Georges Devereux and Clinical Ethnopsychiatry

by Tobie Nathan : (1)

(Translated from the French by Catherine Grandsard)

"Go find a master..."

In the course of my formative years, I encountered schoolteachers, educators, professors, guides... Towards them, I experienced admiration or anger - often indifference - before them, I felt fear or pride; at times they rewarded me; often they scolded me, sometimes they humiliated me - most often they ignored me and that was how it should be! Only once did I experience the pain of having a master. In his presence, I felt suspended, as though any personal thinking were interrupted. This experience somewhat resembles entering a convent - in fact for a long time, a very long time, I felt cloistered within his thinking. I traveled the spaces, theories, beings and yet I remained confined to the very spot where he had left me since our last meeting. My ideas followed the strict progression of what he accepted to entrust me with. I must point out that this wasn't deliberate on his part, rather, it was a mechanism, a sort of machinery. Actually, I didn't like meeting with him; I avoided those one on one encounters during which he confidently purred away... reminiscing, uttering sentences which were sometimes profound, sometimes merely reasonable, dispensing advice or criticism, which he gave out generously. Our work meetings were long - lasting four hours, twelve hours... I would come out crushed. He dislocated me, as one takes apart a puppet ; he broke my shell as one shells a walnut, he stoned me like an olive, throwing my naked flesh out to the world... And it was like a new beginning: I was left with the courage and recklessness of newborns.
I was fascinated by his intelligence - the kind of intelligence I prefer, agile, sharp, loathing boredom above all else, skipping over explanations without ever becoming sibylline, mystic, or sophistic... Yet he left me dumbfounded by contradiction... He endlessly spoke of humanity, comprehension, reason, friendship yet only abstract theories interested him; he stated that the only true value was mature love within a stable couple and repeatedly praised the radiant bawdiness of the Mohave Indians; he idealized psychoanalysis, described it to us as the only true therapy, yet he despised flesh and blood psychoanalysts whom he considered garrulous show-offs. I met him in 1969 - he hated Marxists, leftists, protesters, agitators, all those he referred to as « social negativists », and in fact any thought remotely inspired by Marxism; yet he consistently behaved as a rebel, a fundamental anarchist. (3) He owned a single tie, a plaid tie, which he wore every Saturday afternoon, the day of his seminar. In private conversations, he described all ethnologists as jokers - except Marcel Mauss - all psychologists as eccentrics - except Freud, and only up until 1915. He praised the pursuit of progress yet claimed that there had been none in the Humanities for the past fifty years. He sometimes acted as if he were inviting me to share fragments of his private life, immediately denying me any authentic knowledge of him. Such was Georges Devereux, my master. Today, I know a master leads one to the hidden but never reveals it, never points it out, never explains it - he is the path leading to it... for one cannot all at once be the container and the content.
I worked with him for ten years - from 1971 to 1981 - first under his direction, and then more and more with him, like an apprentice: together, we founded the first ethnopsychiatry journal (Ethnopsychiatrica), we often discussed together the concrete extensions his teachings should include. He endlessly complained about not having a laboratory or research funds for his students, of not receiving attention from administrative authorities. Yet he carefully avoided all contact with officials of any kind representing the administration. (4) In the last days of our relationship, he acted towards me as towards a future heir, asking me to teach his seminar when he couldn't because his respiratory insufficiency made it difficult for him to breathe. He insisted that I obtain a course at the Ecole des Hautes Etudes which I taught for a year in 1977-1978. At the time, I was too little to know that one doesn't inherit from a master; one is merely transformed by him! I learnt this to my cost one day! On a Saturday of 1981, we were four of his students gathered together to start the first ethnopsychiatry consultation - four clinicians, psychiatrists, psychologists, with psychoanalytic training. Indeed, we had theoretical knowledge of what was then already referred to as ethnopsychiatry - the study of specific manifestations of disorders in certain cultures, the analysis of traditional treatment systems - but no idea of the real practices that such knowledge could produce. That same evening, he ended all relations with me. I like to think that by acting in this way, he was simply taking once again his true place, that of a master, to guide me one last time; teaching me to leave: I'd like to keep thinking that, in fact, he wished to pass on to me the rage to go on. In any case, it is the lesson I think I learned: I've mostly worked on clinical issues.

The contradictions of theoretical ethnopsychiatry

The ethnopsychiatry which Georges Devereux taught us was theoretical, descriptive and explanatory. He made out index cards sorting out thousands of anecdotes of all kinds, field notes, short clinical observations. This is how he constructed his books; he also taught in this fashion. His rare lectures - he didn't like giving talks, and preferred to debate, argue, discuss - were a long list of small observations. For over thirty years, he had patiently accumulated unusual, contradictory, paradoxical facts. Though he was always attempting audacious conceptual breakthroughs, original constructions, his true passion was that of the scholar, his ambition, knowledge. Yet his theory of complementarism, inspired by Jordan, Bohr and Heisenberg isn't that of a practitioner of physics designing experimental set ups to try to capture the electron, but rather it is that of a creator of general theories of matter. His writings are peppered with general statements on the nature of beings : humans are like this; culture is that; the superego is made up of this, stress of that.
I wish here to examine two fundamental impacts of Georges Devereux's thinking on psychoanalysis and psychotherapy.

1. The first was to compel the clinician to take into consideration facts he didn't know about, whose existence he never even suspected, to whom he therefore gave no importance a priori - for example that one can read psychological disorders through the lens of specific cultural determinants. In other words : the statement (number 1) : B, son of A, himself the head of a Fon lineage of Benin, was driven mad by the voduns because he refused to take on the ritual responsibility incumbent upon him since his father's death is as true as the statement (number 2): B was overcome by a profound melancholic sadness following the death of his father, A, to whom he was strongly attached by bonds both deep and ambivalent. This first blast still hasn't been metabolized by the field of clinical psychotherapy which, up until now, hasn't been able to take it into consideration technically, forever trying to be rid of the first statement.

2. The second impact is methodological. For Devereux, psychoanalysis creates the phenomenon it observes.

« The psychoanalytic experiment not only elicits the behavior which it studies, it actually creates it - exactly as the opponents of psychoanalysis have told the psychoanalyst all along, though he refused to listen. » (5)

It is therefore the task of the psychoanalyst to always create fruitful material, open to elaboration, to new productions, to life. For, just as a biologist can set up experimental designs which, taken too far, can destroy the very object of his experiment, a psychoanalyst is always at risk of creating a clinical situation turning the patient into a vegetable.(6)

« The behavior so produced also includes the patient's specific responses to the existence of the therapist and to the physical and formal setting of the analysis. It includes, above all, responses to the experience of being analyzed and it is this experience which is unique and altogether unlike ordinary life experiences. It is even probable that it is this which elicits transference. »(7)

Thus, as early as 1966, Devereux had reached crucial methodological formulations regarding psychoanalysis - formulations in which he attributes the entire responsibility of the process to the psychoanalyst who provokes, triggers, creates, who, in the end, generates and interprets his own productions. This also underscores the responsibility of the therapist and the intellectual dead-ends in which the interpretation of possible therapeutic failures inevitably get stuck.
Such are the two essential methodological points based on which I will attempt to describe what ethnopsychiatry has developed into, at least the ethnopsychiatry we practice at the University of Paris 8.

Practices

As I said earlier, as early as 1981, we seized upon the methodological premisses of ethnopsychiatry in order to develop new practices. I must point out that, for ten years, Devereux's seminar was attended by young psychiatrists and psychologists, who were all faced with new clinical problems that were starting to appear in France. From then on, ethnopsychiatry was redefined by force of circumstance, moving beyond its status as a descriptive theory towards the invention of therapeutic settings for the treatment of immigrant populations. This ethnopsychiatry was first and foremost a research approach to clinical work, but it also constituted a theoretical and political experiment. For, if it prompted us to rethink the practice of psychoanalysis, I believe it also led us to think in an radically new way about the place we are willing to give to immigrant populations and their cultures in the modern societies we are contributing to build.

In fact, I would gladly define the Georges Devereux Center as an experimental space for mediation between scientific systems of thought, and thought systems brought with them by immigrant populations. At a time of what is referred to as globalization, it seems impossible for us to consider actual social practices - as well as political action, in fact - without addressing the question of the place we attribute to systems from other worlds.

Languages versus language (langue et langage)

But let us return to clinical considerations. Changes in settings which stem from the questioning of doctrine often result in fruitful innovations. I can say today that simply introducing a translator in the psychotherapeutic setting sufficed to turn upside down the pleasing theoretical construct that was ours at the beginning. First, the patients' statements were no longer « interpretable » - or more precisely: the interpretation - and namely psychoanalytic interpretation - appeared oddly superfluous. Indeed, what place was to be given to slips of the tongue, or to specific arrangements of signifiers when the primary urgency first resided in the literal comprehension, then in the necessary comparison of the systems thus brought together - and first of all the languages! I claim that the diffidence my psychoanalyst colleagues generally display towards languages - and not language - stems from the fact that introducing a second language and its necessary representatives (translators, family, friends) makes it impossible to « listen », according to the usual sense we give that word in our profession. An then, we gradually discovered that it wasn't merely a matter of speaking the language of the patient, but also of speaking about languages. In the end, this is a considerable advantage because speaking about languages, publicly discussing the translation of the patient's and his family's statements ipso facto turns the patient into an expert, a necessary partner, an ally in an enterprise of exploration, knowledge and especially of acting on negativity. Indeed, the mediator's translation, immediately submitted to the patient, becomes debatable, invites contradiction. He or she can discuss the subtleties, the intention; comment on the partiality of the translator. For if the words of the patient become questions about his world, and as such about the world, these questions, quite understandably, are of interest not only to the therapist. As soon as they appear, the patients join the debate, contributing to the translation, to the discussion of etymologies, the exploration of the thousands of mechanisms at work in the making of possible statements, the choices allowed by the language and those it prohibits.(8)
From time to time, when the exploration of the meanings of a word became too problematic, too conflicting, a proverb would appear. "Why does she say « God blessed me when he gave me this son »? Hasn't she experienced so many problems because of his illness?" Is this a mere figure of speech?" "Custom" one might say? The husband answers: "At home, we often say: el kerd fi 'en ommou gha-zal." How should this proverb be translated? Probably literally, first: "In the eyes of its mother, the monkey is a gazelle." And it sounds just right... For isn't this mother forever praising her drug abusing son who has been plaguing her for the past five years? Someone in the gathering explains... Is it the patient, a family member, the therapist, a co-therapist? What does it matter? Talking about languages can bring everyone to agree; the meaning of a proverb as well. "The proverb means that in general, one tends to find only qualities among one's close relations"... Yes but... How are we to understand it in this case? Does it mean that she doesn't dare complain about her son, for fear that the words of a mother might put a curse on him? Or only that she is partial? Does she wish to ward off fate, she who has suffered so much from a cruel destiny? Is it merely a complaint worded in a coded form? All this is open to discussion, commentary, argumentation, initiating reminiscences, attempts at demonstrations and theoretical constructions.
Treating language as a thing - more precisely as a system of things - suddenly opens the psychotherapeutic space to real debate in that it henceforth contains a means for the speakers to reach an agreement, instead of finding themselves confined yet again within the closed field of dual conflict where the question is always to determine which of the two better understands the meaning of what is said. This is why clinical ethnopsychiatry takes place within a group - a group of therapists who come from different worlds, who practice multiple languages, a group thus containing a multiplicity of interpretations. The multiplicity of possible statements creates and stabilizes a space which can thus avoid degenerating into an arena of dual confrontation. The innovation of clinical ethnopsychiatry has been to consider this transformation of the clinical setting as specifically worthy of interest.
The growing experience we acquired in the handling of translations gradually led us to adopt languages as a comprehension model, in an attempt to resolve the contradictions inherited from theoretical ethnopsychiatry. Let me try to explain in what way. I would first define every language as an object manufactured by a group which in turn manufactures one by one the individuals belonging to this group. Indeed, it is clearly absurd to wonder who created the French language - absurd because the answer is obvious! The speakers manufacture the language every day - any one of them being capable of modifying in a durable way a word, an expression, a pronunciation, a rule of syntax, provided the modification is accepted by the group. The creation of new expressions by present day second generation North African immigrants in our suburbs or by rap music groups demonstrates that the French language isn't manufactured only in the Académie française but mostly in the streets. And since it is obvious that language is one of the systems that most strongly contributes to the development of the individual, one can conclude that the group manufactures an object which, in turn, manufactures the individuals of the group.
Again, the model of language provides us with a logical, reasonable and robust solution. There is no difference, from this perspective, between let's say a Malinke speaker and a French speaker. There is no doubt that each of them has been "manufactured" by a language, itself manufactured each day by their group. It is precisely because the Malinke person and Frenchman are identical that they are both manufactured by a language. One could also say that the fact that they are both manufactured by a language proves that they are identical. The problem is that the objects by which they've been manufactured are different : the Malinke language isn't the French language. It thus becomes absurd to discuss a possible opposition between universalism and relativism. This is mere common sense: the universal nature of man is obvious, it is not worth discussing. If humans are the same, the objects manufactured by groups of humans are different. The difference worth studying is located in objects, not in humans -not in their biology, nor their social structure, nor their psyche. I will try to demonstrate how this notion solves a series of contradictions and opens the way to original and effective technical settings.

The question of recovery

This notion also solves the old problem posed by recovery and the endless question: can one consider recoveries obtained by cultural therapies as being of the same nature as those obtained through "scholarly" therapies? What I refer to as "scholarly" therapies are those psychotherapies claiming to proceed from the scientific observation of "nature." It goes without saying that I am in no way taking a stance on their scientific value. The question of recovery is crucial because if, on the one hand, therapeutic systems are radically heterogeneous, and, on the other, recoveries obtained by these different systems were all of the same nature, we would then have to abandon the claim of theories of psychopathology to a general explanation, both of disorders and of action upon the disorders. Yet, to think in this way clearly seems too difficult - professionals' resistances are huge! This explains why most authors who have attempted conceptualizations in the field of ethnopsychiatry have always proposed Western-based explanations of the therapeutic effects of cultural systems, effects which have been routinely observed. They ascribe the improvements observed in patients either to "transference" (Roheim), to "suggestion" (Freud and many psychoanalysts after him), to the "placebo effect",(9) to "beliefs" (Levi-Strauss) or to "social reorganizations" (Zempleni, along with many anthropologists). Some, like Devereux, do not recognize any real effect other than palliative:

« Thus, one cannot consider that the shaman accomplishes a "psychiatric cure" in the strict sense of the term; he only provides the patient with what the Chicago School of Psychoanalysis would call a "corrective affective experience" which helps him reorganize his defense system but does not allow him to reach the genuine insight without which there is no real cure. »(10)

Transference, suggestion, placebo effect, belief... these are all "Western" concepts which make it possible to reject cultural explanations by interpreting them. Of course, the days are over (yet it wasn't so long ago) when the thought of "primitive" peoples was considered prelogic,(11) magical or infantile .(12) But today, interpretation - be it sociological, structuralist or psychoanalytic - is the principal instrument used to disqualify theories belonging to groups and communities, and, consequently, to disqualify their therapeutic practices(13). Those who from the start deny actors in a system the capacity to totally account for the system they manage, are doomed to interpret these actors' theories, their results, the entire system. As a result we have a psychiatrist, a psychoanalyst, an ethnographer feeling at home everywhere he (or she) goes. Such a nomad will tend to annex any cultural therapy he approaches, translating it into ready-made theoretical tokens. Having become an expert, he won't learn anything of substance about the people with whom he comes into contact. Isabelle Stengers has perfectly described this problem:

"As I have already emphasized, only those who see themselves as purely « nomadic », are irreparably destructive and/or tolerant, those who can no longer be frightened or distressed by anything; and the group which identifies as such can only send out experts The psychoanalyst, when he views himself as a « modern practitioner » also views himself as « nomadic », freed from the illusory bonds that attach others. Henceforth, the analyst can consider himself « at home » wherever he is, since his practice defines any « territoriality », any sedentary way of life as open to « analysis »."(14)

So, we must take a stance: do cultural therapies cure patients? Or, even worse, do they cure them for the "wrong reasons"(15)? This is the first question we will have to answer seriously. In any event, it is always in the name of recovery that the Senegalese patient continues to consult the marabout, the Moroccan to consult the fkih and the patient from the Limousin the magnetic healer. Since, justifiably, it is by way of this criteria that patients allow the persistence - and even the development(16)- of such systems, making it possible for the objects of their worlds to continue manufacturing new cases, new beings, we must pay attention to their arguments. The Moroccan has usually experienced that amulets heal; the Senegalese that sand speaks, and the person from the Limousin that hands convey a fluid. They don't believe in the healer, as is generally claimed, they respect the objects of the professional: an amulet, sand, a fluid - and the mastery he has acquired.

The question of the validity of cultural theories:

How should we consider the concepts which organize cultural therapeutic systems? As "representations," "beliefs" or genuine theories? If we think of them as "representations," we deny them, in effect, any claim to describing objects of the world: they speak of things, we, of representations; they, of the action of the fetishes, we, of the belief in the action of the fetishes; they, of the demands of the dead, we, of mourning feelings; they, of the constraints imposed by the gods, we, of "paternal complexes" If we could find a way to respect their claim of describing the world, then we should consider cultural therapeutic systems as genuine theories. And if theories they are, it becomes necessary 1) to learn them; 2) to experiment with them concretely; 3) to compare their clinical efficiency, or at least their concrete effects, with the efficiency of "scholarly" therapies. This is a challenge, in as much as these theories often aren't taught but rather they are transmitted through initiation. Moreover, these theories are rarely explicit, never presented as systems of ideas. Rather, they inform the technical actions of the therapist and can only be re-constructed. Finally, to consider them as genuine systems of thought would require of those who decide to learn them that they more or less adopt the professional identity of those who practice them. Yet it is socially impossible for a Western clinician to take on the identity of a Colombian shaman, a Moroccan fkih, a Nigerian baba-lawo - not to mention that of a magnetic healer from the Limousin! Here again, we come up against professional resistances. This is why, to avoid the problem, most authors(17) consider cultural theories, as "pre-notions," "fantasies," "beliefs" and sometimes even as the survival in adults of infantile sexual theories.(18) As was often the case, G. Devereux recognized the problem and expressed himself vividly on the subject:

« This is why we can never be certain data of primitive "psychiatrists" represent authentic scientific intuitions or if they are mere fantasies derived from a model of cultural thinking »(19)

It should be noted that for Devereux, should the theories of traditional therapists prove to be of interest, they would be so only in terms of intuition. Thus, he writes further-on in the same text, referring to the Sedans in Viet Nam :

« ...These are merely people who are inclined towards speculation, but whose insights remain sterile in as much as they are not integrated within a scientific context and are not correlated with other insights of the same order, but only with mythology. »(20)

Yet cultural theories are perceived by those who make use of such therapeutic systems as being as genuine as « scholarly » theories. Patients, and we have all experienced this, do not oppose the two worlds. Rather, they try to take advantage of both. Indeed, it is the « scholars » who are at war, not the clients! At war with each other, in the first place,(21) but also with those they designate as "charlatans." Again, the ethnopsychiatrist should follow the users' example when constructing his concepts, taking seriously cultural theories - approaching them not as "representations", but as genuine theories the specific rationale and necessity of which he will have to explicit. In brief, he will have to explain how the phenomenon apprehended by these theories is apprehended correctly and how these theories permit an effective grasp of the world.

What to do about groups?

Ethnopsychiatry needs the concept of "culture", or at least a concept acknowledging the existence of groups. French anthropologists and especially sociologists have an increasing tendency to do without such a concept (often with good reason), preferring the more vague notions of « worlds » or « universes ». Moreover, the increasingly active processes of globalization of information, habits, laws, commodities, tend to make this notion seem out-of-date, perhaps somewhat prematurely obsolete. Yet at the same time, a series of new elements have emerged reminding us that in psychopathology, groups cannot be done away with - whether such groups are referred to as "ethnic groups" or as "communities." Indeed, more and more frequently "therapists" appear who re-invent "cultural" treatment systems. For example, a Tahitian Tahua who, in the wake of an existential crisis, suddenly decides to seek initiation among the New Zealand Maori and is tattooed there from head to toe;(22) or a woman healer in a Mali village who organizes (invents? re-invents?) new rituals to the djinnas claiming all the while that she is merely re-instating a timeless tradition; (23) or a female nganga, a healer from Northern Congo, settled in Brazzaville, who creates a new method of extracting malignancy.(24) And what of this healer from a social housing development in the northern suburbs of Paris who reads the cards for the depressed unemployed on the dole?(25) These people all gather around them numerous patients. They present and see themselves as "cultural" therapists. It seems to me that, today, if the social sciences are to be innovative, they must imperatively conceive of methods allowing for these « subjects » to be considered as competent and creative, in no way puppets or robots! For, after all, these people haven't chosen to be initiated in just any old trade but in the art of healing. Our observations in ethnopsychiatry have increasingly led us to a somewhat strange hypothesis: It may be that psychopathology and culture entertain stronger bonds than was once suspected. For if it turned out that nowadays, in this period of globalization, it were mostly through an illness - or one of its most pernicious forms, the obligation to heal others - that "culture" might suddenly invest a person, then illness - and especially mental illness - and culture would form a couple more closely linked than ever before, though such an alliance would remain as mysterious as ever.(26)
First, it must be said that any social science is the science of groups. Even clinical psychology, based on the study of individual cases, necessarily leads to the creation of groups - admittedly artificial groups, the only expert of which is the researcher. Indeed, what social reality might a group have, for example made up of all the people classified by psychologists and psychiatrists under the heading of Paranoid Schizophrenia? These are simply statistical groups, "homogeneous groups of patients," people whose only common characteristic is of having been classified in a given category by professionals. In this case, how could one possibly construct the truth by way of a real debate taking on the patients as partners?
In the modern world, social groups are often formed in a battle opposing specific interests to experts. Recent examples: people with AIDS, united in associations, succeeded in imposing their expertise, thus upsetting the perspectives and priorities of researchers in the field.(27) The pressure of gay movements compelled the American Psychiatric Association to delete homosexuality from the list of mental disorders. Sometimes, isolated researchers help to constitute such groups through their brilliant personal efforts. Oliver Sachs, for instance, has succeeded in imposing the idea that modern research in neurology consists in investigating the actual experience of patients, who are the only ones capable of describing the unique strangeness of their world.(28) Thus, recognition by groups is sought after by an increasing number (though still to few) of modern researchers in social sciences in order to acquire partners able to question the validity of their hypotheses.(29)
Ethnopsychiatry can be practiced only in this manner. Indeed, the ethnopsychiatrist always has a double who incessantly questions him on the legitimacy of his perspectives, methods and results, namely the healer or the "natural" therapist of the populations he treats. The good fortune of the ethnopsychiatrist, his asset, is merely epistemological: among all clinicians, he is the only one to have a necessary contradictor. We must also remember that in other universes, groups of "patients" are also often genuine social groups. For example, in Morocco, the group made up of all those who have been possessed by a certain djinn is possible and constitutes a reality of experience. Such a group can be found in certain zaouias (30) in which the followers can devote themselves to the 'hadra, the ritual trance.
In other words, the question of ethnopsychiatry necessarily calls forth actual social groups which, nowadays, have lost the distant, literary and somewhat imaginary nature conveyed in yesterday's ethnology. We meet Bambaras, Dogons, Mandingos... every day, in the street, in the subway, in our offices. Such cohabitation requires managing relations with different communities, given that, as all groups, these tend to produce representatives. We are in the urgent need of a theory which will allow us to recognize and call upon these groups and their representatives. Thus, the ethno part of the term "ethnopsychiatry" is a reminder to the ethnopsychiatrist of his own methodological requirement: to appeal to actual constituted groups and their representatives in order to validate his (or her) propositions and hypotheses.
Today, however, there is an added complexity. Sometimes, it turns out to be concepts constructed by practitioners that end up generating genuine social groups.
First example: The description of a neurological syndrome by Gilles de la Tourette led, several decades later, to the creation of an extremely active association (especially in the United States), the Tourette Syndrome Association.(31) Here, the group is defined by the disease. While keeping close ties with the doctors and neurologists who created it, the association challenges them incessantly, prompting them to actively pursue research, propose new etiologic hypotheses, discover new treatments.
Second example: It is reasonable to consider that Freud's definition of homosexuality as a "psychic structure" allowed people with homosexual practices who saw themselves as "deviant," to imagine they were members of a particular category, then constitute a social group: the gay movement. Today, the movement questions the experts - psychiatrists, psychoanalysts, endocrinologists, biologists, who created them - having designated itself as their unavoidable partner.
Third example: The description by Benjamin, followed by Stoller, of "transsexuals" gradually brought individuals to first create a social group then a pressure group requesting surgery from doctors and identity changes from administrative authorities... Here, the group originally defined by a bio-psychoanalytic concept - they refer to themselves as Benjaminites, inspired by the name of their "creator" - has become a pressure group compelling professionals to adopt new ethical standards, a new moral code, indeed a new philosophy.
Thus, we must face the evidence: social practices, which are always the applications of social sciences, generate the creation of new social groups which in turn question their creators.

Therapeutic settings

Attempts in this field - ethnopsychiatry, transcultural psychiatry, comparative psychiatry, folk psychiatry - always started from the acknowledgment of differences, but then got bogged down in an endeavor to recapture universality. This is what renders them "soft," fragile and, of course, questionable. Most of the time, the authors adopt the hypothesis according to which the psychological or psychopathological structure is universal, merely "colored" by culture. Jilek, for example, quite rightly points out that the usual position in "comparative psychiatry" has been to consider culture as having a pathoplastic rather than pathogenic influence on psychopathological symptoms.(32) Some authors, considering the strangeness of pathologies referred to by Anglo-Saxons as culture bound syndromes, venture a little farther, though quite timidly. Michael Kenny, for example, proposes the idea that certain morbid entities, such as smallpox or the measles are unequivocally universal, whereas the Malaysian latah would be a sort of "social theater".(33) It remains to be seen, however, in what way a "social theater" might make up a psychopathology. Georges Devereux was perhaps alone in noting that this constituted a true epistemological problem calling for the creation of a full-fledged discipline. Yet it must be said that his works are replete with the same type of contradictions I have indicated. For instance: if there is an irreducible specificity to Mohave psychopathology,(34) through what miracle could psychoanalysis possibly account for it? Indeed, even reduce it to something already known elsewhere? Unless we consider this psychopathology to be in no way specific; or rather that its specificity is nothing but an illusion. Here we find ourselves almost insulting the Mohave, sympathetically considering them poor theoreticians, barely capable of naïvely approaching - and only "symbolically" - Freud's thinking.
To put an end to this type of contradiction, my proposition is to apply to therapeutic settings the conception drawn from our experience with languages and translation. Groups manufacture therapeutic settings; and it is these therapeutic settings that manufacture, not human beings, of course - and here they differ from languages - but patients. This proposition solves a series of problems, creates new ones and entails technical and theoretical consequences.
First, this proposition is rational, materialistic, and rejects any compromise with mystico-philosophical positions, in good keeping with rationality.
It has the advantage of being perfectly congruent with what is known about traditional therapeutic systems. In many African groups, for example, people don't refer to a person as a treatment specialist but as someone who has touched things - not knowledge but things, objects. I believe these systems know - or, more precisely, they postulate - that patients are manufactured by things, those things that the therapists belonging to the group have learned to handle. On the other hand, it fits rather well with traditional theories that have so far been considered mythical and/or symbolic, according to which humans manufacture fetishes, look after them, feed them, all the while receiving sustenance from them - in no way impeding that fetishes in turn manufacture humans.
This proposition makes it possible to once and for all rid ourselves of those vague, catch-all notions such as "belief" or "conviction" - notions which can only generate attitudes of tolerance, indeed even condescension.
This proposition also makes it possible to understand why people from non-Western societies expect from a therapist that he (or she) manufacture them from their own objects, yet are also prone to accepting other types of manufacturing, agreeing to go along with, in a sense to try out, other types of patient-manufacturing. We are thereby afforded a new perception of a curious fact that has ceaselessly bewildered clinicians, namely the paganism, the sort of spontaneous therapeutic polytheism of patients all over the world, who never hesitate to straddle the so-called metaphysical opposition between "natural" and "supernatural," between "rational" and "irrational," seeking help successively, sometimes even simultaneously, from a psychiatrist, a psychotherapist, but also a healer, a charismatic church, etc. Finally, feeble and contradictory reasoning can thus be avoided, such as the "either, or" argument - either Western reason or traditional irrationality - as well as the postmodern logic of juxtaposition, the "why not?" stance - why not both the psychiatrist and the healer - this vague crossbreeding rightly criticized by Devereux in his 1968 preface to The Psychotherapy of a Plains Indian. The very fact that patients so willingly accept the ethnopsychiatric setting demonstrates that any true therapy should always strive to reach the level of complexity of which are capable those it is intended to serve.
It also allows us to understand why, when we consider traditional therapeutic objects, in the course of an ethnopsychiatry consultation, patients willingly accept to take part in the discussion with us. When we demonstrate some competence, certain statements can make the entire gathering agree, just as the discussion around the meaning of a word or a proverb can make everyone agree. Formulations such as the following: the jnoun throw stones at noon; or every person has a rab of the opposite sex; or this child spends each night talking with the spirits which is why he hasn't been able to learn the language of humans, etc.
But the theoretical implications are considerable:
In terms of psychopathology, according to this proposition, the core of a person is no longer located inside him (or her), but in a public space, within the objects invented by the group and manufactured by professionals. I must make it clear that I am referring to patients and not persons as such.
In order to account for what ethnopsychiatry brings to light, we need to change the very object of psychopathology. It would no longer be a matter of studying symptoms, syndromes, structures, even illnesses, but of describing and then learning the use of therapeutic objects such as they are invented and manufactured by human groups. When I speak of objects, I mean all kinds of objects: theories, prayers, songs, but also things - plants, statuettes, calabashes, skulls, etc.
And there is no reason to think that what has just been said holds true only for non-Western groups. On the contrary, I think such a theory is just as useful with our native patients. In other words we are much closer to the reality of our clinical work when we consider our patients as "manufactured" - rather than spontaneous - manufactured by our own theory, of course, but also by the successive theories of those professionals who inevitably preceded us.
In a word, the ethnopsychiatry we practice is not relativistic: it is constructivist.

Ethical consequences

If ethnopsychiatry is constructivist, then the patient loses his status as an object, a strange and feeble being to be probed until interesting elements come to light. It is no longer possible to "interpret" her functioning with a theory. She becomes a necessary partner, an indispensable alter ego in a common research enterprise. Ethnopsychiatry has developed the habit of rethinking with the patient both his personal suffering - as do talk therapies - as well as the theories which have informed this suffering, which have, as we have seen, constructed and elaborated it... To generalize the logic of ethnopsychiatry to all patients, regardless of their origin, would lead us never to hesitate in considering them as "constructed" as "cases;" to postulate that this manufacturing concerns and interests them; and that they are the privileged recipient of what the theory thinks about them. Thereby promoted informant, the patient is invited to discuss the observations of the therapists, to argue their hypotheses, and finally to share the responsibility of the treatment thereby worked out in common.
Thus conceived, ethnopsychiatry generates an ethical rigour through a sort of natural process since any information concerning her is necessarily and systematically submitted to the patient's attention. The obligation to share interpretations with the patient, the construction of "truth" in the course of a genuine debate in which she truly participates, are part of its theoretical postulates and thus of its routine clinical practice. In fact, such a therapy truly achieves the ideal of psychoanalysis - to allow the patient to grasp part of what constituted her.

Demarcations

Although Georges Devereux probably would've disagreed - but can the dead be made to speak? - both technically and politically with the practice of clinical ethnopsychiatry - I am firmly convinced that his inspiration has been passed on. His continuous strive towards scientific rigour and specialization; his never-ending interest in related disciplines, biology, ethology, physics, what wasn't yet referred to as cognitive psychology, considered as practices and not results, constitute, in my opinion, the most innovative aspect of his work. It is for this reason that we chose to name after him the university centre I have directed for the past five years. And it is this perspective, which we can qualify today as materialistic, constructivist and research-oriented that the ethnopsychiatry I practice attempts to take as far as clinical work will allow.

Definition

Finally, to conclude, I would now define ethnopsychiatry as follows:

1. A clinical discipline taking as its object the analysis of all therapeutic systems, viewed as systems of objects; all systems without exception nor hierarchy, those claiming to be "scholarly" as well as those purporting to belong to a specific collective or community - be it ethnic, religious, or social. Ethnopsychiatry sets out to describe these systems, to extract their own rationality and especially to demonstrate their necessary character. This discipline claims a specific scientific rigour stemming from the fact that, considering therapeutic systems as the property of groups - according to the aforementioned formula: groups manufacture objects which in turn manufacture persons - it seeks to demonstrate its hypotheses through the development of methods allowing representatives of these groups to take a stance on their validity.

2. A discipline which sets out to test the concepts of psychiatry, psychoanalysis and psychology in light of theories belonging to the groups whose therapeutic systems it studies. It creates situations, imagines settings, invents methods intended to test these theories in light of the cultural and clinical realities it observes.

A clinical practice which considers that the processes and results of points (1) and (2) are of concern primarily to the patients; a practice interested in engaging in a true debate with them; finally, a practice deliberately setting up spaces prohibiting on the part of therapists the practice of insulting(35) patients, their families or their groups- by this I mean that it isn't satisfied with simply leaving the respect of this rule up to the moral value of the therapist, but rather it actively engages in constructing a setting which concretely precludes such a practice.

Translated from the French by Catherine Grandsard

Bibliography

Berger L., 1997 - Anthropologie politique des systèmes de soins magico-religieux. L'exemple des cultes de possession bamanan au Bèlèdugu (Mali). Mémoire de DEA d'Anthropologie, sociologie du politique et du développement. Université Paris 8.
Chlyeh A., 1995 - La thérapie syncrétique des Gnaoua marocains. Thèse de doctorat d'ethnologie, Université de Paris VII.
Clément C., 1980 - "De l'angoisse à la méthode" par Georges Devereux. Libération du 20 mai 1980, p. 34.
Collignon R., 1989 - "Pour un retour sur les "culture-bound syndromes" en psychiatrie transculturelle." Santé, Culture, Health, VI, 2, 149-162.
Devereux G., 1969 - Ethnopsychiatrie des indiens mohave . Tr. fr. : Paris, Synthelabo, Les empêcheurs de penser en rond, 1996.
Devereux G., 1970 - Essais d'ethnopsychiatrie générale , Paris, Gallimard.
Devereux G., 1972 - Ethnopsychanalyse complémentariste . Paris, Flammarion.
Devereux G., 1980 - De l'angoisse à la méthode dans les sciences du comportement. Paris, Flammarion.
Dozon P. - 1995 : La cause des prophètes. (politique et religion en Afrique contemporaine) Paris, Le Seuil.
Foucault M., 1997 - « Il faut défendre la société. » Cours au Collège de France. 1976. Paris, Gallimard, Seuil.
Freud, Totem et tabou, Paris, Payot, 1968.
Gauchet M., 1985 - Le désenchantement du monde . Paris, Gallimard.
Grunberger B., Dessuant P., 1997 - Narcissisme, christianisme, antisémitisme ; Actes Sud.
Jilek G. , 1982 : Culture "Pathoplastic" or "Pathogenic"? A key question of Comparative Psychiatry. Curare (Journal of Ethnomedicine and Transcultural Psychiatry) , Heidelberg, 5: 57-68.
Juillerat B. - 1991 : dipe chasseur. Une mythologie du sujet en Nouvelle Guinée. Paris, P.U.F.
Levy-Bruhl L. - La mentalité primitive. Paris, P.U.F., réédition.
Nathan T., Hounkpatin L. - 1996 : La parole de la forêt initiale. Paris, Odile Jacob.
Ortigues M.C., Ortigues E. - Oedipe africain. Paris, Plon, 1966.
Piault C. ed. - Prophétisme et thérapeutique. Albert Atcho et la communauté de Bregbo. Paris, Hermann, 1975.
Pignarre Ph., 1997 - Qu'est-ce qu'un médicament ? Paris, La Découverte, 1997.
Pouillon J. - 1970 : "Malade et médecin : le même et/ou l'autre. Remarques ethnologiques." - Nouvelle Revue de Psychanalyse, 1, 76-98.
Pradelle de la Tour C.H. - 1997 - Le crâne qui parle. Ethnopsychanalyse bamileke . Paris, EPEL.
Pury (de) S., 1998 - Traité du malentendu. Théorie et pratique de la médiation interculturelle en situation clinique. Paris, Synthélabo, Les empêcheurs de penser en rond.
Róheim G., 1943 : Origine et fonction de la culture. Paris, Gallimard, 1967.
Sacks O. , 1996, Un anthropologue sur Mars. Sept histoires paradoxales Paris, Le Seuil.
Saura B., 1993 - Politique et religion à Tahiti . Tahiti, Éd. Polymages-scoop
Stengers I, 1997 - Cosmopolitiques I, La guerre des sciences . Paris, Paris, La découverte-Synthélabo, les Empêcheurs de penser en rond, 1996.
Stengers I, 1997 - Cosmopolitiques, tome 7, Pour en finir avec la tolérance. Paris, La découverte-Synthélabo, les Empêcheurs de penser en rond.
Stengers I., 1995 - "Le médecin et le charlatan" in T. Nathan et I. Stengers - 1995 : Médecins et Sorciers, Les empêcheurs de penser en rond, Paris, Synthélabo.
Tourette (G. de la) - 1885 : "Etude sur une affection nerveuse caractérisée par l'incoordination motrice accompagnée d'écholalie et de coprolalie (jumping, latah, myriatchit)" ; Archives de neurologie , 9, 19-42 et 158-200.
neurologie , 9, 19-42 et 158-200.

 

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Notes

(1) Ph D ; Professor of Clinical Psychology and Psychopathology, Centre Georges Devereux, University of Paris 8

(2) Centre Georges Devereux - Centre Universitaire d'aide psychologique, Université de Paris 8, 2, rue de la Liberté, 93526 Saint-Denis cedex 02, France.

(3) "In 1968, he is furious. « My heart was heavy with anguish and worry for those young people in the process of preparing a unlivable, totalitarian world for themselves. There wasn't a chance that they would succeed in establishing their anarchist, idealistic world. » Catherine Clément: "De l'angoisse à la méthode" par Georges Deverux. Libération, May 20 1980, p. 34. (Quote translated from the French by C. Grandsard)

(4) "Georges Devereux remained unknown because he was always a rebel, first and foremost towards the establishment: he never asked for anything from anyone, and this is palpable. Where did his strange genius come from, this sort of burnt sorcerer above himself?" Ibid., p. 34.

(5) Devereux, G. From Anxiety to Method in the Behavioral Sciences, The Hague, Paris, Mouton & Co, 1967, p. 302.

(6) "Bohr and Jordan conclusively proved that, if one seeks to determine completely the functions of life, one must reach so deeply into the organism, one must disturb so radically its essential state, that one abolishes thereby the very phenomenon one seeks to study: Life." Ibid, pp. 288-289.

(7) Ibid, p. 302

(8) Concerning this matter, see Sybille de Pury, Traité du malentendu. Théorie et pratique de la médiation interculturelle en situation clinique. Paris, Synthélabo, Les empêcheurs de penser en rond, 1998.

(9) See the stimulating discussion of the concept of placebo in Ph. Pignarre - 1997: Qu'est-ce qu'un médicament ? Paris, La Découverte, 1997.

(10) Devereux, Essais d'ethnopsychiatrie générale , Paris, Gallimard, 1970, p. 18. (Quote translated from the French by C. Grandsard)

(11) Levy-Bruhl L. - La mentalité primitive. Paris, P.U.F., new edition. In recent psychoanalytic texts, one comes accross arguments very similar to those of the beginning of the century: "Primitive man made weapons and tools which he rendered sacred, investing them with a magical power greater then his own. In the same fashion, he manufactured idols and fetishes, signifying projections of his narcissism. The idols represented (and still represent nowadays, to the extent that their worship still survives, in more or less disguised forms) the virtues and powers that man would like to possess in an absolute fashion... thus the idols become a prop of his projected hatred and could be feared." B. Grunberger, P. Dessuant : Narcissisme, christianisme, antisémitisme ; Actes Sud, 1997. Hence, there is no interest here in the techniques of fetish makers and users - nor in their philosophy or their construction of the world - once again reduced to the status of infantile masturbators.

(12) Freud, S. Totem et tabou, Paris, Payot, 1968 (Totem and Taboo). See also the critique of the Western representation of "primitives" in M. Gauchet, Le désenchantement du monde. Paris, Gallimard, 1985.

(13) See certain present day works representing what one could qualify as "old style" ethnopsychiatry, an ethnopsychiatry which denies the specificity of its own approach to the world, which interprets the actions and, above all, thoughts that it ascribes to those it observes. In this type of approach, if others do indeed act, they do so guided by intuition whereby the theories they construct to justify their actions can only be considered as facts to be observed. Examples: Ortigues M.C., Ortigues E. Oedipe africain. Paris, Plon, 1966 or Pradelle de la Tour C.H., Le crâne qui parle. Ethnopsychiatrie bamileke, Paris, E.P.E.L., 1997 for Lacanian interpretations; Juillerat B., dipe chasseur. Une mythologie du sujet en Nouvelle Guinée. Paris, P.U.F., 1991, for more "classical" psychoanalytic interpretations.

(14) Stengers, Cosmopolitiques, tome 7, Pour en finir avec la tolérance. Paris, La découverte-Synthélabo, les Empêcheurs de penser en rond, 1997. (Quote ranslated from the French by C. Grandsard)

(15) I quote here an expression coined by Isabelle Stengers in "Le médecin et le charlatan" in T. Nathan et I. Stengers, Médecins et Sorciers, Les empêcheurs de penser en rond, Paris, Synthélabo, 1995.

(16) For example, the exponential development in large cities throughout the world of prayer groups which are genuine traditional therapeutic organizations adapted to the modern world. See Piault C. ed., Prophétisme et thérapeutique. Albert Atcho et la communauté de Bregbo. Paris, Hermann, 1975; Dozon P., La cause des prophètes. (politique et religion en Afrique contemporaine) Paris, Le Seuil, 1995; Nathan T., Hounkpatin L., La parole de la forêt initiale. Paris, Odile Jacob, 1996.

(17) With the noteworthy exception of Marcel Mauss.

(18) See G. Ròheim (1943) Origine et fonction de la culture. (Origin and Funtion of Cuture) Paris, Gallimard, 1967.

(19) Devereux, Ethnopsychanalyse complémentariste . Paris, Flammarion, 1972, p. 252. (Quote translated from the French by C. Grandsard)

(20) Ibid, p. 256.

(21) See I. Stengers, Cosmopolitiques I, La guerre des sciences . Paris, Paris, La découverte-Synthélabo, les Empêcheurs de penser en rond, 1996.

(22) Saura, B. Politique et religion à Tahiti . Tahiti, Éd. Polymages-scoop, 1993.

(23) Berger, Anthropologie politique des systèmes de soins magico-religieux. L'exemple des cultes de possession bamanan au Bèlèdugu (Mali). Mémoire de DEA d'Anthropologie, sociologie du politique et du développement. Université Paris 8, juin 1997.

(24) Field data collected by Geneviève Nkoussou and Jérôme Weisselberg, unpublished.

(25) Personal observation.

(26) See Pouillon's description of theDangaleat where any calling is first an affliction. In other words: it is an illness which promotes the individual to the social position he will hold and qualifies him for this function. Pouillon J., 1970, "Malade et médecin : le même et/ou l'autre. Remarques ethnologiques." Nouvelle Revue de Psychanalyse, 1, 76-98.

(27) It isn't surprising that it is in Foulcault's wake that one finds the most innovative attempts in including patient associations in research, for example in the works of Daniel Defert. The recent publication of Foucault's lectures at the Collège de France provides us with theoretical leads for reusing « subjugated knowledges ». "By «subjugated knowledges » I also mean a series of knowledges that were disqualified as non-conceptual knowledges, as knowledges that were insufficiently elaborated: naïve knowledges, hierarchically inferior knowledges, knowledges beneath the level of scholarly or scientific requirements... it is through the reappearance of these local knowledges of people, of these disqualified knowledges that a critique was initiated." [Quote translated from the French by C. Grandsard] Michel Foucault, Il faut défendre la société. Cours au Collège de France. 1976. Paris, Gallimard, Seuil, 1997, p.9.

(28) Oliver Sacks, Un anthropologue sur Mars. Sept histoires paradoxales . (An Anthropologist on Mars) French translation: Paris, Le Seuil, 1996.

(29) I even think it is the only methodology, at least for psychopathology and psychotherapy, which affords a way of avoiding Popper's criticism accusing psychoanalysts of producing "non refutable" statements.

(30) Brotherhood also including a therapeutic function, gathered around the tomb of a saint. See, for instance, A. Chlyeh, La thérapie syncrétique des Gnaoua marocains. Thèse de doctorat d'ethnologie, Université de Paris VII, 1995.

(31) The original text : G. de la Tourette, 1885, Etude sur une affection nerveuse caractérisée par l'incoordination motrice accompagnée d'écholalie et de coprolalie (jumping, latah, myriatchit), Archives de neurologie , 9, 19-42 et 158-200.

(32) Jilek G., Culture "Pathoplastic" or "Pathogenic"? A key question of Comparative Psychiatry. Curare. (Journal of Ethnomedicine and Transcultural Psychiatry), Heidelberg, 1982, 5: 57-68.

(33) Quoted by Collignon in Pour un retour sur les "culture-bound syndromes" en psychiatrie transculturelle. Santé, Culture, Health, VI, 2, 149-162.1989.

(34) Devereux, Ethnopsychiatrie des indiens mohave . French translation: Paris, Synthelabo, Les empêcheurs de penser en rond, 1996.

(35) I refer to Isabelle Stengers' use of this expression (la pratique de l'injure) - Seminar, 97/98.

 

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