BASIC CONCEPTS OF ANTHROPOLOGICAL PSYCHIATRY

Retour au texte français

 

Contents of this Chapter :

1) Illness: the building of a representation

2) Nosography: cultural classifying of diseases representations

3) Nosology: systemic organizing principle of diseases representations

4) The origin of diseases

5) Symbolic axiology: utilization of a traditional nosography

6) Symbol and diabol

7) The notion of symbolic and diabolic shifter

 

"Man is a sick animal"... said Miguel de UNAMUNO.

What is properly a sickness (especially a mental one)? How shall we come to an agreement on how to talk about it? How does an anthropological approach describe the building of an illness (especially a mental one) and, more generally, the building of a personality?

What are the bases of that description, what method is used, what are the results obtained?

1) Illness: the building of a representation:

Medicine considers illness as a natural object, and defines it as a functional trouble of the body. We may admit this definition, while observing that illness is altogether something else, let us say the idea that grows in our mind about it when we think as individuals (sick persons, sick-nurses, healers, kin of a sick person...) or as members of society (citizens, members of a cultural group...). The representation of illness is a part of illness itself.

Is this statement well grounded? Unquestionably, the representation of illness has an influence on the behaviour of the sick, and of his/her entourage, with consequences - sometimes severe, sometimes happy - on the issue of the illness.

But we can go further:

- the representation of illness leads to its classification into a nosographic category. Handling problems through categories is a feature of the human mind, and induces a similar behaviour towards the problems thus collected together .  

- the representation of illness notably influences the experience of the sick person, sometimes making  easier the fact of being sick, sometimes making it unbearable. Perhaps it may mobilize the defence mechanisms of the organism (but this still remains an hypothesis). 

- to a large extent, the representation of illness takes part  in elaborating  therapeutic strategies and attitudes. It induces or prevents therapeutical behaviours, which sometimes are decisive.

This is worth for all kind of diseases, whatever their origin and their seat may be. For instance, we point out how difficult it is to treat rationally  the diabetes of patients belonging to some cultural traditions, just as it is difficult to treat rationally nicotinism, alcoholism or obesity in Western societies. The difficulties are due to the social representation of these diseases in the considered societies.

In the case of mental illnesses (which is a nosographic category in European tradition), one would be  tempted to think that the representation is the illness itself. Why? Well, because the symptoms of these diseases  vary considerably according to the evolution of their social representations. Hysteria is a typical example: it was very frequent under its canonical form at the end of the XIXth Century, especially among women, whilst today it takes  hidden aspects, to such an extent that one says it is vanishing. Indeed, our society as a whole has become hysterical... Generally, Oedipian   neuroses often give way to less differentiated neurotical states, which are said borderline. Psychoses would be steadier? No... for schizophrenia appears under so many and so multiple forms, which are often unprecedented (for instance in co-morbidity with addictive states), and its prognosis today is  so different  from  the teaching of KRAEPELIN, that we  cannot speak about it, except by using a very wide definition, which loses any specific meaning. Epidemiological studies, for instance the OMS study which came to the conclusion that schizophrenia had the same prevalence all around the world, adopted the definition of the American School of Psychiatry: this definition does not take into account  evolutive differences, which however are crucial to the patients: a spontaneously curable psychosis and a chronic one are labelled as one and the same. Anyway, why are the great majority of schizophrenic states spontaneously curable in most traditional societies, whereas in Europe and Northern America they become chronic? This matter can be dealt with, only if there is an epidemiological query.

Once socially constructed, the  representation of illness still has to settle into a person's mind, so that this person comes to define him/herself and to behave according to that image, thus confirming people's opinion which defines him/her as sick.

Besides, there is no reason to reject the hypothesis, that the mental representation of a given pathological state could in fine affect the  patient's cerebral functioning.

2) Nosography: cultural classifying of diseases representations :

Those who have had the chance of working overseas as physician, know that all peoples have their own classification of diseases, better said they have representations for the diseases that they identify in their own setting. Sometimes these classifications will appear  simplistic or partial to a superficial observer. However, they are an essential part of their culture. They are absolutely not arbitrary, and the more we get to know them, the more we become able to understand their complexity. They ground upon categories, the relevance of which is admitted far beyond the public health field. For example, they can be based on a twofold opposition  (hot and cold, dry and wet, yang and yin), or on a system of features combined with one another, as in the Galenic theory of Humours which ruled Western medicine during a thousand years. It is possible to meet with these features again  in connected, or sometimes in apparently unconnected fields: eating habits, marriage customs, myths... The healing practices rest on logical connections which are established between homologous sites in these fields. A good and simple example is the following: when someone suffers a cold disease, he must not drink too much water, which is wet, thus cold, and so on.

Such endogenous nosographies (i.e. peculiar to a non-western traditional culture) concern also psychiatry, once admitted that traditional cultures seldom separate mental diseases from physical ones, or that they have a different way to distinguish them, than Westerners have. Frequently, the main or the only evidence that a disease belongs to a given nosographic category is its admitted cause. So, the same category (for instance, all the diseases caused by witchcraft) can include in all logic some mental diseases (such as an attack of panic, with a feeling of imminent death) and other ones to which a western physician will give a physical explanation (such as a severe malaria). One may believe altogether that Plasmodium falciparum is the responsible factor of malaria, without excluding the determinant role of the witch.  Indeed, why did the mosquito bite just this man, at this precise moment? The operating cause can always be distinct from the efficient cause.

The big question remains to know whether traditional nosographies, coming from a popular or from a scholar origin, are only destined to be replaced by more accurate theories (those of scientific knowledge), or whether they have some special relevance. Anthropological psychiatry is convinced of their relevance, when applied to their own cultural field. In order to understand this somewhat provocative statement, it is necessary to grasp the existence of an organizing principle, underlying both cultural nosography and any individual pathological state.

3) Nosology: a systemic organizing principle for the representation of diseases:

A system is made from interacting elements. The word "interacting" implies that any change to an element will necessarily affect every other one. When comparing the nosographies which are used in various cultures, one can guess right away that these notions are relevant:

- we can see some of the causal categories taking more or less importance, changing form, branching off, sometimes vanishing and being replaced by others which seem to take up, differently, a similar place in the system. For instance, in Central Africa and in the Gulf of Guinea, witchcraft is almost identical with hoodoo practices (everyone can be a witch). On the contrary, the two notions are clearly marked off in Senegal (witches are beings apart). In North Africa, witchcraft becomes manifold with various forms of  immediate evil influence ("immediate" means that they do not make use of objects), as evil eye, evil food... which tend to draw nearer to mediate practices (puppets pricked with needles, buried objects...) without being assimilated to them. In Southern Europe, exists the same belief  as in Morocco, but the notion of poisoning tends to replace that of evil food: it seems to be the modernization of the African notion of Night flesh. In Northern Europe, it seems that witchcraft makes use of mediate practices. However, the notion of evil eye does not disappear.

- regarding the syndrome categories (the various forms that diseases can take), we observe similar transforming processes: for each causal category, there are typical syndromes, the assigning of which is unquestionable, and atypical ones, the cause of which is doubtful.   The occurrence of a typical syndrome varies, from one  culture to another, depending on the significance of the causing event in the sight of the concerned culture. It seems, thus, that the patient builds the symptoms of his disease with the cultural materials at his disposal.

However, cultural nosography is not satisfactory as an organizing principle.  It is only a cultural attempt for approaching as closely as possible the genuine organizing principle of diseases, which remains unreachable. Indeed, atypical syndromes are so numerous, that we must consider cultural nosography to be nothing but an imperfect instrument. Occidental nosography, we know, is not an exception to that statement. We also can ascertain that a patient, especially a psychotic one, devotes a part of his elaborating energy to transform cultural data, and it may be asked why he does so, and for what aim. At this point, we meet again the Freudian notion of psychic causality: some psycho-dynamic processes escape social causality (while resting on it), and distort (in other words elaborate) collective data for individual reasons. But there is something else:   

Culture is not reductible to what one can say about it. There is a hidden, implicit part in the cultural functioning.  What appears in the sunlights, is nothing else than the self-referential, self-justifying, ideological talk that culture utters about itself. Nosography is a part of that talk. By nature, it can only comment upon the most conformist side of pathogenesis. Consequently, while stating that a true organizing principle does exist, and while trying to find it behind cultural nosography, yet we know that it will remain inaccessible, except as a guideline which we name "nosology" by convention.

In our meaning, nosology is an implicit cultural system, which determines both the building of mental diseases and their syndromic form, the patients not being aware of the process, and the scientists and masters of knowledge not grasping more than scraps of it. In this perspective, nosography occupies, in the cultural talk, the place that nosology occupies in the real world. It says what culture has managed to know about it.

4) The origin of diseases:

Without prejudice to other origins (for instance the biological one), anthropological psychiatry points out to two kinds of causal processes: people's cultural belonging, and their social position.

- cultural belonging places the human being into a network of meaning. It gives everybody a proper position, which defines him in the eyes of the others as well as in his own eyes. It is a vital need, the effects of which are good, except when  the assigned place is ill-defined, fuzzy, or really unfavourable. Sometimes a place reveals itself as unfavourable, only in peculiar circumstances, as when a sudden cultural change happens, for instance during a migration. Sometimes, someone understands, as a casual discovery, that the place on which he had founded his personal identity was unstable. As we have seen, culture has its faults, its failures. It claims to give a global explanation of human experience, while far from being able to do it. Its contradictions sometimes unsettles its coherence. Even when the contradiction only concerns some side aspect of culture, it can be serious for that person who based on it his/her existence. When this contradiction begins to reveal itself, it may be the starting point of a mental disease (see further: diabol).  

- the power relationship in the social intercourse  also plays its role as  pathogenetic. We can note that the social trajectory of psychiatric patients is nearly always downwards. It matters little whether it is a causal factor, or the consequence of a previous disease. Even in this latter case, the worsening of social position leads to a vicious circle, which keeps up or heightens illness. In Hospitals, these phenomena are obvious and almost experimental. Provisionally or not, the in-patient stands at the lowest grade of a social ladder where the physician, the chief-nurse... stand on the highest steps. He tries to maintain himself in this milieu; he tries to recover a better position in a competitive relationship with other patients. On a very small scale, the internal exchange between patients plays there the same regulating role as the international exchange or the money-market for the global society: that is to say, fixing the value of things and people. During this exchange, one becomes a little richer, another one a little poorer. Not so much in terms of money, but more in terms of symbolic capital. The problem is, that the symbolic capital which has a value inside the Hospital, has none outside. However, a patient who succeeds in improving his symbolic capital, at the same time improves his social position inside the hospital and gets a better chance to leave it in favourable circumstances.

As a symbolic system, culture provides the exchange processes with value marks, and main references. The course of exchange gives a value to things and people according to supply and demand. The social position of each individual goes upwards or downwards, as they earn or lose symbolic capital. The one who earns symbolic capital earns also social prestige, and thereby he gets the possibility of  acquiring easily the necessary material and symbolic resources. Other people have to do without, unless they use unlawful means such as robbery, racket and so on. There lies the origin of many behavioural troubles.

We are attempting to describe in general terms the pathogenetic process (which happens when symbolic capital is wasted, and social position  tumbles down) and the therapeutic process ( when just the contrary happens). At the start of these processes is the exchange of goods and the exchange of signs, that is to say the interaction between human beings. Interaction is unceasing and endless. It continuously produces results, such as behavioural sequences and representations (because we are made in such a manner, that we always have in our mind an image of what we are doing, and who we are while doing it). One of the most important representations, for our concern, is of course personal identity which can be both imaginary and symbolic, and is necessarily disturbed in mental illnesses and dissociated in schizophrenia.

5) Symbolic axiology: utilization of a traditional nosography:

The traditional nosography used in Senegal and neighbouring countries, studied by the School of Fann (H. COLLOMB, M. DIOP, E. & M.C. ORTIGUES, A. ZEMPLENI, J. RABAIN and others) enabled us to understand three points:

Let us look into it more closely:

According to Senegalese traditional healers, there are four main causes of mental disease: in the Wolof language, they are named Jine,  Rab,  Dömm,  Ligeey. Between them, combinations are many, allowing a very subtle interpretation of the numerous  clinical variants encountered.

Each of these causal explanations is eventually connected with the axes of personal identification, such as it works in the Wolof-Lebu society:

It is possible to represent the foregoing graphically:

Mixed societies                                                                   Patrilinear societies 

The left diagram is relevant to a society, of which the parenthood system has preserved equality between both family lines, the father's and the mother's ones, figured by the diagonal axes. The right diagram represents a patrilinear parenthood system, where only counts the father's filiation, here figured by a vertical axis. In both diagrams, the horizontal one represents the social and/or matrimonial alliance. In the right diagram, the diagonal line with interrupted tracing is what remains from the mother's filiation in a patriarchal society. The corresponding traditional beliefs are mentioned by their Wolof name, at the relevant place.

If we take into account, that every human being has two parents, two family lines, and has to conclude an alliance when aiming to breed; if we admit, that our symbolic insertion in this network is the more important factor of our personal identity; then we come to the conclusion that the significance of those diagrams is universal . This statement is confirmed by the fact that it is not only in a Wolof-Lebu context that mental troubles can be studied as impacts of former events (traumas, family conflicts, "incestuous" or "incestual" confusions), transmitted through generations and affecting the patient's personal identity.

In several oceanian cultures, the father's role in pregnancy is officially ignored. Women are believed to become pregnant by the power of ancestral spirits. Husbands are thus discharged from any responsibility, as from any rights on "their" offspring. Even if that belief does not prevent at all men and women from "playing together", it is indeed the official beliefs, in the culture of these peoples, which determine the social roles and postures.  In these societies, the father's axis is rubbed off. In our diagram, the situation would be represented as follows:

                       Matrilinear society

In the Occidental tradition, as it existed at the beginning of XXth Century, the family model was patriarchal. However, peculiar circumstances led to another kind of rubbing off: the Ancestors ceased to be more important than the immediate genitors, the parents. Gradually, the intimate relationship between a man and a woman has become more important than the linkage sealed through them, between their families. Family stopped being a lineage and became nuclear. In this case, the scheme will be modified as follows:

                      Societies with nuclear families

At that time S. FREUD stated that the myth of Oedipus was a universal complex, and a model for psychic structure. In our diagram, we place the Oedipian triangle (father, mother, Ego) inside the larger scheme of family lines and alliance. As a matter of fact, the Oedipian complex can be considered as universal, but it takes its structural importance only when a larger structure, which builds personal identification by introducing the individual in a network of lineages and social relationships, has failed. In the nuclear family, for any individual, the best way (perhaps the only one) of building a satisfying personal identity is Oedipian rivalry. We can also assess that the mechanism  of personal identification itself has changed: in a lineage parenthood society, it builds upon the insertion into a relational network, structured both by the family lines and by the social links; in a modern society, it lies on solitary self-assertion through competition and rivalry. 

The evolution of the Western family goes on. Nowadays, the nuclear family is not really the norm anymore, the symbolic role of the father is fading away, Oedipian references are becoming blurred. For young people, the first reference seems to be more and more their belonging to a group of youths of the same age. The situation could be described as follows:

 Post-modern society

For the first time, the two axes of Filiation are now both failing, in their symbolic function. The mother's side axis, because it lost, centuries ago, its social legitimacy; the father's side axis, because it recently began to fade. In compensation, the Alliance axis takes more and more importance. Consequently, if the band of friends disappears or scatters, the young  often feels seriously distressed, with clinical consequences such as suicide attempts.... However, although less efficient, the faded axes remain active, in another way: a principle of African anthropological clinics, which seems to be relevant in Europe too, is that an axis which is not useful to symbolic identification starts producing symptoms. In other words, we are sick from what we are (our personal identity), and we are what the symbols defining our identity let us be.

6) Symbol and diabol:

We have to repeat here that there is a strong connection between symbols and culture. We may consider culture as a network of meanings which refer to one another, and  form together a kind of symbolic map of the world. The meaningful units of that network are called symbols. Their characteristics is their double meaning, one being in relation to the things they symbolize (the Signified), the other one in relation to other symbols. It is necessary, indeed, that the various elements which compound culture should form together a coherent whole, able to give a convincing explanation of the world , in the eye of most people. This is the meaning of the Greek word σύμβολον, symbol, coming from the  verb συμβάλλω which litterally means "to throw together", that is to say, "to bring together, to connect, to compare". Originally, a symbol was a broken object, the two fragments of which were given to bearers who did not know each other until the joining up of the fragments allowed their recognition: in short, reunion makes sense.

At the opposite, there is a verb διαβάλλω, "to throw through", which finally means "to separate, to disunite" and also, among others, "to slander, to deceive". The derived noun is διάβολον, "what disunites", and also "calumny". The masculine form of this word is διάβολος, "the slanderer", and also, in the Christian tradition, the Devil. The suggested image is an element of a whole, which in its relation with other elements ruins the unity and coherence of the whole, which therefore ends up with meaning nothing. In short, disunion destroys the sense.

Clearly, on the etymological plane, symbol and the devil are antithetical. What does it mean in reality?

When a patient becomes delirious, he goes through a very painful and distressing experience, where he sees all his usual references breaking down. He loses the natural sense of evidence. This feeling was simply due to an impression of coherence of the world given by culture, as long it was functioning rightly for him. What psychiatrists call the primary delusional experience is, on the contrary, the experience of an incomprehensible world, where among other horrors, the limits between Self and Other are abolished. Often, this experience is understood as the intrusion into the  borders of the Self of an external force, the best figuration of it being the Devil in our cultures. If we give to the word symbol its etymological meaning mentioned above, one is allowed to use the word diabol for the antonymous concept, that is to say, the element that destroys the  coherence of live experience. Now, this element does exist. We can find it in almost all cases of psychosis, on condition that we do some searching, and that this should not be too remote from the beginning of the trouble. Very soon, indeed, the delirious process (working through) erases the memory of the initial trouble, replacing it by a secondary mental coherence, which is certainly delirious too, but gives back to the patient  a semblance of security.   

Under which form can we observe a diabol? In the account given by patients of their first delirious moments, one can often point out a thing, a word, a belief, a voice, in short something which has suddenly upset the order of things, and from which nothing will ever be as it was before. That thing is and will remain unaccountable for it is a rough factum brutum, round which the further delirium will display its vain attempts to restore the lost coherence.

However, for any external and neutral observer, a diabol is a symbolic object just as any other one, not even specially uncanny. As a matter of fact, it is a symbol, but the meaning of that symbol has been radically disavowed (Verwerfung, forclusion) for the psychotic patient, and only for him, so much so, that it cannot be reinserted into a meaningful context anymore.

To recognize a diabol, is to know the exact place where reason failed, and to know what ghost was dwelling there. It is to grasp all of a sudden, what was seen by the patient in the mirror that Culture was holding up to him: a fracture in his personality, linked with a fracture in the culture; a geometrical locus where the collective and the individual mingle, and discover together that their common basis is but a vacuum.

7) The notion of symbolic and diabolic shifter : 

This notion originates in the work of the linguist Roman JAKOBSON. He calls shifter the personal pronoun which, he states, differs from the noun precisely because it does not designate, by itself, any referent, any object, but switches the talk in either way. In a conversation the person who speaks calls himself "I", but as early as the next sentence this "I" becomes a "you": the switch of pronoun indicates that the speaker is not the same. It is a continuous gymnastic, that  we are are so accustomed to as speaking beings that we find it easy. But this is not the opinion of young children learning to speak, nor that of psychotics who prefer to anchor their frail identity on to a single and stable word, using either the third person of speech to designate themselves (it is the most secure), or (if they see themselves only in an other person's desire) using the second person.

Jeanne FAVRET-SAADA, an anthropologist who studied sorcery in the Norman "Bocage" area, revived the notion of shifter  in a peculiar acception. She noted, in the practice of some "désorceleurs" (healers who withdraw the spell), an astonishing way of doing which made them able to canalize the latent violence of the victims, and turn them into aggressors: the aim is to attack the Sorcerer in order to defend oneself, to stop being overcome and resigned, and then little by little to become enterprising and self-assured. Evidently such evolution is good for the victims' farm estate, and helps contend with the chronical bad luck they endure. About this practice, the author speaks of shifter of violence.    

The family is the closesest group, the role of which is to construct the personality of any child born in its bosom by inserting him into a social symbolic structure. Necessarily, it is also the place where the failures of that construction occur.  With regards to Senegal (but he could have made the same statements anywhere) Henri COLLOMB described some situations where the family relationships compel the kin into a permanent rivalry, owing to ambiguous identification processes. In such families, may exist a floating violence, a death wish which initially has no definite object, but suddenly focuses on someone, with heavy consequences (H. COLLOMB, Sorcellerie-Anthropophagie, genèse et fonction (in French), L'Evolution Psychiatrique, XLIII, III, 1978). The bridge between floating violence and the pointing out of some next of kin, often a child, who will henceforth be a victim of processes however unconscious, is, according to FAVRET-SAADA, although  in another context, a shifter of violence.

Let us generalize these notions:

Just as the Oedipus complex, and owing to its personal pronouns (I, You, He/She), language has a triangular structure. One may admit, it contributes to the structuration of the child's personality. A personality is not psychotic in so far as it becomes able to establish a distance from the object he desires, without hallucinating it, and not confusing the thing with the word that signifies the thing. The "pronominal gymnastic" we have spoken about is there to give help to that work. At the same time it is a mark of its achievement. A good use of the pronouns lies with the reciprocity of symbolic exchanges: as a matter of fact, this is only when the security of the persons (and of their desire) is granted during the intercourse, that they will accept to renounce their illusory almightiness and imaginary identification, and enter into the challenging but fruitful game of triangular relationships, which imply recognition of others as human persons, with the same rights and status as oneself.

When these conditions of security and reciprocity are not granted, speech exchanges are made in a very special way, that may be detected through observation. A great part of the assertions have no definite addressee, even no clearly defined emitter; the same ambiguous, vaguely aggressive sentences are pronounced by one speaker, then by another one, without one knowing whom they are addressed to;  the pronominal terms are hazy, often impersonal; the shifter function of the pronouns is no longer correctly fulfilled; neither the speakers, nor the relationships between them are defined by these statements, which are emotionally pregnant, potentially threatening, thus adding to the looseness of the personal relationships. In such situations, my hypothesis is that one should appeal to another kind of shifter, in order to replace the failing personal pronouns. This other shifter is the diabolic shifter, which works as an imaginary projective identification.

In this view, we could say that the diabolic shifter is an imaginary unpersonal pronoun, which transforms symbolic language into an imaginary one. As far as it is applied to one of the kins, it transforms him into a designed patient. Affecting his personal identity, it transforms him into a psychotic. The diabolic shifter, besides, is not a word. It is a linguistic function (a way of speaking in a well-defined context) which instead of helping to clarify the communication, blurrs its meaning. It is used to designate someone in the group who will be henceforth  the mad one, and to designate what in his speech and in the speech of his family group, will have no meaning henceforth . It works on two levels:

Ornaments from the King Ghezo palace, Abomey (Benin Republic)

Bibliography (in French)

Links (in French)

Back to frontpage

Back to preceding chapter

Retour au texte français