Ethnopsychiatry and social psychiatry

Abstract

There is an imperialist dimension in occidental science; for instance, mental illnesses are defined and classified according to occidental criteria, which we in the western world tend to consider universal. In the medical model, reinforced by the developments of psychopharmacology, the sequence diagnosis — drugs — discharge tends to exclude the personal and social dimensions. Even the psychoanalytic approach does not get away from the concept of individual illness, and minimizes the social dimension of existence. In traditional African cultures, mental illness is integrated into social order and cosmic order. Each member of the culture has precise conceptual and operational models for the causes of the illness: the patient is the victim of an aggression, carried out by a living person or by a ghost, acting as representative of the law of the group. The social discourse, in particular, the healers, masks and reveals a deep and holistic truth: illness is the outcome of the characteristic and fundamental aggressiveness of the human species. The various representations, changing from one ethnic group to another, reflect two fundamental types of conflictual situations: conflict with the other, derived from the original conflict with the mother; and conflict with the law, which emanates not from the father but from the ancestors or the gods. A typical example is described: the Rab system used by the healers of Senegal. Man is not an isolated individual, perceiving his isolation, separated from the others and from the world. He is a link in a chain, very much part of a lineage, engaged in the universe, protected by the ancestors and the gods. Illness has a social value: it is a sign of a disorder in the community. The healer, whose knowledge and power have been acquired through initiation, does not address himself to the patient: his action, through symbolic procedures, is directed to the community. Not only does he aim at freeing the patient from the illness, but at restoring order in the group. African ethnopsychiatry is therefore a social psychiatry in the fullest sense. Occidental cultures have privileged other models: the medical model centered around the concept of illness, the psychological model around the concept of personality. The social model has not yet obtained the privileged place which it will perhaps reach once the essential importance of the social aspect of mental illness is recognized. These views have led the author to his action-research during twenty years of psychiatric practice and teaching in Senegal (1958–1978), where he found that the medical model as imported from France had proven inefficient. The Fann mental hospital, a cultural heritage of the colonial status, was changed from a closed asylum into a living community, open to families, friends, and former patients at any time of the day or night. A member of the family of each patient had to be hospitalized with him and to share the same life during his whole stay. All kinds of community activities were set out. A blurring of the roles of staff and patients took place. Slowly, madness, because of this liberal acceptance, disappeared from the institution. What has been possible in Africa cannot be achieved in Europe at the present. The pre-eminence of the medical model, the rigidity and hierarchy of the medical power, the heaviness and bureaucratic routines of the health care system are formidable obstacles.