This blog reflects my deep interest in the different ways the various cultures and subcultures in this world conceive of the world and our lives within it. I was born in Asia, hold a UK passport, lived for most of my adult life in France, and now live in the US as a resident alien, working as a psychotherapist in private practice in San Francisco. Issues of cultural identity and displacement are very close to 'home' for me, and for many of my clients.

Thursday, April 14, 2011

First, Know Your Djinn: More on Ethnopsychiatry

Ethnopsychiatry was developed in Paris by Dr Tobie Nathan—a classically trained psychiatrist treating immigrant patients from West and North Africa, who did not respond well to methods based on a Western paradigm.

A significant part of the problem these particular clients have is that they have not been able to acculturate to the host culture, and so they live in a dislocated zone: between a culture from which they have been separated, and one within which they do not or cannot fit. Since much of their problem consists in this dislocation, the act of being reconnected with their ancestral culture, and strengthened in their identity as one who carries this culture, even in a foreign land, is a vital part of their return to health.

Patients at the ethnopsychiatry center are seen with their families, by a treatment team which includes an ‘ethno-clinical mediator’, who is a specialist in the patient’s language and culture. The consultation happens in the patient’s own language, with an interpreter so that the patient does not have to translate their reality through the filter of a foreign language which lacks or distorts the ideas they need to express.

Ethnopsychiatry: basic assumptions
Ethnopsychiatry posits that our culture is intrinsic to who we are, rather than something overlaid on top of a ‘neutral’ self. Our personal identity therefore is inextricable from our cultural identity.

Ethnopsychiatry is based on structuralist analysis: the idea that anything (including any symptom) has meaning only by virtue of its position at the intersection of a matrix of interwoven relationships. So behind any pathology is a whole system of thought, actions, actors, and purposes--which constitute its meaning and its usefulness in expressing psychic dis-ease.

In order to effectively treat someone, you have to use their own, culturally-ratified values and beliefs. Each culture has its own system of values and beliefs around personal misfortune, illness, therapists, and treatment techniques. This is of course not only true of people from traditional cultures—in Western society, we believe that talking about emotions will help, that crying is good for us, and that taking pills can make us better. These are no more ‘normal’ than going to a shaman and making a fetish doll; they just seem more normal to us, since we grew up being taught that these are effective means of curing ourselves.

“Curing” the client involves making meaning out of the patient’s symptoms, in terms of their own cultural mythology and values. This results not only alleviates symptoms, but helps the client (re)connect to their culture—strengthening their identity, as part of a stronger cultural identity.

Example 1: The djinn
The djinn (spirit), is an important part of the range of psychopathologies available to the people of North Africa. To think of a djinn merely as an imaginary spirit would be an error, since this leaves out the web of social and cultural factors that carry the real significance of the djinn in peoples’ lives. A djinn is radically other, but still the mirror image of the human being. Djinns have gender, they can reproduce by having children, and they have a religion, being Muslim, Christian, Jewish or Pagan. However, “they live in the other world; the world of the night, the desert, the forest, the bush, of rubbish, of ruins, of sewers, of the blood of animals”. Djinns are creatures of boundaries and limits. One of their functions is to mediate difficult transitions.

Since all djinns are different, in order to treat someone possessed by a djinn, the healer must get to know the djinn, find out its name and geneology, discover what its intentions are, investigate what it desires and needs, identify the objects it likes, and define the acts and rituals it expects. With this information, the healer can enter into rites that constitute negotiations with the djinn. Finally the healer can identify the benefits the client gains from his or her association with the djinn.

In this approach, ethnopsychiatry joins James Hillmann, with his insistence on respecting the pathology for its living message, rather than trying to diagnose it, dissect and label it, analyze and interpret it. It also joins with the most effective traditional healers in that the aim is not to cure the patient of believing in djinns, but rather to respect the djinn and treat with it in a creative, ritualistic way according to its nature, for the good of the patient, the healer and in some cases also the djinn itself.

Dr Nathan relates a case study concerning a child who becomes possessed by a djinn. The child is the identified patient, but in fact the symptoms relate to the parents’ problems with fitting into the host culture, as well as to the father’s past history, as a spiritually ‘pure’ man who was celibate for 40 years before marriage. The djinn possesses the boy when he starts school; in other words, when he enters into the foreign French society in which they live, and becomes therefore himself in some ways a foreigner, which makes him ‘impure’ culturally. (It’s notable that when the djinn possesses the boy, he insults his father in French, not in Arabic.) The djinn represents the otherness and impurity to which the father cannot adjust, and at the same she represents the solution to the problem, for the presence of the djinn takes the boy out of school and compels the family to return to tradition in order to treat the boy.

Much of the treatment in ethnopsychiatry seems to consist in the patient being heard and understood by people who understand his or her language and culture. The normalization and validation, and the intrinsically healing effect of being mirrored within this containing relationship cannot be underplayed. Discussing the symptoms within the context of the client’s culture helps the client to constitute a meaning for the symptoms. This helps the patient to reinforce—or in the case of children of immigrants to create—their identity within their cultural framework. Which translates to a reinforcement or creation of his or her identity per se.

Sometimes however, the ethnopsychiatric team goes further, deliberately representing the patient’s problem to the patient in terms which it considers will most likely facilitate (re)construction of meaning, and subsequent healing. This is always done by taking into account not only the cultural interpretation of the symptoms, but also the key ways the culture itself is constituted. Example 2 shows how this is done.

Example 2: Drug addiction in a gypsy family

In gypsy (Roma) society one of the “basic cultural defense mechanisms lies in strengthening the cultural borders, constantly defining a limit between the inner and outer worlds”. Since the tribe moves continually, the culture is not held externally, but rather each individual holds the culture within them, and “is the guardian of the group’s soul”. Drug addiction is new in French gypsy society, and it threatens this system. Drugs come into gypsy society through the gadjé (mainstream house-dweller culture), and drug addiction is considered to be a sign of a kidnapped soul.

In the case of a young gypsy woman addicted to heroin, and rejected by her mother who considers her to have crossed over to the gadjé and to have become non-human, the ethnopsychiatry team points out to the mother and daughter that the drug problem is not part of gypsy culture. They then suggest that the problem is linked to the death of the grandmother, because since she died, the family has no longer been protected (magically). They do this based on their knowledge that gypsy culture is “organized on the basis of witchcraft logic, in which every individual is involved sooner or later, either as a victim or perpetrator of acts of witchcraft”.

The mother, it turns out, has long suspected that the mother of her gadjé daughter-in-law used witchcraft to attract her son. The team encourages the mother to follow the dead grandmother’s request that she go to church and pray regularly (this gypsy tribe is traditionally Christian). After this, the mother brings to them an object she has found, which is clearly a curse set by a member of the family.

The treatment has consisted in reducing the isolation both of the daughter within the family, and of the family within the culture, by reinserting both mother and daughter within the cultural belief system. The intervention has also set in motion various self-healing actions within the culture:
1. The evil was identified as coming from outside, from the gadjé, which activates the “closing-in response of the gypsy world”.
2. Drug-addicted people are seen as “kidnapped souls”, so the treatment has to follow that cultural meaning, and counterbalance the kidnapping. Identifying the cause of the addiction as a curse made by someone in the family restores agency to mother and daughter, who can now make meaning of the situation and resort to counter-curses to combat the drug addiction, within the system of the culture.


Ethnopsychiatry is a profoundly pragmatic practice, based on a structuralist analysis of meaning, the individual and society. It is similar to certain other strands of psychotherapy in that it considers a symptom to arise not from intra-psychic pathology, but rather to be the best and truest possible expression of a dis-ease that has a social or familial cause. Tobie Nathan, like James Hillman, believes that, “in cases of psychic disorder, the patient’s suffering expresses the deepest truth of his being.” And like Hillman he considers that “healing” the patient is an act of monotheistic aggression. Instead of analyzing the symptom and diagnosing it, ethnopsychiatry addresses it within its own (cultural) system of meaning.

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