INT’L. J. P S Y C H I A T R Y IN MEDICINE, VOl. 7(4),1976-77
HEALTH PRACTICE AT THE TECHNOLOGIC/FOLK INTERFACE: WITCHCRAFT AS A CULTURE-SPECIFIC DI AGN 0SIS*
SANFORD I?.WEIMER, M.D. Staff F‘sychiatrist Pacific Medical Center
NORBETT L. MINTZ, PH. D. Senior Staff Psychologist McLean Hospital Principal Associate in Psychiatry Harvard Medical School
ABSTRACT
“Witchcraft illness” is a widespread belief among many people, even after acculturation t o technological concepts of illness etiology. Two cases are presented t o show that such beliefs can complicate physical or psychological dysfunctions. or themselves can be the primary origin of physical or psychological dysfunctions. In both instances, witchcraft beliefs take o n a dynamic of their own and must be resolved both in terms of the patient’s culture as well as the clinician’s treatment plan. Considering such phenomena from the vantage point of family systems provides useful insights into etiology as well as amelioration. The latter requires engaging all parties in the health care system-clinician, patient, family, and indigenous !xalth caretakers.
Witchcraft beliefs provide both an etiological explanation for illness phenomena as well as a prescriptive means to influence these phenomena. This belief system partly is magical thinking and partly is empirical understanding. The empirical part shares aspects with other etiological and prescriptive systems. For example, as we will note later in the paper, there are
* Support for this and other research associated with the PHS Indian Health Service Mental Health Clinic was made possible by a Career Development Award, NIMH No. K1-MH-31, 212, t o Dr. Mintz. 351 @ 1977. Baywood Publishing C o . .
InC.
doi: 10.2190/16H5-6XU7-85UV-T6NC http://baywood.com
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some structural similarities in the tactics of witchcraft amelioration and that of family psychotherapy. Instances of bewitchment and sorcery appear with some regularity among a variety of ethnic and folk subcultures. On more occasions than many physicians realize, witched patients appear in medical clinics and emergency rooms. This especially is the case where members of these cultures are in close contact with their primary culture as well as the dominant, technologic society. Examples of such contact situations are city hospitals located in ghetto or barrio neighborhoods and Public Health Service (PHS) hospitals located on Indian reservations. As partial assimilation to the dominant culture takes place, a choice develops among folk culture and ethnic peoples as to the desired intervention for someone who is ill. Under these circumstances, patients may visit medical facilities as well as curunderos, medicine-men or psychic healers [ l ] . Experiences of the authors on the Navajo Indian Reservation show that patients need not think of these options as conflicting. Indeed, for many Navajos these apparent alternatives are synergistic-Navajo health ideology relegates “Anglo” health practices to affecting useful symptom relief while awaiting a cure, the latter to be accomplished only by an indigenous healing ceremony. Generally, cases of bewitchment illness presenting to an emergency room are not recognized as such by ethnic-alien physicians, nor do physicians often enough interview for this possibility. As Detre and Kupfer point out, too frequently “the health care delivery system’s inappropriate emphasis on [conventional] medical expertise and its under-emphasis upon social support and human services has prevented it from providing considerate and thoughtful attention to patients in need. This lack of understanding of the patient’s life situation” can lead to diagnosis and treatment which is inappropriate and ineffective [2] . The consequences of such inappropriate diagnosis and ineffective treatment in witchcraft cases should not be minimized; being witched is a life-threatening condition, analogous to the infant conditiocs of “hospitalism” [ 3 ] or to failure to thrive syndromes [4] and to the adult conditions of “wasting away” associated with population resettlement [5] or to multiple illnesses following the death of a spouse [ 6 ] . Even closer examples, in terms of the direct relations of beliefs t o lifethreatening physiological dysfunction, are the cases reported by Hackett and Weisman, by Cappannari, et al., and by Cannon. Hackett and Weisman report on a patient with some thoracic symptoms who was seen by a physician as an outpatient [7]. Based on an unexplained density in his chest films, the patient was told he had cancer. Over succeeding months he lost weight, grew weaker and continued to suffer from his respiratory symptoms, all the while being convinced he had terminal cancer. A family member finally prevailed on the patient to be seen at a medical center, where the diagnosis of cancer was refuted. Following this technological equivalent of “dewitchment ,” the patient began to gain strength and weight. A similar fortunate outcome was reported by Cappannari, et al. [ 8 ] . A woman with regional enteritis had been told that
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her mother-in-law had hexed her. Despite both hospital treatment and indigenous de-hexing procedures (done independently, with no crossconsultation nor coordination), the patient’s condition grew worse. A third hospital admission resulted in a psychiatric consultation. Interviews uncovered the hex threat and the previously unsuccessful de-hexing attempt. While still in the hospital, a minister with de-hexing experience was recruited to help the patient. This coordination and mutual sanctioning of efforts probably was responsible for saving the patient’s life. Less fortunate outcomes were reported by Cannon [9]. He reviewed many cases of “voodoo” death. In one case, a villager who was diagnosed by a shaman as being hopelessly witched had a mourning ceremony held for him. Within a few days he died. The previously cited paper by Hackett and Weisman [7] also reports a less fortunate outcome in which they were unable to save the life of a man who was reacting to a verbal threat by his mother. The threat had the structure of a hex, although neither mother nor son came from a culture involved with hexes. The mother threatened that if the son went against her wishes, “something dire would happen” to him. He did defy his mother, supported by his wife, and shortly afterward developed asthma (with n o prior clinical history). Despite hospitalized care, the patient died soon after the onset of illness. The intent of this report is to sensitize clinicians to the significance and seriousness of witchcraft as a relevant diagnostic category among many ethnic and folk subcultures, and to offer some guides to a better understanding and improved management of such cases. Two contrasting and typical cases of witchcraft, presenting as medical emergencies on the Navajo Indian Reservation, are offered as illustrations. These cases can be distinguished clinically, with a basic understanding of the cultural forces and family dynamics at work. Effective intervention may best be synergistic, combining both moderntechnological and indigenous treatment approaches. The first case describes a young woman with a prior history of psychosocial disturbances. Witchcraft beliefs played a complicated and interactive role for this patient and her family as her disturbance became more chronic. Her problems resolved slowly following interventions by indigenous practitioners and by PHS health personnel. The second case is that of a young man with no antecedent history of psychosocial problems. He experienced anxiety and acute abdominal pain directly attributable to witchcraft beliefs. Because witchcraft beliefs played a primary role in his case, the symptoms resolved quickly, following medical evaluation and indigenous intervention. Case #I A. V. was a twenty-year-old, married, Navajo female, second oldest of eleven surviving siblings, mother of one child, who participated in domestic activities and sheepherding. She, her husband and her child lived in a rural area in a camp dominated by her tradition-oriented, maternal grandmother.
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A. V. appeared to the PHS Hospital’s Medical Clinic on a weekend night, having had symptoms of nocturnal restlessness and hyperventilation, followed by unresponsiveness. This was the third time A. V. had come to this clinic for similar problems. During her early teen-age years this patient was seen elsewhere several times for problems of school anxiety. The first and second of these current nocturnal attacks occurred six months apart. The third attack, which occurred the evening after the second one, was when the authors first made contact with A. V. The unresponsive patient was brought in by her husband, accompanied by several of her family members. When seen by the first author, the patient was lying on the examining table as if asleep. Vital signs were normal and the neurological examination was unremarkable, except for the altered state of consciousness and attenuated response to pain. The rest of the physical examination was likewise unremarkable for this asthenic young woman in no acute distress. Colorfully attired in traditional Navajo dress, the family stood in a cluster near the examining room, anxiously awaiting the diagnosis. A nurse-interpreter assisted with the family interview, done both in English and in Navajo. An attempt to obtain more information about the patient’s present illness was somewhat unproductive, since the relatives merely repeated the material already given in the old chart. At this point the question of witchcraft was raised. At first the family became silent. In their ensuing discussion, the interpreter reported that the family had been concerned about this possibility. They had noted strange, animal-like tracks near the spot where the couple had been herding sheep. In fact, the family had been on the way to have a Hopi medicine-man “dewitch” the patient, but they sought the opinion of the PHS physician before proceeding. After reassuring the family that there was no detectable organic disease, they were encouraged to take the patient to the indigenous practitioner. The family also was encouraged to bring the patient back to the Mental Health Clinic two days later. This was recommended, not only because of the two prior episodes, but also because the examining physician had learned that A. V. had been distressed earlier in the day of those episodes. The family agreed to return and departed with the patient. Two days later, A. V., accompanied by a maternal aunt, appeared in the Medical Clinic. The patient was shy but relaxed. She related that two nights ago she had visited a local, female Navajo “dewitching” practitioner. During the curing ritual, the woman “removed a bone” from the patient’s head (a not-uncommon maneuver) as well as a white powder “resembling peyote.” A. V. stated that she felt much better and now had no fears or anxieties. Nevertheless, she seemed interested in getting help at the Mental Health Clinic. The aunt then proceeded to chastise the physician (S. R. W.) for sending the patient to an indigenous practitioner. A resident of the semi-urbanized enclave which contained the government schools, hospital and other agencies,
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the aunt had been converted to a revivalist, Christian sect and was in serious and continuing conflict with the rest of her tradition-oriented family. It became obvious that A. V. was caught in the middle of this family struggle. If the aunt’s dismissal of Navajo culture had been absolute, the physician would have been in the untenable position of trying t o persuade a Navajo to accept the rejected Navajo tradition. Through further discussion, however, it became clear that the aunt’s beliefs were actually a mixture of Christian and Navajo mysticism. Therefore, by devising a treatment plan that combined traditional Navajo and modern Anglo resources (specifically mental health), acceptance was obtained from the aunt. On the following day this same aunt appeared in the hospital. In a distraught, accusatory manner she reported that A. V. was “lying paralyzed” in a hogan (the traditional Navajo earthen and wooden house). A mental health team, consisting of a Navajo Mental Health Worker and a visiting “Anglo” psychiatrist, made an emergency visit to see the patient.’ Missing signs that a ceremony was in progress, they entered the dark hogan. The team had unknowingly intruded on a solemn “blackening” ceremony which was being held to cleanse A. V. of “contamination with the dead.” The team was permitted to determine that A. V. was neurologically intact; however, their unannounced entrance was an error which probably contributed to the patient’s seven month delay in returning to the PHS for help. When the patient finally did present to the Medical Clinic one night, S.R.W. again was on night call. The family’s story was similar; the husband reported A. V.’s restless behavior during her sleep. This time, however, the patient was alert and oriented, and she accepted an appointment in the Mental Health Clinic for the following morning. Over the next several weeks there were frequent Mental Health Clinic visits during which A. V. was seen, by the second author, both alone and with her husband. This psychotherapy slowly provided A. V. with periods of relief from her symptoms and led to the young couple’s decision to move to the camp of the husband’s family, a few miles away from her grandmother’s camp. The move helped A. V. to withdraw from the battlefield of her aunt and grandmother.
Case #2
K. G. appeared in the Medical Clinic late one Saturday afternoon. A Navajo in his mid-twenties who was intermittently employed, K. G. arrived in the Clinic accompanied by his cousin and two Navajo policemen. He complained of severe abdominal pain. K. G. was very uncooperative, refused to be Navajo Mental Health Workers are bi-lingual. Thcy have been trained by the “Anglo” mental health professionals t o a high degree of proficiency in dealing with psychosocial problems of their own people. The visiting “Anglo” psychiatrist was substituting for NLM, the Mental Health Clinic’s Director, who was away o n vacation.
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examined, verbally abused the medical staff and the police, and insisted on leaving the clinic. His speech pattern was disjointed and confused, with loose associations and seemingly bizarre content. All attempts to calm him by reassurance and explanation failed, and the patient continued to resist our attempts at physical examination. The dilemma was whether to yield to his demands and to allow him to leave in a combative state, possibly intoxicated by drugs or alcohol, or to sedate him forcibly to examine for the possibility of serious intra-abdominal disease and/or possible toxic delirium. Upon further questioning, K. G. revealed that he urgently *shed to leave to see a Hopi medicine-man. He attributed his pain to being witched-the placement of a deer hair in his intestine by a sorcerer. The suggestion that a medicine-man be summoned to the hospital for joint consultation was rejected by the patient. Eventually the patient was calmed with 75 mg of intramuscular thorazine, in order to proceed with the physical examination. No suggestion of organic lesion was found and the patient was discharged, at his insistence. The recommendation was that K. G. consult a medicine-man and that his cousin keep an eye on him for a few days. If the episode did not resolve, he was to return to the Medical Clinic. After several days, when the patient had not returned, a field health worker was informed of the case for follow-up. Investigation revealed that K. G. belonged to a family which lived near the hospital. The family as a group had been treated recently by a Navajo “dewitching” practitioner for removal of a witch’s spell, but the patient, for reasons not known, was not present at that ritual. He developed his attack of abdominal pain several days thereafter, when he was brought to us at the hospital. After leaving the hospital, he went to a Hopi medicine-man who “dewitched” him and his pain subsided. No further intervention by us appeared necessary. Three months later K. G. was treated in the Clinic for unrelated medical problems, and indicated that there had been no recurrence of this episode.
Case Discussion These two cases illustrate examples of what a general medical practitioner might encounter when working with people who hold witchcraft beliefs. As in any clinical problem, accurate diagnostic evaluation leads to the most judicious course of action. In cases of “primary” witchcraft (K. G.), settling for a conventional psychiatric diagnosis, such as conversion hysteria, could lead to an ineffective treatment plan. Psychotherapy or tranquilizers are as useless as surgery in treating patients claiming to have a deer hair placed in their intestine by a sorcerer. A traditional healing ceremony must be included in whatever plan is followed, if success is to be achieved.’ In cases such as A. V.’s,
’
In some cultures, it might be possible for physicians t o treat witchcraft cases with placebo interventions. However, the physician must first ascertain if the patient would accept “dewitching” interventions as being possible by someone outside the patient’s cultural context
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which involve complications of witchcraft, a combined approach is appropriate; that is, one which includes indigenous practices but does not solely rely on them. “Primary” witching (K. G.) or complications of witching (A. V.) will not be discovered unless the category of witchcraft is included in the differential diagnosis and compared to available data. In the case of A. V., several features could alert the observer to complications of witchcraft. Persistence of an illness and unsuccessful clinic visits would incline the patient and family to be suspicious of witchcraft. The onset of mysterious spells coming at night, as well as fainting and loss of appetite, are typical correlates of witching among Navajos [lo]. Probing by the examining physician revealed a family history of sighting “mysterious tracks” near where A. V. had been herding sheep. This information is only useful if the examiner is aware of the cultural significance of such stories. A. V.’s personality and family setting are important as well. There was evidence that A. V. had become a focal point of intense conflict in the extended family. Her own psychic vulnerability (indicated by her history of teen-age difficulties) gave additional impetus to her developing symptoms of witchcraft illness. But once developed, witchcraft symptoms become functionally autonomous from their psychological origins and both the interpersonal dynamics and the witchcraft dynamics must be attended to, on their own terms. In the case of K. G., the diagnosis of “primary” witchcraft was more easily determined, although, in such cases the examining physician also requires some relevant cultural information. To the culturally unaware physician the patient’s complaint of deer hair in the intestine might seem bizarre, whereas, to the culturally knowledgeable person this is recognized as a direct communication of witchcraft. Kluckhohn [lo] calls this form of witchcraft among Navajo Indians “wizardry.” It involves insertion at a distance (by a witch) of a foreign object somewhere in the victim’s body. The list of objects is large, but not unlimited, and among Navajos deer hair figures prominently as an object for insertion. The setting for episodes of wizardry are even clearer and more stereotyped than for most other forms of witchcraft. The episode is characterized by a sudden onset of sharp, localized pain. The victim is usually someone who in some way has been neglected by the family. Generally, help is sought from a practitioner of another tribe; Navajos most often get such help from a Hopi medicine-man [ 101 . Real or fancied wrongs by the neglected person’s significant others then get soothed in the reconciliation and social support which occurs when that person becomes a victim and requires treatment. Viewing these two cases of witchcraft from the vantage point of family systems yields useful insights. It is a well accepted principle of family therapy that a vulnerable family member may become an identified patient when family integrative mechanisms fail [ 111 . Unresolved conflicts between powerful members of the family, unattended psychological problems in
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influential members other than the identified patient, unusual loss of love or attention, and disruption of usual routines or cultural patterns-all these are examples of processes which are observable among families in crisis and are associated with symptom display in an identified patient. This symptom display, in turn, leads to certain strategic gains by the victim: attention indirectly is drawn t o the family problem; intervention can be obtained outside the family system; and all the members of the family are drawn together in an attempt at problem solving. Given a culture where succumbing to witchcraft is an accepted, even expected, part of symptom display, it is not surprising that some patients will present in such a fashion. In considering the possibility of witchcraft involvement, the examining physician looks for specific indications. Clements discovered that one common witchcraft stimulus for many cultures, including Navajo, is mystery or rarity of symptoms [ 121 . When patients have difficulty in applying the common explanations for illness, or when illnesses are mysterious or unusual-particularly when they d o not yield to the accepted treatments-witchcraft becomes a prominent fear. Actual witchcraft symptoms to be seen by emergency room physicians include fainting, acutely localized pain, chronic loss of appetite, and sudden onset of sensory or motor dysfunction. When witchcraft becomes a serious diagnostic consideration, one has several choices for treatment-indigenous medicine, modern physical medicine, some form of psychotherapy-singly, sequentially or in combination. An important issue in developing treatment plans is whether witchcraft is the direct cause of the patient’s symptoms or one of several complicating factors in a symptom picture not otherwise comprehended by the victim or family. In A. V.’s case, a combination of factors warranted a combined treatment approach. Ruling out the possibility of neurological impairment, her symptoms were compatible with those associated with witchcraft. The family members present at our first interview further confirmed the witchcraft aspects, and also expressed their intention to take A. V. to a Hopi “dewitching” practitioner. These facts justified the decision not to discourage the family from pursuing cultural relief. On the other hand, A. V. had been brought to the clinic twice before, within six months, to be treated for similar symptoms. Thus, pharmacological treatment (minor tranquilizer); and previous indigenous health treatment was not completely effective. One may conclude then that the fear of witchcraft may have been only one of several psychosocial contributors to A. V.’s symptoms, and that concurrent referral to the Mental Health Clinic therefore was appropriate. In the case of K. G., the sudden onset and dramatic nature of the symptoms called for a sequential approach: first a reliance on physical medicine and then a transfer to indigenous care. The nature of his complaint demanded serious consideration of organic pathology. The differential included some kind of intra-abdominal catastrophe with possible toxic delirium, as well as witchcraft fear. The patient was so uncooperative that he had to be restrained chemically
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in order to examine him. While appearing to be free of organic pathology, there still remained enough lingering doubt to wish to arrange for consultation with an indigenous practitioner in the hospital (where K. G. could continue to be observed) instead of releasing the patient. The patient did not accept this, and so was allowed to pursue this consultation outside of the hospital. Routine follow-up was instigated, but no referral of the patient to Mental Health was done. The reason for this choice is that neither the medical record nor the initial interview revealed any prior psychosocial pathology; so after reasonably eliminating organic pathology, one was left with witchcraft fear as the primary diagnosis rather than a complicating factor.
The Cultural Interface Some usual steps in formulating a differential diagnosis and treatment plan were involved in the above presentations. In familiar situations it often is safe to take these steps for granted. But in a new context, such as a cross-cultural interface, being “routine” can be disastrous. Therefore, it is important to be aware of some key aspects of the diagnostic interview, so that these aspects can be implemented consciously. Primary among these is the fact that this process is an intensely interpersonal one. “The patient influences the doctor and the doctor influences the patient; diagnosis is one of the complex resultants of this interaction. The diagnosis depends not only on the symptoms and manifestations of the patient, but also on the doctor’s training, familiarity with the patient and his culture, and his attitudes toward the patient, which are in turn influenced by the patient’s attitudes toward him [13] .” The clinical goals of the differential diagnosis are to provide a clear description of the situation, to define the field of inquiry, to exclude the irrelevant, and to order the several possibilities. An important interpersonal goal of the differential diagnosis is to restate the presenting problem in terms of these probabilities, in order to communicate to the patient that the clinician has heard and understood the patient’s complaint and is prepared to make recommendations, if such are possible. These goals attained, one next turns to the treatment plan. This plan not only must be appropriate to the diagnosis, but it must be designed to permit appropriate behavior by all parties in the health system: the clinician must see it as embodying effective action; the patient and family must be able to accept and to understand (albeit within their own belief system) the clinician’s action; and the patient and family must be willing and able to carry out recommendations. Frank has shown that this sharing in a belief system not only provides a rationale for the disorder and its treatment, but makes possible renewed hope for relief [14]. In contrast, if one does not enlist this total system support, therapeutic failure is more likely to be the result. It is important to realize that culture plays an integral role in these
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patient-clinician interactions. Cultural assumptions are unseen yet facilitating when shared, but are blinding and impeding when not shared [ 151. Thus, cultural components of the clinician-patient relationship automatically are taken for granted and assimilated by the clinician in the situation where both are middle class, technologically educated people. But these components tend t o be ignored, rejected, or inappropriately diagnosed if the cultural information given by the patient is strange and incomprehensible to the clinician. “In cultures where witches are perceived as a constant threat, very real difficulties may arise in [the physician’s] separating psychoneurotic anxiety from rational, culturally determined fear. Obviously, fear of witches should not automatically be labeled a phobia; nor should a preoccupation with witches and witchcraft be seen as an obsession. On the other hand . . . [one should not] assume that fear of witches could not be a phobia. . . . The distinction depends on the cultural standards of the group to which the individual belongs [13] .” Such cultural standards are not readily available to most physicians. Thus “the decision as to whether a given act is appropriate or inappropriate must often necessarily be a lay decision, simply because we have n o technical mapping of the various subcultures in our society, let alone the standards of conduct prevailing in each of them [16] .” Detre and Kupfer suggest that the emergency room triage team should include “a community worker who is preferably a cultural and ethnic representative” of the neighboring subculture
PI. By using such resources to acquaint oneself with the culture of a patient population, the clinician will find that medical beliefs often are parallel to, and not exclusive of, technologic understanding [ 171 . The challenge for the technologically trained practitioner in a folk-cultural situation is to include such cultural beliefs in the diagnostic and treatment formulations. It is the practitioner’s task to “maintain an orientation in [his/her] own culture, in the culture under study, and in the private world of the patient under discussion [13] .”
Expanding the Health Care Network Most patients presenting to a medical practitioner or facility have consulted with a person other than a physician prior to arrival [18]. This person may have been a relative, a friend or a non-physician health practitioner. Among members of the dominant class in a technological culture, these prior consultations often are with associated health practitioners, such as dentists, optometrists, social workers. But among many ethnic and social class subcultures, these consultations may be with alternative health practitioners, such as medicine-men, curanderos or psychic healers. Associated health practitioners have well-established relationships to the medical profession, and referral from them and to them is an accepted part of good practice. Alternative health
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practitioners, however, d o not have established relationships with the medical profession. Consequently, little knowledge exists about when and how referral could take place. This poses a challenge for education. We have pointed out the advantages for the clinician in being aware of cultural factors influencing a population, as well as aware of the indigenous resources available to cope with specific cultural dynamics. Similarly, educational efforts need to be undertaken to turn alternative health practitioners into associated health practitioners. Programs such as the NIMH-sponsored training of Navajo medicine-men bring these alternative practitioners into the overall health network [ 191. Such efforts will provide physicians with a more educated case-finding group, as well as with a resource for the physician to make an appropriate indigenous referral. REFERENCES
1. L. Saunders, Cultural Differences and Medical Care-The Case f o r the Spanish Speaking People o f the Southwest, Russell Sage, New York, 1954. 2. T. P. Detre and D. J . Kupfer, General Hospital Psychiatric Services, in American Handbook o f Psychiatry, D. X . Freedman and J. E. Dryud, (eds.), Basic Books, New York, pp. 607-618, 1975. 3. R. Spitz, Hospitalism, Psychoanal. Study Child., 1, pp. 53-74, 1945. 4. D. Rosenn, L. Stein and M. Bates, The Differentiation of Organic From Environmental Failure to Thrive, paper delivered at Amer. Ped. SOC.,April 19, 1975. 5. E. L. Thomas, The Possibility of Using Physiological Indicators for Detecting Psychiatric Disorder, in Approaches t o Cross-Cultural Psychiatry, J . M. Murphy and A. H. Leighton, (eds.), Cornell U., Ithaca, pp. 161-186, 1965. 6. E. Gunderson and R. Rahe, Life Stress and Illness, Thomas, Springfield, Ill., 1974. 7. T. P. Hackett and A. D. Weisman, “Hexing” in Modern Medicine, in Proceedings of the Third World Congress o f Psychiatry, Philosophical, New York, pp. 1249-1252, 1961. 8. S . Cappannari, B. Rau, H. S. Abram and D. C. Buchanan, Voodoo in the General Hospital, JAMA, 232, pp. 938-940, 1975. 9. W. B. Cannon, “Voodoo” Death, Psychosom. Med., 19, pp. 182-190, 1957. 10. C. Kluckhohn, Navajo Witchcraft, Beacon, Boston, 1944. 11. S. Minuchin, L. Baker, B. Rosman, et al., A Conceptual Model of Psychosomatic Illness in Children-Family Organization and Family Therapy, Arch. Cen. Psychiat., 32, pp. 1031-1038, 1975. 12. F. Clements, Primitive Concepts of Disease, Univ. Calif. Publ. Amer. Archeol. & Ethnol., 32, pp. 185-252, 1932. 13. C. Savage, A. H. Leighton and D. C. Leighton, The Problem of CrossCultural Identification of Psychiatric Disorders, in Approaches to CrossCultural Psychiatry, J. M. Murphy and A. H. Leighton, (eds.), Cornell U., Ithaca, pp. 21-63, 1965.
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14. J . D. Frank, Persuasion and Healing, John Hopkins, Baltimore, 1961. 15. J . P. Spiegel, Some Cultural Aspects of Transference and Countertransference, in Individual and Familial Dynamics, Masserman, (ed.), Grune & Stratton, New York, 1959. 16. E. Goffman, Asylums, Doubleday, New York, 196 1. 17. 1. Adair and K . W. Deuschle, The People’s Health, Appleton, New York, 1970. 18. E. Friedson, The Profession of Medicine-A Study in the Sociology of Knowledge, Dodd Mead, New York, 1970. 19. R. Bergrnan, The Importance of Psychic Medicine-Training Navajo Medicine-Men, NIMH Mental Health Program Reports, 5 , pp. 20-43, 197 1.
Direct reprint requests to: Norbett L. Mintz, Ph.D. McLean Hospital 115 Mill Street Belmont, Massachusetts 02178
HEALTH PRACTICE AT THE TECHNOLOGIC/FOLK INTERFACE: WITCHCRAFT AS A CULTURE-SPECIFIC DI AGN 0SIS*
SANFORD I?.WEIMER, M.D. Staff F‘sychiatrist Pacific Medical Center
NORBETT L. MINTZ, PH. D. Senior Staff Psychologist McLean Hospital Principal Associate in Psychiatry Harvard Medical School
ABSTRACT
“Witchcraft illness” is a widespread belief among many people, even after acculturation t o technological concepts of illness etiology. Two cases are presented t o show that such beliefs can complicate physical or psychological dysfunctions. or themselves can be the primary origin of physical or psychological dysfunctions. In both instances, witchcraft beliefs take o n a dynamic of their own and must be resolved both in terms of the patient’s culture as well as the clinician’s treatment plan. Considering such phenomena from the vantage point of family systems provides useful insights into etiology as well as amelioration. The latter requires engaging all parties in the health care system-clinician, patient, family, and indigenous !xalth caretakers.
Witchcraft beliefs provide both an etiological explanation for illness phenomena as well as a prescriptive means to influence these phenomena. This belief system partly is magical thinking and partly is empirical understanding. The empirical part shares aspects with other etiological and prescriptive systems. For example, as we will note later in the paper, there are
* Support for this and other research associated with the PHS Indian Health Service Mental Health Clinic was made possible by a Career Development Award, NIMH No. K1-MH-31, 212, t o Dr. Mintz. 351 @ 1977. Baywood Publishing C o . .
InC.
doi: 10.2190/16H5-6XU7-85UV-T6NC http://baywood.com
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some structural similarities in the tactics of witchcraft amelioration and that of family psychotherapy. Instances of bewitchment and sorcery appear with some regularity among a variety of ethnic and folk subcultures. On more occasions than many physicians realize, witched patients appear in medical clinics and emergency rooms. This especially is the case where members of these cultures are in close contact with their primary culture as well as the dominant, technologic society. Examples of such contact situations are city hospitals located in ghetto or barrio neighborhoods and Public Health Service (PHS) hospitals located on Indian reservations. As partial assimilation to the dominant culture takes place, a choice develops among folk culture and ethnic peoples as to the desired intervention for someone who is ill. Under these circumstances, patients may visit medical facilities as well as curunderos, medicine-men or psychic healers [ l ] . Experiences of the authors on the Navajo Indian Reservation show that patients need not think of these options as conflicting. Indeed, for many Navajos these apparent alternatives are synergistic-Navajo health ideology relegates “Anglo” health practices to affecting useful symptom relief while awaiting a cure, the latter to be accomplished only by an indigenous healing ceremony. Generally, cases of bewitchment illness presenting to an emergency room are not recognized as such by ethnic-alien physicians, nor do physicians often enough interview for this possibility. As Detre and Kupfer point out, too frequently “the health care delivery system’s inappropriate emphasis on [conventional] medical expertise and its under-emphasis upon social support and human services has prevented it from providing considerate and thoughtful attention to patients in need. This lack of understanding of the patient’s life situation” can lead to diagnosis and treatment which is inappropriate and ineffective [2] . The consequences of such inappropriate diagnosis and ineffective treatment in witchcraft cases should not be minimized; being witched is a life-threatening condition, analogous to the infant conditiocs of “hospitalism” [ 3 ] or to failure to thrive syndromes [4] and to the adult conditions of “wasting away” associated with population resettlement [5] or to multiple illnesses following the death of a spouse [ 6 ] . Even closer examples, in terms of the direct relations of beliefs t o lifethreatening physiological dysfunction, are the cases reported by Hackett and Weisman, by Cappannari, et al., and by Cannon. Hackett and Weisman report on a patient with some thoracic symptoms who was seen by a physician as an outpatient [7]. Based on an unexplained density in his chest films, the patient was told he had cancer. Over succeeding months he lost weight, grew weaker and continued to suffer from his respiratory symptoms, all the while being convinced he had terminal cancer. A family member finally prevailed on the patient to be seen at a medical center, where the diagnosis of cancer was refuted. Following this technological equivalent of “dewitchment ,” the patient began to gain strength and weight. A similar fortunate outcome was reported by Cappannari, et al. [ 8 ] . A woman with regional enteritis had been told that
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her mother-in-law had hexed her. Despite both hospital treatment and indigenous de-hexing procedures (done independently, with no crossconsultation nor coordination), the patient’s condition grew worse. A third hospital admission resulted in a psychiatric consultation. Interviews uncovered the hex threat and the previously unsuccessful de-hexing attempt. While still in the hospital, a minister with de-hexing experience was recruited to help the patient. This coordination and mutual sanctioning of efforts probably was responsible for saving the patient’s life. Less fortunate outcomes were reported by Cannon [9]. He reviewed many cases of “voodoo” death. In one case, a villager who was diagnosed by a shaman as being hopelessly witched had a mourning ceremony held for him. Within a few days he died. The previously cited paper by Hackett and Weisman [7] also reports a less fortunate outcome in which they were unable to save the life of a man who was reacting to a verbal threat by his mother. The threat had the structure of a hex, although neither mother nor son came from a culture involved with hexes. The mother threatened that if the son went against her wishes, “something dire would happen” to him. He did defy his mother, supported by his wife, and shortly afterward developed asthma (with n o prior clinical history). Despite hospitalized care, the patient died soon after the onset of illness. The intent of this report is to sensitize clinicians to the significance and seriousness of witchcraft as a relevant diagnostic category among many ethnic and folk subcultures, and to offer some guides to a better understanding and improved management of such cases. Two contrasting and typical cases of witchcraft, presenting as medical emergencies on the Navajo Indian Reservation, are offered as illustrations. These cases can be distinguished clinically, with a basic understanding of the cultural forces and family dynamics at work. Effective intervention may best be synergistic, combining both moderntechnological and indigenous treatment approaches. The first case describes a young woman with a prior history of psychosocial disturbances. Witchcraft beliefs played a complicated and interactive role for this patient and her family as her disturbance became more chronic. Her problems resolved slowly following interventions by indigenous practitioners and by PHS health personnel. The second case is that of a young man with no antecedent history of psychosocial problems. He experienced anxiety and acute abdominal pain directly attributable to witchcraft beliefs. Because witchcraft beliefs played a primary role in his case, the symptoms resolved quickly, following medical evaluation and indigenous intervention. Case #I A. V. was a twenty-year-old, married, Navajo female, second oldest of eleven surviving siblings, mother of one child, who participated in domestic activities and sheepherding. She, her husband and her child lived in a rural area in a camp dominated by her tradition-oriented, maternal grandmother.
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A. V. appeared to the PHS Hospital’s Medical Clinic on a weekend night, having had symptoms of nocturnal restlessness and hyperventilation, followed by unresponsiveness. This was the third time A. V. had come to this clinic for similar problems. During her early teen-age years this patient was seen elsewhere several times for problems of school anxiety. The first and second of these current nocturnal attacks occurred six months apart. The third attack, which occurred the evening after the second one, was when the authors first made contact with A. V. The unresponsive patient was brought in by her husband, accompanied by several of her family members. When seen by the first author, the patient was lying on the examining table as if asleep. Vital signs were normal and the neurological examination was unremarkable, except for the altered state of consciousness and attenuated response to pain. The rest of the physical examination was likewise unremarkable for this asthenic young woman in no acute distress. Colorfully attired in traditional Navajo dress, the family stood in a cluster near the examining room, anxiously awaiting the diagnosis. A nurse-interpreter assisted with the family interview, done both in English and in Navajo. An attempt to obtain more information about the patient’s present illness was somewhat unproductive, since the relatives merely repeated the material already given in the old chart. At this point the question of witchcraft was raised. At first the family became silent. In their ensuing discussion, the interpreter reported that the family had been concerned about this possibility. They had noted strange, animal-like tracks near the spot where the couple had been herding sheep. In fact, the family had been on the way to have a Hopi medicine-man “dewitch” the patient, but they sought the opinion of the PHS physician before proceeding. After reassuring the family that there was no detectable organic disease, they were encouraged to take the patient to the indigenous practitioner. The family also was encouraged to bring the patient back to the Mental Health Clinic two days later. This was recommended, not only because of the two prior episodes, but also because the examining physician had learned that A. V. had been distressed earlier in the day of those episodes. The family agreed to return and departed with the patient. Two days later, A. V., accompanied by a maternal aunt, appeared in the Medical Clinic. The patient was shy but relaxed. She related that two nights ago she had visited a local, female Navajo “dewitching” practitioner. During the curing ritual, the woman “removed a bone” from the patient’s head (a not-uncommon maneuver) as well as a white powder “resembling peyote.” A. V. stated that she felt much better and now had no fears or anxieties. Nevertheless, she seemed interested in getting help at the Mental Health Clinic. The aunt then proceeded to chastise the physician (S. R. W.) for sending the patient to an indigenous practitioner. A resident of the semi-urbanized enclave which contained the government schools, hospital and other agencies,
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the aunt had been converted to a revivalist, Christian sect and was in serious and continuing conflict with the rest of her tradition-oriented family. It became obvious that A. V. was caught in the middle of this family struggle. If the aunt’s dismissal of Navajo culture had been absolute, the physician would have been in the untenable position of trying t o persuade a Navajo to accept the rejected Navajo tradition. Through further discussion, however, it became clear that the aunt’s beliefs were actually a mixture of Christian and Navajo mysticism. Therefore, by devising a treatment plan that combined traditional Navajo and modern Anglo resources (specifically mental health), acceptance was obtained from the aunt. On the following day this same aunt appeared in the hospital. In a distraught, accusatory manner she reported that A. V. was “lying paralyzed” in a hogan (the traditional Navajo earthen and wooden house). A mental health team, consisting of a Navajo Mental Health Worker and a visiting “Anglo” psychiatrist, made an emergency visit to see the patient.’ Missing signs that a ceremony was in progress, they entered the dark hogan. The team had unknowingly intruded on a solemn “blackening” ceremony which was being held to cleanse A. V. of “contamination with the dead.” The team was permitted to determine that A. V. was neurologically intact; however, their unannounced entrance was an error which probably contributed to the patient’s seven month delay in returning to the PHS for help. When the patient finally did present to the Medical Clinic one night, S.R.W. again was on night call. The family’s story was similar; the husband reported A. V.’s restless behavior during her sleep. This time, however, the patient was alert and oriented, and she accepted an appointment in the Mental Health Clinic for the following morning. Over the next several weeks there were frequent Mental Health Clinic visits during which A. V. was seen, by the second author, both alone and with her husband. This psychotherapy slowly provided A. V. with periods of relief from her symptoms and led to the young couple’s decision to move to the camp of the husband’s family, a few miles away from her grandmother’s camp. The move helped A. V. to withdraw from the battlefield of her aunt and grandmother.
Case #2
K. G. appeared in the Medical Clinic late one Saturday afternoon. A Navajo in his mid-twenties who was intermittently employed, K. G. arrived in the Clinic accompanied by his cousin and two Navajo policemen. He complained of severe abdominal pain. K. G. was very uncooperative, refused to be Navajo Mental Health Workers are bi-lingual. Thcy have been trained by the “Anglo” mental health professionals t o a high degree of proficiency in dealing with psychosocial problems of their own people. The visiting “Anglo” psychiatrist was substituting for NLM, the Mental Health Clinic’s Director, who was away o n vacation.
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examined, verbally abused the medical staff and the police, and insisted on leaving the clinic. His speech pattern was disjointed and confused, with loose associations and seemingly bizarre content. All attempts to calm him by reassurance and explanation failed, and the patient continued to resist our attempts at physical examination. The dilemma was whether to yield to his demands and to allow him to leave in a combative state, possibly intoxicated by drugs or alcohol, or to sedate him forcibly to examine for the possibility of serious intra-abdominal disease and/or possible toxic delirium. Upon further questioning, K. G. revealed that he urgently *shed to leave to see a Hopi medicine-man. He attributed his pain to being witched-the placement of a deer hair in his intestine by a sorcerer. The suggestion that a medicine-man be summoned to the hospital for joint consultation was rejected by the patient. Eventually the patient was calmed with 75 mg of intramuscular thorazine, in order to proceed with the physical examination. No suggestion of organic lesion was found and the patient was discharged, at his insistence. The recommendation was that K. G. consult a medicine-man and that his cousin keep an eye on him for a few days. If the episode did not resolve, he was to return to the Medical Clinic. After several days, when the patient had not returned, a field health worker was informed of the case for follow-up. Investigation revealed that K. G. belonged to a family which lived near the hospital. The family as a group had been treated recently by a Navajo “dewitching” practitioner for removal of a witch’s spell, but the patient, for reasons not known, was not present at that ritual. He developed his attack of abdominal pain several days thereafter, when he was brought to us at the hospital. After leaving the hospital, he went to a Hopi medicine-man who “dewitched” him and his pain subsided. No further intervention by us appeared necessary. Three months later K. G. was treated in the Clinic for unrelated medical problems, and indicated that there had been no recurrence of this episode.
Case Discussion These two cases illustrate examples of what a general medical practitioner might encounter when working with people who hold witchcraft beliefs. As in any clinical problem, accurate diagnostic evaluation leads to the most judicious course of action. In cases of “primary” witchcraft (K. G.), settling for a conventional psychiatric diagnosis, such as conversion hysteria, could lead to an ineffective treatment plan. Psychotherapy or tranquilizers are as useless as surgery in treating patients claiming to have a deer hair placed in their intestine by a sorcerer. A traditional healing ceremony must be included in whatever plan is followed, if success is to be achieved.’ In cases such as A. V.’s,
’
In some cultures, it might be possible for physicians t o treat witchcraft cases with placebo interventions. However, the physician must first ascertain if the patient would accept “dewitching” interventions as being possible by someone outside the patient’s cultural context
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which involve complications of witchcraft, a combined approach is appropriate; that is, one which includes indigenous practices but does not solely rely on them. “Primary” witching (K. G.) or complications of witching (A. V.) will not be discovered unless the category of witchcraft is included in the differential diagnosis and compared to available data. In the case of A. V., several features could alert the observer to complications of witchcraft. Persistence of an illness and unsuccessful clinic visits would incline the patient and family to be suspicious of witchcraft. The onset of mysterious spells coming at night, as well as fainting and loss of appetite, are typical correlates of witching among Navajos [lo]. Probing by the examining physician revealed a family history of sighting “mysterious tracks” near where A. V. had been herding sheep. This information is only useful if the examiner is aware of the cultural significance of such stories. A. V.’s personality and family setting are important as well. There was evidence that A. V. had become a focal point of intense conflict in the extended family. Her own psychic vulnerability (indicated by her history of teen-age difficulties) gave additional impetus to her developing symptoms of witchcraft illness. But once developed, witchcraft symptoms become functionally autonomous from their psychological origins and both the interpersonal dynamics and the witchcraft dynamics must be attended to, on their own terms. In the case of K. G., the diagnosis of “primary” witchcraft was more easily determined, although, in such cases the examining physician also requires some relevant cultural information. To the culturally unaware physician the patient’s complaint of deer hair in the intestine might seem bizarre, whereas, to the culturally knowledgeable person this is recognized as a direct communication of witchcraft. Kluckhohn [lo] calls this form of witchcraft among Navajo Indians “wizardry.” It involves insertion at a distance (by a witch) of a foreign object somewhere in the victim’s body. The list of objects is large, but not unlimited, and among Navajos deer hair figures prominently as an object for insertion. The setting for episodes of wizardry are even clearer and more stereotyped than for most other forms of witchcraft. The episode is characterized by a sudden onset of sharp, localized pain. The victim is usually someone who in some way has been neglected by the family. Generally, help is sought from a practitioner of another tribe; Navajos most often get such help from a Hopi medicine-man [ 101 . Real or fancied wrongs by the neglected person’s significant others then get soothed in the reconciliation and social support which occurs when that person becomes a victim and requires treatment. Viewing these two cases of witchcraft from the vantage point of family systems yields useful insights. It is a well accepted principle of family therapy that a vulnerable family member may become an identified patient when family integrative mechanisms fail [ 111 . Unresolved conflicts between powerful members of the family, unattended psychological problems in
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influential members other than the identified patient, unusual loss of love or attention, and disruption of usual routines or cultural patterns-all these are examples of processes which are observable among families in crisis and are associated with symptom display in an identified patient. This symptom display, in turn, leads to certain strategic gains by the victim: attention indirectly is drawn t o the family problem; intervention can be obtained outside the family system; and all the members of the family are drawn together in an attempt at problem solving. Given a culture where succumbing to witchcraft is an accepted, even expected, part of symptom display, it is not surprising that some patients will present in such a fashion. In considering the possibility of witchcraft involvement, the examining physician looks for specific indications. Clements discovered that one common witchcraft stimulus for many cultures, including Navajo, is mystery or rarity of symptoms [ 121 . When patients have difficulty in applying the common explanations for illness, or when illnesses are mysterious or unusual-particularly when they d o not yield to the accepted treatments-witchcraft becomes a prominent fear. Actual witchcraft symptoms to be seen by emergency room physicians include fainting, acutely localized pain, chronic loss of appetite, and sudden onset of sensory or motor dysfunction. When witchcraft becomes a serious diagnostic consideration, one has several choices for treatment-indigenous medicine, modern physical medicine, some form of psychotherapy-singly, sequentially or in combination. An important issue in developing treatment plans is whether witchcraft is the direct cause of the patient’s symptoms or one of several complicating factors in a symptom picture not otherwise comprehended by the victim or family. In A. V.’s case, a combination of factors warranted a combined treatment approach. Ruling out the possibility of neurological impairment, her symptoms were compatible with those associated with witchcraft. The family members present at our first interview further confirmed the witchcraft aspects, and also expressed their intention to take A. V. to a Hopi “dewitching” practitioner. These facts justified the decision not to discourage the family from pursuing cultural relief. On the other hand, A. V. had been brought to the clinic twice before, within six months, to be treated for similar symptoms. Thus, pharmacological treatment (minor tranquilizer); and previous indigenous health treatment was not completely effective. One may conclude then that the fear of witchcraft may have been only one of several psychosocial contributors to A. V.’s symptoms, and that concurrent referral to the Mental Health Clinic therefore was appropriate. In the case of K. G., the sudden onset and dramatic nature of the symptoms called for a sequential approach: first a reliance on physical medicine and then a transfer to indigenous care. The nature of his complaint demanded serious consideration of organic pathology. The differential included some kind of intra-abdominal catastrophe with possible toxic delirium, as well as witchcraft fear. The patient was so uncooperative that he had to be restrained chemically
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in order to examine him. While appearing to be free of organic pathology, there still remained enough lingering doubt to wish to arrange for consultation with an indigenous practitioner in the hospital (where K. G. could continue to be observed) instead of releasing the patient. The patient did not accept this, and so was allowed to pursue this consultation outside of the hospital. Routine follow-up was instigated, but no referral of the patient to Mental Health was done. The reason for this choice is that neither the medical record nor the initial interview revealed any prior psychosocial pathology; so after reasonably eliminating organic pathology, one was left with witchcraft fear as the primary diagnosis rather than a complicating factor.
The Cultural Interface Some usual steps in formulating a differential diagnosis and treatment plan were involved in the above presentations. In familiar situations it often is safe to take these steps for granted. But in a new context, such as a cross-cultural interface, being “routine” can be disastrous. Therefore, it is important to be aware of some key aspects of the diagnostic interview, so that these aspects can be implemented consciously. Primary among these is the fact that this process is an intensely interpersonal one. “The patient influences the doctor and the doctor influences the patient; diagnosis is one of the complex resultants of this interaction. The diagnosis depends not only on the symptoms and manifestations of the patient, but also on the doctor’s training, familiarity with the patient and his culture, and his attitudes toward the patient, which are in turn influenced by the patient’s attitudes toward him [13] .” The clinical goals of the differential diagnosis are to provide a clear description of the situation, to define the field of inquiry, to exclude the irrelevant, and to order the several possibilities. An important interpersonal goal of the differential diagnosis is to restate the presenting problem in terms of these probabilities, in order to communicate to the patient that the clinician has heard and understood the patient’s complaint and is prepared to make recommendations, if such are possible. These goals attained, one next turns to the treatment plan. This plan not only must be appropriate to the diagnosis, but it must be designed to permit appropriate behavior by all parties in the health system: the clinician must see it as embodying effective action; the patient and family must be able to accept and to understand (albeit within their own belief system) the clinician’s action; and the patient and family must be willing and able to carry out recommendations. Frank has shown that this sharing in a belief system not only provides a rationale for the disorder and its treatment, but makes possible renewed hope for relief [14]. In contrast, if one does not enlist this total system support, therapeutic failure is more likely to be the result. It is important to realize that culture plays an integral role in these
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patient-clinician interactions. Cultural assumptions are unseen yet facilitating when shared, but are blinding and impeding when not shared [ 151. Thus, cultural components of the clinician-patient relationship automatically are taken for granted and assimilated by the clinician in the situation where both are middle class, technologically educated people. But these components tend t o be ignored, rejected, or inappropriately diagnosed if the cultural information given by the patient is strange and incomprehensible to the clinician. “In cultures where witches are perceived as a constant threat, very real difficulties may arise in [the physician’s] separating psychoneurotic anxiety from rational, culturally determined fear. Obviously, fear of witches should not automatically be labeled a phobia; nor should a preoccupation with witches and witchcraft be seen as an obsession. On the other hand . . . [one should not] assume that fear of witches could not be a phobia. . . . The distinction depends on the cultural standards of the group to which the individual belongs [13] .” Such cultural standards are not readily available to most physicians. Thus “the decision as to whether a given act is appropriate or inappropriate must often necessarily be a lay decision, simply because we have n o technical mapping of the various subcultures in our society, let alone the standards of conduct prevailing in each of them [16] .” Detre and Kupfer suggest that the emergency room triage team should include “a community worker who is preferably a cultural and ethnic representative” of the neighboring subculture
PI. By using such resources to acquaint oneself with the culture of a patient population, the clinician will find that medical beliefs often are parallel to, and not exclusive of, technologic understanding [ 171 . The challenge for the technologically trained practitioner in a folk-cultural situation is to include such cultural beliefs in the diagnostic and treatment formulations. It is the practitioner’s task to “maintain an orientation in [his/her] own culture, in the culture under study, and in the private world of the patient under discussion [13] .”
Expanding the Health Care Network Most patients presenting to a medical practitioner or facility have consulted with a person other than a physician prior to arrival [18]. This person may have been a relative, a friend or a non-physician health practitioner. Among members of the dominant class in a technological culture, these prior consultations often are with associated health practitioners, such as dentists, optometrists, social workers. But among many ethnic and social class subcultures, these consultations may be with alternative health practitioners, such as medicine-men, curanderos or psychic healers. Associated health practitioners have well-established relationships to the medical profession, and referral from them and to them is an accepted part of good practice. Alternative health
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practitioners, however, d o not have established relationships with the medical profession. Consequently, little knowledge exists about when and how referral could take place. This poses a challenge for education. We have pointed out the advantages for the clinician in being aware of cultural factors influencing a population, as well as aware of the indigenous resources available to cope with specific cultural dynamics. Similarly, educational efforts need to be undertaken to turn alternative health practitioners into associated health practitioners. Programs such as the NIMH-sponsored training of Navajo medicine-men bring these alternative practitioners into the overall health network [ 191. Such efforts will provide physicians with a more educated case-finding group, as well as with a resource for the physician to make an appropriate indigenous referral. REFERENCES
1. L. Saunders, Cultural Differences and Medical Care-The Case f o r the Spanish Speaking People o f the Southwest, Russell Sage, New York, 1954. 2. T. P. Detre and D. J . Kupfer, General Hospital Psychiatric Services, in American Handbook o f Psychiatry, D. X . Freedman and J. E. Dryud, (eds.), Basic Books, New York, pp. 607-618, 1975. 3. R. Spitz, Hospitalism, Psychoanal. Study Child., 1, pp. 53-74, 1945. 4. D. Rosenn, L. Stein and M. Bates, The Differentiation of Organic From Environmental Failure to Thrive, paper delivered at Amer. Ped. SOC.,April 19, 1975. 5. E. L. Thomas, The Possibility of Using Physiological Indicators for Detecting Psychiatric Disorder, in Approaches t o Cross-Cultural Psychiatry, J . M. Murphy and A. H. Leighton, (eds.), Cornell U., Ithaca, pp. 161-186, 1965. 6. E. Gunderson and R. Rahe, Life Stress and Illness, Thomas, Springfield, Ill., 1974. 7. T. P. Hackett and A. D. Weisman, “Hexing” in Modern Medicine, in Proceedings of the Third World Congress o f Psychiatry, Philosophical, New York, pp. 1249-1252, 1961. 8. S . Cappannari, B. Rau, H. S. Abram and D. C. Buchanan, Voodoo in the General Hospital, JAMA, 232, pp. 938-940, 1975. 9. W. B. Cannon, “Voodoo” Death, Psychosom. Med., 19, pp. 182-190, 1957. 10. C. Kluckhohn, Navajo Witchcraft, Beacon, Boston, 1944. 11. S. Minuchin, L. Baker, B. Rosman, et al., A Conceptual Model of Psychosomatic Illness in Children-Family Organization and Family Therapy, Arch. Cen. Psychiat., 32, pp. 1031-1038, 1975. 12. F. Clements, Primitive Concepts of Disease, Univ. Calif. Publ. Amer. Archeol. & Ethnol., 32, pp. 185-252, 1932. 13. C. Savage, A. H. Leighton and D. C. Leighton, The Problem of CrossCultural Identification of Psychiatric Disorders, in Approaches to CrossCultural Psychiatry, J. M. Murphy and A. H. Leighton, (eds.), Cornell U., Ithaca, pp. 21-63, 1965.
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14. J . D. Frank, Persuasion and Healing, John Hopkins, Baltimore, 1961. 15. J . P. Spiegel, Some Cultural Aspects of Transference and Countertransference, in Individual and Familial Dynamics, Masserman, (ed.), Grune & Stratton, New York, 1959. 16. E. Goffman, Asylums, Doubleday, New York, 196 1. 17. 1. Adair and K . W. Deuschle, The People’s Health, Appleton, New York, 1970. 18. E. Friedson, The Profession of Medicine-A Study in the Sociology of Knowledge, Dodd Mead, New York, 1970. 19. R. Bergrnan, The Importance of Psychic Medicine-Training Navajo Medicine-Men, NIMH Mental Health Program Reports, 5 , pp. 20-43, 197 1.
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