History of Mental Illness: A Cultural Psychiatry Retrospective

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Examining “mental illness” in societies where different world views, thought worlds, and habit patterns prevail is ordinarily frowned by social scientists since it involves analysis of phenomena steeped in modern conventions of knowledge. This book contravenes this position giving reasons for and ways of circumventing social science scruples. It formulates and provides details about they systems of healing of conditions of psychiatric interest that would have been found in ancient traditional and early modern period. It draws on the findings of Indian epidemiologists who have surveyed the prevalence and distribution of psychiatric disorders in modern and traditional settings of contemporary India. Their findings support the position that such conditions would have been found in earlier historical epochs.

In the book, information from cultural anthropology is used to formulate ideas and a perspective that encompass salient cultural and historical parameters of India as a sociocultural entity which have stood the test of time. Emphasis is placed on how Indian culture, religion, morality, sociology, and philosophical psychology which shape the world view and habit patterns of Indian peoples everywhere and throughout millennia. This nexus of ideas constituted the ontology and epistemology about psychiatric conditions in earlier historical epochs. It shaped their form, content and meaning and it provided a basis for approaches to healing. Normal and not so normal conceptions about behavior and well being are discussed based on indigenous systems of meaning. The manner in which psychiatric conditions were and still are formulated in the compilations of Caraka, Susruta, Vagbhata, and Bela are reviewed compared along with religious and spiritual viewpoints. Discussion of approach to conditions of psychiatric interest rooted in traditional Indian values provides a basis for critique and plea for broadening the scope and depth of the already vibrant and scientifically compelling psychiatry of contemporary India. The book aims to make modern psychiatry more responsive to India’s understanding of the human condition.

Horacio Fabrega Jr. is a practicing clinical neuropsychiatrist who is Professor of Psychiatry and Anthropology at the University of Pittsburgh. His academic work spans the fields not only of clinical and descriptive psychiatry but also of ethnomedicine, medical anthropology, and cultural psychiatry. He is the author of four books and over one hundred and fifty articles in peer review journals in these fields. He was Director of Medical Student Education Program at University of Pittsburgh School of Medicine for fifteen years. For the last ten or so years his work has encompassed evolutionary psychology and psychiatry, involving theoretical study of the way conditions of psychiatric interest have changed during various phases of Human biological and cultural evolution. India represents case study for this position and the book summarizes it.

Foreword

This is the first book to take a comprehensive look at mental illness in India. It approaches the subject from the perspectives of history and social science and leaves no stone unturned in its attempt to paint a picture of the way mental disorders have historically been understood and treated in India in the past and also in the present. While focusing on India, Fabrega’s book, especially in its historical discussion of the pre-modern period, inevitably includes the whole of South Asia. Crucial to fabrega’s enterprise is the recognition that mental illness is a universal phenomenon that has affected all peoples throughout documented history. What separates one way of understanding and dealing with it from another is the social and cultural environment in which mental illness occurs.

An important part of fabrega’s book examines mental illness in South Asia’s indigenous medical tradition of Ayurveda. Understood from the Sanskrit word unmade, a mental disorder was a behavioural condition in which a person acted as if he were intoxicated. What may be considered as the mental or psychological problem went almost completely unremarked. Another form of mental illness found in ancient South Asia and mentioned in the early medical treatises of Ayurveda was possession. Recently, Frederick Smith has clarified the idea of possession in South Asia by showing that there was both good and bad possession; the former was associated with religious rites and activities, the latter with morbid conditions and the medical tradition of Ayurveda veda. The current work of Fabrega takes us beyond these basic ideas and helps us to understanding mental illness in a much wider context. In other words, his work may be regarded as a psychological reading of South Asian history and culture that will help to deepen and redefine the history and present understanding of psychiatry and psychology in South Asia. It is a most welcome addition to the scholarship in general and to the series Indian Medical Tradition.

Preface and Acknowledgements

The medicine of traditional India represents an early watershed in the worldwide evolution of medicine. In its many compilations Ayurveda explicitly addresses conditions that one may safely construe as of psychiatric interest. Its texts furnish a lens which one can use to discern how such conditions were conceptualized and dealt with a form of sickness within the scholarly, academic medical community of traditional India.

Viewed broadly, Ayurveda ‘psychiatry’ involves only the medical component of the many institutions that India evolved to formulate, understand, and cope with human emotional and behavioural problems. However, this is not to minimize the importance of Ayurveda but to emphasize that a civilization as rich as India’s in areas of science, philosophy, moral exposition, literature, art, social and political theory, and religion exemplified a host of other ‘non-medical’ approaches and solutions to the universal problems of psychological distress, disorder, and social comportment posed by conditions of psychiatric interest. A history of mental illness in India, therefore, involves taking into account not only an understanding of its medicine but also an appreciation of its diverse intellectual and cultural traditions and social practices and institutions outside of medicine per se, for these were also necessarily involved in formulating, appropriating, ‘domesticating’, coping with, and in the final event healing conditions of psychiatric interest.

It should be emphasized that combing the social and cultural fabric of traditional India searching for its understandings and resources for handling conditions of psychiatric interest constitutes an intellectual enterprise that is fraught with intellectual, academic pitfalls. For social scientists and historians to do so is impious: such an enterprise exemplifies the worst of ethnocentrism and anachronism. It reflects not only hubris and arrogance but is also intellectually, philosophically nonsensical. The concepts ‘mental illness’ and ‘psychiatry’ and their representation in the discipline and institution which has evolved around them represent inventions of the modern era and especially its science and medicine as determined by distinct cultural, historical and politico-economic circumstances. How can one presume to realistically discuss something as historically and culturally enmeshed in our history and social fabric as ‘mental illness’ and psychiatry’ are in a different society? Such constructs and what they prefer to and shape are the product of a distinct culture, and historical period. Western and modernist ideas, beliefs, and values about behaviour and medical phenomena represent one of many slants and conceits that human communities have evolved to make sense and handle a universal problem; namely, conditions of psychiatric interest. Other societies and historical mentalities simply did not share the theoretical conceits let alone the political, economic, sociological, and cultural conditions which in today’s modern world have made ‘mental illness’ and ‘psychiatry’ understandable, theoretically meaningful, and also socially problematic.

This book takes into consideration these criticisms and addresses them by drawing on ideas and generalizations based on findings of research from several sciences. It reviews and discusses the implications of the proposition that conditions of psychiatric interest are universal, a proposition supported by diverse lines of research in evolutionary biology, genetics, and comparative epidemiological and clinical psychiatric research. This, it is reasonable to presume that in ancient India conditions of psychiatric interest were on display, there to be observed in their respective cultural attire, and dealt with via meaningful social practices and institutions in other words, while psychiatric conditions are universal they are also shaped, given meaning, and dealt with in cultural terms.

The book builds on the insights of social scientists, especially anthropologists and social historians, who have expounded on the hazards and limitations of comparative research, which are imposed by theoretical problems of cultural relativism and historical anachronism. On the basis of generalizations from studies in cultural medical anthropology and social history of medicine, the argument pursued in this book presumes that all societies and cultures past and present necessarily evolve resources of knowledge and practice in order to cope with behavioural disturbances and breakdowns. The task is to use modern psychiatric and social science insights about sickness behaviour and psychiatric phenomena as a frame of reference for providing a reasonable picture of how conditions of psychiatric interest were formulated and dealt with in a culture and civilization of long ago. This method of procedure is reflected in the subtitle of this book: a cultural psychiatry retrospective means using contemporary generalizations about conditions of psychiatric interest derived from study of contemporary populations of India and elsewhere as a platform on which to examine the past of India as this has come to be understood I diverse disciplines; and bring to light how it formulated and handled psychiatric conditions.

The science and practice of modern clinical neuroscience psychiatry is not just a ‘Western’ achievement. India’s contemporary academic psychiatry is its equal. Indian scientists and psychiatrists are not just found in India’s research and academic, clinical centres, but many, following their training there, have migrated worldwide. The psychiatry research establishments of India and their efforts with respect to research, education, and practice exemplify the best of modern psychiatry worldwide.

India’s contemporary psychiatric establishment is special in that it is embedded in an alive, vibrant history and culture whose accomplishments in medical and mental health related knowledge, scholarship, and practice exemplify an ancestry of millennia and have become legendary. In the span of but a few generations India has had to weather the onslaught of imperialism and colonization by an alien culture and its science, medicine, and politico-economic dynamism. In a context of imposed Westernization and modernization India has had to accommodate to the modern perspective about phenomena of psychiatric interest, and considerably more, of course. India has served as a willing and gifted student and appropriated and even perfected its patron’s wares. But the mixture of intellectual and practical traditions and resources involving sickness and healing, the ancient and the modern, are pulsating realities in the contemporary social, medical scene that do not easily integrate with one another. Thus, one who intends to sort out the history of psychiatric illness in India has to learn what if any residua and realia of its past ideas, beliefs, and accomplishments I this area of knowledge and practice are represented in its contemporary approach to mental-illness.

Looked at differently, India presents one with an opportunity to examine, as though it presented a test case, the cultural evolution of psychiatry. A cultural psychiatry retrospective also involves examining the history of mental illness in India from the standpoint of social and cultural evolution, sorting out what has been retained from the past, what represents the new, and how each of these packages of knowledge and practice relate to one another.

There are many individuals who have provided me with direct, generous assistance in what has been an approximately four-year enter-prise. I would like to thank Drs. Deborah P. Bhattarcharyya, Mitchell Weiss, Dominik Wujastyk, Kenneth Zysk, G. Jan Meulenbeld, Richard Shweder, Joseph Alter, and Mary Ganguli. They have addressed my many annoying queries for material, references, and information; however, they cannot be held responsible for limitations if not deficiencies of my base of knowledge and reasoning. Members of the library staff of Western Psychiatric Institute and Clinic have been uniformly patient, helpful, and generous, and I want to single out David Killinsky who has shouldered the bulk of request. Jane Flanders provided editorial help during early stages of the manuscript. Kendall Stanley has helped me in preparing bibliographies and final manuscripts and my mental health has been kept serviceable as a result of her careful, painstaking work. Friends have provided me with support and encouragement in pursuing something that in today’s academic psychiatry community is viewed at best as peripheral and at worst as trivial and off the main road of relevant and supportable topics having practical significance for clinical care. Among persons who have been encouraging and supportive I include Drs. John Fong, Thomas Detre, and Paul Soloff. I want to express special appreciation of my wife, Joan Rome Sporkin, for being patient with my intellectual obsessionalism and providing me with consistent support and encouragement in the face of my intellectual self-absorption.
This book is dedicated to my grandchildren.