God in modern Indian devotionality. Hanuman has evolved from a subordinate role in the epic Ramayanas into one of the most adored gods of modern India (Kalyan, 1973). He is especially popular among the rising, but still fragile, urban middle class (Lutgendorf, 2007) who constitute the majority of help-seekers in Mehndipur. The devotional pilgrimage context is significant in help-seeking. The majority of visitors are ordinary pilgrims (ya¯trı¯) who wish to see the holy place, have a short pause from daily stress, and worship its deities in the context of popular Hindu devotion (bhakti). They may pray for their family’s health, progeny and well-being as is customary in Indian temples. Many of the pilgrims, seek help because they suffer from afflicting spirits and/or mental disorders. These conditions are called generically bhu¯t-pret kı¯ bı¯ma¯rı¯/rog, that is illnesses (bı¯ma¯rı¯, rog) associated with spirits bhu¯t-pret), best translated simply as ‘spirit illness’ (Pakaslahti, 2008) or ghost illness (Freed and Freed, 1993). Of the several local synonyms the most common is san_kat:. Ordinarily it denotes in Hindi crisis, calamity, misfortune’ but in Balaji it connotes specifically afflicting spirits (bhu¯t-pret).8

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In Balaji the help-seeking patients and their families mix with the majority of normal, healthy pilgrims. Basically, all of them participate in the culturally valued and emotionally uplifting temple ceremonies officiated at by priests. Social stigma and isolation – so commonly accompanied by or feared in mental disorders – are likely to be counteracted or reduced (Pakaslahti, 1998). The many recovered former patients visiting for thanksgiving are living testimonials to the efficacy of healing in Balaji. Such a hopeful atmosphere, stories of previous cures, mutual help and peer-group camaraderie provide for a therapeutic milieu (Kakar, 1982).

12.3

THE NETWORK OF HEALERS IN BALAJI

As noted above, the healing fame of Balaji derives essentially from the fairly recent lifework and legacy of the charismatic healer-priest Ganeshpuri. No written documents exist of his working methods, although oral data circulates among elder pilgrims and present healers. He is said to have given each help-seeking patient and family personal attention, advice and treatment. After his demise, his style of work was carried on by his eldest nephew and disciple, Ramjilal. At age 90, he may still give at times much soughtafter consultations in his home for help-seekers. Personalized service is not possible anymore in the congested and often noisy main temple of today, with its incessant stream of help-seekers making a speedy round of prayers. The present priests (pu¯ja¯rı¯) of the main temple, officiating to Balaji and his divine ministers, need to be fast in accepting offerings and bestowing benedictions. One hears critiques from patients’ families that the priests of today do not have time for their problems. This does not, however, seem to affect devotion towards the temple divinities.9 However, a recent study (Pakaslahti, 2005) documented how personalized services of a large number of resident professional healers are available for helpseekers outside the temple precincts in pilgrim guesthouses. Qualitative and quantitative data showed that they play a central role in the current healing culture of Balaji as specialists of diagnosing and treating spirit illness. They maintain that their services are complementary to the temple ceremonies and not an alternative to them. Several of them have previously sat in on the consultations of Ramjilal, learning from his techniques. In this way there is a direct continuity of the healing tradition to present skills. Visiting healers are called bhagat which means ‘devotee’ – from bhakti religious devotion – and ‘one abstaining from meat and alcohol’ (McGregor, 1993) – a discipline associated with purity, morality and self-control. All were followers of the Monkey God, but in the Hindu eclectic fashion, could also worship other gods, most often the Mother Goddess Kali, sometimes folk deities whose shrines are located on the Balaji hill. Most interestingly, two thirds of the healers lived in and around Delhi (Pakaslahti, 2005), but visited Mehndipur on a regular basis and stayed there with their assistants from several days to two weeks at a time for treating patients. Daily treatment sessions were held in their chosen guesthouses, less frequently in front of a Kali temple on the hill, or near the burial shrine of Ganeshpuri, the paradigmatic healer. The healers in the study cohort (N ¼ 18) were all Hindus, predominantly male, literate, mostly urban. All visiting healers had their basic consultations at their domicile in their home towns and villages. Healers also recommended and brought with them groups of

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patients and their families on their visits to Balaji. There healers could also recruit new patients from among helpseekers. The majority of the healers impressed me by their general interpersonal relation skills and ability in discerning psychological and interpersonal problems. The general atmosphere at the healers’ consultations was optimistic and supportive. None used drugs, physical restraints or custodial care.10 There was much scope for informal talking, warm emotions and refreshing humor. Treatments were essentially family and group oriented. Healers appeared to draw from a broad common pool of verbal and non-verbal therapeutic techniques. (Pakaslahti, 1998, 2004, 2005, 2006, 2008). These included, for instance, counseling, group discussions, home tasks, cognitive structuring through mantras, amulets (ta¯tr¯z) ritual activities and home tasks for families. The choice of techniques depended on the particular style of the healer, type of problems, assessed needs and treatment responses of the clients. Many were well-versed in religious legends and healing stories, which they could skilfully recount for therapeutic purposes. Most, but not all healers, encouraged trance performances in spirit roles during the group sessions (darba¯r) comprising multiple families, with music, singing and dance. Illnessassociated afflicting spirits (bhu¯t-pret) were made to appear and talk in trance (pes´¯ı) by patients, their family members, the healer or his assistants. Verbalization of problems and conflicts took place in an emotionally protective group context. Full treatment aimed at transforming afflicting spirits (bhu¯t) into helpers (du¯t). Also, the process strove to find peace for troubled ancestor spirits (pitr) of the family (Pakaslahti, 1998, 2006, 2008). For less serious problems, treatments could be short verbal and ritual interventions. However, consultations were usually repeated over a period of time, with intervening home care and home tasks for the whole family, until sufficient help was obtained. Healers provided thus, a continuity of care. During home care healers could be reached by their mobile phones for prompt consultation. Sometimes long-term supportive relationships were built up with families. Healers always had one or more assistants or co-therapists who were often their recovered patients. Minor healing cults could build up around more successful healers. Finally, it may be appropriate to note a relative religious permeability of the consultations of the healers. All had some patients of the Sikh and Jain religions both at their domiciles and in Balaji. The home consultations of two healers working in religiously mixed localities were attended regularly also by a minority of Muslim clients. However, for temple rituals Muslims were not recommended to Balaji, but referred to Muslim Sufi shrines (darga¯h). One healer also occasionally treated Indian Christian patients in Delhi.

12.4

BACKGROUND AND HELP-SEEKING PATHWAYS OF PATIENTS

What is the background and help-seeking pattern of the patients suffering spirit illness. Two little known cohort studies carried out in Balaji provide unique and challenging data about patients who attend a healing shrine. The first data set was collected by Indian psychiatrists led by Satija (1981). During a three month period in 1980, they interviewed 100 consecutive patients staying in five Balaji guest houses. The second data set is from the anthropologist Dwyer (2003) who in 1992–1993

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interviewed, with an assistant, 734 patients, met on random days at the entrance of the Balaji main temple. Their findings are presented together below for the first time and reanalyzed. My comparisons with available population statistics add an epidemiological perspective. Tables 12.1–12.3 present socio-demographic and help-seeking findings from both data sets side by side. An overall visual comparison shows their remarkable similarity and Table 12.1 Sociodemographic data of Balaji patients in 1980, in 1992–1993 and 1991 census of India regional data.

Female Age Range 15–39 yr Married Urban Literacy rate Degree, other higher qualification Hindu religion Three Upper Castes11 Business, govt. service12

First data set 1980

Second data set 1992–1993

Census of India Regional data 1991

N ¼ 100 %

N ¼ 734 %

N ¼ 295.4 milliona %

54 82 62 82 80 12

50.6 78.2b 74.1 73.8 83.2 18.3

45.4 NA NA 26.4 44.1 NA

98 62 32

Almost allc Mostlyc Predominantly middle classb

NA NA NA

NA, not available. a The total population of the states named in Table 12.2. b Calculation made by myself from raw data sent by Dwyer in 2004. c Not estimated quantitatively.

Table 12.2 Percentage of patients in two data sets per state; proportion of patients in second data set per million population (census of India 1991). First data set Second data set 1980 1992–1993 States Uttar Pradesh Delhi Haryana Rajasthan Madhya Pradesh Punjab Other states and from abroad

N ¼ 100 %

N ¼ 734 %

All patients in second data set/ million population

Urban patients in second data set/ million urban population

Rural patients in second data set/ million rural population

28

31.5

1.7

5.8

0.6

18 12 14 16

19.3 16.1 14,7 10.2

15.1a 7.2 2.5 1.1

15.1a 17.7 7.0 2.8

3.7 1.1 0.6

4 8

4,5 3.7

1.6 —

5.5 —

0.3 —

a Both data sets counted patients from Delhi as urban. The Census of India 1991 assessed 10% of the Delhi inhabitants as rural and 90% as urban.

BACKGROUND AND HELP-SEEKING PATHWAYS OF PATIENTS Table 12.3

155

Help seeking prior to Balaji.

Variables

First data set 1980

Second data set 1992–1993

N ¼ 100 %

N ¼ 734 %

Prior allopathic practitioners Prior traditional practitioners Referred to Balaji by family and relatives Previous successful treatment at Balaji

90 NA 66 8

89 62.5a most NA

NA, not available. a Personal communication by Dwyer (2004).

consequently, stability of the findings over time, despite some major changes at the healing site over the two study times.

12.4.1 Socio-Demographic Findings Table 12.1 shows, most remarkably, that the Balaji patients were predominantly from outside Rajasthan. Moreover, most patients were from urban areas: 82% and 73.8% respectively. This was almost diametrically opposite to the regional urban rate of 26.4%. Furthermore, the great majority of patients were literate; 80% and 83.2% respectively, almost double the regional literacy rate. Table 12.2 gives a breakdown of the Balaji patients by state in the two data sets. Over 85% of subjects in both data sets came from outside Rajasthan, mainly from neighboring states and from Delhi. The populous state of Uttar Pradesh leads in both data sets. Some patients were from more distant parts of India and a few from abroad. Proportionately to the corresponding populations, the highest frequency of patients was from Delhi and Haryana The other states were far behind. Strikingly, Balaji attracted far more patients from among the urban than the rural population of every state. A recent study (Pakaslahti, 2005) showed that the Balaji patients had a broadly similar interstate distribution, urban domicile and literacy rate as the healers visiting there.

12.4.2 Prior help-Seeking Table 12.3 Presents data relating to the help-seeking trajectory to Balaji in the first and second data sets. Help-seeking pathways of patients who came to Balaji for treatment showed a medically pluralistic pattern. About 90% had prior visits to allopathic doctors for their presenting illness; that is Western medical doctors (there was no data on how many of them were psychiatrists). In the second study, 62.5% of the patients also had prior visits to traditional healers – secular and religious (Hindus or Muslims pı¯rs13) I calculated that at least half of the patients had visited both allopathic and traditional practitioners.14 Allopathic doctors had been by far the preferred primary choice and traditional practitioners clearly less so. About half of the patients had prior consultations with both types of treatment providers. The studies did not assess to what extent patients in Balaji used the services of healers.

156

12.5

HEALTH-SEEKING BEHAVIOR FOR PSYCHIATRIC DISORDERS IN NORTH INDIA

ON SYMPTOMS AND DIAGNOSES OF PATIENTS FROM TWO PERSPECTIVES

This section moves to clinical issues, relating to symptoms and diagnoses of the Balaji patients and the extent to which spirit illness coincides with psychiatric symptoms and diagnoses. Material will be presented from two perspectives: 1) Western descriptions of psychopathology and mental disorders, from research carried out in Balaji and 2) direct accounts of symptoms and diagnosis of spirit illness from healers and patients in Balaji. A comparison of the two perspectives needs to be made with the reservation that symptom descriptions are not a focus of the healers’ attention. They do not classify symptoms of their patients into distinct illness categories of disorders. Symptoms are subsumed by healers under a system of conceptual metaphors which structure cognitively patient experience for therapeutic communication (Pakaslahti, 1998, 2008). Two anthropological studies have recorded undefined lists psychological and physical symptoms of patients in Balaji. Seeberg (1992:310) noted for example depression, loss of interest, anxiety, irritability, reduced speech, weakness and bodily pains. Dwyer (2003:39, 152) has a rather similar list of commonly encountered symptoms: headaches, dizziness, bodily aches and pains, loss of appetite, lethargy and weakness, depression, irritability and so on. In a psychoanalytic study, Kakar (1982:282) estimated that his interviewees in Balaji suffered from neurotic psychopathology, most often of hysteric type. In other words, all three reports refer to symptoms which occur in less severe psychiatric, non-psychotic disorders. For psychiatric research and mental health care, diagnoses are essential. The cohort study presented in the preceding section, led by Satija (1981, 1984) assessed the diagnostic distribution of 100 consecutive patients interviewed in Balaji. This study showed that the vast majority (92%) suffered from diagnosable psychiatric illnesses. The diagnostic distribution was; 48% neurotic disorders, 26% functional psychoses, 12% organic psychoses and 6% other psychiatric disturbances. Comorbidity and somatic diseases were not assessed. How do healers and patients in Balaji talk about symptoms and distress? Healers are not familiar with Western psychiatric vocabulary. Healers and patients prefer spirit terms which belong to a shared idiom of distress, culturally familiar to most help-seekers (Pakaslahti, 1998, 2004, 2008; F. Smith, 2006). In Balaji even literate and urban patients seem to feel spirit concepts more ‘natural’, than psychological terms. This is evident from questions directed to me by educated patients: Here in Balaji we talk about spirit illness (san_kat:) and spirits (bhu¯t). What would you say in hospital language? We speak of these problems as spirit illness (san_kat:). Do you categorize them as psychological?

Although healers have more interest in initiating psychotherapeutic processes than getting detailed symptom descriptions, they are not unaware of psychopathology. I have asked experienced healers to describe the most common symptoms and signs (sanket, cinh) of spirit illness, san_kat:. Here are excerpts from one such interview: There are many symptoms which may indicate spirit illness. The patient’s face is not bright (tez). He has lost his interest and enjoyment, he is anxious and fearful of normal things.

ON SYMPTOMS AND DIAGNOSES OF PATIENTS FROM TWO PERSPECTIVES

157

He can lose weight and may complain of a lump in the throat. There is heaviness in his body, backache, pains in his feet and legs. Some say they cannot walk. Others are afraid that they have some serious disease, like cancer . . . After medical check-up the doctor says that his body is OK. Blood tests are alright, also the heart. There is nothing wrong with his bones. Still, the patient cannot walk. When the doctor says you are OK the patient says I am (still) very ill. The doctor’s assurances do not help . . . Why? Because it is spirit illness (san_kat:), not bodily disease. A patient may scream and panic suddenly, hear voices in his ears, be afraid of the dark and startle at nonexistent shadows. He may become stubborn, indolent and overbearing, he quarrels with his family and repels his wife. If you ask him to work, he will protest that he cannot and gets angry . . . spirit illness takes away a person’s will and energy.

We see that the healer described in ordinary language a number of psychological, physical and behavioral symptoms. A psychiatrist knows that they are common in various mental disorders, mostly of non-psychotic varieties. The healer summed up in pithy vernacular terms how spirit illness affects the patient’s health as a whole and his psychosocial functioning: It causes three main damages: it scatters the mind (man), it weakens the body (tan) and it spoils livelihood (dhan). Healers define their practice as ‘working with spirits’ (bhu¯t-pret ka¯ ka¯m). This means that they restrict their competence to cases of spirit illness. Therefore they consider it important to attempt to distinguish spirit illness from physical diseases, which belong to the domain of medical professionals. A healer explained to me: When a new patient comes we have to find out if his problems are due to physical illness (s´arı¯rik bı¯ma¯rı¯) or spirit illness (bhu¯t-pret kı¯ bı¯ma¯rı¯). Only in the latter case we will start treatment (ila¯j karenge). If his illness is physical (s´arı¯rik), we send him for treatment to a doctor.15 If the patient has both illnesses he needs both treatments.

To establish this basic differential diagnosis, healers will ask new patients and their families if the patient has been seen by an (allopathic) doctor, what he said and whether his medicines helped. Here are typical statements by clients: The doctor said I have nothing (mana¯ kar diya¯). Since I still felt ill I came to Balaji, A father said, about his ill daughter: ‘The doctor found nothing wrong with her. Then a relative felt that her illness might be due to spirits (u¯parı¯ cakkar) and said that she should be taken to a healer (bhagat).’ A patient described why he had come to Balaji: ‘When medicines do not help, we presume that it is spirit-illness (bhu¯t-pret kı¯ bı¯ma¯rı¯) and seek help from healers (bhagat)’ An aunt of her niece; ‘we had taken her to many doctors. They found no bodily disease (s´arı¯rik bı¯ma¯rı¯) in her. Then we started to think that she suffered from ‘‘something else’’ (kuch aur) and came to Balaji’

These responses illustrate clinically the primacy of allopathic medicine reported in the helpseeking statistics of Table 12.3. The answers also show how the possibility of spirit illness arises in the minds of patients and their families. If the doctor’s treatments are effective from the viewpoint of their clients, they feel no need to consult healers. If not, they may start to think of spirit illness and consulting traditional healers. Presumed spirit illness (san_kat:, bhu¯tpret kı¯ bı¯ma¯rı¯ etc; see note 8.) when interfering sufficiently with normal life, motivates

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HEALTH-SEEKING BEHAVIOR FOR PSYCHIATRIC DISORDERS IN NORTH INDIA

people to seek help from healing shrines and healers, that is from culturally appropriate specialists of the illness. One of the better known options in North India is Balaji. Prior medical consultations function as an unwitting differential diagnostic screen. Healers are aware in principle that physical illnesses may cause mental symptoms. It is in their interest that such patients are treated by medical practitioners. It depends on the clinical skills of the primary doctors to recognize and treat such physical diseases as for example diabetes, renal disease, tuberculosis, hyperthyroidism, hypothyroidism and so on. A Western psychiatrist has similar concerns, as diagnoses of functional psychiatric disorders imply the exclusion of somatic causes of the symptoms.

12.6

THREE ACCOUNTS OF HELP-SEEKING

Here we look at three patient case histories illustrating how the different perspectives (presented) in this chapter may tie together concretely in the help-seeking pathways of medical pluralism. The patients16 were interviewed by me in Balaji. As mentioned previously there is no research data on what percentage of the Balaji patients had visited psychiatrists, although presumably it is a minority. These three patients were perhaps less typical, in the sense that two were involved in ongoing (private) psychiatric outpatient treatment and one family had experience of previous successful psychiatric treatment. All three patients consulted allopathic doctors first and Balaji later on in their medically pluralistic search for effective treatment. In all cases resort to Balaji had been advised by relatives and friends, not by doctors. The patients did not consider using different practitioners as contradictory, but were aware that allopathic doctors might be critical of their going to Balaji for treatment. Patients and families needed understanding of illness in culturally supportive, meaningful terms. The case studies17 are followed by a summaries with ICD-10 diagnoses made by me, the help-seeking pathway and healers’ assessments. In the healers’ assessments, it is notable that the patient’s family was included in the diagnosis and treatment recommendations. In no case did the healer make discouraging comments about consulting allopathic practitioners.

12.6.1 Vishal I met Vishal at the morning consultations of a widely respected senior healer.18 The patient was a 26-year-old, unmarried university graduate of Rajput caste, employed in a large Delhi firm for outsourcing of business processes. Soft-spoken, polite, with a minor facial tic, communicative, he is accompanied by his solicitous mother and pensioner father. They tell that he had suffered from some timidity, but had been healthy until five months ago. At that time he had been taking an English course at the British Council, preparing for possible transfer to the United Kingdom. In the class he suddenly started to feel intense fear, palpitations, dizziness and difficulty in breathing, without perceived cause. He and his parents thought it might be a heart attack. A medical check-up, including ECG, was normal. Since then he has been afraid of speaking in meetings and had to quit his English course due to recurring anxiety symptoms. He also became fearful in crowds, buses, trains and

THREE ACCOUNTS OF HELP-SEEKING

159

elevators and in crossing large open spaces. Consequently, he has tried to avoid or minimize such situations. Thorough examination by an internist did not reveal any physical pathology. He was prescribed benzodiazepines. A psychiatrist diagnosed panic attacks and prescribed antidepressants. The medicines helped him in doing his work. When he tried to stop his prescribed medicines, the troubling symptoms recurred in a few days and he re-started the drugs. Vishal was planning to get married this year, to a girl of his parents’ choosing. He said he and the bride have basically agreed. Now, due to his illness, marriage was postponed; about which he did not express visible disappointment. I asked him and his parents how they had decided to come to Balaji. The father said it had been recommended by a friend who had been satisfied with help received for a family member by a Balaji healer. The father added an idiomatic phrase often heard at healing shrines: ‘both medicines (dava¯) and prayer (dua¯) may be needed’. I asked what Vishal hoped treatment at Balaji would do for him. He said that he needed more help in addition to the medicines. He wanted to know why he was suffering panic attacks; or if it was ‘something else’. Vishal had told his psychiatrist that the family wanted him to pray at the temple of Balaji. The doctor had said ‘if you wish to pray it’s fine, but don’t stop your medicines’.

Summary Psychiatric diagnosis F40.1 Phobic anxiety disorder which started with acute social phobia, then generalized to other situations Help-seeking pathway. GP. ! internist ! psychiatrist ! healer in Balaji. Simultaneous use of psychiatrist and healer Healer’s assessment: ‘there are spirits (bhu¯t) (afflicting) your family but the boy suffers most . . . you should all make offerings and (perform) rituals at the temple and then daily at home; you can come back to me after one month’

12.6.2 Ram Ram was a 44-year-old shopkeeper of the Vaishya caste from the town of Kanpur, some 400km away. He was brought to Balaji by his worried family, led by his only son. I met them consulting a healer to whom they had been recommended by a former patient of his. The patient is sitting quietly on the floor. He looks confused, haggard and fearful, with occasional tremulous movements of his head and hands. He did not speak spontaneously, but briefly answered questions asked by his son and by his wife after a latency period. He could tell me his name, home address and profession, but seemed perplexed about his orientation for time and place. The son said that his father had been hard-working, previously healthy and normal until about a month ago. He had been doing everything he could to prepare the future dowries of his five daughters. Then his recently-married eldest daughter had been expelled by her in-laws after quarreling with her mother-in-law. Ram was accused of having concealed that his daughter has mental problems. The in-laws demanded that the marriage be cancelled, and that they would keep the dowry as compensation for the deception.

160

HEALTH-SEEKING BEHAVIOR FOR PSYCHIATRIC DISORDERS IN NORTH INDIA

Talking with the family, I learned that the eldest daughter had apparently suffered a brief psychosis, but had well recovered with psychiatric medication. She was now present and talked normally with her brother and mother; showing no apparent evidence of psychosis. Subsequent to the failed marriage arrangements, the father had been upset and disturbed for a month. He could not sleep and was unable to concentrate when at work in his shop, or on other tasks. He had become erratic, agitated and confused. His son took him to a GP who gave him an injection and prescribed benzodiazepines. The patient’s agitation decreased, but his mental confusion continued. His family felt he had to be watched, for fear that something calamitous might happen to him. I asked the son why they had not seen the psychiatrist recommended by the GP? The family had been afraid that a ‘mental hospital’ would bring more stigma on the family and severely impact the marriage prospects of the unmarried daughters. The family hoped that Ram would get better in Balaji, where many people had received help. Now the family’s intense new worry was that Ram was very exhausted by the long and stressful journey, had stopped eating and had started to refuse to drink water.

Summary Psychiatric diagnosis F23.9 Acute unspecified psychotic disorder (provisional until full medical check-up) Help-seeking pathway: GP. ! Balaji, although GP suggested psychiatric treatment Healer’s assessment: ‘first, the daughter had spirit illness, then it spread to the family and now all are suffering; the father is in shock (sadma¯); he must be taken to a hospital due to his physical condition. After that they can come back’. The son drove the next evening to Delhi and took his father to the renowned All India Medical Institute.

12.6.3 Mr Gupta Mr Gupta is a distraught 42-year-old bank manager of the Vaishya caste, whom I met on the bus to Balaji. During much of the six-hour trip he told me his life story. He had lived and worked in Delhi, but because of disputes with his supervisor at work he had been transferred three months ago to a small office in a distant tribal area in Orissa, in East India. ‘There was nothing, only snakes. I am very afraid of them. . . . I was separated from my family and relatives. I could not cope with it any more. . . . I went to a GP, but he said I should go to a specialist. Then I took a train to Delhi to see a psychiatrist. He put me on sick leave and gave me medication. This has given me some relief’. He still feels depressed and has suicidal ideas. ‘Even today I thought I shall kill myself, or try to get a pension rather than return to Orissa’. He was coming to Balaji for a second visit. The first time he came with his wife, who was now indisposed to make the long bus journey. He had not told his psychiatrist about his going to Balaji, because he was afraid of being criticized. He thinks that he is suffering from spirit illness (san_kat:). ‘Also other things have happened. My wife has been ill and the doctor does not know why. My son got hurt in a traffic accident (with minor injuries) though no fault of his’.

SUMMING UP FOR FUTURE RESEARCH

161

I asked him why he chose to come to Balaji. He said that a relative had recommended it. ‘I place my trust in Balaji and I would like to meet a healer who could guide me. A long time ago my mother had fits. Doctors said they were just hysteria and medicines did not help. She started to go to a healer and his healing sessions. She did offerings (pu¯ja¯) and was given mantras. Her health was restored and the fits did not return’. I met him once more in Balaji three days later. He told me that he met a healer, who said that the whole family is afflicted by spirits, most of all himself. The healer had recommended that they should all come to his home consultation in Delhi. Offerings, rituals and home tasks were prescribed. Now he feels a bit relieved. The healer suggested that he should also continue the medicines that the doctor had prescribed.

Summary Psychiatric diagnosis: F32.2 Severe depressive episode without psychotic symptoms Help-seeking pathway: GP ! psychiatrist ! Balaji; Simultaneous use of psychiatrist and healer, did not reveal to his doctor. Healer’s assesment: spirit illness, wife and son are also troubled; all should come next time together. Now rituals in Balaji and home advice.

12.7

SUMMING UP FOR FUTURE RESEARCH

This chapter explored psychiatric, socio-demographic and cultural aspects of health-seeking behavior for mental disorders at the temples of Balaji in Rajasthan, 270km from Delhi, in North India. Like various other shrines in India both Hindu and Muslim, they are reputed to provide help to patients with mental disorders culturally expressed in widely prevalent time-honored idioms of spirit affliction as illnessess associated with spirits. The particular healing tradition at Balaji could, paradoxically perhaps, be called a ‘modern tradition’. It used to be a minor local cult connected with the Monkey God Hanuman. Some decades ago it was renewed and vitalized by a charismatic priest and healer now considered by many as a saint. Since then Balaji’s ascendency as a healing and pilgrimage site is impressive. It has been facilitated by improved communications and the rising general popularity in India of Hanuman as a helping god in life crises, especially popular among India’s urban and literate middle class (Lutgenforf, 2007). Help seeking from Balaji for mental suffering and spirit illness has far surpassed local limits drawing regional, interstate and even occasional transnational psychiatric patients (from Nepal, from UK and US of Indian descent). This trend appears to be increasing. Psychiatrically, it is of central importance to know what kind of mental disorders patients at healing shrines may suffer. Previous psychiatric research in Balaji (Satija et al., 1981) showed that 92% of patients suffered from diagnosable psychiatric illnesses, mainly of the neurotic variety. New psychiatric diagnostic and classification systems (1CD-10, DSM-IV) would be more reliable. Regrettably, so far only one study has systematically assessed psychiatric illnesses in any of India’s healing shrines with modern methodology. Raguram et al. (2002) found severe mental disorders in all interviewed patients in a South Indian temple. Compared to the Balaji data, this shows that healing shrines may serve psychiatrically different clienteles.

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Help-seeking in Balaji has far surpassed local limits, drawing regional, inter-state and even trans-national help-seekers. I have recently encountered Nepalese help-seekers there, as well as some help-seeking psychiatric patients of Indian descent, from the United Kingdom and United States. The trend may be increasing. A reanalysis of previous studies (Satija et al., 1981; Dwyer, 2003) performed in Balaji and their comparison with populations statistics showed that far more urban and literate patients were attracted there than rural and illiterate ones. Patients tended to be of middle social class both in terms of caste end profession. Two thirds of the patients came from Delhi and its surroundings. The Balaji patient data thus challenges earlier generalizations that help-seeking from healing shrines is basically associated with illiteracy, rural domicile and low social status. Serious empirical research is necessary to clarify why educated patients are attracted to Balaji, especially from Delhi and its surroundings, where psychiatric services are among the best in the country. Furthermore, the clienteles of Indian healing shrines would need to be studied empirically, one by one. For instance, some other temples cater to local rural populations (Raguram et al., 2002); others attract patients regionally (Skultans, 1987; Sebastia, 2007) and still others on interstate or national levels (Pfleiderer, 1988). However, so far systematic patient data is available only from the temples of Balaji (Satija et al., 1981; Dwyer, 2003) and Mutthuswamy (Raguram et al., 2002). It is clear that without adequate psychiatric studies, including relevant helpseeking and socio-demographic data, it is not possible to assess the role of healing shrines relative to psychiatric health care in India. Help-seeking in Balaji is a secondary resort, set in North Indian medical pluralism. It is not associated with non-use of modern medical services. The vast majority of patients had first seen allopathic doctors readily available in urban settings. If experiences as insufficient, a visit to Balaji could be suggested by relatives, friends and satisfied ex-patients. Half of the patients had also visited traditional healers some of whom had guided them to Balaji for more intensive treatment. The role of allopathic general practitioners is central to the patients’ help-seeking patterns. It has been estimated that about 20–25% of consultations in primary health care are due to emotional problems (Channabasavanna et al., 1995). The role of general practitioners is also crucial for identifying and treating medical conditions underlying diffuse psychological symptoms. When effective, this would function as an unwitting differential diagnostic triage for unnecessary resort to healing shrines in somatic illness. Healers of Balaji do not wish to treat physical illnesses, but only ‘spirit illness’, that is mental suffering. There is no statistical patient data from Balaji, or apparently from any other Indian healing shrines, on prior and ongoing psychiatric treatments. In this chapter, three accounts of help-seeking illustrated some possible patterns, for instance simultaneous use of both psychiatry and traditional healing. The extensive study by Halliburton (2004) in Kerala, showed how psychiatric patients could circulate in any order between modern psychiatry, Ayurvedic healing and religious shrines. It would be relevant to know more about treatment choices and patterns of psychiatric patients in North India with appropriate methods and patient cohorts. The pilgrimage settings of Balaji provides a culturally valued, supportive and nonstigmatizing atmosphere for many people suffering mentally. The local idiom of spirit illness and its treatment – when acceptable to patients and their families – tends to reduce stigma and empower positive family resources. Moreover, today in Balaji professional consultations

NOTES

163

of a large number of healers, specialists of treating spirit illnesses, are available for the suffering patients and their families. Like the patients, most healers came from outside Rajasthan; mainly from urban areas of North India, especially from Delhi and its surroundings. Healers studied in Balaji were serious professionals whose work could be characterized in Western terms as culturally relevant traditional family and group psychotherapy. Their role is central in the present healing culture of Balaji (Pakaslahti, 1998, 2004, 2005, 2006). Little explored healer networks may exist also elsewhere in connection with other shrines in India (Cohen, 2005), but these await ethnographically sensitive psychiatric research. It is concluded that in medically pluralistic modern societies such as India, traditional healing for mental disorders can be a culturally vital and valid component of health-seeking behavior. For better understanding of the complex issues and questions involved, planning, starting and implementing of multidisciplinary empirical research projects is needed.

NOTES 1. This is the common anglicized spelling. Also Mehandipur and Menhdipur occur. 2. Another recently hugely popular pilgrimage place of Hanuman in Rajasthan, the Salasar Balaji is also sometimes called simply Balaji. In 2004, I did not find there treatments of spirit illness. 3. Many of these shrines are taken care by Shaivite priests of Nath and Yogi families. Some of the folk deities, such as Guru Gorakhnath and Gogaji are syncretistic, worshipped by both Hindus and Muslims in North India. An unverified story tells that there was a Muslim Shrine on the hilltop in Moghul times. 4. The oldest existing temple structure of the Mehndipur valley, off the beaten track is a beautiful, possibly eighteenth century Krishna-Narasinha temple whose priest practices hereditary healing skills for the local Meena community, almost unknown to outsiders. See also note 6. 5. For instance, interestingly, 5 km as the crow flies from Balaji, I found, on a hilltop, the tomb (darga¯h) of a Muslim saint called ‘Balapir’. 6. A village elder of a local Meena community told me that Ganeshpuri had been invited by them to Mehndipur. I found his ancestral family shrine 20 km away from Mehndipur, in the place indicated by him. 7. For the village pantheon, see Seeberg, 1992; Pakaslahti, 1998; Dwyer, 2003; Lutgendorf 2007, pp. 262–270. 8. There are a number of other local synonyms (hava¯, u¯parı¯ cakkar, etc.) Afflicting spirits are not seen in Hindi as ‘malign’ but basically as ‘unhapppy’ beings in search of release from ghostly existence. An extensive discussion of spirit terminology and concepts based on textual analysis is found in Pakaslahti (2008). 9. The temple rituals, devotional services and main deities are described elsewhere (Pakaslahti 1998). 10. One could see in Mehndipur psychotic patients chained by their families. They were taken to devotional services in the temple but usually not to healers who treated less severe cases. 11. Mostly Vaishya, the traditional merchant caste (varn..a). 12. These could be considered as ‘middle class’; of the others, 26% were students and 24% housewives whose social class was not estimated. 13. Sufi healers of Muslim shrines (darga¯h) commonly visited also by Hindu patients, such as Matka Pir and Panch Pir in Delhi, Sagar Tal in Badayun and so on. (Pakaslahti unpublished field research).

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14. As 89% had visited allopaths, 11% had not done so; 62.5% had visited traditional healers. Therefore, at least 51.5% had visited both (62.5 – 11.0 ¼ 51.5). 15. The term ‘doctor’ used by healers, patients and families usually refered to allopathic rather than Ayurvedic and homeopathic practitioners. 16. Names changed. 17. Interviews were open-ended and semi-structured, with elements from PSE-SCAN (Wing et al., 1990) and EMIC (Weiss 1997); all were at least partially audiotaped or videotaped. 18. He was, in fact, the highly esteemed Ramjilal mentioned previously as the last practicing disciple of the charismatic healer priest Ganeshpuri.

REFERENCES Agarval, S.P., Goel, D.S., Icchapujani, R.L. et al. (eds) (2004) Mental Health: An Indian Perspective 1946–2003. Ministry of Health and Family Welfare (Govt. of India), 544. Available at: http:// mohfw.nic.in. Bhugra, D., Gopinath, R. and Bhintade, R. (2004) Mental health of Indians in the UK, in (eds S.P. Agarval, D.S. Goel, R.L. Icchapujani, R.N. Salhan and S. Shrivastava) Mental Health: An Indian Perspective 1946–2003, Ministry of Health and Family Welfare (Govt. of India), pp. 249–55. Available at: http://mohfw.nic.in. Campion, J. and Bhugra, D. (1997) Experiences of religious healing in psychiatric patients in South India. Soc Psychiatr Epidemiol, 32(4), 215–21. Carrin, M. (ed.) (1999) Managing Distress – Possession and Therapeutic Cults in South Asia. Manohar, New Delhi. Carstairs, G.M. and Kapur, R.L. (1976) The Great Universe of Kota. Hogarth Press, London. Chadda, R.K., Agarwal, V., Singh, M.C. and Raheja, D. (2001) Helpseeking behaviour of psychiatric patients before seeking care at a mental hospital. Int J Soc Psychiatry 47(4), 71–8. Channabasavanna, S.M., Raguram, R., Weiss, M.G. et al. (1993) Ethnography of psychiatric illness. NIMHANS J, 11(1), 1–10. Channabasavanna, S.M., Sriram, T.G. and Kumar, K. (1995) Results from the Bangalore Centre, in ¨ stu¨n and N. Sartorius). Mental Illness in General Health Care: an International Study (eds T.B. U John Wiley and Sons Ltd, Chichester, pp. 79–97. Cohen, D.J. (2005) Narrative healing: ghost exorcism and memory. Doctoral dissertation. University of Virginia: Department of Anthropology. De Sousa, A. and De Sousa, D.A. (eds). (1984) Psychiatry in India. Bhalani Book Depot, Bombay. Dein, S. and Sembhi, S. (2001) The use of traditional healing in South Asian psychiatric patients in the U.K.: Interactions between professional and folk psychiatries. Transcult Psychiatry, 38(2), 243–57. Desjarlais, R., Eisenberg, L., Good, B. and Kleinman, A. (1995) World Mental Health. Problems and Priorities in Low-Income Countries. Oxford University Press, New York – Oxford. Dwyer, G. (2003) The Divine and the Demonic: Supernatural Affliction and Its Treatment in North India. Routledge and Curzon, London & New York. Freed, R.S. and Freed, A.F. (1993) Ghosts. Life and Death in North India. University of Washington Press, Seattle. Gangolli, L.V., Duggal, R. and Shukla, A. (2005) Review of Healthcare in India. Cehat, Mumbai. Halliburton, M. (2004) Finding a Fit: Psychiatric pluralism in South India and its implications for WHO studies of mental disorder. Transcult Psychiatry, 41(1), 80–98. ICD-10. (1992) Classification of Mental and Behavioural Disorders. WHO, Geneva. Jadhav, S. (1995) The ghostbusters of psychiatry. Lancet, 345, 808–9. Kakar, S. (1982) Shamans, Mystics and Doctors. Unwin, London, pp. 83–86. Kalyan Shri Hanuman Ank. (1992) (A Hindi compendium on Hanuman). Gita Press, Gorakhpur. Kapur RL. 1979. The role of traditional healers in mental health care in rural India. Sos Sci Med, 13b, 27–31.

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Kapur, R.L. (2004) The story of community mental health in India, in (eds S.P. Agarval, D.S. Goel, R.L. Icchapujani, R.N. Salhan and S. Shrivastava). Mental Health: An Indian Perspective 1946–2003. Ministry of Health and Family Welfare (Govt. of India), pp. 92–100. Available at: http//mohfw.nic.in. Kleinman, A. (1980) Patients and Healers in the Context of Culture. University of California Press, Berkeley. Leslie, C. (1998) Introduction, in (ed. C.C. Leslie) Asian Medical Systems: A Comparative Study. Motilal Banarsidass, Delhi, 3, pp. 1–17. Lutgendorf, P. (2007) Hanuman’S Tale – the Messages of a Divine Monkey. Oxford University Press, New York. McGregor, R.S. (1993) The Oxford Hindi-English Dictionary. Oxford University Press, Delhi. Neki, J.S. (1973) Psychiatry in South-East Asia. Br J Psychiatr, 123, 257–69. Pakaslahti, A. (1996) Temples and healers. Traditional treatment of psychiatric patients in India. (video) Book of Abstracts. X World Congress of Psychiatry. Madrid, August 23–28. Pakaslahti, A. (1998) Family-centered treatment of mental disorders at the Balaji temple in Rajasthan, in (eds A. Parpola and S. Tenhunen) Changing Patterns of Kinship and Family in India. Studia Orientalia 84. the Finnish Oriental Society. Gummerus, Helsinki, pp. 129–66. Pakaslahti, A. (2000) Research and scientific advisor in J.Aaltonen. Kusum – a Documentary Film of Healing. Illume, Helsinki. Pakaslahti, A. (2001) Ritual possession trance and dissociative disorder: a cross-cultural comparison. World Psychiatric Association: Transcultural Psychiatry Newsletter/Autumn. Pakaslahti, A. (2004) Plato’s cave: on techniques of traditional healers and some western reflections. An ethnopsychiatric study from India. Abstracts of 6th Annual Advanced Institute on Cultural Psychiatry. June 3 & 4, Montreal. Pakaslahti, A. (2005) Traditional healers as culturally accepted/sanctioned mental health practitioners, in (eds S. Malhotra, S. Sharan, N. Gupta and A. Malhotra) Mental Disorders in Children and Adolescents. Need and Strategies for Intervention. CBS Publishers and Distributors, Delhi, pp. 215–29. Pakaslahti, A. (2006) Transcultural vignettes of spirits and psychiatry (in Finnish), in Ajattelen – Olen Siis Psykiatri (eds J. Korkeila, M. Heinimaa and T. Svirskis). Duodecim, Helsinki, pp. 38–69. Pakaslahti, A. (2008) Terminology of spirit illness: an empirical study from a living healing tradition, Vol 7, in Mathematics and Medicine in Sanskrit. Papers of the World Sanskrit Conference 2003 (ed. D. Wujastyk). Motilal Banarsidass Publishers, Delhi, pp. 155–92. Pfleiderer, B. (1988) The semiotics of ritual healing in a North Indian Muslim shrine. Soc Sci Med, 27(5), 417–24. Raguram, R., Venkateswaran, A., Ramakrishna, J. and Weiss, M.G. (2002) Traditional community resources for mental health: a report of temple healing from India. Br Med J, 325, 38–40. Satija, D., Singh, C.D., Nathawat, S.S. and Sharma, V. (1981) A psychiatric study of patients attending Mehandipur Balaji temple. Indian J Psychiatry 23(3), 247–50. Satija, D.C. and Nathawat, S.S. (1984) Psychiatry in Rajasthan, in Psychiatry in India (eds A. De Sousa and D.A. De Sousa). Bhalani Book Depot, Bombay, pp. 119–60. Sebastia, B. (2007) Les Rondes De Saint Antoine: Culte, Possession Et Troubles Psychiques an Inde Du Sud. Aux lieux d’eˆtre, Montreuil. Seeberg, J. (1992) Sankatfolk (in Danish) Moesgaard: Aarhus University. Skultans, V. (1987) Trance and the management of mental illness among Maharashtrian families. Anthropol Today, 3(1), 2–4. Smith, F. (2006) The Self Possessed – Deity and Spirit Possession in South Asian Literature and Civilization. Columbia University Press, New York. Sri Balaji Maharaj Ghata Mehandipur Trust. No date. (Accessed 21 November 2007). Available at: http://Balajimehandipur.org. Varma, V.K. and Wig, N.N. (2002) Mental health services for developing countries. Presentation held at the XII World Congress of Psychiatry August 24–29. Official Congress Abstracts. Weiss, M.G. (1977) Critical Study of Unmada in the Early Sanskrit Medical Literature: An Analysis of Ayurvedic Psychiatry With Reference to Present-Day Diagnostic Concepts. Doctoral dissertation, University of Pennsylvania, Philadelphia.

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Weiss, M.G., Sharma, S.D., Gaur, R.K. et al. (1986) Traditional concepts of mental health disorder among Indian patients: preliminary report of work in progress. Soc Sci Med, 23(4), 379–86. Weiss, M.G., Desai, A., Jadhav, S. et al. (1988) Humoral concepts of mental illness in India. Soc Sci Med, 27(5), 471–7. Weiss, M.G., Isaac, M., Parkar, S.R. et al. (2001) Global, national, and local approaches to mental health: examples from India. Trop Med Int Health, 6(1), 4–23. Weiss, M.G. (1997) Explanatory model interview catalogue: Framework for comparative study of illness experience. Transcult Psychiatry, 34, 235–63. Wing, J.K., Babor, T., Brugha, T. et al. (1990) SCAN. Schedules for clinical assessment in neuropsychiatry. Arch Gen Psychiatry, 47(6), 589–9.

CHAPTER 13

Anxiety, Acceptance and Japanese Healing The Role of Traditional Healing in Japanese Mental Health Fumitaka Noda Professor of Psychiatry Department of Human Welfare, Faculty of Human Studies, Taisho University, Tokyo, Japan; Adjunct Professor, University of British Columbia, Vancouver, Canada

Abstract Japanese society tends to be summed up by its vertical structure, collectivism and maternal principle of embracing all. Japanese psychology is characterized by consideration for others and mutual amae [dependence] based on concepts such as giri[sense of obligation] and ninjyo [humane empathy]. People living in this society that demands sensitive attention to interpersonal relations always feel anxious as to how best to conduct themselves. Their anxiety is not clear-cut or logical. Consequently the way to deal with it is influenced by the Japanese religious climate, which embraces much ambiguity and offers healing. Morita therapy, often used for treating anxiety will be discussed as an example. Drawing from Zen Buddhism, Morita therapy essentially helps people accept their destiny. In addition, the way people and traditional healers coexist reveals uniquely Japanese ambiguity and wisdom for accepting life as it is. Through these descriptions I hope to illustrate how healing and salvation work for Japanese.

13.1

INTRODUCTION

This chapter does not discuss the direct collaboration between traditional healers and psychiatrists in Japan. It is my intention to deal with how the Japanese cultural climate, and especially its religious aspect has characterized psychiatry in this country. In considering Taijin Kyofusho (TKS or anthrophobia), a Japanese culture-bound syndrome, ‘anxiety’ is pointed out as a very important pathological factor in the Japanese cultural climate. Feeling ‘anxiety’ is ultimately what prompts sufferers to seek consultation Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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with traditional healers and/or psychiatrists. Whether the treatment for anxiety should aim for ‘healing’ or ‘salvation’ is a major issue in Japan. It seems that there is a difference between the Western and Japanese attitudes as to how anxiety should be conquered. Should it be ‘battled with’ or ‘accepted’? Through discussion of these issues I hope to examine what traditional healing means in the Japanese psychiatric landscape.

13.2

JAPANESE PSYCHOLOGY

Let us first explore key concepts and characteristics that provide some insight into understanding the Japanese psychology. Since the end of the closed-door policy of the Shogun period and particularly since the beginning of Meiji era (1868) Japan has been exposed to Western civilization, which has led to the formation of a national identity. There have been many theories about Japanese identity. The Chrysanthemum and the Sword is perhaps the seminal work for contemporary theories (Benedict, 1946). It was based on research on Japanese culture and personality by an American anthropologist during World War II, and was conducted with the methods of cultural anthropology. It was an attempt to ‘assume what Japanese is by examining commonplace behaviour of everyday life’. Particularly noteworthy in this work is the author’s juxtaposing of the Occidental Christian culture as ‘the culture of sin’, and the Japanese counterpart as ‘the culture of shame’. Benedict viewed Japanese behavioral codes as being controlled by ‘the perception of others’ rather than ‘inner rules’. She concluded that fealty, filial piety, giri [sense of obligation], ninjyo [humane empathy] and such, the by product of the Japanese hierarchical system, played an important role in the life of Japanese people. There have been many other theories about Japanese identity. Some of the representative views on ‘Japanese psychological characteristics’ were offered by NAKANE, Chie. From the vantage point of cultural anthropology, she argued that ‘Japan is a vertical society operated by vertical organizations and with a developed sense of hierarchy’ (Nakane, 1970/ 1972). She also pointed out that; ‘Unlike Western societies based on individualism, Japanese society is characterized by collectivism, and its emphasis is on unifying. The sociological unit is represented by ‘‘ie [family]’’ ’ (Nakane, 1972). KAWAI, Hayao applied Jungian psychology to observing Japanese society and concluded that it is a ‘maternal society’. He explained the group-oriented nature of the society by concluding that Japanese psychology is shown through the function to ‘embrace’ and is characterized by maternity that encompasses everything with absolute fairness (Kawai, 1972). KIMURA, Bin, a philosopher and psychopathologist pointed out ‘the bloodline identity held by Japanese’ and explained giri ninjyou by referring to the importance of the interpersonal relationships emphasizing psychological space between people (Kimura, 1972). With the background of psychoanalysis DOI, Takao came up with the key concept of ‘amae [dependence]’ for understanding Japanese mentality and discussed giri [sense of obligation] and ninjyo [human feelings], as well as inside/outside differentiation (Doi, 1973). As seen above, despite significant changes in the contemporary era, the main psychological characteristics of Japanese culture have basically remained the same; valuing group-oriented behavior rather than individuality; being loyal to a group; valuing the effort to protect its hierarchy (vertical society); propensity to ‘dependence’ rather than independence; and having affinity toward ‘maternal’ rather than ‘paternal’ ways. The

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concept of ‘inside/ outside’ is another crucial characteristic influencing interpersonal relations, where relationships are categorized as either ‘inside’ or ‘outside’. In the ‘inside’ relationship one can be frank and unreserved, while with the ‘outside’ relationship one has to be polite and reserved. There are further subcategories for ‘outside’ relationships. Business relations and acquaintances have more ‘inside’ flavor compared with total strangers, who are on the outer edge. With the former, one need not bother practicing ‘enryo [restraint]’. Ultimately Japanese people are constantly aware of having to gauge their distance from others (Doi, 1973). Thoughtfulness is the essence of Japanese wisdom on how to survive living in restricted spaces, in a densely populated country and in coexisting with society/community. It is the wisdom needed to live in harmony with, and without bothering others. To that end, being too assertive is resented. Rather, in order to survive in this society, Japanese must do so through the art of reading each other’s minds, and by accepting the kindness of others graciously, while allowing others to expect their non-verbalized needs to be met at the same time. What is valued in the meantime is to keep the right psychological distance so as not to intrude upon the others’ sphere of privacy. In order to be thoughtful, polite and accepting of kindness of others, one must have a keen sense for constantly detecting what others are thinking and feeling. The spirit of Japanese hospitality lies not in asking others what they want to do or what they would like to eat, but in correctly guessing what others want to do or what they wish to eat and offering it to them. For instance, at a traditional Japanese inn (ryokan) a guest is served green tea upon arrival, and a hot bath would be already drawn and ready for him/her. They are offered not because the guest has requested or demanded those services, but because of anticipating the guest’s wishes. At some exclusive restaurants, instead of creating a menu and taking orders from the menu items listed, the chef would rely on their observation of the customers in choosing what to serve. This style derives from the spirit of ‘thoughtfulness’ with which one tries to read the minds of others and offers what seems to be most suitable for them. Instead of greeting someone with ‘How are you?’ the Japanese often use ‘Otsukare sama [you must be tired]’. This is an expression of thoughtfulness, asking others if they are tired from work or entertaining clients. In saying ‘How are you?’ one is directly asking how the other is feeling, but there is no inference. In ‘Otsukare sama’ one is making a guess about how the other is feeling. In fact Japanese people frequently use the word ‘tired’ in a variety of ways. The expression seems to represent Japanese idioms of distress. What then tires the Japanese so much?

13.3

JAPANESE ANXIETY

The fatigue felt by the Japanese is caused by psychological distress rather than physical. The Japanese tendency for being considerate of others’ thoughts and feelings is prone to cause interpersonal anxiety. In the Japanese cultural climate being able to read others’ needs is an important virtue. It is the ability to guess and then grant non-verbalized wishes of others. An example of such virtue is to casually ask for an opinion from someone who does not say anything at a meeting. The assumption is that the silent individual does have something to say but is exercising ‘enryo [restraint]’ by not expressing it. To guess that and offer that person an opportunity to speak is regarded as providing a way for that person to

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save face and to show respect. If one is not good at reading the minds of others like that, one is exposed to criticism as ‘not thoughtful’ or ‘insensitive’. To my knowledge, this Japanese virtue is not highly valued in Western societies. If someone remains quiet, it is considered to be their own choice and decision, and it is assumed that the person will speak when ready to do so. The very act of worrying about that person’s ‘enryo [politeness]’ would be considered as an interference with the autonomous mind of another individual. In a society that operates under this kind of Japanese value system one must be constantly aware of one’s own degree of ‘thoughtfulness’, and must always make sure that it is calibrated properly. If you are ‘too thoughtful’ you run the risk of being called intrusive, and if you are ‘not thoughtful (enough)’ you could be labeled as insensitive. People in this society live with a high level of anxiety concerning their relationships with others. Those with a sensitive demeanor are more prone to illness caused by anxiety. Taijin kyofusho TKS or anthrophobia, one of the culture-bound syndromes of this society, is a typical example. One of the characteristics of this syndrome is phobia of eye contact. It is not the fear of others’ eyes, but the fear of the possibility that one’s ‘own gaze could be hurting others’. Those who suffer from this fear do not have piercing or ferocious eyes at all, but tend to be timid and reserved people. To put it more forcefully, Japanese existence is haunted by anxiety. To live with that anxiety is ‘tiring’. To face and deal with that anxiety is also ‘tiring’. In order to process that anxiety properly we need explanatory models. The religious climate of the country nurtures such models.

13.4

THE RELIGIOUS CLIMATE OF JAPAN

In general, Japanese are not devoutly religious. Though it is said that most Japanese believe in Mahayana Buddhism, very few actually practice their faith deeply in day to day life. Religious protocols are adhered to mostly at significant life events, especially at funerals. This does not, however, contradict the fact that the influences of Buddhism and Shintoism are deeply rooted in Japanese lives. Though we do not submit ourselves to the Buddha or gods, we are taught to revere them. We are told that Buddhist and Shinto deities symbolize ancestral spirits, and taking them lightly could result in divine punishment. Even if we feel such a thought is unscientific, we make a habit of visiting and praying at shrines and temples every now and then. Obon and New Year are two major events in the Japanese calendar. Obon is usually celebrated for three days around August 15 although there is a slight variation depending on the region. It is the time for corporate holidays across the country, and many people return to their hometown. Obon is the time when the ancestral spirits are believed to return to the family in this world. Little torches called Mukaebi [welcoming and guiding fire] are lit along the path from the gate to the door of the house. By lighting the way it is hoped that the ancestral spirits won’t get lost. At the end of Obon, Okuribi [fire for send-off] is lit to guide the spirits back to the other world. In some areas Okuribi are put into lanterns and floated down the river. Called Toronagashi, it is a beautiful summer sight in this country. Around Obon many large festivals are held in different areas enticing people to enjoy themselves and participate in Bonodori [Obon dance]. The festivals have the purpose of praying for good weather, bountiful harvest,

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health and happiness. Over Obon people make visits to family graves, to pray for their relatives. Many employ monks to chant Buddhist sutras. It is a time when this world and the other world commune with each other. In other words, the dead and the living are believed to mingle together and enjoy each others’ company. It is a celebration both for those of this world and those who have passed on. Obon is a symbolic event that shows how Japanese incorporate their ancestors into their lives. It is closely related to the Buddhist background of Japan. New Year’s celebration is also a major national event. People take the notion of a ‘new year’ very seriously, and wish to get rid of all the grime of the old self from the former year and to start a new self with the new year. It is customary to pray to the Buddhist and Shinto deities for protection and good luck in the new year. The period from the evening of December 31 to the beginning of January is very meaningful, and much of the population visits shrines and temples at that time. They pray and purchase items such as an arrow to fend off evil spirits and a variety of talismans. Those who were not lucky in the previous year sometimes arrange for a Shinto ‘ritual of purification’, hoping to shed the bad luck of the year just passed. It is not as if everyone believes in the scientific value of these things, but they are practiced almost like rites of passage from one year to another. Most of the rituals over the New Year’s celebration are of Shinto background, which attests to the Shinto culture of this nation. Buddhism was started by the Buddha in India and was brought to Japan in the sixth century via China and Korea. Shinto is an inherently Japanese religion with its origin in Japanese mythology, and is said to be at the root of the Imperial Family. In the modern era Japan Buddhist temples and Shinto shrines merged; temples and shrines coexist on many grounds and premises. People pray at both, and in many cases do not even distinguish between the two. There is a saying: ‘Man turns to god only in trouble’. The general idea here is that the ‘god’ could be either the Buddha or a Shinto god. Seen from another perspective, this ambiguity lived by Japanese can also be labeled as the ability to ‘embrace all’. Because of this tendency, the gods Japanese turn to readily encompass new religions, including the ones that emerged after the mid nineteenth century, as well as traditional healers such as shamans. In a way, Japanese religions do not have a strong presence in Japanese society; neither Buddhism nor Shintoism assert themselves loudly. They are unlike Christianity or Islam in terms of the tenacious spirit of missionary work. In the Japanese religious climate, and I am not referring to the religions themselves here, there is no clear and firm logic for how things should be. There are only a few commandments guiding how life should be lived. The religious climate accepts and embraces human existence itself, and is just there like the wind. SHINRAN (1173–1263), the founder of the Jodo-Shin [True Pure Land] Buddhist sect stated in Tannishou, a collection of his works: ‘Even a good person attains birth in the Pure Land, so it goes without saying that an evil person will’ (Jodo, 1997). This seemingly illogical logic exemplifies the spirit of mercifulness and salvation. Zazen or meditation is a well known element of Zen Buddhism. The Japanese do not practice it in their daily lives. It is however, reflected in the traditional Japanese arts and culture such as the tea ceremony, flower arrangement, Noh drama, haiku and ink brush painting. There is no question that the religious climate of the country has contributed to the formation of Japanese cultural norms mentioned earlier including giri, ninjyo, loyalty, amae and enryo [restraint].

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When a Japanese person faces anxiety in this religious climate they lack firm ‘logic’ on how things should be. Japanese people tend to harbor roundabout anxiety as observed in the case of worrying about how eye contact could hurt others, rather than suffering from the more direct anxiety of hurt from the other person’s gaze, for instance. It follows that it is difficult for the Japanese to eliminate anxiety.

13.5

LOCAL TREATMENT (MORITA THERAPY)

Most Japanese people being treated for anxiety receive the benefits of contemporary drug treatment, psychotherapy or cognitive behavioral therapy. Here, I wish to introduce a uniquely Japanese therapy that has affinity with the above mentioned religious and cultural climate of this country. It is because of its affinity with Japanese cultural traditions and norms that Morita therapy seems to function well as an example of how Japanese face anxiety. Morita Therapy was devised by a psychiatrist named MORITA, Shoma (1874–1938). It is reported that Morita himself suffered from a neurosis he named Morita Shinkeishitsu. It is similar to social anxiety disorder as described in DSM-IV. Shinkeishitsu as used here, however, refers to the intensification of typical Japanese characteristics such as scrupulousness, shyness, self-reflection, attachment and desire to live better (desire for life). A person with this condition is prone to react oversensitively to their mental and physical condition or changes (Morita called it ‘hypochondriac base’). As a result the person becomes fixated on very normal physiological conditions; for example, a heavy feeling in the abdomen right after a big meal, or feeling palpitation after exercising. The harder they try to clear that condition, the more attention is focused on it. Consequently they feel extremely sensitive about those organs, which increases the anxiety level, and the sense of discomfort actually intensifies around the particular organs of concern (‘mind-body interaction’). Under such conditions, they become fixated on the notion of how things must be, leading to a discrepancy with the reality of the situation and the significance of the symptoms. This discrepancy in thought intensifies fixation and causes so-called Shinkeishitsu symptoms. Observing that the harder one tries to clear this kind of anxiety, the more preoccupying it becomes, Morita termed it toraware [fixation]. He felt that the only way to break free from fixation was to live with it, and came up with a series of behavioral therapies called Morita Therapy. The original method consisted of different phases spent at a treatment centre; an initial period of absolute rest when one does nothing but lie in bed, then a period of light work, followed by a period of normal work. In the first period of doing nothing but lying down, one is faced squarely with the anxiety and fixation. Through that experience the person starts feeling tired of being a person overwhelmed by the fixation and feels the urge to do something. This budding interest is called ‘desire for life’. One starts finding pleasure in being able to carry out light work such as minor housekeeping, and begins to be gradually freed from the fixation. Through experiencing the following work period, the person gets exposed to the world outside, and regains the normal emotional range that had been lost because of the fixation. In that process emerges a paradoxical awareness that accepting reality ‘arugamama [as is]’ is the way to ultimately ease the anxiety. The goal of Morita Therapy is not to clear away the symptoms, but to learn to live with the symptoms with the sense of ‘arugamama [as is]’.

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Another purpose is to restore and empower the ‘desire for life’ and ‘strength for life’ that the anxiety had clouded over. To learn that anxiety itself is the ‘ability to live’ is crucial. (Ishiyama, 1986; Kora, 1965; Kondo, 1953; Morita, 1983; Reynolds, 1976) Particularly worthy of note about Morita Therapy is that the therapist never asks about or discusses the inner psyche of the client. No matter how persistent the client is in trying to steer the discussion in that direction, the therapist must avoid discussing it. They only act as a mediator for the client to learn a sense of ‘arugamama [as is]’ with conviction through experiencing lying down and working, and through the passage of time. Although Morita himself does not refer to it, there is much in common between the spirit of Zen and Morita therapy. SUZUKI, Daisetsu is one of the best known contributors to the introduction of Zen to the rest of the world. He described Zen as follows (Suzuki, 1938): 1. Its concentration on the spirit leads to the neglect of form. 2. Or, rather, it detects in any form of description the presence of the spirit. 3. Deficiency or imperfection of form is held to be more expressive of the spirit, because perfection of form is likely to attract one’s attention to form and not to the inner truth itself. 4. The deprecation of formalism, conventionalism or ritualism tends to make the spirit stand in all its nakedness or aloneness or solitariness. 5. This transcendental aloofness or the aloneness of the absolute is the spirit of asceticism, which means the doing-away with every possible trace of non-essentials. 6. Aloneness translated in terms of the worldly life is non-attachment. 7. When aloneness is absolute in the Buddhist sense of the word, it deposits itself in all things from the meanest weeds of the field to the highest form of nature. The spirit expressed here is none other than the attitude to accept arugamama [as is] as arugamama, without being influenced by form or decoration. Western psychotherapy as represented by psychoanalysis uses the method that leads the client to arrive at the ‘nature of the inner issues’ through the process of facing one’s inner self. The psychoanalyst focuses on how to best help the client find their inner self. The process is through words. Morita Therapy, on the other hand, does not regard words as important. The Morita therapist only assists their clients in experiencing the state of nonattachment described by Suzuki. This method could be placed at the opposite pole from Occidental ‘logic’. As we have seen, the Japanese cultural climate is not tortured by logical matters. Anxiety cannot be conquered by logic. Japanese psychiatrists dealing with clients’ anxiety in such a cultural climate have no choice but to recognize the effectiveness of the concepts and attitudes typified by Morita Therapy, while concurrently taking advantage of Western psychotherapy.

13.6

COEXISTENCE WITH TRADITIONAL HEALERS

In the 1980s, when I was involved in providing mental health care as a psychiatrist in Vancouver, Canada, a young woman from one of the remote islands of Okinawa in Japan came to see me. My recollection is that she suffered from bipolar disorder. While I was treating her, strange things often happened. At the end of each meeting we would agree on

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the next step of the treatment, and yet she would sometimes cancel the next meeting all of a sudden, change her mind about taking medication or suggest a totally different method of treatment. She was an intelligent and reliable person, so after experiencing many incidents like that, I asked her to explain what was happening. She hesitantly told me that along with my treatment she was talking to a shaman, called a yuta practicing back home in Okinawa. The reason she frequently changed her opinion about treatment was because she was influenced by what her yuta was telling her. I had heard about the existence of female shamans called by that name in Okinawa and how they possessed unusual abilities that attracted many people to seek their help. This was the first time I was made aware of the presence of shamans who could even affect people living outside the country. What interested me most about this case was the attitude of the patient. I detected her ambivalence. She seemed to want to use suggestions made by both myself and the yuta. She acknowledged that she was ‘ill’, and therefore felt the need for treatment by a psychiatrist like myself. At the same time she was not convinced by my explanation about why she was ill or how her illness developed. It was hoped that she would recover if a good and convincing explanation for these questions was offered. And that was what she was seeking from the traditional healer she consulted. I never heard what her yuta said. I guessed that she would have probably suggested that the patient stop using the medications I had prescribed, in favor of alternative medicine. It is not clear why my patient did not follow such advice. It could be that it didn’t conform with her own way of thinking about scientific matters. It could also be that she decided to take only the spiritual aspect of the yuta’s advice. This might have consisted of doing something to appease the ancestral spirits or to donate to a religious organization. I was young then, and to be honest, I was not pleased with the simultaneous intervention of a yuta who hindered the treatment I prescribed. Looking back now though, I feel the impressive power of the yuta who gets consulted even by those living abroad. The more I learn about the support for yuta by Okinawans, the more importance I find in the role they play as highly respected and trusted consultants in Okinawan society. The results of research conducted by RHI, Bou-Yong show how hospitalized patients with schizophrenia came to the psychiatric department for treatment; namely if they came directly, or following other medical or non-medical treatment. This research was conducted at the request of the World Health Organization in the Western Pacific area with the focus on East Asia (Rhi, 1995). The area included the provinces of Hunan and Sichuan in China, as well as Japan, South Korea, Malaysia and the Philippines. The results show that the ratio of people who seek psychiatric treatment from the beginning is 75% in Japan; 39.6% in South Korea; 32.5% in Hunan Province; 26.8% in the Philippines; 25.8% in Sichuan Province; 9.4% in Malaysia. Compared with their counterparts in other countries, Japanese patients tend to seek psychiatric treatment right away, and not many visit nonmedical caregivers or practitioners of traditional alternative medicine. Only 4.7% of the Japanese patients consulted shamans, compared with 30.4% in South Korea, 65.8% in Malaysia and 52.6% in the Philippines. It must be pointed out, however, that the data for Japanese patients was collected exclusively in Tokyo (Rhi, 1995). MIYANISHI, Teruo et al. conducted similar research at Wakayama Medical University in Wakayama prefecture in western Japan. Their results were quite different from those mentioned above. In 1981 and 1991 they interviewed outpatients who visited the Department of Psychiatry at this university hospital regarding their use of traditional healers. In the 1981 research (N ¼ 117), 55% of the interviewees and 58% of schizophrenia

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Table 13.1 Types of traditional healers consulted by psychiatric outpatients.

Traditional religion Modern new religion Contemporary new religion Shaman

1981

1991

40% 41% 2%

5% 41% 14%

12%

19%

patients consulted traditional healers before visiting a psychiatrist. Twenty-eight percent of all the interviewees and 31% of the schizophrenia patients continued to see traditional healers even after they started to receive psychiatric treatment. The results of the 1991 research (N ¼ 112) were not much different; 54% of the interviewees and 56% of the schizophrenia patients consulted traditional healers before seeking psychiatric help, and 35% of the interviewees and 42% of the schizophrenia patients continued to visit traditional healers along with receiving psychiatric treatment. To the question if they thought traditional healers were effective or not, 51% answered ‘Yes’ in 1981, and 56% said the same in 1991. The kinds of traditional healers they visited in respective years were shown in Table 13.1 (Miyanishi, 1995). Compared to big cities like Tokyo, places like Wakayama Prefecture and Okinawa have their own local cultural climate. In such areas, more patients appear to trust and visit traditional healers both prior to and after starting psychiatric treatment. In addition, in Japan people tend to seek opinions of religious practitioners rather than shamans. Until the 1980s Buddhist monks and Shinto priests of traditional religions were mainly consulted. Since the 1990s, modern new religions that were established after the mid nineteenth century, as well as contemporary new religions that emerged after World War II, have appeared to gain adherents. However, the research by NAKA, Koich about Okinawa had different results. He reported that 50–80% of psychiatric patients or their families consulted yuta, Okinawan shamans, before and after psychiatric treatment (Naka, Toguchi and Takaishi, 1985) It is most interesting that many of the people acknowledge the effectiveness of traditional healers though they receive psychiatric treatment at the same time. An old Okinawan saying: ‘Half by doctor, and half by yuta’ indicates that people do not believe 100% in either psychiatrists or yuta. It shows that people pick and choose who to consult depending on the circumstances and symptoms of their disorders. It is believed that one can turn to a yuta only after they experience a state of being possessed, thereby gaining prophetic ability. The trance-like state is called kamidari and in Okinawan language it literally means ‘god descends’. The political authorities of Okinawa were afraid that the positive reputation of yuta would cause confusion, and persecuted them from the beginning of the twentieth century until after World War II. The tradition of yuta was not eradicated however, and is still alive and well in the cultural climate of Okinawa today. This must be due to the fact that people regard yuta as doing half of the job of healing, as the above saying goes. It can be said that a yuta is someone who has experienced illness herself. OHASHI, Hideshi, a renowned researcher of yuta has described in detail the process of becoming a yuta. It closely resembles the onset of schizophrenia (Ohashi, 1998). In fact there are

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some reports from psychiatrists about being consulted by such yuta in the making, who cannot stand the mental and emotional stress of the process of kamidari (Ishigaki, 1999). Yuta live on the border between sacredness and madness, and possess a transcendental power that attracts those in search of cures for their anxiety, it seems. As already seen with Morita Therapy, this is also a help-seeking behavior that goes beyond Western ‘logic’.

13.7

HEALING AND SALVATION

Up to this point I have discussed how Japanese deal with their ‘roundabout anxiety’. OE, Kenzaburo won the Nobel Prize for Literature in 1994. In his acceptance speech ‘Japan, the Ambiguous, and Myself’, he touched upon the ambiguity of the Japanese language and people (Oe, 1994). Ambiguity is rooted in the Japanese cultural climate in positive and negative ways. The fact people seek help from both medical professionals and traditional healers as seen in the popular aphorism: ‘Half by a doctor, and half by yuta’, is the embodiment of that ambiguity. But it is the resilient way of being for Japanese people who pursue healing and salvation at the same time. The ‘as is’ stance for treatment may appear nebulous and ambiguous from the Western logical point of view. There is something ambiguous about the Japanese anxiety itself that people in this country have to face. As discussed before in connection with ‘praying in times of trouble’, one aspect of ambiguity is comprehensiveness. I believe that the honest wish of Japanese patients faced with illness is to find convincing healing and salvation no matter how ambiguous the methods seem to be. Concerning this point DAIGUJI, Makoto argues: ‘Though religions bring healing as a by-product, they do no set out to achieve that as a goal’. I feel that religions represent some kind of worldview on human suffering or a salvation from it. Curing is only a by-product. Therefore, even if actual curing does not take place through religions, a patient who finds some sort of realization or interpretation that gives meaning to their life is led to salvation. It would be ideal if one could be cured by prayer, but even if that does not happen, acquiring the ability to live by accepting illness can turn into a kind of salvation. That sort of healing/curing and salvation is beyond medical treatment. (Daiguji, 1996)

After many years of treating both Japanese and Western patients, I am keenly aware of the cultural differences exhibited in interviews. It is not a simple matter to pinpoint the chief complaint from Japanese patients. To the question: ‘What is the problem?’ the patient could respond by prefacing the answer with ‘Actually, ten years ago . . . .’ Often the preface is not the direct cause of the issue, and it can take a long time before finding out that the patient is there because of insomnia that started a week before. This is because a Japanese patient tends to want to tell everything about themselves to the psychiatrist, and then obtain a diagnosis. Consequently the interview develops from the periphery to the inner core of the problem in a spiral form. On the other hand, a Western patient would start with the main point such as ‘I feel depressed’, and then expand the description from the core to the periphery. I cannot help detecting the differences among a variety of verbal cultures. Occidental people take great care when telling a story because of the belief that what is verbally expressed is all there is. Japanese people, brought up in a less verbally oriented

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culture, focus on telling it all rather than honing presentation skills on how to tell a story. As a result they tend to be long-winded and lack clarity. Given the limitation of time for interviews, that kind of attitude can be summed up as amae [dependence/indulgence]. Japanese patients would resent psychiatrists who try to summarize the story and get to the point by thinking, ‘This doctor does not listen’. How the psychiatrist draws out the issue is crucial with an Occidental patient, and there amae hardly materializes in interviews. A good psychiatrist must accept amae from Japanese patients, while clearly explaining the process and result to Occidental ones. Anxiety felt by Japanese is the tip of an iceberg that is a large ‘illness narrative’. It does not take a clear shape, but consists of various parts and facets. Some of them can be shared with medical practitioners, and some other parts with religious authorities or non-medical practitioners like shamans. The ‘illness narrative’ must be an intricate maze that starts with ‘Actually ten years ago . . .’ It cannot be told in a straightforward and logical manner. The only way to get the details is to go back and forth. It seems to me that psychiatrists and traditional healers share the responsibility of understanding the ‘illness narrative’ to the patients’ satisfaction and dealing with ‘roundabout anxiety’ or ‘ambiguous anxiety’. In that sense, we are here as catalysts who bring a certain gratification to the patients’ desire for healing and salvation.

ACKNOWLEDGMENT I acknowledge Dr MIYANISHI, Teruo for providing me with the result of his research work in Wakayama prefecture. I also acknowledge Dr Ronald Wintrob and Ms YAMANOUCHI, Etsuko who have helped me complete this manuscript.

NOTE 1. In Japan, names are spelled family name first, and capitalized, followed by first name. Therefore, I have followed the Japanese way of listing peoples’ names in this chapter.

REFERENCES Benedict, R. (1946) The Chrysanthemum and the Sword-Pattern of Japanese Culture, Houghton Mifflin Company, Boston. Daiguji, M. (1996) Kokoro no ‘yamai’ to kokoro no ‘iyashi’ – seishinigaku kara mita ‘iyashi to sukui’ no ichisokumen [‘Illness’ and ‘Healing’ of Mind: An aspect of Healing and Salvation seen from the Psychiatric Perspective], Toyo Bunka, 46, 97–115. Doi, T. (1973) The Anatomy of Dependence, Kodansha International Ltd., Tokyo. Ishigaki, H. (1999) ‘Shamanizumu teki fudo to seishinkai [The Shamanistic Climate and Psychiatrists]’, Bunka to Kokoro [Culture and Mind], 3 (1), 43–8. Ishiyama, F.I. (1986) Morita therapy: Its basic features and cognitive intervention for anxiety treatment. Psychotherapy, 23 (3), 375–81. Jodo, S.H. (1997) The Collected Works of Shinran Vol. 1, Honganji-ha Publishers, Kyoto. Kawai, H. (1976) Boseishakai Nihon No Byori [Pathology of Japan, a Maternal Society], Chuokoronsha, Tokyo. Kimura, B. (1972) Hito to Hito Tono Aida – Seishinbyorigakuteki Nihonron [Psychological Space Between People – Japan Seen From Psychopathological Perspective], Kobundo, Tokyo.

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Kondo, A. (1953) Morita therapy: a Japanese therapy for neurosis. American Journal of Psychoanalysis, 13, 31–7. Kora, T. (1965) Morita therapy. International Journal of Psychiatry, 1, (4), 611–40. Miyanishi, T. (ed.) (1995) La funci´on que desempen˜a la curandera folkl´orica japonesa en los tratamientos de la enfermedad mental, in La Medicina Tradicional Maya, Wakayama University, Japan, pp. 51–5. Morita, S. (1983) Seishin Ryoho Kogi [Lectures on Psychotherapy], Hakuyosha, Tokyo. Naka, K., Toguchi, S., Takaishi, T. et al. (1985) Yuta (shaman) and community mental health on Okinawa. International Journal of Social Psychiatry, 31, 267–74. Nakane, C. (1970) Japanese Society, University of California Press, Berkeley. Nakane, C. (1972) Human Relations in Japan: Summary Translation of ‘‘Tateshakai No Ningen Kankei’’ (Personal Relations in a Vertical Society), Ministry of Foreign Affairs, Tokyo. Oe, K. (7 December 1994), Japan, The Ambiguous, and Myself, Nobel Lecture, http://nobelprize.org/ nobel_prizes/literature/laureates/1994/oe-lecture.html Ohashi, H. (1998) Okinawa Shamanizumu No Shakaishinnrigakuteki Kenkyu [Sociopsychological Research on Shamanism in Okinawa], Kobundo, Tokyo. Reynolds, D.K. (1976) Morita Psychotherapy, University of California Press, Berkley. Rhi, B.Y. (1995) The health care seeking behavior of schizophrenic patients in six east Asian areas. International Journal of Social Psychiatry, 42 (3), 190–209. Suzuki, D.T. (1938) Zen Buddism and Its Influence on Japanese Culture, The Eastern Buddhist Society, Kyoto, pp. 11–2.

CHAPTER 14

Dissatisfied Seekers: Efficacy in Traditional Healing of Neuropsychiatric Disorders in Bali Robert B. Lemelson Research Anthropologist, Semel Institute of Neuroscience, UCLA, California, USA

Abstract In a discussion of patients suffering from obsessive-compulsive disorder (OCD) and/or Tourette’s Syndrome (TS), in Bali, Indonesia, traditional healing and psychiatric perspectives are utilized to highlight the power and weakness of each to treat these conditions. Given that they are drawn from the same culture, should not indigenous explanatory models provide meaning and be more efficacious at relieving the suffering of people with OCD and TS like symptoms? What if they provide an understandable meaning for patients but these meanings have no efficacy? Ethnographic data on Balinese models for illness is presented. Multiple data sources were utilized to frame the complex Balinese traditional healing systems. Forty patients were interviewed regarding their utilization of traditional healers, healers were observed treating patients and interviewed regarding their treatment regimens and explanatory models. Traditional explanatory models for illness provide an understandable and integrated system of meaning for these disorders, but are not successful in relieving symptomatology. Neurobiological approaches, traditional healing and ethnographic methods are compared and contrasted to highlight the strengths and weaknesses of each in relation to issues of exegesis and efficacy.

14.1

INTRODUCTION

Interviewer(RBL): I need to understand, can you explain about your experience there, do you like or dislike the way the healer (dukun)treated you? Gusti: I like it . . . Because of what he said, it seems that what he said is true, the disease is here like a stone . . . it’s painful. Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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RBL: And the last time, when you saw different dukuns . . . was the treatment the same or different? Gusti: Different. There was one who used incenses to smoke my face . . . There was one who gave massage therapy, but different kind of massage . . . he only massaged my stomach, not my breasts. And also there was one who used a metal stick, this long. He said it was to kill the disease. RBL: But, did it help? Gusti: No. I got burned on my skin because of the burning metal. RBL: If you compare him with dukuns in the past, is his method of treatment extraordinary? Was the massage the same? Is it harder and more painful than the previous ones? Gusti: The previous one was very rough, I screamed because of the pain. RBL: Was there any change after that? After the treatment? Gusti: On the following day, yes, maybe a little, but the day after, it came back. It did not disappear forever . . . (interview with a patient with chronic Tourette’s Syndrome, Bali, 2001)

The cultural construction of meaning has been a central issue in contemporary anthropology (Shore, 1996; Strauss and Quinn, 1998). How sufferers of different disorders understand, interpret and narrate their suffering has also been explored at length (Kleinman, 1989; Mattingly and Garro, 2000). The construction of meaning, or its lack, is central to the phenomenology of certain neuropsychiatric disorders such as OCD (Rapoport, 1989; Okasha et al., 1994) How individuals make sense or meaning out of bizarre psychological states that have meaninglessness as their defining characteristic is a question that has rarely been addressed. The assumption is that cultural meaning systems provide the basis for framing and interpreting all forms of experience, including psychopathology, and that this meaning construction is innately therapeutic. Traditional healing, its practitioners, explanatory models and social contexts, have been and remain a potent force in much of the world for providing multiple levels of meaning for illness and suffering. In this chapter, I examine the relationship of how the complex meaning systems provided by traditional healing interpret, explain and provide treatment approaches for patients suffering from two distinct but related neuropsychiatric disorders in Bali, Indonesia. In this regard the question of efficacy (Csordas and Lewton, 1998) and its relation to meaning, needs to be addressed. What if these cultural models that provide meaning for disorder and suffering are not helpful at providing symptomatic relief, let alone recovery?

14.2

OBSESSIVE COMPULSIVE DISORDER AND TOURETTE’S SYNDROME

Obsessive-compulsive disorder (OCD) is one of the most common mental illnesses. A disorder that was once seen as extremely rare is now thought to occur in two of every 100 Americans (Karno et al., 1988). The prevalence estimate of OCD in children is at least 2–4%, and an even larger number may have subclinical OCD (Grados et al., 1997). Similar

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rates have been established internationally (Staley and Wand, 1995), making OCD one of the most common major mental illnesses worldwide. (Clarizio, 1991). Although Tourette’s Syndrome (TS) is less prevalent, interest and research in that disorder has increased markedly in the last decade. Once thought of as one of the rarest disorders (incidence of one in a million), TS is now recognized as occurring considerably more frequently. While ‘pure’ TS rates are still quite low (1.9–6.7 per 10 000 [Tanner, 1997]), when TS is included with other, less serious tic disorders that occur in up to 25% of school-age children, it results in tic disorders being regarded as among the most common childhood neuropsychiatric disorders. Again, the psychiatric epidemiologic literature suggests there are similar rates cross-culturally (Staley et al., 1997). OCD, characterized by intrapsychic repetitive thoughts and behaviors the individual cannot stop themselves from doing, and doing in a repetitive way, and TS, with its bizarre movements and vocalizations, may seem to be unrelated. However, neurobiological research conducted in the last two decades shows them to be related disorders from a number of perspectives. Clinical research has documented a multi-directional overlap between TS and OCD from familial-genetic, phenomenological, comorbidity and natural history perspectives. Given increasingly sophisticated understanding of the neurobiological mechanisms, the efficacy of chemotherapeutic treatment and the perceived failure of psychodynamic (as opposed to cognitive-behavioral) psychotherapy to alleviate the symptoms of these disorders, many, but not all, researchers have a strong, biologically deterministic perspective on OCD. In terms of patient care and relief of suffering, this biological emphasis has been generally positive. Through the use of a biological model, suffering has been greatly reduced and psychosocially the bizarre symptoms have been partially destigmatized. The biological account of TS and OCD is robust and has a high heuristic value in terms of efficacy and relief of suffering of patients afflicted with these disorders, as evidenced by the efficacy of psychopharmacological treatment protocols. Current psychiatric treatment of these disorders in the West focuses on cognitivebehavioral psychotherapy and/or psychotropic medication. However, in much of the developing world such therapies are either unavailable, or if available are prohibitively expensive for the vast majority of people in these societies.

14.3

TRADITIONAL HEALING OF NEUROPSYCHIATRIC DISORDERS: MEANING AND THE ISSUE OF EFFICACY

Given that many patients in the developing world rely on traditional healing in seeking relief from the chronic symptoms of these disorders (Desjarlais et al., 1996, p. 54), the following questions must be asked. What is the proper role for indigenous explanatory models in an analysis of a neuropsychiatric disorder? How effective are indigenous explanatory models in explaining these illnesses? Given that these models are drawn from the same culture as are the sufferers of these disorders, should they not provide meaning and be more effective at relieving the suffering of people with OCD-like symptoms? How efficacious are traditional healers in both treating either the disease or illness (Kleinman, 1991)? Some, such as Jilek (1993) argue that traditional healing is at least as and frequently more effective than modern medical and psychiatric approaches for a variety of disorders, including various mood disorders, psychosomatic and somatoform syndromes, acute or reactive

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psychotic states, and alcohol and drug dependence. Jilek, and others, (Keyes, 1985) implies that the more traditional healers are able to help make meaning out of the ‘text’ of an illness episode; they are more equipped to cure it. This fits well with anthropological notions that exploring a culture’s explanatory models, structures of meaning, belief systems and so forth, will generate a more meaningful and efficacious way to look at illness experience. But what if no local categories fit these types of illness? While the phenomenology of psychopathology is always sifted through complex cultural meaning systems involving differing constructions of person, self and emotion, it does not necessarily follow that indigenous explanatory models have an elaborated category for framing and explaining such experiences. What if the indigenous explanations are not syntonic with the phenomenological reality of differing psychopathological states, such as the repetitive, apparently meaningless cognitions of OCD? How do different disorders intersect with different explanatory models? I propose two basic positions in this chapter. The first (unsurprising to most psychiatrists, unacceptable to some anthropologists) is that a psychiatric perspective is indispensable to understanding and treating disorders such as OCD and TS. It is indispensable, precisely because it can offer relief from suffering, even considering the problems associated with ‘the professional transformation of suffering’ (Kleinman, 1991). Conversely, if the explanatory models that traditional healers in Bali use to explain OCD-like symptoms do not offer direct help to the patient, what should we make of their ‘transformation of suffering’? What if patients choose pathways of healing that offer no symptomatic relief? Should Western psychiatric perspectives by default be invoked as the most salient model for treatment in cross cultural contexts? For some patients, in some contexts, with these disorders, psychiatry’s reductive, essentializing and universalizing treatment approaches really could help alleviate their suffering. This said, however, it is clear that central aspects of the symptomatology of these disorders in Bali cannot be explained or understood if a psychiatric explanatory model is the only model used. Ethnographic methods and approaches must be used to help explain their culturally unique aspects. In this chapter I explore a model for a combined approach that furthers the cross-cultural understanding of these disorders while allowing their fundamental cultural expression to complete our situated understanding of both their culturally contextualized and inherently biological nature. The data were gathered as part of a larger fieldwork project exploring cultural aspects of mental illness in Indonesia.1 The data for this chapter is drawn from fieldwork conducted in Bali over a 20 month period in 1996–1997. For a more extensive discussion of methodological issues involved in this study, see Lemelson 2003. In the 20 months of my fieldwork, I met with, interviewed and conducted participant observation with approximately 20 healers and explored issues around their notions of illness causation and treatment. In the latter half of my fieldwork I picked a sample of five healers whom I visited and interviewed at length over the course of a number of months. I tried to pick a sample of healers who represented the range of healing practices or specialties of healers in Bali, including the following: Balian usadha: high-caste male healers who read sacred ethnomedical texts; Balian metuan or tapakan: a spirit medium, who channels gods, ancestors; Balian apun: masseurs; Balian kebal: practitioner of mystical or martial arts; Balian tenung: diviners (see Lemelson (1999), for a further discussion of Balians).

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Four of the five had treated OCD or TS patients in my sample. In addition, I observed four of the six subjects in my research, whom I was engaged with in person-centered ethnography, visiting, consulting and receiving treatment from different healers. I interviewed them afterwards about their experience at the healers, their beliefs about its efficacy (or lack thereof) and their plans for future treatment by this or another healer. The next section explores the explanatory models that traditional healers invoke to give structure and meaning to patients with OCD and TS syndromes in Bali. In order to understand these explanatory models, the reader must have an understanding of traditional Balinese ‘medicine’. The first section introduces the Balinese traditional healing system.

14.4

INTRODUCTION TO BALINESE TRADITIONAL HEALING SYSTEMS

In Bali, traditional healing and indigenous theories of disease are complex and widely used. In Indonesia as a whole, traditional or ethnomedical medical practitioners are frequently consulted in addition to obtaining allopathic medical care (Setyonegoro 1983; Ferzacca, 2001). Even contemporarily, in some areas they are the only source of treatment (Hay, 2003). In Bali a strong syncretism exists between traditional and allopathic medical care. Thong (1993) notes that 70% of patients went to a modern health facility before going to a traditional healer. Indigenous Balinese medicine remains a prominent – for some afflictions, the predominant – component in health care (Heinze, 1988). The system is diverse and pluralistic, with many categories of indigenous healers operating under a spectrum of disease theories. Traditional medical practices have maintained remarkable stability in the 100 years of detailed ethnographic observation in Bali (Hobart, 1997). Even with the introduction of a modern medical system, with its network of community health centers and hospitals, traditional healers continue to draw a large client base. Balians and dukuns are traditional healers whose activities include healing of illness in addition to specialization in religious ceremonies, sorcery, counsel of bereaved family members through the channeling of deceased relatives’ spirits, as well as advice and charms for attracting or keeping lovers (Connor, Asch and Asch, 1986; McCauley, 1984a, 1984b). Numerous categories of balian’s exist, with various types of roles, statuses and knowledge. Given this extensive literature on traditional healing in Bali (Connor, 1982a; McCauley, 1984a; Connor, Asch and Asch, 1986; Wikan, 1990; Hobart, 1997), I have attempted to create a skeletal summary rather than an ethnographic exploration of Balinese traditional healing. The purpose is to bring into relief some of the common explanatory models used by dukuns and balians and relate these to how meaning is constructed for the symptoms of OCD and TS. With differing degrees of importance, humoral theories, hot-cold dichotomies, biomedical models, possession, sorcery, magic, violations of religious and moral norms (including the improper enactment of rituals), and spirit intrusion, imbalance, or disharmony in the patient’s environment all have a place in Balinese folk theories involving the causes, symptomatology, treatment and outcome of illness (Lovric, 1992; McCauley, 1984a; Ruddick, 1986).While this listing is obviously abbreviated it serves as an adequate, introductory outline of Balinese disease theory.

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Below I present a greater explication of these explanatory models. The data are drawn from a search of the literature, my fieldnotes and quotes from traditional healers whom I interviewed. In addition, where relevant, I include quotes from respondents in the clinical study to demonstrate their understanding of these models.

14.5

BROAD PHILOSOPHICAL ORGANIZING FEATURES OF BALINESE HEALING

A number of distinctions have been proposed for understanding Balinese explanatory models for traditional healing. As in many ethnomedical systems, personalistic explanations play an important role (Foster and Anderson, 1978). The Balinese distinguish between two major categories of illness: those caused by some factor of the physical environment, such as food or weather, and those directly and intentionally caused by another party, whether human, demonic or divine (Ruddick, 1986). Numerous authors (Eisman, 1990; Jensen and Suryani, 1992; Thong, 1993) have commented that the most central ordering principle of Balinese cosmology is the distinction between buana alit (little world) and buana agung (literally, great world) and the Niskala (the unseen world) and sekala (the visible world). Another distinction that is parsed differently for the Balinese as opposed to Western psychiatry is the difference between physical and mental illness (Hobart, 1997). He notes that under the latter category fall numerous problems like family issues, inheritance problems, village-wide issues of conflict, and ‘distress arising out of uncertainty or unfulfilled wishes in almost any sphere – political, economic, romantic or artistic’ (Hobart, 172). Another broad cultural conceptualization believed to underlie explanatory models of health and illness is the kanda mpat, or four sibling spirits. Each child is born with these spirits, and each controls both demonically related vice (bajangs) and positive aspects of one’s personality (Lansing, 1995). Many lontar sacred texts are discourses on the nature, care and strengthening of these ‘four siblings’. These forces are personified and have multivalent symbolic connotations. Although some (cf. Eisman, 1990; Ruddick, 1986) state that the spiritually potent concept of kanda mpat is rarely discussed or referenced outside of life cycle rituals, I did find it discussed in several different clinical settings in the OCD/TS sample, in conversations between healers and patients. The use of the kanda mpat can be seen in the following transcript. The setting is an interview between a psychiatrist and a mother and father about the behavior of their son who has TS and who has been fighting with peers at school and with siblings at home.2 PSYCHIATRIST: WAS there any disturbance from the brother? I mean, I asked about kanda mpat because it’s common in Bali. FATHER: Well, maybe the Ari-Ari [afterbirth] was disturbed. (The brother) didn’t care for the AriAri at home. PSYCHIATRIST: Did you ask the dukun about this? FATHER: We did. PSYCHIATRIST: WHAT was its [the spirit’s] request?

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FATHER: IT was that he had been purified directly at the temple. MOTHER: THE dukun said he had to be purified, paid, and be given holy water in cemetery. PSYCHIATRIST: after he was purified [di-Bayuh], was there any change? FATHER: after several days, it relapsed again like this.

14.5.1 Disharmony and Imbalance in a Culturally Constituted Behavioral Environment Howe (1984) notes that different, interrelated aspects of Balinese cosmology and ethnopsychology are structured by ideals of balance, order and equilibrium. This idea of the need for harmony is related to illness beliefs that link the experience and/or expression of disturbing emotions to serious physical and mental ailments (H. Geertz 1961, cited in Hollan and Wellankamp, 1994). In my research, subjects did refer to these notions of balance. One patient in the OCD study discussed this idea in relation to his onset of illness and the after-effects of this sense of unbalance. He stated that he constantly felt ‘unbalanced’ (kesimbangan) and began to have obsessions about forgetting to take his medicine and subsequent catastrophic illnesses. Another patient, when he couldn’t remember the license plate of a car that had passed by, felt dizzy (pusing) and disoriented. Another central idea related to the concept of balance, frequently cited as being salient to Balinese cultural meanings around health and illness, is the notion of a vital life force, or bayu. This concept, shared throughout insular and mainland Southeast Asia, is seen as present in all matter, both alive and dead. However, it is a force that is sensitive to disturbance and can be depleted through being startled, fear, or other disturbance of balance. Bayu needs to be gede (strong or large) to maintain health. This concern with balance and harmony, order and disorder (Heider, 1997) is offset by the concern with witchcraft and the ‘paranoid ethos’ (Schwartz, 1973) it implies. Among the Toraja, Hollan and Wellankamp (1994) note ‘the emphasis on social harmony and nonaggression that coexists with interpersonal cautiousness and mistrust . . . the cultural emphasis on ‘order’, constraint, and smooth interpersonal relationships’ (Hollan and Wellankamp, 217). This harmony is not effortless and comes at a psychic cost, as Wikan (1990) documents. References to these concepts can be found throughout lontar texts that the Balian Usadha utilize to diagnose and treat illness (Nala, 1996).

14.5.2 Problems in the Physical Environment and in Astrological/ Calendrical Systems Related to notions of balance and harmony and order and disorder is the idea that proper spatial organization helps align the buana agung and buana alit. Orientation of buildings, notions of pollution and purity in relation to body organization, and the importance of proper orientations of social relations and hierarchy have long been cited as principal organizing features of Balinese culture (Mead and Bateson, 1942; Geertz, 1973, 1975; Eisman, 1990). The symbolic connections are numerous. The hypercognization in Balinese

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culture around ‘Calendrical notions’ (Geertz, 1973) penetrates Balinese notions of health, illness and personality. Fieldnotes from an OCD patient also support this notion: I only went one time to a dukun for help with my problem. He told me that there were problems with my birth date, and that I needed to make an offering [banten meluasang]. The dukun said because my birth date was keras [harsh or strong] I had to make this offering.

The symbolic placement of offerings for the gods or ancestral spirits (linggih and merajan) is a common form of cultural therapy for illness related to balance and orientation of environment. Reorganizing the spatial arrangement to create balance with the ancestors in both the Niskala and sekala is a key to this. A father of a boy with TS stated the following: I’m also confused and not sure of what I’m supposed to do. The dukun said that something had disturbed [the spirit of house yard]. My yard has lost its caretaker/watchman [referring to the spirit]. It was because we moved the old house to the north, and we didn’t pay this [spirit] proper attention. He said I had to make an offering to the spirit that was disturbed. After that I paid, but I didn’t notice any improvement [in my son].

14.5.3 Humoral and Hot/Cold Distinction Another example that reveals the interrelated quality of explanatory mechanisms in Balinese ethnomedical theories is the hot-cold distinction (Laderman, 1992). Humoral theory is central to notions of illness and health. Illness is perceived as a disruption of the elemental humors. These distinctions are again related to notions of order and disorder, balance and unbalance, controlled and uncontrolled. Hollan notes that strong emotions are hot and that this is ‘antithetical to the ‘‘coolness’’ of health’ (1988, 58). The Balinese interrelate hot-cold notions with beliefs surrounding illness, health and emotion (Wikan, 1989). A dukun described the interrelationship between humoral notions of health, illness and the Niskala, in his analysis of a young girl with TS. The body condition is not good because the weather disrupts the balance between the body and the environment. For example, in the rainy season, the earth and sky are cold; it also makes the head and the foot cool and the stomach hot, and if [people] eat cold food, the reaction between warm stomach and cold food will cause illness.

This dukun went on to describe his diagnostic process: When I take care of the patient, I check them directly by facing them and checking their eyes. If the color of the eyes is yellow, it means their condition is hot. If the color of the eyes is red it means the condition is hotter, which is bad; and if blue color, it means cool. Proper balance of hot and cold food is very important to support the proper function of the system of the body. If the body does not get good nutrition, it makes the bayu of the body weak. Hence, disease will come more easily to the body and make the body function with a lot of problems.

14.5.4 Sorcery/Poisoning by Envious Neighbors or Family Members Throughout Southeast Asia, the concept is common that a person with an intent to harm others can use a spirit or substance (Murdock, 1970) for that purpose. Ruddick (1986) notes

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that many Balinese believe that balians may use black magic to cause illness at the behest of someone who harbors a grudge against, is jealous of or has been spurned by the victim.3 Sorcery was frequently invoked as a cause of problems for OCD patients. Below is an excerpt from my fieldnotes: Another (dukun) stated that Pak Sudiasih was obviously the victim of black magic. Pak Sudiasih searched for a balian who was an expert in black magic (ilmu hitam/magis) who could protect him from the sorcery that he believed was the cause of his condition. He received a magical golden amulet (susuk) that the balian had interwoven with magic words (mantra-mantra).The balian also conducted a lengthy purification ceremony made with elaborate offerings.

Sorcery is seen to be easier when a person’s bayu is weak because of other problems. A dukun stated, ‘The process of people becoming bewitched is easier when their bayu is weak and they cannot resist the magic; at that time, it is easy for the magic to go through’. Sorcery is believed to cause emotional upset and is also invoked in interpersonal communication problems. Business competition is frequently cited as a cause of witchcraft. While some ambivalence exists about the reality and degree of magic influencing the lives of typical Balinese, the belief in and fear of magic and sorcery is a recurrent theme for those struck with disease. For example, one OCD patient in my research couldn’t return home because of the fear of sorcery. He went to a dukun, who treated him with holy water (tirta) and a purification ceremony but still advised him to stay at his uncle’s house in a distant village. He didn’t return home for over six months. A dukun explained it as follows: For example, the man is interested in a pretty girl; but the girl didn’t like him, and it made the man hurt and very sad and angry. The man goes for help to a dukun who does black magic. The dukun will help him if he gives him a certain amount of money. The dukun then uses the black magic power . . . A few days later, the woman begins to always think about the man and wants to see him. She will become crazy just wanting to see him. If she couldn’t see him, it would make her nervous; if she cannot handle her emotions about seeing that man, she becomes crazy and always calls out the man’s name.

14.5.5 Improper Enactment of Ritual and Subsequent Offending of Spirits Throughout Southeast Asia, illness is often seen as a punishment for offenses against the many spirits that inhabit the village and surrounding countryside. These spirits are believed to cause illness or emotional or interpersonal problems when they have not been sufficiently propitiated with offerings or are made upset with improper placement of buildings or by a ceremony done incorrectly or not at all. Given the complexity of the Balinese ritual calendar, this is almost inevitable. In Bali there are numerous classes of spirits that must be propitiated on a daily basis (Wiener, 1995). The Balinese culturally constituted behavioral environment regarding spirits is wide and deep. Spirits are seen in ritual performance forms, such as the topeng opera and wayang kulit (skin puppet) performances. Of more direct relevance than the higher gods are the deities and spirits of local shrines, village temples and ancestors that inhabit the family compound and reside in the family temple. In addition, a class of spirits,

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the buta-kala, manifests in destructive ways. In addition to the buta-kala, numerous spirits and ghosts inhabit rivers, graveyards, ravines and banyan trees. These have various names (wong samar, roh jahat, tonya, memedi) and have different attributes. This relation between spirit offense and illness can be seen in the following dialogue with a dalang, a puppet master endowed with spiritual powers. PUPPETEER: Here in Bali, there are a lot of Memedi. They include the Tuyul, Wong Samar, and Tonya. They are ghosts. RBL: Do they disturb or help? PUPPETEER: It depends. Sometimes they help, but sometimes they eat us too. For instance, if we have a deal with them and we betray them, they will disturb us; but if we keep our promise, they will help us. RBL: So, we must give offerings? PUPPETEER: Yes, offerings, daily or monthly. RBL: If not? PUPPETEER: They disturb us. RBL: disturb us so that we go crazy? PUPPETEER: We can suffer from mental illness or physical illness that can’t be cured, and we finally die.

An OCD patient discussed the following dukun’s explanation for her condition, demonstrating the problems that arise if proper offerings are not given to gods or spirits or if placement of the house yard is improper: The dukun stated that I became sick because of a nonmedical problem, that is, my ancestral spirit made me sick. He said it was because I didn’t make the proper ritual ceremony for her house. Before we built our house, it was a rice paddy and Dewi Sri (rice goddess) still lived there. He said we should have made a ritual ceremony to move God Sri. He stated I would recover after making the proper offerings.

14.5.6 Reincarnation/Inheritance of Ancestor’s Characteristics or Flaws Reincarnation (punarbhawa) or continual rebirth into the world until one attains the perfect life and is unified with God is cited as one of the five principal beliefs of Balinese Hindus (Jensen and Suryani, 1992). Sickness and misfortune in this life may be connected with the reincarnating spirit’s sins from his or her former life. Illness can be perceived as being caused by a neglect of an important ritual by the family or by mistakes in a ritual already completed (Connor, Asch and Asch, 1986). Similarly, in fieldnotes from a TS case: His family initially brought him to a dukun. According to his mother, the dukun said that his illness was ‘‘passed down’’ or inherited (pembawaan or keturunan) from his deified ancestors. This was

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seen as a punishment due to the family’s lack of offerings (sesajen of the type pekeling) at the family temple or shrine (sanggah). He needed to do a purification/sanctification (mecaru) ceremony. The traditional healer gave him holy water (tirta) in an attempt to rectify the past mistakes and purify and sanctify Mosin. Unfortunately, there was no change in his symptoms after the treatment by the dukun.

Below, an extended transcript of an interview with a dukun regarding OCD symptomatology is presented to demonstrate how these concepts are utilized to explain OCD- and TSlike behaviors. This interview is presented at length to show how an individual dukun used these various explanatory models to construct meaning out of OCD symptoms. RBL: I’d like to ask you about someone who has a problem. They find they have to do something over and over again, and although they want to stop, they are unable. An example would be a man who felt his hands are dirty and needed to wash them. However, he felt he had to wash them repeatedly, for up to an hour, even though they were clean. Have you ever seen someone like that? DUKUN: Yes. A man came who was the son of a high priest. He always felt dirty. He would wash himself but never feel purified. I felt this patient was like a battery that is not working very well. I sent my power to the patient’s body in order that my power will destroy the patient’s problems, like a medicine that destroys bacteria. There is another case of a father who always wanted to look neat or dress up neatly. When his children came close to him and made him dirty, he became very angry and slapped his child. This is a kind of over-focus on something or belief in a certain thing. Another example is someone who had cleaned his or her yard already and then the neighbor came and made it dirty. The one who cleaned it will hate the neighbor and never say hello to his neighbor. After this, he lost his self-confidence and became very confused, and his family took him here. I gave him a treatment. RBL: Can you tell me about how you treat such patients who come and see you? DUKUN: My treatment is just the same as a medical treatment. First I make the diagnoses by asking him about his problem. Second is therapy by asking help from God. After meditating, I will get the answer to the problem. The answer could be he is ill because of magic. Another is that his food was poisoned. Another was that the patient became sick because of the position of his house. RBL: Have you seen other people with similar problems? DUKUN: Yes. Maybe he thinks too much and a lot of things are in his head that made him forget. Another example is a woman . . . who feels scared because her body feels heavy. She can’t stop thinking about her body. This problem was caused by magic. A man loved her and put a magic spell on her because this woman would not give him any response and sent magic [guna-guna] to her in order that this woman would love him. RBL: What did the woman feel when the man put a magic spell on her? DUKUN: She wanted to go to that man’s house. She was always making trouble in her house in order that her family would kick her out, so she could go to that man’s house. She couldn’t stop thinking about that man. I tried to help her by stopping or killing the magic stuff in her body. So the power, which can kill the magic stuff, doesn’t have any relationship with medical science. We call that an ‘‘invisible power’’ in Bali. In another compound, someone put poison on someone else because of jealousy. The person who put poison was very clever and very careful. So it was hard for me to find out the cause. The poison attacked the brain and the liver. The patient became very confused and had a bad stomach ache.

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RBL: Tell me about any other kind of symptoms or conditions that you treat that could be related to people thinking about something over and over or doing something over and over. DUKUN: According to my opinion that kind of sickness is because of a problem with their thinking and relationship with their ancestors. They must forget their thought and just pray. Nobody is perfect in this world. Kepongor are people who become crazy because of their life before reincarnation; they promised to do something for their god, and they didn’t fulfill it. They died and their spirit was reincarnated again on this Earth, and at that time their ancestor’s spirit was asked for what they had promised in their first life to God, and God made them crazy and made sure they didn’t have any hope in their life. Usually giving or doing what they had promised to God will cure them. They know from the dukun that their problem is Kepongor. Sickness and problems are different. I take an approach that is important for the Balinese– that is, somebody who is born, inheriting from Panca Srade, must ask about reincarnation. Somebody who was reincarnated into the boy, maybe still has sins, sins from the earlier life, so the boy is carrying those sins now. You must know his situation and his relation with his ancestors.

In this extended discussion we can see the complex utilization of multiple, intertwined explanatory models; magic and sorcery, reincarnation, poisoning, improper enactment of rituals etc. Each one of these can have salience for interpreting illness for individual sufferers and their families, and can provide a framework of meaning for their illness. Their knowledge base – and ability to frame the symptoms in a culturally syntonic manner – is evident in their explanations of the symptoms. Balinese culture provides a complex system of meaning for understanding and framing illness. Given the belief that such meaning making is crucial for a treatment to have efficacy, one would think that such complex, multilayered and multivalent explanatory models should be very effective at relieving symptoms and suffering. Given that they provide meaning for the illness, should not the suffering be lessened? When I approached the question of whether traditional healing techniques are efficacious in relieving suffering, I was guided by the assumption that many of the cases I would be seeing had an identifiable neuropsychiatric base. I was also aware that approaches (such as psychoanalytic or psychodynamic psychotherapy) using a therapeutic model focused solely on interpreting the personal symbolism (e.g. Obeyesekere, 1981) and meaning of the symptomatology have been criticized for their purported lack of efficacy in relieving the symptoms in the neuropsychiatric disorders. Given all of the above, how efficacious were traditional healers (in these cases) for relieving the ongoing symptoms and associated intrapsychic suffering and social dysfunction caused by OCD and TS as measured by patients’ self-reports of decreasing symptoms and relief from suffering?

14.6

DOES THE MEANING MAKING OF TRADITIONAL HEALING PLAY A ROLE IN REDUCING SYMPTOMS AND SUFFERING IN NEUROPSYCHIATRIC DISORDERS?

The most striking result that I found among patients with OCD and TS is their reports of the perceived lack of efficacy of traditional healers and the powerlessness of traditional healing to relieve their suffering. Of the 40 cases, 22 had been to dukuns for help with their symptoms. Seven had gone more than five times, with several going ten or more times.

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The following field/case note, from the subject whose quote opened this chapter, illustrates a patient’s efforts to seek help from different healers, and is a typical response. Initially she was taken to a balian. She ended up visiting 11 balians, who offered a number of competing explanatory models for her illness. While one healer said her illness was the result of a bebainan and that she had been poisoned (racun); another healer said that the cause was her impure house yard and environment. She also went to a Balian uat. He agreed she could have bebainan, and he massaged her to search for bebai. He could not find one. He thought the cause of her illness was mysterious (gaib). He told her family that they had to make an offering to a holy spirit being (roh-roh halus) in the form of person anthropomorphic rice offering (nasi wong-wongan). He stated she needed to conduct the ritual Mecaru manca warna (five differently colored offerings used to purify the family compound land). She went also to a balian paica, a balian who specializes in herbal medicines. He prescribed her a boreh, a traditional medicine made of roots (Akar-akaran) and the bark of a tree (kulit kayu pulai). According to another healer, however, her illness was the result of a leyak (witch) attack. Another balian stated that she needed to go to the ocean to ask supplication of a spirit (roh) that would help with her condition. Another balian treated her with the smoke of rubbish collected from the beach, from a cemetery (sampah kuburan), and from a crossroads (all inauspicious or spiritually powerful/dangerous places) and many types of ‘filthy things’. He also had the family look for the hair of a monkey (bulu monyet), a black dog (bulu anjing hitam), a black cat (bulu kucing hitam) and a pig (bulu induk babi). She had to promise all of her ancestors that she will make offerings to them. He also suggested she go to the beach and to the graveyard at midnight to pray for relief from her symptoms. She received a very painful series of massage and spinal adjustments from a balian urat, who also placed hot metal on her skin, which burned her, and put caustic substance in her eyes in order to drive out the spirits plaguing her. Ibu Muta had no relief or reduction of her symptoms. She often felt she wanted to die because there was no change in her condition.

Out of all the patients, only one (a TS patient with mild OCD symptoms) noticed any improvement after seeing numerous dukuns, and that improvement was seen as temporary. Indeed, given the waxing and waning nature of TS symptomatology, this could be a response attributed to the dukun but actually part of the clinical course of the disorder. None of the other patients described any temporary or lasting symptom reduction as a result of their treatment by traditional healers. If efficacy can be simplistically defined as a measure of the ability of a procedure to influence the health outcome of a patient (or a whole population [WHO, 1977]), traditional healing for these patients lacked efficacy. Current research I am undertaking on Tourette’s Syndrome in Java, utilizing a community rather than clinical sample, also points to the lack of efficacy of traditional healing on neuropsychiatric patients. What could be the reasons for the lack of efficacy of traditional therapies for neuropsychiatric disorders? The most obvious one stems from the neurophysiologic basis of these conditions. In a similar way to the failures of psychoanalysis to provide symptomatic relief of OCD and TS symptomatology, traditional healing, while interpreting and framing these disorders and their effects, does not appear to alter the neurophysiologic basis sufficiently to relieve symptoms and the suffering from these symptoms. If one takes seriously a neurobiological approach to neuropsychiatric disorders such as Tourette’s Syndrome it is

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hard (but not impossible – see Schwartz, 2002) to posit a therapeutic mechanism that does not produce an alteration of neurotransmitter systems. Secondly, while the explanatory models above provide general contexts of meaning for the complex and interpenetrating worlds of health, emotion, moral discourses, personal experience and so on, they do not specifically address the complex phenomenology that sufferers of these disorders experience. That is, in general, they do not provide a cultural model or frame that has salience for the sufferer’s symptomatology and experience of the course of a chronic and debilitating disorder. Finally, there is a nosological issue. Interestingly, what particular psychiatric explanatory models one invokes to understand these disorders impacts on how efficacious traditional healers and healing are. If one views these as neuroses or, in the case of the DSM, as anxiety disorders, then (according to Jilek (1993)) traditional healing should be as effective as or more efficacious than Western medicine. However, if one views these as neurological disorders, Jilek (1994) notes that traditional healing is in most cases ineffective in organic brain syndromes. While OCD and TS are not ‘organic brain syndromes’ per se, this biological emphasis should be noted. Indeed, this chapter is not positing a simplistic distinction between biomedicine and traditional healing of neuropsychiatric disorders in Bali. The lack of efficacy of traditional healing is mirrored, to a certain extent, by problems with biomedical treatment of these disorders in Bali. First, there are the problems with identification and understanding of OCD and TS. Few patients are adequately diagnosed and treated for these disorders, because of the lack of familiarity on the part of the typical health care worker, nurse or general practitioner. Only two of the eight psychiatrists (serving a population of approximately 2.5 million Balinese) had any familiarity with these disorders, and only a tiny percentage of patients received care. The psychiatrists generally prescribed medications appropriate for these conditions; for OCD, either an older generation tri-cyclic antidepressant or (at the time of this research) the newly introduced selective serotonin reuptake inhibitors (SSRI). For TS, a neuroleptic such as haloperidol was given in low dosage. While psychiatrists in Indonesia don’t have the array of pharmacological agents available in some Western countries, their utilization of the drugs they do have follows biomedical standards of care. In addition, similar to studies in the West (Jimenez, 2001) the side effects of the neuroleptic treatment caused a number of patients to stop taking their medication regimen. While most of the TS patients could financially afford the treatment with neuroleptic, the more costly SSRIs were generally far beyond the patients’ ability to continue taking the drugs for more than a few weeks. Thus, even if the patients could theoretically receive psychiatric treatment comparable to the West, few could afford it. In addition, many TS patients have concurrent OCD and related mood disorders. Treatment with a neuroleptic alone can exacerbate these disorders, if not given in conjunction with a SSRI or tri-cyclic antidepressant. Finally there is the issue of meaning, again. In my experience, Balinese patients were skeptical consumers of psychiatric care. Because this care was expensive and offered only symptomatic relief (in particular for the TS cases, less so for the OCD cases), as opposed to total remission, patients were often questioned whether the diagnoses was accurate, or the treatment effective. Patients frequently returned to traditional healers after receiving psychiatric treatment. So clearly psychiatric care has its own set of difficulties in treating these disorders in Bali and other places in the developing world.

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CONCLUSION Different disorders must intersect with different explanatory models in different ways. Indeed, in my other research on long-term outcomes among patients who were formerly acutely psychotic, traditional healing has been heavily used and highly regarded by patients. In agreement with the reports of Connor, Asch and Asch’s (1986) work, patients whom I saw generally experienced positive outcomes when they sought help from balians for recovery from a psychotic episode. Given their emphasis on the efficacy of traditional healing for psychotic episodes (and my data presented elsewhere is largely in agreement) and the data presented here showing a lack of efficacy for patients with OCD and TS, a clear distinction arises. This difference in outcome of traditional medicine for different forms of psychopathology points toward a new direction for future research in transcultural psychiatry and anthropological studies of mental illness. Different cultural systems of meaning around health, illness and suffering should be analyzed and related to discrete disorders identified by biomedicine and psychiatry. The categories of psychiatry should be taken seriously for their heuristic value and efficacious power and an attempt made to link them, and the phenomenological experiences they entail, with indigenous categories of illness, emotion and self. However, traditional epidemiologic methodologies would be strengthened by the inclusion of ethnographic approaches, in particular extensive person-centered ethnography. The data derived from such an approach can often counter the more universalizing and homogenizing data derived from epidemiology – particularly if one is interested in how cultural explanatory models influence and shape symptomatology. This approach is relevant not only to strengthen arguments for an anthropological approach to psychopathology but also to provide a rich technique for understanding cultural variation and meaning systems. Such research would rely on biological psychiatric data and theory, whereby one can identify baseline biological phenomena, but with culturally specific manifestations and a unique cultural signature. Indeed, this signature emerges in unexpected (and perhaps unavailable) forms through other methods for gaining ethnographic data and is certainly overlooked or misinterpreted through standard forms of psychiatric research.

NOTES 1. For information on the wider findings see Lemelson 1999, 2003. 2. Behavioral disturbances and problems with social and peer relations are common among children with Tourette’s Syndrome. 3. A brief anecdote from my fieldwork should illustrate the ubiquity of sorcery and poisoning as an explanatory model for illness. My field assistant, Wayan, in his late forties, came from a very poor background and only finished the second grade. Midway through my fieldwork, he became ill for over a week with fever and headaches. We met after he recovered somewhat, and he spoke at length about his belief that someone in his second wife’s family had been putting poison in his food. He was absolutely convinced that this was the cause of his illness. We then went to visit a friend of mine, who was a professor (docent) of English at the University in Singaraja. She had spent several years in Australia studying for her master’s degree. Her first reaction on hearing that Wayan had been ill was ‘‘Oh, Wayan, someone must be poisoning you because they are jealous of

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your good fortune in working for Robert.’’ It should be noted she said this in all seriousness. I was surprised that this would be the first thought or explanatory model she would invoke to explain an illness episode.

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Laderman, C. (1992) Malay medicine, Malay person, in Anthropological Approaches to the Study of Ethnomedicine, Gordon and Breach Sciences, Amsterdam. Lansing, S (1995) The Balinese, Harcourt Brace, New York. Leckman, J.F., Grice, D.E., Boardman, J. and Zhang, H. (1997) Symptoms of obsessive-compulsive disorder, American Journal of Psychiatry, 154(7), 911–17. Lemelson, R. (1999) Rechecking the Color of Chickens: Indigenous, Ethnographic and Clinical Perspectives on Obsessive-Compulsive Disorder and Tourette’s Syndrome in Bali, Dissertation, UCLA, University Microfilms. Lemelson, R. (2003) Obsessive-compulsive disorder in Bali: the cultural shaping of a neuropsychiatric disorder. Transcultural Psychiatry, 40(3), 377–408. Lovric, B. (1992) Rhetoric and Reality. Unpublished doctoral dissertation, University of Melbourne, Melbourne, Australia. Mattingly, C. and Garro, L. (eds) (2000) Narrative and the Cultural Construction of Illness and Healing. University of California Press, Berkeley. McCauley, A. (1984a) The Cultural Construction of Illness in Bali. Department of Anthropology, University of California, Berkeley, California. McCauley, A. (1984b) Healing as a sign of power and status in Bali, Social Science and Medicine, 18(2), 167–72. Mead, M. and Bateson, G. (1942) Balinese Character, New York Academy of Sciences, New York. Murdock, G. (1970) Theories of Illness: A World Survey, University of Chicago Press, Chicago. Nala, N. (1996) Usada Bali, Upada Sastra, Denpasar, Bali. Okasha, A., Saad, A., Khalil, A.H. et al. (1994) Phenomenology of obsessive-compulsive disorder: A transcultural study, Comprehensive Psychiatry, 35(3), 191–7. Obeyesekere, G. (1981) Medusa’s Hair: An Essay on Personal Symbols and Religious Experience, University of Chicago Press, Chicago. Rapoport, J. (1989) The Boy Who Couldn’t Stop Washing: The Experience and Treatment of Obsessive-Compulsive Disorder, Penguin Press, New York. Ruddick, A.C. (1986) Charmed Lives: Illness, Healing, Power and Gender in a Balinese Village, Dissertation, Brown University (University Microfilms No. 8617621). Schwartz. J. (2002) The Mind and the Brain: Neuroplasticity and the Power of Mental Force. Regan Books, New York. Schwartz, T. (1973) Culture and context: The paranoid Ethos in Melanesia, Ethos, 1, 153–74. Shore, B. (1996) Culture in Mind: Cognition, Culture and the Problem of Meaning, Oxford University Press, London. Staley, D., Roxburgh, W. and Shady, G. (1997) Tourette disorder: A cross-cultural review, Comprehensive Psychiatry, 38(1), 6–16. Staley, D. and Wand, D. (1995) Obsessive compulsive disorder: A review of the cross cultural epidemiological literature, Transcultural Psychiatric Research Review, 32, 127–41. Strauss, C. and Quinn, N. (1998) A Cognitive Theory of Cultural Meaning, Cambridge University Press, Cambridge. Setyonegoro, R. (1983) Traditional Healing Practices:Proceedings in Asian Mental Health Teaching Seminar on Traditional Healing, Jakarta, Indonesia, Ministry of Public Health, republic of Indonesia. Tanner, C.M. and Goldman, S.M. (1997) Epidemiology of Tourette syndrome, Neurologic Clinics, 15(2), 395–402. Thong, D. (1993) A Psychiatrist in Paradise: Treating Mental Illness in Bali, White Lotus, Bangkok. Wiener, M. (1995) Visible and Invisible Realms: Power, Magic and Colonial Conquest in Bali, University of Chicago Press, Chicago. Wikan, U. (1989) Managing the heart to brighten the face and soul: Emotions in Balinese morality and health care, American Ethnologist, 17, 294–310. Wikan, U. (1990) Managing Turbulent Hearts: A Balinese Formula for Living, University of Chicago Press, Chicago. World Health Organization (1977) Report RAD 78.2. Geneva, Switzerland.

CHAPTER 15

Islamic Religious and Traditional Healers’ Contributions to Mental Health and Well-being M. Fakhr El-Islam Academic Consultant, Behman Hospital, Helwan, Cairo, Egypt

Abstract The Islamic religion provides Moslems with an extensive code of conduct that defines norms of behavior in everyday life. Religious practices of worship are used by Moslems to relieve tension and ameliorate their own distress with everyday stresses or during physical or mental illness, for example invocation of God, prayers, fasting . . . The Islamic religion encourages religious self-help by worship but does not condemn the use of religious practice by others, for example relatives, friends, healers and psychiatrists to reinforce patients’ appeal to God through worship. The Moslem identity is collective and the Moslem ego is a group ego. Traditional healers use not only religious Islamic concepts but also derivatives of pre-Islamic, para-Islamic and neo-Islamic rituals. The Islamic religion provides the background against which abnormal mental experiences and expressions are defined. Though psychiatrists and traditional healers commonly see each others’ failures, clinical observations provide evidence that Islamic religious concepts could help to ameliorate anxiety, guilt and suicidal ideas, and reduce mental disorder attributed to supernatural agents.

15.1

INTRODUCTION

That psychiatrists and traditional healers are unwitting partners that contribute to the mental health and well-being of Moslems is a common, everyday observation by mental health workers in Islamic communities. Islamic concepts and religious rituals are employed for self-help and help of others; to maintain and regain mental health. The ‘secure’ self, Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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according to Islamic concepts, has been freed from tension and distress by the faith and religious practices of believers. The cultural background of Moslem communities derives most from religion, though older and newer traditions modify the culture. Traditional healers arouse conflicting attitudes among Moslems in various communities. Psychiatric patients often consult both traditional healers and psychiatrists, either concurrently or after one fails to relieve distress and suffering. Since families are the main welfare agents in most Moslem communities, many family members experience the dilemma of divided loyalty to these two sources of healing. By including healthy individuals in the ritual (e.g. religious) practice, traditional healers are less stigmatizing to patients than psychiatric institutions. In Western countries psychiatric medicine is practiced by general practitioners, as primary care doctors treat all types of medical disorders; including psychiatric disorder, for example in United Kingdom, thus reinforcing the concept that these disorders are equally accessible to treatment without stigma. In most developing countries, including the Islamic world, primary care doctors are not prepared for dealing with psychiatric disorders because of their poor grounding in psychiatry and hence Moslem patients do not have the Western advantage of being included in the general ‘run’ of patients. The present chapter tries to illustrate the general accessibility of Islamic concepts and practices to evaluate, describe and prescribe in the field of mental health. The Islamic religion provides Moslems with an extensive, elaborately detailed code of conduct which is derived from the holy book (Koran) and from the teachings of the prophet (Mohamed) and Moslem scholars. Norms of behavior follow from basic rules by which recent events are measured so that the Islamic code remains comprehensive and updated with after-life rewards for approved behavior and punishments for wrongdoing. The function of the Islamic clergy is to guide the Moslem public.

15.2

MENTAL HEALTH AND MOSLEM IDENTITY

Belonging to the group of Moslems provides the basis for developing an identity fulfilling the values of goodness and fairness in interpersonal relationships. The code approved by Islam’s basic rules is shown in the development of beliefs and attitudes that build up the Moslem identity. Conception of the after-life with its rewards and punishments ensures a system of conditioned learning which is reinforced by observational learning from the behavior of other Moslems. The basic rules of Islam make most events understandable and even acceptable as God’s will. Thus, suffering from distress (physical or mental) is considered a trial or test for endurance that is rewarded in the after-life and calls for invocation of God for relief. Losing hope in God’s relief is never to be entertained by the faithful Moslem. Belonging to the Islamic society is socially conditioned by operant conditioning. Religious belonging is positively reinforced by social approval and support, as well as by heavenly rewards in the after-life. Antireligious or a-religious attitudes are positively extinguished by social, and sometimes legal, disapproval and by the threat of punishments in the after-life. Islam codes extensively for rights and wrongs. The human superego, the censor of behavior, is programmed according to the principle that all behavior is permitted unless stated otherwise. Internalization of socially shared religious criteria builds up the Moslem

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group (collective) ego which contrasts with the Western individual ego. The former ego is energized by filial and kinship piety and embodies a sense of responsibility and duty towards fellow Moslems.

15.3

THE ISLAMIC RELIGION IN EVERYDAY MENTAL LIFE

Regular life stresses and challenges induce distress in everybody. The Moslem faithful feel supported by benediction from God to cope with life stresses. This inspires them with healthy solutions and resolutions time after time. Patient endurance is continued until difficulties clear or come to an end. Patience as such is rewarded in the after-life. It is active patience that is emphasized by the Islamic code. This involves active deliberation and group consultation to train the untrained in the management of everyday life problems. All stresses are tests/trials of endurance and patience. Acceptance of stress as God’s will with underlying heavenly wisdom avoids both projection of blame onto others and introjection of blame in the form of guilt. Accordingly, the way forward is more worthy of attention. Hopelessness, which is equated with blasphemy, should be countered by invocation and appeal for God’s relief and clearance. Stress elicits the support for a Moslem by other Moslems. Individual responsibility is circumscribed by the limitations of their physical and mental capabilities. Individual responsibilities run apace with their input into the genesis of stressful events. Collective effort is the outcome of a collection of group egos. Unacceptable thoughts about religion, or about harm to self or others, are attributed by Moslems to the devil, who endeavors to tempt men with weak faith into wrong-doing, or to deviate them from probity and goodness. In relating to ‘the other’, a good Moslem’s priority is tolerance and forgiveness without sacrificing safety of the group or dignity of the Islamic religion.

15.4

ISLAMIC SELF-HELP THERAPY BY PRAYER

The Islamic religion distinguished itself from pagan religions by the absence of intermediate figures between Moslems and God. Confession of misdeeds is made to God directly, without intervention of the clergy. Invocation of God in order to achieve success and prosperity is also direct, without the need to go through a Moslem religious figure to conduct a religious service for this purpose. Religious ‘healers’ of distressed Moslems are not ‘formally’ qualified to do anything more than simply advising them to (more diligently?) practice their own religion by means of invocations, prayers, fasting and recitations of the Koran. Nikbakt-Nasrabadi (1994) described the effect of Koranic recitations on reducing pain. Some Moslem clerics recite certain verses of the Koran to get over specific life difficulties, but the majority believes that all verses have equal potential to help achieve relief and a sense of security among Moslems. Responsibility and retribution for ancestors’ evil deeds is not supported or condoned by the Islamic religion. Aal-e Yassin (1995) found that religious therapy had a greater impact (e.g. on obsessional disorder) in patients who adhered to the religious code. Such patients seem to possess ‘religious receptors’ which take religious advice by others.

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ISLAMIC RELIGION AS A BACKGROUND YARDSTICK IN MENTAL HEALTH

Religiously-shared Islamic beliefs about the devil, malign magic or jinn should be well known to psychiatrists who are involved in the diagnosis of mental disorders (Table 15.1). Delusions of control of thoughts, feelings and/or acts by external agents, which could be signs of serious mental disorder, are elicited only if their contents extend beyond what Islamic culture attributes to agents formulated as devil, malign magic or jinn. Magical thinking is considered pathological among Moslems if it replaces logical thinking and has contents beyond the religiously-shared beliefs, for example about envy, bad omens or good omens.

15.5.1 Abstract vs Concrete Formulations As formulated by Islamic religion, temptation to wrongdoing by the devil is not associated with any sensory perception of the devil by vision, hearing, touch and so on. A person who reports such sensory perceptual experiences is thought to be in need of psychiatric treatment for hallucinatory experiences (Botros et al., 2006). Unacceptable repetitive thoughts are almost invariably attributed by Moslems to the devil. This relieves guilt about owning and possessing these intrusive obsessional ruminations. However, attributions to the devil may evoke another form of self-blame, for weakness in the face of temptations by the devil and inability to get rid of undesired or disapproved thoughts in one’s own mind. Delusions of psychotic patients may lose their pathological extrapolations with treatment, and then they can be contained in the religiously-shared repertoire of belief systems; psychotic patients develop a religious form of insight as they get better. Delusions involving extensions of normal religious beliefs are more likely to disappear than secular delusions (El-Islam, 1980). God waives responsibility for evil actions of ‘madmen’, for example harming others, until they recover their sanity (Chaleby, 2000).

Table 15.1 defined.

Islamic religion as the background against which mental illness is

1-Delusions versus religiously-shared beliefs about the devil/jinn, especially delusions of control by other agents. 2-Magic (illogical) thinking versus religiously shared beliefs about envy, bad omens, good omens. 3-Hallucinatory experiences versus religiously shared beliefs about temptation by the devil. 4-Obsessions versus religiously shared beliefs about devil-intimated thoughts. 5-Flight into health through religious supernatural concepts after accommodation of remitted symptoms in religious repertoire, that is religious insight.

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15.5.2 The Normal/Pathology Border Beliefs and practices are considered indications of mental illness if they are out of keeping with Islamic cultural and family backgrounds. They would also be out of harmony with the individuals’ usual personality characteristics. Such beliefs and practices induce mental suffering and discomfort in the Moslem individual and/or those around them and hamper their adjustment in human environments (the family, work and social interactions). Healers and psychiatrists offer guidance in accordance with the patients’ code of conduct derived from the Islamic religion. Secular legislation in most Moslem countries derives from and/or is consistent with the Islamic code of conduct.

15.6

THE RELATIONSHIP BETWEEN PSYCHIATRISTS AND RELIGIOUS HEALERS

Variation in the public and legal attitudes to traditional healers who use the Islamic religion extends from approval (e.g. in Saudi Arabia) through a neutral attitude (e.g. in Egypt) to complete illegality (e.g. in Tunisia). Koranic verses, religious prayer services and Islamic teachings are most appropriately used by the person seeking better mental health for their own sake. Religious healers who employ the same religious tools (Table 15.2) do so for money or reputation, although this role is not clearly assigned to them by any Islamic instruction or institution. Religious self-help by worship is clearly preferred as it is carried out with greater sincerity and humility. Attempts to subject the effects of Islamic worship on mental health to a controlled comparative study were opposed by the religious clergy in one Islamic country, as they thought it would be blasphemous to investigate the ‘undoubted worth’ of Islamic religious practice. In practice, religious and professional healers are likely to encounter the failures of each others’ interventions. Religious healers should not be allowed to harm patients, for example by beating the patient, allegedly to drive out a possessing spirit (jinn), or to supplement religious practice by consuming ‘natural’ herbs, some of which could be poisonous. Islam does not empower the clergy to perform exorcism. It is perfectly

Table 15.2 ‘Religious’ and psychiatric practice. The Moslem clergy have no mediation functions between man and god. Their only function is to guide to the Islamic code of conduct. Religious healers are – banned in some Arab countries, for example Tunisia – legalized in some Arab countries, for example Saudi Arabia – subject to no legislation in some Arab countries, for example Egypt Investigation of the health advantages/disadvantages of religion is sometimes equated with blasphemy. Religious and psychiatric practitioners are more likely to see patients representing each other’s failures than each other’s successes.

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ISLAMIC RELIGIOUS AND TRADITIONAL HEALERS’ CONTRIBUTIONS Table 15.3 What psychiatrists need in their psychotherapy in order to use Islamic religious concepts. to have adequate knowledge about each patient’s religious sect, a detailed religious history of each individual patient, to identify ‘slots’ in patient’s cognitive religious schemas in which additional religious knowledge could ‘take’ or fit, and to exclude all patients without appropriate religious ‘slots’. Psychiatrists do NOT need to share or belong to the same religious concepts as their patients.

legitimate for psychiatrists to treat cases resistant to self-help by worship and to complement treatment of those with partial success. Agitated patients are too disturbed to be treated effectively by traditional healers, although after they are tranquillized in hospital, relatives are free to take them (while continuing their tranquilizing medication) to religious healers, for example over a weekend and return them to hospital to continue their psychiatric treatment. Psychiatrists should have adequate knowledge of their patients’ religious beliefs before considering the employment of the religious belief system in any form of psychotherapy (Table 15.3). The religious history of patients should indicate their receptivity to such beliefs. However, the treating psychotherapist does not need to share the patients’ beliefs.

15.7

TRADITIONAL HEALING PRACTICES IN THE ISLAMIC WORLD

The practice of traditional healing in Moslem communities sometimes goes back to the preIslamic era. Elaborate rituals to deal with unpleasant feelings during grief go back in history to the ancient Egyptian dynasties. The rituals used to combat worries and fears related to envy by others or to the adversity of devil or jinn may be based on Islamic concepts. However, the rituals used to treat these feelings include not only Islamic religious rituals, but also the pre-Islamic rituals of trance induction, negotiation with jinn through ‘experts’ and the appeasement of jinn through sacrifices. Throughout history, the Arabs before, during and after the prophetic era, acquired rituals from their neighbors to deal with unpleasant feelings and undesirable behavior, for example the African zar ritual. The practice of visiting shrines of deceased religious clergy (Moslem equivalents of saints) is associated with expiation of guilt and the relief of tension through elaborate rituals which were not practiced in the prophetic era (El-Islam, 1967; Ozturk, 1964). According to Al-Issa (2000) ‘both exorcism and magical practices seem to have been allowed in Islamic society, as long as they are practiced in the name of God to help people . . . rather than inflict harm on them in collaboration with the devil’ (p. 64). Two case vignettes are provided in order to show how Moslem patients suffering from psychiatric disorder have divided loyalties, and seek care through the two systems: Islamic traditional healing and the medical/psychiatric, and how they could benefit from both.

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CASE I Maryam, aged 39, had been an only wife for 24 years of a wealthy businessman when she was referred to the only psychiatric clinic in Doha, Qatar. She had recurrent chest pain, for which no organic cause was found. It is unique in this community for a rich man to have only one wife for such a long period of time. Moreover, she gave her husband only four children, in a society where the number of wives and children is a measure of status. Maryam thought that she was the subject of envy by the ‘evil eyes’ of neighbors and friends, because of her success in keeping the marriage monogamous and limiting her offspring to four in this community that favored a large number of children. The evil eyes of others symbolize the wish that the healthy, wealthy, successful and life-enjoying individuals lose their wealth, health and social success. Maryam became convinced that the envy, which had been going on for eight years, gave her the ache in the heart and made her children unsuccessful at school. None of the physicians consulted by Maryam took a psychiatric history, and she was referred to the psychiatric clinic as a last resort. She was taken by members of her parental family to a religious healer because of her medically unexplained symptoms. He read verses of the Koran to nullify the effects of envy and prescribed amulets for Maryam and each of her four children, to guard against further envy from ‘the evil eye’ of others in the community. The amulets contained folded pieces of paper, on which the healer wrote Koranic verses. The psychiatrist explained that Maryam’s stressful thoughts could produce bodily discomfort and advised her to read, recite or listen to records from the Koran for herself and for her children as self-help by worship instead of paying a religious healer to do this. It turned out that Maryam was forced by her parents into an arranged marriage when she was 15 years old, and that the onset of her present health problem coincided with the attempt by her husband to force their eldest daughter into an arranged marriage when she became 15 years old! Maryam’s identification with her daughter was discussed in psychotherapy. By proxy, the psychiatrist used Maryam to instill assertive skills into her children and let them develop age-appropriate self-management skills at home and at school. The chest pain disappeared and Maryam remained well for six years, until she initiated another psychiatric consultation because an adolescent son consumed a can of beer and she was fearful that he could become an alcoholic.

CASE II Khalid was 20 years old when he presented with ‘fits’ or ‘faints’ in which he fell down and had a sustained contraction of all body muscles, since he was rejected two months earlier in his attempt to become engaged to a girl from a rich family, because of his limited means of living. Physicians prescribed vitamins and tonics to ‘strengthen his nerves’, to no avail. They found nothing wrong with his heart or joint system and after physical investigation proved negative, they referred him to

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(CONTINUED) the psychological medicine hospital in Kuwait. Concurrently, at the suggestion of family members, Khalid was advised to visit a religious healer who reputedly had powers of exorcism and would therefore be able to rid him of the bad spirit (jinn) possessing his body. After careful history taking from Khalid and from the information given by relatives who observed the ‘faints’ the psychiatrist found no evidence of epileptic seizures. He explained to Khalid that the ‘faints’ were psychological in origin and that they were associated with the blow to his self-esteem and to his esteem by others, when the attempt to arrange a marriage for him failed. Then Khalid told the psychiatrist about the suggestion of his family to seek the help of the religious healer. The psychiatrist told him that if he personally felt like visiting the traditional healer he could do so, provided the healer is not allowed to beat the patient’s body, allegedly to rid it of jinn possession. Khalid was also warned against consumption of any herbs or herb concoctions because this might include toxic herbs. Khalid went to the religious healer and rejected beating. He was not offered any herbs. The healer recited verses of the Koran in a loud voice, which were repeated collectively by the patient and accompanying family members. He also practiced ‘mahu’ in which some Koranic verses, written on a plate, were washed away in water that the patient drank. In addition to explanation and reassurance of Khalid by the psychiatrist, verbal expression of anger was encouraged and his self-esteem was strengthened by cognitive psychotherapy. He took pride in his achievement at university and went again to the traditional healer1 to show him how well he fared. Khalid asked whether it was the healer or the psychiatrist who made him better and the latter’s answer was that both treatments helped, but it was Khalid who helped himself by improving his outlook on life and capitalizing on his scholastic achievements to rebuild his selfesteem. 1

The same traditional healer telephoned the psychiatrist later on and was informed of the differences between epileptogenic and psychogenic seizures. Later on, epileptic clients were discovered and referred by the healer to the psychiatric service where Khalid was treated.

CONCLUSION The Islamic religion is a fundamental part of culture in most Arab and Islamic countries. Its extensive code of conduct offers a yardstick for measurement and evaluation of behavior. Because psychiatry deals with normalization of behavior, understanding of the Islamic religion is as important to psychiatrists as it is for traditional healers. Though traditional healers and psychiatrists commonly sequentially deal with each other’s treatment failures, some patients opt for combined treatment at the same time, in order to tap all possible healing resources. Clinical experience suggests that religious concepts of patients could help in their understanding and in building empathy by psychiatrists. Western trained

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psychiatrists who are not ethnocentric should study their patients’ culture, including religion, in order to be able to help those with different backgrounds who have receptivity to their own socially shared concepts, schemas and codes. Medical and traditional treatments could be easily integrated as complementing each other and not alternatives. Both affect the mental defense and biological mechanisms within the individual. Medical healing is supported by evidence-based material and traditional healing is based on the psychic realities shared by both the healers and sick individuals. Because many sick Moslems present themselves with somatic symptoms, it is best that they should be assessed first by medical personnel at least to exclude possible organic problems. The Islamic concept of self-help by worship therapy facilitates access to traditional healing without traditional healers for the benefit of the patients, families and communities.

REFERENCES Aal-e Yassin, S.A. (1995) The Role of Pastoral Counseling in the Treatment of Compulsive Washing in Women Who Adhere and Those Who Do Not Adhere to Religious Commandments, University of Tehran, Tehran. Al-Issa, I. (2000) Mental Illness in Medieval Islamic Society, in Al-Junun, Mental Illness in the Islamic World (ed. I. Al-Issa) International Universities Press, Madison, pp. 43–70. Botros, M., Atalla, S.F., and El-Islam, M.F. (2006) Schneiderian first rank symptoms in a sample of schizophrenic patients in Egypt. The International Journal of Social Psychiatry, 52, 424–31. Chaleby, K. (2000) Forensic psychiatry and Islamic law, in Al-Junun (vid inf) pp. 71–98. El-Islam, M.F. (1967) The psychotherapeutic basis of some Arab rituals. The International Journal of Social Psychiatry, 13, 265–8. El-Islam, M.F. (1980) Symptom onset and involution of delusions. Social Psychiatry, 15, 157–60. Nikbakt-Nasrabadi, A.R. (1994) The Effect of Listening to Recitation of the Holy Koran on Reducing Pain Following Abdominal Surgery, University of Tarbiat Moallam, Tehran. Ozturk, O.M. (1964) Folk Treatment of Mental Illness in Turkey, Magic Faith and Healing, Free Press, New York, pp. 343–6.

CHAPTER 16

Bringing Together Indigenous and Western Medicine in South Africa: A University Initiative Dan L Mkize Professor of Psychiatry, Nelson Mandela School of Medicine, Univeristy of KwaZulu-Natal, Durban, South Africa

Even in precapitalist Africa, the conceptions of health and a healthy individual were equally as encompassing as that of the World Health Organisation which defines health as the state of complete physical, social, mental, and psychological well-being. (Dennis Ityavyar, 1991)

Abstract Medicine and health care in Africa is shaped by complex socio-political and economic processes. Like many people throughout the world, Africans developed their own health and healing systems, including ways of diagnosing, classifying and treating diseases and illnesses. The conceptions of health and a healthy individual in Africa have always been as encompassing as those of the World Health Organization, which defines health as the state of complete physical, social, mental and psychological well-being. In Africa, both traditional and Western medicine exist side by side and are utilized by the African population, each catering to the needs of the individual and the community. Traditional medicine has, for a long time, been ridiculed and suppressed. At the present moment there is an emergence of interest and lively debate on traditional medicine. Its role is being brought to light in the interest of reclaiming the dignity of the nation and of the traditional healers who were previously marginalized. In South Africa, a need has been identified to explore traditional medicine and its relationship with Western medicine, with a view to finding concepts and methods that could accommodate both systems, without violating the fundamental beliefs of either.

Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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INDIGENOUS AND WESTERN MEDICINE IN SOUTH AFRICA

INTRODUCTION

The history of medicine and health care in Africa is shaped by complex socio-political and economic processes. Like many people throughout the world, Africans, from time immemorial, developed their own health and healing systems; including ways of diagnosing, classifying and treating illness and diseases. The conceptions of health and of a healthy individual in Africa have always been as encompassing as those of the World Health Organization, which defines health as the state of complete physical, social, mental and psychological well-being. Traditional healers drew on extensive knowledge of healing methods and materials accumulated and passed down from one generation to the next and based on a complex socio-cultural and religious belief system. Today, both the indigenous health system and the Western health systems exist side by side and are utilized by the African population, each catering to the needs of the individual and the community. Although distinctive therapeutic ideas, practices and institutions existed within individual African societies, a pan-African philosophy is discernable. Centering on metaphysical causes, for example discontented gods, spirits and ancestors, healers practiced a holistic approach – the ultimate goal being to restore the individual to a harmonious relationship within the family, community and social order. Upon assessing the social, spiritual and physical symptoms of a patient’s condition, a healer identified the cause of illness and prescribed herbal remedies and strategies for equalizing unbalanced relationships within the social or spiritual order. In this way, every aspect of an individual’s wellbeing was taken into account and treated accordingly. Health practitioners were highly prevalent within African communities and specialized in everything, including mental health. Some specialized as diviners, midwives, bone-setters, surgeons, magicians or healers, while others channelled their energy into making charms and amulets for warding off evil spirits. Most medicine men and women practised part-time, while a select few made it their profession. Virtually every home had a resident part-time healer of some sort; thus, all members of the community had ready access to health services. One of the most salient features of the indigenous health system was the extent to which it depended upon the support and participation of the community. The recovery of an individual required family or community participation in healing and reconciliation rituals. In addition, the entire community involved itself in health care delivery by participating in such things as environmental sanitation, community planning, quarantining communicable disease, rehabilitating and reintroducing individuals back into society. Thus, African practitioners and communities worked hand in hand to preserve and implement a welldefined and widely accepted social health care programme. Such a philosophy continues to form the basis of indigenous health care systems today.

16.2

THE INCEPTION OF WESTERN MEDICAL SYSTEMS

As Western missionaries and later, colonial forces began to proliferate on the African continent, so too did Western methods of dealing with illness and disease. Initially, modern medical services were limited to ports and centers of administration and commerce, and were only available to Europeans. After World War II, medical facilities expanded somewhat; however, unequal access to these facilities was already well established. Medical

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practitioners and other health service personnel were predominantly centralized in urban areas, providing a higher standard of medical service primarily for the privileged classes. This trend has continued to the present day. Western medical systems took a very different approach to treating the patient as well as the particular ailment. Healing strategies focused more on the individual and on more rigorous and scientific standards for understanding causes of illness and disease. This approach drew upon encyclopaedic scientific theory and practice, using surgical procedures and drugs to rid the body of disease. In this way, the physical condition of the patient became the primary focus, with little or no consideration of the social, spiritual and mental state of the patient. As a result, the integral role of the community, inherent to indigenous health and healing systems, was largely ignored (Update No. 6.6, 1995). As Western values and prerogatives were increasingly imposed upon Africans by missionaries and colonial administrators during the colonial era, various African practices and traditions were frowned upon and some actively suppressed. Janzen (as quoted in Update No. 6.6, 1995) has described this process and its effect on indigenous medical practice in Zaire: ‘The effect on concrete consultations was that diagnosis and divination with a prophet-seer was seen as conflict-arousing, prone to politicize the population, thus dangerous. Open consideration of witchcraft was punishable. Innocuous herbal treatment and bone setting was tolerated’. The situation was similar throughout colonized countries in Africa, and resulted in indigenous health systems becoming dichotomized and creating a relationship typically characterized by conflict between traditional and Western medical systems. Upon independence, African nations inherited and maintained existing governmental health programmes. Western medical systems continued to be favored and propagated by African governments, while indigenous systems were reduced to a low status. Nevertheless, throughout the colonial period and subsequent nationalist movements, indigenous practitioners maintained their knowledge and skill and continued to provide important treatment services for their communities. Today, inadequate and unequally distributed governmental health services characterize the majority of national health programs, making hospitals, medical personnel and medical treatment inaccessible to the majority of the African population. The World Bank reported that for the years 1985–1990, in the whole of Africa there was an estimated one doctor per 9000 people and one nurse per 2000 people. A number of other problems, such as lack of financial resources and proper training facilities for medical personnel, characterize Africa’s national health care programs. Consequently, much of the population utilizes both Westerntrained health care personnel and indigenous practitioners; sometimes at the same time, other times in sequence. Numerous scholars and health care organizers are proposing that an integration of indigenous and national medical systems might help to solve some of these problems while at the same time fostering better use of both health care systems. Although indigenous African healers continue to be ignored, or mentioned and dismissed summarily, or ridiculed in much of the current health literature, some African countries have implemented health programs utilizing the services of indigenous healers, especially in the mental health care field (Update, No. 6.6, 1995). As we enter ‘the African century’, health related trends should include an increased recognition of the benefits of adopting a variety of approaches to diagnosis and healing; achieving and maintaining wellness through the use of natural, mental and spiritual influences, in addition to pharmacological and surgical treatments.

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The indigenous health system has, for a long time, been ridiculed and suppressed. Those who are opposed to indigenous healing state that they have been flooded with evidence of unhealthy and dangerous practices by traditional healers (van Eeden, 1993). Some people have actually been hostile to it, referring to it in derogatory terms, such as ‘mumbo-jumbo’. At the present time there is an emergence of interest and lively debate about the effectiveness of indigenous medicine. The role of the traditional healers is being brought to light in the interest of reclaiming the dignity of the nation and of those individuals who were previously marginalized and maligned, in accordance with the African Renaissance. South Africa’s traditional healers, who were ignored and sometimes legally ousted and suppressed by ‘white man’s medicine’ during the apartheid years are a step closer to being elevated to their rightful place in the health care system (Baleta, A., 1998).

16.3

PROSPECTS FOR A NEW AFRICAN HEALTH CARE SYSTEM

The possibility of collaboration between national and indigenous health care programs is highly controversial. Many national health care organizers uphold Western medical systems as superior, assuming indigenous systems to be non-scientific, less rigorous and ineffective. Others recognize the strengths and possible compatibility of the two systems and thus advocate, with caution, their integration. The debate is multi-faceted and has been a point of contention among African health care organizers for a long time. Two of the most obvious obstacles to successful national health care service in Africa, lack of financial resources and lack of trained health services personnel, might be surmounted if proponents of the two systems cooperated. While Western health care has many benefits and has proven to be effective in reducing the infant mortality rate and in raising life expectancy, it is expensive, impersonal and largely unavailable and inaccessible to many Africans. Indigenous practitioners are more widely used because they are more accessible to the majority of the population. The integration of indigenous practitioners into national health care systems would allow more people to benefit from modern medical services while maintaining indigenous approaches to a more holistic healing, and encouraging community participation in the overall health care delivery system. Although practitioners of modern medicine are wary of the safety and efficacy of indigenous practices and medications, some African governments have begun to licence indigenous practitioners and inventory their practices through scientific assessment of indigenous medical knowledge, and through the study of indigenous philosophies regarding health and healing. It has been suggested that indigenous healers, trained in both Western and indigenous procedures, could serve as practitioners of maternal and child health, family planning and public health. Many specialists, such as bone setters, herbalists, circumcisers, midwives and snake and scorpion bite specialists could also serve as valuable resources. In addition, there is growing evidence that herbs used by indigenous healers contain useful medicinal properties. Replacing various commercial drugs with indigenous herbs could cut already exorbitant pharmaceutical costs. Taking into consideration the multi-cultural nature of South Africa, it is of the utmost importance to explore the indigenous health system and its relationship with the Western health system, with a view to finding concepts and methods that could accommodate both systems, without violating the fundamental beliefs and practices of either (Update No. 6.6, 1995).

OBJECTIVES OF THE AFRICAN HEALTH CARE SYSTEM (AHCS)

16.4

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The term ‘traditional medicine’ refers to ways of protecting and restoring health that existed before the arrival of modern medicine. As the term implies, these approaches to health belong to the traditions of each country, and have been handed down from generation to generation (Fact Sheet No. 134, 1996). Traditional and indigenous medical systems have persisted for many centuries, even in parts of the world where modern health care is readily available. In the last few years, however, the idea of mobilizing the manpower component of traditional medicine for purposes of primary health care, particularly in rural areas, has been gaining ground in many countries (Bannerman, 1977). A project bringing together the indigenous health system and the Western health system was initiated by the Dean of the Nelson Mandela School of Medicine, University of KwaZulu-Natal, South Africa. It was to be called the African Health Care System (AHCS). The Dean requested three African academics: a psychiatrist, a biochemist and a dermatologist to drive the process forward. All three are Western trained health professionals. This was going to be a daunting task because of the limited knowledge the three had of the indigenous methods of healing. Therefore, in developing a work plan, the first requirement was to consult and work with reputable traditional healers who are well versed in the indigenous health system. Three organized groups of traditional healers (KwaZuluNatal Traditional Healers Council, Umgogodla Wesizwe Trust and Mwelela Kweliphesheya), were approached. A number of meetings were held; planning together and charting the way forward as equal partners. Mutual trust was developed. This was not a smooth journey; there were potholes, like all roads under construction. All stakeholders made mistakes; some people on both sides were unhappy and indeed angry. However, meetings started bearing fruit and mutual trust was established. This culminated in the signing of a memorandum of understanding (see Appendix).

16.5

OBJECTIVES OF THE AFRICAN HEALTH CARE SYSTEM (AHCS)

There are three broad objectives:

 Research This would include research on classification, etiology, diagnosis and treatment of diseases. A bibliography of all material written about the AHCS in Southern Africa would be compiled. Identification of herbs, their therapeutic efficacy, effects and sideeffects would be done following the Good Clinical Practice Guidelines. Treatment of specific diseases, such as tuberculosis, malaria and HIV/AIDS would receive first priority.  Education and Training Indigenous healers would be trained in Western health care practice, for example, in rehydrating babies and treating cholera patients, and recognizing those conditions which are best treated by Western trained doctors, in order to bring about early referral. Indigenous healers would be encouraged in the home based care of people with terminal

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illnesses. Western heath care practitioners would be trained in the AHCS by indigenous healers who had developed a module on AHCS at undergraduate and postgraduate levels. A certificate, later a diploma and ultimately a degree in the AHCS would be developed by the university.  Empowerment The focus would be to empower indigenous healers so that they can take their rightful place in our society. Empowerment also includes protection of Intellectual Property Rights, as well as the commercialization and patenting of indigenous herbal medicines. These three objectives fit very well with the Traditional Health Practitioners Act of South Africa (2004), which states that one of the objects and functions of the Interim Traditional Health Practitioners Council of South Africa [Chapter 2 paragraph 5(e)], is to promote and develop interest in traditional health practice by encouraging research, education and training.

16.6

RESOURCES

The AHCS initiative was to utilize existing Faculty of Medicine and University resources.

16.7

STAKEHOLDERS

The stakeholders included all interested university personnel, indigenous healers, interested individuals and organizations. It has a working relation and close collaboration with Ayuverdic, Tibetan and Chinese systems of health care.

16.8

NETWORKS

The AHCS initiative was to collaborate and network with the Reference Center on Traditional Medicine, Department of Health, both nationally and provincially, Department of Science and Technology, Department of Arts and Culture, other Universities, eThekwini Municipality, Medical Research Council, National Research Foundation, Human Sciences Research Council, South African Development Countries, World Health Organization and all interested institutions and individuals.

16.9

WORK PLAN

The work plan was as follows:

    

to establish an office, later a unit and finally a center for AHCS; to raise funds; to network and expand membership; to host a regional conference; to host an international conference.

APPENDIX

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CHALLENGES

The following challenges were anticipated:

 Stigma – One big challenge that we face as a university, is the stigma associated with traditional healing methods. This stigma arises from muthi killings; murdering people and removing organs for sale to traditional healers for medicinal use.  Herbal medicine toxicity – Another challenge is the large number of multiple organ failures we see at our hospitals due to herbal toxicity. We must work together to eliminate these dangerous practices.  Secrecy – Indigenous healers are not willing yet to share their knowledge, experience and modus operandi. In the past, Westerners have come to African societies under the guise of doing research and ended up stealing their indigenous knowledge and intellectual property rights, then vanishing into thin air.

CONCLUSION Bringing together the Indigenous health care system and the Western health care system by the university has been successfully achieved. It is called the African Health Care System. As a result, an endowed Chair of African Health Care has been established at the university, with funding from the National Research Foundation of South Africa.

REFERENCES Baleta, A. (1998) South Africa to bring traditional healers into mainstream medicine. The Lancet, 352, 554. Bannerman, R.H. (1997) WHO’s programme in traditional medicine. WHO Chronicle, 31, 427–8. Fact Sheet No 134 (1996) Traditional Medicine, Available at:.http://who.int/inf-fs/en/fact134.html. Jones, J.S. (1998) Traditional healers here to stay. SAMJ, 88, 1057. Sue, D.W. (1999) Advocacy and indigenous methods of healing, Available at: http://www. counseling.org/conference/advocacy8.htm. Traditional Health Practitioners Bill (2004). Update No, 6.6. (1995). Working towards an effective African Health Care Program, Available at: http://polyglot.lss.wisc.edu/afrst/outreach/units/health.html. van Eeden, A. (1993) The traditional healer and our future health system. SAMJ, 83, 441.

APPENDIX MEMORANDUM OF UNDERSTANDING between Indigenous Healers in KwaZulu-Natal, as represented by KWAZULU-NATAL TRADITIONAL HEALERS COUNCIL (eTHEKWINI LOCAL BRANCH), MWELELA KWELIPHESHEYA & UMGOGODLA WESIZWE TRUST and the

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UNIVERSITY OF NATAL Nelson R Mandela School of Medicine on

cooperation and collaboration in African Health Care System This alliance recognizes that:

 indigenous healers are playing an important role in the provision of health care in South Africa;  it is important to preserve this system of traditional knowledge and practice;  this system of knowledge should be developed and given space to interface with Western health care systems;

 indigenous knowledge is in danger of being forgotten and, thus, in need of revival and protection;  there is also a possibility of such knowledge being exploited to the detriment of its rightful custodians. Guided by the mission and objectives of our organizations, we commit ourselves to work together to conclude an agreement/s based on the following principles and areas of activity:

 exploring education and training programs for indigenous practitioners in Western health practice;  exploring education and training programs for Western health care practitioners on indigenous knowledge and practice;

 promoting research and the documentation and development of indigenous health care knowledge so that it may effectively serve South Africans;

 supporting commercialization and entrepreneurship initiatives stemming from the utilization of indigenous knowledge;

 promoting agricultural methods aimed at the preservation and conservation of plants used for healing purposes. Within the limits of the resources that are available to them or that may be raised from other sources, the parties propose to give substance to their collaboration by means of projects, the terms of reference for which shall be agreed before implementation, including: defining the duration, right of use of facilities and related resources, financial obligations, publications and intellectual property rights. Projects shall adhere to institutional, local, provincial and national protocols, ethical guidelines, rules and laws.

CHAPTER 17

Globalization and Mental Health Traditional Medicine in Pathways to Care in the United Kingdom Ajoy Thachil and Dinesh Bhugra Section of Cultural Psychiatry, Health Services and Population Research Department, Institute of Psychiatry, King’s College, London, UK

Abstract British society is a multicultural entity that is the result of a long history of immigration and emigration. Globalization has contributed to the endurance of this phenomenon. Some migrant groups demonstrate significantly higher rates of both severe mental illness and common mental disorders. Health beliefs, presentations of illness and pathways to care of many immigrant groups are complex and often involve consultations with traditional healers. The growing popularity of Complementary and Alternative Medicine (CAM) among those with mental illness and its overlap with traditional medicine renders it an important factor in pathways to care. Research in this area has focused on the British Asian subset of immigrants, leaving other groups poorly researched. Given the higher vulnerability of some of these groups, and particularly the Black British group, to severe mental illness, this calls for a redefinition of the ethnic research agenda. Pilot collaborative approaches with CAM practitioners can serve as a template for similar approaches with traditional healers and ensure quicker access to care.

17.1

INTRODUCTION

Britain has historically been a country of immigration and emigration. It has always been relatively open, and the British population is the product of the ethnic and cultural intermingling of new migrants with those who were already there. With globalization, the lifting of trade barriers and the new flexibility of labor markets, the endurance of

Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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regional conflicts and the failure of many nation states, the political redefinition of what constitutes a national border (e.g. the European Union) and the historical ties of the Commonwealth, large-scale migration to and from the United Kingdom is here to stay. Over many centuries, sizeable numbers of various ethnic groups have made their home in the United Kingdom (UK). Relatively little is known about the use of traditional alternative medical therapies in these populations. Research from developing countries demonstrates that immigrants with mental health problems often resort to both biomedical and folk systems of medicine (Weiss, 1992; Kapur, 1979; Sandoval, 1979). When they migrate, each group brings with it a set of traditional health beliefs and values but then undergoes a process of acculturation over time. The first generation immigrant may contact a traditional healer at some point. Once acculturated, a key question is whether subsequent generations consult traditional healers. Early migration to the British Isles encompassed Pre-Celtic, Celtic, Roman, AngloSaxon, Norman and Norse influences. Later arrivals included Central and Eastern European Jews, Huguenots from France and Switzerland, the Romany (Gypsy) people and the Irish. The conventional picture of post-World War II migration focuses on nonwhite immigrants from the ‘New Commonwealth’ with immigration seen as a succession of ‘waves’ – first from the Caribbean, then from India and Pakistan, then from Bangladesh, and now asylum-seekers from many strife-torn countries in Asia and Africa. However, there was substantial net emigration and two-way Irish migration throughout this period. Inflows decreased after 1971, but not to a great extent. The post-war years also saw significant immigration of Italians, Greek Cypriots, Turks and Turkish Cypriots. In addition, there has always been significant, labor-related migration via the work permit and other systems, a phenomenon that increased in numbers as the United Kingdom gradually became part of a European labor market. For most of the 1980s and early 1990s, immigration remained at similar levels to emigration. Recent trends demonstrate an increase in net immigration, reflecting economic globalization, increasing economic integration and labor mobility within the European Union (EU), and the relative strength of the UK labor market. In addition, globalization has seen increased instability in a number of countries (in Central and Eastern Europe, in Asia and in Africa). This, coupled with the fall in transaction and travel costs, has enabled the establishment of social and logistical networks that in turn allow large numbers of people to come to the UK, legally or otherwise (Glover, et al., 2001). The new arrivals include people from Poland and other countries of the eastern and central parts of the EU, as well as those from Balkan countries, from the Middle East and North Africa, from sub-Saharan Africa, from China and other parts of East Asia. Finally, there are immigrants from Western Europe, South Africa, Australia and New Zealand. The 2001 Census of Population reflects this ethnic diversity, with 85.7% of the population identifying themselves as white British and the remaining 14.3% ranging from other white groups to South Asians to African–Caribbeans to Chinese (Census Dissemination Unit, 2001).

17.2

MIGRATION, MENTAL HEALTH AND TRADITIONAL MEDICINE

Research has demonstrated higher rates of schizophrenia in immigrants to the United Kingdom, with particularly high rates for people of African–Caribbean origin (Harrison,

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et al., 1997). Studies also show that rates of admission for schizophrenia and affective psychoses among African–Caribbeans are 3–13 times higher than the rates for white patients (van Os, et al., 1996) and that the prevalence of common mental disorders in Irish and Asian groups is significantly higher than in their British counterparts (Weich, et al., 2004). The prevalence of dementia is also higher in African–Caribbeans and Greek Cypriots (Livingston, et al., 2001). Racial discrimination occurs in British society, leading to suffering and disadvantage and possibly also to mental illnesses (Bhui, 2002). Research has shown that the experience of interpersonal racism and perceiving racism in the wider society each have independent effects on the risk of common mental disorders and psychosis, after controlling for the effects of gender, age and socio-economic status (Karlsen, et al., 2005). There are also indications that African–Caribbean communities stigmatize mental illness more heavily (Harrison, et al., 1989). Studies have also shown that shame and stigma; causes of mental illness; family reputation; concealment; problems seeking help; and lack of collaboration lead to people from Asian communities being reluctant to access help from mainstream mental health services (Wynaden, et al., 2005). Given this context, and the fact that language barriers, religious beliefs and incongruence of explanatory models have an impact on help-seeking, it is not surprising that traditional healers play a part in the pathways to care of at least some of these diaspora population groups (Dein and Lipsedge, 1998). However, as the proportion of younger, educated (whether in the United Kingdom or elsewhere) and second generation immigrants increases, such consultations are likely to decrease, with consequent alterations in the overall pattern. In addition, the last two decades have witnessed a significant upsurge of interest in Complementary and Alternative Medicine (CAM) in the United Kingdom, where 1 in 10 of the adult population consults a CAM practitioner every year, and 90% of these contacts happen outside the National Health Service (NHS) (Thomas, et al., 2001). A BBC telephone survey (Ernst and White, 2000) found that the use of CAM in the United Kingdom yielded a one-year prevalence of 20%. This upsurge is reflective of global trends (Thachil, et al., 2007). Though CAM is becoming an increasingly regulated area, current evidence indicates that many CAM services are, in fact, delivered by practitioners who may be categorized as traditional healers in another context (House of Lords, 2000). This is further supported by evidence that lists of CAM approaches compiled from diverse sources viz. textbooks, primers, guides and interviews with CAM practitioners from the United Kingdom, demonstrate a significant overlap with traditional medicine (Thachil, et al., 2007). This indicates that in the case of many such practitioners, a distinction between traditional medicine and CAM may well be an impractical, if not artificial one.

17.3

TRADITIONAL MEDICINE AND PATHWAYS TO MENTAL HEALTH CARE

17.3.1 The South Asian Community The earliest British studies (Aslam, 1979; Healy and Aslam, 1990) found that South Asian patients in Bradford, where there is a large Muslim population that migrated from Pakistan, frequently used traditional healing practices. Hakims, who are physicians practising Unani

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medicine, were commonly consulted. Unani is a form of medicine widely practised in the Indian subcontinent that traces its origins back to Hippocratic and Galenic medicine. The word Unani itself means Ionian and the system is known as Unani Tibbia. The secrets of Unani medicine were originally passed from Byzantium to Sassanid Persia by fleeing Nestorian Christians declared heretics by the orthodoxy of Constantinople. The Nestorian refugees set up a medical school in Jundishapur, south of modern Teheran, from where their formulae were incorporated by the Arabs during the early conquests of Islam. It was then further refined in Baghdad and Cairo, where it absorbed ideas from the ancient medical practices of Pharaonic Egypt, Sumeria, Assyria and Babylon. Unani Tibbia was finally codified into a system by the Arab scholar Ibn Sina (Avicenna). After codification, it passed into the curricula of the Central Asian Universities of Samarkhand and Tashkent. It finally arrived in the Indian subcontinent with another group of refugees, this time fleeing the conquering armies of Genghis Khan (Dalrymple, 1994). The Unani approach focuses on holism, simultaneously taking into account physical, mental and spiritual well-being. It is guided by an understanding of the temperament (Mizaj) of the patient, heredity and its effects, the presenting complaints, physical signs and symptoms, clinical observation, and examination of the pulse (Nubz), urine and stool. Treatment consists of a regimen encompassing lifestyle, diet and prescribed herbal medicines. These include dietary manipulation (Ilaj-bilGhiza), pharmacotherapy (Ilaj-bil-Dawa), climato-therapy (Ilaj-bil-Hawa) and regimental therapy (Ilaj-bit-Tadbir). Regimental therapy includes venesection, diaphoresis, diuresis, Turkish baths, massage, cauterization, purging, emesis (Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy, Government of India, 2007). While Unani medicine has completely vanished from the areas where it was born and developed, it flourishes in the Indian subcontinent (Dalrymple, 1994). Some of the Bradford hakims held recognized qualifications in their home countries, though the majority were unqualified. An average consultation with the Bradford hakims lasted about 20 minutes, with physical examination being restricted to feeling the pulse. One hundred and seventy-nine patients were treated over a four-week period, of which 30% had a psychosexual problem, 13% had excessive fatigue (which Aslam diagnosed as depression), and the others suffered from physical illnesses. The majority of consultations were for psychiatric problems often related to sexual anxiety. Apart from the prescribed herbal preparations, dietary manipulations were commonly recommended as part of treatment. If the illness was determined to result from the jealous glance of another person (the evil eye or nazar), the ta’wiz, consisting of holy words from the Koran incorporated into an amulet, was used. If it was determined that the patient had broken a religious edict or appeared to be in an altered state of consciousness (inferred as a state of possession), a supernatural illness was diagnosed, and the patient referred to a mullah. Aslam suggested that Asian patients may prefer to see a traditional healer because there is no language barrier; they have more time, are more holistic and include the whole family in the process of assessment and treatment (Aslam, 1979; Healy and Aslam, 1990). Later studies among British Asians (a term that refers to UK residents of South Asian origin) do not reveal this extent of consultation with traditional healers. In 1983, Johnson, et al. (1983), conducted a large-scale household survey of primary care use by British Asian, Afro-Caribbean and white communities in West Midlands inner-cities. They found that Asians reported very little use of traditional remedies or practitioners. However, 51% of Afro-Caribbean, 33% of white and 24% of Asian respondents felt that traditional

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remedies were better than conventional biomedicine in treating many conditions; for instance, chronic fatigue. In 1986, Donaldson (1986) undertook a community survey of 786 South Asian patients in Leicester, from a sample based on general practices. The study population included all men and women aged 65 years and over who were of Indian and Pakistani origin living in the city of Leicester. Almost all had been born in India, mainly in Gujarat and the Punjab, but most had come to Britain after living many years in East Africa. Since they had been living in Britain, 67% had consulted their general practitioner within the preceding month, as opposed to only 6% who had consulted a traditional healer. The proportion of those who had consulted their GP was similar to that found during the same period by Blakemore (1982), who studied 348 older adults of Afro-Caribbean and Asian origin and 52 of white European origin living in Birmingham. Both studies found that immigrants consulted GPs more than the indigenous population. Donaldson speculated that this may be related to cultural differences in illness behavior and attitudes towards medical services. This could also be related to acculturative stress among immigrants. Other studies among South Asians from the same period indicate, however, that consultations with traditional healers, though not uncommon, were not as widespread as the use of traditional remedies. In her community sample of 388 Sikhs living in Southall, West London, Karmi (1985), found that 46% used traditional medicines. There was no difference in place of birth, education, marital status or employment between those who used traditional medicines and those who did not. A significant minority (22%) had visited a hakim when they became unwell, before seeing a GP. Hakims, who frequently advertised their services in local newspapers, were consulted most commonly for digestive and respiratory problems. Bhopal (1986), in a community based interview study of 65 Asian patients (from a GP register) and a questionnaire study of health professionals in Glasgow, found that a high proportion had an awareness of traditional remedies. However, few people preferred traditional medicine to Western medicine, though opinion was divided regarding safety. The interviews appeared to indicate that the healers’ ability to communicate in a way acceptable to the patient and to induce faith in the therapy offered was central to them being consulted. More recently, Dein and Sembhi (2001), in their sample of 25 South Asian psychiatric patients in the London Borough of Waltham Forest, found that seven (28%) had consulted a traditional healer at some point during their psychiatric illness. Another three had used home remedies (generally folk medicines or herbs) for their psychiatric illness, and five had consulted traditional healers for non-psychiatric illness. Of the sample, 12 had schizophrenia, 12 depression and one had bipolar affective illness. Several of those who had not consulted such professionals stated that they would consult them if they were available, accessible in the United Kingdom and affordable. Use of traditional healers was significantly related to age, with patients younger than 40 years being more likely to consult a traditional healer. Humoral theories were commonly posited to explain mental illness and particular foods were commonly used in treatment. The interviews revealed a recurrent theme of concurrent use of traditional remedies and professional psychiatric treatments. The patients consulted Unani, Homoeopathic and Ayurvedic practitioners, as well as religious healers from both Muslim and Hindu traditions. Ayurveda, like Unani, is a system of medicine widely practised in the Asian subcontinent. However, its roots are local and ancient, dating back over 5000 years. Ayurveda is based on three major texts which students at the ancient Indian Universities, Nalanda and Takshashila, were required to memorize in their entirety. They include the Charaka Samhita and the Sushruta Samhita (both compiled

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circa 1000 BCE) and the Ashtanga Hridayam (compiled 500 CE). Ayurveda focuses on the imbalance of the three doshas (humors) in the body resulting in disease (Prathikanthi, 2007). The three doshas are vata (wind), pitta (bile) and kapha (phlegm). During a consultation, the Ayurvedic physician first ascertains the specific tri-dosha constitution (prakriti) of the patient and then identifies the presence and magnitude of any dosha imbalance (vikriti). This imbalance can be altered through specific treatments, changes in diet, lifestyle or other activities. The consultation encompasses a detailed somatopsychic history and an eight-point physical examination including the pulse, condition of urine and stool; appearance of the tongue, eyes and skin; quality of speech and general appearance. Ayurveda specifically emphasizes a holistic approach to health and identifies a strong connection between mind and body. It considers disease (and health) as a function of a dynamic interaction between the individual and the environment (Chopra and Doiphode, 2002). Ayurvedic texts describe a distinct branch of clinical practice focusing on mental health, called Graha Chikitsa. They describe clinical features of psychosis (unmada), depression (chittavisada), anxiety (chittodvega), alcohol misuse (madatyaya), obsessions (atattvabhnivesa), hysteria/conversion disorder (apatantraka), hypochondriasis (gagodvega), personality disorders and mental retardation, with aetiological roles for both mental and physical processes and their interactions with the environment (Chopra and Doiphode, 2002; Prathikanthi, 2007; Ramachandra Rao, 1990). In India, a sizeable proportion of the population use Ayurveda, with Ayurvedic hospitals, clinics, pharmacies and medical schools being part of the public sector as well as a regulated private sector (Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy, Government of India, 2007). It is noteworthy that in recent years, its use has increased in the West, including the United Kingdom (House of Lords, 2000). Interestingly, Dein and Sembhi’s finding that most patients used traditional remedies and professional psychiatric treatments in tandem is concordant with the findings of earlier research by Campion and Bhugra (1997) from the Indian subcontinent. This showed that of 198 consecutive psychiatric patients attending a hospital in South India, 89 had sought between 1 and 15 sessions from either Hindu, Muslim or Christian healers during the course of their illness. An average of 30% of patients claimed some benefit from healer consultation, though the majority had discontinued such treatment at the time of their hospital treatment. The number of patients visiting healers was related significantly to their income and age, with those under 17 years more likely to receive such help than those older. This finding again correlates partly with the findings of the London study (Dein and Sembhi, 2001). It may be noted that, despite the difference in sizes and contexts, both studies sampled patients using mainstream psychiatric services, leading to very similar findings. This begs an important question; is culture of origin the key factor underpinning the patterns of use of traditional healing among Asian psychiatric patients? The answer may lie in cross-cultural, community-based, observational studies of robust design that include both quantitative and qualitative methods.

17.3.2 The African-Caribbean and African Communities In contrast to the wealth of research available on the use of traditional healing practices by Asian immigrants, primary evidence of the use of traditional healing by those with mental health problems from other immigrant groups is scarce. What limited information is

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available relates almost exclusively to the African–Caribbean and African communities, and this will be the focus of the current section. The earliest recognized instance of African–Caribbean traditional healing in Britain relates to the arrival of Mary Jane Seacole, a nineteenth century Jamaican nurse who had made a name for herself treating cholera and yellow fever in Panama and Jamaica. The mixed-race daughter of a traditional healer, her efforts to join the official contingent of nurses bound for the theatre of war was rebuffed by the establishment. Undaunted, she went to the Crimea on her own initiative and in 1856, established the British Hotel near Balaclava in order to provide ‘‘a mess-table and comfortable quarters for sick convalescent officers’’. She also attended to the wounded on the battlefield. One soldier wrote in his memoirs: ‘‘She was a wonderful woman, all the men swore by her, and in case of any malady, would seek her advice and use her herbal medicines in preference to reporting themselves to their own doctors. That she did affect some cure is beyond doubt, and her never failing presence amongst the wounded after a battle and assisting them’’. However, her efforts made her bankrupt by the end of the war. Her story was then carried by the British press and money was raised by subscriptions to pay off her debts (Fryer, 1984). In 1857, she published The Wonderful Adventures of Mrs. Seacole in Many Lands. The book was a great success, and Mary Seacole became a popular figure, an acknowledged heroine of the Crimean War. She was awarded the Crimean Medal, the French Legion of Honour and a Turkish medal, becoming the first Black woman to make her mark in British public life. She spent the rest of her life traveling and working between London and Kingston, Jamaica (Brooke, 1995). After a long interregnum, traditional healing among African–Caribbean and African immigrants returned to the attention of mainstream health services after World War II. Post-war traditional healing in the African–Caribbean and African communities has been closely linked to religion. Of these, African–Caribbean religion, in particular, has been posited to embody responses to oppression and exploitation and to enable the expression of spirituality, with the formation of a shared communal identity facilitating social support. Historically, the two dominant strands in African–Caribbean religion have derived from native African religions and European Christianity. While the former was suppressed, the latter was initially imposed upon slave communities and then encouraged by missionaries among freed slaves. Current beliefs encompass a range of syncretic blends, although the African elements are less overt in black British Christianity than they are in the Caribbean and in Africa (Loewenthal and Cinirella, 2003). Newer black religious movements have since emerged, including Rastafarianism in the Caribbean and the United Kingdom (Hickling and Griffith, 1994). However, the dominant form of black religion in the United Kingdom is Christianity with African influences (Jules-Rosette, 1980). A belief prevalent among immigrants from rural (and to a lesser extent urban) African–Caribbean and African communities is that it is possible to influence the health or well-being of another person by undertaking directed action from a distance. Culturally sanctioned ways of dealing with this often involve consulting traditional healers and the use of counter-measures including religious rituals and magic. More specifically, a belief in Obeah has been encountered among the African–Caribbean diaspora in Britain, with various countermeasures being deployed. Obeah is a term used in the West Indies to describe a form of witchcraft containing elements of Christianity, animism, folk medicine, mysticism and personal malevolence. It is associated with both benign and malign magic.

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In some of the Caribbean nations, Obeah encompasses religious practices originally derived from the Central and West African religions of slaves, which then borrowed from the rituals of a later wave of migrants, Hindu indentured laborers from India. Thus, this form of Obeah came to adopt elements of Hindu worship (particularly Kali puja – the worship of the Hindu Goddess Kali) into an already eclectic blend (McNeal, 2003). In other parts of the Caribbean, Christians absorbed elements of Obeah into their religion and vice versa (Roach, 1992; Lefley and Bestman, 1977). Obeah is practised in Surinam, Jamaica, the Virgin Islands, Trinidad, Tobago, Guyana, Belize, the Bahamas, St Vincent and the Grenadines, Barbados and other countries in the Caribbean. African–Caribbean patients with mental illness or their carers may believe that an Obeah curse has been placed upon the patient and have been known to consult an Obeah man (a traditional healer specializing in the removal of an Obeah curse) to counter this (Dein, 1997; Roach, 1992; Lefley and Bestman, 1977). Possession states have also been encountered among African–Caribbean patients, for example in West Indian Pentecostalists, and they often approach Pentecostal Christian religious healers for exorcism (Dein, 1997; Ward and Beabrun, 1981). Possession indicates the takeover of a person’s mind and body by an external force such as a spirit, deity or ancestor. The force then controls the person’s thoughts and actions and deprives them of responsibility for these. In many parts of the world, possession states are culturally sanctioned and considered normal, with people freely admitting to having spirits and deities speak and act through them. Anthropologists have demonstrated that this mode of expression is often used by disadvantaged members of a group to gain otherwise unattainable ends. The possessed person enters a trance-like state and may perform actions that are totally out of character (Dein, 1997). Citing anecdotal reports, Dein has pointed out that this state may be misdiagnosed as schizophrenia in multicultural Britain and treated as such. However, he posits that a more satisfactory outcome is likely if an exorcism ritual is performed by the relevant religious healers. He also cautions that the treating psychiatrists need to be alert to the interpersonal problems and family dynamics that may have played a role in precipitating the illness (Dein, 1997). Most African–Caribbean people who practice Christianity in the United Kingdom tend to be part of black-led churches, with predominantly black memberships. The most popular faiths are Pentecostal and Charismatic Christianity, and Seventh Day Adventism (Loewenthal and Cinirella, 2003). In 1993, Cochrane and Howell’s random community sample of black men in the West Midlands showed that 52% belonged to Pentecostal Churches (almost completely black-led), 27% to white-led churches (Church of England, Roman Catholic) with 4% Rastafarian, and 18% citing no religious affiliations (Cochrane and Howell, 1995). Leadership in black-led churches tends to be strong and respected, since religious leaders emerge by force of personality, charisma, popularity and dedication to the needs of their communities. The culture of such churches emphasizes enthusiastic prayer, including speaking in tongues, dance and trance-like possession states, and on living a moral, family-centred life, with good physical health practices, and kindness and helpfulness to others (Loewenthal and Cinirella, 2003; Howard, 1987). The very nature of the culture of such faiths often renders the participation of the religious healer in pathways to mental health care inevitable. To understand such processes, Allen and Wallis’ observations of pathways to care among white Scottish Pentecostalists, delineating six typical help-seeking pathways are useful (Allen and Wallis, 1992). These include:

COMPLEMENTARY AND ALTERNATIVE MEDICINE

1. 2. 3. 4. 5. 6.

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divine healing as an alternative to the National Health Service (NHS); divine healing as a first resort followed by use of the NHS; divine healing as a supplement to the NHS; divine healing as a last resort; NHS only; and neither.

Factors influencing choice of pattern of utilization among the Scottish Pentecostalists included the type of disorder, its seriousness and suddenness of onset, and its imputed cause, all of which hold relevance to similar faith communities of different (black, in this case) ethnicity. This is particularly germane given the close links between religion, and particularly Pentecostalism, in black British communities, traditional healing, their perceptions of mental illness and pathways to mental health care.

17.4

COMPLEMENTARY AND ALTERNATIVE MEDICINE – RELEVANCE AND COLLABORATION

The Cochrane Collaboration defines CAM as ‘‘a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health systems of a particular society or culture in a given historical period’’ (House of Lords, 2000). Recent decades have witnessed a significant growth of interest in Complementary and Alternative Medicine (CAM) in the United Kingdom, where about 1 in 10 of the adult population consults a CAM practitioner every year, with 90% of these contacts happening outside the NHS (Thomas, et al., 2001). Despite the lack of a credible evidence base, depression and anxiety are two of the leading indications for using CAM worldwide (Thachil, et al., 2007). As discussed earlier, current patterns of health service delivery outside mainstream medicine render a clear demarcation between CAM and traditional medicine difficult and impractical. The upsurge in the number of CAM consultations has led to providers of conventional health care attempting to address the issue. In 2000, the UK House of Lords ordered a Select Committee on Science and Technology to examine the issue and make recommendations for public health policy. The disciplines it examined included osteopathy, chiropractic, acupuncture, herbal medicine, homoeopathy and aromatherapy (the so-called Big Five of the CAM world based on popularity and currently available evidence of efficacy); purely complementary approaches like the Alexander Technique, Bach flower remedies, massage, counselling stress therapy, hypnotherapy, reflexology, shiatsu, meditation and healing; long-established and traditional systems of health care such as Ayurveda, traditional Chinese medicine, yoga, anthroposophical medicine, nutritional medicine, naturopathy and Maharishi Ayurvedic medicine, and alternative approaches that lack a credible evidence base such as crystal therapy, iridology, radionics, dowsing and kinesiology. The evidence they received from almost all the different therapists indicated that at the point of diagnosis, if the practitioners thought that their treatments would not work, the patients are usually referred to a mainstream medical practitioner (House of Lords, 2000). Some of the reasons for the use of CAM include the relatively lower incidence of adverse effects, perceived effectiveness, a desire for egalitarian relationships with medical

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practitioners, a holistic approach to the individual’s problems and dissatisfaction with conventional health care (Ernst, 2000; Astin, 1998). Kleinman, as cited by Vincent and Furnham (1997) has suggested that there are several areas where CAM consultation styles may hold more appeal than those of mainstream medicine. These include: 1. Emphasis on overall experience of illness – CAM therapists often take into account social and familial issues during their assessment of a patient, whereas conventional medicine focuses on the individual patient and the specific complaint and bodily organ/s involved. As patients will experience their problem in the context of their family and work and so on and may even see these things as the cause of their problems, they may prefer the CAM approach. 2. Simple language – The language of conventional medicine may have become too technical and difficult for patients and their families to understand. CAM practitioners are more likely to use language familiar to patients and their families. 3. Lay explanations – CAM explanations for disease are often easier for a patient to understand than technical medical explanations. CAM explanatory models are also more likely to consider factors such as emotional and social factors in disease and hence, hold relevance to the patient’s overall experience. This may lead to more concordance between patients’ and practitioners’ explanatory models. 4. Illness without pathology – Patients sometimes feel that something is wrong but are told after examination by a mainstream medical practitioner that no pathology can be found to support their perceptions of illness. However, in many cases the patients continue to feel unwell. CAM practitioners are often more willing to diagnose and treat such symptoms and to provide an explanation, an approach obviously more satisfactory for the patient. The House of Lords Select Committee Report noted that in several UK medical schools, some exposure to the main issues relevant to CAM is currently part of standard undergraduate curriculum (House of Lords, 2000). While concluding with clear recommendations for funding CAM research on efficacy, safety and cost-effectiveness, the report also discovered a dearth of credible information on CAM approaches, both within the NHS and the public domain. However, around the same time, the United Kingdom Department of Health (DOH) had published an Information Pack on CAM for Primary Care Groups (PCGs) which dealt with six therapies: acupuncture, aromatherapy, chiropractice, homeopathy, hypnotherapy and osteopathy (Department of Health, 2001). This has in part been responsible for several of these therapies being made accessible to patients by PCGs and for the UK Department of Health funding several CAM research projects. In fact, a 1995 survey found that 40% of GP partnerships in England provide access to CAM for NHS patients (Thomas, et al., 1995). A successful example of an integrative healthcare model is the Southampton Centre for Complementary and Integrated Medicine, which operates a contract with the Dorset Area Health Authority. This represents a formal contract within the NHS for provision of CAM services which operates in two parts. The first part is an integrated medicine unit which the Center operates every month at a GP practice in Dorset. GPs in local clinics are able to refer patients with any of six specific conditions to this clinic. These conditions include those with mental health aspects for example Chronic Fatigue Syndrome, Irritable Bowel Syndrome, migraine headache, child behavioral problems and eczema. The second part of the contract allows patients to travel to the Center in Southampton for treatment. This service has proved to be quite popular with

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GPs, especially as a way of dealing with patients whom they have found difficult to help (House of Lords, 2000). Older initiatives include the Qalb Centre in East London, established in 1993 by a group of mainly Asian professionals, including social workers, counsellors and a psychiatrist. This provides a holistic form of counselling and complementary therapies for Asian, African and African–Caribbean people with mental health problems. The complementary therapies available include reflexology, massage and yoga. Many clients are referred to Qalb by mainstream psychiatric services (Fernando, 2003). Examples of other initiatives offering Traditional Chinese Medicine and Acupuncture include a pilot GP-referred community mental health clinic in East London and the selfreferred Gateway Clinic at Lambeth Hospital (a Mental Health Unit in the South London and Maudsley NHS Foundation Trust) (Au and Hiew, 2002). Current trends across the United Kingdom indicate that such attempts at pragmatic collaboration are by no means the exception (House of Lords, 2000).

CONCLUSION Research from the developing world has shown that pathways to care for mental illness are diverse and are dependent on socio-cultural and economic factors (Patel, et al., 1997; Razali and Najib, 2000). Reasons cited for the use of traditional healing and complementary medicine include a congruence of explanatory models, the desire for egalitarian relationships with medical practitioners, the relatively lower incidence of adverse effects, perceived effectiveness, a holistic approach to the individual’s problems and dissatisfaction with conventional health care (Kapur, 1979; Astin, 1998; Patel, et al., 1997; Razali and Najib, 2000). It is interesting that these relate so closely to the reasons cited by Healey and Aslam (1990) and Bhopal (1986) following their seminal studies among South Asian immigrants in the United Kingdom. Research that explores these issues would be invaluable to mental health services in multicultural Britain. As Cochrane and Sashidharan (1995) point out, ‘‘there is a lack of research pertaining to common mental health experiences in the (ethnic minority) communities at large’’. This, as discussed earlier, is particularly germane to the interaction of traditional healing and mental health among African–Caribbean and African communities. The higher vulnerability of these communities to severe mental illness and the complex pathways they follow into mental health care renders such work vital to their care (Bhui, et al., 2003). In this context, the dearth of such research almost 60 years after the arrival of the African–Caribbean immigrants of the Windrush generation (Phillips and Phillips, 1998) calls for a redefinition of the ethnic health research agenda. Understanding the dynamics of consultations with traditional healers and CAM practitioners, and the profile of their clientele is important for mainstream medicine, as it may provide insights that can help structure culturally appropriate services for patients (Karmi and McKeigue, 1993). Currently available evidence from both community and hospitalbased research indicates that consultations with traditional healers play a significant role in the pathways to mental health care of British Asians (Aslam, 1979; Donaldson, 1986; Bhopal, 1986; Dein and Sembhi, 2001). The collaborative health care approaches that have been successfully implemented with CAM may provide a template for similar safe referral pathways and collaboration with traditional healers (House of Lords, 2000; Au and Hiew, 2002). This can enable quicker access to mental health services for patients from ethnic

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minority and immigrant groups, thereby avoiding such critical delays as may contribute to the duration of untreated psychosis, the prolongation of common mental disorders, treatment-resistance and disability. As already discussed, patients from black and Asian backgrounds appear to differ from white patients in their utilization of state mental health services, have higher rates of detention and have more complex pathways into care (Johnson, et al., 1983; Bhui, et al., 2003; Raschid and Jagger, 1992). The related issues are important to the development of services that are effective, efficient and culturally competent. Far from being relevant only to some ethnic minorities, such initiatives should logically hold relevance across the multicultural spectrum of the UK population. In the context of globalization, the multicultural nature of British society, and the entry of new migrants of different ethnicities, research into the pathways to care of all such groups is of vital importance to nationwide health service planning and provision.

REFERENCES Allen, G. and Wallis, R. (1992) Pentecostalists as a medical minority, in Alternative Medicine in Britain (ed. M. Saks), Clarendon Press, Oxford. Aslam, M. (1979) The Practice of Asian Medicine in the United Kingdom, PhD thesis, University of Nottingham, UK. Astin, J.A. (1998) Why patients use alternative medicine: results of a national study. JAMA, 279, 1548–53. Au, S. and Hiew, S. (2002) Integrating western medicine and traditional Chinese medicine in GP surgeries and the community: a review of two pilot schemes. The Journal of the Royal Society for the Promotion of Health, 122 (4), 220–5. Bhopal, R.S. (1986) The inter-relationship of folk, traditional and western medicine within an Asian Community in Britain. Social Science & Medicine, 22 (1), 99–105. Bhui, K. (ed.) (2002) Racism and Mental Health: Prejudice and Suffering, Jessica Kingsley Publishers, London. Bhui, K., Stansfield, S., Hull, S. et al. (2003) Ethnic variations in pathways to and use of specialist mental health services in the UK. Systematic review. British Journal of Psychiatry, 182, 105–16. Blakemore, K. (1982) Health and illness among the elderly of minority ethnic groups living in Birmingham: some new findings. Health Trends, 14 (3), 69–72; 279, 1548–53. Brooke, E. (1995) Women Healers: Portraits of Herbalists, Physicians and Midwives, Healing Arts Press, Rochester. Campion, J. and Bhugra, D. (1997) Experiences of religious healing in psychiatric patients in South India. Social Psychiatry and Psychiatric Epidemiology, 32, 215–21. Chopra, A. and Doiphode, V.V. (2002) Ayurvedic medicine: core concept, therapeutic principles, and current relevance. Medical Clinics of North America, 86, 75–89. Cochrane, R. and Howell, M. (1995) Drinking patterns of Black and White men in the West Midlands. Social Psychiatry and Psychiatric Epidemiology, 30, 139–46. Cochrane, R. and Sashidharan, S.P. Mental health and ethnic minorities: a review of the literature and implications for services. University of Birmingham and Northern Mental Health Trust [February 1995] at www.academicarmageddon.co.uk/library/ETHMENT.htm. Dalrymple, W. (1994) City of Djinns – A Year in Delhi. Flamingo. London, HarperCollins. Dein, S. (1997) ABC of mental health: mental health in a multi-ethnic society. British Medical Journal, 315, 473–76. Dein, S. and Lipsedge, M. (1998) Negotiating across class, culture and religion: psychiatry in the English inner city, in Clinical Methods in Transcultural Psychiatry (ed. S.O. Okapu), American Psychiatric Press, Washington DC. Dein, S. and Sembhi, S. (2001) The use of traditional healing in South Asian psychiatric patients in the UK: interaction between professional and folk psychiatries. Transcultural Psychiatry, 38, 243–57.

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Patel, V., Simunyu, E. and Gwanzura, F. (1997) The pathways to primary mental health care in highdensity suburbs in Harare, Zimbabwe. Social Psychiatry and Psychiatric Epidemiology, 32 (2), 97–103. Prathikanthi, S. (2007) Ayurvedic treatments, in Complementary and Alternative Treatments in Mental Healthcare(eds J.H. Lake and D. Spiegel), American Psychiatric Publishing Inc., Washington DC. Phillips, M. and Phillips, T. (1998) Windrush: The Irresistible Rise of Mult-Racial Britain, Harper Collins, London. Ramachandra Rao, S.K. (1990) Mental Health in Ayurveda: source book of Charaka & Sushruta Samhita. National Institute of Mental Health and Neuro Sciences, NIMHANS Publications, Bangalore. Raschid, A. and Jagger, C. (1992) Attitudes to and perceived use of healthcare services among Asian and non-Asian patients in Leicester. British Journal of General Practice, 42, 197–201. Razali, S.M. and Najib, M.A. (2000) Help seeking pathways among Malay psychiatric patients. International Journal of Social Psychiatry, 46 (4), 281–9. Roach, R. (1992) Obeah in the Treatment of Psychiatric Disorders in Trinidad: An Empirical Study of an Indigenous Healing System. MSc. thesis: McGill University. Sandoval, M. (1979) Santeria as a mental healthcare system; an historical overview. Social Science and Medicine, 13B, 137–51. Thachil, A.F., Mohan, R. and Bhugra, D. (2007) The evidence base of complementary and alternative therapies in depression. Journal of Affective Disorders, 97 (1–3), 23–35. Thomas, K., Fall, M., Parry, G. et al. (1995) National Survey of Access to Complementary Healthcare via General Practice. Medical Care Research Unit, SCHARR, Sheffield. Thomas, K.J., Nicholl, J.P. and Coleman, P. (2001) Use and expenditure on complementary medicine in England: a population based survey. Complementary Therapies in Medicine, 9, 2–11. van Os, J., Castle, D.J., Takei, N. et al. (1996) Psychotic illness in ethnic minorities: clarification from 1991 census. Psychological Medicine, 26, 203–8. Ward, C. and Beabrun, M.H. (1981) Spirit possession and neuroticism in a West Indian Pentecostal community. British Journal of Clinical Psychology, 20, 295–6. Weich, S., Nazroo, J., Sproston, K. et al. (2004) Common mental disorders and ethnicity in England: the EMPIRIC study. Psychological Medicine, 34 (8), 1543–51. Weiss, C.I. (1992) Controlling domestic life and mental illness: Spiritual and aftercare resources used by Dominican New Yorkers. Culture, Medicine and Psychiatry, 16, 237–71. Wynaden, D., Chapman, R., Orb, A. et al. (2005) Factors that influence Asian communities’ access to mental health care. International Journal of Mental Health Nursing, 14 (2), 88–95. Census of Population (2001) Census Dissemination Unit. http://cdu.census.ac.uk/ (6 November 2007).

CHAPTER 18

Psychotherapy or Religious Healing? The ‘Therapeutic’ Cult of Charismatic Catholics in Italy Micol Ascoli Consultant Psychiatrist, East London NHS Foundation Trust, London, UK

Abstract Religious healing is nowadays a widespread phenomenon in Western industrialized societies, where different healing rituals have had a substantial impact on all social class groups. This chapter focuses on one of the most widespread religious healing practices in Italy: that of Charismatic Catholics; Pentecostal religious groups and communities, officially recognized by the Catholic Church, that gather to read the Bible, to praise God, to pray ‘in tongues’ and, most of all, to heal those who suffer, in their bodies and souls, using the ‘words of science’ and the ‘charisma of healing’ sent to the faithful by the Holy Spirit. Following a brief introductory description of demographic and historical data about the origins and the development of the Charismatic movement in Italy, its institutional setting, its relationships with the Catholic Church and its theological foundations, the author analyzes the underlying conception of illness of these religious groups, as well as the therapeutic mechanisms involved in the religious rituals believed by Charismatic Catholics to result in healing. Finally, the author discusses the theoretical differences between the foundations of the Catholic Charismatic religious healing rituals and those of modern Western psychotherapies.

18.1

INTRODUCTION

Charismatic movements and Pentecostal Churches within the Christian religion began to spread in America in the late nineteenth century, initially within the Protestant Church. The Catholic Charismatic movement, called Catholic Charismatic Renewal, originated after the Vatican Council II (1962–1965). Charismatic movements now are found in 204 countries in Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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the world, in various shapes, structures and juridical status in the different countries, with an estimated number of followers of about 100 million. In Italy, the Catholic Charismatic Renewal movement originated in the early 1970s. This Pentecostal cult, called ‘Renewal in the Spirit’, defines itself as being essentially ‘a stream of grace’, it lacks an officially recognized founder and includes about 300 000 believers. The faithful gather in ‘groups’, ‘communities of alliance’ and ‘communities of life’. While such groups can be described as simple assemblies of believers who gather to pray, the communities represent a more complex form of social and religious aggregation. The ‘communities of alliance’ recognize a specific missionary purpose and are regulated by a set of norms or a formal statute subject to the approval of the local diocese. The faithful belonging to the ‘communities of life’ go as far as living together and having communal ownership of members’ property and other resources. The religious leaders, often called ‘animators’, are responsible at a local, regional or national level, for the groups, the communities, the activities, the associations and the training centres within Renewal in the Spirit, whose statute of incorporation was formally approved by the Italian Episcopal Conference in 1995. Renewal in the Spirit is therefore an association of the faithful that is officially recognized by the Catholic Church. Renewal in the Spirit is a highly structured organization with a constitution, a National Committee, regional coordinators, a National Council, a secretariat and a press office, an administration and accounting office and an official web site. Among its many services are a crisis helpline, an official journal, a publishing company and formal training courses. The theological basis of the Catholic Charismatic movement is of a Trinitarian nature.1 Its doctrine highlights the continuity of the pentecostal experience of the apostles,2 who received their charisma from the Holy Spirit, and recognizes the role of the Holy Spirit as a powerful re-evangelizing agency in society, as well as the living presence of the Holy Spirit in the everyday life of the faithful. Renewal in the Spirit claims to have re-discovered a new and deeper experience of personal faith, leading to a renewed relationship with God, and to a profound conversion and transformation of the lives of the faithful. Popes Paul VI and John Paul II have formally acknowledged the Catholic Charismatic movement. In several formal addresses, they have praised different aspects of Renewal in the Spirit, while at the same time cautiously encouraging its members to maintain their links to the Roman Catholic Church. Interestingly, in his many public addresses to Renewal in the Spirit between 1979 and 2002, Pope John Paul II never explicitly mentioned the healing rituals of the Charismatic Catholics. Pope Benedict XVI has not yet formally addressed any official message to Renewal in the Spirit. However, before being elected as Pope Benedict XVI, Cardinal Joseph Ratzinger was the Head of the Congregation for the Doctrine of the Faith, and the author of the document ‘Instructions on the prayers to obtain healing from God’,3 where specific guidelines are given in order to prevent any excess or derailment of Charismatic religious healing.

18.2

THE CHARISMATIC THEORETICAL APPROACH TO ILLNESS

The Catholic conceptualization of illness is officially expressed in the document ‘Instructions on the prayers to obtain healing from God’, published by the Congregation for the Doctrine of the Faith in 2000.4 In the Catholic Doctrine, illustrated in this document,

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illness has several meanings and purposes and can be understood in different ways. Illness can represent a means of spiritual purification and of reunion with Christ, in deep spiritual conjunction with His passion, and the participation of the sick person in Christ’s redemptive suffering. It can also represent a test for the just and a positive occasion for exercising Christian charity, for those associated with the sick person. An illness can be a privileged moment of prayer, to implore healing or to entirely accept the disease with faith and abandonment as a manifestation of God’s mysterious will. Most importantly, an illness can represent, through a miraculous healing and the recovery of the whole person, body and soul, the testimony of God’s power and the triumph of God’s domain over Evil. In this case, the illness is ultimately there to show, through miraculous healing, that Jesus can forgive the sufferer’s sins. On the other hand, illness, according to Catholic doctrine, is also closely related to Evil. An illness can be God’s punishment for one’s sins, in which case the sick person imploring God for healing ultimately acknowledges and confesses to be rightly punished for sins committed in the past. In this sense, the illness can be a means for making the sinner mend his ways and for the conversion of the disbeliever. In any case, having accepted God’s will, the person’s desire to be healed is admirable and deeply humane. The above named document also includes a number of disciplinary guidelines on how to conduct the prayers required to obtain healing from God. These guidelines state that the prayers should be led by an ordained minister who should attempt to maintain an atmosphere of serene devotion within the assembly, that the ceremonies should be authorized by a bishop or a cardinal, that the leaders should not resort to manifestations of hysteria, artfulness, theatricality or sensationalism, and that if healing occurs during the prayer, it should be cautiously accepted and testimonies should be accurately collected and submitted to the local ecclesiastical authority. The Catholic Charismatic conceptualization of illness does not diverge from that described above, and the underlying conceptualization of illness that supports the Charismatic faith does not exceed the limits imposed by Roman Catholic doctrine. However, as far as healing rituals are concerned, their guiding principle for the Charismatic Catholics is very simple: the patients are ill, in their bodies and/or souls, because they have experienced some subtle but ongoing difficulties in their encounter with God, and only through a return to proper religious practice can they be freed. Going back to religion, through prayer, is therefore, their only recognized and proper way to be healed. In other words, the explanatory model of illness of these religious groups entails a redefinition of the meaning of physical and mental illness at a purely metaphysical level. This metaphysical meaning of the illness clashes or might be even considered totally incompatible with the interpretations and the etiological models of illness typical of conventional, scientific, contemporary medicine. In spite of this, adherents of these religious healing rituals may still, simultaneously, use some aspects and practices of alternative medicine as well as scientific Western medicine, as they might view healing as multidimensional and consider faith healing as essential to healing of the spirit as medical treatment is to healing of illness episodes. Nevertheless, in many testimonies witnessed by the author, in Italy and in the United Kingdom, the path leading the person to seek religious healing within Charismatic groups or communities often starts with a substantial failure of Western medicine to provide the expected treatment or produce the desired outcomes or recovery. The following testimony illustrates these points.

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Everything started in 2001, when I began to experience back problems. I underwent surgery but I didn’t get any better. After an operation on my left leg, I suffered from DVT (deep venous thrombosis) and severe depression. I could only walk with crutches and my depression was getting worse by the day. I even considered suicide. I was fed up with medications and my life was getting more and more difficult. I was eventually healed in 2006, when I attended the Charismatic Community [. . .] with my wife. During the prayer, Jesus touched me with his love and healed me. It was like my body didn’t belong to me any more, it belonged to Jesus. He had got into my heart and He wanted to purify it. By the time I got back home I was already walking better. I was not in pain any more. With time, my back pain and depression cleared up and I understood that only Jesus could have been such a good doctor. I have stopped all medications since then.5

18.3

THERAPEUTIC FACTORS IN CATHOLIC CHARISMATIC RELIGIOUS HEALING

Catholic Charismatic healing rituals occur during the prayer meetings of these groups or communities, where prayers of the faithful are guided by charismatic leaders or animators. The animators have the specific task of conducting the prayers according to the inspiration of the Holy Spirit. Animators are those who, upon completion of a long spiritual journey within the community, have the following gifts (‘charisma’), which are specific to charismatic prayer: 1) Prophecy; that is the ability to speak with people for their enlightenment, exhortation and comfort. 2) ‘Speaking in tongues’; that is the ability to pray in a much deeper way, united with the Holy Spirit who expresses Himself through the animator, by means of language unintelligible to others (glossolalia). 3) The gift of interpretation; that is the ability to translate to the congregation of the faithful what has been expressed ‘in tongues’. 4) The ‘language of knowledge and science’; which consists of a particular form of spiritual enlightenment of the animators, a specific gift that God is believed to have given them, enabling them to communicate to the congregation in such a way that the faithful can better understand specific truths of the faith. 5) Discernment; that is the ability to understand whether or not what is felt in the group prayer comes from the Holy Spirit, and to lead the group prayer in such a way as to prevent derailment. 6) Healing; that is breaking free from ‘negative forces’ and bodily illness, if God so wishes. Therefore, the very definition of charisma entails the presence of a ‘gifted’ animator as well as a collective dimension in which the charisma reveals itself. Each of the charisma listed above seems to be there to be extended from the Holy Spirit to the larger community through the activities of the animators. The prayer leaders are not considered to be healers. They are rather recognized as vessels through whom the Holy Spirit’s messages and healing powers are transmitted to the congregation in general and to the sufferers in particular. The animators describe themselves not as healers or therapists personally gifted with miraculous powers or other therapeutic skills, but as figures that act in a more impersonal manner, under the inspiration of the ‘charisma of healing’ that the Holy Spirit gave them, to enable them to extend that spiritual healing to all the faithful attending the prayer ceremony.

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The congregation’s belief in and respect for the animators’ authority derives from several sources: from the long spiritual journey they accomplished within the community, often over a period of many years; from the continuing ‘evidence of a link’ between the animators and the Holy Spirit, as shown by their speaking in tongues, interpreting and prophesying; sometimes, even from years of being praised in ‘testimonials’ from congregants who ‘attest’ that they have been healed through the efforts of the animators. However, unlike what happens in other salvation cults, where healing is believed to result from some sort of ‘supernatural powers’ of the cult leader, the healing procedures of Charismatic Catholics are based on the presence of the group of faithful that gather to pray, guided by the animators, rather than on some leader’s personal healing power. In the author’s experience with charismatic groups in Italy and in the United Kingdom, as well as from review of multiple Catholic Charismatic web sites, the claim that ‘only the Lord Jesus Christ is the real healer’ is constant and universal, whilst the one basic principle to direct the prayer is to look for what will bring the congregation into a more complete relationship with Jesus Christ (not with the animators). This principle is clearly expressed by Fr Peter C. Sanders: A young woman called Martha once approached me asking if she could learn to heal. My response distressed her somewhat. I said, ‘‘I don’t really know how to heal. I have never healed anyone, so I would not be able to teach this. Only Jesus Christ is the Healer. Our job is to lead broken people to His Presence and He will take care of the rest.’’ Martha insisted on coming to the Healing Institute. When we broke into work groups, she would wave her hands over people’s broken areas, attempting to transfer energies that she hoped would alleviate ailments. I shared that healing is not about such techniques, but about genuine prayer and intercession. She could not conceive this and stopped coming after two sessions.6

18.4

DISCUSSION

From the author’s perspective as a psychiatrist and psychotherapist, the basic therapeutic factor of Charismatic Faith Healing is rather non-specific and consists of the redefinition of the meaning of one’s illness at a spiritual level, within the context of a group dynamic. When Charismatic healing takes place, this always occurs within a collective framework. Those who approach the Charismatic group or community in search of healing go through a process of redefinition of the meaning of their suffering, where healing is seen as part of a more complex and all-encompassing spiritual ‘journey of renewal’, which occurs through a powerful process of re-socialization within a religious community that is perceived as a real family metaphor. This collective dimension provides the sufferers with extraordinarily strong support and reassurance that they can immediately perceive. Furthermore, the charismatic healing occurs within a ritual framework, in an atmosphere of great emotional intensity, based on an exalting salvation ideology shared by the whole group. The psychological climate of exultancy and jubilation during the group’s meetings accompanies the healing and results in a subjective feeling of radical change, which goes much beyond the simple recovery from an illness, and in the adoption of a new and all-pervasive worldview, after which nothing is perceived like before. The Charismatic healing is always framed within a global renewal, and it is experienced like a total spiritual regeneration that, in the subjective perception of the new follower, marks a clear boundary in their life, between what was before and what came afterwards.

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According to the definition of ‘psychotherapy’ that one may hold, Catholic Charismatic religious healing could be considered as a form of ‘culture-specific psychotherapy’. There are many possible definitions of the term ‘psychotherapy’. Some of them are very broad, while others are narrowly restricted. In the author’s opinion, a possible definition of psychotherapy that may be useful to distinguish it from a religious healing practice could be the following: Psychotherapy is a therapeutic relationship that implies emotional, affective and cognitive aspects, that avails itself of specific psychological procedures, and that arises within an interpersonal encounter between a patient who suffers and a present and active therapist. The therapist practices according to a theory of psychological development and of the symptoms’ occurrence, a therapeutic technique consistent with this theory, an authentic interest in the patient’s well-being and within the framework of professionally shared ethical principles. Different schools and types of psychotherapy could be included within this definition. They differ from one another by a number of structural factors, such as the duration of treatment, the goals of treatment, the procedures and techniques used, the treatment setting, the patient’s degree of activity and participation in the therapeutic process, and the distinctive and specific features of the psychological relationship between the patient and the therapist. In the author’s opinion, the main difference between contemporary Western psychotherapy and Catholic Charismatic faith healing is that in the latter the therapist is ultimately not present. Although one could argue that the animator of the charismatic group, as a matter of fact, plays the role of the psychotherapist, a deeper analysis of the Charismatic leader’s role would show that this is not the case. Those who have faith in Charismatic religious healing are ultimately engaged in a relationship with transcendent and therefore not-present entities (The Holy Spirit, Christ or God), rather than with the animators. The animators who lead the charismatic healing practices offer themselves only as simple mediators of a transcendent entity to whom they entirely attribute the responsibility and the power of their own acts. The charismatic leaders are only acting as secondary agents, as mere ‘vessels’ who, in order to produce change, need to depend on a much more powerful ally, the Divinity, who alone has the real power to heal and what is believed to be recovery can only occur if patients believe in the existence of such a divine ally. The charismatic leaders are therefore absent in their personal identities, they are absent as founding human figures who interact in the complex dialectics of the emotional exchanges between patient and therapist. The charismatic leaders take no ultimate responsibility for the healing process and their own psychological world does not take part in any personal therapeutic relationship with the patients. On the other hand, psychotherapy as a process is largely the opposite. Psychotherapists are personally and directly engaged in the therapeutic relationship without any mediator, with their cognitive and affective presence, with their activity, with their therapeutic technique and with their personal skills used to support the therapeutic relationship. Psychotherapists directly take upon themselves the responsibility of the treatment, of its course, duration and outcome, of the answers to give to the patients and of the relationship with them. A psychotherapist works in the ‘here and now’ of this relationship that is therefore configured as an authentic interpersonal encounter. This active presence of the therapist anchors the patient to the therapeutic process. The present and active therapist is a concrete

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figure that the patient, in the very moment of their crisis, can cling to, a concrete figure that the patient can invest with intuitive perceptions and hopes. The therapist’s internal dimension is an active reality, perceived and realized by the patient, who shapes it and makes it real as a hope of healing. A therapy is specific when the patient perceives a field of symbols, created by a healer, a shaman or a psychiatrist (Csordas and Kleinmann, 1990). Therefore, we can consider as specific any kind of intervention that contains within itself a cluster of aspects, mutually empowering themselves according to a symbolic coherence, and that produces a specific effect. The ideology of religious healing causes in the patient a state of ‘expectant faith and hope’ (Frank, 1973) on which the healing ritual operates, resulting in a tangible and extremely powerful psychobiological experience (Prince, 1976). Compared to this experience, the psychotherapeutic experience is nearly ‘abstract’. This could be one of the reasons for the success of religious healing practices, even in Western industrialized societies. The experience of religious healing produces a change in what Frank (1973) calls ‘the patient’s assumptive world’, that is the whole of the patient’s assumptions about the nature of the world, resulting in the adoption of a new, all-pervasive worldview (Tseng 2000). What the author has witnessed, in charismatic religious healing ceremonies, is a radical redefinition at a metaphysical level, of the key explanatory models, theoretical orientation, technique, aims and purposes of contemporary Western psychotherapies in a general sense. All these are aspects that the author considers incompatible with the non-religious conception of psychiatric disorders and psychotherapy. As far as explanatory models are concerned, the secular concept of illness becomes, in Charismatic faith healing, evil, defined as a crisis in the relationship with God, needing to be restored through prayer, which applies in the same way to any sufferer, no matter what their personal history might be. At the same time, the medical concept of health as mere absence of disease becomes the idea of salvation, understood as the static end point of a long spiritual journey. Confidence in a skilled, active and present psychotherapist, entirely responsible for the therapeutic process becomes faith in a transcendent almighty entity expressing itself by means of a mediator (the charismatic leader). Change becomes conversion, understood as the adoption of a radically different and all-pervasive worldview. The therapist’s presence and activity in the complex and evolving dialectics of the emotional exchanges with the patient becomes a false presence of a mediator between the sufferer and a powerful transcendent entity. Finally, the idea of a long exploratory process aimed at understanding one’s personal historical pathway to the illness, the reasons behind it and the mechanisms causing the persistence of the symptoms or life problems, typical of many Western psychotherapies, becomes a powerful, psychobiological experience of sudden revelation of truths and meanings that are in no way personal to the sufferer, but that are shared with the whole congregation and valid for everybody who shares the group’s belief system.

NOTES 1. According to the Christian doctrine, God exists as a one and only being, though manifesting itself through three distinct entities or agencies (the Trinity): the Father, the Son (incarnated as Jesus Christ) and the Holy Spirit. This doctrine, known as Trinitarianism, represents the main

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theological foundation of the Charismatic cults, within which the Holy Spirit is believed to be the divine agency manifesting itself during the prayer meetings and producing healing of the sick. 2. In the Christian doctrine, Pentecost is the descent of the Holy Spirit upon the Apostles and the community of Christ’s disciples gathered in Jerusalem after the death of Jesus Christ. According to the Christian belief, the Holy Spirit took the form of tongues of fire, its descent upon the Apostles resulted in a state of sacred possession during which the Apostles received from the Holy Spirit the gifts of speaking in tongues and prophesying. 3. Rome, Congregation for the Doctrine of the Faith, 14 September 2000, http://www.vatican.va 4. Ibid. 5. www.gesurisorto.it 6. Fr Peter C. Sanders, Oratorian, Catholic Charismatic Centre on the World Wide Web, http:// ccc.garg.com

REFERENCES Congregation for the Doctrine of the Faith (14 September 2000) http://www.vatican.va Csordas, T.J. and Kleinman, A. (1990) The therapeutic process, in Handbook of Medical Anthropology: Contemporary Theory and Method (Revised Edition) (eds C.F. Sargent and T.M. Johnson), 1996, Greenwood Press, Westport, CT. Frank, J. (1973) Persuasion and Healing: A Comparative Study of Psychotherapy, The John Hopkins University Press, Baltimore, Maryland. Prince, R. (October 1976) Psychotherapy as the manipulation of Endogenous Healing Mechanisms: A transcultural survey, Transcultural Psychiatry Research Review, 13, 115–33. Sanders, P. Oratorian, Catholic Charismatic Centre on the World Wide Web, http://ccc. garg.com Tseng, W.S. (2000), Handbook of Cultural Psychiatry, Academic Press, San Diego, http://www gesurisorto.it

BIBLIOGRAPHY Cooper, K. (2001) The Catholic Charismatic Renewal, Catholic Truth Society, London. Cordes, P.J. (1997) Call to Holiness: Reflections on the Catholic Charismatic Renewal, The Lithurgical Press, Minnesota. Csordas, T.J. (1994), The Sacred Self: A Cultural Phenomenology of Charismatic Healing. University of California Press, Los Angeles. Csordas, T.J. (2002), Body, Mind, Healing: Contemporary Anthropology of Religion, Palgrave Macmillan, New York. Laurentin, R. (1986), Speaking in Tongues: A Guide to Research on Glossalalia, William B. Eerdmans Publishing, Grand Rapids, MI. Sanders, P. (2003), Healing in the Spirit of Jesus: A Practical Guide to the Ministry, Wine Press Publishing, Enumclaw, WA, USA. Suenens, L.G. (1975), A New Pentecost? The Seabury Press, New York. http://www catholicfraternity.net http://www ccr.org.uk http://www holyspiritinteractive.net http://www iniziativadicomunione.it http://www religion-cults.com http://www rns-italia

CHAPTER 19

Maori Knowledge and Medical Science The Interface between Psychiatry and Traditional Healing in New Zealand Mason Durie Phychiatrist and Professor of Maori Research and Development, Massey University, Palmerston North, New Zealand

Abstract Like other indigenous populations, Maori in New Zealand developed a system of knowledge shaped by a close relationship with the natural environment. Out of that knowledge system, an approach to healing evolved. Although colonization in the nineteenth century led to a suppression of traditional healing and forced healers to practice in a covert manner, over the past 30 years there has been a renewed interest in traditional healing and its relationship to mental health programs. Equally important, however, has been the incorporation of Maori perspectives on health into modern mental health delivery systems. This has led to an expanded Maori mental health workforce that includes tribal elders as well as Maori health professionals. Although there are sometimes misunderstandings between cultural and clinical dimensions, Maori patients now have the opportunity to be cared for in an environment where healing and treatment can occur in parallel. As a result there have been improvements in treatment compliance, patient satisfaction and treatment outcomes.

19.1

INTRODUCTION

The indigenous people of New Zealand are Maori. Of Polynesian origin they first settled in New Zealand around 1000 CE, some 800 years before British colonization. Maori currently represent around 15% of the total population and at the 2006 census accounted for some 563 329 individuals with a median age of 22.7 years. (Statistics New Zealand, 2007). Like indigenous populations in other developed countries, Maori experience lower standards of health and have an increased prevalence of mental disorders and suicide (Baxter, 2007, pp. 121–38). Maori patients are more likely to be admitted to an inpatient unit (63% for Maori, 33% for European) (Trauer et al., 2004, pp. 83–6). Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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Prior to colonization Maori built a system of health around experience gained from close associations with the natural environment, reflecting a detailed knowledge of native plants and associated healing properties, as well as deep understandings of human motivation and encounters. The guardians of traditional knowledge were known as ‘tohunga’. Among other areas of expertise, ‘tohunga’ had responsibilities for healing and occupied positions of status and respect. But by the early twentieth century their influence had greatly waned and they were not afforded recognition until relatively recent times. The re-emergence of traditional healing as a contemporary health intervention is in sharp contrast to the political and professional climate in New Zealand a hundred years ago when healers were outlawed. Passed in 1907, the Tohunga Suppression Act effectively blocked the practice of traditional healing, at least in any public way, and not only led to a loss of traditional knowledge but also to a loss of confidence in the use of healing methods. However, following the repeal of the Act in 1964 there was greater acceptance of ‘tohunga’, not only within Maori communities but also within the wider society. The revived interest coincided with claims by indigenous peoples that their own world views, practices and cultures should not be subverted or oppressed but allowed to take a rightful place in modern societies. At the same time there was a worldwide awareness of the limitations of conventional medicine especially where it undervalued the human factor in favor of technological and pharmacological interventions. Increasingly the call was for better understanding of the significance of a whole-of-person approach to health and healing and the relative contributions that might be made by psychiatric treatment and traditional healing (Durie, 2001, pp. 157–65).

19.2

TRADITIONAL HEALING IN CONTEMPORARY NEW ZEALAND

Although the extent of traditional healing in contemporary New Zealand is not known, modern healers appear to have sizeable followings and there is an increasing interest in the traditional methods among Maori. After the repeal of the Tohunga Suppression Act, the struggles by healers to have their practices recognized and, at the very least tolerated without fear of recrimination, have been partly successful, though there remains some hesitancy about practicing openly for fear of exposure to ridicule and to regulations that constrain practice. Some healers, however, have been ready to take their place alongside other health providers (Durie, 1998, pp. 208–10). In 1995, for example, the Central Regional Health Authority, signed a contract with Te Whare Whakapikiora o te Rangimarie for the delivery of traditional healing services. A formative and process evaluation of the service showed that attendance was high, over 200 new cases being registered in a six month period and 1766 cases in total being registered (Lawson Te Aho, 1996). A survey of Maori women in 1984 had also found high interest in traditional healing. Of the 1177 survey participants, one in five indicated that a traditional healer would be consulted if there were a ‘mate Maori’ (i.e. an illness attributable to cultural or spiritual causes) (Murchie, 1984, p. 83). Meanwhile, at the request of some healers, the Ministry of Health has completed a set of standards for traditional healers (Ministry of Health, 1999). The standards cover responsibilities to ‘Mauiui’ (patients), liaison with other providers, the collection and dispensing of ‘rongoa’ (medicines), and a code of practice for ‘Tohunga Puna Ora’ (healers). While not prescribing an accreditation process for healers, the

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standards recommended regular training and supervision for trainees with defined training objectives. Traditional healing in New Zealand has not been rigidly defined but there are a number of features which distinguish it from conventional medical treatment. First, it occurs within a distinctive cultural context. It is important not to equate traditional healing simply with the administration of prepared plant products any more than modern medicine should be regarded as synonymous with over-the-counter sales of pharmaceuticals. Healing is governed by established (though often unwritten) codes of practice that draw on ethical, cultural and philosophical principles, as well as the use of particular plant materials. In this respect, the rationale for the healing activity will not be found solely in the physical remedies offered, but, just as important, in the traditions, beliefs and culture of the clients and the practitioners (Durie, 1996). It is not useful to attempt to understand traditional healing in terms of biomedical concepts and scientific proof. Though certain plants used in healing may have anti-bacterial or other therapeutic activity, and can be analyzed scientifically (Brooker, Cambie and Cooper, 1981), it is misleading to ascribe health changes only to those properties and to fail to appreciate other components of the healing process. Sometimes traditional healing is thought to occur in rural areas, close to tribal villages. Certainly a number of well known healers live and work in small communities and enjoy tribal patronage. But traditional healing is not confined to customary settings or tribal oversight. Many healers, male and female, operate within urban and metropolitan centers. In the greater Auckland region, although the numbers of healers cannot be quantified, they are thought to be ‘significant’ (Parsons, 1985, pp. 213–34) and in 1992 a national association of healers was formed in metropolitan Auckland rather than within a tribal territory. Of the wide range of physical treatments employed, most traditional healing methods use medicines derived from plants. Leaves, bark, roots, twigs, berries may be applied externally, swallowed as a potion, chewed or inhaled (Macdonald, 1973). The development of a Maori pharmacopoeia (Rankin, 1994), despite the risk of isolating one aspect of healing from the wider context, is at least an indication of the specificity and extent of traditional Maori medicines, ‘rongoa rakau’. In most cultures many people have some folk knowledge of the medicinal properties of plants, even if it is only as domestic and occasional users. Healers, however, have a much more extensive knowledge and have recourse to a large number of agents as well as interventions that do not use plant material. Maori traditional healers, have varying degrees of experience with massage (‘mirimiri’), incantations (‘karakia’), water therapy, suffusions, heat applications. However, in addition to possessing specialized knowledge about remedies and ailments, traditional healers are also distinguished by a capacity to combine physical treatments with ritual, interpretation of symbols and signs (such as dreams), prognostication, and an understanding of human interaction, including contact with the environment. In this respect they operate at a level well beyond a detailed knowledge of plants and plant properties (Robinson, 2005, pp. 214–22). In New Zealand the status of healers has changed over time. Previously ‘tohunga’, were required to enter ‘whare wananga’, specialized houses of learning, where they underwent extensive training that was rigorous, exacting and several years long (Rolleston, 1988). Entry requirements took into account tribal endorsement, the protection of tribal knowledge and tribal aspirations and healers were afforded respect and status. From an early age

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‘tohunga’ were immersed in tribal ritual and tradition and to a large extent they became the carriers of tribal culture. Contemporary healers are no longer so clearly aligned with tribes, nor are arrangements for their selection and training always explicit. As often as not expertise and credibility has been based on a natural skill or gift which in time has been ratified by the community. Personal qualities have been valued regardless of attendance at reputable houses of learning, or reputation as a tribal leader. In short not all healers have been set apart from others since childhood, or are recognized as tribal leaders. Nor is it possible to identify specific training programs for healers or to presume that all healers have emerged from similar backgrounds.

19.3

THE STRUCTURE OF MAORI HEALING PROCESS

Typically, ‘tohunga’ engage in a three-phase healing process that includes assessment, spiritual reparation and the recommendation of specific remedies. In the first phase, assessment, the aim is to uncover the cause of the problem and to map out an approach to alleviate the distress that it has caused. The focus tends to be on a search for evidence of a breach of protocol which might have given rise to offence or insult. A parallel focus on relationships within the family and between the family and the wider community complements the process. The underlying assumption is that the problem reflects a breakdown in relationships as a consequence of some unwise action or a failure to meet a social expectation. Assessment leads to a working formulation and corroboration is sought from family members who are invited to become part of the healing process. Incantations, ‘karakia’, comprise the main feature of the second phase of the healing process. Usually the ‘karakia’ is selected because it has particular significance to the occasion and is offered by the ‘tohunga’ as a measure of reassurance, protection, and restitution. ‘Karakia’ are often centuries old and employ references to the traditional gatekeepers of knowledge and the environment. However, many contemporary healers use ‘karakia’ that are based on Christian prayers – the intentions may be the same (reassurance, protection, restitution) but the references are to Christ and God rather than to Maori deities and forgiveness is stressed. In the third phase of the healing process the healer recommends specific remedies. These may include ‘rongoa’ such as juices from various native plants, or may require family members, as well as the ‘patient’ to undertake symbolic steps to ‘undo’ a perceived wrong. Immersion in running water, a pilgrimage to a sacred site, recitation of a ‘karakia’, reconciliatory gestures towards other members of the community, and disposal of items that may be associated with the problem, might all be recommended to the family. Underlying the healing process is the concept of ‘tapu’. Maori developed a system of knowledge that grouped events, places, actions and the environment according to the degree to which they were either safe or prohibited (Robinson, 2005, pp. 100–104). Under certain circumstances people might also be declared ‘tapu’, especially if they needed to be treated with caution to avoid possible misfortune for the wider community. Women who had recently given birth, for example were regarded as ‘tapu’ and were sequestered away from village life and the demands of everyday life thereby reducing the risk of infection and harm to either mother or baby. Over time, however, and especially after the advent of Christianity, ‘tapu’ became synonymous with sacredness, and the more mundane

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notion of risk was overshadowed by the attribute of sanctity. A paradigm shift occurred. ‘Tapu’ objects became hallowed or special, rather than objects warranting (for practical reasons) high levels of caution. Illness, as distinct from injury (which had a more obvious cause), was often seen as an infringement of ‘tapu’. Where there was a deliberate or accidental breach of a community convention or a social code, poor health was considered a likely outcome. Even though the causations of illness are differently regarded, similarities with a public health approach to medicine are obvious; both place emphasis on the link between illness, community and the environment. It is possible to conceptualize ‘tapu’ as a risk management framework which identifies situations of risk and prescribes approaches for avoiding the risk. Healers were sufficiently knowledgeable about their community, including any threats to health, to know how risk might be averted. The healer’s task was to restore balance between spiritual, mental, physical and family dimensions. Distinctions between physical disorders and mental disorders were not usually observed and poor health, regardless of the nature of the condition, suggested a lack of balance. A bodily ailment (such as a skin rash) might, for example be regarded as a reflection of mental processes, social circumstances and spiritual experiences. Similarly, health problems that would now be classed as mental disorders were deemed to have physical, as well as spiritual and family components. No matter what the ailment, the threephase healing process explored spiritual, mental, physical and social dimensions and used a range of remedies that addressed those four domains.

19.4

INDIGENOUS KNOWLEDGE AND SCIENCE

Harmonizing traditional healing and modern psychiatric treatment brings two different systems of knowledge into contact with each other – indigenous knowledge and science. For indigenous populations the relationship between people and the environment forms an important foundation for the organization of knowledge, the categorization of life experiences, and the shaping of attitudes and patterns of thinking. Because human identity is regarded as an extension of the environment, there is an element of inseparability between people and the natural world. The individual is a part of all creation and the idea that the world or creation exists for the purpose of human domination and exploitation is absent from indigenous worldviews (Duran and Duran, 1995, pp. 14–15). Instead, an ecological approach based on a symbiotic relationship has not only led to careful stewardship of the environment and natural resources, but also to a way of thinking within which health and illness are conceptualized as products of relationships – between individuals and wider social circles, and between people and the natural world. In this view the search for knowledge and understanding, especially in connection with the human condition, requires an outward flow of energy (a centrifugal pathway) rather than an introspective (centripetal) focus. Although some models of mental health such as those derived from communication theory have emphasized external relationships as key to explaining a disorder, for the most part modern psychiatric practice has promoted diagnostic and therapeutic methods where answers are sought within the individual. Much psychotherapy, for example, assumes that human behavior is a product of internal motivation, idiosyncratic patterns of responding, and internalized conflicts, and biological theories explain mental illness as an internal malfunction of synapses,

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hormones and bio-chemicals. In modern times Maori attitudes to sickness and health do not discount personal factors such as a ‘chemical imbalance’ but also place importance on determinants that can be attributed to an ‘imbalance of relationships’ (Tau, 1999). ‘Matauranga Maori’, Maori knowledge, recognizes the inter-relatedness of all things, draws on observations from the natural environment, and is imbued with a life force (‘mauri’) and a spirituality (‘tapu’) that accentuates the integrity of the knowledge system (Solomon, 2005, pp. 217–21). The juxtaposition of different bodies of knowledge requires that the integrity and distinctiveness of each be recognized and respected. Both indigenous knowledge and science are shaped by particular worldviews and each is bounded by a set of conventions that confer credibility and consistency – as well as limitations. Importantly the tools of one should not used to analyze and understand the foundations of another, nor should it be concluded that a system of knowledge that cannot withstand scientific scrutiny, or alternately a body of knowledge that is incapable of locating people within the natural world, lacks credibility. ‘Rationality must be understood to be a culture specific notion; one culture’s rational thought is not necessarily the same as another’s. Indeed, the rational thought that underlies scientific inquiry and biomedical practice is but one type of thought’ (Waldram, Herring and Young, 1995, pp. 214–18).

19.5

INDIGENOUS HEALING AND BIOMEDICINE

Because science has become a dominant global knowledge system, scientific method and objective measurement underlie approaches to health and illness across Western and Eastern countries. If a conclusion cannot be supported by empirical evidence, if practice is not evidence based, or if there is an inability to replicate results, then doubt is cast on effectiveness. Assumptions that there is only one approach often means that systems of knowledge not based on scientific principles run the risk of being rationalized according to scientific method (Semali and Kincheloe, 1999, pp. 20–1). The non-science knowledge base may be scientifically unbundled and manipulated to coincide with science, even if it is thereby rendered meaningless because it is out of context with other components of the parent knowledge system. By the same token indigenous people have often dismissed science as a knowledge system because it seems incapable of explaining spiritual phenomena or even recognizing the existence of nature as something more than a scientifically-observable construct (Knudtson and Suzuki, 1992, pp. 63–5). Indigenous communities have a number of reasons to be suspicious of science. Scientific research has often been used to characterize indigenous peoples in ways that reduce their standing in the eyes of other citizens, and not infrequently researchers have plundered indigenous knowledge, reconstructed its meaning and published findings as if they were their own. A further concern is linked to methodology. While analysis into smaller and smaller components is a standard scientific method, indigenous knowledge places greater emphasis on the construction of models where multiple strands can be accommodated to make up an interacting whole. Understanding comes not so much from an appreciation of component parts as from synthesis into a wider context – the centrifugal approach. While there are similarities between traditional healing and bio-medicine in so far as both are based on distinct methodologies and are carried out by practitioners who are

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recognized by their respective communities as having acquired skill and knowledge, there are also substantial and quite fundamental differences. Indigenous healing is based on tradition, which accepts that the medicines, techniques and knowledge of the past are effective because they are time tested and, in many instances, reinforced by the connection of humans with the natural environment. While new approaches to treatment may be incorporated, traditional healing is primarily informed and guided by the traditions of the past. Because the acquisition of knowledge relied heavily on the oral tradition and healers tend to gain understanding over a life time, healers are relatively old by the time they are able to use their skills wisely and exhibit considerable variation in their mode of practice. They are less concerned with proving the efficacy of their methods because they have faith in traditional medicines and do not need to question them. In contrast, biomedicine is empirical and positivist, based on a philosophy of skepticism (Gaines and Davis-Floyd, 2004, pp. 95–109). While its origins could also be described as traditional, it is constantly seeking new medical knowledge which in turn is scrutinized and verified. This means that medical knowledge is always changing and that older practitioners have difficulty keeping abreast of modern trends. Between physicians there is a fairly universal standard level of knowledge that is the same no matter where the doctor was trained. Essentially the difference is between science and faith (Waldram, 1955, p. 71). Scientists have difficulty accepting faith – or indeed any knowledge base that has not been subjected to scientific investigation. This does not necessarily mean that faith has no validity or that it can be dismissed because it lacks scientific credibility. But it does present barriers in terms of using one set of criteria to understand the other. In practice, however, the distinction between traditional healing and biomedicine is not always as sharp or as clear as might be supposed. Many traditional healers do employ aspects of the scientific tradition and build new elements into their range of healing techniques. In addition there are many biomedical practitioners who depend on faith as much as science when healing patients, and who prescribe medication according to time honored practices rather than up to date developments in medical science (Durie, 1997).

19.6

INDIGENOUS HEALING CONTRIBUTIONS TO GLOBAL MENTAL HEALTH

In order to further appreciate traditional healing in modern times, three principles are worth discussing: cultural integrity, medical pluralism, self determination. Traditional healing services are inextricably entwined with culture. Their philosophical roots, delivery systems, treatments and ways in which healers are recognized, are consistent with wider cultural belief systems and values. This does not mean they are confined to the past or that they lack relevance if they are not exact replicas of historical approaches; but their dynamism is a reflection of broader cultural dynamics. They depend for their credibility on the cultural codes of the communities they serve, using language, concepts and healing methods that are aligned with the values and persuasions of their clients. There are two implications arising from the principle of cultural integrity. The first is that healing which is far removed from the cultural realities of its peoples, cannot be justified as traditional, even though the clients may be from a distinct cultural grouping. Second, while similarities between traditional healing and Western healing can be

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identified, traditional healing can only ever be completely understood through the culture of its origin. In this respect it can never be entirely rationalized because it has some parallels with biomedicine, nor do biomedical explanations come anywhere near identifying the essence of traditional healing. Medical pluralism is a characteristic of modern society (Baer, 2004, pp. 109–16). A single disease may have vastly different histories in different cultures because sociocultural factors are themselves determinants of morbidity and mortality (Kunitz, 1994, pp. 121–44). It is therefore not surprising that people seek help from a variety of helping agencies, often at the same time. Conventional medical treatment or modern health care may be accessed along with alternative healing practices not normally considered scientific. While this might appear to be inconsistent, even nonsensical, nonetheless the phenomenon is sufficiently widespread to suggest that healing is not the province of any single profession or group, nor is a single approach always likely to be regarded as comprehensive, at least in the minds of patients and their families. Choice is an important safeguard. While modern health care might hold attractions for certain aspects of healing, it may do little to satisfy cultural explanations or cultural sanctions. By the same token, traditional healing by itself may appease cultural preferences but be insufficient to bring about the health gains currently available from medical science. In effect medical pluralism enables the patient to have the best of all worlds: cultural validation, symptomatic cure (or relief), a greater sense of control over the disease process as well as better understanding of its multi-dimensional causation, and the benefit of two (or more) expert opinions. Problems may arise, however, when one expert is unwilling to tolerate a pluralistic approach to healing and insists that the remedies employed by the other be abandoned. Confronted with an either – or situation, the patient may decide against one for the wrong reasons and in the process be disadvantaged. Similarly, if there is embarrassment or any sense of intolerance, knowledge about other concurrent treatments may be withheld from one or other of the healers, again with some risk to health because of incompatibility of treatments. The important implication from the principle of medical pluralism is that patients, consumers, should not be placed in the position of having to choose between one approach or the other, nor should they be discouraged from discussing involvement in traditional healing or any other type of healing program. There is merit in a national health system being able to accommodate more than a single approach to treatment and healing, especially at the primary health care level where pluralism is especially appropriate. The third principle, self determination, is linked to the aspirations of indigenous peoples the world over. They have argued that positive development, whether in cultural, social or economic terms, should be premised on the principle of self determination. While the principle does not have universal support from governments because it has overtones of cession from the state, in practice most peoples understand self determination in quite practical ways. It means, for example being able to design, implement and manage programs in health, education and environmental management; to make decisions about the formulation of policies and the allocation of resources; and to retain a cultural identity even in the absence of majority support. Traditional healing is part of the rubric of self determination because it affirms native control and authority and appeals to a pre-colonial era when healing and wider cultural values were synchronized (Warry, 1998, pp. 111–19).

EXPLORING THE INTERFACE

19.7

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Despite the methodological gulf between indigenous knowledge and science and between biomedical interventions and traditional healing, there is room for each system to find accommodation alongside the other without distorting the fundamental values and principles upon which each rests (Taiepa, 1998, pp. 143–52). In the early 1980s a new approach to Maori social and economic development shifted the focus away from an assimilatory pathway with high levels of state dependency, towards greater autonomy, the development of a positive economy, social equity and cultural affirmation. It was followed by an upsurge in Maori delivery systems across the education, justice, social services, and health sectors and the modification of existing practices to reflect Maori values, networks and processes. Part of the impetus for change came from alarming social statistics that revealed excessively high Maori rates of incarceration, unemployment, educational failure and hospitalization. The evolution of active Maori participation in mental health services coincided, therefore, not only with the transfer of mental health services from institutional care to community centers, but also with the indigenous rights movement, positive Maori development, increasing recognition of the significance of culture to mental health, and Maori over-representation in mental health services. Although resurgence in traditional healing and the use of customary healing agents was to become an important part of mental health care, a more widespread movement saw the delivery of services based on indigenous concepts, protocols and models, alongside contemporary mental health care. In effect the New Zealand mental health system was radically transformed by the incorporation of indigenous knowledge and practices into assessment, treatment and rehabilitation. At least three approaches can be identified in the post-assimilatory era. First, as already discussed, there has been an increase in the utilization of traditional healing, mostly as an alternative to mainstream services though sometimes as a supplementary activity. Second, many health services have added Maori values, perspectives and customary practices to treatment programs, creating a bicultural formula; and third, a number of Maori centered techniques have been developed either independent of other processes or alongside them. Usually they aim to strengthen cultural identity.

19.7.1 Maori Health Perspectives When they were introduced in 1982, conceptual foundations for Maori mental health, based on indigenous worldviews, were viewed with skepticism. The prevailing view, that health was a universal concept, transcending culture, gave little recognition to the fact that the ‘norm’ was actually based on Eurocentric philosophies, culture and methods. Maori health perspectives challenged the mono-cultural assumptions and introduced other ways of considering health. ‘Te Whare Tapa Wha’, for example was a construct that compared good health to the four sides of a house with balance between spirituality (‘taha wairua’), intellect and emotions (‘taha hinengaro’), the human body (‘taha tinana’) and human relationships (‘taha whanau’) (Durie, 1985). It was a holistic prescription that resonated with Maori communities not only because it was consistent with indigenous worldviews but also because it created an opportunity for active engagement with health services at a time

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when health care was regarded as the province of health professionals. Moreover, the Maori perspective was consistent with an emerging view of health care that questioned the increasing reliance of Western approaches to mental health on medication and a parallel rejection of spirituality and ecological relationships.

19.7.2 Demonstration Projects By 1984 a small number of Maori health initiatives had been established. Essentially they pioneered a system of health care that incorporated Maori knowledge, Maori models of practice, and Maori staff. ‘Whaiora’, for example was the prototype for a mental health service where Maori values permeated the milieu. As a mental health facility within a large psychiatric hospital, it was developed around Maori values and philosophies, staffed by Maori nurses and a Maori psychiatrist, but also incorporated conventional methods of treatment (Rankin, 1986). The distinctiveness arose from the observance of customary ceremonies to receive new patients and their families, the incorporation of spiritual encounters into patient management, the inclusion of families in aspects of treatment, and the employment of tribal elders to oversee the cultural milieu. While Western treatment methods, including standard pharmacological regimes were used, much emphasis was placed on relationship-building and strengthening cultural identity.

19.7.3 Maori Providers In the deregulated environment, the number of Maori providers of mental health services rapidly expanded. Hauora Waikato a Maori community mental health service that had evolved from Whaiora, was able to offer a wide range of clinical and support services for inpatients, outpatients, forensic and long-term clients. Maori workforce development also became a major focus. Te Rau Matatini, an independent body funded by the Ministry of Health spearheads a drive for increasing Maori mental health workforce capacity through increased recruitment, retention, the migration of mental health knowledge and skills to the primary health care sector, and a harmonization of clinical and cultural skill sets. Other programs also facilitate Maori entry into the professional workforce. The Henry Rongomau Bennett Memorial Scholarships, named after the first Maori psychiatrist, are intended to foster Maori leadership within the sector, and Te Rau Puawai, a program at Massey University provides bursaries to assist Maori undergraduates and postgraduates who are either already working or intend to work in mental health services. All three workforce programs recognize that Maori mental health workers need to be doubly skilled in order to work effectively at the interface between medical science and indigenous knowledge.

19.7.4 Service Realignment Government funded District Health Boards have taken two broad approaches to addressing Maori mental health needs. Contracts have been awarded to Maori providers for community-based services – by Maori for Maori – and conventional services have developed

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protocols that reflect Maori values and communication Maori processes as well as linking more directly to Maori networks (Williams, 1997, pp. 54–8). Elders, ‘kaumatua’, are sometimes employed to oversee cultural interventions and there have been deliberate efforts to employ qualified Maori staff as well as Maori support staff. Having greatly expanded Maori participation in the delivery of mental health services, there has been a more recent focus on quality and the development of quality assurance measures. While global and national measures have a place there has also been interest in developing measures that can reflect Maori values and worldviews, as well as clinical progress. For example, an outcome measure, Hua Oranga assesses the results of mental health interventions by measuring impacts on spirituality, emotions and intellect, physical health, and the quality and quantity of social relationships. It adopts a triangulated approach and collates responses from patients, clinicians and family (Kingi, 2002).

19.8

IMPACTS

The emergence of an indigenous mental health pathway has been endorsed by health authorities and by tribes. But its application has exposed a number of tensions between the two approaches with some concerns about the way mental health services are construed and delivered (Robertson et al., 2002, pp. 328–44). Several Maori providers and consumers are questioning the use of a diagnostic manual such as DSM IV as an appropriate basis for addressing mental health problems because it seems to conflict with cultural understandings. Nor is it totally accepted that mental health problems can be best understood as a series of illnesses or disorders, rather than, for example micro- and macro-breakdowns in human and environmental relationships. Tension between cultural approaches and clinical approaches has also led to divergent pathways even within the same service. Maori cultural workers often consider that the narrow DSM framework does not allow for human factors to be appreciated and used in the healing process. In their view a diagnosis does not represent an adequate understanding of the situation. Clinicians on the other hand often regard cultural suggestions as peripheral to the central issue and a distraction from clinical management. Although the two dimensions can jointly contribute to a more comprehensive understanding, and a management plan that makes more sense to patients, they are not infrequently introduced independently of each other, allowing for fragmentation and confusion. The introduction of indigenous perspectives and practices has also brought extra demands on mental health services. Aligning perspectives, priorities and cultural interventions as well as clinical inputs, has often been challenging since it has required balancing generic service delivery against targeted approaches to specific populations. On this point there is ongoing political debate. Champions of neo-liberalism argue that mental health is color blind and individuals should be considered entirely on the basis of need without recourse to consideration of ethnicity or race. However, that view overlooks evidence from medicine and psychiatry suggesting a strong link between illness and ethnicity (Reid, Robson and Jones, 2000). As societies become increasingly multicultural, knowledge of cultural nuance and cultural styles of communication, especially in the practice of psychiatry where physical evidence (such as blood tests) is not always very helpful, will be more and more important. Practice will need to adapt to differing cultural norms. Not only should outcome indicators be relevant to indigenous and ethnic populations, but clinical

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process indicators that measure the quality of care should also be culturally responsive (O’Brien, Boddy and Hardy, 2007). Meanwhile, despite the tensions that inevitably must arise as bodies of knowledge come into close contact, the gains far outweigh the difficulties. In the reformed New Zealand mental health system, mental health care provides opportunities for interventions based on medical science and indigenous knowledge to be delivered together. The ‘mix’ has four obvious advantages. First, understandings of sickness make more sense when they are conveyed in a manner that is based on culturally relevant frameworks. Second, because the effectiveness of mental health care and treatment depends on biological, psychological, sociological and cultural contributions, the use of indigenous and scientific perspectives in tandem provides for greater coverage and relevance. Third, tools for assessing, managing and measuring mental health problems can be enhanced by incorporating perspectives derived from the two bodies of knowledge. Fourth a mental health team that incorporates clinicians and cultural practitioners, including healers, can ensure a wider context for patient management and care than two parallel but separate teams.

REFERENCES Baer, H.A. (2004) Medical pluralism, in Encyclopaedia of Medical Anthropology Health and Illness in the World’s Culture (eds C.R. Ember and M. Ember), Vol. 1, Kluwer Academic/Plenum, New York. Baxter, J. (2007) Mental health: psychiatric disorder and suicide, in Hauora: Maori Standards of Health IV: A Study of the Year 2000–2005 (eds B. Robson and R. Harris), Te Roopu Rangahau Hauora a Eru Pomare, Wellington. Brooker, S.G., Cambie, R.C. and Cooper, R. (1981) New Zealand Medicinal Plants, Heinmann, Auckland. Duran, E. and Duran, B. (1995) Native American Postcolonial Psychology, State University of New York, Albany. Durie, M. (1985) A Maori perspective of health. Journal of Social Sciences and Medicine, 20 (5), 483–6. Durie, M. (1996) A Framework for Purchasing Traditional Healing Services, A report prepared for the Ministry of Health, Department of Ma¨ori Studies, Massey University. Durie, M. (1997) Maori science and Maori development. People & Performance, 4 (3), 20–6. Durie, M. (1998) Whaiora (Second Edition), Oxford University Press, Auckland. Durie, M. (2001) Mauri Ora the Dynamics of Maori Health, Oxford University Press, Auckland. Gaines, A.D. and Davis-Floyd, R. (2004), Biomedicine, in Encyclopaedia of Medical Anthropology Health and Illness in the World’s Culture, Vol. 1 (eds C.R. Ember and M. Ember), Kluwer Academic/Plenum, New York. Kingi Te, K. (2002) Hua Oranga a Maori Mental Health Outcome Measure, PhD Thesis, Massey University, Palmerston North. Knudtson, P. and Suzuki, D. (1992) Wisdom of the Elders, Stoddart, Toronto. Kunitz, S.J. (1994) Disease and Social Diversity the European Impact on the Health of NonEuropeans, Oxford University Press, New York. Lawson-Te Aho, K. (1996) Service Evaluation of Te Whare Whakapikiora O Te Rangimarie a Maori Traditional Healing Service (an Interim Report), Te Aho Associates, Wellington. Macdonald, C. (1973) Medicines of the Maori, William Collins, Auckland. Ministry of Health (1999) Standards for Traditional Maori Healing, Ministry of Health, Wellington. Murchie, E. (1984) Rapuora Health and Maori Women, Maori Womens Welfare League, Wellington. O’Brien, A.P., Boddy, J.M. and Hardy, D.J. (2007) Culturally specific process measures to improve mental health clinical practice: Indigenous focus. Australian and New Zealand Journal of Psychiatry, 41, 667–74.

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Parsons, C.D.F. (ed.) (1985), Notes on Maori Sickness Knowledge and Healing Practices, in Healing Practices in the South Pacific, Institute for Polynesian Studies, University of Hawaii Press, Honolulu. Rankin, J. (1986) Whaiora: A Maori cultural therapy unit. Community Mental Health New Zealand, 3 (38), 38–47. Rankin, J. (1994) Maori Healing Practices, GP Weekly, 12 October, 1994) 6–7. Reid, P., Robson, B. and Jones, C. (2000) Disparities in health: Common myths and uncommon truths. Pacific Health Dialogue, 7, 38–48. Robertson, P., Huiwai, T., Potiki, T. et al. (2002), Working with Maori who have alcohol and drugrelated problems, in Management of Alcohol and Drug Problems (eds G. Hulse, J. White and G. Cape), Oxford University Press, Melbourne. Robinson, S.T. (2005) Tohunga the Revival Ancient Knowledge for the Modern Era, Reed Publishing, Auckland. Rolleston, A. (1988) He Kohikohinga: a Maori Health Knowledge Base, Department of Health, Wellington. Semali, L.M. and Kincheloe, J.L. (eds) (1999) What is Indigenous Knowledge, Voices From the Academy, Palmer Press, New York. Solomon, M. (2005) The Wai 262 claim: A claim by Maori to Indigenous Flora and Fauna: Me o Ratou Taonga Katoa, Waitangi Revisited Perspectives on the Treaty of Waitangi (eds M. Belgrave, M. Kawharu and D. Williams), Oxford University Press, Melbourne. Statistics New Zealand (2007) Quickstats About Maori: Census 2006, Department of Statistics, Wellington. Taiepa, T. (1998) Collaborative management – Enhancing Maori participation in the management of natural resources, in Proceedings of Te Oru Rangahau Maori Research and Development Conference (ed. H. Te Pumanawa), School of Ma¨ori Studies, Massey University, Palmerston North. Tau, T.M. (1999) Matauranga Maori as an epistemology. Te Pouhere Korero Maori History Maori People, 1, 10–23. Trauer, T., Eagar, K., Gaines, P. et al. (2004) New Zealand Mental Health Consumers and Their Outcomes, Mental Health Research & Development Strategy, Health Research Council, Auckland. Waldram, J.B. (1955) The Way of the Pipe Aboriginal Spirituality and Symbolic Healing in Canadian Prisons, Broadview Press, Ontario. Waldram, J.B., Herring, D.A. and Young, T.K. (1995) Aboriginal Health in Canada Historical, Cultural, and Epidemiological Perspectives, University of Toronto Press, Toronto. Warry, W. (1998) Unfinished Dreams Community Healing and the Reality of Aboriginal Self Government, University of Toronto Press, Toronto. Williams, T. (1997) Traditional healers, in Perspectives on Transcultural Mental Health (eds B. Ferguson and D. Barnes), Transcultural Mental Health Centre, Parramatta, Australia.

CHAPTER 20

Future Partnerships in Global Mental Health Foreseeing the Encounter of Psychiatrists and Traditional Healers Mario Incayawar Director, Runajambi – Institute for the Study of Quichua Culture and Health, Otavalo, Ecuador

Abstract Mental disorders are highly prevalent worldwide, yet mental health care is scarce or inappropriate, especially in developing countries. The majority of the 450 million patients with mental disorders around the world are not receiving even the most basic mental health care. In developing countries, 76.3–85.4% of serious cases receive no treatment. Unfortunately, the unnecessary suffering is likely to worsen, as the global burden of disease attributable to psychiatric and substance use disorders is expected to rise in the coming decade. This chapter unveils some important traditional healers’ contributions. Among them are the following: (i) the role their psychosocial and clinical skills have played in the implementation of community and public health treatment programs for physical illness; (ii) their facilitation of culturally competent clinical care; and (iii) their limited, although effective, participation in unique collaborations with psychiatric treatment personnel. It also highlights their role in diminishing stigma related to mental illness and the reintegration of prison inmates and children soldiers into their communities. This chapter urges that the contributions of traditional healers should be welcomed in a world characterized by serious biomedical workforce shortages, limited funding, global mental health service inequalities and enormous unmet needs for mental health services.

20.1

THE GLOBAL BURDEN OF MENTAL ILLNESS

During the past two decades, research on illness prevalence in countries around the world has shown that mental disorders are highly prevalent worldwide, and mental health care is Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

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scarce or inappropriate, especially in developing countries (Alarcon, 2003; Desjarlais et al., 1995). Until recently, the true magnitude and social impact of mental disorders was literally unknown. The landmark Global Burden of Disease study, conducted by the World Health Organization, and the World Bank, in conjunction with Harvard University, (Murray et al., 1996) found that four of the ten leading causes of disability through the world, for persons age five and older, are mental disorders. Together, mental disorders (including suicide) account for 15.4% of the overall burden of disease from all causes; second only to cardiovascular conditions (18.6%) and slightly more than the burden associated with all forms of cancer (15%). Respiratory conditions (4.8%) and even infectious and parasitic diseases (2.8%) are far behind. However, despite the worldwide public health importance of psychiatric disorders and their associated higher rates of disability, they are undertreated compared with physical illnesses in high-, low- and middle-income countries alike (Ormel et al., 2008). The four most pervasive psychiatric disorders worldwide are unipolar major depression, bipolar disorder, schizophrenia and obsessive-compulsive disorder. The main message of the Global Burden of Disease study is that the impact of mental illness on overall health and productivity throughout the world is profoundly under-recognized. It also clearly indicates that there is a great need to re-order health care service priorities if we are to improve the health status of the world population (Murray, Lopez, Harvard School of Public Health, World Health Organization, and World Bank, 1996). The World Health Organization (WHO), in its report in 2001 that focused on mental health, estimated that ‘one in every four people develop one or more mental or behavioral disorders at some time in their life, both in developed and developing countries’ (World Health Organization, 2001). The WHO estimates that around 450 million people are currently suffering from mental conditions and are in need of care. According to the former WHO Director-General, Dr Gro Harlem Brundtland, the organization is, ‘making a simple statement that mental health – neglected for far too long – is crucial to the overall well-being of individuals, societies and countries’ (World Health Organization, 2001). Even in the Unites States, one of the most technologically advanced countries in the world; mental illness is far from adequately diagnosed and treated. The first US Surgeon General’s report on mental health and mental illness was not published until 1999. It is a groundbreaking summary of 3000 scientific papers, as well as consultations with mental health care providers, advocacy groups and patients. The report made two main points: (i) that mental health is fundamental to health and that good mental health is essential to leading a healthy life, and (ii) that mental disorders are real health conditions (U.S. Department of Health and Human Services, 1999). According to the National Advisory Mental Health Council Behavioral Science Workgroup report, about one in five Americans will be affected by mental illness in their most productive years of life (National Institute of Mental Health, 2000). It is estimated that mental illness costs American society nearly $200 billion annually in lost earnings alone; patients with serious mental illness earned, on average, $16 306 less in their 12 months earnings (Kessler et al., 2008). The current social and economic burden of mental illness in the United States of America is enormous. Realizing the national importance of mental illness, the National Institute of Mental Health responded with a strategy to confront this enormous challenge ‘to improve mental health and clinical care in the United States and beyond’ (National Institute of Mental Health, 2000).

MEDICAL WORKFORCE SHORTAGE AND ALLOCATION OF FUNDS

20.2

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It is estimated that there is about half a billion people in the world suffering from mental illness. The number of identified cases is probably an underestimation due to difficulties of Western trained mental health workers in making a psychiatric diagnosis of patients from other cultures (Mackin et al., 2006). And the median age for the onset of any mental disorder is around age fourteen (Kessler et al., 2005). Nevertheless, mental illness in young people goes unrecognized and untreated (Friedman, 2006). Beyond the suffering associated with the psychiatric condition itself, there is the additional suffering due to lost productivity. According to Patel, Saraceno and Kleinman (2006) the overwhelming majority of the 450 million patients with mental disorders ‘are not being provided with even the basic mental health care that we know they should and can receive’. The inequalities in access to mental health services is an immense challenge globally. In a recent international mental health survey conducted in 14 countries in the Americas, Europe, Middle East, Africa and Asia, 35–50% of serious psychiatric conditions in developed countries were untreated in the year before the interview. In developing countries, 76–85% of serious cases received no treatment (Demyttenaere et al., 2004). As Mckenzie, Patel and Araya pointed out, mental health services in the developing world ‘are often greatly under-resourced, under strain, and leave most people with mental health problems with no care’ (McKenzie, Patel and Araya, 2004). The above-mentioned neglect becomes inexcusable when considering the mental health of the world’s indigenous peoples (Cohen, 1999; Durie, 2003b; Kunitz, 2000). Not only is there an almost complete absence of mental health services designed for their particular needs, but psychiatric research on this vulnerable population is very limited (Cohen, 1999). In South America, there are no mental health services available to the indigenous peoples that take into account their socio-cultural characteristics and languages. The fact is that 30 million indigenous people in South America, comprising up to 10% of the general population, live in conditions of severe misery and neglect (Incayawar, 2007).

20.3

MEDICAL WORKFORCE SHORTAGE AND ALLOCATION OF FUNDS

The medical workforce shortage is a major contributing factor to inadequate mental health care in both developed and developing countries (World Health Organization, 2006). Although the shortage is most severe in the poorest countries, the medical workforce shortage also affects more affluent countries, especially their rural communities, and is threatening their health care organizations (Cofer and Burns, 2008; GoodyearSmith and Janes, 2008). In the United States, a physician shortage is likely if current levels of medical education and training and population ageing trends persist (Salsberg and Grover, 2006). The migration of physicians from poor to rich countries such as the United States, the United Kingdom, Canada and Australia is an important contributor to the medical workforce shortage in many lower-income countries and is a growing obstacle to global health (Mullan, 2005) For example, ‘Ghana, with 0.09 physician per thousand population, sends doctors to the United Kingdom, which has 18 times as many physicians per capita’ (Chen and Boufford, 2005).

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The World Health Organization (WHO) acknowledges the existence of immense disparities in allocation of resources and funds. The Americas, with 10% of the global burden of disease, has 37% of the world’s health workers and spends more than 50% of the world’s health financing. In contrast, the African Region has 24% of the burden of disease, but only 3% of the world’s health workers and spends less than 1% of the world’s total health expenditure (World Health Organization, 2006). There is a wide disparity in the type and size of the mental health workforce throughout the world. The median number of psychiatrists varies from 0.06 per 100 000 population in low-income countries to nine per 100 000 in high-income countries. For psychiatric nurses, the median ranges from 0.1 per 100 000 in low income countries to 33.5 per 100 000 in high income countries (World Health Organization, 2001). The needless suffering is expected to worsen as the global burden of disease attributable to mental, neurological and substance use disorders continues to rise in the coming decade. Understandably, Patel, Saraceno and Kleinman emphasize that, ‘. . . research evidence will not reduce this inequity. To make a change, the moral case must be heard’ (Patel, Saraceno and Kleinman, 2006).

20.4

UNVEILING TRADITIONAL HEALERS’ CONTRIBUTIONS

The data reviewed above suggest that the world’s population cannot rely completely on biomedicine to solve their mental health problems. They look insurmountable, at least in the mid and short term. It is in this context of global and local health inequalities, mental health service scarcity, and mental health neglect, that the contributions of traditional healers should be highlighted. There are two lines of analysis on how traditional healers could help improve the mental health status of the most underserved populations in the world. The first is related to the sizeable traditional healers’ workforce that is living in just those regions of the world with the most limited biomedically-oriented mental heath workers and resources. The second is associated with traditional healers’ roles in social action, community- and family-centered interventions, and their clinical diagnostic and therapeutic skills.

20.4.1 Valuable Overshadowed Partners In Africa, South America and some regions of Asia and the Pacific Islands, traditional healers are widely available, although their precise numbers are undetermined. Moreover, it is in precisely those places that bio-medically oriented mental health practitioners are scarce, making it very difficult to expand the coverage of mental health services. For example in Tanzania, Uganda and Zambia, the ratio of traditional healers to general population is 1:200 to 1:400, while the availability of Western trained health professionals is 1:20 000 or less. A survey of the US Agency for International Development found that in the sub-Saharan Africa, traditional healers outnumber biomedically-oriented health practitioners by 100 to 1 (WHO, 2002). It is estimated that in low-income countries there is one psychiatrist for one million people, with no multidisciplinary team and availability of few psychiatric drugs

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(McKenzie, Patel and Araya, 2004). In the Andean region of South America the situation is even more dramatic. In 1986, the first two Quichua (Inca) physicians graduated from the medical school in Quito, Ecuador. Today, almost 20 years later, there is a total of five Quichua physicians, including one psychiatrist, for an estimated population of 5 million indigenous people in the country ‘With this pace of change, the existing staff, the available psychiatric services, and the mental health of our communities will not improve in the foreseeable future’ (Incayawar, 2007). Given the meager presence of Western psychiatry in the developing countries, some people might quite easily conclude that nothing can be learned from poorer countries or that nothing exists there to improve their population mental health.

20.4.2 Traditional Healers’ Psycho-Social and Clinical Skills Traditional healers are actually a sizeable force in global mental health. Their community-, family-based psycho-social interventions have been found to yield positive clinical outcomes (Frank and Frank, 1991; Jilek and Todd, 1977; Kleinman, 1980; Kleinman and Gale, 1982; Torrey, 1986). Some evidence points in the direction that they also have the necessary clinical skills to identify patients with major psychiatric disorders (Beiser et al., 1972; Incayawar, 2008; Westermeyer and Zimmerman, 1981). Their ‘explanatory models’ of illness and their healing techniques are complex and diverse. Traditional healers’ therapies include the use of herbal medicines, physical manipulative techniques, and healing rituals involving the spirit world and supernatural intervention. Some of their clinical skills that could be utilized in a collaborative effort with biomedically-oriented health service staff are listed below. Physical Illness and Disease. In recent decades, African traditional healers have actively participated in health promotion, health education and preventive public health programs using the WHO’s approach of primary care teams. They have participated in projects to treat and to prevent diarrhea, HIV infection/AIDS treatment and prevention, referral to tuberculosis, leprosy and malaria treatment programs, and referral of children immunization programs. Healers have participated in projects designed to improve nutrition and food supplies, safe drinking water and sanitation. Their contribution has been promising in child delivery, maternal and child health care and family planning (pregnancy monitoring, risk referral, contraceptive distribution), and pain management. In other regions of the world such as China, New Zealand, India, South Korea and Malaysia, biomedicine and traditional medicine are practiced alongside each other in a systematically-integrated manner (Akpede, Igene and Omotara, 2001; Bannerman, 1983; Bastien, 1994; Bodeker, 2001; Droz, 1997; Durie, 2003a; Hesketh and Zhu, 1997; Hoff, 1992; Lethlaka, 1978; Oswald, 1983; Smit, 1994; WHO, 2002). Culturally Competent Clinical Care. Having access to health services sensitive to patients’ and communities’ values, language, notions of illness causation and treatment preferences results in improved quality of care (Galanti, 1997; Gray, 1996). Local traditional healers, being members of the same community and culture as their patients, could fulfill this needed role. They could play a key role in expanding mental health care delivery by reaching remote rural communities, as well as marginalized urban ones, or culturally different minority communities that are currently underserved or not served at all by their national health care systems.

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They can also help reduce clinicians’ diagnostic and evaluation bias when they are working with unfamiliar and culturally diverse populations (Malgady, Rogler and Costantino, 1987) or in circumstances where clinicians are trying to apply their biomedical knowledge to interpret culturally-specific syndromes such as ‘nervios’, ‘wounded heart’, ‘amok’ and so on. The chapter by Incayawar in this book provides intriguing results related to the psychiatric diagnostic abilities of Quichua traditional healers. The author proposes that their diagnostic skills could be useful for screening purposes (Incayawar, 2008). Current Outstanding Psychiatrist-Healer Collaborations. Attempts to establish mental health partnerships or collaborations with traditional healers have been rare. In North America, some efforts to do that started decades ago, but were limited in scope and impact (Jilek and Jilek-Aall, 1978; Jilek and Todd, 1974; Koss, 1987; Ruiz and Langrod, 1976). It is worth noting that mental health has been neglected even in China, where traditional healers have gained a prominent role in community and public health programs, as described in the chapter by Dr Xudong Zhao in this book. Most countries in Latin America have not adopted the World Health Organization’s recommendations concerning traditional medicine and the use of traditional healers; therefore, the lack of experience in the region is almost absolute. Several chapters of this book do address this theme of the integration of biomedical and traditional healing. They include the experiences of Incayawar and Bouchard with the Quichua people in the Andean region of Ecuador, the experiences described by Shore, Shore and Manson with several American Indian communities, Durie’s extensive experience with the Maori population in New Zealand; and the South African momentum conveyed as a case study by Mkize. They are truly unique and exemplary initiatives in the world that have the potential to improve global mental health through their close collaboration between indigenous healers and biomedically trained clinicians.

20.4.3 Additional Contributions of Traditional Healers Traditional healers are contributing to the well-being of people not only in the clinical arena – they are directly or indirectly helping to relieve psychosocial problems that underlie mental illness. Stigma. Stigmatization of people suffering from a mental disorder, and their families, is encountered in many, if not most countries around the world. The fear of being labeled as mentally ill, the personal and family shame associated with it and the risk of being ostracized by one’s community are formidable barriers to accessing mental health care. The stigma carried by mentally ill patients and their families is dramatic in countries such as India, and China, as described in several chapters in this book. As stated in a recent newspaper article in India ‘The fear of being labeled and rejected by society is so high that people don’t come forward. It is the hypocrisy of urban Indians that adds to the stigma. ‘In contrast, visiting a traditional healer for any mental condition is not stigmatizing. Pakaslahti’s chapter in this book rightly notes another aspect of traditional healing; the setting in which traditional healing occurs, ‘provides a positive culturally valued, nonstigmatizing atmosphere’. Reintegrating Prison Inmates into the Community. Barlowe’s chapter is a unique account of his experiences as an American Indian traditional healer helping those who few mental health clinicians want to treat. Barlowe describes the means by which American Indian

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prison inmates in the United States are receiving culturally meaningful support, gaining direction in their lives and enhancing their self-esteem. This experience could probably be applied in other contexts and countries. Integrating Child Soldiers into the Community. Another example of traditional healers’ contribution comes from the treatment of rape victims and child soldiers in sub-Saharan Africa. In a moving presentation titled ‘Trauma Recovery in War-Torn Africa: Incorporating Traditional Healing’ in Psychosocial Recovery Programs, Leslie Snider, M.D., M.P.H., from Tulane University School of Public Health and Tropical Medicine, documented the roles of traditional healers in assisting the psychosocial recovery of African communities impacted by civil war. ‘They have assisted in burial rituals, cleansing ceremonies for rape victims and child soldiers, designed to pave the way for their meaningful re-entry into society. In these settings, indigenous healers function not only as health practitioners, but also as guardians of native history, beliefs, culture, values and social order – all critical for the recovery of post-war societies’. After the civil war in Sierra Leone, for example, many former child soldiers were welcomed back into their communities only after a meaningful cleansing ceremony was performed that included fasting, repentance and bathing in local rivers. Those ceremonies were instrumental for social acceptance and forgiveness for the children. Their role in the war initially left them marginalized, isolated, and often times abandoned or repelled. Psychiatric Agricultural Rehabilitation. In Tanzania, a unique community psychiatric program emerged from the concerted effort of local villagers, traditional healers and biomedically trained mental health workers. The program aimed to treat and rehabilitate people with severe mental illness in rural communities. Patients and relatives were relocated in a village of farmers, fishermen or craftsmen. Local villagers, healers and mental health workers provided the treatment and follow-up, while a psychiatrist provided weekly consultation. They even planned shared mental health training programs (Kilonzo and Simmons, 1998).

20.5

FORESEEING FUTURE PARTNERSHIPS

Considering the many workforce and financial struggles of biomedically oriented mental health services to improve the mental health of most national populations around the world, and the contributions of traditional healing techniques, such as those described in the chapters of this book, the role that traditional healers can play in global mental health could be considerable. Western psychiatry is capable of impressive results when dealing with specific psychiatric conditions and individual patients, but its ability to impact the turmoil and misery generated by social upheaval, natural disaster and civil war is very limited. Contemplating a partnership between psychiatrists and traditional healers looks plausible and beneficial for improving access to mental health services. Avoiding critical delays may help reduce the duration of untreated mental disorders, treatment-resistance and disability. These issues are important to the development of services that are effective, efficient and culturally competent. Around 40% of the clients of traditional healers suffer from mental illness (Saeed et al., 2000). In addition, most of the world population relies on traditional medicines to meet their health care needs. We also know that patients and their families often make

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simultaneous use of both traditional and biomedical treatments and value both approaches to healing. Research from the developing world has shown that pathways to care for mental illness are diverse and pluralistic and consistently include the use of traditional medicines. In developed countries, the majority of the population practices medical pluralism as well. A clear example is given in Drs Thachil and Bhugra’s chapter in this book, relating to Indian communities in the United Kingdom. Durie, referring to the situation in New Zealand, in which 15% of the population is Maori, proposes that a ‘combination of conventional services and indigenous programs is needed’ (Durie, 2003a; Durie, 2003b). Little is know about the efficacy, safety or cost-effectiveness of the involvement of traditional healers in the provision of mental health care. Research is needed to determine how mental health workers can better collaborate with traditional healers in order to improve access, diagnosis and successful treatment of persons suffering from mental illness. It is also necessary to understand the effects of different types of mental health policy decisions concerning traditional medicines on access, equity and treatment outcomes. This book proposes that future partnerships with traditional healers are a promising option in improving global mental health. It argues that the contribution of traditional healers should be welcomed in a world with widespread biomedical workforce shortages, limited funding, global mental health service inequalities and enormous unmet mental health care needs.

ACKNOWLEDGMENT My deepest gratitude goes to Ronald Wintrob, MD, for his insightful and useful comments on my manuscript. I would also like to thank Sioui Maldonado Bouchard for her assistance in reviewing the English usage.

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Malgady, R.G., Rogler, L.H. and Costantino, G. (1987) Ethnocultural and linguistic bias in mental health evaluation of Hispanics. American Psychologist, 42 (3), 228–34. McKenzie, K., Patel, V. and Araya, R. (2004) Learning from low income countries: Mental health. British Medical Journal, 329 (7475), 1138–40. Mullan, F. (2005) The metrics of the physician brain drain. New England Journal of Medicine, 353 (17), 1810–18. Murray, C.J.L. and Lopez, A.D. (1996) The Global Burden of Disease – A Comprehensive Assessment of Mortality and Disability From Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020, Harvard School of Public Health on behalf of the World Health Organization and the World Bank, Cambridge, MA. National Institute of Mental Health (2000) Translating Behavioral Science into Action: Report of the National Advisory Mental Health Council Behavioral Science Workgroup), Available at http://www.ti-gr.com/Resources/Publication%20 Materials/ NIMH-Translating% 20Behavioral% 20Science%20into%20Action.pdf Ormel, J., Petukhova, M., Chatterji, S. et al. (2008) Disability and treatment of specific mental and physical disorders across the world. The British Journal of Psychiatry, 192 (5), 368–75. Oswald, I.H. (1983) Are traditional healers the solution to the failures of primary health care in rural Nepal? Social Science and Medicine, 17 (5), 255–7. Patel, V., Saraceno, B. and Kleinman, A. (2006) Beyond evidence: The moral case for international mental health. American Journal of Psychiatry, 163 (8), 1312–15. Ruiz, P. and Langrod, J. (1976) Psychiatrists and spiritual healers: partners in community mental health, in Anthropology and Mental Health, Mouton, Chicago, pp. 77–81. Saeed, K., Gater, R., Hussain, A. and Mubbashar, M. (2000) The prevalence, classification and treatment of mental disorders among attenders of native faith healers in rural Pakistan. Social Psychiatry and Psychiatric Epidemiology, 35 (10), 480–5. Salsberg, E. and Grover, A. (2006) Physician workforce shortages: implications and issues for academic health centers and policymakers. Academic Medicine, 81 (9), 782–7. Smit, J.J. (1994) Traditional birth attendants in Malawi. Curationis, 17 (2), 25–8. Torrey, E.F. (1986) Witchdoctors and Psychiatrists – the Common Roots of Psychotherapy and Its Future, Harper & Row, New York. U.S. Department of Health and Human Services (1999) Mental Health: a Report of the Surgeon General – Executive Summary, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, Rockville, MD. Westermeyer, J. and Zimmerman, R. (1981) Lao folk diagnoses for mental disorder: Comparison with psychiatric diagnosis and assessment with psychiatric rating scales. Medical Anthropology, 5, 425–43. WHO (2002) WHO Traditional Medicine Strategy 2002–2005, World Health Organization Geneva, Geneva. World Health Organization (2001) The World Health Report 2001 – Mental Health: New Understanding, New Hope, World Health Organization, Geneva. World Health Organization (2006) The World Health Report 2006 – Working Together for Health, World Health Organization, Geneva.

Index

Note: Figures and Tables are indicated by italic page numbers, Boxes by bold numbers, and notes by suffix ‘n’ abstinence, in psychotherapy professional relationship 34–5 Acceptance/endurance in Islamic religion 199 in [Japanese] Morita therapy 172, 173 Africa collaboration between mainstream medical practitioners and traditional healers 210–14 history of health care systems 208–10 inception of Western medical systems 208–10 integration of child soldiers into community 257 traditional healers’ contributions 210–14, 257 see also South Africa African–Caribbean community in UK mental illness rates 216–17 traditional healing practices 220–3 African Health Care System (AHCS) 211 challenges to be faced 213 education and training plans 211–12 networks 212 objectives 211–12 proposed 210 research proposals 211 resources 212 stakeholders 212 work plan 212 Alaska Natives traditional healer use factors associated with 97–102

health policy impacts 104–5 population-based survey 94–7 Alcohol treatment programs 124 Altered states of consciousness research into 74 see also Possession states; Trance-like state Alternative medicine, see Complementary and alternative medicine (CAM) Amae [dependence/indulgence] 177 American Indian ‘holocaust’ 109 American Indian Religious Freedom Act 16, 103 American Indians Northern Plains tribes 10, 11, 16, 101, 127–9 prison inmates [US] 110–11 traditional healing programs 115–17, 118–19, 257 Southwest tribes 10, 101, 125–6 traditional healer use in collaboration with mainstream medical practitioners 20–22, 127–8, 129–32 factors associated with 97–102, 124 health policy impacts 104–5 population-based survey 94–7 urban-based studies 101, 103, 124 war veterans, treatment of 10, 21, 101, 125–9 see also Lakota Sioux traditional healers; Native Americans; Navajo traditional healers American Indian Vietnam Veterans Project (AIVVP) 10, 125

Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health Edited by Mario Incayawar, Ronald Wintrob, Lise Bouchard and Goffredo Bartocci © 2009 John Wiley & Sons, Ltd. ISBN: 978-0-470-51683-6

262 Amerindian population [in Latin America] health disparities 80–1 see also Quichua people; Shuar people [Ecuador] Ancestors’ deeds, responsibility for 190, 199 Andes failure/absence of mainstream health service 54, 81, 253 traditional healers 9, 53, 81 see also Ecuador; Peru; Quichua people Androphobia 167, 170 Anent [ritual chanting] 73 Anthropocentrism 112 Anxiety disorders 57, 60, 61, 172, 192 Arugamama [as is] 172, 173 Autonomy versus dependency 29–30 Ayahuasca [psychotropic beverage] current use 41, 70 legal issues 47–9 traditional use 41 see also Natem [hallucinogenic compound] Ayurveda medicine system 219–20 Balaji [North India] case studies 158–61 growth as healing center 151–2 prior help-seeking of patients 155, 162 socio-demographic data on patients 154, 155, 162 symptoms and diagnoses of patients 156–8 traditional healers in 152–3, 162–3 ‘Balance and harmony’ concept in American Indian approach to justice 117–18 Balinese cosmology 185 Bali [Indonesia], study into mental illness 182–93 Balian [Balinese healer] 182, 183, 185, 187, 191 diagnostic process 186 Balinese traditional healing 181–4 explanatory models 184–90 astrological/calendrical systems 186 concepts underlying 184 disharmony/imbalance 185 hot/cold distinction 186 humoral theory 186 improper enactment of rituals 187–9 inheritance of ancestor’s characteristics/ flaws 188–90 physical environment 185–6 reincarnation 188–90

INDEX sorcery 186–7 lack of efficacy for neuropsychiatric/ neurophyiologic disorders 190–2 Banisteriopsis caapi 41, 47, 48, 69 Basket repair analogy [Native American] 116 Bhagat [Indian healers] 152 Bipolar disorder, treatment of 173–4 Botanics 3–4 British Isles migration to 216 see also United Kingdom (UK) Buddhism, in Japan 170, 171 Canada, First Nations people 117 Candomble 7–8 Caste 35 Catholic Charismatic faith healing 6, 231–2 animators [prayer leaders] 6, 232, 233, 234 compared with psychotherapy 234–5 conceptualization of illness 230–1, 235 as spiritual regeneration 233 therapeutic factors 232–3 Catholic Charismatic movement 229, 230 Catholic Church, in Ecuador 55, 71 Catholic doctrine, on illness 6, 230–1 Center for International Environmental Law 48 Charisma [gifts] 6, 232 Charismatic Christianity 222, 229 Charlatans, legitimacy and 19, 20, 21 Child soldiers, integration into community 257 China difficulties facing mental health professionals 137–8 ethnic groups 137 factors affecting chronic-illness treatment 139 folk healers 141, 145, 146 medical care system 136, 137 mental health service 136 prevalence of mental health disorders 136 see also Traditional Chinese Medicine (TCM) Chinese patients, help-seeking behaviors 138–41 Christian fundamentalist faith healing 6 Cinchona tree bark 3, 37–8, 39–40 see also Quinine Coca current use 3, 37, 40 legal issues 47 traditional use 3, 40

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Cocaine 37, 40 Cognitive-behavioral psychotherapy 181 Collaboration between mainstream medical practitioners and traditional healers 18, 22, 256 in Africa 210–14 future partnerships 257–8 in Islamic countries 198, 201–2, 204, 205 in Latin America 63, 86, 89 in New Zealand 248, 258 in North America 20, 127–8, 129–32, 256 collaboration model 131 guidelines for collaboration 129–30 in UK 224–5, 258 Collectivism, Japanese 168 Colonial trauma syndrome 118 Colonialism Native Americans affected by 110, 112, 115, 118 Quichua people affected by 8–9, 55, 80 Common Heritage of Mankind concept 43 Communally held knowledge, indigenous medicinal knowledge as 43, 44 Community confidentiality 132n1 Community Holistic Circle Healing [Canada] 117 Community participation in healing Africa 208 Islamic countries 199 North America 113, 117, 118 Complementary and alternative medicine (CAM) 2 definitions 15, 223 National Center [US] 2–3 reasons for use 13–14, 223–4 traditional medicine merged into 14 use in UK 217, 223–5 US expenditure 2, 14, 94 Confidentiality 28, 32 Convention on Biological Diversity 45 Coordinating Body of Indigenous Organizations of the Amazon Basin (COICA) 47–8 Cultural integrity, traditional healing and 243–4 Curanderismo 7 Curandero 72 Curare 38 Dalang [Balinese puppet master] Decision-making process in psychotherapy 32–3

188

Dependency, in Eastern societies 29–30 Depression 55, 61, 71, 156, 219, 220, 232 N,N-dimethyltryptamine (DMT) 41, 69 Doctor–patient relationship in China 138, 143 psycho-cultural variables relevant to 29–35 traditional model in China 143 in India 28–9 traditional versus Western approaches 26, 27 Western models 27–8 Dukun [Balinese healer] 183, 186, 187, 188–90, 191 Ecuador indigenous people 55 mental health services 54, 81 research on traditional healers 55–60 methodology 55 social structure 8–9, 55, 80 traditional healers 9, 53, 61, 72–4, 81 Education and training plans, in South Africa 211–12 Emotional states, expression as metaphors [in China] 140 Enryo [restraint] 169, 171 Evidence-based decisions 2, 19 Exorcism among African–Caribbean communities 222 Islamic attitudes 201, 202 Explanatory models of illness in Balinese traditional healing 184–90 in Catholic Charismatic faith healing 230–1, 235 Maori point of view 241, 242 Quichua point of view 57 Faith healing 5–7 Family Group Conferencing [Maori] 117 First Nations Intellectual Property Act 47 Folk healers, in China 141, 145, 146 Ganeshpuri [Brahmin priest] 151 General practitioners, treatment of psychiatric disorders 198 Genocide 110 Genograms 119 Giri [sense of obligation] 168, 171 Global Burden of Disease study 252

264 Global burden of mental illness 252–3 Globalization, effect on immigration to UK 216 Guaja´n, Dr Mercedes 82, 83 Guilt culture 33, 115 Hakim [Asian healer] 217, 218, 219 Hallucinogens 41, 69 experience by psychiatrist 74–5 survey of use among Shuar people 69–70 therapeutic use 75–6 see also Ayahuasca [psychotropic beverage]; Natem [hallucinogenic compound] Hanuman [Monkey God in Hindu religion] 151 ‘Hard science and technology’ interventions 139, 147 ‘Harmony and balance’ concept in American Indian approach to justice 117–18 Balinese cosmology 185 Healing conferences, in North American prisons 118 Healing and salvation in Catholic charismatic faith healing 233 in treatment of Japanese patients 176–7 Help-seeking behaviors among ethnic groups in UK 217 in China 138–41 in India 153–5, 158–61 in North America 97–102 Herbal medicine 3 in Maori healing 239 toxicity 201, 204, 213 Herbalists, Chinese 141, 146 Historical trauma 112 effect of Native American methods of healing 113–14 Holistic approach American Indian traditional healing practices 129 Traditional Chinese Medicine 142 Unani medicine 218 Hot/cold distinction, in Balinese ethnomedical theories 186 Huairashca/wairashca [‘victim of malign spirits’], as diagnosis 56, 85, 85 Humoral theories 186, 219 Hypnotherapy, in Traditional Chinese Medicine 145

INDEX Illness narrative, Japanese patients 176–7 Imprisonment, effects 108–9, 117 Incas, see Quichua people Incayawar, Dr Mario 81, 89 (photograph) Jambihuasi project 82, 83, 88 India Ayurveda medicine system 220 doctor–patient relationship, traditional versus Western approaches 25–35 migrants to Britain 216, 219 psychiatric services 150 psychotherapy 28 traditional healers 150, 152–3 Indian Health Service (IHS, USA) health care facilities 21, 102, 104 traditional healer use survey funded by 95, 102–3 traditional healing and 20, 104 Indigenous healing, see Traditional healing practices Indigenous health system, in Africa 208, 210 Indigenous knowledge as common heritage of mankind 43 contrast with science 241–2 definitions 39 Indigenous medicinal knowledge actions to protect 45–6 intellectual property rights and 3–4, 43–5 Indigenous people bio-medicinal knowledge 3, 38 definitions 38–9 health disparities 80–1 inequalities in mental health service provision 80–1, 253 oppression by colonists/settlers 8–9, 55, 80, 110, 112, 115 use of various medicinal plants 39–41 see also Native Americans; Quichua people Individualized medicine 128, 129 Integrated traditional/Western health care programs 9–11, 17, 255 future partnerships 257–8 in Latin America 9, 62–3, 86, 86 in New Zealand 91n4, 248 in South Africa 210–14 Intellectual property rights indigenous medicinal knowledge and 3–4, 43–5, 212 legal basis 38, 41–2 patent system and 42–3 Introspection 31

INDEX Islamic religion as background yardstick in mental health 200–1 code of conduct 198–9 in everyday mental life 199 Islamic self-help therapy 199 Jambihuasi health care program [Ecuador] 63, 80, 81–8 date of creation 82, 90n2 first integrated clinic 82–3 founding collaborators 82 goal/mission 82 headquarters 82, 84 health officials’ and physicians’ reactions 87 integrated traditional/Western approach 63, 82, 85, 86 political reactions 87–8 Quichua community response 86–7 Japan religious belief systems 170–2 schizophrenia treatment studies 174–5 traditional healers 174, 175–6 Japanese anxiety 167, 169–70 Japanese hospitality 169 Japanese psychology 168–9 Jodo-Shin Buddhist sect 171 Justice system, failure for indigenous people 117 Karakia incantations [in Maori healing] 239, 240 Karma 33, 34 Koranic recitations 199, 203, 204 Lakota Sioux traditional healers 16 legitimacy status 19–20 Laos 62 Latin America mental health services 81, 253 traditional healers 9, 53, 61, 72–4, 81 Law breaking, as expression of indigenous solidarity 110 Legal issues intellectual property rights current situation 41–6 empowerment in South Africa 212 examples of medicinal plants 46–9 Legitimacy 18–20 charlatans and 19, 20, 21

265 Llaqui [Quichua illness category] 9, 54 case studies/vignettes 57–9 Quichua diagnoses 56–7, 59, 60 Western clinical diagnoses 58, 60, 61 see also Anxiety disorders; depression Maca [botanical] 4 ‘Magic witch doctors’, in China 141, 146 Mahayana Buddhism 170 Maikiwua [hallucinogenic compound] 69, 70, 71 Maldonado, M.G, see Incayawar, Dr Mario Mamma [alcoholic beverage] 69, 70 Mancharishca [‘victim of malign spirits’], as diagnosis 56, 86, 86 Maori healing process, structure 240–1 Maori health perspectives 245–6 service realignment to deal with 246–7 Maori mental health service providers 246, 247 Maori people [New Zealand] 237 explanatory models of illness 241, 242 health status 237 male youths 117 Maori traditional healers 62, 238–41 training of 239–40 Medical pluralism 244 in Africa 208 in Bali 183 in Latin America 85, 85 in New Zealand 248 in North America 104–5 in North India 155–63 Medical workforce shortage 253–4 Medicine men [Native American] 126, 128–9 Mehndipur [North India] 150, 151–2 see also Balaji [North India] Mestizo [mixed-race people in Latin America] 49n3, 68, 80 Modified states of consciousness (MSC) characteristics 75 research into 74 Modoc war 110, 112 Monkey God Hanuman [in Hindu religion] 151 Monoamine oxidase inhibitor (MAOI) action 41, 69 Morita therapy [Japan] 172–3 compared with Zen 173 Moslem identity, mental health and 198

266 Natem [hallucinogenic compound] 69 experience by psychiatrist 75 survey of use 70 use by shaman 69, 73 see also Ayahuasca [psychotropic beverage] National Center for Complementary and Alternative Medicine [US] 2–3 National Medical Expenditure Survey, American Indians and Alaska Natives 94, 95 Native Americans criminalization of spiritual practices 103, 114 genocide 110 life history [of author] 108 Northern Plains tribes 10, 11, 16, 101, 127–9 see also Lakota Sioux traditional healers population 1–9 prison inmates [US] 110–11 traditional healing programs 115–17, 118–19, 257 songs and ceremonies 113, 114 Southwest tribes 10, 101, 125–6 traditional healers, integration into contemporary medical approach 9–11, 19–20 war [late-19th century] 108, 110, 112 see also American Indians Navajo traditional healers 20, 101 Needless suffering due to mental illness 253 ‘Neo-shamanism’ 70 Neurasthenia, as diagnosis 140 Neurological disorders, treatment of 85, 192 New Year’s celebration, in Japan 171 New Zealand mental health system 245–7 impact of indigenous practices 247–8 traditional healers 62, 238–41 Ninjyo [empathy] 168, 171 North India, traditional healers 150, 152–3 Number of health care professionals 209 Obeah [African–Caribbean ‘religion’/ witchcraft] 221–2 Obon festival [Japan] 170–1 Obsessive-compulsive disorder (OCD) Balinese ethnomedical models 185, 189–90 Islamic view 200 prevalence 180–1 treatment by traditional healers 186, 187, 189–90, 191, 192

INDEX Oppression by colonists/settlers of Native Americans 110, 112, 115, 118 of Quichua people 8–9, 55, 80 Oregon Department of Corrections (ODOC) inmate population profile 111 Native American healing programs and conferences 115–17, 118–19 religious service section 108 Oregon state prison system Native Americans in 110–11 personal comments from inmates 119–20 Otavalo [Ecuador] 83–4 Jambihuasi headquarters 82, 85 Pan American Health Organization (PAHO) on mental health services in Latin America 81 on traditional medicine 17 Patent system 42 criteria 42–3, 48 Patient’s expectations [of therapy] 34 Patient–therapist social distance 34 Pentecost 236n2 Pentecostal Christian religious healers 222, 223 Pentecostal Churches 222, 229 Peru 4, 8, 40, 54, 86 Pharmaceuticals, botanically based 37–8 Physical illnesses distinction from mental/spiritual illnesses 85, 158, 184 traditional healers’ work on public health programs 255 Plant Patent Act 48 Possession states 222 Post-traumatic stress disorder (PTSD) effect of traditional healing practices 126, 128 prevalence among American Indian veterans 10, 125 Prison life in US 108–9 Psychiatrists in Bali 183, 192 in China 137 collaboration with traditional healers 18, 21, 256 future partnerships 257–8 in Islamic countries 198, 201–2, 204, 205 in Latin America 63, 86, 89 in North America 20, 127–8, 129–32, 256

INDEX

267

in India 150 consultations prior to traditional healer visit 159, 160, 162 Psychological sophistication 30–1 Psychologists, in China 137, 138 Psychotherapy in China 137–8, 147 compared with Catholic Charismatic faith healing 234–5 as contractual relationship 27–8 definitions 26–7, 234 Psychotria viridis 41, 69 Psychotropics, South American indigenous knowledge 37–51 Puberty ceremonies 110, 115–16 Qalb Centre [London, UK] 225 Qigong movement 145, 146 Quichua people 54–5, 79–80 botanical and medicinal knowledge health disparities 81 social exclusion 8–9, 55, 80 traditional healers 9, 53, 81 see also Yachactaita Quinine current use 40 legal issues 46–7 traditional use 39–40

3–4

Rape victims, integration into community 257 Rastafarianism 221 Rational-legal legitimacy 18–20 Redemption 118 Reimbursement of traditional healers 10, 20–1, 104, 126, 129 Reincarnation, Balinese Hindu belief 188 Religious belief systems African–Caribbean religion 221 Japanese 170–2 Native American, criminalization of 103, 114 psychotherapy and 33–4 Religious faith 5 Religious healers in China 146 in Islamic countries 201, 203, 204 in UK African–Caribbean community 222 Religious healing rituals 6–7 ‘Renewal in the Spirit’ movement 6, 230 Resource allocation, global view 254 Restorative Justice movement 117

Rights of passage 110–11, 115–16 Runajambi Institute [Otavalo, Ecuador] 88–90 achievements 89–90 goal/mission 88–9 research studies 89 WPA-TPS international (2005) conference co-sponsored by 90 Rurashca [victim of sorcery], as diagnosis 57, 59, 60, 85 Salish Indians 9, 124 Sanskara 33–4 Schizophrenia misdiagnosis in UK 222 treatment of, in East Asia 174–5 Seacole, Mary Jane [Jamaican nurse] 221 Secrecy of traditional healers 213 Self determination of indigenous people 244 Senegal, traditional healers 62 Shame culture 33, 115 Shinkeishitsu [hypochondriac/fixation symptoms] 172 Shintoism 170, 171 Shuar people [Ecuador] 68 collaboration as psychiatrist 71–2 previous research 70 use of hallucinogenic 69–70 witchcraft victims 72 Shuar shaman 72–4 Shungu nanay [heart pain], symptoms 56, 58 Sierra Leone, child soldiers 257 Smudging lodge ceremony [American Indians] 128 Social anxiety disorder, treatment of 172–3 Sociocultural belief systems, psychotherapy and 33–4 Sociotropy 30 Somatization tendency, in China 140 Sorcery illnesses resulting from 57, 59, 72, 186–7 see also Witchcraft South Africa guidelines for recognition of indigenous medicinal knowledge 4, 213–14 integrated traditional/Western health care system 210–14 see also African Health Care System legalization of traditional healing practices 4, 19, 212 South America, see Latin America

268 South Asian community in UK, traditional healing practices 217–20 Southampton Centre for Complementary and Integrated Medicine [UK] 224–5 Spirit illnesses case studies 57–60, 158–61 distinction from physical illnesses 157 in Ecuador 56–7, 86, 86 in India 151–2, 163n8 symptoms 57, 156–7 Stigma mental disorders 152, 256–7 traditional healing practices 213 Supernatural determinism 5 Survey of American Indians and Alaska Natives 94 clinical characteristics 96 cultural characteristics 96 demographic characteristics 96 sample design 94–5 traditional healer use factors associated with 97–2 health policy impacts 104–5 measurement of 95 reasons for low reported use 102–4 see also Alaska Natives; American Indians Survival mechanisms, Native Americans 112 Sweat lodge ceremony [American Indians] 128 Taijin Kyofusho syndrome (TKS) 167, 170 Talk therapy 138 Talking circle [American Indians] 128 Tamoxifen 38, 49n1 Tanzania, community integrated psychiatric program 257 Taoist approaches 143, 146–7 Tapu concept [in Maori healing] 240–1 Telehealth outreach workers, in American Indian clinics 127 Therapist–patient social distance 34 Thoughtfulness, Japanese people 169 Tic disorders 181 see also Tourette’s Syndrome Tohunga [Maori healers] 238 training of 239–40 Tohunga Suppression Act (1907) 238 Tourette’s Syndrome (TS) 181 treatment of 186, 188–9, 191, 192

INDEX Trade-Related Aspects of the Intellectual Property Rights Agreement 45–6 Traditional Chinese Medicine (TCM) categories 141 diagnostic procedures 143 dynamic nature of diagnoses 143–4 number of practitioners in China 142 prejudice against 142 psychotherapeutic and communicative aspects 142–5 therapeutic techniques 144–5 Traditional healers in Africa 208 African–Caribbean and African communities 220–3 attitude of mainstream physicians 14, 20, 54 in Bali 182, 183–91 coexistence with psychiatrists in Bali 183, 192 in Japan 173–6 in North India 155, 157–63 collaboration with mainstream medical practitioners 18, 20–22 in Africa 210–14 future partnerships 257–8 in Islamic countries 198, 201–2, 204, 205 in Latin America 63, 86, 89 in New Zealand 248 in North America 20, 127–8, 129–32 global contributions 254–7 hallucinogenic compounds used by 41, 69 in India 28, 150, 152–3 in Japan 174, 175–6 in Latin America 9, 54, 61, 72–4, 81 legitimacy status 19–20 in New Zealand 62, 238–41 in North America 94–105, 123–32 numbers 142, 254–5 psycho-social and clinical skills 61, 62, 255–6 reimbursement of 10, 20–1, 104, 126, 129 in UK, South Asian community 217–20 see also Balian; dukun; hakim; medicine man; Shuar shaman; tohunga; yachactaita; yuta Traditional healing practices biomedicine and 242–3 contributions to global mental health 243–4 cultural basis 243–4

INDEX in Moslem communities 202, 203–4 research 14, 15–16, 54, 62 American Indian healers 125–9 Quichua healers 55–61 subordination to medical approach 14, 17, 20 in UK South Asian community 217–20 Traditional Health Practitioners Act of South Africa (2004) 212 Traditional legitimacy 18, 19 Traditional medicine definition 15, 39 integration with contemporary medical approach 9–11, 17, 62–3, 85, 86 renewed interest in 16–17 WHO’s interest 16–17 Trance-like state Japanese shaman 175, 176 possessed person 222 Trepanation 49n2 local anesthetic used 40 Trinitarianism 230, 235n1 Tropane alkaloids 4, 69 Tsuakratin [good Shuar healer] 73

Unani medicine system 217–18 treatment regimen 218 United Kingdom (UK) African–Caribbean and African communities mental illness rates 216–17 traditional healing practices 220–3 Department of Health information pack on complementary and alternative medicine 224 migration to 215–16 South Asian community, traditional healing practices 217–20 use of traditional healers among immigrant communities 218–19 United States earning losses due to mental disorders 252 legitimation bodies 19 patent system 42–3, 47, 48–9 prison life 108–9 reimbursement for traditional healing services 20–1

269 Surgeon General’s report on mental health 252 see also American Indians; Native Americans Utilization technique 145 Verbalization of emotions and symptoms 16–17, 31–2 Veterans Administration (VA), collaboration with traditional healers 10, 20, 102, 104, 125, 126, 129 Vital life force, in Southeast Asian cosmology 185 Wawekratin [evil Shuar healer] 73 Weber’s Theory of Legitimate Rule 18 Whaiora mental health service [New Zealand] 246 Wicasa Wakan [Lakota Sioux ‘holy man’] 16 Wishin [Shuar shaman] 72–4 Witch doctors, in China 141, 146 Witchcraft disease and 72, 187 see also Sorcery World Health Organization (WHO) definitions 15, 39, 208 on global impact of mental disorders 252 on resource allocation 254 schizophrenia treatment study [in East Asia] 174 on traditional medicine 15, 16–17, 256 Yachactaita [traditional Quichua healers] 9, 53, 81 attitude of mainstream physicians 54 in collaborative approach to health care 62, 82, 85, 86 diagnostic abilities 61 clinical and health policy implications 62–3 psychiatric case identification skills 56–64 Yuta [Okinawan shaman] 174, 175–6 trance-like state [kamidari] 175, 176 Zen Buddhism 171 Morita therapy and 173 Zung Self Rating Depression Scale Quichua version 55 scores 56, 61