Approaches to Cross-Cultural Psychiatry 9781501742750

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APPROACHES TO CROSS-CULTURAL PSYCHIATRY

APPROACHES TO

CROSS-CULTURAL PSYCHIATRY Edited by

Jane M.

Murphy

and

Alexander H. Leighton

Cornell University Press ITHACA,

NEW YORK

Copyright

©

1965

by Cornell University

Press

All rights reserved

CORNELL UNIVERSITY PRESS First published

1965

Library of Congress Catalog Card Number: 65-13631

PRINTED IN THE UNITED STATES OF AMERICA BY VAIL-BALLOU PRESS, INC.

Preface

THIS

work, reporting on methods and concepts for comparamental

tive studies of

outgrowth of

efforts

illness in different cultural

groups,

is

the

sponsored by the Cornell Program in Social

Psychiatry to explore and understand the nature of some of the

problems confronting research in have approached

this topic

this field.

The

contributors

through reviews of the

literature,

The exploratory field among studies were carried out Eskimos, Navahos, and Mexicans, as well as British and Acadian French in Nova Scotia. In the early 1950's, two epidemiological studies were undertaken in northeastern America. One study was concerned with seminar discussions, and

a rural

county

in

trial investigations.

Maritime Canada. This, the Stirling County

Study, was formulated and directed

The

by Alexander H. Leighton.*

research was conducted through Cornell's Department of

Sociology and Anthropology on the campus

York.

The

other epidemiological study, the

Study, concerned an area in metropolitan

by Thomas A.

C. Rennie,t

who

Ithaca,

New

Midtown Manhattan

New

directed

at

it

York. Instituted

until his death in

Other chief investigators in the Stirling Study were B. P. Dohrenwend, J. S. Harding, C. C. Hughes, D. C. Leighton, D. B. Macklin, the late A. M. Macmillan, the late G. E. McCreary, J. M. Murphy, A. L. Nangeroni, R. N. Rapoport, and M.-A. Tremblay. f For the Midtown Study, the other main investigators were P. Kirkpatrick, T. S. Langner, S. T. Michael, M. K. Opler, V. Rubin, L. Srole, and A. Weider. *

v

Preface

vi

it was based at the Cornell University Medical College in York City. The main results of the two studies have been reported in a series of volumes which give detailed presentations

1956,

New

of theoretical orientations, methods employed, and analysis of findings.* After Rennie's death, the Stirling

and Midtown Studies

were joined under the directorship of Alexander H. Leighton and the name "Cornell Program in Social Psychiatry" was adopted.

The two

investigations of populations in

were conceived with somewhat

Western culture

similar frames of reference.

Although each faced unique problems and pursued

a separate

course of data gathering and analysis, the exchange of ideas in defining concepts

and developing methods of research gave

a measure of comparability to the

was

interest in

the full range

two

studies. In

both there

of psychiatric disorders from

psychoses and mental deficiency to psychoneuroses and behavior disturbances. it

From

the theoretical viewpoint, however,

seems probable that psychoneurotic and psychophysiologic

symptoms

are the kinds

most directly under the influence of

different sociocultural experiences

with significant distribution tionalized groups.

pay

The

and most

likely to be

in nonhospitalized

found

and noninstitu-

investigators determined, therefore, to

special attention to discovering the mild as well as the

severe forms of mental

illness.

To

accomplish

this,

questionnaire

interviewing was employed as one means of case-finding in each of the studies. In Stirling County, a fishing, lumbering, and subsistence-

County Study: A. H. Leighton, My Name Is Legion York: Basic Books, 1959); C. C. Hughes, M.-A. Tremblay, R. N. port, and A. H. Leighton, People of Cove and Woodlot (New Basic Books, i960); D. C. Leighton, J. S. Harding, D. B. Macklin, Macmillan, and A. H. Leighton, The Character of Danger (New Basic Books, 1963). Midtown Study: L. Srole, T. S. Langner, S. T. Michael, M. K. and T. A. C. Rennie, Mental Health in the Metropolis (New * Stirling

(New RapoYork: A. M. York: Opler,

York:

McGraw-Hill, 1962); T. S. Langner and S. T. Michael, Life Stress and Mental Health (New York: The Free Press of Glencoe, 1963).

Frejace

vii

farming region inhabited by two main ethnic groups, English

and French Acadian, the research program was concerned with studying community

The

life in

its

analysis of sociocultural

background

in cultural

total

impact upon individuals.

environment focused on contrasts

well as on differences in degree of

as

and "disintegration." The concepts of

"social integration"

tegration and disintegration provided a

framework for

in-

selecting

communities displaying both adequate and inadequate functioning, the features of

which were predicted

to have differen-

on mental health and mental illness. Hence social disintegration was considered to be a pattern or combination of a number of noxious conditions. The criteria by which this

tial

effect

process was identified included such factors as poverty, secularization,

cultural confusion, fractured social relationships, and

rapid sociocultural change. Other components of the process are inadequacies in

leadership,

recreation,

com-

associations,

munication, and control of crime and delinquency.

The aim was tions

to find out

whether there are important correla-

between the prevalence of psychiatric symptoms and

residence in integrated or disintegrated communities. Other aspects of

were

life

experience, such as age, sex, and ethnic identity,

also investigated.

surveyed to

elicit

A probability sample

of 1,010 adults was

sociocultural information and data

of both a physical and psychiatric nature.

The

physicians were also interviewed about the

on health

county's local

members

of the

sample, and mental and other hospital rec-

statistically selected

ords were considered

when they

pertained to the sample

mem-

bers.

The Midtown

Study,

already noted, dealt with a section

as

of Manhattan in the city of

study area,

Midtown

is

a

New

York. In contrast to the rural

much more complex and

society with several ethnic groups represented:

heterogeneous Irish,

German-Austrian, Hungarian, Czechoslovakian, Polish,

Old American, and tions

others.

Broad diversity

exists in the

Italian,

British,

occupa-

and professions present, and the span of economic

levels

Preface

viii

extremely wide. In

is

status"

this

was employed

as a

order to uncover

in

study the concept of "socioeconomic

way

of quartering the environment

sociocultural

patterns

which

with the distribution of psychiatric symptoms.

A

correlate

number of

the elements of social disintegration used in the Stirling Study

were given attention stress"

was analyzed

in the

Midtown

in terms of

homes, economic deprivation, alence survey in

"life

broken

as

and so on. The prev-

health,

ill

Midtown was

Study. For example,

components such

carried out with a probability

sample of 1,660 adults.

Allowing for the many eralization

some

studies,

The

limitations to

comparison and gen-

imposed by the differences of procedure

conclusions are nevertheless

tentative

differences

in the

environment encompassed by

in

two

possible.

the

terms

"urban" and "rural" and by the divisions of Western society into ethnic groups such as French, English, Irish, and Italian

did not parallel major differences in the prevalence of psychiat-

disorder in the

ric

two sample

populations.

Psychoneurotic

symptomatology formed an overwhelming part of the ture of disorders

among

total pic-

these nonhospitalized people, and

it

was much more prevalent than had been suspected. In the Stirling

Study the factors of advancing

and of low occupational living in a disintegrated rates of

symptoms.

age, of being a

woman,

position, as well as the experiences of

environment were correlated with high

Among

the

Midtown

adults,

advancing age

and low economic position had similar relationships. This platform of trends,

Western and developing

as well as general interest in

non-

countries, raised several questions for

exploration in contrasting groups: 1.

is

What

kinds of psychiatric disorders are there and what

the actual prevalence in groups that practice life-ways very

different

from those of the West? That

cultural contrasts than those

found

in

is

to say, will greater

Midtown and

Stirling

bring to light significant qualitative and quantitative differences?

Preface

Do

2.

the apparent influences of age, sex, and occupational

position hold

up

residence have

cross-culturally?

when looked

How may

3.

ix

rural or

urban

sociocultural disintegration be defined cross-

and does

culturally,

What effects do

at in cross-cultural perspective?

it

continue to have the same association

with prevalence of psychiatric disorders?

What

4.

tensive

all

the effect of cultural change, so rapid and ex-

is

around the world, on these interrelated factors? In

other words,

do the patterns of

acculturation,

and low socioeconomic position have

social

rapid

disintegration,

similar

relevance for the epidemiology of disorders in non- Western populations?

As

a start

toward investigating cross-cultural problems of

type,

many

questions of concepts, theory, methods, and feasi-

bility

had to be reviewed by members of the Cornell Program.

According

to interests

this

and opportunities, the contributors chose

particular topics

and decided on various ways of exploring them.

The approaches

entailed field studies as well as

and

libraries;

and

this

book

is

one

work

in clinics

result.

The volume has been organized so common theme are grouped together.

that

chapters with a

In order to link the

chapters to the overall purpose of the book, the editors have

prepared an introductory the chapters.

comment preceding

These two chapters, the

general orientations written first

by one

first

all

but two of

and the eighth, are

or both of the editors.

The

chapter, "Cross-cultural Psychiatry," concerns history of

the field, definition of terms, and a

be approached.

It

map

of the problems to

opens Part One, which focuses predominantly

on questions of identifying and surveying for psychiatric orders.

cultural jMethods for Psychiatric Research," begins Part

which

dis-

Chapter VIII, "Social Science Concepts and Cross-

deals

Two,

mainly with sociocultural approaches useful to cross-

cultural psychiatric research.

Following the

first

chapter in Part

One

are

two

chapters

x

Preface

concerning identification of disorders in societies with cultures

very different from that of the West. other in that Chapter

II

They complement

devoted to disorder

is

Western psychiatric terms, while Chapter indigenous conceptions of

illness

III

each

defined in

as

addressed to

is

and deviance. The next two

chapters take up questions about certain indicators that might

be employed to estimate the prevalence of disorder in different cultures.

Chapter

IV

discusses a questionnaire,

which

with the possibility of employing physiological

The

indicate psychiatric disorder. also

deal with a

common

problems of establishing

and children. Their of the

work done

Two

Part

is

They concern among

VII,

the special adolescents

heightened by the fact that most

consists of four chapters.

The

sideration to the socially shared

Chapter VIII,

first,

IX concerns

an instrument for intensive studies of

with a focus on analysis of cultural

ill

roles.

the

life

story

and well individuals

Chapter

X

gives con-

sentiments characteristic of

and discusses what meaning they

different groups of people

may

might

so far has dealt with adults.

has been mentioned above. Chapter as

deals

VI and

criteria of disorder

interest

V

tests that

next chapters,

theme.

largely

is

concerned with psychophysiologic symptoms. Chapter

have for mental health and mental

illness.

Chapter XI

is

the report of an exploratory field study in which certain of

were given trial and in up between some kinds of psy-

the previously described techniques

which

correlations are pointed

symptoms and some kinds of social experiences. described in this volume was carried out between 1956 and i960. In 1961 some of the investigators began a com-

chiatric

The work

prehensive epidemiological study of a rural area in Nigeria. Dr.

T. Adeoye Lambo, tendent of the

who was

Aro Hospital

for

at that

time Medical Superin-

Nervous Diseases

in the

West-

ern Region of Nigeria, was co-director of this study, which

was

called the Cornell-Aro

Many in this

Mental Health Research Project.

of the methods of data gathering and analysis discussed

book were applied

in the Nigerian study,

and further

Preface effort

was made to

xi

substantiate their validity and reliability.*

Our coverage of the field in this volume is, of course, partial selective. Taken together, however, the chapters deal with number of technical questions both conceptual and meth-

and a

odological that are germane to a wide variety of problems re-

garding the relationship of sociocultural environment to psychiatric disorder.

Our hope

is

that they will be useful to others

approaching cross-cultural psychiatry.

Jane M. Murphy Neiv York,

New

York

April, 196$

* A. H. Leighton, T. A. Lambo, C. C. Hughes, D. C. Leighton, J. M. Murphy, and D. B. Macklin, Psychiatric Disorder among the Yoruba: A Report from the Cornell- Aro Mental Health Research Project (Ithaca,

N.Y.: Cornell University Press, 1963).

Acknowledgments

ALTHOUGH

this

volume comprises the individual work of

fourteen contributors,

it

represents a

common

enterprise largely

undertaken within one framework. This general acknowledg-

ment therefore supplements the specific acknowledgments appear in the notes appended to the separate chapters.

The

book has been sponsored by

research reported in this

the Cornell

Program

in

that

Social Psychiatry, which, in turn,

administratively attached to the

Department of Psychiatry

is

in

Department

the Cornell University Medical College and to the

of Sociology of the College of Arts and Sciences in Cornell

when

University. During most of the time

this

volume was

being developed and written, the Program was also attached to

Department of Anthropology.

the

The cial

Cornell Program in Social Psychiatry has received finan-

aid

from

a

number

The work

of institutions.

been mainly supported by

a

Foundation's Behavioral Science Division.

The

Cornell Program

however, an outgrowth of the Stirling County Study and

is,

the a

herein has

program grant from the Ford

Midtown Manhattan Study. Both

these Studies constitute

fundamental background for the projects described in

book.

The

Stirling

County Study was

derived primarily from four sources:

Fund, the Carnegie Corporation of xiii

this

carried out with funds

the Milbank Memorial

New

York, the Depart-

Acknowledgments

xiv

ment of National Health and Welfare of Canada, and partment of Public Health of the Province of

The Midtown Manhattan Studv was

the

Nova

De-

Scotia.

given financial aid from

the National Institute of Mental Health in the United States

Public Health Service, the Milbank Memorial Fund, the Grant

Foundation, the Rockefeller Brothers Fund, and the Corpora-

Company. These foundations

tion Trust

of course,

are not,

book and

the authors, owners, publishers, or proprietors of this are not to be understood as approving,

bv

virtue of their grants,

any of the statements made or views expressed

therein.

In addition to this general support, the following

The work

noted.

by

represented in Chapter

II

to be

is

was made

possible

fellowships granted to Charles Savage and Alexander

H.

Leighton from the Center for Advanced Study in the Behavioral Sciences.

Alaska,

A

study of Eskimos on

referred to throughout this

is

in Chapters

II,

III,

IV, VII, and IX.

St.

Lawrence

book and

Island,

specifically

The 1954-195 5

investiga-

was conducted by Charles C. Hughes and Jane M. Murphv from funds supplied by the Social Science Research Center of Cornell University and by Dr. and

tion of this population

Mrs. Rex Murphv.

The

1940 studv was carried out by Alex-

ander H. Leighton and Dorothea C. Leighton on a joint fellow-

from the Social Science Research Council. The study of

ship

VI was supported

adolescent

svmptoms reported

by

from the Health Research Council of the City of

a grant

New

York and

Council

is

in

The Health Research

backing to the study of child-

Chapter VII. Chapter

X

reports

comparative analvsis of materials gathered in the Stirling

County Study and Funds for the poration of

the

New

statistical

Program

Cornell-Navaho Southwest Project.

latter project

were given by the Carnegie Cor-

York.

Several chapters of this

of

Chapter

the Foundations Fund.

also giving financial

hood svmptoms described a

in

book have been written

in the light

guidance given by consultants to the Cornell

in Social Psychiatry. Special

acknowledgment

is

there-

Acknowledgments

xv

fore given to Melvin S. Schwartz, David B. Macklin, and John S.

Harding.

This book has been reviewed in whole or in part by a number of colleagues.

Some

of these reviews have been

by authors

of one chapter for authors of other chapters. Outside the

list

of

contributors and statistical consultants, grateful acknowledg-

ment

is

made

especially to Dr.

William T. Lhamon, Professor

and Chairman, Department of Psvchiatry, Cornell University Medical College, and Dr. Robin M. Williams, Sociology, Cornell University, editorial

who

serve as

Jr.,

Professor of

members of an

board for the Cornell Program in Social Psychiatry.

Dr. Allan R. Holmberg, Professor and Chairman of the De-

partment of Anthropology, and Dr. Gordon Streib, Professor

and Chairman of the Department of Sociology, both of Cornell University, have also reviewed the manuscript. For reading and

commenting on to

particular chapters,

appreciation

is

expressed

Robert Ascher, Charlotte Babcock, David V. Becker, Laurel

H. Hodgden, Alice L. Nangeroni, and Peter Stokes. Technical assistance has been given by Veronica A. Shaw and Marlene Mandel. Administrative and secretarial help has come from Amorita Suarez, Dee Watt, Norma Bain, and Donna Hamilton.

For

all

this aid

and

express sincere thanks.

assistance, the editors

and the authors

Biographical Notes on Contributors

Gloria

J.

tice. A4rs.

Berk

is

presently a psychotherapist in private prac-

Berk received

lege School for Social

a master's degree

Work. Before

from the Smith Col-

joining the staff of the

Payne Whitney Adolescent Psychiatric Out-Patient Clinic of the

New

York

Hospital, she participated in the

Bureau of Mental Hygiene Co-ordinated

work

in Hartford, Connecticut,

Community Mental Health

of the

and the

Clinics of Brooklyn.

Charles C. Hughes, Professor of Anthropology and Director of the African Studies Center at Michigan State University, received his Ph.D. degree in anthropology from Cornell University. Dr. Hughes has been a Fellow at the Center for Advanced Study in the Behavioral Sciences and has done research in

Nova

publications include

Scotia,

Alaska,

An Eskimo

(Cornell University Press,

Liberia,

and Nigeria. His

Village in the

i960)

field

Modern World

and co-authorship of Peo-

Cove and Woodlot (Basic Books, i960) and Psychiatric Disorder among the Yoruba (Cornell University Press, 1963). He has published articles on Eskimo culture, cultural change and social psychiatry in such journals as the American Anthropolople of

gist,

Current Anthropology

Thomas

S.

Langner,

ciology)

at

the

New

,

and the Journal of Social

Issues.

Assistant Professor of Psychiatry

York University School xvii

(So-

of Medicine,

Biographical Notes on Contributors

xviii

received

his

Ph.D. in sociology from Columbia University.

Dr. Langner has done anthropological research in Mexico and

American Southwest; race relations research for the AntiDefamation League; propaganda analvsis for the Voice of the

He

America, and studies of the aged. a

program of

sity,

is

currentlv engaged in

interdisciplinarv research at

New

York Univer-

Department of Psvchiatry. His publications include con-

tributions to

many

scholarlv journals as well as co-authorship

Hundred Over

of Five

Sixty

(Russell

Sage,

1956), Mental

Health in the Metropolis (McGraw-Hill, 1962), and Life and Mental Health (The Free Press of Glencoe, 1963).

Alexander H. Leighton, Director Social Psychiatry,

is

of the Cornell

Stress

Program

in

Professor of Psvchiatry (Social Psychia-

try) at the Cornell University Medical College and Professor

of Sociologv and Professor of Anthropology at the College of

Arts and Sciences, Cornell University. Dr. Leighton received his

medical degree from Johns Hopkins Medical School.

Advanced Study

has been a Fellow at the Center for

Behavioral Sciences and the holder of

from the Carnegie Corporation of

The Governing

include 1945),

1949),

Men

of

Human Relations in My Name Is Legion

tion to Social Psychiatry

a

New

a

He

in the

Reflective Fellowship

York. His publications

(Princeton University Press,

Changing World (E.

(Basic Books, 1959),

P.

An

Dutton,

Introduc-

Thomas, i960), and coWoodlot (Basic Books, i960),

(Charles C.

authorship of People of Cove and

The Character of Danger (Basic Books, 1963), and Psychiatric among the Yoruba (Cornell University Press, 1963).

Disorder

Dorothea

C.

Leighton

is

Clinical Associate Professor of Psy-

chiatry (Social Psychiatry) at the Cornell University Medical

College and Senior Research Associate and Lecturer in the De-

partment of Sociology and in the Department of Anthropology of the College of Arts and Sciences, Cornell University. Dr.

Leighton received her medical degree from Johns Hopkins Medical

School and has done

field

research

among

the Xavaho, Zuni,

Biographical Notes on Contributors St.

xix

Lawrence Eskimos, and Yoruba. She has been doing epidemioCounty Study, now a part of the

logical research in the Stirling

Her publications include The Navaho Door (Harvard University Press, 1944), The Navaho (Harvard University Press, 1946), Children of the People (Harvard University Press, 1947), The

Cornell Program in Social Psychiatry.

co-authorship of

Character of Danger (Basic Books, 1963), and Psychiatric Disorder among the Yoruba (Cornell University Press, 1963).

Edward Llewellyn Thomas macology

at the

is

Associate Professor of Phar-

University of Toronto and Medical Research

Associate at Ontario Hospital,

New

Toronto.

He

received his

medical training at McGill University. Before the war, he trained as an engineer at the University of

London and

is

at

present carrying on his research at the Institute of Bio-medical Electronics, a joint project

between the Faculty of Medicine

and the Faculty of Engineering

Thomas

is

to

University of Toronto. Dr.

also a part-time Professor of

versity of Waterloo,

man

at the

Psychology

where he has been teaching

Factors Engineering in Canada.

He

at the

Uni-

a course in

Hu-

has contributed articles

Science, Canadian Medical Association Journal,

Canadian

Psychiatric Association Journal, Radiology, Canadian Journal of

Psychology

,

Journal of Aerospace Medicine, and the Journal

of Projective Techniques.

Masterson,

James

F.

at the

Cornell University Medical College,

Clinical Associate Professor of Psychiatry is

Director of the

Research Project on Psychiatric Disorder in Adolescents and is

in charge of the Adolescent Division of the

Payne Whitney

Out-Patient Department. Dr. Masterson received

his

degree from Jefferson Medical College and combines search interests with part-time practice in psychiatrv.

medical his

re-

He

has

contributed to journals such as Psychiatry, Journal of Nervous

and Mental Disease, American Journal of Psychiatry and The Medical Clinics of North America. ,

Biographical Notes on Contributors

xx

Jane M. Murphy is Assistant Professor of Anthropology in the Department of Psychiatry of the Cornell University Medical College and Research Associate in the Department of Sociology and in the Department of Anthropology, College of Arts and Sciences in Cornell University. Dr.

Murphy

received

her Ph.D. degree in anthropology from Cornell University and has done field

work

in Alaska,

Nova

Scotia,

and Nigeria. She

contributed to the research of the Stirling County Study and is

currently with the Cornell Program in Social Psychiatry.

Her

An

publications include collaboration on

in the

Modern World

Eskimo Village

(Cornell University Press,

authorship of Psychiatric Disorder

among

the

i960), co-

Yoruba (Cornell

University Press, 1963), and articles on cross-cultural psychiatry and psychotherapy in

World Mental Health,

Memorial Fund Quarterly, and Magic,

by Ari Kiev (The Free

Seymour Parker,

Faith,

the Mil bank

and Healing, edited

Press at Glencoe, 1964).

Associate Professor of Anthropology and

Associate Professor of Social Science at Michigan State University,

was formerly

a cultural anthropologist in the

ment of Psychiatry of the Jefferson Medical

Depart-

College.

He

received his Ph.D. degree in anthropology from Cornell University,

and

his field

work

Mexico, and Alaska. social structure of a

working on

a

includes research in

He

Nova

Scotia,

New

has also participated in studying the

mental hospital in England, and

is

currently

study of mental health among Negroes in Phila-

delphia. Dr. Parker has contributed to

many

journals such as the

American Anthropologist, American Sociological Review, Psy-

Human

chiatry, Ethnology,

and

Tom

Associate Professor in the Department of

T. Sasaki

is

Sociology, University of

New

Relations.

Mexico. His Ph.D. degree in

sociology was received from Cornell University. field

work among

the

Navaho and

has served as a social science consultant to the

He

has done

Apache and Navaho Indian

the Jicarilla

Biographical Notes on Contributors

Tribe

xxi

well as to various training and extension programs in

as

American Southwest. Dr. Sasaki was formerly Field Di-

the

rector of the Cornell-Navaho Project in Technological Change.

He

the author of Fridtland,

is

munity

in

Transition

has published

articles

New

Mexico:

New

Business,

Charles Savage

is

Navaho Com-

(Cornell University Press,

i960)

and other

Issues,

Rural Sociology,

journals.

Director of Research, Spring Grove State

Hospital, Baltimore, Maryland. Dr. Savage received his ical

and

about the American Indians in the Ameri-

can Anthropologist, Journal of Social

Mexico

A

degree from the University of Chicago and

is

med-

a graduate

Washington School of Psychiatry and a member of the American Psychoanalytic Association. He has been a Fellow at the Center for Advanced Study in the Behavioral Sciences; earlier he was Acting Chief of the Adult Psychiatric Branch of the

of the National Institute of Mental Health.

experience

among

the

Navahos

in

New

He

has had field

Mexico and the Yoruba

of Nigeria and has contributed papers to numerous journals

such

as

American Journal of Psychiatry, Journal of Nervous

and Mental Disease, Archives of Psychiatry and Neurology Psychoanalytic Review, Diseases of the Nervous System, and Psychiatry.

Marie-Louise Schoelly

is

Clinical Assistant Professor of Psy-

chiatry in the Division of Child Psychiatry of the Cornell University Medical College. She received her medical education at

the University of Zurich, Switzerland, and took her psychiatric

residency at the Psychiatric University Clinic in Basel, Switzerland.

She

is

currently engaged in research concerning psychiat-

symptoms in childhood and also practices psychiatry in New York City. Dr. Schoelly has written on the use of curare in electroshock therapy and on psychosis associated with tetany in such journals as the Journal of American Physical Medicine and the Monthly Review of Psychiatry and Neurology. ric

Biographical Notes on Contributors

xxii

Albert

Sherwin

C.

is

Clinical

Associate Professor of Psy-

chiatry in the Department of Psychiatry and Director of the

Division of Child Psychiatry in the Cornell University Medical College.

He

received his medical degree from Columbia Uni-

versity Medical College of Physicians and Surgeons. In addition

to a part-time practice, Dr.

Sherwin

doing research on child-

is

hood symptoms. He has published articles on the relationship between psychopathology and music as well as papers on various psychiatric disorders found in children in journals such as

American Journal of Psychiatry, Journal of Nervous and Mental Disease, Bulletin of the New York Academy of Medithe

cine,

and the Journal of Chronic Diseases.

Kenneth

F.

Tucker, who received

Cornell University Medical College,

his is

medical degree from

a Clinical Instructor in

Psychiatry at that institution. Currently he devotes the major part of his time to the private practice of psychiatry.

He

has

participated in the research on adolescence conducted at the

Payne Whitney

Clinic.

Journal of Psychiatry

He

has contributed to the

American

Contents

Preface,

by Jane M. Murphy

v

Acknowledgments

xiii

Biographical Notes on Contributors

xvii

Part One. Identifying and Surveying Psychiatric Disorders I

Cross-cultural Psychiatry

BY ALEXANDER II

The Problem

H.

LEIGHTON AND JANE M.

MURPHY

3

of Cross-cultural Identification of

Psychiatric Disorders

BY CHARLES SAVAGE, ALEXANDER DOROTHEA III

C.

H.

LEIGHTON, AND

LEIGHTON

2

Native Conceptions of Psychiatric Disorder

BY JANE M. MURPHY AND ALEXANDER

IV

1

The Use

H.

LEIGHTON

Symptoms as Indicators among Eskimos BY JANE M. MURPHY AND CHARLES C. HUGHES

64

of Psychophysiological

of Disorder

V

The

Possibility of

108

Using Physiological Indicators

for Detecting Psychiatric Disorder

BY EDWARD LLEWELLYN THOMAS xxiii

l6l

Contents

xxiv

VI

Some

Criteria of Psychiatric Disorder in Adolescents

BY JAMES

MASTERSON, KENNETH TUCKER, AND

F.

GLORIA BERK

VII

87

Criteria of Psychiatric Disorder in Children

BY ALBERT

Part VIII

I

Two.

SHERWIN AND MARIE-LOUISE SCHOELLV

C.

219

Assessing the Socio cultural Environment

Social Science Concepts

and Cross-cultural Methods for

Psychiatric Research

BY JANE M. MURPHY N

IX

The

I

Life History in Cross-cultural Psychiatric Research

BY CHARLES

X

25

HUGHES

C.

Society and

Sentiments in

285

Two

Contrasting Socially

Disturbed Areas

BY SEYMOUR PARKER AND TOM

XI

Psychophysiological in

Two

BY THOMAS

T.

SASAKI

Symptoms and

329

the Status of

Women

Mexican Communities S.

LANGNER

360

Concluding Note

BY ALEXANDER Index

H.

LEIGHTON AND JANE M.

MURPHY

393

398

Charts

IV- 1

IV-2

Age-sex distribution of the Bristol Ecological Area population (Ninth Census of Canada, 1951)

151

Age-sex distribution of Sivokak village for 1955

152

Figures IV- 1

Frequency diagram based on raw data of the

Stirling

weighted scores for three samples IV-2

Frequency

distributions of

villagers, Stirling

HOS

community

127

scores for residents,

Eskimo

and

Stirling

neurotics with best-fitting normal curves

IV-3

Comparison of Eskimo and

IX- 1

Schematic representation of data-gathering techniques

IX-2

Role

"nesting"

as

Stirling response patterns

illustrated

130

286

by Eskimo apprentice

hunter, hunter, and boat captain

XXV

128

298

Charts

IV- 1

IV-2

Age-sex distribution of the Bristol Ecological Area population (Ninth Census of Canada, 1951)

151

Age-sex distribution of Sivokak village for 1955

152

Figures IV- 1

Frequency diagram based on raw data of the

Stirling

weighted scores for three samples IV-2

Frequency

distributions of

villagers, Stirling

HOS

community

127

scores for residents,

Eskimo

and

Stirling

neurotics with best-fitting normal curves

IV-3

Comparison of Eskimo and

IX- 1

Schematic representation of data-gathering techniques

IX-2

Role

"nesting"

as

Stirling response patterns

illustrated

130

286

by Eskimo apprentice

hunter, hunter, and boat captain

XXV

128

298

Tables

IV-

1

IV-2

Eskimo Health Opinion Survey questionnaire Eskimo

HOS

scores, psychiatric

ABCD

1 1

ratings,

and

independent evidence of svmptom patterns

XI- 1

Twenty-two Item Score

XI-2

Number

142

373

of interviews in Mexico City

by

and

district

social class

XI- 3

Sample

376

age and education

characteristics:

come, and residence

XI-4

Average

number

XI-5

sex,

in-

(in per cent)

symptoms

of

Score) according to

by

378

(Twenty-two

sex, residence,

Item

and income

Complaints reported on Twenty-two Item Score by sex

and city (in per cent) XI-6

379

384

Attitudes toward female equality

and sex

(in per cent)

by

residence, income,

387

xxvi

Part

One

IDENTIFYING

AND

SURVEYING PSYCHIATRIC DISORDERS

Cross-cultural Psychiatry

I:

By Alexander H. Leighton and Jane M. Murphy

IF one takes a broad definition of social psychiatry, then

it

is

appropriate to regard cross-cultural psychiatry as occupying a

on certain aspects in the relationship between

position within this field and as focusing certain ways.

two

1

The

point of attention

is

orders of phenomena: psychiatric disorders and sociocul-

tural environment.

As

areas of interest, the fields of social

cross-cultural psychiatry rest

on

the assumption that there

and is

an

interdependence between psychiatric and sociocultural processes that

is

in

some measure

distinct

from the

relationships

between

psychiatric processes and organic experiences or heredity. It is

well recognized, however, that such compartmentaliza-

tions are as false to fields

of

human

phenomena

science.

versus environment and

in psychiatry as

The

body

old arguments about heredity

versus

mind have been

not settled in the twentieth century, and that

human

they are in other

it is

set aside if

generally accepted

functioning cannot be adequately comprehended

viewed from one orientation to the exclusion of theless, a division

others.

if

None-

of the total problem into subfields such as

cross-cultural psychiatry facilitates

the organization of ideas

along lines that are amenable to research and that utilize the con3

Approaches

^ cepts and

skills

to Cross-cultural Psychiatry

of different disciplines. Current specialization of

by the intention of achieving an ultimate convergence in which fuller understanding of psychiatric phenomena will be reached through a number of perspectives. Within the broad framework of interest in causes of psychiatric disorder it is not only permissible but useful to ask what is more and what less important. The goal may be heuristic unfocus

thus justified

is

derstanding or

it

may

be a desire to modify and control. In the

latter case the investigator

is

concerned with the major obstacles

overcome and opportune points

to be

in the process. effort

Those

at

that promise the

which most

to initiate

change

effect for the least

can be considered the most important whether the phe-

nomenon

in question be considered part of genetics, physiology,

psychology, cultural processes, or some division or overlapping area in one or

more of

these.

The purposes of this chapter are, therefore, to explain what we mean by cross-cultural psychiatry, trace briefly its history as a

body of thought and

investigation, define terms,

and

list

some

of the important problem areas.

Nature and History of Cross-cultural Psychiatry Cross-cultural psychiatry, as conceived here,

is

a

way

of ob-

serving and ordering facts about the processes of psychiatric

by studying people in numbers rather than as individual patients and by comparing the sociocultural processes of different groups of people. There are, as it happens, many disorders

groups that can be isolated for comparative analysis within

Western

society.

Thus comparisons can be made between

ethnic

enclaves that have been transplanted into complex societies. 2

Nonetheless, the full scope of interest in cross-cultural psychiatry

is

worldwide.

It

includes concern with people in their

native habitats and deals with maximal cultural contrasts, identi-

(though probably misnamed) by such differentiating terms "Western" and "non- Western"; "underdeveloped," "develop-

fied as

ing," and "industrialized"; "primitive"

and

"civilized."

Cross-cultural Psychiatry

One problem

of basic research

is

5

to discover

what

factors or

combinations of factors in the environment produce, encourage, or perpetuate what kinds of psychiatric disorders.

toward

this

end

is

A

first

step

How

to sort apart universals and variables.

do

the patterning, frequency, and duration of psychiatric disorders

vary in the light of sociocultural differences? appear in more or

disorders

the

less

What

psychiatric

same form in many

—perhaps —regardless

all of culture? In view of known, conditions such as mental deficiency, chronic brain syndrome, and some types of schizophrenia appear

populations

what

already

is

to exist in

A

all

human groups.

further interest

is

to discover

kinds of psychiatric disorders bear

what relationships various (when looked at in cross-

cultural perspective) to the universal categories of the

—being male, being female, or being

situation

in the life-arc of childhood, adolescence, maturity,

cence. Since there

is

employ age and sex

wide variation in the

may

way

and senes-

cultural groups

and obligations, the pat-

in defining rights

terning of cultural roles

exert a major influence

development and distribution of psychiatric symptoms. lows, therefore, that questions about

human

at different points

human

universals

on the It fol-

and cul-

tural differences are fundamental.

Although by no means is

still

a

new

in a formative stage.

defining

cross-cultural psychiatry

field,

There

is

considerable fluidity in

problems and a great deal of variability in the terms used to denote its character. In an early phase it was referred to its

as "primitive psychiatry,"

and it has also been called "anthropoand "ethnopsychiatry." These designations have usually been employed in connection with studies of vari-

logical psychiatry"

ous exotic types of psychopathology found in specific cultural groups.,

Among

anthropologists

the

"psychiatric anthropology," but

field

is

sometimes

more commonly

it is

known

as

subsumed

under "culture and personality." These titles tend to emphasize an interest in what psychiatry can offer to an understanding of

Approaches

6

to Cross-cultural Psychiatry

on the

cultural processes and focus attention

relatively

normal

development and functioning of personality in different cultural

on psychiatric

contexts rather than

By

disorders per

among

the welfare-minded and

se.

those involved in the ad-

ministration of psychiatric services, the field has been included

under "public health psychiatry" and "psychiatry for developing countries." These labels clearly indicate a major interest in treatment, control, and Finally and

more

psychiatry,"

tural

—where

possible

—prevention.

specifically the field has

been called "cul-

psychiatry,"

"transcultural

and,

here,

as

"cross-cultural psychiatry."

This multiplicity of names makes nication and choice of words.

difficult the task

The problem

disciplinary nature of the topic talk in several languages at once

of

commu-

indicates the inter-

and the consequent necessity to

—

at a

minimum

psychiatry, social science, and public health.

the languages of

It also

indicates that

phenomena similar ideas by

the people interested in this subject see the pertinent

from many points of view and may

refer to

several different terms.

We two

have selected the term "cross-cultural psychiatry" for

reasons:

(i) the phrase adequately conveys the fact that

in this field the

inquiry search

is

is

main conceptual and methodological tool for

comparative analysis, and

who

"cross-cultural" re-

a familiar idea to social scientists in the

use allows us to identify with and

its

(2)

draw on the

United

States;

efforts of those

have concerned themselves with cross-cultural research

methods.*

Modern to have

scientific

endeavor in cross-cultural psychiatry

begun with Kraepelin.

He

is

said

traveled extensively to see

whether the "disease" types he had specified could be found in places other than * It

has

Europe. His attention was primarily, though

should be noted here that our approach to cross-cultural psychiatry

much

in

common

at a general level

research being carried out

Canada.

with the transcultural psychiatric

by Wittkower,

Fried,

and their colleagues

in

Cross-cultural Psychiatry

7

not exclusively, directed toward heredity and "racial" tendencies.

Freud

3

was

also interested in culture

and cultural differences,

by such anthropological contemporaries and Lang as well as by the Lamarckian tradition

influenced in this area as

Tylor, Frazer,

Europe regarding the inheritance of acquired

in

He

characteristics.

racial experience

concerned himself with the possibility that

transmitted through the unconscious to succeeding gener-

is

At

ations.

root, his ideas

were primarily within the framework

of evolutional biology as this was conceived at the turn of the

century.

Meyer's psychobiological approach

4

included attention to the

probable effects of social and cultural factors in personality de-

velopment and to subsequent patterns of adaptation course of

life.

Impelled

by

this interest,

himself familiar with the ideas of such

Mead,

W.

later to

I.

all

along the

he sought out and made

men

as

George Herbert

Thomas, and William McDougall.

exchanges with anthropologists such

He went

Edward

as

on

Sapir,

Ruth Benedict, Bronislaw Malinowski, and others. As the names above reflect, there was considerable expansion of interest in the relationships between personality patterns and cultural milieu

World War spread

II

from some time

—especially

concern for

this

in the field

up through

in the twenties

United

States.

had tapered

By

off

1950 wide-

somewhat

probably because of the ending of the war. At that time the urgency for seeking the causes of human conflict, especially as they might hinge on cultural differences, began to sixties,

lessen. In the

however, there are noticeable evidences of some

revival.

Before and during the war period, the widened scope of interest

was perhaps due more

to

anthropologists'

psychiatric ideas than to psychiatrists'

becoming

delving into interested in

cultural anthropology. 5

sake of inquiry

is

The union of the two disciplines for the marked by a number of collaborative efforts

beginning with the Kardiner and Linton seminars at Columbia University which started in the mid-thirties. 6 Today there is a

Approaches

8

to Cross-cultural Psychiatry

sizable roster of joint anthropological

and psychiatric studies

as

number of books specifically on this topic. 7 When at its height the combined approach had a stimulating influence which suffused much of American anthropology. This was not limited exclusively to an interest in mental and emowell as an expanding

tional

problems but appeared in a broadened view of the "whole

man" and

of

human

relations in cultural situations.

During

this

period the subfield of "culture and personality" achieved considerable popularity. It acquired academic standing as an area of specialization in the graduate

A

ments.

number of

programs of anthropology depart-

field investigations

were designed for the

and dream materials. The Oedipal theme and various hypotheses from psychoanalytic theory were of Rorschach

collection

taken into cultures.

Up

field

work

One major

until

for examination in different nonliterate

effort involved national character studies.

mid-century two trends of thought had been evident

Much

in cross-cultural psychiatry.

and

of the early psychiatric inter-

non- Western groups had been dominated by biological

est in

racial determinism.

and with

ality,"

was

order,

it

Later the

much

pervaded

field

of "culture and person-

of the thinking about psychiatric dis-

by

determinism.

cultural

Although

acknowledgment was often made to "biological factors," the written and even more the spoken words of many anthropological investigators did this,

there

was often

not seem to treat these as a feeling that there

is

real.

More than

something reprehensi-

ble about giving credence to hereditary factors as controlling

human

behavior in any important way.

for this are manifold, but

No

doubt the reasons

beyond the myopia common to most

specialized interests and resistance to anything that

from the feeling of working on

the central

might detract

complex of

causes,

At

a time

there

were

when

racist ideas were a focus of world struggle, liberal-minded

also matters of

moral and

political belief.

people were reluctant to do anything that might appear to strengthen such a framework for injustice and crime.

The

rational basis for cultural determinism rested largely

on

Cross-cultural Psychiatry

9

assumptions of psychological determinism, and this in turn drew

on dynamic psychiatry, particularly psychoanalysis. This reliance was, however, somewhat selective, overlooking heavily

Freud's fundamental ideas about constitutional factors as well as

more diffuse conceptions of multiple biological influences which permeate much of the rest of psychiatry. Since World War II there has been a dropping away of insist-

the

ence on cultural determinism, owing in part to "culture and personality" losing ground as an area of interest. This in turn

followed on the realization that a great deal more

work was

needed in developing and validating research methods.

It also

awareness that quick answers to

stemmed from the growing world problems were not yet on

The

the horizon.

influence of cultural determinism has also diminished

through the advance of knowledge on

work similarities. The

Expanding anthropological variation

and cultural

of the relationship

field

many

relevant fronts.

has clarified both cultural early spectacular theories

between culturally defined child-rearing

practices

and basic personality patterns have been progressively

modified

as

more

solid information

about peoples of different

backgrounds has accumulated. Equally, demonstrated progress in the fields of genetics is

more

and biological determinants

difficult for students

is

such that

of personality to ignore.

these accounts, a fairly balanced cognizance

is

now

On

it

all

given both

to cultural and biological considerations and to the interplay

between them. It is

obvious, of course, that anthropology and psychiatry

have not been the sole contributors to the development of ideas regarding the relationships between sociocultural and psychiatric

phenomena. From other branches of behavioral science

have come general semantics, communication theory, the concept of role, the concept of class structure, field theory, and reference group concepts.

Gregory Bateson, Leonard

Names such S.

Cottrell,

Ruesch, Robert Merton, and Lloyd

as

Alfred Korzybski,

Kurt Lewin, Jurgen

Warner

help illustrate the

Approaches

10

to Cross-cultural Psychiatry

ence in studies

of

culture

through Dollard and Miller. 8 tend to emphasize situations

been

reflex theory have long

and conditioned

point. Learning

potentially important but have had, in fact, relatively

little influ-

and psychiatric disorder except

The as

from these various

ideas

fields

of etiological importance and,

hence, at least indirectly refer to culture.

We

article to present

have attempted in a recent

ideas that have

emerged over the

on psychiatric

by saying 1.

as

disorders. 9

Malaya), koro

as:

such

specific disorders,

China), and loitiko

(in

cul-

These can be summarized

that culture has been conceived

(in

how

exert causal or determining

Determining the pattern of certain

Utah

years as to

last fifty

ture and cultural situations might

influences

some of the

(in the

Indian cultures of Northeast America) 2.

Producing basic personality types, some of which are espe-

cially vulnerable to psychiatric disorder; 3.

Producing psychiatric disorders (usually considered

latent

for a time) through certain child-rearing practices; 4.

Having

a selective influence

on

a population's potential for

psychiatric disorder as well as the pattern of disorder through

types of sanctions and whether

"shame" or "guilt"

is

en-

gendered; 5.

Precipitating disorder in an otherwise adequately function-

ing personality by confrontation with stressful roles;

Perpetuating disorder by rewarding

6.

such

as

7.

it

in prestigeful roles

holy man, witch doctor, or shaman;

Precipitating disorder

by changing more

rapidly than per-

sonality systems are able to tolerate; 8.

Producing disorder through the inculcation of sentiments

(beliefs

and values) that produce emotional

personality, such as fears, jealousies, 9.

Affecting

the

distribution

of

and

states

damaging to

unrealistic aspirations;

some kinds of disorder

through breeding patterns; 10.

Influencing

the

amount and

distribution

through patterns of poor hygiene and nutrition.

of

disorder

n

Cross-cultural Psychiatry

The above

are

all

couched in terms of possible variations be-

tween sociocultural groups such

as

would

quencies and kinds of disorder. There

namely that culture per

idea,

se

—that

result in different fre-

is,

one overarching

also

is

any and

cultures

all

produces a certain amount of psychiatric disorder. This

arises

because regulation of the basic natural urges in the growing-

human organism

is

logically injurious.

conceived to be both universal and psycho-

Although sociocultural factors may vary

the degree and extent of their effects

in

from group to group, they

have been thought to produce some damage and some disorder in

all.

apparent that the point in current cross-cultural psy-

It is

chiatry

is

no longer to prove that culture

rather to ask

what kind of

it is.

So far

as the total process

development of psychiatric disorder

in the

would seem best

to

for one, or for

theory,

is is

is

concerned,

it

assume that hereditary, biological, and

psychological factors are

which

a cause

major cause, but

a

is

all

three engaged.

any subarea within one,

To

as a

claim dominance

matter of general

and

to express a linear conception of cause

out of keeping with what

we know

about

effect all

the

More germane is an approach discover and map out the interrelated

processes in the world around us. to the topic that aims to

factors

and the nature of their interrelationships. Definitioji of

It is

Terms

appropriate at this point to define "psychiatric disorders"

and "sociocultural environment" more precisely. I.

By

we mean all those behaviors, emocommonly regarded as proper for the 10 psychiatrist. More specifically the term includes

psychiatric disorders

tions, attitudes,

attention of a

and

beliefs

brain syndromes, mental deficiency, the functional psychoses,

psychophysiological disorders, psychoneuroses, personality

trait

disturbances, sociopathic behavior, and acute situational reactions. In

our

use, then, "psychiatric disorder" has a

broader connotation than "mental

illness,"

which

is

somewhat often re-

Approaches to Cross-cultural Psychiatry

12

and severe psychoneuroses.

stricted to the functional psychoses

All of these patterns of psychiatric disorder are conceived as

phenomena having

process

origin, course,

and outcome which

can be fully understood only in relation to the total of the individual.

We

life

history

hazard the guess that the disorders most

thoroughly affected by sociocultural experiences and therefore

most are

vary according to different sociocultural factors

likely to

symptoms of

a

psychoneurotic and psychophysiologic na-

ture.

On

these

symptoms can be

part of a person's genetic and constitu-

may

be precipitated, maintained, or inhibited

the other hand,

and

tional heritage

by such

it is

apparent that tendencies toward

physiological events as a long illness or sustained malnu-

trition.

In the

predominantly hereditary or organic disturbances,

sociocultural factors

may

be related to cause (and hence influ-

ence the prevalence of such disorders) through breeding patterns or patterns of physical hygiene.

Furthermore the function-

ing of people with psychiatric disorders which are chiefly of hereditary or physiological origin the sociocultural setting in

may

which they

relate significantly to

find themselves. If the

sociocultural environment offers protection,

makes fewer de-

mands, or has the resources for therapy, the course and out-

come

of the process

may

be very different from that in an en-

vironment which lacks these properties.

What

has been said thus far about psychiatric disorders refers

to the province of psychiatry in

points in this

volume

Western

culture.

At

several

(especially Chapters II and III) the prob-

lems of cultural relativity and variable conceptions of disorder

and deviance will be taken up. For the most part

comparing Western views with those found

this involves

in other groups in

order to discover the areas of overlap and divergence.

underlying principle regards just as

we

we do

As an

take an attitude of inclusiveness in these

in dealing

with the range of psychiatric

phenomena as defined in Western thought. While systematic studies are needed to

reveal the kinds of

Cross-cultural Psychiatry

13

behavior that are considered normal and abnormal in different cultural groups,

seems unnecessary to waver in the face of

it

though

cultural relativism as

As

ards of functioning.

a

we

completely lacked valid stand-

beginning there

society no matter

We

what

its

evidence that some

is

command

disorders are so impairing as to

recognition in any

cultural patterning.

do not mean to imply that

all

beliefs

and knowledge

about the causes and cures of psychiatric disorders can be put on the same plane.

The

distinction

between magical and

scientific

explanations obviously remains a necessary and fruitful one. But the fact that they are quite different orders of explanation, and

involve contrasting

ways of dealing with

for ignoring either one.

through witchcraft

is

The

belief that

clearly apposite as a

some kinds of psychiatric disorders oriented therapy

Our concern

is

just as

events,

not reason

is

one has been "hexed"

background feature is

in

the fact that magic-

apparently effective in some instances.

for the

moment, however,

is

less

with ideas of

cause and methods of cure than with the question of

what forms

of emotion, belief, and behavior are considered psychiatric in other cultural streams of thought. For basic research

we

believe, to allow the definition of the

it is

phenomena

unwise,

to be col-

ored by etiological assumptions and views of treatment emerging

from our

own

tradition or other traditions.

To

discover further

information about causal factors, which can then be employed in

developing methods of prevention and therapy,

is

the major rea-

son for conducting the kinds of research that constitute the topic of this book. This very fact argues strongly against build-

ing preconceptions of cause into the definition of the

about which

we

are

situation in

which

correlations

we

II.

phenomena

making inquiry in order to avoid a later would be obscured by dazzling

real findings

ourselves inserted.

In using the phrase socio cultural environment

we employ

a combination of concepts thought to be advantageous for the

kinds of studies discussed here. a

way

It is a

combination that provides

of talking about the total configuration of

what

is

going

Approaches

14

to Cross-cultural Psychiatry

on outside the individual organism whose psychiatric characteristics

are of concern.

Certain important distinctions between "society" and "culture" need to be emphasized in studies focusing strictly on social structure or strictly

on

cultural processes. In a recent paper

Kroeber and Parsons point to a confusion about what and what cultural that has not yet been

by

frequently glossed over

with

full

tion."

11

is

social

and that

clarified

"is

the use of the term socio-cultural

awareness that the hyphen

is

no symbol of integra-

equally to be recognized, however, that in any

It is

empirical situation the

two

are intertwined and that

many

times

the differences cannot be fully specified. For the purpose of investigating the relationships

between psychiatric phenomena

characteristic of individual personalities

and the

mental factors that impinge upon them,

we

Following customary usage, "society"

ships.

beings

who

Except for

ber of hermits, this definition

it more two components.

defined as a group of

together in a system of social relation-

live

minuscule and presumably diminishing num-

a

all

is

human

beings live in social groups. Although

and generalization are widely accepted,

immediately evident

just

of groups should be studied for characteristics that

There

as

There

are artificial

natural groups (a mental hospital as

And as

there are

compared

and

may

have

compared to

town). There are small groups and large (families to national units).

not

aspects

are short-lived groups

committee or task force

(a

it is

what kinds of groups or what

significance in psychiatric disorder.

and long-lived

as

environ-

have found

appropriate to combine than to separate the

human

many

as

a

compared

institutional as well as

compared

to a

community).

homogeneous and heterogeneous groups (a tribe These different characteristics influence

to a city).

the degree and kind of system of relationships

group operates, but

all,

at

by which

the

one or another level of generalization,

can be said to exhibit the structural and functional qualities of a social system.

Psychiatric studies are currently going on in nearly

all

these

Cross-cultural Psychiatry contexts. In cross-cultural psychiatry

we

/y

have elected to focus

on perduring and culturally cohesive groups localized in natural geographic habitats. There are, however, several questions about choosing a group and setting analytic boundaries around it for study purposes, which together with the problem of population mobility will be taken

"Culture" of

is

expresses

its

in Chapter VIII.

an abstraction which encompasses the total

of a society.

life

up

It is

way

a precipitate of the group's history

adaptation to the physical environment.

It is

and

charac-

by what A. I. Hallowell has called a "psycho12 logical reality." That is, it refers to the shared patterns of belief, feeling, and knowledge the basic values, axioms, and assumptions that members of the group carry in their minds as guides for conduct and the definition of reality. Along these lines C. P. Snow has observed: "Without thinking about it, they respond alike. That is what a culture means." 13 And Ruth terized especially

—

—

Benedict has spoken of "the unconscious canons of choice" that characterize one group in contrast to another. 14

Besides social relationships, technology, economics, religion,

and other aspects of human

life,

culture refers to the inter-

connections and interdependencies that bind part to part to

make

whole. Culture

a

is

constantly changing;

it is

transmitted from one generation to the next; and

have

it.

When

The

learned; all

it is

societies

however, varies from one group to another.

style,

the variation between groups

is

marked

it is

appropriate

to speak of different cultures.

Combining "sociocultural" with "environment" emphasizes any given individual is composed of other

that the milieu for

individuals

who

share similar or reciprocal sociocultural experi-

ences. This usage of terms also underscores the fact that the

group

as a

whole

exists in particular physical

circumstances of

climate, altitude, natural resources,

and the presence or absence

of noxious agents, such as the tsetse

fly,

disease.

That

chiatry

is

these factors

may

which produce endemic

be relevant to cross-cultural psy-

demonstrated in localizations of psychiatrically impor-

1

Approaches

6

to Cross-cultural Psychiatry

tant diseases such as trypanosomiasis in Africa.

way, one must

also consider theories

such

1

"'

In the same

as those that

propose a

relationship, for example, between the inclemency of the arctic

environment, and the various manifestations called "arctic hyste18

ria."

Thus, similar to the definition of psychiatric disorders,

our view of environment

is

made broad enough

ple types of sociocultural factors that

may

to include multi-

be causally related to

different kinds of disorders.

Problem Areas

in Cross-cultural Psychiatry

This volume makes no attempt ever, underlying the

areas

1.

at

being comprehensive.

How-

various approaches three main problem

may be noted.

COMPARATIVE STUDY OF DIAGNOSTIC ENTITIES Within Western culture we

tients

with each other.

The

are

accustomed to comparing pa-

results of psychiatric examinations,

history-taking, and continuing observation of various cases are laid side larities

by

side in clinical analysis.

may

and differences

comparative analysis and

Groups of

cases

thus be assembled with further

tests, all

aimed

at elucidating the char-

acter of the underlying psychological processes. this

method of

with simi-

essentially qualitative analysis that

It is

through

most of what

we understand about psychiatric disorder has been derived. What happens when this procedure is extended between tures?

Can

it

be rendered more objective and susceptible to

quantitative treatment? ties

What

can be learned

as to the potentiali-

and limitations of cultural influence? These problems of

diagnostic entities are taken

2.

cul-

up mainly

in Chapters II

and

III.

COMPARATIVE EPIDEMIOLOGY

As

applied to psychiatry, comparative epidemiology refers to

the study of prevalence or incidence of disorder in different populations. Such study has several uses.

Cross-cultural Psychiatry First,

it

ij

helps in the planning of services, both as to kind and as

to distribution.

Second,

we

studies

are at the edge of a virtually

hence there collecting.

helps add to scientific knowledge. In cross-cultural

it

a

is

first

two or more

cultures,

what the ultimate aim may

ploring causes.

way

of doing

this. If

from which it

deals

with

questions that has to be asked in comparing

may

Third, epidemiology

we may

one systematic

studies can be carried out, for

psychiatric disorder in gardless of

is

will lay a quantitative baseline

it

manner of other

one of the

continent; and

primary need for observation and information

Epidemiology

done successfully, all

unknown

By

be used

more or

less re-

be. as

an instrument for ex-

studying populations with different cultures

find associations

between certain cultures or subcultures

on the one hand and the distribution of certain types of psychion the

atric disorder

tions

is

other.

The

demonstration of such associa-

then a basis for additional comparative studies, designed

to elucidate reasons, together with longitudinal and experimental investigations.

We

can clarify theories of cause by making them

and then checking prediction by means of epidemiological surveys.

a basis for predicting findings

Discussions

of the

problems connected with comparative

epidemiology thread throughout

this

book but

are especially

prominent in Chapters IV, V, VI, VII, and XI. 3.

COMPARATIVE STUDIES OF PERSONALITY AND PERSONALITY FORMATION

While the

first

two problem

areas

concern the frankly patho-

logical or at least deviant, comparative study of personality in

different cultural settings implies an interest in

What

normal processes.

can be learned about personality from comparative studies

of "nature's experiments" through data collecting and analysis?

Attacks on ideas

this question

have led in the past to a wealth of

and the development of theory, but,

as

noted

earlier, effort

1

Approaches

8

to Cross-cultural Psychiatry

has dwindled since the war.

of making

One

reason

is

probably the

difficulty

studies in a variety of cultural contexts that are suffi-

ciently explicit and factual to permit a satisfying comparative analysis for checking theories. It

is

plain that

we

need operative

more easily converted into research practice, by which to identify and classify the phenomena

theories that can be

better systems

of interest, and better instruments with which to detect and count. Dealing with these needs

would seem

beyond present work with projective

tests,

to be the next steps

symbolic interpreta-

and the reporting

tions, descriptions of child-rearing practices,

of isolated

life histories.

These topics

will be discussed chiefly in Chapters

IX and X,

although the chapters on children and adolescents (VI and VII) are indirectly pertinent.

Approaches to

all

the problem areas just outlined are closely

related. Quantitative information

orders and their trends in time

is

about the distribution of

necessary for an understanding

of the meaning of personality studies case analysis.

One may

clinical case studies as

as

well as for comparative

regard the personality studies and the

being

end of

at the intensive

a series of

related problems that has epidemiology at the extensive end.

intensive studies leave

can generalize.

The

unanswered questions

set in the

as to

how

When

one

the intensive can

context of the extensive, and both in a knowledge

of the relevant sociocultural systems, areas of doubt

reduced and

The

far

extensive studies, on the other hand, leave us

unsatisfied about underlying meaning.

be

dis-

sets

may

be

of findings mutually illuminated.

Notes 1.

A. H. Leighton,

in Social Psychiatry

Leighton,

An

J. S.

N. Wilson, eds., Explorations York: Basic Books, 1957); see also A. H.

Clausen, and R.

(New

Introduction to Social Psychiatry (Springfield,

111.:

Charles

Thomas, i960); and "Culture and Mental Health," in Trends in Modern American Society, C. Morris, ed. (Philadelphia: University of PennsylC.

vania Press, 1962). 2.

E. D. Wittkower, and

J.

Fried,

"Some Problems

of Transcultural

Cross-cultural Psychiatry Psychiatry," in Culture and Mental Health,

'9

M. K. Opler,

ed.

(New

York:

Macmillan, 1959). 3. S. Freud, Totem and Taboo (New York: New Republic, Inc., 193 1 ). 4. A. Meyer, Psychobiology: A Science of Man, compiled and edited by E. E. Winters and A. M. Bowers (Springfield, 111.: Charles C. Thomas, 1957)5. C. Kluckhohn, "The Influence of Psychiatry on Anthropology in America during the Past One Hundred Years," in Personal Character and Cultural Milieu, D. G. Haring, ed. (Syracuse: Syracuse University Press,

1956) , pp. 485-5336.

(New

A. Kardiner, The Individual and His Society

York: Columbia

University Press, 1939); see also Kardiner, R. Linton, C. Du Bois, and Columbia J. West, The Psychological Frontiers of Society (New York:

University Press, 1945). 7.

The

a

on psychiatric problems

literature

flected in

number

numerous of books.

articles

The

in different cultures

is

re-

published in professional journals as well as

following

is

a selection of

books that indicate part

of the coverage of world areas or that deal with problems in crosscultural

psychiatry

and

have

bibliographies

that

might be

R. Linton, Culture and Me?ital Disorders (Springfield,

111.:

useful:

Charles C.

J. W. Eaton, and R. J. Weil, Culture and Mental DisComparative Study of the Hutterites and Other Populations (New York: The Free Press of Glencoe, 1955); M. K. Opler, ed., Culture and Mental Health (New York: Macmillan, 1959); J. C. Carothers, The African Mind in Health and Disease [Monograph Series No. 17 (Geneva: World Health Organization, 1953)]; M. K. Opler, Culture, Psychiatry, and Human Values: The Methods and Values of a Social Psychiatry

Thomas, 1956); orders:

A

(Springfield, 111.: Charles C. Thomas, 1956); N. Kline, ed., Psychiatry in the Underdeveloped Countries, Report of Roundtable Meetings, Atlantic

City, N.J.,

1 1

6th Annual Meeting of the

tion (Washington, D.C.:

American Psychiatric AssociaAmerican Psychiatric Association, i960); E. A.

Weinstein, Cultural Aspects of Delusio?i: A Psychiatric Study of the Virgin Islands (New York: The Free Press of Glencoe, 1962); M. J.

An Etlmo-Psy chiatric Study of Rural Ghana Northwestern University Press, i960); P. M. Yap, Suicide in Hong Kong, with special reference to attempted suicide (New York: Oxford University Press, 1958); G. M. Carstairs, Twice Bom: A Study of a Cormnunity of High-Caste Hindus (London: Hogarth Press, Ltd., Search for Security:

Field,

(Evanston,

1957)

111.:

-

J. Dollard, and N. E. Miller, Personality and Psychotherapy (New York: McGraw-Hill, 1950). 9. A. H. Leighton, and J. M. Murphy (formerly Hughes), "Cultures as Causative of Mental Disorder," Milbank Memorial Fund Quarterly, vol. 8.

39 (July 1961).

Approaches

20 10.

Man

A. H. Leighton, in Relation to

chiatric

Books,

to Cross-cultural Psychiatry

My Name Is

Culture [Vol.

Legion: Foundations for a Theory of The Stirling County Study of Psy-

I,

(New

Disorder and Sociocultural Environment

York: Basic

1959)].

A. L. Kroeber, and T. Parsons, "The Concepts of Culture and of Social System," American Sociological Review, vol. 23, no. 5 (Oct. 1958). 12. A. I. Hallowell, Culture and Experience (Philadelphia: University of Pennsylvania Press, 1955). 13. CP. Snow, The Two Cultures a?id the Scientific Revolution [The Rede Lecture, 1959 (New York: Cambridge University Press, 1959)], 11.

p. 11. 14.

R. Benedict, Vatterns of Culture (Boston: C. Carothers, op. cit.

Houghton

A4ifflin, 1934).

15. J. 16.

S.

Novakovsky, "Arctic or Siberian Hysteria

graphic Environment," Ecology, vol.

5

as a

(1924), pp.

1

Reflex of the Geo-

13-127.

II:

The Problem of

Cross-cultural Identification

of Psychiatric Disorders By

Charles Savage, Alexander

H. Leighton,

and Dorothea C. Leighton

EDITORIAL NOTES

The

questions posed in the present chapter arise

from the

relationship of psychiatric disorder to culture. Psychiatric activities

and ideas form a subpattern within the family of Western

cultures,

and the definitions of psychiatric disorders have

their

Western views about what human nature is or ought to As phenomena, the disorders are patterns of behavior and

base in be.

feeling that are out of keeping with cultural expectations

that bother the person

who

acts

and

feels

and

them, or bother others

around him, or both. Since, however, different cultures are by definition different systems of standards

lows that what garded

may

activities

is

it

fol-

may be rewoman who in

be disturbing in one culture

as desirable in another.

America

and expectation,

Thus

the

man

or

hospitalized for hearing voices or jailed for his sexual

might have

this

behavior ignored, accepted, or even

venerated in some other cultural group.

An

extreme proponent of cultural

relativity,

using this line

of argument, could deny the possibility of identifying and

enumerating the same kinds of psychiatric disorder in markedlv 21

to Cross-cultural Psychiatry

Approaches

22

different cultures.

might run, defined

Any

pattern of behavior, so the argument

healthy or sick only to the extent that

is

by

defined as psychiatric disorder in the West, but

it

is

so

may

be

it

a given culture. Certain patterns of behavior

does not

follow that they will be so defined in another culture. Con-

we

versely, behavior patterns that

may

be defined in other cultures

between

contrast, furthermore,

discrepancies are apt to be.

disorder

atric

two

in

To

regard as normal or admirable as

abnormal.

cultures, the

The

more

greater the

radical these

speak, then, of "the same psychi-

different

cultures,"

is

virtually

self-

contradictory.

Such an extreme view with regard

two

bodies bilities

which

for variation is

more or

less

among

cultures

necessary to the

infinitely plastic, that all of us as

human

every form of first,

to cultural relativity

rather doubtful assumptions.

we

is

One

is

limitless.

first, is

begin

em-

that the possi-

The

second,

that personality life

is

are capable of

With regard to the evident among known

behavior and feeling.

despite the considerable variation

cultures the range does not appear to be boundless.

On

the con-

trary, the evidence suggests that there are denominators and

limitations

common

to

all

sociocultural systems. This applies not

only to certain specific patterns such to larger functional attributes. tural

groups

known

as the incest taboo,

There

are, for instance,

is

no

cul-

that lack patterns of leadership and fol-

lowership, or that have no set of rules regarding

and what

but also

what

is

right

wrong.

In a similar

way one may

argue that the evidence available

against a theory of infinite plasticity in personality.

It

seem more probable that there are some biological factors

work found

that influence the in

at

norms and deviations of personality

any sociocultural group. Hence, from the point of

view of psychiatry we there are

is

would

some

also universal

may

characteristics

say that although cultures

differ,

common to all cultures and hence The mentally deficient, the per-

forms of deviance.

Cross-cultural Identification of Disorders

son

who

kills

and the person

indiscriminately

who

23

exhibits un-

controlled excitement are possible examples. If,

however, one rejects an extreme view with regard to cul-

tural relativity, he

must

also

on the

basis of available anthro-

pological evidence reject a corresponding extreme of biological

determinism. culture,

Some behavior

pertinent to psychiatry

is

relative to

and cultural differences must enter to some extent into

the definitions and perceptions of psychiatric disorders.

problem then

If

is:

far can

start

and the

tions of disorder

how

we

we go

with our traditional Western

criteria

The

defini-

by which we recognize them,

with these into other cultures with some

hope of being able to identify comparable phenomena?

THIS

chapter attempts to point out a lattice of criteria whereby

psychiatric disorders as they occur

among

adults

nized outside the European family of cultures. first

chapter of this book, a reason for this interest

discovering something about etiology. lence and incidence studies as a

what kinds of course, and the

As soon ever, he

ent,

as

way

We

be recog-

want

is

in the

the hope of

to use preva-

of gathering evidence about

sociocultural factors influence the origin, the

outcome of psychiatric

one begins to define the

disorders. criteria of disorder,

becomes aware of an enormous number of

questions. sion,

may

As noted

They buzz about

in the

mind and

how-

difficult

in the air of discus-

coming and going from here and there, disturbing, insistand unconnected or perhaps connected only dimly by un-

—

clear premises.

In part the problem arises from the language of psychiatry itself,

which, although technical,

consistent.

Moreover,

many

is

often neither precise nor

of the terms for disorders and even

symptoms imply

theories of cause, so that

rate reference to

phenomena from reference

it is

difficult to sepa-

to etiological ideas.

Approaches

2j.

This distinction

you wish check the

to Cross-cultural Psychiatry

of course, of fundamental importance

is,

examine the phenomena

to

in order to develop

Another

set of questions

common

hovers around the matter of deviance

most behavior recognized

to

psychiatric disorder, and in

any

it

would seem

ment of Sapir

is 1

in our society as

By

how-

itself,

from being an adequate guide. The com-

far

Two Crows, who denied that two "We suspect that he is crazy." On the

on the Indian,

and two make four was:

Two

other hand, perhaps

Crows was

had transcended the ordinary be considered

as a result

a charac-

is

desirable as one criterion

definition of disorder in another culture.

ever, deviance

also

and

ideas.

and conformity. Deviance from cultural expectation teristic

when

deviant

as

a

mathematical genius

rules of counting.

by members

A

person

who may

of his cultural group

of accidental events; in some tribes, for instance, a

man who had

two wives and

the bad luck to lose

through sickness might be regarded

six children

finally as a witch,

and hence

deviant.

Turning the coin

we must

over,

deviance from cultural standards

is

also

observe that just as

not sufficient evidence of

psychiatric disorder, so conformity and adaptation are not sufficient evidence of

by persons

absence.

its

whom we

It is

possible for roles to be filled

would say were psychoneurotic or schizophrenic. In talking with Navahos we have noted that impairment from senility was not perceived as either illness

as

clinicians

or deviance, but rather a part of the expected behavior

(role) of older people.

A

similar

problem

arises

from the

fact that in the diagnosis of

psychiatric cases there are sociological, biological, and psychological parameters,

makes

it

any one of which may predominate. This

impossible to describe psychiatric disorder in unitary

terms and leads the diagnostician to jump from one level of discourse to another. ourselves with

or

less

two

traditional

For example,

different in

in defining illness

we

find

and divergent models, the one more

clinical

medicine,

the

other

statistical.

Cross-cultural Identification of Disorders

According

the medical view,

to

if

person has treponema

a

pallidum in his system he has syphilis and he

not contagious, and

is

Furthermore,

syphilis.

not in any

if

everyone

way

is ill.

Even

impaired, he

recognized

agent

causal

specific

ditions of this sort

some organ or growth

is

factors are at

Cause

in this sense,

replaced

is

—blood sugar we

cancer the disorder is

may

by

these malfunctions,

even be fairly well-founded

however,

criteria

is

not part of the diagnosis as a critical

factor

for recognizing the pathology cell

and so on.

say with Knight of syphilis," or,

if

we must

in the

is

thought probable, of course,

work producing

carry this model over into psychiatry then 2

this

no

diabetes,

in

electrocardiogram reading, microscopic

level,

characteristics,

instance

is

center of disorder in con-

and tuberculosis. The agent

in syphilis

in diagnosis

If

it

con-

considered to be the malfunctioning of

and in some instances there theories.

—for

The

set of organs. In

characteristics of cells. It

unknown

is

has

is still

which there

also applies to conditions in

coronary thrombosis, and cancer.

as it

is

has

ill.

This viewpoint

that

he

if

still

community

else in the

so that deviance consists in not having syphilis, he

sidered

25

that a "touch of schizophrenia

not syphilis,

have

is

we would

like a

at least like diabetes.

criteria that point infallibly to

touch

But to do pathology;

they can be more complicated than the blood sugar or electro-

cardiogram but they must have specificity.

At

times

it

at least a

almost seems that

comparable degree of

we

have such

criteria,

but on closer scrutiny they tend to melt away.

A

clinical

example will serve

as illustration.

A

young woman

calls a psychiatrist,

asking for an appointment. She complains of

backache. She

again and breaks the appointment, saying she

is

calls

going south to see her doctor. She shows up for the broken

appointment

fifteen

minutes early. She enters the

office

fur-

glasses. Her hair is slicked back. She sits on the couch and then moves over to a chair by the window. A dark flush creeps up over her neck and face. Even

tively.

tensely

She wears dark

Approaches

26

before she has said a psychiatrist's

She then

word

that she

the conviction has is

a

formed

in the

an acute paranoid schizophrenic.

relates that she has violated a taboo.

mate with nist,

mind

to Cross-cultural Psychiatry

She has been

piano salesman. She complains that he was a

inti-

Commu-

watching her, and that the doctors in a where she was examined for ulcer symptoms have

that the police are

hospital

planted a radio in her stomach.

Even

if

she vomited a radio,

many

to cling to our original diagnosis.

of us

Are there not

points evident so that one can say: this less?

Yet

all

would

is

still

be inclined

sufficient critical

schizophrenia, regard-

symptoms which we inAs a two weeks of tranquilizers

the immediate signs and

terpret as schizophrenia could point just as well to panic.

matter of

fact, in this patient after

and psychotherapy

all

the schizophrenic indicators disappeared

and have not returned over still

recur,

a period of several years.

sion in

symptoms.

We

also possible that the

with periods of remis-

know, however, from other cases that it symptoms will never return, or if they do

they will again be of brief duration and related to

We

could

and the natural history of the case might eventually

establish the patient as schizophrenic, but

is

They

stressful events.

can go further and say that in some situations her be-

havior would not be regarded rather as realistic fear

—

if,

as

symptomatic even of panic, but

for example, she lived in a police state

in the midst of a stringent

campaign against communism. The

"radio in her stomach" might turn out to be an uneducated person's version of

some medical maneuver involving the use of

radioactive isotopes.

This example demonstrates be.

The same problem

how

illusive the clinical

model can

occurs, of course, with diagnosis in other

branches of medicine, and the difference the degree in psychiatry

is

is

one of degree

—but

considerable. If psychoneurosis rather

than schizophrenia were chosen for

illustration,

the problem

would appear even greater. The idea of disease as a type of malfunction works well so long as the agent causing the malfunction, or a central aspect of the malfunction, or both, can be

detected with a high degree of accuracy and reliability. In

Cross-cultural Identification of Disorders

where there deal with

have difficulty meeting these criteria except an organic condition. Usually what we have to

we

psychiatry

27

is

malfunctional behavior. This immediately raises the

is

whom?" There

question: "Malfunctional according to

are

two

broad types of possible answers: those according to cultural expectations,

we

atry. If

and those according to dynamic theories of psychilean heavily on the first of these, we are back again to

we lean on the other, we we wish to investigate.

the problem of deviance. If

answers into the questions

The

statistical definition

of normal and deviance

plained and easily applied, but

if

of difficulties. Strictly applied,

possibility of finding the majority of

neurotic. If

medicine,

it

brings

it

would

it

any

cultural

own

its

out the

rule

group to be

were utilized in this manner in other branches of and tooth decay would be ob-

trouble,

tonsilitis, sinus

most people have them. In

literated as types of illness because

some

easily ex-

is

employed independently of

concepts about function and malfunction, share

are building

parts of the

world malaria, hookworm, and vitamin

defi-

ciency would be similarly eliminated.

We

have given here only a bare indication of the questions

that can be raised.

They

they are also slippery premises. It

is

numerous, complex, and entangling;

are as

to foundations

Now,

find that

there are

.

.

.

many

not exist in nature, and

it

,"

for

the

"But

as

"How

if

.

.

.

,"

about a case such

"Suppose

as

.

.

?" .

possible "supposes" and "ifs" that

do

occurred to us in due time that perhaps

some of these were wrong consequently,

of hidden

full

notable, too, that they cut across each other

with introductory expressions such

you should

and

questions.

We

turned from them,

being and took up a

time

different

approach.

What we

did was to select one

as a psychiatric disorder

tions: this

(1)

By what

and then

criteria

of these criteria

most other cultures

would

as well?

entity recognized

we

answer two ques-

would

condition in a person in our

Which

by one each

I

tried to

I as

own

a psychiatrist diagnose

society and culture?

(2)

expect to remain employable in

We

did not seek general criteria

Approaches

28

would

that

to Cross-cultural Psychiatry

distinguish

all

disorder

criteria for each recognized

psychoneurosis,

deficiency,

from nondisorder, but only

clinical

such

entity

as

mental

and obsessive-compulsive person-

Attention was concentrated on observable phenomena

ality.

and, to the greatest extent possible, theories of psychological

all

definitions based

on

and sociocultural cause were avoided.

The review at the

of criteria was conducted in the autumn of 1957 Center for Advanced Studies in the Behavioral Sciences in

a series of

weekly seminars. Four

psychiatrists participated: the

Hamburg. The guide employed in the 1952 Diagnostic and Statistical Manual issued by the American Psychiatric As-

authors and Dr. David

was the

deliberations

of Mental Disorders, sociation. By January 1958 a set of criteria had been developed upon which the four psychiatrists could agree. Hamburg

moved on

the Center at this time, but the authors

left

vite a

group of anthropologists to participate

to in-

in a continua-

tion of the seminar, reviewing the criteria in the light of the cultural

fa-

were Ethel Albert,

Ward Goodenough,

Hymes, David Mandelbaum, Milton

Singer, and Charles

miliar.

Dell

group with which each anthropologist was most

The

participants

Wagley. The

cultural groups that served as the

main points of

reference were the Rundi of Burundi (Africa), the Eskimos of

Lawrence Island (Alaska), the Gilbert Islanders (MicroNavahos (American Southwest), the Tapirepe (Bra-

St.

nesia), the zil),

and the peoples of

In June

Leighton to

India.

were taken by Savage and A. Farms, Arizona, and reviewed during a two-

1958 the criteria

Many

Walsh McDermott and his staff, who had run an experimental clinic for Navahos during the preceding three years. Although the Many Farms Clinic was not conday

session with Dr.

cerned with psychiatric disorder countered some

cases.

as such, it

The Navaho

had inevitably en-

assistants, particularly the

"health visitors," were a valuable source of criteria offered in the

several steps.

comment. 3 The

following pages are the upshot of these

Cross-cultural Identification of Disorders

29

Criteria for Identifying Psychiatric Disorder

Non-Western Cultures

in

BRAIN SYNDROME The

APA Manual

divides psychiatric disorder into

two major

groups: the brain syndromes, which compose mental disturbances resulting from or precipitated

everything

by

lesions of the brain;

and

including mental disturbances in which brain

else,

damage is secondary, absent, or never yet demonstrated. The number of categories in each major group is about the same, but the number of cases occurring in nature is far different. The

much

brain syndromes are

having so

many

subdivisions

ciated organic malfunctions esting,

So

it

and

asso-

therapeutically useful, inter-

differentiations.

syndrome has the following

are seen in a variety of organic con-

and judgment, and manifest

The

latter

unwarranted list all

may

lability

and shallowness

agitation, irritability,

and "corny" joking.

syndrome and to discuss would be lengthy, repetitive, and

the subcategories of brain

concerned with only a small proportion of the psychiatric disorder likely to be found in

We

abil-

take the form of easily provoked cry-

their cross-cultural criteria

tion.

reason for their

impairment of orientation, memory, comprehension,

of affect.

To

The main

that the causal agents

and easy to frame numerous

ity to learn,

ing,

is

make

far as behavior goes, the brain

main components, which texts:

fewer.

shall therefore

monest subcategory

handle the matter

—

senile disorders

total instances of

any general popula-

by taking

—for more or

discussion and treat selected others in a

summary

the

com-

less detailed

fashion.

The

remainder will be omitted. I.

SENILE DISORDERS

Within

the

senile

disorders

we

include

the

cerebral-

cardiovascular difficulties as well as disturbances from the direct

aging of the brain. Below are given the items that require con-

Approaches

jo

to Cross-cultural Psychiatry

making a diagnosis of senility. The first two are matters of background or contextual evidence. The remaining three are components of senile behavior itself. Since each of sideration in

these can also occur as a part of other patterns of disturbed

behavior, and no single one disorder

is

called a

essential, it

is

syndrome.

warrant stating that the condition

whether these are is

The

least fifty

why

this

sufficient to

present.

A. Age. For operational purposes, should be at

evident

diagnosis consists in eliciting

Its

plural evidences and then judging

is

we

suggest that a person

years old to be placed in this classification.

degree to which determination of age

is

a

problem

varies

With some peoples, such as the Gilbert Lawrence Island Eskimo, birth dates are known and so there is no difficulty. Among others such as the Rundi, the Navaho, and the Tapirepe, nobody is apt to know when he or anyone else in his group was born. In this case approximations can be achieved by finding out the dates of well-

from culture to Islanders

known

culture.

and the

St.

events (great storms, famines, accession of a chief, etc.)

and then asking which of these was

closest to the birth of the

person in question. This method has been used considerably by anthropologists and others in compiling

life histories.

In the interpretations of responses about age, one must also be

aware that

in

some

cultural groups answers of "young," "old,"

"middle-aged," or even answers in terms of years such thirty," refer to appearance

and

as

"about

status rather than chronological

We were once told by a Navaho, for instance, that a certain

age.

individual five years previously had been "about the same age

he

is

now."

B. Signs of age. Usually with senility there

is

indication of

physical wearing out: muscular wasting, general feebleness, dryness

and

and atrophy of the

skin,

and tortuous, pipe-stem systemic

retinal arteries.

Evidence of ticular

this sort is

not likely to be

difficult to ascertain.

may

require taking into account par-

characteristics of the

population under study due to

Its evaluation,

however,

Cross-cultural Identification of Disorders

5/

prevailing conditions of diet, disease, climate, and type of work.

As

show

well known, some groups

is

physical changes earlier

than others, and within any group there vidual variation. In other words,

is

concomitant of itself

may

or

parallel.

C. Loss of recent

This

also considerable indi-

and the syndrome

senility varies as to age of onset,

may not be

is

this suggestive

retention of remote

memory with

memory.

an exceedingly characteristic and early manifestation of

the senile syndrome.

Standards of

remote

The

recall,

of checking both recent and

memory and ways

must, however, be

crucial items to

employ

customarily interested.

worked out

are those things in

is

which people

are

A common practice in our own society from

for the psychiatrist to learn privately

what the person he

for each culture.

is

member

a family

examining had for lunch that day and then

ask him. This procedure loses

usefulness in a culture

its

meals are the same or in which lunch

is

not taken.

where

We

all

believe,

however, that substitute questions can be devised that will reveal this

type of

memory impairment.

D. Habit deterioration. This

refers particularly to matters of

personal care, neatness, and cleanliness.

It

may

manifest

itself in

lack of sphincter control, in sloppiness of dress, care of hair and fingernails,

While

and in

eating.

the standards of proper care must be

known

for a given

culture in order to detect this kind of personal deterioration, there are

few

if

any cultures

in the

world that do not have such

The Tapirepe, for instance, go about nearly naked, yet if a man exposes his glans penis, he is considered to have something wrong with him, and women must be attentive to standards.

maintaining proper bodily postures. E. Transient confusion. Here

we

are

ception, misidentification of people,

the environment. brief.

The

condition

During the daytime

ing the night

is

and misinterpretation of

frequently intermittent and

senile persons

wander about,

fail

concerned with misper-

may

be normal yet dur-

to recognize the people they

Approaches

%2

encounter and

confuse them

Thurber's grandfather thing

was his

when during

a deserter

grandson:

to Cross-cultural Psychiatry

may

with those

known

have been an example of

youth.

in

this sort of

the night he shot a policeman, thinking he

from Meade's army, and then the next day asked

"What was

around the house

There can be

last

the idee of

night?"

little

all

them cops taryhootin'

4

doubt that transient confusion would be

noted by the people of virtually any culture, and

it

seems proba-

ble that a history-taking psychiatrist could learn of

formants were willing to

tell

his in-

it if

him.

Let us pause a moment to take stock, after

example,

this first

of criteria that might be employed cross-culturally. Within our

own society it is perhaps evident that senility is easy to recognize when the condition is advanced and information is available. The criteria are clear enough for that. The diagnosis can be difficult

and uncertain in cases where impairment

which information

situations in

slight

is

withheld, or in which

is

and

features conspire to obscure the picture. This latter occurs

time to time with people

who

through remote

memory

in

special

from

and habit

continue to perform roles they have been carrying out the greater part of their

For

lives.

a

may

long time no one

that they are disoriented for time, place, and person.

mentions

this sort

of thing

among

recalls the case of a professor

to a

home. His

The the

new

lectures,

that

it

was

many

is

said,

5

lectured so well to his classes

was not discovered

house and thereafter could never find

existence of

odd one

Thomas

older fishermen, and one of us

who

that an advanced state of senility

moved

suspect

remained for

a

until he

way

his

time unimpaired.

borderline cases and the occurrence of

obscured by special circumstances do not

require that the senile category be written off as too nebulous. If

one were to

on the

insist

on such standards, he would

also

have to

uselessness of virtually every disease entity

demiology.

The

point

is

and

insist

all

epi-

rather to recognize the limits of preci-

sion that are attainable in trying to "count every case" and to

focus on research problems that are workable within this level of

approximation.

Cross-cultural Identificatioji of Disorders

When we

turn to the application of the senile criteria to an-

other culture, our expectations must not be higher than the attainable in our

bound

to occur.

there a

much

own. The same

new

The

question

difficulties is:

and

risks of error are

Are there more of them, or

and different order of difficulty such

as to

is

suggest

greater, or a particular kind of, error?

We cannot generalize to

all

the cultures of the world, but

we

can say that for the cultural groups reviewed by our seminar, the answer

We

was no.

do not

absent, or that differences in the total different groups

count obtained in two

might not be due to cultural factors rather than

to differences of true prevalence. a

However, the

criteria

measure of cross-cultural applicability, and

if

do have

one wished

and count cases in two or more different cultural

to identify

groups,

problems are

assert that cultural

it is

reasonable to believe that through careful study of

made such One would not,

the particular conditions in each, adaptations could be

degree of comparability.

as to yield a useful

furthermore, need to be in the dark as to the likely sources of

and ways could be found for evaluating their extent. It would remain true that minor differences could be due to cul-

error,

tural factors just as

technique.

Major

they could to chance and to variation in

differences,

however, that stood up under

peated surveys and cross-checks on methods and sources of

would command serious attention as genuine tween the populations with respect to senility.

To

summarize,

it

bias,

differences be-

seems that although cultural difference adds

from an already complex

to rather than subtracts it

re-

does not appear to present insuperable

set of

difficulties,

problems,

and

many

of

the theoretical problems noted in the introduction to this chapter lose their

importance

when

actual groups are considered.

have not been seriously bothered with questions of statistical

concepts

of

normal,

of

deviance,

We

clinical versus

or

of

cultural

relativity.

must be admitted, however, that we have begun with one of the easiest syndromes for which to propose cross-cultural criIt

teria.

As progress

is

made

to other categories, especially those

Approaches

$4 that have

to Cross-cultural Psychiatry

no known organic etiology,

it

can be expected that the

outlook will not remain so comfortable. 2.

SOME ADDITIONAL TYPES OF BRAIN SYNDROMES conditions to be mentioned here are those due to toxic

The

agents, infections, trauma, nutritional deficiency, disorders of

metabolism, and tumor. In

all

of these, diagnosis depends on

discovering and noting the characteristics of behavioral dis-

turbance and identifying the underlying organic condition or agent.

Acute disorders of the brain such as from high fever or the ingestion of some poisons may produce delirium, a fairly clearcut pattern of behavior.

It

involves rapid onset, disorientation

for place, time, and people, delusions, hallucinations and, outstandingly, fear.

When

this

occurs in the setting of an infection,

especially with a high fever, the presumptive evidence of a brain

syndrome

so strong that

is

could hardly have

any instances of mistaken diagnosis

statistical significance. It is

reasonable to ex-

pect that the same situation would obtain in another culture, the

symptoms being what they are and presenting no particular masked by cultural differences.

the physical signs of acute

infection

characteristics

apt

Delirium without evidence of a concurrent infection different matter diagnostically. possible organic causes,

such

as

There

are a

to

is

be

a far

wide variety of

and there are nonorganic syndromes

psychoneurotic dissociation and the acute onset of

schizophrenia that

may

for a time at least be indistinguishable

from delirium. The brain syndrome diagnosis then depends on finding the organic cause, or some concomitant neurological evidence of brain damage. Accomplishing

among

patients of our

exceedingly doubtful. there

is little

better.

The

The

own

culture,

With people

ground for expecting

best one can say

is

it

that the

this

and the

is

very

difficult

results are often

of other cultural groups

would be

either

problem

rare.

is

worse or

behavioral manifestations of other brain disorders, par-

Cross-cultural Identification of Disorders

$j

ticularly those that are chronic, are almost infinitely manifold little syndrome islands of more symptoms such as the Korsakow, which presents memory defect combined with a remarkable capacity to

and varied. Here and there occur or

less clear

gross fill

this

gap with plausible invention.

diagnosis depends not primarily

on the

On

the whole, however,

identification of particu-

of behavior, but on finding neurological signs of

lar patterns

disturbance and evidence of having taken a

having a disease that affects the brain, such

had

a serious

blow on the head, with some

known

as syphilis;

poison; of

of having

indication of cranial

injury; of having physical appearance and history of nutritional

deficiency;

of having endocrine disturbance; and of having

X-ray or electroencephalographic indication of the behavioral aspects do not raise

any questions

tumor. Since

a

that have not al-

ready been mentioned under senile disorder, or that will not be taken up

The

later,

we may pass them by.

identification of organic trouble within the is

far-advanced cases.

On

is

the other hand, the procedures involved

and the interpretation of

questions because of cultural factors.

results

There

should not raise is,

practical question of getting people to submit to

volved, and this might be affected

it

however, the all

that

is

in-

culture. The matter is not own society, and one could much more difficult among

by

always easy among persons of our readily anticipate that

that

usually difficult, except in extreme and

affecting the brain

are objective,

body

would be

people unacquainted with the European brand of medicine.

The

identification of possible toxic agents that

body from

To

come

into the

the outside presents a comparable set of problems.

deal with these

it

would obviously be

desirable to learn

one could about the use of alcohol and drugs and the bility of poisons in

all

availa-

whatever cultural groups he intended to sur-

vey. Thus, the fact that Navahos take Jimson weed (Datura) means they consume stramonium alkaloids. The Many Farms Clinic had seen a case of one severely disturbed girl with a his-

tory of eating

this plant.

She tried to disrobe and run out of the

Approaches

36 clinic

to Cross-cultural Psychiatry

and the doctors had

difficulty restraining her.

Behavior of

type has been linked with Datura intoxication ever since

this

Captain John Smith's crew was was founded.

affected at the time

Peyote, which contains mescaline, usual clinical picture

Jamestown

another example.

is

The

of people with widely dilated pupils,

is

perspiring freely, in a trancelike state, living in an internal world

from which they can be aroused but prefer not

The main

to

perform ordinary functions,

to.

problem, however,

about the identification of

toxic agents in peoples of other cultures

some

that are

is

the possible use of

unknown to us, thus leaving the matter exceedThe behavioral aspects of many brain syn-

ingly open-ended.

dromes are nonspecific, and knowledge varieties of agents that

presence

incomplete

as to the

can produce them. Furthermore, even in

the case of those agents that are tests for their

is

known, few

reliable

and valid

exist.

These considerations do not appear very important in surveys of psychiatric disorders in general populations of North ica,

but

we

might be in

have to recognize that they

Amerspecial

groups. In approaching other cultures the possibility does exist that brain

syndromes of various obscure types are

significant.

This

target

if

a

is

a matter to

number of

because they do not

have in mind

cases are discovered

fit

statistically

as a possible research

which

alert suspicion

well into the other categories to be de-

scribed presently, or because the prevalence of one or

more

gories of these other disorders seems unusually high

and might

cate-

contain unrecognized brain syndromes. If

we

look back

now

sidering senile disorder,

at the conclusions it is

evident that

reached after con-

by

contrast

we

have

here the likelihood of some major problems as a result of cultural factors.

The problem

is

not,

however, a general theoretical

stumbling block and does not involve

much

puzzling over

how

to recognize abnormal behavior in groups with different stand-

ards and systems of sentiment.

The problem

is

much more

Cross-cultural Identification of Disorders specific: it

may

it

consists in the possibility that in

cultural groups

be customary to consume foods, herbs, and extracts that

affect the brain but are

and physiology. The

some of

that

some

37

unknown

difficulties are

our own modern

pharmacology

to the fields of

not diminished by the fact

drugs, such as iproniazid (for

tuberculosis), have turned out to be able to affect brain

ways not at first coming into use and

new

and be-

drugs are continu-

havior in

realized. Since

ally

are being distributed over the world,

there

is

some of these may

the possibility that

set

going one or

another kind of brain syndrome.

MENTAL DEFICIENCY Following the Manual's usage, all

grades of retardation.

it

has

no subcategories

The

we

include in this classification

category

as

we

propose to employ

that parallel those in brain syndrome,

only groupings according to degree of impairment. In our culture and society degree

is

defined

norms of performance, and

by

this has

statistical

deviation

from

been highly standardized

through

tests. It is often expressed as I.Q., with less than 70 being considered an indication of marked handicap, 70 to 85 borderline, and over 85 as reaching into the normal range and

above. Intelligence testing

is

a highly specialized field,

and the prob-

lems of comparing persons brought up with different kinds of

background, especially cultural, are well recognized. tions of

more genuinely disorder.

The

defini-

normal and subnormal (and supernormal) are much

For

statistical

this

than with other types of psychiatric

reason and because of the influence of up-

bringing and experience, each sociocultural group does have to

be a measure of

itself,

concerned. This

is

where the milder types of deficiency

not,

dition approximates an I.Q.

we

—that

where the conof 70 or under. In almost any cul-

grossly impairing kinds of defect

ture,

are

however, necessarily true for more is,

those

think, behavioral standards could be established that

would enable one

to single out the grossly defective.

The

fol-

Approaches

38

lowing

criteria

to Cross-cultural Psychiatry

might be employed for identifying the more ob-

vious degrees of impairment.

A. History.

A

story of growth and development that shows

marked delay compared to other children of the same group. We have in mind particularly such matters as age of sitting up, walking, talking, recognizing people, developing commonplace manual

One

skills,

and grasping simple

difficulty

ways of handling the age

when

instructions.

that culture could involve radically different

is

children, so that cross-cultural comparison of

walking, talking, and so on occurred would be

inappropriate. This

is

certainly a matter to consider, especially

under some conditions, but for the kind of behavior that stands out in the history of persons issue does

who

have an I.Q. of 70 or

view. In the cultural groups reviewed

some

less,

the

not seem significant from the epidemiological point of

by the seminar

there

were

differences in standard expectations regarding child devel-

opment, but none of these was great enough to create problems of any serious proportion.

length with a

number

of

The

matter was also discussed

Navaho informants and

it

at

was evident

that they considered slowness in walking and talking as

indicators of retardation ("his

some

mind not strong enough

good

to take

care of himself") and that their standards were close to our

own. B. Current performance. If tests exist that are standard in the culture, they

may

help.

The

degree of retardation being con-

by very simple questions of memory, counting, informa-

sidered here, however, can be detected

aimed tion,

at

checking ordinary

levels

and puzzle solving. Data can

close to the person as to

how

also

be gathered from those

he performs in the daily round of

work, feeding, dressing, and understanding what people say to him.

One must be

alert to the fact that in

some

cultural groups

there are roles for the mentally deficient that might cult to find such persons.

make

it diffi-

Thus, the Buddhist Monastery

in

Cross-cultural Identification of Disorders

Burma may be India could

We

and being

a refuge for retarded boys,

on occasion help conceal

a

Sadhu

in

retardation.

conclude that gross manifestations of mental retardation

can be identified and difficult to detect

mild forms

that, conversely,

may

and distinguish from behavior that

The

rather than the result of intellectual disability. is

compared

cross-culturally, but rather,

how

cultural

problem,

upward from

far

gross toward the mild this identification can proceed. is

is

real

be very

not whether mental retardation can be identified and

therefore,

answer

39

likely to be forthcoming, but

it

No

the

general

does seem probable

that standards could be set, at least after field

trial,

for any

two

or three particular cultural groups one desired to survey.

WITHOUT DEMONSTRABLE ORGANIC DISEASE

PSYCHOSIS

I.

SCHIZOPHRENIA

The

is

vexatious because of the

among psychiatrists At the Second

International Congress of

diagnosis of this condition

range of opinion

as to

cluded and excluded.

what should be

much

Psychiatry in 1957 the focus was on schizophrenia, and

disagreement was in evidence.

The range

with intractable, incurable, irreversible

in-

stretched from people to

illness

those

who

manifested only some autistic thinking. It

is,

however, possible to select and specify

the range, and

we

have chosen what

tom complex

that

most American

The

we

a section within

believe to be the

psychiatrists

would

sympaccept.

criteria are:

A. Delusions.

A

delusion

may

be defined

as a belief at vari-

ance with those beliefs or sentiments accepted in the cultural

system to which the individual belongs. 6 the beliefs characteristic of a culture

most circumstances the presence of

is

An

understanding of

therefore mandatory. In

a delusion

evidence of psychosis, and where there

is

is

presumptive

lack of indication

Approaches to Cross-cultural Psychiatry

40

pointing to other psychoses, the most likely possibility

common

phrenia. Further, a

feature

is

is

schizo-

that schizophrenic delu-

sions are directed against cultural sentiments

and

at the

same

time are strongly influenced by them.

As

evident, the concept of delusion

is

cultural definition,

is

primarily a matter of

and hence confronts us with the problem of

While there may conceivably be some deluwould be false in all cultures of the world (for in-

cultural relativity. sions that

stance, that

human

beings have wings),

effort to catalogue these

it

is

apparent that an

would not get us very

far. It

must be

accepted that the content of delusions cannot be the basis of epidemiological comparisons between cultures. delusion

if

a

wandered up

man

in our society

It

would be

into his head and caused his brains to deteriorate.

In parts of India, however, this idea

is

culturally acceptable, and

apparently has considerable history in the East, being the

a

were to believe that semen had

Ming Dynasty

in China.

One

is

known

reminded of the

formerly held in Europe that a woman's

womb

could

in

belief

move up

her throat and choke her. Delusions can, however, be

into

detected against each culture's network of sentiments for defining reality.

This means that

as instances

of sentiments that are out of

keeping with culture, they can be counted in two or more groups that have different cultures. It

remains possible, even probable, that the character of the

sentiment system in various cultures

may

exert a differential

influence toward obscuring or revealing delusional behavior.

Cultures vary not only as to topics, but also

as to

sharpness with which they define credibility.

lem

this

amounts to

is

the degree of

How

big a prob-

something for investigation in particular

cultures selected for study.

B. Schizophrenic thinking. Like dreaming, schizophrenic think-

ing

is

symbolic and wish-fulfilling. There

is

persistent misinter-

pretation and preoccupation with inner fantasies, so that the

person seems to be out of touch with the world.

and the symbolic are characteristically confused,

The

as in

concrete

the patient

Cross-cultural Identification of Disorders

who

said

and

literally

meant he was "going up

41

in an airplane to

Although the schizophrenic himself often

get perspective."

makes extensive use of symbols, he has difficulty with other people's symbols and is apt to misunderstand metaphor. This kind of thinking, so characteristic of schizophrenia, is hard to describe, yet recognizable after one has become acquainted with

it.

The

quality of thought

is

very different from

shown by the person who is senile, mentally deficient, or slowed up by depression. At the same time, it can be expected to that

present grave problems for an American or European psychiatrist

attempting

ground not

his

detection in a language and a cultural back-

its

own. For these reasons we do not regard

we

strong criterion, and yet

because of

its

are disinclined to omit

frequency in cases of schizophrenia.

thermore, turn out in some cultures to be

than

as a

altogether

it

It

it

could, fur-

less difficult to

detect

we now imagine.

C. Hallucinations. hallucinations hallucinations

there

—

Whereas

consist in

—for

sensory perceptions. Auditory

when nobody

instance, a voice speaking

are probably the

vision, smell, taste,

delusions consist in false beliefs,

false

body

commonest, but feelings,

and touch

also occur.

Cultural sentiments and definitions present the distinguishing of this

some problems

hallucinations are sanctioned or "believed in" except

case.

in

phenomenon. In our own society few

the smaller religious sects.

may not be the

is

parallel disturbances of

Among

by some

of

other societies, however, this

Hearing voices and having

visions

may be

an

expected part of experience and take place on a basis that has nothing to do with schizophrenia or any other psychiatric disorder.

One must

distinguish, then, in part

on the

basis of the cultural

acceptability and appropriateness of the hallucination. Duration

provides another indicator. are

more or

less

Many

schizophrenic hallucinations

continuous for years, whereas those that

arise

purely on a cultural basis are apt to have short duration or occur

only from time to time

So far

as the situation

as cross-cultural

comparison

demands. is

concerned, the remarks

Approaches

42

made

to Cross-cultural Psychiatry

in regard to delusions

may

be repeated here.

not the

It is

reported voice or vision as such that can be counted and com-

pared cross-culturally but the instances in which the voice or vision

is

out of keeping with the cultural framework.

D. Schizophrenic

Schizophrenia

actions.

primarily a dis-

is

order of thinking, but certain individuals develop related characbehaviors that are very striking: withdrawal, gesturing,

teristic

posturing, or lying in a stuporous state. In time there habit deterioration and

scattered,

silly,

manic features but without the manic's tivity

may

occur such

also

superficial

wit.

may

be

with

talk,

Unusual sexual ac-

chronic and open exposure and

as

masturbation.

The

cross-cultural

applicability

of this

criterion

needs comment. Although exceptional instances and

can be pointed out, behavior of

this

type

is

with which

as disordered in all the cultures

scarcely

possibilities

usually recognizable

we

are familiar.

E. Inappropriate affect. This means showing emotion that unsuitable for a given cultural context or failing to tion that

is

called for, or

is

or no outward appearance of emotion. This

little

latter is called "flattened affect,"

and although

a necessary part of the schizophrenic

very marked and

it is

syndrome,

across cultural lines. In India, life is

to

by no means

it is

sometimes

arrests attention.

This criterion in general should not give too

goal of

show emo-

may be laughing when sadness there may be a chronic state of

expected. Thus, there

or solemnity exhibiting

is

downgrade

much

difficulty

where for many people the whole affect, there

might be some

special

problems in distinguishing schizophrenic flattening from other kinds.

This

is

not,

however, something to be expected

fre-

quently in other cultures; and in any event, since the flattening

only one criterion in a syndrome,

it

with others in reaching a conclusion

is

could be evaluated along as to

whether

a schizo-

phrenic complex of symptoms was present or not. F. Personal

under

this

history.

heading.

One

Several is

may

characteristics

that the age of onset

is

be

noted

generally from

Cross-cultural Identification of Disorders

A

the middle teens to the middle thirties.

schizophrenic symptoms after forty

The mode

of onset has

one, a normal

youth

first

43

appearance of

exceptional.

is

two common

alternative patterns. In

change of personality over

suffers a

a

period of a year or so. Although the particulars of this change

vary a good deal,

usually so striking that everyone around

it is

the person takes note of

somehow

strange.

that year he

was

it.

He was

"The

always one of the bunch before, but

different.

seemed to be doing a

year in high school Jim got

last

He

kept more to himself, and he

He

lot of thinking.

wasn't the same guy at

all."

The

other

a bit rigid,

mode

is

one in which

a

who

person

has always been

withdrawn, proud, and uncompromising gradually

beyond the bounds of nor-

accentuates these characteristics

mal and then begins to show delusions and other frank manifestations of the disorder.

A in

its

third possibility

the sudden appearance of schizophrenia

full-blown form, perhaps

From common.

excitement and

much

is

is

less

fear.

There do not appear

first

clinical

to be

being manifest in a state of

experience one would say this

any major and general

cultural

obstacles to our getting personal history data of this type. are always chance

and

situational factors, in

our

There

own society and

in others, that cause the completeness of history to

vary from

case to case. This does raise questions of case comparability, but it

does not promise to be significantly greater cross-culturally

than intraculturally.

Considering the schizophrenic criteria calling again that they constitute a

as

a

whole, and re-

syndrome, so that one looks

for a plurality and evaluates each item in relation to the others,

seems that in most cultures one could detect level of is

impairment that

confirmed by the fact

we

associate

in

very

it

least the

with hospitalization. This

that, so far as

has been found in every cultural

at the

group

we know,

schizophrenia

which people trained European psychiatry have worked. The problem lies in the in

Approaches

44

to Cross-cultural Psychiatry

gradation from obvious schizophrenia to conditions that are bet-

There

ter described as eccentric or maladjusted.

lem that most

if

not

is

with some of the milder forms of schizophrenia can

which the symptoms of the disorder

diagnosing any

symbolic

artist as

own

We

society.

are

at times

is

not hereby

we derive from psychiwe take the matter from we have known schizophrenic

because of meanings

style, or

work. Rather,

the opposite side and say that

who and who did

in

schizophrenic because of his abstract or

atric interpretation of his

patients

and

fit

are part of a role. Schizo-

phrenic thinking expressed in poetry and painting acceptable as art in our

prob-

which persons

cultures provide niches in

all

also the

did find a market for their schizophrenic thinking circulate in fashionable

bohemian

tient in particular,

known

without

circles

their disorder being at first evident in this subculture.

One

pa-

was an outstanding and

to one of us,

successful artist and just as outstandingly schizophrenic. This

was eventually obvious to his colleagues when he went to live on top of a pillar like St. Simon Stylites and then became mute. It

has often been suggested that

might well be an

what we

call

medicine

asset in the role of

schizophrenia

man

or Sadhu.

Delusions, hallucinations, posturing, and symbolic utterances of

unclear meaning might render the incumbent

more

rather than

From both clinical and anthropological experience we are inclined to doubt very seriously that this often happens. The healer or priest role has its requirements and regulations,

less effective.

and the unusual behavior that goes with particular context.

The

role

is,

it

in short,

integrated node in a social system.

The

nearly always has

most often

characteristics of the

we commonly

syndrome

is

highly

a

schizophrenic's behavior

and thinking are not that well controlled or adaptable, not in the kind of patients

see. In fact

the tendency to

at least

one of the

wander

off

the established pathways of society and to break through fences,

no matter

even where

how

self-defeating this

this countersocial

may

appear to be.

or asocial behavior

the oddness of the schizophrenic

may

its

still

is

all

its

And

not marked,

be apparent to others

Cross-cultural Identification of Disorders

may

of his social group even though he

some of

utilizes

his

45

be performing a role that

symptoms. Thus, one of the seminar mem-

bers said that in India people will

tell

you

that there are three

kinds of Sadhus: the quacks, the real thing, and those

who

are

touched in the head.

We

may

say again, therefore, that between the grossly evi-

dent and the almost normal

lem

is

a considerable range,

and the prob-

any two

to hit a similar cutting point for the people in

is

cultures to be compared. This does not

seem impossible, but

it

does require working out standards for particular cultures, and at present

it is

probably not possible for cultures

in general.

PARANOID STATES

2.

We

suggest

two

criteria

taken together as definitive of

this

condition.

A. Delusions of persecution and/or grandeur. The meaning of delusion has already been discussed, and the meaning of "persecution"

is

"Grandeur"

obvious.

refers to

a role

more

far

splendid, powerful, and important than one's actual role; the per-

who

son

thinks he

Napoleon

is

is

the conventional example.

This criterion, then, involves delusions with

a particular

kind

of content. B. Hostility

toward

others.

This

is

expressed in a tendency on

the part of the subject to interpret the entire world in terms of hostility

tion

—

toward himself. Projection

at least in the

is

a part of this interpreta-

simpler sense of the word. That

is

to say, he

reads into the acts of others hostile intentions against himself

which

are actually his

Paranoid behavior

own is

hostility

schizophrenic picture, and yet orders such as brain

toward them.*

thought of most often it

as part of the

occurs widely in other

syndrome and depression. That

it

dis-

occurs

alone as a chronic disorder with tremendous logical elaborations

on the *

As

basis of a is

well

few

false

premises

known, Freud employed

tion of projection.

a

paranoia vera

—

is

a matter

much more complicated

defini-

Approaches

j6

open to question.

to Cross-cultural Psychiatry

Many

not most psychiatrists believe that

if

who seem

does not happen, but that people

at first to

this

have such

symptoms of some

a condition sooner or later develop additional

disorder, usually schizophrenia. Occasionally they turn out not

to be delusional at

but to have justification for their views.

all

Transient paranoid behavior time in almost everyone. for

what we do not

like

It

is

probably found from time to

seems human nature to blame others

but find going on within ourselves.

few

things are so painful as self-reproach and

Few

are so relieving as

righteous indignation.

With

regard to cross-cultural identification,

it

has to be recog-

nized that societies exist in which hostility, suspicion, and what

we would

call false beliefs

of persecution

(e.g.,

by witches)

are

exceedingly prevalent. Several familiar questions immediately

Are we to regard patterns which normal arise.

the society, or do

mass scale?

And

we

these sentiments and behaviors as cultural individuals learn through

have instead a

if it is

clinical

growing up

in

paranoid state on a

a cultural pattern,

how

can one ever

identify the truly paranoid in such a context? It is

easy to puzzle oneself into a state of paralysis

ing further questions along this

key

The

line.

by

issue often

elaborat-

seems the

obstacle to identification and counting of psychiatric dis-

orders in any culture except our own.

But this

us note several things. First, the question

let

comes up

in

major form with only one complex of psychiatric symp-

toms,

and not with psychiatric disorder generally. Second,

symptom complex number of different syn-

paranoid behavior as a clinical entity

which appears dromes, most in people

who

a delusion

is

as a

component

commonly

in a

schizophrenia.

are not psychiatrically

that

it is

ill.

is

a

It is also

Third, our definition of

a false belief according to the standards of

the believers culture.

That

a belief

is

false

according to the

standards of some other culture including our therefore

make

clinically

observed delusion

it

seen transiently

a delusion. Indeed, is

its

own

does not

one of the features of the

resistance to the

conforming

Cross-cultural Identification of Disorders

On

pressures of the social group.

47

we

the basis of these points,

think that culturally patterned sentiments and behavior reflecting

and what persons of our culture would

hostility, suspicion,

call

of persecution, are not to be equated with a mass

false beliefs

paranoid state in any clinical sense of the word.

be considered

as

more

They can

rather

closely related to a normal capacity for

paranoid reaction together with the normal process of culture acquisition. It

remains possible that masses of people in a

still

become

society could in a short time

terms of their

happening regarded

One can

cultural standards.

Whether

visualize this as it

should be

normal or abnormal would depend on the

results of

at a

as

own

and delusional in

hostile

time of great

stress.

or not

examining the actual situation and on standards

with

this particular

one that

is

tural pattern loses

down

this

into

more

a special case,

is

We

general in cross-cultural work.

problem of mass paranoid

therefore, that the

it

phenomenon. But

some of

its

set for dealing

may

and

is

conclude,

state versus cul-

formidable character

specific parts

not

if

one breaks

careful about definitions.

Let us return to the question of identifying paranoid symp-

toms in an individual where the cultural background gives

prominence to cuted.

It is

hostility, suspicion,

symptoms comprise only one of dromes

we

several

are trying to distinguish.

the schizophrenic syndrome, stances

and

beliefs of

being perse-

important again to keep in mind that the paranoid

to

make an

hallucinations,

it

would

identification

components

Thus still

if

be possible in

through

other

is

further reduced

by recognizing

terms of the culture in which is

bewitched

is

something about

is

many

in-

delusions,

schizophrenic thinking, withdrawal, posturing,

inappropriate affect, or history of personality change.

lem

in the syn-

they were part of

it

occurs.

The

that a delusion

The

is

prob-

such in

conviction that one

not a delusion in a witchcraft culture unless there it

that does not

fit

within the range of the

accepted pattern. It is

cases,

here, of course, that

one begins to get into borderline

and competent knowledge regarding the cultural range

Approaches

48

to Cross-cultural Psychiatry

becomes important. Very often the question

is

not one of

specific items as such, but of appreciation of oddity in fit

together. This

may

how

they

be illustrated by a conversation one of us

had with Dr. T. A. Baasher of the Clinic for Nervous Disorders in

Khartoum North, Sudan. A. Leighton asked Baasher

delusion from accepted belief

how

he would distinguish religious

among people coming

to his clinic.

Baasher replied that he could give no general rules, but he could illustrate it

with a case he had seen that involved a murder. Some

two religious leaders in the neighborhood of Khartoum who were great rivals. A follower of one of the men began to hear voices telling him to kill his master's rival. It seemed to him that the voices came from a divine source and he set out to execute their command. Since he did not know his intended victim by sight, he wandered from place to place relying on the voices to let him know when he had come upon the man. Several times he saw someone he thought was his target, but the voices said, "No." Eventually one evening he entered a village where a number of men were sitting under a tree talking. One was on a chair, playing with some little sticks. The voices said that this was the man. The religious follower protested that surely not, he was just a poor individual, not a great leader. The voices, however, said, "Don't you see? It's a disguise. Kill." So the follower speared him. Later the follower was arrested for murder and then sent to Baasher for examination. years ago there had been

"Now," ture for a is it

is

not out of keeping with

man,

and of course he could make

as this disciple did. It

religious

to

fitted

man

is

things.

on

and

his master's

kill

the

wrong

within the cultural range for a

him

But the

together in this case did not

two

kill

a mistake

to hear voices that tell

go and do those

so since the

this cul-

to be extremely devoted to a religious leader, nor

out of keeping for him to undertake to

behalf,

him

said Baasher, "it

man

make

to do things, and for

way

all

sense.

religious leaders in question

these elements

This

is

especially

had made up

their

differences and been friends for over a year prior to the murder.

Cross-cultural Identification of Disorders

Item by item, there

is

nothing that was counter to the culture,

but the whole reflected odd thinking, like the Knight's

move

in

thought he was a paranoid schizophrenic from the story,

chess. I

and examination brought

3.

49

this out."

DEPRESSION AND MANIC STATES

The prototype tion

it is

of depression

characterized

by

grief.

is

As

a pathological reac-

excessiveness and inappropriateness for

the situation and for the standards of the culture.

appear where there sufficient,

is

no external

Thus

where the cause

cause,

or where the gloom in relation to the cause

The

cessively prolonged.

very strong. This

is

sense that

it

inexplicable

is

may

it

is

perhaps what Shakespeare had in mind

is

is

in-

ex-

often

when

he had Antonio say: In sooth It

I

know not why I am so

wearies me;

you say

it

sad;

wearies you;

how I caught it, found it, or came by it, What stuff 'tis made of, whereof it is born, I am to learn; And such a want- wit sadness makes of me, That I have much ado to know myself. But

Criteria cially

may

be stated

as:

weight

loss;

sleep disturbance, espe-

early-morning awakening; constipation; poor appetite;

amenorrhea; the subjective feelings of gloom,

and

tration,

behavior.

difficulty in thinking;

guilt,

poor concen-

and an objective slowing up of

Throughout the occurrence of such symptoms there is in common-sense terms or by the standards of

no adequate cause the

culture.

There

is

Suicidal

preoccupations and

acts

are

common.

often a twenty-four-hour variation, with the worst

feelings being in the early

morning and improvement occurring

toward evening. In some cases negativism and as well as to self

may

hostility to others

be very marked. In a few there are delu-

committed some unforgivable act or delusions of somatic type such as having no intestines or blood.

sions of having a

Some

depressions are cyclical, so that the patient has a

life

Approaches

jo

to Cross-cultural Psychiatry

story of disabling periods with normal performance between, or occasional episodes of manic excitement. Such a history of alter-

nating mania and depression

is,

or course, indicative of the classic

manic-depressive psychosis. This pattern, however, even sic, is

A

if clas-

not by any means common.

number of other

subdivisions are also

we may

thinking, but

employed

in clinical

consider these as too detailed or special-

ized for the purpose of the present chapter.

The manic

state

sometimes not too easy to distinguish from

is

a schizophrenic excitement. Euphoria,

humor, and joking are the

hallmarks, and like depression the state of excitement episodic.

Sometimes

it is

set off

by

a situation,

may

but then

it

be be-

comes detached from the situation and goes on and on. Behavior is unconventional and some of the most strict taboos of the society

may

be broken.

The

expression of the emotions and of

energy takes precedence over convention. Outstandingly there

The

person

busy

the time, and his busyness

is

overactivity.

is

disorganized and distractable like that of a monkey. There

is

all

is

great deal of playfulness with bursts of anger and hostility frustrated; difficulty

and

with

as

with the depression there

is,

a if

as a rule, a lot of

sleep.

In their full-blown form, both depression and manic states can

probably be recognized in any culture. Again, however, protec-

may

tive coloration

How

do you detect depression among people of

gloomy

culture

in India?

is

—

as

Or manic

excitement, as

lem

be afforded by certain cultural backgrounds.

is

is

a generally

by some writers to be the situation where the culture has a high level of

alleged

states

said to be the case in parts of Africa?

The

prob-

the one discussed previously as the borderline case. Culture

adds to the difficulty of differentiation, but not necessarily in an

overwhelming manner. As with

delusions,

the standards for

"excessively" depressed or elated behavior have to be

within each cultural framework. The number of the other hand, parison.

may be open

worked out

instances,

to cross-cultural counting

on

and com-

Cross-cultural Identification of Disorders

As

for the

seminar,

it

was

cultures familiar to felt that

bly did occur in

all

j/

those participating in

the

depression and manic conditions proba-

On

of them.

the other hand,

that several clinical studies in Africa reported

exceedingly rare and excitement

as

very

we

took note

depression as

common by

comparison

with Europe and North America.

PSYCHOPHYSIOLOGIC CONDITIONS These are disorders that are primarily organic in their manifestations and consequences, but in which there are important psychological causes. Clinical studies in Europe and America point to certain

On

nature.

such

symptom complexes

we

a basis

as

being frequently of

this

suggest that the following types of

deserve attention: skin eruptions of the eczematous type,

illness

asthma, hay fever, hypertension, hypotension, peptic ulcer, and colitis.

No

interferences

from

cultural factors are to be anticipated in

distinguishing these symptoms.

The

necessary information can

be obtained by physical examination and fairly simple questions about personal history.

On one

the other hand, major difficulties are likely to appear

tries to establish

This matter

is

in every case,

the role of psychological events as cause.

always

difficult,

requiring exhaustive investigation

and even then one

strong evidence one

way

may

not be able to produce

or the other.

Cultural differences

would surely make the problem worse. Added possibility that a high exists in

many

morbidity rate of chronic

to this

diseases,

is

the

such

as

mask those major psychological component in their the open question as to which organic

parts of the world, could well serve to

disturbances that have a etiology.

when

There

is

also

syndromes commonly involve psychological factors to

a signifi-

cant degree. Clinical opinion ranges from implicating them in practically

all

disorders (through such mechanisms as lowering

resistance) to a

more

limited

cultures other than our

own

it

list

such

as that

given above. In

could well be that a different set

p

Approaches to Cross-cultural Psychiatry

would have major psychological

of syndromes

factors in their

origin and perpetuation. It

remains true, however, that despite

culties,

all

these serious

diffi-

the manifestations of psychophysiologic disorders are

easy to detect cross-culturally.

With

this

one advantage

made by counting

gest that a start can be

we

sug-

the syndromes in a

sample and seeing whether or not their prevalence, incidence,

demographic

features,

contrast markedly

and so on turn out to be the same or

from one

cultural

group to another. With

such a procedure, one could go beyond the conservative

we

syndromes

have given and note the distribution of

toms according to the systems of the body

all

list

of

symp-

as outlined in the

Manual. Oriented by knowledge of such comparative distributions,

one might then carry out intensive physical and psycho-

logical investigation of a selected sample of cases in order to

adduce evidence for or against the presence of compelling psychological influences.

PSYCHONEUROSIS we shall outline two symptom complexes that common among people of our own culture, and

In this section are clinically

then treat in a more Finally

I.

shall discuss

fashion several rarer types.

cross-cultural application of criteria.

ANXIETY REACTION

We in

we

summary

begin with the anxiety reaction or

some form

depression

is

is

state,

because anxiety

the chief characteristic of psychoneurosis. Just as

like

mourning, so anxiety

is

like fear:

it is

excessive

and has either no object or an inappropriate object. The person so afflicted has the subjective sensation of fear, and at times the

outward physiological manifestations, but the and

diffuse. Either

he does not

know why

he

feelings are feels this

the causes he alleges appear improbable to others. fort

vague

way, or

The discom-

and suffering, on the other hand, are apparent enough.

The

criteria

proposed are both objective and subjective. Ob-

Cross-cultural Identification of Disorders jective criteria

may

be stated

as: fast

53

pulse, rapid respiration, pale

skin, sweating, dilated pupils, facial expression of apprehension,

poor

sleep,

and

would

restlessness. Subjective criteria

include:

apprehension, worry, fear of dying, palpitations, cold sweats,

and nightmares. Since

it is

rare to see a person in such an acute or

severe state of anxiety that the objective criteria are immediately

we must usually

evident,

rely

on the

patient's story.

DEPRESSION

2.

The Manual,

following

attempts to

trists,

chotic

make

a

the

thinking

many

of

fundamental distinction between psy-

We

and psychoneurotic depression.

depression

admit, however, that

we

psychia-

have not found the points of

The

entiation sufficiently specific to be workable.

must differ-

distinctions

proposed are too elusive for standardization and the develop-

ment of

reliability

we

consequence

in

judgment between

psychiatrists.

As

a

suggest that the matter be considered primarily

one of degree. This means that the

criteria for identifying

psychoneurotic

depression are the same as those already outlined for psychotic depression.

County Study 7 contains very few cases, all of which

Applying these

yielded one category that

in

the

Stirling

have a history of being severely disturbed, whether episodically

many cases, most of which show mild yet exceedingly chronic disturbance. Both clinical experience and survey work suggest that depression, mixed with anxiety and other symptoms, is a very com-

or chronically, and another category with

mon

type of psychoneurotic disorder. Frequently, especially in

the mixed reaction, there the

functioning

of

the

is

a focusing

body,

and overconcern with

constituting

hypochondriacal

symptoms. 3.

SOME ADDITIONAL TYPES OF PSYCHONEUROSIS

Under

this

heading the following conditions

A. Conversion reactions. These consist

may

be noted.

in anesthesias, paraly-

Approaches ses,

and sensory

to Cross-cultural Psychiatry

losses that are recognizable as psychological be-

cause the disturbances distribution

be consonant with the actual

to

and functioning of nerves.

B. Dissociative

fugue

fail

and multiple

states,

Grouped

reactions.

here

are

personalities.

These conditions appear to be exceedingly tures of

Europe and America at when they do occur

so dramatic

tion and remain long

amnesias,

the

rare in the cul-

present, although they

may

be

as to attract considerable atten-

remembered.

C. Phobias. People with this condition

show unreasonable and

incapacitating fears of specific objects or situations, such as elevators, trains, crowds, or

open

spaces.

D. Obsessive-co?npulsive reactions. intrusion of

unwanted

ideas, or the

Here

the trouble

the

is

need to do things repeatedly,

despite the feeling that they are foolish.

Referring again to the Stirling County Study,

show

its

findings

that psychoneurotic syndromes exclusively of one or an-

other of the six types mentioned above are rare. Although anxiety or depression

may dominate

the picture, there are often

mixtures of symptoms pertinent to the other subcategories. Indeed, the type of psychoneurotic

monly found mixed that

by

defined gories,

it

symptom complex most com-

one in which the distribution of symptoms

is

has to be given the label "Other"

—

that

is is,

so as

the Manual, not specifically in any of the subcate-

although comprising symptoms referable to a plurality of

them.

Many

studies

have

psychophysiologic

symptoms

purely psychoneurotic. neurosis

that

are

a

high

associated

proportion

with

the

of

more

It is

unusual to find a case of psycho-

unaccompanied by

gastrointestinal, cardiovascular, or

musculoskeletal

To

indicated

this

difficulties.

matter of range and amorphousness in psychoneu-

symptoms must be added by item the symptoms comprise

feelings

time or another are experienced

by almost everyone. This means

rotic

still

another consideration. Item

and behavior that

at

one

that the definition of psychoneurosis and the standardization of

Cross-cultural Identification of Disorders

procedures for

recognition are particularly

its

55

difficult.

A

solu-

tion has been to define the disorder in theoretical terms rather

than in terms of phenomena that can be observed.

One such

view,

for instance, gives emphasis to the dominance of unconscious

motivation. This, however, cannot be done in the approach

represented here, for reasons given earlier (p. 27).

Our

inclination, therefore,

is

to identify the

symptoms, and

then estimate the degree to which they produce impairment.

These may be considered

as

two

separate steps.

each individual could be surveyed

how

toms he shows and

first

That

to say,

is

to see what, if any,

these cluster into patterns.

symp-

Both number

and type of symptoms are relevant to the question of whether a psychoneurosis

is

present or not. Multiple diffuse

symptoms

of anxiety could be considered presumptive evidence, but so also

could the presence of one clear-cut phobia without any other

symptoms at all. With symptoms

second step would be to judge

identified, the

impairment. Criteria for

of course, important in

this are,

all

psy-

chiatric disorders, but in the brain syndromes, mental deficiency,

and the psychoses they are implied in the very nature of the

symptoms. This

is

not necessarily so in the case of psycho-

physiologic and psychoneurotic disorders;

person to have

many symptoms

function fairly well.

We

family relationships,

is

possible for a still

suggest in estimating impairment that

attention can be given to four

The

it

of the latter character and

community

main

areas of activity:

relationships,

work,

and recreation.

categories for rating impairment, as proposed in the Manual,

would appear

No

to be serviceable.

impairment.

Minimal. Perceptible incapacity, but not exceeding 10 per cent. Mild. Impairment in social and occupational adjustment, such as

20 to 30 per cent disability.

Moderate. Impairment that seriously but not totally interferes

with the

patient's ability to carry

on

his social

and voca-

tional adjustment, such as 30 to 50 per cent disability.

Severe.

Anything over the preceding.

Approaches

$6

On

such a

to Cross-cultural Psychiatry

scale, the division

between

nificant impairment can be considered

as

and

significant

insig-

lying above "minimal"

and below "mild." "Moderate" and "severe" could probably

mark

the line between unhospitalized patients and the majority

of those

who are hospitalized.

Turning now to the problem of our point of departure

is

cross-cultural identification,

to note again that the psychoneuroses

present particular difficulties because of their protean character,

the lack of congruence in psychiatric definition, and the large

number of marginal

To jump

cases.

from

directly

study of people in one or more other cultures epidemiological study

hand,

it

criteria.

as

is

to

compound

—particularly an

confusion.

On

the other

does seem possible to establish operating definitions and It

cannot be hoped that these will

body's support, but

they

—

this into a

it

may

command

be possible to make evident

every-

just

agreement and disagreement are

are, so that points of

what clear,

well as the extent and limits of the ground covered by the

study.

The symptoms and impairment

criteria that

have been

already mentioned in this section are a sketch of operating defi-

North America. The question now is: Could they be employed in a cross-cultural study? The answer sums up what has already been said about other categories of psychiatric disorder. While it is to be expected that nitions as these

might apply

in

attempts to apply criteria in another culture will increase the

width of the margins of uncertainty, there assuming a priori that the cultures that

this

is

not ground for

renders the problem unmanageable. In

were used for reference

in our seminar there

appeared to be no sweeping barriers to the identification of psychoneurotic symptoms and degrees of impairment. remains, of course, that here and there a particular

might be

The fact symptom

difficult to detect.

For instance, anxiety might be hard to distinguish from tional fear

under certain circumstances. One

features of anxiety ever, if great

is its

free-floating nature.

enough may develop

a

ra-

of the identifying

Genuine

fear,

how-

free-floating character,

Cross-cultural Identification of Disorders

may

while on the other hand anxiety lose

its

condense into a phobia and

free-floating quality. In cultures

where witches

are per-

may

arise in

ceived as a constant threat, very real difficulties separating psychoneurotic anxiety

termined

fear.

from

rational, culturally de-

Obviously, fear of witches should not automat-

be labeled a phobia; nor should a preoccupation with

ically

witches and witchcraft be seen hand,

57

it is

as

an obsession.

On

the other

possible to take one's respect for culture too far

and

assume that fear of witches could not be a phobia. This could lead to finding

no phobias

in a cultural

group

in

which they were

actually present.

What we

are saying, in effect,

is

that the distinction

on the

fear (rational) and anxiety (nonrational) depends tural standards of the

between cul-

group to which the individual belongs. The

content will vary more or

less

from culture

to culture, but the

principle of relationships remains the same.

The

test of

whether the object of fear

concern needs to be son's

mode

of reaction,

tional within the

is

a legitimate source of

One must consider, too, the perwhich may also be rational or nonra-

qualified.

framework provided by the

cultural system of

sentiments. Poorly controlled handling of emotion a clue as to

may

provide

something psychologically wrong in situations where

legitimate witchcraft fear

may

otherwise be hard to separate

from anxiety and phobia. Although

concerned

with

(p.

48)

illustrates

both points

hand there

is

prehension

itself as

there

is

we

are trying to make.

On

the one

measured by cultural standards, and then

symptom

manifestations in the

way the emotion is managed or mismanaged. Finally we should like to suggest that even

if

anxiety were

cultural factors in particular individuals, this

not necessarily prevent our identifying these persons neurotic.

anxiety,

who committed murder

the detection of oddity or abnormality in the ap-

the question of further

masked by

than

rather

hostility

Baasher's story of the religious follower

The very

as

would

psycho-

protean, or multisymptomatic, character of

Approaches

j8

to Cross-cultural Psychiatry

psychoneurosis argues against

this.

connection with schizophrenia,

hang on one symptom.

it

As was mentioned

If this or that

earlier in

unusual to have decision

is

symptom

particular context, other elements of the

is

sufficiently in evidence to permit identification.

own

various situational contexts within our

obscured by a

syndrome

are apt to be

This

culture

is

times obscure one or another aspect of a disorder, and it

true in

which some-

we

think

probable that the same will apply in issues of cross-cultural

identification.

PERSONALITY DISORDER Personality disorder refers to a condition that

and in the

similar to psychoneurosis;

is

outwardly

clinical assessment of cases

often particularly difficult to decide between the two. In

it is

general, personality disorder

is

conceived

as

being more diffuse

than psychoneurosis, spreading through virtually every aspect of personality.

It is also

thought to be

life-long,

beginning

early age and persisting ever afterward, unmodified

Although there

ence.

three of the

by

an

experi-

varieties of this disorder,

more common types occurring

be mentioned for

in our culture

may

illustration.

A. General emotional fly apart

numerous

are

at

under ordinary

instability. tests

of

life

This means a tendency to with symptoms of crying,

screaming, rage, or general confusion. B. Passivity.

A person so afflicted gives in too easily,

lets

others

push him around, and seems to bend without spine to every wind that blows.

C. Hostility

symptoms

and aggression. In personality disorder these

are chronic, or frequently

provoked by very

slight

stimulation, and they are extreme in degree.

We

shall

not discuss here the problem of cross-cultural identi-

fication, since

been tial

said

we would

only be repeating

much

of

about psychoneurotic and other symptoms.

points of concept and

what has

The

essen-

method have already been covered.

Cross-cultural Identification of Disorders

59

SOCIOPATHIC DISORDERS The Manual

considers sociopathic disorders to be a subgroup

under personality disorder, but separately.

The

reason

is

we

find

it

convenient to

list

them

that the central criterion of this cate-

is deviance from cultural expectation. The underlying syndrome may be personality disorder, but it may also be mental

gory

and even brain syn-

retardation, psychoneurosis, schizophrenia,

drome.

As implied above In

group

in the reference to deviance, this

the most culturally defined of

all

is

those reviewed in this chapter.

Western society the category presents major problems be-

cause

it is

so essentially a matter of relationship to norms,

norms vary enormously from one part of the another.

The

question

may

the behavior represented

The

three

main

is

system to

social

be raised, furthermore,

and the

as to

whether

a disorder.

divisions of sociopathic disorder are listed

below. 1.

Dyssocial. This represents amoral disregard for the con-

ventions of society. 2.

Antisocial.

Such persons act against other people with rob-

bery and violence. In the

first

above there

pursuit of one's

own

desire to harm. In the

enjoyment of such

is

disregard for the feelings of others in

hedonistic ends, but there

second there

acts

may

be

a

is

is

direct attack

no

on

deliberate

others,

and

prime reason for carrying them

out. 3.

Addiction. This

commonly means

alcohol,

but also in-

cludes overuse and dependence on a wide variety of drugs.

A that to

feature of is

all

three of these sociopathic patterns, and one

often used as a confirming criterion,

learn

from experience.

No

defeating the behavior proves

unable to relinquish

it.

matter

itself

is

how

a curious inability

costly

and

self-

to be, the sociopath appears

Approaches

60

The

to Cross-cultural Psychiatry

seminar members saw no great difficulty in the identifica-

Most were sure they had

tion of sociopaths in other cultures.

encountered

The

just

such persons in the course of their

seminar members also

felt that in the cultural

field

work.

groups they

knew, there was common recognition of the existence of the sociopathic phenomenon. This might be put in terms such

"Occasionally you find people

who

are

against everything and they cannot help

made

way

way." Or, "There are people

that

regardless,

and there

is

as:

born outlaws; they are it

who

because they are just

go

their

own

nothing that can be done to change

them."

SOME NOTES ON DIAGNOSIS

We

have discussed the possibility of identifying symptom

patterns and impairment cross-culturally, and

cluded that

if

one

we

have con-

selects particular cultures instead of trying to

deal with cultures in general, he will probably be able to establish

operational criteria that will permit the desired comparison

at a useful

and meaningful

We also think

level of approximation.

that operational steps are facilitated

if

the detection of

symptom

patterns and the rating of impairment are used as a primary

focus in cross-cultural estimates.

At

the end of the seminar

it

was

the opinion of most participants, anthropologists and psychiatrists

alike,

culturally.

there

that

When

syndromes

as a

whole

are manageable cross-

one takes up individual symptoms one by one,

plenty of opportunity for postulating

is

and ground for arguments regarding considers the

symptoms

as

difficult situations

feasibility,

but

when one

components of syndromes, and takes

the latter as the unit for counting, the task does not look so difficult.

we do

Although problematic

cases will

undoubtedly occur,

not expect these to be so numerous

as to

cause serious

statistical difficulty.

When sider full

one moves beyond symptoms and impairment to condiagnosis,

especially with regard to the functional

psychoses, the psychoneuroses, and the personality disorders, he

Cross-cultural Identification of Disorders

61

must be prepared to meet considerable challenge. There are

many

bound

subtleties in the diagnostic process that are

by

affected

subtleties

cultural differences.

necessary in any

is

consistency, and

it

A

to be

constant awareness of these

work

that strives for accuracy and

seems appropriate, therefore, to outline a

few. In the psychiatric interview, the patient influences the doctor

and the doctor influences the patient; diagnosis

complex

resultants of this interaction.

The

is

one of the

diagnosis depends not

only on the symptoms and manifestations of the patient, but also

on the doctor's and

ture,

training, familiarity

his attitudes

influenced

by

with the patient and

toward the

patient,

which

the patient's attitudes toward him.

whether he

diagnosis reflects

his cul-

are in turn

Very

often the

and

likes or dislikes the patient,

whether he approves or disapproves of him. Unfortunately the hierarchy of values differs from doctor to doctor, from time to time,

and place to place. "Sociopathic disorder," for instance,

often implies dislike and disapproval. "Depression"

more

flattering than "schizophrenia,"

is

usually

which sometimes simply

implies craziness.

The

may

diagnosis

at times

be

a projection of the physician's

personality onto the patient. This

is

apt to happen in rather

obscure cases where the diagnosis

is

achieved empathetically,

that

is,

by

transient trial identification with the patient.

identification self

one runs the

useful, but

is

with the patient.

To employ

it

risk of

skillfully

one must have a

thorough knowledge not only of the patient and also of one's self

The

and of one's

psychiatrist

will be influenced also

toward

who

by

own

The

his culture,

his attitude

culture.

not only toward

and

his patient

his

toward Western

culture,

toward the

psychiatrist,

but

anthropolo-

by

the atti-

own

culture,

diagnosis will also be influenced

tudes of the informants and patients toward their

mental disease in general.

but

attempts diagnoses in another culture

his informants, his interpreters,

gist colleagues.

Such

confusing him-

and toward

Approaches

62

A diagnosis then

is

to Cross-cultural Psychiatry

the result of a relationship, whether

it

be a

one-one relationship between psychiatrist and patient, or a

more complex one between

psychiatrist-interpreter-informant-

anthropologist-patient. Spiegel establishing relationships

8

has described his difficulties in

and doing interviews with the parents

of disturbed children from American-Irish Catholic families of

He

the lower income bracket in the Boston area.

new One

set of values,

and

new modes

and those found in dealing with psychotic

culties

other

were not psychotic, not

patients,

and people of other cultures

essentially

patients.

diffi-

Yet

and not from an-

These comparable problems of dealing with

culture.

psychotics

a

of behavior.

forcibly struck with the similarities between these

is

these people

as

new

language, a

had to learn

communication

difficulties.

can be described

The psychiatristown culture, in

anthropologist must maintain an orientation in his

the culture under study, and in the private world of the patient

under

discussion.

Our

interest in culture,

important, and possibly

from endemic at

illness

Many Farms

however, should not obscure the very

common, masking

such

as tuberculosis.

effects that

From

can

arise

the discussions

one would suspect that the problem

is

not so

much one

of disentangling neurotic and psychotic complaints from native superstition and folklore as it is of disentangling

such complaints from the organic background and perhaps from the tendency of unlettered peoples to express emotional dis-

comfort

in

terms of aches and pains.

Notes 1. E. Sapir, "Culture and Personality," in Selected Writings of Edward Sapir in Language, Culture and Personality, D. G. Mandelbaum, ed.

(Berkeley: University of California Press, 195 1 ) 2. R. P. Knight, "Borderline States," Bulletin of the Menninger Clinic, vol. 17 (1953), pp. 3.

W.

1-12.

McDermott, K. Deuschle,

"Introducing 131, nos. 3395

Modern Medicine

J.

in a

Adair, H. Fulmer, and B. Loughlin,

Navaho Community,"

and 3396 (January 22-29,

I

9 5o), pp. 197-205 (

Science, vol.

and 280-287.

Cross-cultural Identification of Disorders

*3

Thurber, "The Night the Ghost Got In," My Life and Hard Times York: Harper & Row, 1933). 5. E. Llewellyn-Thomas, "The Prevalence of Psychiatric Symptoms in an Island Fishing Village," Canadian Mental Association Journal, vol. 83 4. J.

(New

(July i960), pp. 197-204.

A. H. Leighton,

A. Clausen, and R. N. Wilson, eds., Explorations York: Basic Books, 1957), Editorial Comment to ch. 2 ("Paranoid Patterns" by J. S. Tyhurst), p. 69. 7. D. C. Leighton, J. S. Harding, D. B. Macklin, A. M. Macmillan, and A. H. Leighton, The Character of Danger: Psychiatric Symptoms in Selected Communities [Vol. Ill, The Stirling County Study of Psychiatric Disorder and Sociocultural Environment (New York: Basic Books, 6.

in Social

Psychiatry

J.

(New

1963)]. 8.

J.

P. Spiegel,

"Some

(New

Cultural Aspects of Transference and Counter-

and Familial Dynamics, York: Grune & Stratton, 1959).

transference," Individual

J.

H. Masserman,

ed.

Native Conceptions of

Ill:

Psychiatric Disorder By Jane M. Murphy and Alexander H. Leighton

EDITORIAL NOTES

An

obvious fact about cross-cultural psychiatry

knowledge and techniques

is

that the

that have been found useful

in

our

society are not necessarily appropriate for investigating a non-

Western group. This chapter attempts clinical definitions

examined in the

last

to

move on from

the

chapter and to delve into

problems involved in obtaining the native outlook on such matters. Its

orientation entertains the possibility that the indigenous

views of another culture might be wholly different from those of Europe and America, or they might be surprisingly the same. It

is

theoretically

of

possible,

course,

that

groups have no idea of psychiatric disorder

happen

if

there were, in fact, no disorders

of that society.

It

could happen

if

all.

among

cultural

This could

the

members

the sociocultural system pro-

vided roles that could accommodate individuals,

at

some

as functional

members

all

equipped with no matter what inadequacies, disturb-

ances, or disorders.

ignore disorders

them "natural"

Or

it

could happen

—to overlook them

if

if

if

the group chose to

they were there, or to

they could not be overlooked. 64

call

Native Conceptions of Psychiatric Disorder probably

It is

safe,

however, to dismiss these

6$

possibilities as so

unlikely as not to warrant serious attention. There appears to be

no culture known today nor

at

any period

so startling an omission in awareness of

its

lack a concept of mental

in history that exhib-

human

behavior

would seem equally

illness. It

as to

foolish to

expect that any people anywhere consider such physical events as a

broken toe or an eclipse of the sun

as psychiatric

phenomena

even though they might figure in the preoccupations or delusions of an individual suffering a psychiatric disorder. Neither

does

seem possible that any people would

it

human being nor

because he thinks of himself as a

crazy

that

any

even a druid-worshipping group, could make very good

society,

man who

Alfred Kroeber once remarked, of a

use, as

man

call a

mute

himself to be a tree and stands

believes

with arms

in the forest

outstretched.

Hence we can assume variability.

may

probability

is

that

way they conceptualize psychiatric disorder. patterns we recognize may not be so regarded, as

differ in the

Some for

The

some bounds to cultural within these bounds cultures

that there are

of the

instance

changes with

psychophysiologic disturbances. havior

is

likely to

age

old

The

or

psychoneurotic

and

content of psychiatric be-

vary in some regards. For example,

it is

incon-

view of what is known about cultures that any group would not have standards of crime and sociopathy; but what behavior is considered criminal obviously differs from culture to ceivable in

culture.

Among many

hunting,

gathering,

groups, an abuse of animals and land

is

and

agricultural

thought of

as

a far

greater offense against the sanctity and viability of the society

than beating one's wife or killing an enfeebled old man.

It is also

certain that the explanatory systems for psychiatric disorder will

be different in other cultures. In approaching cross-cultural studies of psychiatric disorder,

we

are confronted immediately

by

a situation that calls for a

balance between skepticism and confidence. There

confidence that what

we know

already

is

is

reason for

applicable in

some

Approaches

66

ways

to

human

all

indicated that

it is

to Cross-cultural Psychiatry

beings everywhere.

The

previous chapter

not altogether hopeless to attempt identifying

disorders, as conceived in clinical psychiatry,

among

peoples of

very different cultural background. Our current methods of

dis-

covering and evaluating symptoms also seem to provide starting points.

But there

is

need for skepticism that any analysis limited

to these resources alone

would be complete. At

the very

important items of content, norms, and specific deviance might be missed. will, that

If

we

find, as

of

evidence suggests

we

most cultural groups have a word

we

least,

criteria

in their language for

to the view suggested in the last what people in a particular group call "crazy," then opportunity is at hand for exploring what these people mean by "crazy" and how well it actually does relate to what we define as schizophrenia. Beyond this there is

"crazy" and

if

hold at

chapter that schizophrenia

the possibility of picking as latah,

a

koro, and arctic

all

is

up information about syndromes such hysteria which appear to be specific to

given culture, and of gaining illuminating suggestions

as to

causal relationships.

All of this argues for securing the native viewpoint, or range

of viewpoints, and

it

points to questions that should be recog-

nized concerning the use of data-gathering methods that are predicated on Western psychiatric criteria of disorder.

commonly

accepted,

employed thus

we

far in cross-cultural psychiatry have

quirements of freedom from cultural bias only

and

It

is

and methods

believe, that the criteria

met

the re-

at certain points

in limited degree. Until the last seven or eight years,

investigations in non- Western areas have been

most

conducted in

terms of one or another of the following: hospital admission rates,

penal records, vital

statistics

veying with the Rorschach

test,

on homicide and

suicide, sur-

the T.A.T., the I.Q., or other

and observations by itinerant psychiatrists. some respects culturebound, although it has long been thought that the Rorschach was less contaminated

psychological

tests,

All of these are in

than most

tests;

and when the T.A.T. has been used

in cross-

Native Conceptions of Psychiatric Disorder cultural research

it

has usually been adapted to

show

67

situational

stimuli appropriate for the culture being studied. In view of the

unknowns

that confront cross-cultural psychiatry, however,

seems wiser to begin with a search for intelligence, for example,

bly but

The

by no means

than to

with

start

a test that

presuma-

definitely discloses these.

present chapter

is

an effort toward the goal of discover-

ing such indigenous criteria of psychiatric disorders.

It is

ex-

ploratory in nature, and the information was gathered mainly

Murphy

as a part of a general

as a

by

anthropological investigation with

special attention given to health

The study

it

criteria of anxiety or

problems

an Eskimo

in

village.

whole has drawn on the observations and

assess-

ments made by two psychiatrists and one other anthropologist.

THIS

report deals with native conceptualization about psychiat-

ric disorder. In

approaching

background

exists as

this topic, it

a large literature

tendencies of non-Western peoples

Les Fonctions mentales dans

The Mind

of Primitive

tive

apparent that there

on the conceptualizing

for example, Levy-Bruhl's

les societes inferieures,

Franz Boas'

Man, and Paul Radin's Primitive Man As

Philosopher. 1 Although versial, there is

as,

is

much

of this literature

is

now

contro-

no doubt that the magical philosophies of primi-

man have been carefully

In order to illustrate

described and discussed.

some of the

issues

involved in the under-

taking of this chapter, an example of a similar conceptual prob-

lem will be used suggested

by

as

an introduction.

W. H. R. Rivers'

tion of Death."

2

report on

The example "The

has been

Primitive Concep-

Certain liberties have been taken for the sake of

conciseness and clarity, but they do not do injustice to

known

generally about non- Western peoples.

what

is

The example

is

this:

In Melanesia there

is

a

group of people whose language has

two words, "X" and "Y," which,

in

view of what people say

Approaches

68

to Cross-cultural Psychiatry

and do, you soon equate with

and "death." You draw

"life"

conclusion because corpses at the time of burial are called

this

"Y"

and are contrasted to healthy, young individuals called "X."

you

stay with this group long enough, however,

you

If

discover

when they are not dead. person "Y" and bury him if

that sometimes people are buried even

You

learn that the Melanesians call a

he

very sickly or very old

is

who, according

—

bury people

in other words, they

to society, ought to be dead even

if

they are not.

Before long you learn further that the state of "Y-ness"

is

some-

by somebody in the group getting on the person now designated as "Y." further inquiry enhances confusion, because you find that

times thought to be caused

angry and casting Still

a spell

after the person called

now say

he

discover,

On

isn't

"Y"

"Y"

means something

taking thought

has been buried for a while, others

but rather

at all

"Y x ," which, you

gradually

like eternal-life-after-death.

you decide

that the Melanesians have a

very different conception of death from that given in the medical textbooks and collected clinical judgments of the Western world; and yet you have the uneasy feeling that some

as-

pects of this Melanesian life-and-death business have a decidedly familiar ring

and that perhaps your

own

obstructing a nicer division between is

concepts of analysis are

what

is

and what

different

the same.

As

a beginning

a concept

you

ask yourself about the difference between

and a word. Following dictionary usage

to call a concept "a mental

zation be."

3

from

by

a

particulars, an idea of

a thing

what

we

can agree

formed by

generali-

a thing in general

should

impossible to communicate a concept without using

It is

words, but held

image of

it

does not necessarily follow that

group of people

all

the concepts

will each have a specific label in the

language of that group. Nevertheless, in view of the close connection between language and culture, you suspect that this

important area to explore. that

what they

distinguish

Among by

the Melanesians,

the term "Y,"

related to their conception of death,

is

which

is

is

an

you note somehow

the basis of the cultural

Native Conceptions of Psychiatric Disorder

69

practice of burying both dead and nearly dead people.

word "Y"

about

also linked to the cultural beliefs

is

"Y x ." But

in

The

after-life, as

the significance of the difference in the Melanesian

meaning of "Y" and our meaning of the word "dead" does not altogether convince you that the Melanesians cannot tell a dead man from a live one or that they are unaware of the difference between

a state

of rigor mortis and a state in which the heart

beats and breathing goes on, even

if

these functions are impaired

as in a sickly old person.

In an effort to clarify the matter

you put yourself in the body of

Melanesian's position and look at some comparable

thought from one of the Western traditions,

way we hood

a

as for

example the

distinguish people in our kinship systems. In

all likeli-

Melanesian has separate words for male cousin, female

cousin, elder jnale cousin

on the

father's side,

and so on, and he

would be somewhat befuddled by the compression of all these useful distinguishing words into our blanket English term, cousin. He would be correct, we would say, in assuming nevertheless that this evidence does

unable to cousins.

language

men from women

tell

But he would is

important

also

mean

not

that civilized

cousins or old

man

is

from young

be right in noting that our kinship

as a reflection

of behavioral tendencies.

Most English-speaking groups do not have as many rules for distinguishing between people in the cousin category as the Melanesians have. In addition to the value derived from sorting out the conceptual from the linguistic

dimensions of the problem, the

Melanesian example indicates that

illness

to quite different causal mechanisms. cal explanations

such

the

phenomena

cal

and nonmagical

as

At

and death are attributed least

we

note that magi-

the casting of spells account for part of

of illness and death in the Melanesian mind. Magilevels of analysis

should be distinguished. Al-

though magical thinking has been given most attention literature, there

is

in the

evidence that no groups of people are entirely

ignorant of empirical relationships between cause and effect.

Approaches

jo

to Cross-cultural Psychiatry

more thorough investigation of our hypothetical Melanesian group would very probably disclose that while they

For example,

a

believe that the burning of effigies kills people

has an after-life, they also

know

and that the soul

that eternal life does not exist

for physical beings, that old age eventually leads to physical death, and that life

may

be cut off by such nonmagical acts

as

the thrust of a knife into a man's heart.

In beginning to explore the interplay between magical and

nonmagical concepts of the origin, course, and treatment of diseases,

it is

possible to refer to a rather impressive literature

on the topic of primitive medicine. 4 Although

specifically

this

has bearing mainly for theories and classifications of physical

studying psychiatric disorders.

disease, there are guidelines for

One

of these

is

the indication given

by numerous

observers that

magical and nonmagical theories have a compatible coexistence insofar as natural causes and processes explain honjo illness and

death occur

—the nature of

while magical ideas explain afflicted. Also, there is ties

these

why

phenomena,

in other

words

that a particular person

it is

no evidence so

some other

pertain exclusively to physical illnesses and that

order of explanation pertains to psychiatric manifestations.

matter of

fact, primitive

is

far that witchcraft activi-

As

a

medicine has been said to represent an

uncompromisingly psychosomatic attitude toward both causal explanations and treatment. 5 Various psychosocial experiences

such

as the

perception of

ill-will in

interpersonal relations and

the belief in the potency of "hexing" activities are thought to be the veritable causes of disease. Correspondingly, treatment in-

cludes other types of psychosocial experiences such as confession,

group pressure, or acting out the

belief that the disease has

been destroyed or rendered harmless. In view of

this

mentally psychosomatic orientation, one of the

questions to

first

funda-

be asked in studying native concepts of mental disorder

whether and what

a distinction is

is

drawn

at all

between what

is

is

physical

psychical.

Here again we may

find a small but

growing

literature

on

Native Conceptions of Psychiatric Disorder

7/

primitive psychiatry and further bits of information scattered

throughout numerous ethnographic accounts of non-Western peoples.

6

Most of

this material focuses

on various kinds of

easily

observable hysterias and schizophrenias, including the culture-

We

syndromes.

specific

can learn, for example, the kinds of

behaviors that are called Utah or koro? Further, that the

Navahos

believe incest

insanity and that the

mechanism whereby the mind

thought to be a moth that

cifically linked to insanity

nized in non- Western groups.

The purpose It is

of this chapter

is

to

not a comprehensive

ways one might approach the problem,

any claim made for having achieved generalizations about

primitive psychiatry as a whole. Rather, an effort has been to gauge the parameters of the sions based

on the study of

during a given Site

The a

spe-

is

whole range of disorders recog-

progress in that direction.

analysis of all the various is

of Eskimos a dog spirit

is

We

9

ceptualizations pertaining to the

nor

affected

however, few systematic analyses of the con-

are,

make some

is

and that particular kinds of offenses

are part of the causal matrix.

There

can learn

around in the brain. 8

flutters

among some groups

learn that

we

specifically responsible for

is

slice

made

problem and to present impres-

a particular

non- Western group

of time.

and Kelevant Aspects of Eskimo Culture

questions outlined above

group of Siberian Eskimos

Island in the Bering Sea.

in

The

were

raised during the study of

Sivokak village on island

is

St.

Lawrence

situated at a transitional

point between the Alaskan, Canadian, and Greenland

Eskimo

cultures to the east and the Siberian cultures of the Chuckchee,

Koryak, and Kamchadal to the west. Until recently the

St.

Lawrence Eskimos displayed most of the characteristics typical of traditional Eskimo cultures: habitat is usually coastal or islanddwelling; hunting of sea

mammals

is

the main source of food,

clothing, and material equipment; wife-exchange

and religious

beliefs center

on the shaman

is

practiced;

as a medico-religious

Approaches

72

The

practitioner.

St.

to Cross-cultural Psychiatry

Lawrence Eskimos

also shared

many

features of traditional Siberian cultures. This affinity

of the

was espe-

form of shamanism practiced on Lawrence and among the neighboring Chuckchee. 10 cially noticeable in the

It

is

St.

impossible to broach the topic of the psychiatric and

medical views of these Eskimos without reference to the beliefs

and practices of shamanism. Some background on shamanizing

is

shamanize in past

were

11

therefore imperative.

this

Both men and

on the

women

Lawrence shamans enter

basis of a "call."

carried out in private but they follow

The initiation rites are a common pattern. The

novitiate goes through a five-day period of isolation, in the cold

Lawrence

group but the most powerful shamans of the

transvestite homosexuals. St.

the profession

St.

and subjecting himself to

wandering

a variety of hardships.

Dur-

ing this time the prospective shaman enacts death and resurrection in a performance of breaking the bones of a bird and,

presumably, bringing

it

back to

candidates "go something like crazy."

At

that — crazy" "out of

life. It is

the end of this period

better and has "straightened

up

when

in his

him," he acquires a spirit-familiar

him

said

at this

time the

mind but not

the initiate begins to feel

mind what was bothering

who

will subsequently assist

in the healing rites.

As These

shaman does his curing in a seance. usually prefaced by a series of "tricks" of

a practitioner, the

sessions are

ventriloquism or sleight-of-hand.

shaman goes

into a seizure; he

The room

falls,

darkened, and the

is

seemingly unconscious, on

the floor, and then he rises as though possessed familiar. In this guise

by

his spirit-

he carries out various rational and magical

treatments.

There

is

shamanism

a controversial literature itself is

on the question whether

psychopathological

—whether,

that

is,

it

is

necessary for a person to be severely disturbed before he can be recruited to this role. 12

behavior

is

The

contesting view

simply theatrical

is

—demonstrating

that shamanistic

the learned and

highly controlled behavior appropriate to a certain role in

Native Conceptions of Psychiatric Disorder society.

What

13

shaman

zation of

Lawrence Eskimos think about the

the St.

normal or abnormal

73

qualities of

seizure

shamanism

as

and homosexuality

well as their as points

utili-

of refer-

ence in discussing psychiatric disorder will be taken up

later.

obvious that shamanism rests on magical beliefs about the

It is

and cures of

causes

The background

disease.

literature

on

magical disease concepts must be reviewed briefly in order to give context to the St.

Lawrence Eskimo

situation. Several use-

ways of categorizing such beliefs have been developed, first by Clements in a world survey of available ethnographic litera14 ture in then in a reassessment of his categories by 93 2, Hallowell in 193 5, 15 by Rogers in 1942 and 1944, 16 and finally in a somewhat different approach by Whiting and Child in ful

1

1

95 3.

17

Building on earlier work, Rogers in 1944 proposed a topi-

cal outline to I.

which the following explanations have been added:

Proximate Disease Causes A. Object intrusion: Sickness

is

by

believed to be caused

the

intrusion of a physical object into the patient's body.

Sickness

intrusion:

B. Spirit

to be caused

by

C. Sotd loss: Sickness soul

Remote

is

believed to be caused

is

believed

by

the loss of the

by

spirits

during sleep, sneezing, or fright.

Disease Causes

A. Black magic: Sickness activities

burning B.

—

insanity

—the soul being thought to depart from the body or be

stolen II.

—especially

the intrusion of a spirit into the patient.

of

human

is

thought to be caused by the sorcery

beings

—

casting spells, saying evil prayers,

effigies.

Dreaming: Sickness is believed to be caused by an experience in a dream such as the ingesting of an object or the loss of the soul while dreaming.

C.

Violatio?i of taboo: Sickness

is

believed to be caused

transgression against cultural rules

by

a

committed by the patient

or someone else in his family or group.

D. Divine wrath: Sickness

is

believed to be caused

by

the anger

of the gods due to some act of omission or commission relevant to the

way people

are supposed to treat gods.

Approaches

74 It is

to Cross-cultural Psychiatry

evident from this categorization that proximate and re-

mote causes often work hand-in-hand and

may

emerge from these

beliefs involve

that

The

any one

disease

rites

which

such varied phenomena

as the

require both kinds of explanations.

curing

magical extraction of an object from the patient's body; exor-

cism of the possessing

spirit;

by

the recovery of the lost soul

the

medicine man's supernatural powers; discovery by the medicine

man

of the nature of the taboo breach, the eliciting of con-

fession,

and the prescribing of

acts of expiation;

and the medi-

cine man's counteractant sorcery in order to mitigate the force

of the

initial

black magic.

In classifying the same

body

of ethnographic literature,

Whit-

ing and Child focused on another kind of variation in explana-

Their topical headings are

tions of illness. 1.

Agent: The illness-producing agent

may

as follows:

be a living person with

supernatural power, a ghost of an ancestor, a

or an animal 2.

Responsibility: illness,

Act:

The

The

Materials:

etc.

The

perform

may

be the breaking of a taboo,

rituals, etc.

illness-producing materials

strual blood, spirits, 5.

god,

may be solely responsible for his may be entirely in other spheres, with

illness-producing act

sacrilege, the failure to 4.

spirit, a

patient

or the responsibility

other people, 3.

human

spirit.

magical weapons,

may

be poisons, men-

etc.

Means: The means by which the materials have

effect

may

be

ingestion, introjection (material being magically taken or thrust

into the body), removal or loss of the materials, their being used in rituals, etc.

Where do

the St.

Lawrence Eskimos

Interestingly enough, almost

rency in

this

fit

into these schema?

of these ideas have some cur-

ideas were elaborated some were more prevalent than others. In

group although some of the

rather differently and his

all

world survey, Clements noted that the "soul

especially

common

borne out

as

in the Siberian arctic.

well in the

St.

Lawrence

loss" idea

is

This dominance was

data,

but there were also

Native Conceptions of Psychiatric Disorder cases of black magic, taboo violation, divine wrath,

75

and dream

experiences.

Clements observed that

Spirit intrusion presents a special case.

usually the only

form of

sickness attributed to spirit intrusion

insanity (the utterances of the

mad man

is

often being taken as the

may

voice of a resident spirit), although madness

also

be ex-

by soul loss. Clements found that the concept of spirit intrusion was notably absent from Siberian cultures; its absence he believed to be the logical outcome of the high development of the soul-loss idea. It is in the Siberian and Siberian Eskimo plained

groups,

however,

shamanism.

He

that

spirit

possession

the

is

hallmark

of

explained shamanism, therefore, as an atrophied

form of the idea that spirit intrusion causes disease and implied that shamans were sick people. The St. Lawrence Eskimos recognize that

spirit possession

a

is

phenomenon of shamanism,

but they do not therefore regard shamanism to insanity.

any of the

Nor

being equivalent

cases of psychiatric disorders recognized

scribed as such in this study. This fact transitional character of the St.

intrusion

as

did they consider spirit intrusion as relevant to

may

Lawrence

and de-

well relate to the

culture, since spirit

better developed as an explanation of mental disorder

is

among

the central Eskimo groups. (For example, a schizophrenic Eskimo woman from Southampton Island who believed herself to be host to a fox spirit has been well described

Another aspect of the this

literature

by Teicher. 18 )

on Eskimo culture relevant to

chapter concerns the culture-specific disorders that have

been observed and described, often under the general heading of "arctic hysteria."

To

the east of St.

Lawrence

Island

—among —

Greenland, Canadian, and to some extent Alaskan groups

syndrome

called piblokto existed. 19 It

widespread

it

may

historical records

ness.

Some

impossible to

evidence on seventeen cases, mainly

which he summarized temporary

is

tell

how

have been. Gussow recently collected from

states of

as follows:

women,

piblokto involved episodic and

excitement with disturbance of conscious-

seizures lasted a

few minutes;

others nearly an hour.

Approaches

j6

The concomitant

to Cross-cultural Psychiatry

behavior included such things

as

disrobing or

tearing off one's clothes, running away, rolling in the

jumping into

or

(mimicking animal or bird

glossolalia

lake,

a

snow

sounds or jabbering in meaningless neologisms), unusual but harmless acts such as trying to walk on the ceiling, throwing things around, grimacing, mimetic acts, choreiform movements,

and coprophagia. 20 Characteristic psychopathology

Siberian groups.

21

"copying mania"

in

some places

found among the

also

women,

Especially with

—

was

called

this

appeared to be

amurakh.

It

a

included

endless and exhaustive imitative behavior (dancing, running, ob-

scene posturing) which could

somehow be

words or gestures known by the such an

effect.

A

similar disorder

"triggered off"

rest of the

by

group to produce

(though not

as specifically a

female reaction and usually wilder and more paroxysmal) was called menerik. This included periods of screaming and dancing

which culminated

in an epileptoid seizure.

designated as "sickness"

when observed

in

This was natively

some people,

but, as

already indicated, this kind of behavior was also a routine and integral part of shamanizing

on both

sides of the Strait.

The

between these disorders and what was Lawrence Eskimos will be presented later. By the time of our investigations of the St. Lawrence culture

differences and similarities

discussed

by

(1940 and

1

St.

954- 1 95 5) the island had been

outside world for nearly a century. For

was mainly

in contact

in contact

much

with the

of that period

it

with Russian and American whalers, then

with missionaries, with people in the governmental school system, and more recently with

armed

forces.

The

these contacts has Island

members of

the United States

by Lawrence

progressive modernization brought about

meant

that the 1955 culture of St.

was no longer "primitive"

in the classical sense. It

was

a

culture in transition, with a fairly large segment of the population

displaying

various

degrees

of

bilingual

facility.

Public

shamanism had declined, and there was increased mixing of the ideas of

Western and shamanistic medicine. In the process of

Native Conceptions of Psychiatric Disorder

77

Eskimo views of psychiatric disorder, like everything have very probably undergone some modification. These

transition else,

Eskimos exemplify, therefore, what Redfield has described mixture of a "great tradition" and

a "small tradition."

as the

22

Questions raised by the influence of contact in the case of the

Eskimos have been given considerable attention in the following analysis. The effects of cultural contact add another dimension of complexity and represent a problem of almost insurmountable difficulty, because there are

Western groups

left that

Although

outside contacts.

remarkably few isolated non-

have not been somewhat influenced by

from early ethnographies

a certain

amount of reconstruction

possible, the goals of

is

research are inevitably plagued

by

contemporary

the implications of culture

change.

Method The

field work on which this report is based was carried out summer of 1940 by Alexander Leighton and Dorothea Leighton and for the year of 1954— 1955 by Jane Murphy and

in the

The

Charles Hughes.

data on native viewpoints were part of an

epidemiological study of psychiatric disorders in Sivokak village.

Of 1 1

3

were found

falling in the 1 1

3

between 1940 and 1955, have symptoms that A. Leighton identified as

the 495 Eskimos living in the village to

province of psychiatry.

The

case histories

on these

Eskimos combine information from various sources. The

main source was

a series of interviews carried out

by Murphy

with a bilingual key informant, during which the informant was asked to describe the

Eskimos

who formed

cal study.

life

and health experiences of each of the

the base population for the epidemiologi-

Since this was the major data-gathering operation

from which the methodology of

analysis of native conceptualization stems, the this aspect

of the research

is

described in an

extended chapter note. 23 Additional sources included comments

by other

native

informants,

the

available

medical

records,

records of the meetings of the village council (the native govern-

Approaches

78

to Cross-cultural Psychiatry

ing body), information regarding mainland hospital admissions

and federal court

actions, life histories of individual

comments made by

local teachers

and public health nurses, and

by

observations recorded in field notes

two

anthropologists.

It is

Eskimos,

two

the

psychiatrists

and

24

obvious that the case materials consist of a welter of infor-

mation given and recorded in English and derived from both

Western conceptualization. Also, they include

native and

evi-

dence that has varying degrees of reliability and validity. In some cases as

many

as

seven different sources would indicate that one

individual had something psychiatrically wrong with him. In

other instances the information was fragmentary and far from

congruent. (The method used for dealing with

this

problem of

different levels of confidence in an epidemiological study

is

presented elsewhere. 25 )

Having

From

by

natives

we

could then review

on the comments made by Eskimos. of

the specific instances

scribed

we

available this collection of data,

the case materials focusing

pathological

have inferred

a

functioning de-

general

orientation and specific psychiatric ideas which,

psychiatric

we

believe,

represent the conceptualizations of this group of Eskimos.

This method

is

obviously oriented primarily to concepts

contrast, for example, to the

method used by Frake

—

in

in studying

among the Subanun Our focus on concept does not mean a disregard None of the investigators in this study was able to

the linguistic categories of physical disease

of Mindanao. 20 of language.

speak or understand the Eskimo language.

we

achieved proficiency in the language,

been

much

lieu of this,

virtue of a necessity. In order to

were forced to explain

more

we

communicate

their ideas

of us

would, of course, have

better equipped to understand

mo's psychiatric concepts. In

Had any one

at

fully the Eski-

tried to all,

make

a

the Eskimos

through the medium of

a

limited vocabulary in English. Their

terms used in English was sparse. quently, they

knew

knowledge of psychiatric As will become evident subse-

several lay terms for psychiatric

phenomena,

Native Conceptions of Psychiatric Disorder but they

knew none

of the technical terms such as "depres-

sion," "anxiety," "schizophrenia," or "mental deficiency." Their

lack of a psychiatrically sophisticated vocabulary in English and

our lack of proficiency in the Eskimo language meant that

we

had to ferret out their psychiatric views uncommitted to the semantic restrictions of either language.

The

inability to speak

Eskimo did not preclude gathering data

about the meaning of particular Eskimo words. Hughes was especially interested in language, and he contributed

most of the

information that will be presented about the psychiatric concepts that do and those that do not have a label in the

Eskimo

language. Although this part of the methodology was not ex-

on St. Lawrence Island, we incorporated on native words in a later study of the Yorubas

haustively carried out greater emphasis

of Nigeria. 27

Eskimo Psychiatric Orientation

We are quite certain that the Eskimos referred to in this study do not have to

a

word

in their language that directly corresponds

our word "psychiatry."

The

first

question,

therefore,

is

whether they have the idea of psychiatry. At no point in the field

work was

it

stated that

we were

interested in psychiatric

was a definition of psychiatry ever offered for up and elaborate or compare with their own. From materials it was possible to determine that they have

disorders, nor

them

to pick

the case

notions about a variety of behaviors, emotional states, and think-

ing patterns which they recognize as "something being

wrong"

and which they clearly distinguish from purely organic orders.

The most

succinct statement of this referred to a

who by several accounts the widow of a powerful

exhibited psychotic behavior. She

shaman. After

were trying to times to run away

his

to think that people

kill

She tried several

in the

dis-

woman was

death she had begun

her through witchcraft.

middle of the winter, and her son would find her wandering on the bank of the lake. This was summarized by the key informant as, "her sickness is

Approaches

80

to Cross-cultural Psychiatry

getting wild and out of mind, but she might have sickness in her

body

too."

The

fact that the

body-mind dichotomy was

expressed in this statement does not

Eskimos

failed to subscribe to the

previously

tioned

mean

Lawrence

psychosomatic attitude men-

being characteristic

as

the St.

clearly

of

most primitive

groups. Nevertheless, this statement was one indicator

among

many that the two elements were at times conceived separately. The next important question is whether or not our subjects recognize the alliance between

body and mind. Do they have

the

idea of psychosomatic interdependencies? If they

do conceptual-

we

infer as being

ize this

interdependence, what criteria can

employed

to

mark

off

what

reviewing the case materials recognized by us

is

we

as psychiatric

described as either

psychiatric and

what not? In

observed that the disorders

were the ones that the Eskimos

(i) psychologically expressed, or

(2)

psy-

chologically derived.

The

psychologically expressed disorders were those having to

do with personality

characteristics as reflected in patterns of

thought, perception, emotional cluded, for example,

"not right mind," habits," "too

Although

all

much

states,

and behavior. These

what the Eskimos

"ignorant mind,"

in-

called "out of mind,"

"slow to learn,"

"bad

nervous," "easy to get afraid," and so on.

of these

phenomena were manifest

at the

psycho-

logical level, the Eskimos had a variety of explanations about what caused them. As indicated in the first example, one type of explanation concerned magic and witchcraft. In these instances a

psychological experience since witchcraft depends

is

considered to be the causative factor,

on the psychological readiness to be-

lieve in the effectiveness of magic. Surprisingly, this

type ac-

counted for relatively few of the cases about which explanation

was

offered, perhaps because the

Eskimos nowadays are some-

what inhibited on this topic. The other types of explanation had more in common with Western psychiatry, but we do not believe they were imported. They appear to have emerged from rational observation of

human

behavior, and several times they were

Native Conceptions of Psychiatric Disorder

couched

in terms of "this

just

is

what

81

think myself." There

I

were comments, for example, that indicated some awareness of heredity.

The "slow

ning in that family." ness to

wc

(which

by

to learn"

A

syndrome was described

interpreted as personality disorder)

to explain psychological manifestations. It states of

as

—

it's

their

also called in

seemed to be well

unconsciousness or delirium might be

associated with severe physical illness.

once pointed to

"run-

was referred

the informant as "all those brothers are the same

way." Various kinds of physiological events were understood that

as

pattern of eccentricity and habitual odd-

A

blow on

what must have caused

the head

a child

was

(who had

appeared to be developing normally) to change suddenly in her

mind

—she talked or sang nonsense

incessantly. In addition to the

magical, hereditary, and physical explanations, the Eskimos have the notion that

life situations

may

cause psychiatric

illnesses.

For

example, a death in the family might precipitate such an episode.

A

man who

lost a

much-beloved daughter went on an unsanc-

tioned shamanizing binge following her death. Like the Eskimo

shamans, he claimed that he would bring the dead back to

He became

life.

wild and unrestrainable, carrying out various kinds

of quasi-shamanizing activities, until finally a bona fide

shaman

cured him, and after that nobody "paid any attention to

his

shaman."

The

psychologically

physical sensations or

derived

mood

disorders,

disturbances,

usually

involving

were those which the

Eskimos linked to one or another psychological experience. As with the psychologically expressed disorders, even though the

Eskimos do not have the technical terms for explaining phe-

we

nomena

as

inferred

from the

do, a psychiatric frame of reference could be specific case descriptions.

instance of "heart beating too hard"

"too

was

much worrying," one woman was

For example: an

said to be caused

by

said to faint at the sight

of blood and another at being in crowds, a temporary facial paralysis

was

attributed to "too

much

brain work," and another

conversion reaction producing a temporary inability to walk

Approaches

82

was

said to

to Cross-cultural Psychiatry

have been caused because

woman's husband

this

abused her. It

a

appears from this that the Eskimos in our investigation have

way

of identifying and understanding certain kinds of

behavior which can be called a psychiatric orientation.

is

divergent in

With

bears

to

among

the particular content of magical theorizing found

kimos of

It

Western psychiatric thought, especially as evidenced in Western lay attitudes. It is markedly that segment of the conceptual map which involves

some consonance the latter

human

Es-

this area. this

background on orientation

it is

now

possible to turn

to the specific concepts that constitute the psychiatric thinking of

the St.

Lawrence Eskimos.

Eskimo Concepts

Specific

For purposes of continuity,

this section

of the major categories of

symptom

in the previous chapter.

Taking

is

organized in terms

patterns that

drome" or "psychoneurosis," we then review

the

order to see what corresponds and what not. phasized here that

we

view, and our attempt in the

look is

were discussed

a topic such as

at these data

to construct

from

It

"brain syn-

Eskimo data

a clinical point of

from multiple

minds of Eskimos would compare with

in

should be em-

what model of

cases

a clinical

a particular kind of psychiatric entity.

I.

BRAIN SYNDROME

One of the commonest brain syndromes is senility. The St. Lawrence people have a word for the condition when "a person's brain no longer controls him, when he is 'out of mind' as in old age." It is impossible to tell from our data whether this is considered an

illness

or simply one of the natural courses of

life.

was not thought of as an illness for which shaman treatment would be sought. The kinds of aberrant thinking, feelCertainly

ing,

it

and behaving that were noticed by the Eskimos

emplifying

this

condition are very similar to what

we

as

ex-

think of as

Native Conceptions of Psychiatric Disorder

and consistently these manifestations were related to old included "becoming like a child," "crying a lot," "hav-

senility,

age.

83

They

ing to be taken care of," "partly crazy, doesn't

walks to the beach instead, but sometimes

know way home,

in right

mind," "not

up from the ground and eating them,"

eating," "picking things

"making odd sounds

is

at night,"

"trying to

kill

himself," and so

forth.

Regarding other types of brain syndromes there are

two words

in the

Eskimo language for convulsions

at least

—one

of

them especially denotes a state of unconsciousness. Unconsciousness was clearly described, as for example in a brain concussion following a hunting accident. Also, a small child, thought by the public

health

meningitis

Eskimo

nurse

—leading

to

have

brain

a

ultimately to death

in the following

tumor or tubercular described by an

—was

manner. "She was kind of paralyzed,

and then she got very sick before she died. She was unconscious, and she was sounding

any

like a little

direction, shaping to this side

pup, and her face moving in

and that

side."

Epilepsy or epileptoid seizures were described several times. In view of the manifest similarities between some aspects of

psychopathological seizures and the seizures enacted in shamanism,

it

seemed to us that

find out

how

similarities,

this

might be an area

in

which we could

the Eskimos conceptualize the differences and

pathological

the

and

the

nonpathological,

and

whether the one might be used to help define the other. It

appeared that our subjects clearly conceived the difference

between shamanistic seizure and

a variety of kinds of seizures

The distinguishing characteristic of shaman seizure was possession. The other types of seizures or quasi-seizures, involving "falling down unconscious," ranged from epileptoid seizures to fainting episodes. The Eskimos' disthat

were defined

tinction

tween

as illness.

between the

latter

was phrased

as the difference

be-

and "fainting." (Fainting will be discussed with psychoneurotic reactions.)

The

"fits"

kinds of

phenomena described

as "fits" can,

with some

Approaches

84

to Cross-cultural Psychiatry

what Western psychiatry looks upon as evidence of epilepsy. What occurred in these episodes was "stretching out himself," "foaming coming out of mouth,"

assurance, be equated with

"shaping or twitching the face," "snoring very loud," "peeing in her bloomers,"

"when

pee in bloomers."

had

in

mind

It

well again, crying because ashamed of

seems evident from

a certain recognizable

this that the Eskimos syndrome of symptoms which

had been observed often enough to become a pattern of

illness in

their conceptualization.

was

It

said that "fits" of this nature

were caused by the

spirit

of a fox. For example, the father of a child with "fits" was said to

have been hunting one day fox.

When

the fox died,

was

to have

catching foxes.

from from

him wear

wounded but

did not

kill a

this trouble for the

as a coat the net

and there were

their lives.

all

he

began to make

then used for

We heard reports of children who had recovered

this illness, it

when

one of the treatments for a child with

child. In earlier days, "fits"

it

also adults

who had

Apparently the recovery

suffered

(based

rate

perhaps on spontaneous remission) was impressive enough for a specific shamanistic treatment to be accepted as effective. is

Also

it

interesting to note that "fits" are the only psychiatric phe-

nomena

which the Eskimos gave such

for

a specific

magico-

causal explanation.

MENTAL DEFICIENCY

2.

From our

interviewing

Eskimos do not have

it

appeared that the

a general

St.

Lawrence

term for mental deficiency.

suspect therefore that mental deficiency

We

was not conceived

as

being responsive to shamanistic treatments. Although there was

no

overall

term for the condition, there were

many

phrases in

English used to denote a conception of mental deficiency: "slow to

learn,"

quent." follows:

"ignorant mind,"

The

and

—graphically— "not

an elo-

behaviors that clustered in this syndrome are as

"slow of speech," "looking in some direction, some-

times even without blinking," "very

dumb

at school;

he stayed

Native Conceptions of Psychiatric Disorder for years and years in second grade, so he

was

tall

8$

and he

just

shake his head side to side; and he doesn't hunt; and he couldn't find himself a wife,

much

somebody had

to help him," "didn't learn

and she has been going too

in school

with most of the

far

boys around here," "never learned to talk until he was doesn't talk back to

anybody but once she beat up somebody."

This pattern was summarized by one informant

something

person whose mind

like ignorant, a

anything, thick and clumsy, and

he do

even

it

anything about

As can be

five, just

drowned," and "that dull one

sort of grunted, then later he

if it is

when

told to

as,

"We

call it

is

not thinking

do

a thing, then

know

harmful, just because he doesn't

it."

seen, there

were

performance was related to

number of

which mental the formal school system which had a

cases in

recently been introduced into the culture. This fact, together

with the lack of a specific term, might suggest that the conception of mental deficiency had developed as a response to the testing

tainly

bold

ground provided seemed

it

relief.

as

in a

Western

style of education. Cer-

though school brought these phenomena into

It is interesting,

however, that the same kinds of

retarded behaviors were described for certain elderly people

who had

never been exposed to anything except routine Eskimo

culture: "She doesn't

can't say

words";

know how

some of the words

"He

doesn't

to fix things at home, and she

in the right

know much

way

up when he was young and he never hunts,

The

Eskimo

just stays

by

was the

the various particulars of this

tionally thought to be the

it

home."

best evidence that the mental deficiency concept had

origin in the indigenous culture

scribed

either,

about trapping so he gave

its

fact that people de-

syndrome were

handmaidens of sorcerers.

It

tradi-

was

this

kind of person who would be sought out by a black-magic worker and used for errand running. A mentally defective person might be approached by a sorcerer and coerced into collecting nail parings or scraps of hair

whom

evil

was

to be

worked.

from the victim

against

Approaches

86

3.

to Cross-cultural Psychiatry

psychosis

There

is

Eskimo term

a specific

that can be translated as

"crazy" or "insane," and the English word "crazy" was em-

ployed with several variations crazy," "a

little bit

in the case materials

crazy," "out of

—"sort

mind but not crazy," and

of so

on. Generally the term pointed to patterns of behavior and

thought that are indicators of functional psychosis. Sometimes

it

was used for other syndromes, such as a senile person doing things that were "a little bit crazy"; and a person who appeared in

both Eskimo definition and our

personality disorder

was described

own as

observation to have a

sometimes acting "sort of

(This will be more fully discussed under personality

crazy."

disorder.)

Focusing

now on

the delusional,

hallucinatory,

states of unreality involving the cognitive

we

ness,"

in part, sis

face an area for

was

that there

which our data

were

relatively

few

dimension of "crazi-

are spotty.

as delusion

scribe than overt

is

is

phenomena such

not going to do

delusional pattern such its

as,

it

it

if a

as "fits."

was

that covert

St.

However we have

Lawrence Eskimo goes

in a culturally particularistic

In other words there did not appear to be a

with

reason,

more difficult to observe and de-

concluded from our data that crazy he

The

cases of frank psycho-

in this small population. In part, too,

behavior such

and other

common and

way.

specific

for example, the witiko psychosis

systematized beliefs and cannibalistic impulses, which

has been

found among the Northeast Woodland Indians. 28

Lawrence Eskimos provided us with some insights about their view of certain unusual mental states. One of these conditions was called "thinness." "Thinness" enabled people to "see things which other people don't see," to look into the future, to prophesy, to inspect a world of reality Nevertheless the

that

is

St.

normally not observable to other people and thereby to

find lost articles.

This

is

considered a highly valuable attribute

Native Conceptions of Psychiatric Disorder

among Eskimos, and many people their ability.

All shamans were

cultivated

"thin," as

8j

to the best of

it

were

also

numerous

they were called in this culture peculiar gurgling or crackmaking because divination involved ing sounds in the back of the throat). None of the people who were described as "sick in mind" and "crazy" were also called "thin." This is one hint that the Eskimos distinguish between a

minor diviners ("yawners"

as

and culturally patterned delusion

socially useful

—"thinness"

and the cognitive aberrations of being "crazy."

"Out of mind," on

the other hand,

is

a ubiquitous concept,

varying in meaning from unconsciousness and possession to

When

shaman went into possession, he was said to be "out of mind" but not crazy. Presumably this was a way of saying that the shaman was, for the duration of the psychotic reactions.

the

seance, not in possession of himself but rather possessed and

controlled

by

his spirit-familiar.

As was

the case with "thinness,"

the socially useful aspect of "out-of-mindness,"

was not conceived

as

i.e.,

genuine insanity. What, then,

of true insanity in the Eskimos' eyes? Within the limited cases, possibly,

we

we

the

way

the stamp

framework of

could not find the one perfect criterion

suspect, because there simply

insanity in the

is

possession,

Eskimo view,

different elements

is

no

—

quite

mark of

single

insanity being conceived instead as

go together. The psychotic

woman

example believed that somebody was try-

mentioned

as the first

ing to

her through witchcraft. Since witchcraft fear

kill

we

ceedingly widespread,

paranoid belief of

this

is

ex-

could not conclude that a seeming

nature was a criterion of insanity; the

point was, rather, that this belief featured in an

illness also in-

volving wildness and running away.

The

closest

we

could come to

by

experience designated ness"

was the case of

a

a specification of a subjective

the Eskimos as an attribute of "crazi-

woman who

recurrently experienced

periods of nervousness, "fits," and being "crazy and out of mind."

The

report of

what she believed had happened

to her

is

as fol-

Approaches

88

to Cross-cultural Psychiatry

was married as a teenager to an elderly blind man from was greatly mistreated and starved, and she decided that she didn't want to live. She went out in the night during winter, stripped off her clothes, and lay down in the

lows. She

the Siberian side. She

snow so that she would freeze to death. It seemed to her that she went to sleep and then woke up. She saw a lumber house and she went in and found a stove and food, and she ate and got warm. It was like a "white people's" house. She remembered this experience as being similar to a dream. When she woke up she was still in the snow naked and her body had melted the snow clear

down

to the earth.

She did not

but her stomach was

lumber house any more,

see the

She got up and put on her clothes, and

full.

there

was nothing wrong with her body;

it

Then

she started to take a journey, and she

was

There was always

Some

a light in the

of the things this

acquired.

The

a

frozen.

by

a light.

led

sky to show her where to go.

woman

believed happened to her are

actually the motifs in several folk tales

happening onto

was not

—being

led

by

difference

is

that outside of shamanistic possession

no other Eskimo to our knowledge experienced events such

as these.

said or believed that he

The

a

had

improbability that these

experiences were real was enhanced in the Eskimo

oddity of including

a light or

house where food and shelter could be

mind by the

"white people's" house rather than the

Eskimo house found in Siberia. As compared to these inner, subjective

traditional

perception, describe

was apparently much

behavioral

mindness," eating

it

as,

wrong

ting wild"

states of belief

easier for the

associated

characteristics

with

for instance, running away, hiding in

and

Eskimos to "out-of-

odd

places,

things such as feces, and the manic states of "get-

—impulsive,

recalcitrant,

and sometimes homicidal or

suicidal.

Although no this

was used

specific magical theory

order of psychiatric phenomena,

dent that insanity, though variable

major anchor point

in the

Eskimo

it

in

to account for

seems abundantly eviits

manifestations,

psychiatric framework.

is

a

Native Conceptions of Psychiatric Disorder

4.

89

DISORDERS

SOCIOPATHIC

A. Sex deviance. The Eskimos

in this

study recognize several

The concept

kinds of sexual deviance.

of homosexuality

is

especially well formulated, and there are Eskimo words for

"womanlike man" and "manlike woman." Homosexuals who became transvestite shamans were thought to be exceptionally powerful, but homosexuality in

There were no

man was

one

be "a

to the

Eskimos for

many

this

.

years ago

.

?

.

In the States do they have like

young boys

—no moustache, baby-skin

the time.

manner, "Didn't you

some men acting

are pretty worse, they are after

long ago

studied, but

type of behavior, but "anasik"

in the following hesitant

ever hear in the States here

we

There was apparently no English word

anasik."

was described

Up

was severely disapproved.

homosexual, and one or two others were said to

a

little bit

known

itself

transvestites in the population

He is a pretty fatty man,

.

.

?

women, and some One died not too

too.

and he keeps sewing

face,

but he

.

isn't

all

always a real anasik

because later he got a wife."

The St. Lawrence culture recognized wife-exchange between men who had entered into a special kind of brotherhood bond. In addition, the culture was generally permissive regarding occasional

nonformalized heterosexual

fairly easily

affairs,

and divorce could

be achieved. Nevertheless, the Eskimos appear to

have standards of sexual activity that allow them to judge heterosexual

excesses

of a pathological nature.

voyeurism, described

as

"he

is

girls

undressing or sitting on the pot

it's

his

Although

brought in from the outside

of

these

was

always showing us funny pictures

of naked people or looking into people's

habit."

One

this

—

he's

pattern

windows trying

always been that way, involved

—pictures—the

conceived censoriously, and the young

to see

an

artifact

overall behavior

man

in question

was

was

brought before the village fathers for punishment and supervision.

Similar village action

was brought

to bear in controlling one

Approaches

yo

—

two people

or

to Cross-cultural Psychiatry

defined as promiscuous

a girl "going too far

many boys," or "not controllable by her parents." A young man was sent by the Eskimos to a federal jail because, "among other things, he stays home from hunting and 'forces' all

with too

the

women, any woman from

The only

B. Addiction.

recent history of

St.

16 to 60."

intoxicant that could be abused in the

Lawrence culture was

alcohol. Fly-agaric

was used aboriginally on the Siberian side, but there was no mention of it or other local intoxicants by our informants. For many years, however, alcohol was available from American and Russian whalers. In 1878 the St. Lawrence people are reputed to have gone on a

rum debauch during

the hunting season. Failing

to lay in an adequate supply of walrus

population was decimated

by

meat for the winter, the

starvation. Later, a self-imposed

prohibition against the importation of alcohol

was enacted.

Throughout the was not

in our study,

lifetime of

most of the Eskimos

was changing by 1955 when beer could sometimes be obtained privately from soldiers at an installation near the village). This background explains the alcohol

easily accessible

relative lack of experience

(this

with alcohol on the part of the recent

population. Nonetheless the concept of overuse or misuse of alcohol was quite clear, on the basis not only of the 1878 debacle,

but also of observation of specific individuals.

grown up

in the

and

his sensations

me

he

felt

as

whaling era was

known

One man who had

as a

"big drunkard,"

during inebriation were described:

though he were walking two

feet

"He

told

above the

ground." C. Antisocial and dyssocial behavior. There were numerous acts against the rights of others or against

that the

moral prescriptions

Eskimos considered to be punishable or reprehensible.

who

Some

of the individuals

learn

from experience or punishment were thought of

carried out these acts and did not

permanently "bad characters." These

acts

as quite

included stealing,

physical violence against others, and repeated swindling. tain

A

amount of maltreatment of women was not considered

cer-

to be

Native Conceptions of Psychiatric Disorder

91

— abnormal "women used to be pushed low around here" —but even

this

could be carried too

to the village

far, as

when one man was brought

governing body because he beat up

his

wife "too

much." Another kind of sociopathy in the conceptions of these Eskimos is black magic. Although the practice of sorcery and witchcraft, like shamanism,

witching

as

is

on the

an antisocial behavior

is

decline, the still

"You

can't trust that kind of person, he

with

the devil,

and

lots of

concept of

viable; for example:

knows

songs,

is

in

touch

people believe that he killed a

man

recently with his ways."

5.

PERSONALITY DISORDERS

The St. Lawrence language has a term for a person "who knows what he should do but has no sense." By one informant, this was not considered a sickness, nor was it mental deficiency; it meant lack of judgment and often making a nuisance of one's self. As such it seems to parallel rather well our concept of personality disorder. A young man who fitted this pattern was said to be "sort of crazy."

For example, "He goes around saying

a false voice, 'I'm the

United States of America Legion on

island' ";

but

all

the time he knows, of course, that he

informants said that he

is

is

not.

in

this

The

always fooling, and he doesn't take care

of himself.

A

dimension of personality disorders pertinent to Western

psychiatric thinking

is

the passive-aggressive continuum.

It

is

comments under sociopathy that aggressive were recognized as such in this group. There were other

evident from the acts

instances,

however, when aggression seemed to be thought of

a personality feature

even though

the level of intensity that

would

its

expression did not reach

incline

Eskimos to

institute

severe restrictions and restraints against the person. "Getting

very easily" was their native store

was

fired

way

of depicting

from

this post

by

this.

A

when he was

mad

manager of the

the village council be-

cause "he has got the 'educational' for the job but he gets

too quick, the same as

as

left in

mad

charge of the mission

Approaches

$2

when

the missionaries

to Cross-cultural Psychiatry

went on

leave,

it

got into a mess with

everybody's feelings hurt." This kind of response was noticeable to Eskimos and was easily discussed, partially because it required some kind of action or adjustment on their part. The same was

not true of passivity.

We

have

likely to interfere

a less definite picture of its

con-

was thought deviant or with normal functioning. There were assess-

ceptualization, especially as to

ments of people, however,

whether

it

"very humble," "doesn't talk

as

rough to anybody," "very quiet."

It is

evident then that Eskimos

recognize differences in personality and that some of these differences approximate the aggressive-passive polarization. 6.

PSYCHOPHYSIOLOGIC REACTIONS

As

indicated earlier, the Eskimos conceive a relationship be-

tween psychological events and physiological reactions beating hard because of too

much worry,"

"headaches due to

brain work," and "vomiting but not sick, just throwing

she hears a bad story."

of words such

Eskimos,

if

It is

lence, but

there

up when

was no use

"asthma," or "hypertension."

To

the

they suffered from any of these syndromes, they

were described aches."

As might be expected,

as "ulcer,"

—"heart

"trouble breathing," or "head-

as "belly ache,"

not our purpose in

it is

this

chapter to discuss preva-

our general impression from the epidemiological

uncommon. It may be, concepts of these more complex

investigation that asthma, for example, therefore, that the

Eskimos lack

is

psychosomatic reactions because they lack experience with them.

It

may

also

be that the heavy burden of tuberculosis and

other physical diseases in this population masks the prevalence

and reduces the likelihood of conceptualization. (The topic of physiological reactions

7.

is

the focus of the next chapter.)

PSYCHONEUROTIC REACTIONS

The

native vocabulary for neurotic traits

is

quite rich. St.

Lawrence Eskimos have a general term for "worrying too much until it makes a person sick," and others for "easy to get afraid"

Native Conceptions of Psychiatric Disorder

and "too

much

nervous, sitting with head

93

down and

rocking."

—

As can be seen, English terms were also used "nervous," "fear," and "worry." The word "anxiety" was never used, but it

We

appeared that the idea of anxiety was in their minds.

mean

"worry" and "fear" were always qualified as excessive or inappropriate when they were remarked upon as indicators of sickness or malfunction; for example: "You know, he

by

this that

sometimes worried and afraid too much. 'Alingatuk,' that

what we

call the

man who

is

easy to get afraid

when something

happens like bad weather or sickness or out of food. the chairman of this village once, but he that time, he hates to rule the people

is

He became

was worried too much

around here, and so he

refused later on."

There were cases described by Eskimos that correspond to several of the more specific varieties of psychoneurotic reactions known to Western psychiatry. One of these was phobic with a claustrophobic focus: to stay indoors, always

"He

worrying and wants to stay outdoors; he

worrying too much, but is."

don't

I

know what

kind of sickness that

Several appeared to be conversion reactions.

for example,

walk and

was described

can't

as,

how

she

his fingernail

later a

Coast Guard cutter

along the sole of her foot;

and jerked and the doctor told her to try walking time and

of these,

she was beaten so bad by her became paralyzed, but I guess she

thought she was sick because

doctor ran

One

"She was paralyzed once, can't

move around much;

husband, that was just

has been very sick once, even hates

it

jumped

a little at a

now she is okay."

Some

kinds of fainting, as said earlier, were definitely linked in Eskimo minds with psychological events. These types of fainting seemed to be associated with the functioning of the heart, which served as a premonition that a faint would be experienced: "She is become frightened all of a sudden and get the

nervous, heart beating fast," "so nervous she almost collapsed."

These sensations were thought of

as

"heart attacks,"

which

cul-

minated in a swoon or sometimes in the feeling of choking, and

Approaches

94

were concomitants

to Cross-cultural Psychiatry

coming

to such experiences as seeing blood,

near a sick child, or being in a

crowd.

Other symptoms of anxiety that the Eskimos meant when they talked of nervousness were trembling, shaking.

One

sickness"

—

and

restlessness,

was actually called "shaking was one feature of the claustrophobic syndrome mentioned above, and the onset of the illness was coincident case of "nervousness"

this

with the patient's conversion to Christianity. In addition to the equation of "nervous" with "trembling," there was also a meaning that referred to "lack of feeling" in

much

way we

the same

would refer to anesthesias: "During that time this side of my was nervous no feeling." There were two or three cases in which a reaction focusing on the facial muscles was noted: "Her face getting loose right after marriage it went loose or

—

face

something 8.

—then she got

—

all

right."

DEPRESSION

This

is

not

a separate

described in the

last

symptom

pattern category in the system

chapter because depressive symptoms can

feature in several kinds of psychiatric disorders. Since depression is

an important psychiatric concept,

look

at the

Eskimo view of

The concept Lawrence

we wanted

to take a special

it.

of suicide has had a long history in the

culture. In the past, ritual suicide

St.

was practiced

the person seemed to be suffering an interminable

usually

if

ness, if

he thought he could safeguard the

taking his own, or

if

life

ill-

of a sick child

he were excessively despondent.

29

by

The

pattern of such suicides was highly formalized, and the suicidal act took place in a designated public area.

of people

who had

living Eskimos,

died this

no one

in

way

Although we learned

during the

memory

spans of

our study population had committed

ritual suicide.

The

idea that a person might contemplate a private suicide in

moods of

hopelessness or in despair at misfortunes

was

recognized, as indicated in the psychotic episode of the

also

woman

Native Conceptions of Psychiatric Disorder

who

95

Another instance was a crippled girl unsuccessful love affairs, drank part of a

tried to freeze herself.

who,

after several

bottle of Clorox in the

hope that she would

She did not die

die.

but continued to have periods of depression which she described as I

involving disinterest in what happened to her; but she

do die

I

hope they put

reach up and get out of this self

door or window in

a

my

said, "If

can

coffin so I

in case I'm not dead." In addition to

it

by unhappy

report of depressive feelings, there were descriptions

Eskimos that they had observed

person to be sad or

a

even though these emotions did not reach the level of preoccupation with suicidal thoughts.

Thus

the

Eskimo conceptualizations

of mood, at least as portrayed through English, indicate that

they identify patterns that are closely allied to depression.

CONCEPTS FOR SPECIAL PSYCHIATRIC REACTIONS

9.

There were two Eskimo concepts of psychopathology diverge from the Western psychiatric outline

lowing thus observed in

far.

even though death

of these

a sufficient

Western

the

One

is

"voodoo" death,

number of

it is

name

to

it

rarely seen in our culture.

well developed on

St.

activities

Lawrence

that

have been a

fol-

phenomenon

primitive tribes that people in

tradition have put a

through witchcraft

we

—

—thanatomania

30

The concept

psychological

Island.

That

despite the gradual dwindling of sorcery and

it

death

of

—

is

remains viable

shamanism

is

indi-

by the fact that a recent death in the village was explained by numerous Eskimos as being caused by a particular witch and the belief of the deceased that he would die this way. Interestcated

ingly enough, the public health nurse in this instance could offer

no

alternate or

One

other

more kind

plausible cause of death.

of

psychopathology recognized

Eskimos differed from what

is

usual in

specific pattern of piblokto in the eastern arctic;

know whether

the St.

term of reference for

it.

the

Western psychiatry. This

followed very closely what has been reported not

by

as the culture-

however,

we do

Lawrence language includes a specific Only one case was reported in this

Approaches

y6 study, and

it

was described

shaman but

she was partly

way once

to Cross-cultural Psychiatry as follows:

later

in a while, out of

"I thought at first that

on I found out that she does that mind a little bit, I think." The

were sudden, brief in duration, and not manner of shamanism. During these periods of

episodes

patient's

stylized in the

disturbed consciousness she shouted and grimaced.

mindness" lasted for only IO.

The

"out-of-

few minutes.

a

THE CONCEPT OF IMPAIRMENT

The

foregoing makes clear that beside these specific concepts

of patterns of disorder, the Eskimos have the conceptual equip-

ment

for

making judgments about impairment of functioning

produced by psychiatric symptoms and cases

were partly explained

disorders.

Many

of the

with normal

in terms of interference

functioning: not hunting, not trapping, not taking care of the house, having to give

up

a job or leadership role.

Conclusion This chapter has centered on views of psychopathology

Eskimo

found

in an

to the

model of

was used

at the

death

way

as a

village. In

order to summarize,

let

beginning of

this

us return

This model

a hypothetical culture in Melanesia.

report to explore ideas about

of illustrating some of the facets involved in cross-

cultural comparisons of concepts.

In the Melanesian group,

tween

their orientations

were marked

we

noted

first

the differences be-

and those of the West. The differences

in that they

bury not only dead people but

also

near-to-dead people, that they do not have separate words for

dead people and buriable people believe death effigies.

The

is

who

are not dead,

caused by the magic of casting

St.

Lawrence Eskimos

exhibit

and that they

spells or

many

kinds of differences regarding psychiatric disorders.

We

be struck by the differences in cultural practices were a child

wearing

burning

of the same

we

would to see

a fox-trapping net as a cure for "fits"; or

Eskimo sorcerer picking on

a

an

mentally defective person to run

Native Conceptions of Psychiatric Disorder his

a psychotic patient being treated

ominous errands; or

shaman who, patient.

97

in seance, looks

and

much

acts

by

a

"crazier" than his

a study of the Eskimo words on the topic of

Then

phenomena would disclose the lack of an Eskimo counterpart for some of the general terms, such as mental deficiency and senility, which we consider eminently useful; it psychiatric

would show

that

many

of their designations for psychiatric syn-

dromes are descriptive where ours are diagnostic, and that while some of the patterns of thought, feeling, and behavior which we consider to be psychiatric illnesses they also call "illness," others are looked

upon simply

as

"oddness," "badness," or "unhappi-

ness." In the realm of etiological explanation, differences are also

remarkable. Asking Eskimos what they think causes various kinds of psychiatric patterns,

we would

hear of a patient's father

breaking the law of the hunt in wounding but not killing a fox,

enemy

of an

and of

another patient's soul having been captured by

still

marauding

using witchcraft to put a hex on another patient,

spirits

from

whom

the

Eskimo shaman would seek

the soul's release.

A us,

longer acquaintance with the

however, to discover that

St.

Lawrence people permits

conjunction with these basic

in

differences there are equally basic similarities. In the Melanesian

example, further exploration of views about death brought us to

word and the concept. Melanesians have only one word for people they

the value of distinguishing between the

Although the bury

—dead or

fuddlement level

by

alive

as to

—

who

terminology

this

is

dead and

who

is

not a measure of be-

is alive.

At

they distinguish the physical properties of

virtually the

same

criteria

study

we found much

atric

vocabulary varied in

the conceptual

life

from death

used in the West. In the Eskimo

the same situation. Although their psychi-

many

respects,

our subjects recog-

nized disabilities that correspond to the whole range of major

types of disorder identified in psychiatry. labeled

categories

were

different

elaborations, they described the

in

Even though

their

terms of omissions and

symptoms we commonly

associ-

Approaches

p8 ate

with

senility,

we

behaviors control

to Cross-cultural Psychiatry

neurotic reactions, and so on. Since some of the

think of as psychiatric

—figure

—

seizures

and

spiritualistic

seances as well as in psycho-

in shamanistic

pathology and to some extent the same words were used to describe both types of phenomena,

it

was of

interest to learn that

conceptual distinctions are clearly made. In other words, there

was no

difficulty in differentiating

between genuine pathology

and socially useful behaviors that bear some resemblance to psychopathology. At share with us

many

criteria

for telling pathology

share

common

this level

we

can say that the Eskimos

regarding impairment in functioning

from nonpathology,

just as the

Melanesians

physical indicators of the difference between

life

and death.

The Melanesian

illustration

ences and similarities

gave further insight into differ-

by demonstrating

that magical theories

about the causes of death coexist with rational theories. These rational theories are similar to ours in several

ways

—for

instance,

in the awareness that people die of old age or as a result of

physical

illness,

accidents,

and violence.

An

interplay between

magical and natural explanations was also characteristic of the psychiatric orientation of Eskimos in this study. Thus, along

with the ideas about soul

loss,

taboo-breaking, and witchcraft, the

Eskimos pointed to further determining influences such ity,

brain

damage through accidents or

fortunes. Their observations of

to

illness,

as

hered-

and personal mis-

human behavior seem

to have led

concepts about body-mind, nature-nurture, disorder-well-

being that in the gross sense are rather comparable to ours.

From disorder

this exercise in

we

studying native concepts of psychiatric

have concluded that there are noteworthy

differ-

ences between the stream of thought of the St. Lawrence

Eskimos and that of psychiatry. There parallels

which strongly suggest

can reasonably be made.

are,

however, underlying

that cross-cultural comparisons

Native Conceptions of Psychiatric Disorder

99

Notes 1.

L. Levy-Bruhl, Les Fonctions mentales dans les societes inferieures

(Paris: Librairie Felix Alcan, 1922); F. Boas,

The Mind

of Primitive

Man,

York: Macmillan, 1938); and P. Radin, Primitive Man As Philosopher, rev. ed. (New York: Dover, 1957). 2. W. H. R. Rivers, "The Primitive Conception of Death," in Psychology and Ethnology (New York: Harcourt, Brace & World, 1926), pp.

rev. ed.

(New

36-50. 3. Webster's New Collegiate Dictionary, 2nd ed. (Springfield, Mass.: G. & C. Merriam Co., 1953), p. 171. 4. For example, "A Bibliography on American Indian Medicine and Health," compiled by William C. Sturtevant for the Smithsonian Institute, Bureau of American Ethnology (mimeographed) contains approx-

imately 400 references. 5.

H. Ackerknecht, "Psychopathology, Primitive Medicine and

E.

Primitive Culture," Bulletin of the History of Medicine, vol.

14,

no.

1

(1943), pp. 30-67. 6. The most comprehensive study of primitive psychiatry to date is: G. Devereux, Mohave Ethnopsy chiatry and Suicide: The Psychiatric Knowledge and the Psychic Disturbances of an Indian Tribe, Bulletin 175, Smithsonian Institute, Bureau of American Ethnology (Washington, D.C.: United States Government Printing Office, 1961). A useful bibliography on this topic is: M. I. Teicher, "Comparative Psychiatry: Some Refer-

Ethnopsy chiatry," Revue Internationale d? Ethnopsy chologie Pathologique, vol. 1, nos. 1 and 2. " 'Arctic Hysteria' and 'Latah' in Mongolia," Transac7. D. F. Aberle, tions of the Neiv York Academy of Sciences, vol. 14, no. 7 (May 1952), " 'Latah' and 'Amok,' " The British pp. 291-297; see also J. J. Abraham, Medical Journal, February 24, 191 2, pp. 438-439; F. H. G. van Loon, "Amok and Latah," The Journal of Abnormal and Social Psychology, vol. 21 (Jan.-Mar. 1927), pp. 434-444; P. M. Van Wulfften Palthe, "Psychiatry and Neurology in the Tropics," in A Clinical Textbook of Tropical Medicine, C. D. de Langen and A. Lichtenstein, eds. (Amsterdam: G. Kolff, 1936); and P. M. Yap, "The Latah Reaction: Its Psychodynamics and Nosological Position," The Journal of Mental Science, vol. ences

in

Normale

et

98 (Oct. 1952), pp. 515-564. 8. K. Spencer, Mythology and Values:

way Myths

(Philadelphia:

H. Ackerknecht,

An

Analysis of

American Folklore Society,

Navaho Chant1957), P-

3-

K. Rasmussen, "Intellectual Culture of the Igulik Eskimos," Reports of the Fifth Thule Expedition, Vol. VII, no. 1 (Copenhagen, 1920). 10. W. Bogoras, "Chukchee Mythology," in Memoirs of the American 9.

E.

op.

cit.;

wo

Approaches

Museum

to Cross-cultural Psychiatry

of Natural History, Vol. XII, Pt.

[Publications of the Jesup

I

(New

York: G. E. Stechert, 1910)]. 11. J. M. Murphy, "Psychotherapeutic Aspects of Shamanism on St. Lawrence Island, Alaska," in Magic, Faith, and Healing: Studies in Primitive Psychiatry Today, Ari Kiev, ed. (New York: The Free Press of

North

Pacific Expedition, Vol. VIII

Glencoe, 1964), pp. 53-83. 12. G. Devereux, "Normal and Abnormal: The Key Problem of Psychiatric Anthropology," in Some Uses of Anthropology: Theoretical and Applied (Washington, D.C.: The Anthropological Society of Washington, 1956); see also A. L. Kroeber, "Psychosis or Social Sanction," in The Nature of Culture (Chicago: University of Chicago Press, 1952), pp.

310-319. 13.

E.

14. F.

H. Ackerknecht,

fornia Publications in no.

2

15.

op.

cit.

E. Clements, "Primitive Concepts of Disease," University of Cali-

American Archeology and Ethnology,

C/932), pp. 185-252. A. I. Hallowell, "Primitive Concepts of Disease,"

vol.

32,

American Anthro-

pologist, vol. 37, no. 2 (1935), pp. 365-368. 16. S. L. Rogers, "Primitive Theories of Disease," Ciba Symposia, vol. 4, 1 (1942), pp. 1190-1201; and "Disease Concepts in North America," American Anthropologist, vol. 46, no. 4 (1944), pp. 559-564. 17. J. W. M. Whiting, and I. L. Child, Child Training and Personality: A Cross-Ctdtural Study (New Haven: Yale University Press, 1953), pp.

no.

122-123. 18. M. I. Teicher, "Three Cases of Psychosis Among the Eskimos," Journal of Mental Science, vol. 100 (1954), pp. 527-535. 19. E. H. Ackerknecht, "Medicine and Disease Among Eskimos," Ciba Symposia, July-August 1948, pp. 916-921; see also A. A. Brill, "Piblokto

or Hysteria

Among

Peary's Eskimos,"

The

Journal of Nervous and

Disease, vol. 40 (August 1 9 1 3 ), pp. 514-520. 20. Z. Gussow, "'Pibloktoq (Hysteria) Among Polar Eskimos:

Men-

tal

An Eth-

nopsychiatric Study," in Psychoanalysis and the Social Sciences, sterberger and Axelrad, eds., Vol. sities Press,

21.

M. A.

VI (New York:

Muen-

International Univer-

i960).

Czaplicka, Aboriginal Siberia:

ogy (Oxford: Clarendon

A

Study

in Social

W.

Jochelson,

Anthropol-

"The KorAmerican Museum of Natural History, Vol. X, Pt. II [Publications of the Jesup North Pacific Expedition, Vol. VI (New York: G. E. Stechert, 1908)]; and S. Novakovsky, "Arctic or Siberian Hysteria as a Reflex of the Geographic Environment," Ecology, vol.

yak," in

5

Memoirs

Press, 1914); see also

of the

(April 1924), pp. 1 13-127. 22. R. Redfield, Peasant Society and Culture:

An Anthropological Approach to Civilization (Chicago: University of Chicago Press, 1956); see pp. 70-71 for a description of the mixing of disease concepts in Latin

Native Conceptions of Psychiatric Disorder

101

American villages where contact with the Spanish brought knowledge of the humoral pathology of Hippocrates and Galen. See also R. Redfield and M. P. Redfield, "Disease and Its Treatment in Dzitas, Yucatan," Contributions to American Anthropology and History, no. 32 (June 1940).

an explanation of the concepts and methods employed by Murphy in the key-informant interviewing: One must take a number of concepts into account when interviewing about psychiatric disorder. An inventory of these ideas includes such terms as: "normal-abnormal," "dominant-deviant," "functional-malfunc23.

The

following

is

tional," "natural-unnatural,"

The inventory

itself is far

ports to catalogue

is

which concept or

full

concepts

is

like the

phenomena

pur-

It is

which end of the continuum of health

offers the best starting point.

it

not immediately obvious most appropriate for this kind of

of interconnections.

set of

exploration, nor even

and "well-sick." precise, and

from

One way

to illness

of looking at the matter suggests

markedly different cultures the initial step should be to construct \ paradigms of normality and from these to characterize abnormality. ) Another way suggests that the firmest step is to adhere as closely as possible to our own concepts of disorder and to seek counterparts in native

that in

belief.

Decision in this study to work mainly through the apertures of deviance and pathology rather than trying to construct ideas of normality involved a number of considerations. One was that it is doubtful if a person of any cultural background can conceptualize and verbalize normality as well as deviance and pathology. To ask an Eskimo the dimensions of wellness and normalcy is comparable to asking the average man in our society what human nature is. If the question is understood at all, the answer is so axiomatic in the informant's system of thought and feeling that he has difficulty communicating it and is reduced to describing it as "self-evident." "Self-evidence" under such circumstances has a way of being extremely recondite. The concept of deviance has limitations, too. A deviant mode of thinking, feeling, and behaving is as likely to fall on the superior end of the scale and indicate optimal functioning as it is to indicate malfunctioning. It is usually easier, however, to spot evidences of incapacity and handicap than of exceptional ability. Historically many geniuses have gone unrecognized in their time, but few idiots have, even though the levels and shades of incapacity are extremely difficult to judge without testing and

measurement.

Although some understanding of the value and limitations of each of is essential to the researcher, none is the kind of idea that

these concepts

can readily be explained to a native informant. In this study, psychiatric data were obtained in response to the question: "What sickness has

Approaches

102

to Cross-cultural Psychiatry

such and such a person had?" or sometimes even more simply: "Tell me about such and such a person." This orientation appeared to help the key informant on two accounts: ( i ) questions about one person specifically are easier to answer than questions about people in general; and (2) questions about sickness require less generalization than questions about health and normality. Further, the concept of "illness" can be communicated fairly easily, and it can be anticipated that all people have a near equivalent in their

own

language.

After a conceptual approach has been chosen to guide the interviewing, a number of points about key informant selection and qualification remain to be spelled out in order to make clear both the limitations and the extent of data that can be gathered through this means.

One

factor to bear in

common knowledge

is

mind concerns whether

special

knowledge or

sought. For the kind of special knowledge that

of interest in psychiatric epidemiology, an experienced shaman

seem an obvious choice. His knowledge of symptoms and of a large portion of the population during illness

his

is

would

treatment

would have given

a fund of directly relevant information. None of the Sivokak shamans, however, was sufficiently bilingual to permit extensive and systematic interviewing in English. Since we were interested in generally held

him

views of disorder, it seemed appropriate to seek someone convey common knowledge.

who

could

Not all cultures lend themselves to the use of common knowledge as an entre. In some cultures there are areas of knowledge to which only special novitiates have access, and there are cultural segregations that limit the expanse of any one individual's information. In India, for exlife into man's world and woman's world informant most unlikely as a candidate for an epidemiological study except of women. In Sivokak there are no barriers to a free flow of knowledge about people, and a woman key informant was chosen. The decision to ask her assistance rested on a number of factors such as language skill, willingness, and motivation demonstrated in earlier work. Also intimate health information was more easily conveyed in this

ample, the purdah division of

would make

a female

culture between

The

two women,

investigator and informant.

interviews were conducted in twenty-four sessions over the five-

month period of this aspect of the year's study. They were composed of the informant's comments on a limited number of questions, systematically presented, regarding each individual in the 1940-1954 census. The project was explained as an attempt to find out different kinds of things that

had happened to people in the village. The census was described as the means by which we would organize our work. The first question for each person was: "Can you tell me about X.? " followed by: "Did he or she marry?" "Who are their children?" "Has X been sick?" "What jobs

Native Conceptions of Psychiatric Disorder

103

does he or she do?" "Has he or she been to the mainland?" "How far did he or she go to school?" The questions were chosen in the hope of getting as full a record as possible of general life experience. It became evident early in the procedure, however, that the questions were not equally appropriate for keyinformant interviewing. I soon realized that for a culture where all men are hunters and all women are homemakers, the question about jobs was not giving any new information except about those people who held

governmental positions, and those

I

knew

already.

Much

the same applied

regard to schooling, I found that the informant could give accurate data about whether a person had or had not finished the eight-grade school on the island and about those few who had gone be-

to migration.

With

yond. But to ask for grade levels was quite unrealistic. Throughout the series I tried to minimize situations that required the self-deprecation of too many responses such as: "I don't know" or "I didn't quite remember that."

informant had sufficiently which I was interested that she usually gave all the information she knew on the basis of my asking simply: "Can you tell me about X now?" It was clear that the questions regarding illness fell on fertile soil, as did also those about marriages and children. For these I consistently pressed to make sure that I had recorded everything she knew, and that I had given her time to remember. For the more expendable questions I was satisfied with what she gave on her After the

first

two or three

sessions the

internalized the aspects of experience in

own accord. Key informants

have been employed in collecting

many

different kinds

of data such as kinship terms, diet habits, witchcraft, and religion. But to talk of practices

The

is

quite a different matter

mind

question inevitably comes to

how much

as to

from

talking about people.

how much

information about

The opportunity be an open sesame for the expression of personal animosities. On the other hand, if there is no evidence of the informant's personal likes and dislikes, the question of hypocrisy arises. Especially in a psychiatric study this aspect of key-informant interviewing has to be judged in the light of cultural feelings of stigma regarding mental disorder. Can an accusation of mental symptoms stem

people

is

gossip and

is

report of actual events.

to talk about one's acquaintances

may

from malicious

intent against a disliked person? Is mental disorder conceived as something to be ashamed of and therefore repressed from information-giving?

The amount

of data

obtained from the key informant and other

native informants suggests that there

was little reluctance to communiThere was certainly less hesitancy to talk than about some of the old customs and beliefs.

cate psychiatric information.

about mental

illness

Approaches

104

With

to Cross-cultural Psychiatry

no stigma appeared to be attached homosexuality was concerned, if it did not take the form of transvestitism, it is as likely that native informants lacked knowledge of it as that they withheld information. It would be hushed up in the in-

to

it.

the exception of homosexuality

Where

group

as

much

as to outsiders.

Psychoses and mental deficiency did not appear to be something to hide. Mothers were known to be relatively free with their comments that

one or another child had difficulty learning. "Sickness of mind" that reached psychotic dimension was viewed with the same sympathy as were other sicknesses. Likewise psychoneurotic and psychophysiologic symptoms did not seem to be stigmatized by the Eskimos, and it was more a matter of extent of knowledge than of prejudice. Quite aside from cultural stigma, there are questions about reliability that relate to the internal standards by which a key informant herself judges the accuracy of information. How does she sort items into events versus rumors, facts versus fictions? This is by no means an insignificant problem when the informant has grown up relying on magic to explain

many

things.

between magical "truth" and "truth" and scientific sense, it seemed to me that the informant's world was starkly dichotomized between the Eskimo truths of her childhood and the new truths of the white world which she accepted in adulthood. The new criteria did not invalidate past history; they were means of judging current affairs, but they simply did not apply to verification of her past experiences and those of her parents' generation. To her it was absolutely true that people used to die because evil prayers were said against them. "It is a good thing we put away all those old stuffs," she said. Back in those times, people did get sick because they broke the law of the hunt and stole someone else's whale; shamans did see things and hear things of that other reality. Even in terms of the old beliefs, however, there seemed to be standards of accuracv what might be called measures of the reliability of magic! Once, in the presence of her sister-in-law, who was secular to both the old and new faiths, the informant recounted a story concerning an entrancing half-woman, half-seal creature who had been seen on an ice floe. Her sister-in-law said that the story was nonsense. The informant insisted: "It's true; two people saw her!" Thus, like most Eskimos at mid-century, she believed both Eskimo and "white" at the same time. I believe that she gave as accurate data as possible from whichever of her two premises was foremost in her mind at the time, and I conceived of it as my job as an anthropologist to decide which premise was operative at any given moment. For example, it was clear that in both of her intellectual worlds she was aware of the difference between rumor and opinion on one hand and events and history on the other. She In terms of the broad division

in the historical

—

Native Conceptions of Psychiatric Disorder sensed that

I

105

valued her discriminations about the criteria and validity it was possible to divide her

of judgments, and at the end of the study

information into the categories of what she had actually seen herself; what she had heard from the person in question; what she considered her

own

opinion ("That's just what

I

what she conwhat she remembered

thinks myself");

sidered rumors, enlightening and unenlightening;

clearly; what she did not remember; and what she did not recall but thought she could find out, and did find out, from other Eskimos. Motivation is a complex aspect of this kind of interviewing both too much and too little being disadvantageous. This informant appeared to be highly motivated, but I do not believe she therefore gave me false impressions based on a preconceived notion of what kind of information would please me. Since our work was never described as a psychiatric

—

study, she never

knew

fully of this special interest.

In addition to assessing her

own

standards of accuracy

it

was

also

her data about general health by comparing what she said with the health records. There were only 107 health records available for the population of 495, but in 85 per cent

possible to

measure the

reliability of

of the overlay cases she correctly designated the

was described

in the

symptom system that mean that the

record. This obviously does not

nomenclature was the same. It was possible, however, to see that her dethough crude, accurately portrayed a disability of the pul-

scriptions,

monary system,

the cardiovascular system, or the musculoskeletal system.

For example: Health record of an old man ivho died in 1942: "1940: Impetigo contageosa. Lesions about healed. Edema of feet, at times has bloody urine. Urine neg. for protein. Ointment for lesions. 1941: Complaint gastric, vomits dark fluid, pain sometimes, used to drink much whiskey. 1942: Man has jaundice, eyes and entire skin very yellow. Is losing weight rapidly. Has dyspnea, ascites, icterus. Bloody stool and sputum. Died in 1942. Informant's report of his symptoms:

"During his boyhood when he was a young man he used to be a big drunkard. But he quit when he became older. When he getting older he became unhealthy. Sweating most of the time, always sweating, change his clothing about twice a day, especially in the evening he sweating too much and he doesn't feeling good with his belly too. Later on during his sickness his skin became yellowish. I don't know why it became like that, green or yellow pardy, like that all over his skin. And then he died from that, and he had T.B. and he has been vomiting some big chunks of blood, something like that, awful smells too. T.B. that is what he vomits I think. He died in 1944, oh no, 1943. He has been sick and don't feeling good for a long time ago with his urine too. Sometimes he couldn't pass urine so easily I think. It was long before he died that his skin became yellowish too." [Unpublished field notes: J.M.M., 26 June 1955, p. 2.] In addition to asking about reliability,

much information one person can

it

is

also

important to ask

how

give concerning 494 other individuals.

Approaches

io6

To some

to Cross-cultural Psychiatry

extent this depends on the stability of the population, the

amount

of face-to-face contact between them, and the proximity of living arrangements. Certainly such a method would not be appropriate for a study of urban areas where affiliations are based on

class,

occupation, or associ-

and where population mobility makes many acquaintanceships temporary and superficial. Where Sivokak village is concerned, the first indication of the usefulness of this technique was the fact that the 494 questions drew no blanks. There was considerable variation in how much the informant knew about each person, but she had something to say about each name. One of the variations regarding her knowledge of the village population concerned the age of its members. She had less to sav about children than about adults. The age group of five years and under received scanty treatment. This made sense, however, for the length of contact with children ations that cross-cut residence

They have

is less.

lived so

of their lives that there

little

is

not

much

to

note unless they are severely abnormal, do not respond to the shaping

As

processes of culture, or do not survive.

far as the epidemiological

concerned there was no reason to doubt her coverage. She described childhood symptoms that we would call tantrums, mental deficiency, epilepsy, and behavior problems. For other children her descriptions tended to be: "He goes to school. He is beginning to help his father. He is a healthy." Apparently there were no variations relevant to sex. She knew things of psychiatric interest regarding both men and women. Of the 68 cases she contributed, 38 were women and 30 men. Thus her distribution on the basis of sex was similar to that in the overall total from all sources which includes 60 women and 53 men. 113 cases There were differences in the amount of information (and therefore evidence of

a psychiatric

nature

is

—

the likelihood of disclosing the less obvious psychiatric related to kinship ties and proximity.

The most

symptoms)

that

detailed account of

medical and psychiatric history was of herself, then of her immediate family, and from there the degree of detail went out in waves of diminishing description to the extended family, tribe, and village levels. Detail

was

also greater for her

next-door neighbors and, since she lives in the fanned out to less particular information regarding people who live at the peripheries. Nevertheless her coverage of the population in terms of psychiatric descriptions was sufficiently ample to have made this type of key-informant interviewing useful to a study center of the village,

it

of native concepts. 24.

Grateful acknowledgment

by our 25. J. j^T

is

collaborators, Charles C.

given for the use of field notes gathered

Hughes and Dorothea

M. Murphy (formerly Hughes),

Psychopathology

in an

Eskimo Village" (Ph.D.

University, i960), pp. 224-231.

C. Leighton.

"x\n Epidemiological Study of Dissertation,

Cornell

Native Conceptions of Psychiatric Disorder 26. C.

C. Frake,

"The Diagnosis of Disease Among

!0J

the Subanun of Min-

danao," America?! Anthropologist, vol. 63, no. 1 (Feb. 1961), pp. 11 3-1 32. 27. A. H. Leighton, T. A. Lambo, C. C. Hughes, D. C. Leighton, J. M.

Murphy, and D. B. Macklin, Psychiatric Disorder a?nong the Yoruba: A Report from the Cornell-Aro Mental Health Research Project in the Western Region, Nigeria (Ithaca, N.Y.: Cornell University Press, 1963). 28. J. M. Cooper, "The Cree Witiko Psychosis," Primitive Man, vol. 6 (Jan.

1933), pp. 20-24. See also R. Landes,

Ojibwa,"

The

"The Abnormal Among

the

Journal of Abnormal and Social Psychology, vol. 33 (Jan.

1938), pp. 14-33. 29.

A. H. Leighton, and C. C. Hughes, "Notes on Eskimo Patterns of

Suicide," Southwestern Journal of Anthropology, vol. 11, no. 4 (1955), pp. 327-338. 30.

no.

2

W.

B.

Cannon, "Voodoo Death," American Anthropologist,

(1942), pp.

1

69— 181.

vol. 44,

IV The Use of Psychophysiological :

Symptoms

as Indicators of Disorder

among Eskimos By Jane M. Murphy and Charles

C.

Hughes

EDITORIAL NOTES Although

interest in "culture-personality" studies declined in

the postwar era, serious attention was directed during this period to epidemiological research regarding the distribution of psychiatric

symptoms

in nonhospitalized populations. It

that one source of guidance for developing

of previous as these

work

was obvious

methods was

a

study

with psychological screening tests, particularly

had emerged during the war.

Study got under way

When

the Stirling

in the fifties, the late Allister

County

Macmillan

undertook to examine these screening instruments and to

select

would be appropriate for among adults in rural communities. The approach found to be most closely allied to the needs of the Stirling Study was that taken by the armed forces in a or construct and standardize a test that

use

program of screening for neurotic and related symptoms. Nevertheless the questionnaire had to be remodeled to suit the different situation in

which

it

would be 108

used. Unlike the

young

Psy chophy siological Indicators among Eskimos males tested for military service, a rural community "captive audience."

It

/op

is

not

a

comprises, moreover, a broader age range

men and women.

and includes both

With advance knowledge of the community and in consultation with physicians who knew the area, Macmillan devised a questionnaire which he named the Health Opinion Survey (hereafter called the HOS). For purposes of validation and was tried out in communities County but at a distance from it. 1 In

standardization, the questionnaire similar to those of Stirling its

original pretesting form, the instrument consisted of seventy-

five items dealing

questions

nature

such

centering on

—that

as

broadly with health but with a majority of

is,

complaints of a psychophysiological

queries mainly about physiological sensations

numbness, fatigue, or weak

feelings. Items

were taken

from the Army's Neuropsychiatric Screening Adjunct with additional questions

from other instruments such

as the

Minne-

sota Multiphasic Personality Inventory and from suggestions

made by

local physicians.

private, using mobile

The

questionnaire

trailers fitted

out

was administered

as offices,

in

and the ques-

were asked by an interviewer. The whole procedure required about twenty minutes, and the questions as well as the presentation of the project were given with as much care as

tions

possible to avoid causing anger, suspicion, or embarrassment.

During the stages of standardizing this technique and reducing its size to a manageable number of items for surveying larger populations,

two measures

to the same questionnaire

of validity were instituted. Responses

were obtained from

both in-patient and out-patient, neurotic.

By means

achieve a smaller

of

list

statistical

who had procedures

local patients,

been diagnosed it

was

as

possible to

of items (twenty questions) and a con-

comitant scoring system which reached an adequate level of discrimination between the group of

group composed

as fully as possible

of

known "ill" and another people who were presum-

ably "well." Another measure as to whether a given pattern of responses indicated the presence or absence of psychiatric dis-

i

Approaches

io

to Cross-cultural Psychiatry

order was an independent clinical appraisal by a psychiatrist of a

subsample of the pretested group.

This work

as

well as the efforts of others to develop screening

instruments has produced series of survey questions for which

high frequency of positive responses

is

what

correlated with

psychiatrists in a clinical context discover to be psychiatric dis-

order, especially psychoneurosis.

The

fact that the survey ques-

tions tend to

concern psychophysiologic sensations rather than,

for example,

dynamic or interpersonal questions

empirical demonstration. Correlation ent

matter from

a

clinical

is,

is

a

matter of

however, quite of

definition

a differ-

psychoneurosis.

It

should be emphasized that frequent feelings of weakness, upset

stomach, and palpitations do not themselves necessarily constitute psychiatric illness.

Midtown Study,

In the

a rather similar

ployed in developing a screening

test.

2

Called the

Item Screening Score (hereafter referred to Item Score),

this list of questions also

psychophysiologic symptoms, and there

is

a

is

Mexico, which

Midtown

use of the

is

the

last

A

chapter of this volume,

the topic of the present chapter.

when not tells little

buttressed

West-

be noted

as the

or nothing about the type of psychiatric disorder,

duration, or the kind of impairment. ently, register rather

On

The

mental retardation, and sociopathic be-

the other hand, the question

of psychoneurotic

—that

is,

its

questions also, appar-

poorly some of the more severe reactions

as schizophrenia,

indicators

may

HOS. The score on the test by information drawn from other sources

regarding instruments such

ances

made

screening instrument, while the Stirling

the basis of trying to assess populations of people in

havior.

that

study of social

ern society, several drawbacks and advantages

such

is

considerable overlap in the twenty questions selected for

status in

is

Twenty-two Twenty-two

concerned mainly with

and the twenty-two for Midtown.

On

as the

noteworthy aspect

Stirling

HOS

procedure was em-

lists

serve as very

good

and psychophysiologic disturb-

those types of disorder

which

are prevalent in

Psychophysiological Indicators

communities

The

at large.

m

among Eskimos

brevity and rapid scoring

make

possi-

ble the screening of large samples, and the content of the questions

is

not likely to offend or incline people into giving evasive

or misleading answers.

For cross-cultural

studies instruments such as the

Twenty-two Item Score have

HOS

or the

the further asset that the questions,

being mostly concerned with fairly specific sensations, are some-

what

resistant to distortion

when

translated

from one language

to another. Before assuming, however, that such a screening

device can be employed in cross-cultural epidemiology, several questions of feasibility and validity need to be explored in a

circumscribed cultures

trial situation.

other

than

It

could be, for example, that in

urban and rural North America these

physiological indicators are not highly correlated with anxiety, depression, or other psychoneurotic patterns. In such a case, the

questionnaire

The

would

fail as a

present chapter

is

screening instrument.

a report of an exploratory study

made

954- 1 95 5 by two anthropologists, Murphy and Hughes, employing the HOS with a sample of Eskimos from the larger

in

1

study of psychiatric epidemiology described in the

Their Eskimo work followed the

initial

Study during which they collaborated

The

goal of the

to scrutinize the test for

trial its

HOS

chapter.

period of the Stirling in using the

gather data about mental health and mental

Canada.

last

illness

HOS

to

in rural

survey among Eskimos was

usefulness as a

method of surveying

psychoneurotic symptoms in a non-Western population. 3

THIS

chapter reports a

trial

experiment in using and analyzing

the results of a structured questionnaire for gathering data about

mental health in a non-Western culture. For ple of

Eskimos from Sivokak

this

purpose, a sam-

village on St. Lawrence Island in were asked to respond to the Health Opinion Survey questionnaire. A copy of the questionnaire is incorpo-

the Bering Sea

Approaches

ii2

to Cross-cultural Psychiatry

some notes concerning its adminEach question is then reviewed as to its suitability for use in the Eskimo culture. Alternative or additional questions are recommended where knowledge of the culture indicates the possibility of some misunderstanding of the concepts involved, and a quantitative comparison of the Eskimo responses with responses from sample members in the Stirling County Study is rated in the text, together with istration.

presented. In the last section of the chapter, attention

methods for scoring the

HOS

results

so

that

is

given to

the

"illness-

by each Eskimo's responses can be compared with other evidence on the mental health status of the wellness" rating provided

sample members.

The

corollary information used in these final

comparisons consists of key-informant materials and observational data

which have been evaluated by two

psychiatrists.

Questionnaire and Preparatory Steps for Its Administration

The Health Opinion Survey questionnaire used in this study is reproduced in Table IV- 1. The arrangement of items follows Table IV-i. Eskimo Health Opinion Survey questionnaire

Name i.

Sex

Age

*

Highest School Grade Completed

How

has your health been, on the whole? good 2. medium 3. poor Do you have any particular physical or health trouble at present? 1. no 2. yes What sorts of serious illnesses have you had? Illness Age How sick were you? Have you ever had one of the following? (Check any already mentioned in previous question, and omit from mention in this i.

*

2.

3.

4.

question. Illness

Age(s) at

in years

time(s) of

occurrence (s)

Eye

trouble

Ear trouble Sinus trouble

Throat trouble

How sick were you?

Remarks

Psychophysiological Indicators

among Eskimos

113

Bronchitis

Pneumonia Pleurisy

T.B. Boils

&

abscesses

Low blood

(anemia)

Heart trouble High blood pressure Low blood pressure Stomach trouble Diabetes

Bowel trouble Piles

Kidney trouble Bodily injury

Operations

(list)

Rupture (hernia)

Rheumatism Arthritis Sciatica

Neuralgia

Tooth trouble For women: female trouble Other (specify)

5.

Have you 1.

ever had to go easy on your

2.

What

7.

Have you ever had 1.

9.

2.

often

2.

often

*i4.

this last?

you?

How

long did

it last?

never

3.

2.

sometimes felt that

sometimes

3.

feet sweating so that they

never

you were going

to have a nervous break-

once or twice 4. never by your heart beating hard? 1. often 2. sometimes 3. never Do you tend to feel tired in the mornings? 1. often 2. sometimes 3. never Do you have any trouble in getting to sleep and staying asleep? 1. often 2. sometimes 3. never 1.

*i3.

long did

your work because of poor health?

ever tremble enough to bother you?

sometimes

*n. Have you ever down? *i2.

how

to change

Are you ever troubled by your hands or feel damp and clammy? 1.

of poor health?

yes

What age were Do your hands 1.

*io.

age were you? For

no

work because

yes

6.

8. *

no

often

Have you

2.

3.

ever been bothered

Approaches

//^

to Cross-cultural Psychiatry

Table IV-i. Eskimo Health Opinion Survey questionnaire (cont.)

How

you bothered by having an upset stomach?

the time

all

2.

prettv often

3.

not very

much

never

4.

*i6.

often are

nearly

i.

Are you ever bothered by nightmares? (dreams which frighten or upset you?

)

many

*2

2.

times 2. a few times 3. never your arms or legs go to sleep rather easily? 1. often 2. sometimes 3. never Have you ever been troubled by "cold sweats"? 1. often 2. a few times 3. never Do you feel that you are bothered by all sorts (different kinds) of ailments in different parts of your body? 1. often 2. sometimes 3. never Do you smoke? 1. a lot 2. some 3. not at all Are you ever troubled by sick headaches? 1. often 2. sometimes 3. never Do you ever have loss of appetite?

*2

3.

Do you

1.

Do

*i8.

*io.

*2o.

*2i.

often

1.

often

1.

*24.

sometimes

3.

2.

sometimes

3.

Does your food ever seem often

1.

*25.

2.

Do you

never

ever have a bad taste in your mouth?

2.

feel

sometimes

it is

never

tasteless

and hard to swallow?

never necessary to take vitamin 3.

pills

for your health?

sometimes 3. never *i6. Do you depend on patent medicines? 2. sometimes 1. often 3. never often

1.

*2 7.

Do you

2.

feel that

you

are

more

apt to catch contagious diseases than

most people? 1.

yes

2.

no

3.

undecided

How

would you say your health was this past year? 2. good 1. excellent 4. poor 3. fair 5. very poor 29. Do you feel in good spirits? 2. sometimes 1. most of the time 3. very few times Now I'd like to ask some questions about the health of your 28.

close

relatives: 30.

How 1.

31.

has the health of your mother and father been, on the whole?

excellent

2.

medium

3.

How

about your brothers and the whole? 1.

excellent

2.

medium

3.

poor sisters,

how

has their health been, on

poor

A portion of the material has been used in earlier studies and is reproduced here by permission of the author's wife, Mrs. Allister M. Mac*

Psychophysiological Indicators

among Eskimos

115

County Study. The twenty crucial questions are indicated by an asterisk. A few additional questions were asked in both the Stirling and Eskimo studies to provide a rough estimate of the degree to which illness interfered with routine activities and to obtain information on family

the format

employed

health history. takes the

A

form of

a

in the Stirling

further inquiry, not part of the

medical checklist.

HOS

itself,

4

HOS was conducted in the last month of a year's visit on Lawrence Island. By that time most of the study of social change the central purpose of the field trip had been comThe

St.

—

—

and much had been learned about Eskimo culture and about concepts and prevalence of illness. Thus one of the main

pleted,

preparatory steps for the

HOS

trial

hunches and reservations about the

was

to formulate a priori

suitability of

each individual

question in studying psychiatric disorder in this culture.

For the survey, a census of the population in Sivokak village was prepared from government records compiled by the school teacher. Resident in the village during the survey period and

were 146 adults over systematic sample of twenty names was

available for the first-hand interviewing

eighteen years of age.

drawn by

A

selecting the first appropriately aged person in the

census and every subsequent seventh thereafter. 5 Although

it

was not adjusted for equal representation of men and women, the sampling produced ten male

names and ten female names.

Five additional questionnaires were obtained from

and three men. These people had previously given data and

were included

in the

HOS

two women life

history

survey for supplementation

and the publisher from A. M. Macmillan, "The Health Opinion Survey: Technique for Estimating Prevalence of Psychoneurotic and Related Types of Disorder in Communities," Psychological Reports, vol.

millan,

3, Monograph Supplement no. 7 (1957), and by permission of the authors and publisher from C. C. Hughes, M.-A. Tremblay, R. N. Rapoport, and A. H. Leighton, People of Cove and Woodlot: Communities from the Viewpoint of Social Psychiatry [Vol. II, The Stirling County Study of Psychiatric Disorder and Sociocultural Environment (New York: Basic

Books, i960)].

n6

Approaches

to Cross-cultural Psychiatry

and cross-checking. Since there is no reason to think that the Eskimos were either especially ill or especially

additional five

well, the remainder of this chapter focuses

on the twenty-five

questionnaires in order to reflect as large a

number of response

patterns as possible. Although the sample

small,

is

it

represents

population. 1 7 per cent of the adult Prior to the survey, we interviewed key informants to find

out whether the symptoms and sensations discussed in the questions were

known

HOS

Eskimos and whether they could

to the

be translated into the Eskimo language.

We

discovered that

all

the health items qualified in this minimal way. This does not

mean

that

all

items

were equally relevant

as

characteristic

expressions of psychiatric disorder in this culture. But whether

or not the questions on vitamin

pills

and patent medicines, for

example, applied to the Eskimos in terms of psychiatric malfunc-

them and could be language or conveyed by English words that were

tioning, the concepts

stated in their

commonly

were understandable

understood.

The

to

questionnaire

was administered

Eskimos or when necesEskimo language using experienced interpreters with the questions were carefully reviewed before the survey

verbally, either in English to bilingual

sary in the

whom was

instigated.

By

1955 tne Eskimos in Sivokak village were well accustomed

to the procedures of public health programs. People ally

informed of these by the

village leaders,

house to house telling them to appear examinations

of

one kind

tuberculosis, sickness,

or

school or clinic for

at the

another.

were usu-

who went from

Apprehension about

and death was so vivid and so widespread

that cooperation could usually be counted on. Also the

had previously experienced "home nurses or itinerant doctors

who

asked

visits"

many

by

Eskimos

public

questions.

health

With

this

background, there appeared to be a favorable climate for a survey such as the HOS. This was confirmed by the fact that we as

ran into

few problems of

concluded that

it

was

rapport. 6

At

the end of the survey,

feasible to administer

we

such a questionnaire

among Eskimos and

nj

among Eskimos

Psychophysiological Indicators

that the individual queries

were

sufficiently-

meaningful to warrant the further analysis described in the

fol-

lowing pages.

Twenty Questions

Analysis of

The

ideal

way

and standardize an

to design

naire for cross-cultural

work would be

HOS

question-

to start with a large

list

of questions administered in each of several different cultural

groups, so that

we

could be sure the

full

spectrum of significant

psychological reactions and psychophysiological sensations was

being tapped.

The

next step would be to select the questions that

most effectively sort the known psychiatrically these cultures

combine the

from the known

well.

ill

people in

The hope would

then be to

results of the several studies

set of universally appropriate

and determine a core

questions so that cross-cultural

comparisons could be made directly from responses to the same questions. This forecasts an extremely long

and expensive opera-

tion of pretesting, and

we know

what

in reality

we

presupposes that

in

advance

are seeking to discover, namely, the

ways of

it

identifying psychiatrically

ill

people in a foreign culture.

Thus for the purposes of gathering data that this

problem,

let

assumption in view of

(i) the

This

is

not an unreasonable

denominators of the

condition such as need for sleep, fatigue after exertion,

occasional palpitations as well as

and (2) the fact that variations

other physiological events,

in these functions are

significant to the psychiatric status of people

ent cultural origins. For the mental.

We decided to

moment,

then, our attitude

studies, bearing in

variations in psychoneurotic

reactions could be reflected responses.

For example,

probably

from widely

go ahead and ask the questions

been found useful in other specific

illuminate

common

tions have universal applicability.

human

may

us assume at the beginning that certain ques-

mind

is

differ-

experi-

that have

that culture-

and psychophysiological

by weighting and scoring of

questions

about

generalized

chondriacal preoccupations or specific bodily rhythms

the

hypo-

may

be

u8

Approaches

to Cross-cultural Psychiatry

strong indicators in culture A, while sensations of fear

more important

may

be

though one would not want

in culture B, even-

to leave out questions of either kind in cross-cultural studies. It

seems worthwhile, therefore, to review the twenty ques-

what we know about Eskimos and Eskimo Eskimo response patterns with those of Stirling County residents. Although subsequent sections of this chapter build on the results of this review, the purpose here is mainly to systematize a series of recommenda-

tions in the light of

culture and through comparison of the

tions

how

on

the

HOS

might be improved

large-scale study of Eskimos. It

is

in preparing for a

not intended

as a

demonstra-

tion of the relevance or irrelevance of individual items

questionnaire. This is

is

from the

to be especially underscored because there

Midtown

reason to believe from the Stirling and

Studies that

the questions taken separately are not nearly as crucial in indicat-

ing disorder If

we

as is the totality

start

of responses.

with the question:

Eskimo say

'yes'

answer

in several factors,

lies

idiosyncratic,

"What makes

or 'no' to a given item?"

some

some of which

a particular

obvious that the are

more or less some to

related to physical considerations,

and

cultural practices

it is

beliefs,

some

tion or the interview situation, and

nomena. Because of our

to the

wording of the ques-

some

to psychological phe-

interest in cross-cultural comparison,

one aspect of the twenty-question review

"Does an Eskimo respond

in a particular

is

way

to ask ourselves,

because he under-

by the question the same thing that a resident of Stirling County understands?" The second aspect concerns whether

stands

there

is

a similar psychiatric implication in the questions

asked of Eskimos, that tiality for either

is,

when

do the questions have the same poten-

being correlated with or conveying information

we have not operated on the and feelings queried in the twenty

about emotional upsets. Although principle that the sensations

items define psychiatric disorder in either Stirling

among Eskimos, random

it is

selection.

County or

clear that the questions are not an entirely

"Does your food seem

tasteless

and hard to

Psychophysiological Indicators

up

among Eskimos

swallow?" bears a relationship to psychological disturbance in Western culture that would not be true of physical sensations such

experiencing pain

as

we want

when sunburned

or frostbitten.

to look at the questions further to see

if it is

Thus

likely that

a psychological dimension will be dominant and the influence of

cultural

and physical factors minimal.

From

this

viewpoint, the twenty questions seem to

fall

into

five categories.

Questions centering on views, practices, and patterns of

i.

physical

illness.

Present health trouble?

2.

*

27.

Susceptible to contagious disease?

25.

Vitamin

26.

Patent medicines?

pills?

Attention was immediately drawn to questions relating to physical illness because the Eskimos, like

groups, experience a

much

own

than do members of our these

Eskimos

is

many underdeveloped

greater prevalence of physical disease culture. Further, the history of

typical of that of other arctic inhabitants re-

garding the introduction of tuberculosis and periodically devastating epidemics of measles

Eskimos

as a

diseases that

flu,

giving evidence that the

group do not yet have immunity to many of the have

less drastic effects in

of a psychiatric

bility

and

our culture.

component being

related

The to

possi-

positive

responses about present health trouble or susceptibility to contagious disease might therefore be vitiated. It sion,

however, that

the St.

illness

Lawrence Eskimos

was

so

much

was our impres-

a focus of anxieties for

that these questions

might be highly

correlated with psychological disturbance though not in themselves a direct

on

outcome of such disturbance. Also, the question is appropriately worded: "Do you feel more

susceptibility

* Although the questions have been rearranged in order, the numbering system has been retained for cross-reference to pp. 1 12 to 114.

Approaches

120

to Cross-cultural Psychiatry

apt to catch contagious diseases than most people?"

seemed an adequate

The

such,

it

reflector of preoccupation with health.

questions about need for vitamin

were

cines

As

and patent medi-

pills

the only ones not consistently asked.

Such

pills

and

medicines are not part of the existing culture and are not readily

Thus we asked about them only

available.

in situations

understanding was certain. In looking back on our

where

field notes

and reviewing the affirmative responses to these questions when they were asked,

The

overcome by had

also

by

schooling. Mail ordering

a great deal to bridge the gap.

was one of the

Western medicine

and most enduring attractions the white

first

world offered to "cure-alls"

we had

mainland for hospitalization, by Na-

training camps, and

done

these matters than

physical isolation of the Island had been largely

trips to the

Guard

Eskimos seemed

that the acculturated

more knowledgeable about

to be far

supposed.

tional

we found

this

physically

population,

debilitated

and "wonder drugs" had great significance

and

as objects

about which to center, however unrealistically, the hopes and fears

our

concerning the health situation of the Island. Thus, despite

initial

misgivings about the four questions involving physical

knowledge of the Eskimo

health, fuller

situation suggested that

these items are particularly suitable. 2.

Questions involving food and the gastrointestinal tract ivhere diet habits might be relevant.

A

15.

Upset stomach?

22.

Loss of appetite?

23.

Bad

24.

Food

first

as a

tasteless?

reaction to the

to think of

taken

taste?

it

HOS

in connection

whole,

it

questionnaire

Four out of the twenty items concern

some aspect of the alimentary canal Although

No

this

—stomach

upset, food, taste,

other bodily system receives so

focus

that,

seems to emphasize questions involving the

gastrointestinal tract.

and appetite.

when we began

with the Eskimo survey was

may

much

attention.

be appropriate in Northeast America,

Psychophysiological Indicators

among Eskimos

121

Lawrence Island. Our reservations, therefore, mainly concern the number of items on this theme and the correspondingly fewer items on other themes that might be more pertinent to the Eskimos. Also, however, there were

it is

not necessarily so on

diet patterns that

We

St.

might influence responses to these questions.

doubted that "upset stomach" would have much psy-

chiatric significance in the

Eskimo population.

complaints were extremely

common

poor

health, mild epidemics of flu,

the times of poor hunting

Gastrointestinal

as a reflection of generally

and

diet variations.

when food was

During

scarce people ate meat

was rotting and which in better times would have been consumed only by the dogs. They did not ordinarily eat "high meat," although as in other Eskimo groups this was sometimes a necessity. The public health nurse for the Island held the view that

that lean periods

were correlated with outbreaks of stomach

trouble and attributed this to periodic waves of food poisoning.

Although lean periods were not continuous, food was rarely In addition, diet habits were being revolutionized.

plentiful.

Many

people preferred white man's food to Eskimo food, and

some children refused altogether to eat native meat because they found the odor offensive. Although responses about taste and appetite might be

somewhat ambiguous

population undergoing such change in

in such an underfed

diet,

our skepticism about

was somewhat allayed by the fact that outside Eskimos said they recognize a link between emotional disturbance and at least one of these items loss of these questions

the

HOS

situation,

—

appetite.

Of

these four questions, then,

tions about "upset

we have

greatest reserva-

stomach" and greatest confidence in

"loss of

appetite." 3.

Questions in "which wording might influence response.

We

13.

Tired in morning?

19.

Ailments

all

over?

did not believe that the "morning tiredness" question

would apply

to the

Eskimos

— not because they lack the idea and

sensations of tiredness but because they have

different sleep

Approaches

122 habits.

to Cross-cultural Psychiatry

work

People sleep during the daytime and

necessary in view of hunting

possibilities.

We

at night if

were consistently

impressed by the irregularity of sleep patterns and believed that

was increased by the nearly continuous darkness or continuous light depending on the season of the year. Since the Eskimos do understand fatigue, we would recommend that questions about this sensation be recast in more understandable terms such as, "Do you tend to feel tired a lot?" or "Are you tired even

it

when you wake up?" The question on ailments is bothered by all sorts (different parts of

your body?" This

is

stated:

"Do you

feel

you

are

kinds) of ailments in different

the most abstract of

all

the items

and requires the greatest generalization from the respondent.

We anticipated that questions about specific sensations would better understood.

It

was intended

be

that this question elicit re-

sponses indicative of hypochondriacal concern and of those

psychologically induced organic discomforts that have the distinguishing feature of shifting

all

around the systems of the

body. This intent was probably not conveyed

in the

complicated

wording of the question. Since there are Eskimo words for overconcern with illness and malingering, these phenomena are

known

them and would probably have been more profitably explored by two or three more concrete questions.

clearly

4.

It

to

Questions in which cultural practices might be pertinent. 17.

Arms

20.

Smoke?

or legs asleep?

seemed to us that the item on "arms and

would lack

legs

going to sleep"

psychiatric significance because of a cultural practice

of the Eskimos. Customarily they

sit

on the

floor

without back

support and with their legs extended straight out in front of

them. This posture almost invariably produces numbness in peo-

who do not habitually sit that way, and even Eskimos say it becomes uncomfortable and that they frequently have numb feelings. This is one of the few questions that was stated simply

ple

Psychophysiological Indicators

123

experience this sensation?" rather than "Are

"Do you bothered

among Eskimos

or

recommend

troubled

by

sensation?"

this

you Thus we would

a restatement of the question in the latter

form

in

order to reduce the likelihood that a cultural practice will mask the psychophysiological import.

The nate

other question in which cultural practice might predomi-

"smoking." In studying

is

a

group that does not have

to-

would obviously be meaningless. bacco As it happens, the St. Lawrence Eskimos, both men and women, have long made use of tobacco in many forms. There were no available, this

question

restraints of propriety to control the use of

the presence of missionaries or latterly

adopted the missionary view.

Nor were

by some of

hibited Stirling

ill

who

effects of

common

the factors that relate to

have

smoking.

practice, unin-

smoking patterns

we would recommend that worded: "Do you feel you smoke

County,

Eskimos be 5.

a

those

there restraints in 1955

based on medical awareness of the possible

Because smoking appeared to be such

tobacco except in

among

in

the question for

too

much?"

Questions that do not appear to he distorted by cultural or physical considerations. 9.

10. 11.

Hands tremble? Hands or feet sweat? Nervous breakdown?

21.

Sick headaches?

14.

Trouble sleeping?

12.

Heart beating hard?

18.

Cold sweats?

16.

Nightmares?

The judgment

of the adequacy of the "hands tremble" item

was supported by descriptions we heard of trembling and shakworry and depression ("shaking sickness"

ing as expressions of

has already been referred to, p. 94). Variations in tendency to perspire a

were recognized; for

"big sweater."

We

instance,

one

man was

described as

did not hear of this sensation in association

Approaches

124

to Cross-cultural Psychiatry

we

with emotional disturbance but neither did dence that

it

might not be

have any

a psychiatric variable.

The

evi-

phrase

"nervous breakdown" was used by some of the acculturated Eskimos, and, as indicated in the last chapter, the concept was

approximated by a number of Eskimo words. headaches" has

people in Stirling County.

by

tone that

a colloquial

It is

phrase "sick

readily understandable to

doubtful that

we presume

the Eskimos, and

is

The

this

was

assimilated

that their responses refer to

ordinary headaches. This did not seem to be a distortion of significance.

The

question on "trouble sleeping" avoids the

"morning tiredness" and seemed to be an

culties described for

adequate

way

diffi-

to ask about sleep disturbance.

During the year of investigation

we were

impressed

by

the

degree to which fear was generated and expressed in the Eskimo

group

—fear of witchcraft,

fear of

hunting on the ice or being this

was undoubtedly

becoming

sick

with tubercu-

and fear of the physical dangers of

fear of going hungry,

losis,

lost in the arctic storms.

fear,

realistic

and

we

Much

of

realized that the

problems of distinguishing between fear and anxiety are some-

what

similar to those of differentiating

between organic symp-

toms that stem from physical malfunction and organic commainly of psychological derivation. Nonetheless

plaints that are it

seemed to us that any symptoms such as palpitations and "cold which might be a physiological expression of fear, de-

sweats,"

served special attention.

We

heard

many

descriptive accounts of people having the

sensation of heart pounding. reactions to "scary" events.

Eskimos conceive of situations

this

and "normal"

of "worrying too

considering

it

a

Some were simply

We

also learned,

symptom

in others, that u

much" and

as is,

the reporting of

however, that the

"psychiatric" in

they linked

it

some

to states

too easy to get afraid" as well as

normal reaction to psychological trauma. Also

the Eskimos look

upon palpitations as a premonition of a "faint," and some of them viewed a "faint" as chiefly characterized by

the cessation of the heart beat rather than

by unconsciousness.

A

Psychophysiological Indicators

among Eskimos

"faint" was, in fact, described as "dying a

marked

among

in the last

little

125

bit."

As

re-

chapter, fainting seemed to be quite frequent

the Eskimos.* Thus, besides noting the appropriateness

we would recommend further exploration of this area through questions such as, "Do you take weak turns?" "Do you get dizzy or faint often?" and "Do you ever of the palpitation item,

lose consciousness?"

7

Other questions that could be asked

as

ways of investigating the psychology and would refer to "choking sensations," "hair-raising experiences,"

physiology of fear

and "goose

We

flesh."

expected that the item on nightmares might be espe-

also

cially appropriate to a

group that practices witchcraft and other

forms of spiritualism. During the year there were a number of

which Eskimos elaborated in dreams. For example, two saw a big animal prowling around the village at night. This was so vivid a threat that for several

"scares"

or three people thought they

young men took turns standing watch to guard the vilSome people had "bad dreams" about this eerie creature.

nights lage.

Nor should "voodoo"

Among

witchcraft. to

death be ignored in a group that believes in

were imputed would be pertinent to ask about example, "Have you ever felt that you

these Eskimos, several deaths

"voodoo" sorcery, and

"voodoo" experiences; for

it

were being hexed and might die?" This concludes the statement of recommendations and conjectures based

on knowledge of Eskimo

summarized

as

culture.

The review can be

an attempt to separate those questions which

seem to be equally good indicators for the Eskimos from those questions

which might not

be.

We

judged ten questions to be

appropriate for the Eskimos in their present form

("present

health trouble," "susceptibility to disease," "vitamin pills," "pat-

ent medicine," "loss of appetite," "hands tremble," "hands or * Also, as remarked in the last chapter, conversion reactions seemed to be more prevalent than anticipated. Although conversion is not related to the point in hand nor directly relevant to other points in these five categories, we do want to observe that questioning in this area would

seem

desirable.

Approaches

126

sweat,"

feet

"nervous

to Cross-cultural Psychiatry

breakdown,"

"sick

we

"trouble sleeping"). Eight questions,

headaches,"

and

would have

thought,

different meaning, either being unintelligible because of wording

("tired

mornings" and "ailments

all

over") or referring to be-

havior and sensations that are especially

common

for cultural

and physical reasons and for which the enhanced or reduced psychiatric implications would have to be established through

work ("smoking," "arms and

further

stomach," mares").

We

and "food

The detail

were undecided about two questions ("bad

taste,"

tasteless").

credence of these ideas can

by comparing

now

be examined in greater

the areas of convergence and divergence in

response patterns of the Eskimo sample and

One

"upset

asleep,"

legs

"cold sweats," and "night-

"heart beating hard,"

of the Stirling groups

two

subjects living in rural communities.

The

Stirling samples.

sample of 1,003

a probability

is

other

a

is

group of

ninety-three diagnosed neurotic subjects from in-patient and outpatient services in the general area of Stirling County.

swers from

this latter

group were those mentioned

The

an-

earlier as

HOS scores em-

having been used in selecting and weighting the

ployed in the Stirling Study.

We

know, then, that the two Stirling samples are different: a group identified as "symptom-carriers"; the other is a typical community population in which, we can presume, the one

is

symptom-carriers are

made

much

less

concentrated.

An

assumption

for the twenty-question review as well as for this compara-

tive analysis like that

is

that the sample

from the Eskimo

village

is

more

of the Stirling communities than like the population of

neurotic patients in terms of the prevalence of

ill

people. This

view rests on the strong unlikelihood that the Eskimo sample would include as great a number of symptom-carriers as a group purposefully defined as neurotic

—even though, one could

few more psychiatrically the Eskimo village owing to the dearth

there might be a in

services. Figures

IV- 1 and IV- 2 present

ill

guess,

people maintained

of hospital and clinic

HOS

data on the three

Psychophysiological Indicators

among

Eski?nos

127

populations showing that the Eskimo village sample and the sample of Stirling

community respondents

to each other than either

Figure IV- 1 constructed

is

a

are indeed

more

similar

to the sample of neurotic patients.

diagram of each of the three populations,

by scoring

sample respondent. Stirling

is

HOS

the

The

information given

scoring system

Study has been employed, and

it

by each

worked out

in

the

has been assumed that

the samples are an adequate reflection of the populations as

r

35%t

0

28




Stirling

Stirling

neurotic sample

community sample

_

Eskimo village

sample

on raw data of the Stirling weighted scores for three samples. Ordinate = percentage of sample population. Abscissa = Stirling weighted HOS scores. The range is from o to 28, low scores meaning illness and high scores "wellness." Figure IV- 1. Frequency diagram based

wholes.

The

lations are

similarities

and differences between the three popu-

brought out more coherently by the application of

shown

probit analysis as

in

Figure IV- 2. This analysis was

undertaken in order to examine the consistency of the raw data with the normal distribution of frequencies. probit technique,

it

By means

of this

has been possible to project the presumed

normal population from the evidence provided

in the sample

study. 8 This figure appears to verify the similarity of the

two

16%

14% -

12%

-

10% -

10% Stirling

B%-

M-

-

(P

-

community residents

20 5.7

6%-

Well

-=»

4%-

2%0% 12% Stirling neurotics

10%

Figure Stirling

ft

=10.8

cr

-

4.9

IV -2. Frequency community

normal curves

distributions of

residents,

and

HOS

Stirling

scores for

Eskimo

villagers,

neurotics with best-fitting

Psychophysiological Indicators

community populations and

among Eskimos

their difference

from

129

that of the

neurotics.

The

next task

is

to look at the

for the individual questions.

Eskimo and

Stirling responses

These materials are given

in Figure

IV-3. Each lined bar represents two standard deviations around the

mean per cent of

the Eskimos responding "often," "some-

times," or "never" to each question.

same meaning for the for the neurotics.

The checked

Stirling respondents,

The

use of

bars have the

and the dotted bars

two standard deviations conby showing the range

tributes to the understanding of these data

which two-thirds of the responses

in

fall,

assuming normal

distributions.

Inspection of this chart indicates that there

response pattern for the Stirling patients that of the Stirling

is

which

a characteristic

is

different

from

community members.* The general paradigm

of the patients' response pattern (based on averaging)

is

for 25

per cent to respond "often," 44 per cent "sometimes," and 31 per cent "never." The paradigm for the community residents is 9 per cent "often," 24 per cent "sometimes," and 67 per cent "never." Because the Eskimo sample is small, the range of 2

standard deviations

is

considerably broader than the ranges for

the Stirling samples. Nevertheless the

HOS

it is

immediately apparent that

questions produced a unique distribution of responses

among Eskimos.

It is

theoretically possible that

all

the Eskimos

would have responded "never" to every item, in which case we would have concluded that these questions were probably meaningless

and certainly incompetent for differentiating psychi-

ill Eskimos from those in good mental health. Also the Eskimo pattern is, for some questions, similar to that of the

atrically

*

Nineteen of the questions provide a trichotomous response pattern; one requires the choice of "yes" or "no." This gives a total of 59 possible comparisons. For the Stirling community residents and the Stirling patients there are only nine instances where the standard deviation ranges overlap. This includes the questions on vitamin pills and patent medicines, which are omitted from Figure IV-3 because not every Eskimo was asked these questions.

Figure IV-3. Comparison of Eskimo and Stirling response patterns* Eskimo

I.

villagers

Stirling

community residents

Stirling neurotics

Present health trouble?

1

^5

0%

40%

20%

60%

60%

100%

2. Susceptible to diseases?

Often

Sometimes

Never

100%

* The diagram for each question is arranged so that the figures at the bottom represent the percentage of the population responding Often, Sometimes, or Never. The bars represent two standard deviations around the mean for the

respective population, and the

middle of the bar. the facts that:

(1)

The

mean

for each

(the Stirling residents

tions

drew

indicated

the three samples are different in

range for the smaller sample (the Eskimos)

two

is

by

a line

difference in the lengths of the bars

and the

is

through the explained by

and, hence, the

larger than that for the other

Stirling neurotics),

a particularly large or small

size,

is

number

and

(2)

where ques-

of responses in the Often,

Sometimes, or Never category, the range is smaller than if the mean had more nearly approached 50 per cent. It should be further noted that where a question elicited no responses in a given category (and this occurred only for the Eskimos in the Often category for questions 6, 8, 9, 11, and 17, and in the

Never category for question 13) the two standard-deviation range is from o to 13.7 per cent.

in this instance,

130

for zero,

IV -3

Figure Loss of appetite?

3.

0% 4.

(cont.)

100%

20°/c

Bad taste?

*