The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology Scheper-Hughes and Lock

The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology Author(s): Nancy Scheper-Hughes and Margaret M. Lock

ARTICLES

NANCY SCHEPER-HUGHES

Department of Anthropology, University of California, Berkeley

MARGARET M. LOCK

Department of Humanities and Social Studies in Medicine, McGill University

The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology

Conceptions of the body are central not only to substantive work in med­ical anthropology, but also to the philosophical underpinnings of the en­tire discipline of anthropology, where Western assumptions about the mind and body, the individual and society, affect both theoretical view­points and research paradigms. These same conceptions also influence ways in which health care is planned and delivered in Western societies. In this article we advocate the deconstruction of received concepts about the body and begin this process by examining three perspectives from which the body may be viewed: (1) as a phenomenally experienced indi­vidual body-self; (2) as a social body, a natural symbol for thinking about relationships among nature, society, and culture; and (3) as a body politic, an artifact of social and political control. After discussing ways in which anthropologists, other social scientists, and people from various cultures have conceptualized the body, we propose the study of emotions as an area of inquiry that holds promise for providing a new approach to the subject.

The body is the first and most natural tool of man—Marcel Mauss (1979[ 1950j)

Despite its title this article does not pretend to offer a comprehensive review of the anthropology of the body, which has its antecedents in physical, psychological, and symbolic anthropology, as well as in ethnoscience, phenomenology, and semiotics. Rather, it should be seen as an attempt to inte­grate aspects of anthropological discourse on the body into current work in med­ical anthropology. We refer to this as a prolegomenon because we believe that insofar as medical anthropology has failed to problematize the body, it is destined to fall prey to the biological fallacy and related assumptions that are paradigmatic to biomedicine. Foremost among these assumptions is the much-noted Cartesian dualism that separates mind from body, spirit from matter, and real (i.e., visible,

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palpable) from unreal. Since this epistemological tradition is a cultural and his­torical construction and not one that is universally shared, it is essential that we begin our project in medical anthropology with a suspension of our usual belief and cultural commitment to the mind/body, seen/unseen, natural/ supernatural, magical/rational, rational/irrational, and real/unreal oppositions and assumptions that have characterized much of ethnomedical anthropology to date. We will be­gin from an assumption of the body as simultaneously a physical and symbolic artifact, as both naturally and culturally produced, and as securely anchored in a particular historical moment.

In the following pages we will critically examine and call into question var­ious concepts that have been privileged in Western thinking for centuries and which have determined the ways in which the body has been perceived in scien­tific biomedicine and in anthropology. This article is descriptive and diagnostic. Its goal is both the definition of an important domain for anthropological inquiry and an initial search for appropriate concepts and analytic tools.

We are writing for three audiences. First, we hope to introduce general an­thropologists to the potential contributions of medical anthropology toward un­derstanding an intellectual domain we all share—the body. Second, we want to draw the attention of medical anthropologists to writings on the body not usually recognized for their relevance to the field. And third, we wish to speak to clini­cians and other health practitioners who daily minister to mindful bodies. The resulting effort is necessarily partial and fragmentary, representing a somewhat personal itinerary through paths of inquiry we believe to hold particular promise for theory building and further research in anthropology generally, and in medical anthropology particularly.

The Three Bodies

Essential to our task is a consideration of the relations among what we will refer to here as the "three bodies. 112 At the first and perhaps most self-evident level is the individual body, understood in the phenomenological sense of the lived experience of the body-self. We may reasonably assume that all people share at least some intuitive sense of the embodied self as existing apart from other individual bodies (Mauss 1985119381). However, the constituent parts of the body—mind, matter, psyche, soul, self, etc.—and their relations to each other, and the ways in which the body is received and experienced in health and sickness are, of course, highly variable.

At the second level of analysis is the social body, referring to the represen­tational uses of the body as a natural symbol with which to think about nature, society, and culture, as Mary Douglas (1970) suggested. Here our discussion fol­lows the well-trodden path of social, symbolic, and structuralist anthropologists who have demonstrated the constant exchange of meanings between the "natu­ral" and the social worlds. The body in health offers a model of organic whole­ness; the body in sickness offers a model of social disharmony, conflict, and dis­integration. Reciprocally, society in "sickness" and in "health" offers a model for understanding the body.

At the third level of analysis is the body politic, referring to the regulation, surveillance, and control of bodies (individual and collective) in reproduction and

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sexuality, in work and in leisure, in sickness and other forms of deviance and human difference. There are many types of polity, ranging from the acephalous anarchy of "simple" foraging societies, in which deviants may be punished by total social ostracism and consequently by death (see Briggs 1970; Turnbull 1962), through chieftainships, monarchies, oligarchies, democracies, and mod­em totalitarian states. In all of these polities the stability of the body politic rests on its ability to regulate populations (the social body) and to discipline individual bodies. A great deal has been written about the regulation and control of individ­ual and social bodies in complex, industrialized societies. Foucault's work is ex­emplary in this regard (1973, 1975, 1979, 1980a). Less has been written about the ways in which preindustrial societies control their populations and institution­alize means for producing docile bodies and pliant minds in the service of some definition of collective stability, health, and social well-being.

The "three bodies" represent, then, not only three separate and overlapping units of analysis, but also three different theoretical approaches and epistemolo gjes: phenomenology (individual body, the lived self), structuralism and symbol­ism (the social body), and poststructuralism (the body politic). Of these, the third body is the most dynamic in suggesting why and how certain kinds of bodies are socially produced. The following analysis will move back and forth between a discussion of "the bodies" as a useful heuristic concept for understanding cul­tures and societies, on the one hand, and for increasing our knowledge of the cultural sources and meanings of health and illness, on the other.

The Individual Body

How Real is Real? The Cartesian Legacy

A singular premise guiding Western science and clinical medicine (and one, we hasten to add, that is responsible for its awesome efficacy) is its commitment to a fundamental opposition between spirit and matter, mind and body, and (un­derlying this) real and unreal. We are reminded of a grand rounds presentation before a class of first-year medical students that concerned the case of a middle-aged woman suffering from chronic and debilitating headaches. In halting sen­tences the patient explained before the class of two hundred that her husband was an alcoholic who occasionally beat her, that she had been virtually housebound for the past five years looking after her senile and incontinent mother-in-law, and that she worries constantly about her teenage son who is flunking out of high school. Although the woman's story elicited considerable sympathy from the stu­dents, many grew restless with the line of clinical questioning, and one finally interrupted the professor to demand "But what is the real cause of the head­aches?"

The medical student, like many of her classmates, interpreted the stream of social information as extraneous and irrelevant to the real biomedical diagnosis. She wanted information on the neurochemical changes which she understood as constituting the true causal explanation. This kind of radically materialist think ing, characteristic of clinical biomedicine, is the product of a Western epistemol­ogy extending as far back as Aristotle's starkly biological view of the human soul in De Anima. As a basis for clinical practice, it can be found in the Hippocratic

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corpus (ca. 400 B.C.). Hippocrates' and his students were determined to erradi-cate the vestiges of magico-religious thinking about the human body and to intro­duce a rational basis for clinical practice that would challenge the power of the ancient folk healers or "charlatans" and "magi," as Hippocrates labeled his medical competitors. In a passage from his treatise on epilepsy, ironically entitled "On the Sacred Disease," Hippocrates (Adams 1939:355-356) cautioned the Greek iatros (physician) to treat only what was observable and palpable to the senses:

I do not believe that the so-called Sacred Disease is any more divine or sacred than any other disease, but that on the contrary, just as other diseases have a nature and a definite cause, so does this one, too, have a nature and a cause.

It is my opinion that those who first called this disease sacred were the sort of people that we now call 'magi'. These magicians are vagabonds and charlatans, pretending to be holy and wise, and pretending to more knowledge than they have.

The natural/ supernatural, real/unreal dichotomy has taken many forms over the course of Western history and civilization, but it was the philosopher-mathe­matician Rene Descartes ( 1596- 1650) who most clearly formulated the ideas that are the immediate precursors of contemporary biomedical conceptions of the hu­man organism. Descartes was determined to hold nothing as true until he had es­tablished the grounds of evidence for accepting it as such. The single category to be taken on faith, as it were, was the intuited perception of the body-self, ex­pressed in Descartes's dictum: Cogito, ergo sum—I think, therefore I am. From this intuitive consciousness of his own being, Descartes proceeded to argue the existence of two classes of substance that together constituted the human orga­nism: palpable body and intangible mind. In his essay, "Passions of the Soul," Descartes sought to reconcile material body and divine soul by locating the soul in the pineal gland whence it directed the body's movements like an invisible rider on a horse. In this way Descartes, a devout Catholic, was able to preserve the soul as the domain of theology, and to legitimate the body as the domain of science. The rather artificial separation of mind and body, the so-called Cartesian dualism, freed biology to pursue the kind of radically materialist thinking expressed by the medical student above, much to the advantage of the natural and clinical sciences. However, it caused the mind (or soul) to recede to the background of clinical theory and practice for the next three hundred years.

The Cartesian legacy to clinical medicine and to the natural and social sci­ences is a rather mechanistic conception of the body and its functions, and a fail­ure to conceptualize a "mindful" causation of somatic states. It would take a struggling psychoanalytic psychiatry and the gradual development of psychoso­matic medicine in the early 20th century to begin the task of reuniting mind and body in clinical theory and practice. Yet, even in psychoanalytically informed psychiatry and in psychosomatic medicine there is a tendency to categorize and treat human afflictions as if they were either wholly organic or wholly psycholog­ical in origin: "it" is in the body, or "it" is in the mind. In her astute analysis of multidisciplinary case conferences on chronic pain patients, for example, Corbett (1986) discovered the intractability of Cartesian thinking among sophisticated cli­nicians. These physicians, psychiatrists, and clinical social workers "knew" that pain was "real" whether or not the source of it could be verified by diagnostic

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tests. Nonetheless, they could not help but express evident relief when a "true" (i.e., single, generally organic) cause could be discovered. Moreover, when di­agnostic tests indicated some organic explanation, the psychological and social aspects of the pain tended to be all but forgotten, and when severe psychopath­ology could be diagnosed, the organic complications and indices tended to be ignored. Pain, it seems, was either physical or mental, biological or psycho-so-cial—never both nor something not-quite-either.

As both medical anthropologists and clinicians struggle to view humans and the experience of illness and suffering from an integrated perspective, they often find themselves trapped by the Cartesian legacy. We lack a precise vocabulary with which to deal with mind-body-society interactions and so are left suspended in hyphens, testifying to the disconnectedness of our thoughts. We are forced to resort to such fragmented concepts as the bio-social, the psycho-somatic, the so-mato-social as altogether feeble ways of expressing the myriad ways in which the mind speaks through the body, and the ways in which society is inscribed on the expectant canvas of human flesh. As Kundera (1984:15) recently observed: "The rise of science propelled man into tunnels of specialized knowledge. With every step forward in scientific knowledge, the less clearly he could see the world as a whole or his own self." Ironically, the conscious attempts to temper the materi­alism and the reductionism of biomedical science often end up inadvertently re­creating the mind/body opposition in a new form. For example, Leon Eisenberg (1977) elaborated the distinction between disease and illness in an effort to distin­guish the biomedical conception of "abnormalities in the structure and/or func­tion of organs and organ systems" (disease) from the patient's subjective expe­rience of malaise (illness). While Eisenberg and his associates' paradigm has cer­tainly helped to create a single language and discourse for both clinicians and social scientists, one unanticipated effect has been that physicians are claiming both aspects of the sickness experience for the medical domain. As a result, the "illness" dimension of human distress (i.e., the social relations of sickness) are being medicalized and individualized, rather than politicized and collectivized (see Scheper-Hughes and Lock 1986). Medicalization inevitably entails a missed identification between the individual and the social bodies, and a tendency to transform the social into the biological.

Mind/body dualism is related to other conceptual oppositions in Western ep­istemology, such as those between nature and culture, passion and reason, indi­vidual and society—dichotomies that social thinkers as different as Durkheim, Mauss, Marx, and Freud understood as inevitable and often unresolvable contra­dictions and as natural and universal categories. Although Durkheim was primar­ily concerned with the relationship of the individual to society (an opposition we will discuss at greater length below), he devoted some attention to the mind/body, nature/society dichotomies. In The Elementary Forms of the Religious Life Dur-kheim wrote that "man is double" (1961119151:29), referring to the biological and the social. The physical body provided for the reproduction of society through sexuality and socialization. For Durkheim society represented the "highest reality in the intellectual and moral order." The body was the storehouse of emotions that were the raw materials, the "stuff," out of which mechanical solidarity was forged in the interests of the collectivity. Building on Durkheim, Mauss wrote of the "dominion of the conscious [will] over emotion and unconsciousness"

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(1979t19501:122). The degree to which the random and chaotic impulses of the body were disciplined and restrained by social institutions revealed the stamp of higher civilizations.

Freud introduced yet another interpretation of the mind/body, nature/culture, individual/society set of oppositions with his theory of dynamic psychology: the individual at war within himself. Freud proposed a human drama in which natural, biological drives locked horns with the domesticating requirements of the social and moral order. The resulting repressions of the libido through a largely painful process of socialization produced the many neuroses of modern life. Psychiatry was called on to diagnose and treat the dis-ease of wounded psyches whose egos were not in control of the rest of their minds. Civilization and its Discontents may be read as a psychoanalytic parable concerning the mind/body, nature/culture, and individual/society oppositions in Western epistemology.

For Marx and his associates the natural world existed as an external, objec­tive reality that was transformed by human labor. Humans distinguish themselves from animals, Marx and Engels wrote, "as soon as they begin to produce their means of subsistence" (1970:42). In Capital Marx wrote that labor humanizes and domesticates nature. It gives life to inanimate objects, and it pushes back the natural frontier, leaving a human stamp on all that it touches.

Although the nature/culture opposition has been interpreted as the "very ma­trix of Western metaphysics" (Benoist 1978:59) and has "penetrated so deeply . . . that we have come to regard it as natural and inevitable" (Goody 1977:64), there have always been alternative ontologies. One of these is surely the view that culture is rooted in (rather than against) nature (i.e., biology), imi­tating it and emanating directly from it. Cultural materialists, for example, have tended to view social institutions as adaptive responses to certain fixed, biological foundations. M. Harris (1974, 1979) refers to culture as a "banal" or "vulgar" solution to the human condition insofar as it "rests on the ground and is built up out of guts, sex, energy" (1974:3). Mind collapses into body in these formula­tions.

Similarly, some human biologists and psychologists have suggested that the mind/body, nature/culture, individual/society oppositions are natural (and pre­sumed universal) categories of thinking insofar as they are a cognitive and sym­bolic manifestation of human biology. Ornstein (1973), for example, understands mind/body dualism as an overly determined expression of human brain laterali zation. According to this view, the uniquely human specialization of the brain's left hemisphere for cognitive, rational, and analytic functions and of the right hemisphere for intuitive, expressive, and artistic functions within the context of left-hemisphere dominance sets the stage for the symbolic and cultural dominance of reason over passion, mind over body, culture over nature, and male over fe­male. This kind of biological reductionism is, however, rejected by most contem­porary social anthropologists who stress, instead, the cultural sources of these oppositions in Western thought.

We should bear in mind that our epistemology is but one among many sys­tems of knowledge regarding the relations held to obtain among mind, body, cul­ture, nature, and society. We would point, for example, to those non-Western civilizations that have developed alternative epistemologies that tend to conceive of relations among similar entities in monistic rather than in dualistic terms.

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Representations of Holism in Non-Western Epistemologies

In defining relationships between any set of concepts, principles of exclusion and inclusion come into play. Representations of holism and monism tend toward inclusiveness. Two representations of holistic thought are particularly common. The first is a conception of harmonious wholes in which everything from the cos­mos down to the individual organs of the human body are understood as a single unit. This is often expressed as the relationship of microcosm to macrocosm. A second representation of holistic thinking is that of complementary (not opposing) dualities, in which the relationship of parts to the whole is emphasized.

One of the better known representations of balanced complementarity is the ancient Chinese yin/yang cosmology, which first appears in the I Ching somewhat before the 3rd century B.C. In this view, the entire cosmos is understood as poised in a state of dynamic equilibrium, oscillating between the poles of yin and yang, masculine and feminine, light and dark, hot and cold. The human body is likewise understood as moving back and forth between the forces of yin and yang—some-times dry, sometimes moist, sometimes flushed, and sometimes chilled. The evolving tradition of ancient Chinese medicine borrowed the yin/yang cosmology from the Taoists and from Confucianism a concern with social ethics, moral con­duct, and the importance of maintaining harmonious relations among individual, family, community, and state. Conceptions of the healthy body were patterned after the healthy state: in both there is an emphasis on order, harmony, balance, and hierarchy within the context of mutual interdependencies. A rebellious spleen can be compared to an insubordinate servant, and a lazy intestine compared to an indolent son. In the Nei Ching, The Yellow Emperor's Classic of Internal Medi­cine, the Prime Minister counsels: "the human body is an imitation of heaven and earth in all its details" (Veith 1966:115). The health of individuals depends on a balance in the natural world, while the health of each organ depends on its rela­tionship to all other organs. Nothing can change without changing the whole. A conception of the human body as a mixture of yin and yang, forces of which the entire universe is composed, is altogether different from Western body concep tions based on absolute dichotomies and unresolvable differences. In ancient Chinese cosmology the emphasis is on balance and resonance; in Western cos­mology, on tension and contradiction.

Islamic cosmology—a synthesis of early Greek philosophy, Judeo-Christian concepts, and prophetic revelations set down in the Qur'an—depicts humans as having dominance over nature, but this potential opposition is tempered by a sa­cred world view that stresses the complementarity of all phenomena (Jachimow icz 1975; Shariati 1979). At the core of Islamic belief lies the unifying concept of Towhid, which Shariati argues should be understood as going beyond the strictly religious meaning of "God is one, no more than one" to encompass a world view that represents all existence as essentially monistic. Guided by the principle of Towhid humans are responsible to one power, answerable to a single judge, and guided by one principle: the achievement of unity through the complementarities of spirit and body, this world and the hereafter, substance and meaning, natural and supernatural, etc.

The concept in Western philosophical traditions of an observing and reflex­ive "I," a mindful self that stands outside the body and apart from nature, is

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another heritage of Cartesian dualism that contrasts sharply with a Buddhist form of subjectivity and relation to the natural world. In writing about the Buddhist Sherpas of Nepal, Paul suggests that they do not perceive their interiority or their subjectivity as "hopelessly cut off and excluded from the rest of nature, but [rather as] . . . connected to, indeed identical with, the entire essential being of the cosmos" (1976:131).

In Buddhist traditions the natural world (the world of appearances) is a prod­uct of mind, in the sense that the entire cosmos is essentially "mind." Through meditation individual minds can merge with the universal mind. Understanding is reached not through analytic methods, but rather through an intuitive synthesis, achieved in moments of transcendence that are beyond speech, language, and the written word. For, the essence of world meaning is unspeakable and unthinkable. It is experientially received as a perception of the unity of mind and body, self and other, mind and nature, being and nothingness.

The Buddhist philosopher Suzuki (1960) contrasted Eastern and Western aesthetics and attitudes toward nature by contrasting two poems, a 17th-century Japanese haiku and a 19th-century poem by Tennyson. The Japanese poet wrote:

When I look carefully

I see the nazuna blooming By the hedge!

In contrast, Tennyson wrote:

Flower in the crannied wall,

I pluck you out of the crannies,

I hold you here, root and all, in my hand, Little flower—but if I could understand What you are, root and all, and all in all, I should know what God and man is.

Suzuki observes that the Japanese poet Bashö does not pluck the nazuna, but is content to admire it from a respectful distance: his feelings are "too full, too deep, and he has no desire to conceptualize it" (1960:3). Tennyson, however, is active and analytical. He rips the plant by its roots, destroying it in the very act of admiring it. "He does not apparently care for its destiny. His curiosity must be satisfied. As some medical scientists do, he would vivisect the flower" (Suzuki 1960:3). Tennyson's violent imagery is reminiscent of Francis Bacon's descrip­tion of the natural scientist as one who must "torture nature's secrets from her" and make her a "slave" to mankind (Merchant 1980:169). Principles of monism, holism, and balanced complementarity in nature, which, like those described above, can temper perceptions of opposition and conflict, have largely given way to the analytic urge in the history of Western culture.

Person, Self, and individual

The relation of individual to society, which has occupied so much of contem­porary social theory, is based on a perceived "natural" opposition between the demands of the social and moral order and egocentic drives, impulses, wishes, and needs. The individual/society opposition, while fundamental to Western ep

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istemology, is also rather unique to it. Geertz has argued that the Western con­ception of the person "as a bounded, unique . . integrated motivational and cognitive universe, a dynamic center of awareness, emotion, judgement, and ac­tion . . . is a rather peculiar idea within the context of the world's cultures" (1984:126). In fact, the modern conception of the individual self is of recent his­torical origin, even in the West. It was really only with the publication in 1690 of John Locke's Essay Concerning Human Understanding that we have a detailed theory of the person that identifies the "I" or the self with a state of permanent consciousness that is unique to the individual and stable through the life span and physical change until death (Webel 1983:399).

Though not as detailed, perhaps, it would nonetheless be difficult to imagine a people completely devoid of some intuitive perception of the independent self. We think it reasonable to assume that all humans are endowed with a self-con­sciousness of mind and body, with an internal body image, and with what neu­rologists have identified as the proprioceptive or "sixth sense," our sense of body self-awareness, of mind/body integration, and of being-in-the-world as separate and apart from other human beings. Winnicot regards the intuitive perception of the body-self as "naturally" placed in the body, a precultural given (1971:48). While this seems a reasonable assumption, it is important to distinguish this uni­versal awareness of the individual body-self from the social conception of the individual as "person," a construct of jural rights and moral accountability (LaFontaine 1985:124). La personne morale, as Mauss (1985119381) phrased it, is the uniquely Western notion of the individual as a quasi-sacred, legal, moral, and psychological entity, whose rights are only limited by the rights of other equally autonomous individuals.

Modern psychologists and psychoanalysts (Winnicot among them) have tended to interpret the process of individuation, defined as a gradual estrangement from parents and other family members, as a necessary stage in the human ma­turation process (see also Johnson 1985; DeVos, Marsella, and Hsu 1985:3-5). This is, however, a culture-bound notion of human development, and one that conforms to fairly recent conceptions of the relation of the individual to society.

In Japan, although the concept of individualism has been debated vigorously since the end of the last century, it is still the family which is considered the most "natural," fundamental unit of society, not the individual. Consequently, the greatest tension in Japan for at least the past four hundred years has been between one's obligations to the state versus obligations to the family. Individual needs and wishes (i.e., the unsocialized, uncultivated side of humans) were met cov ertly, during "time out" from real society, often in the "flower and willow world" of the night quarters.

The philosophical traditions of Shintoism and Buddhism have also militated against Japanese conceptions of individualism. The animism of Shinto fosters feelings of immersion in nature, while many of the techniques of Buddhist con­templation encourage detachment from earthly desires and gross passions, expe­rienced in the attainment of mu or nothingness. Neither tradition encourages the development of a highly individuated self.

In all, Japan has been repeatedly described as a culture of "social relativ­ism," in which the person is understood as acting within the context of a social relationship, never simply autonomously (Lebra 1976; Smith 1983). One's self‑

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identity changes with the social context, particularly within the hierarchy of social relations at any given time. The child's identity is established through the re­sponses of others; conformity and dependency, even in adulthood, are not under­stood as signs of weakness, but rather as the result of inner strength (Reischauer 1977:152). One fear, however, which haunts many contemporary Japanese is that of losing oneself completely, of becoming totally immersed in social obligations. One protective device is a distinction made between the external self (tatemae)—the persona, the mask, the social self that one presents to others—versus a more private self (honne), the less controlled, hidden self. Geertz has described a sim­ilar phenomenon among the Javanese and Balinese (1984:127-128).

Read argues that the Gahuku-Gama of New Guinea lack a concept of the person altogether: "Individual identity and social identity are two sides of the same coin" (1955:276). He maintains that there is no awareness of the individual apart from structured social roles, and no concept of friendship—that is, a rela­tionship between two unique individuals that is not defined by kinship, neighbor­hood, or other social claims. Gahuku-Gama seem to define the self, insofar as they do so at all, in terms of the body's constituent parts: limbs, facial features, hair, bodily secretions and excretions. An assault on any part of the body (stealing feces, for example) is tantamount to an attack on the person, as occurs in sorcery accusations. Of particular significance is the Gahuku-Gama conception of the so­cial skin, which includes both the covering of the body and the person's particular social and character traits. References to one's "good" or "bad" skin indicate a person's moral character or even a person's temperament or mood. This is com­patible with a society in which social relationship is expressed in touching, fon­dling, stroking, holding, and other immediate physical manifestations. Gahuku-Gama seem to experience themselves most intensely when in contact with others and through their skins (see also LaFontaine 1985:129-130).

Such sociocentric conceptions of the self have been widely documented for many parts of the world (see Shweder and Bourne 1982; Devisch 1985; Fortes 1959; Harris 1978) and have relevance to ethnomedical understanding. In cultures and societies lacking a highly individualized or articulated conception of the body-self it should not be surprising that sickness is often explained or attributed to malevolent social relations (i.e., sorcery), or to the breaking of social and moral codes, or to disharmony within the family or the village community. In such so­cieties therapy, too, tends to be collectivized. Levi-Strauss (1963) has noted that in transcendental and shamanic healing, the patient is almost incidental to the rit­ual, which is focused on the community at large. The !Kung of Botswana engage in weekly healing trance-dance rituals that are viewed as both curative and pre­ventive (Katz 1982). Lorna Marshall has described the dance as "one concerted religious act of the !Kung [that] brings people into such union that they become like one organic being" (1965:270).

In contrast to societies in which the individual body-self tends to be fused with or absorbed by the social body, there are societies that view the individual as comprised of a multiplicity of selves. The Bororo (like the Gahuku-Gama) un­derstand the individual only as reflected in relationship to other people. Hence, the person consists of many selves—the self as perceived by parents, by other kinsmen, by enemies, etc. The Cuna Indians of Panama say they have eight selves, each associated with a different part of the body. A Cuna individual's tem

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perament is the result of domination by one of these aspects or parts of the body. An intellectual is one who is governed by the head, a thief governed by the hand, a romantic by the heart, and so forth.

Finally, the Zinacanteco soul has 13 divisible parts. Each time a person "loses" one or more parts he or she becomes ill and a curing ceremony is held to retrieve the missing pieces. At death the soul leaves the body and returns to whence it came—a soul "depository" kept by the ancestral gods. This soul pool is used for the creation of new human beings, each of whose own soul is made up of 13 parts from the life-force of other previous humans. A person's soul-force, and his or her self, is therefore a composite, a synthesis "borrowed" from many other humans. There is no sense that each Zinacanteco is a "brand-new" or to­tally unique individual; rather, each person is a fraction of the whole Zinacanteco social world. Moreover, the healthy Zinacanteco is one who is in touch with the divisible parts of him or herself (Vogt 1969:369-374).

While in the industrialized West there are only pathologized explanations of dissociative states in which one experiences more than one self (schizophrenia, multiple personality disorder, borderline, etc.), in many non-Western cultures in­dividuals can experience multiple selves through the normative practice of spirit possession and other altered states of consciousness. In Haiti and Brazil, where the spirits of voodoo or condomblé are believed to have distinct personalities that are expressed both in food, drink, and clothing preferences and in particular be havioial traits, those in training as "daughters of the saints" must learn how to change their own behavior in order to "invite" possession by particular saints. Once possessed and in trance, the spirit visitors are free to come and go, appear and disappear at will, much to the pleasure and entertainment of all present. Such ritualized and controlled experiences of possession are sought after throughout the world as valued forms of religious experience and therapeutic behavior. To date, however, psychological anthropologists have tended to "pathologize" these al­tered states as manifestations of unstable or psychotic personalities. The Western conception of one individual, one self effectively disallows or rejects social, re­ligious, and medical institutions predicated on ethnopsychologies that recognize as normative a multiplicity of selves. In recent years some psychiatrists and psy­chotherapists in the United States have begun to acknowledge that "possession" (as the experience of more than one self) may be a more valid and parsimonious explanation of certain altered states of consciousness in patients than recourse to classical psycho-pathological diagnoses such as Multiple Personality Disorder (MPD) (see Anderson 1981; Beahrs 1982; Crabtree 1985; Allison 1985).

Body imagery

Closely related to conceptions of self (perhaps central to them) is what psy­chiatrists have labeled "body image" (Schilder 1970119501; Horowitz 1966). Body image refers to the collective and idiosyncratic representations an individual entertains about the body in its relationship to the environment, including internal and external perceptions, memories, affects, cognitions, and actions. The existing literature on body imagery (although largely psychiatric) has been virtually un­tapped by social and especially medical anthropologists, who could benefit a great

THE MINDFUL BODY 17

deal from attention to body boundary conceptions, distortions in body perception, etc.

Some of the earliest and best work on body image was contained in clinical studies of individuals suffering from extremely distorted body perceptions that arose from neurological, organic, or psychiatric disorders (Head 1920; Schilder 1970119501; Luria 1972). The inability of some so-called schizophrenics to dis­tinguish self from other, or self from inanimate objects has been analyzed from psychoanalytic and phenomenological perspectives (Minkowski 1958; Binswan ger 1958; Laing 1965; Basaglia 1964). Sacks (1973 [1970], 1985) has also written about rare neurological disorders that can play havoc with the individual's body image, producing deficits and excesses as well as metaphysical transports in mind-body experiences. Sack's message throughout his poignant medical case histories is that humanness is not dependent upon rationality or intelligence—i.e., an intact mind. There is, he suggests, something intangible, a soul-force or mind-self that produces humans even under the most devastating assaults on the brain, nervous system, and sense of bodily or mindful integrity.

While profound distortions in body imagery are rare, neurotic anxieties about the body, its orifices, boundaries, and fluids are quite common. Fisher and Cleveland (1958) demonstrated the relationship between patients' "choice" of symptoms and body image conceptions. The skin, for example, can be experi­enced as a protective hide and a defensive armour protecting the softer and more vulnerable internal organs. In the task of protecting the inside, however, the out­side can take quite a beating, manifested in skin rashes and hives. Conversely, the skin can be imagined as a permeable screen, leaving the internal organs de­fenseless and prone to attacks of ulcers and colitis. Few medical anthropologists have examined social dimensions and collective representations of body imagery, although Kleinman's work on the somatization of depression in the aches and pains of Chinese and Chinese-American patients is one example (1980; Kleinman and Kleinman 1985). Another is Scheper-Hughes's description of impoverished Brazilian mothers' distorted perceptions of their breastmilk as sour, curdled, bit­ter, and diseased, a metaphorical projection of their inability to pass on anything untainted to their children (1984:541-544).

Particular organs, body fluids, and functions may also have special signifi­cance to a group of people. The liver, for example, absorbs a great deal of blame for many different ailments among the French, Spanish, Portuguese, and Brazil­ians, but to our knowledge only the Pueblo Indians of the Southwest suffer from "flipped liver" (Leeman 1986). In their national fantasy about the medical sig­nificance of the liver the French have created a mystical "phantom organ," one altogether fierce in its tyranny over the rest of the body and its ability to inflict human suffering (Miller 1978:44). The English and the Germans are, by com­parison, far more obsessed with the condition and health of their bowels. Dundes takes the Germanic fixation with the bowels, cleanliness, and anality as a funda­mental constellation underlying German national character (1984), while Miller writes that "when an Englishman complains about constipation, you never know whether he is talking about his regularity, his lassitude, or his depression" (1978:45).

Once an organ captures the imagination of a people, there appears to be no end to the metaphorical uses to which it may be put. Among "old stock" Amer‑

18 MEDICAL ANTHROPOLOGY QUARTERLY

jean Midwestern farmers, for example, the backbone has great cultural and eth-nomedical significance. When illness strikes at these industrious and "upright" people, being forced off their feet comes as a grave blow to the ego. Even among the elderly and infirm, well-being is defined as the ability to "get around," to be on one's feet. Obviously, the ability to stay "upright" is not confined to the mere technical problems of locomotion; it carries symbolic weight as well. As Erwin Strauss pointed out, the expression "to be upright" has two connotations to Americans: the first, to stand up, to be on one's feet; and the second, a moral implication "not to stoop to anything, to be honest and just, to be true to friends in danger, to stand by one's convictions" (1966b:137). Among rural Midwester­ners laziness is a most serious moral failing, and "spinelessness" is as reviled as godlessness. It is little wonder that a therapy concerned with adjusting perceived malalignments of the spine—chiropractic medicine—would have its origins in middle America (Cobb 1958).

Blood, on the other hand, is a nearly universal symbol of human life, and some peoples, both ancient and contemporary, have taken the quality of the blood, pulse, and circulation as the primary diagnostic sign of health or illness. The traditional Chinese doctor, for example, made his diagnosis by feeling the pulse in both of the patient's wrists and comparing them with his own, an elabo­rate ritual that could take several hours. The doctor was expected to take note of minute variations, and the Nei Ching states that the pulse can be "sharp as a hook, fine as a hair, taut as a musical string, dead as a rock, smooth as a flowing stream, or as continuous as a string of pearls" (Majno 1975:245). Snow (1974) has de­scribed the rich constellation of ethnomedical properties and significances at­tached to the quality of the blood by poor black Americans, who suffer from "high" or "low," fast and slow, thick and thin, bitter and sweet blood. Linke (1986) has analyzed the concept of blood as a predominant metaphor in European culture, especially its uses in political ideologies, such as during the Nazi era. Similarly, the multiple stigmas suffered by North American AIDS patients in­clude a preoccupation with the "bad blood" of diseased homosexuals (Lancaster 1983).

Hispanic mothers from southern Mexico to northern New Mexico focus some of their body organ anxieties on the infant's fontanelle. Open, it exposes the newborn to the evil influences of night airs, as well as the envious looks and wishes of neighbors. Until it closes over, there is always the threat of mollera caida, "fallen fontanelle," a life-threatening pediatric disorder (Scheper-Hughes and Stewart 1983).

In short, ethnoanatomical perceptions, including body image, offer a rich source of data both on the social and cultural meanings of being human and on the various threats to health, well-being, and social integration that humans are believed to experience.

The Social Body The Body as Symbol

Symbolic and structuralist anthropologists have demonstrated the extent to which humans find the body "good to think with." The human organism and its

THE MINDFUL BODY 19

natural products of blood, milk, tears, semen, and excreta may be used as a cog­nitive map to represent other natural, supernatural, social, and even spatial rela­tions. The body, as Mary Douglas observed, is a natural symbol supplying some of our richest sources of metaphor (1970:65). Cultural constructions of and about the body are useful in sustaining particular views of society and social relations.

Needham, for example, pointed out some of the frequently occurring asso­ciations to right- and left-handedness, especially the symbolic equations, on the one hand, between the left and that which is inferior, dark, dirty, and female, and, on the other hand, between the right and that which is superior, holy, light, dom inant, and male. Needham called attention to such uses of the body as a conve­nient means of justifying particular social values and social arrangements, such as the "natural" dominance of males over females (1973:109). His point is that these common symbolic equations are not so much natural as they are useful, at least to those "on the top" and to the right.

Insofar as the body is both physical and cultural artifact, it is not always possible to see where nature ends and culture begins in the symbolic equations. "Just as it is true that everything symbolizes the body," writes Douglas, "so it is equally true that the body symbolizes everything else" (1966:122). For the psy­choanalyst social practices are always referred back to their unconscious repre­sentations of the experience of self with the body; symbolic anthropologists work in the opposite direction, taking the experiences of the body as representation of society. Where Bruno Bettleheim attributes the practice of Australian subincision to male envy of the procreative female-mother, since the practice transforms the male penis into a facsimile of the female vulva (1955), Mary Douglas suggests that what is being carved in human flesh during this public ritual is a graphic image of society: the two halves of the Australian moiety (1966).

Ethnobiological theories of reproduction usually reflect the particular char­acter of their associated kinship system, as anthropologists have long observed. In societies with unilineal descent it is common to encounter folk theories that emphasize the reproductive contributions of females in matrilineal and of males in patrilineal societies. The matrilineal Ashanti make the distinction between flesh and blood that is inherited through women, and spirit that is inherited through males. The Brazilian Shavante, among whom patrilineages form the core of po­litical factions, believe that the father fashions the infant through many acts of coitus, during which the mother is only passive and receptive. The fetus is "fully made," and conception is completed only in the fifth month of pregnancy. As one Shavante explained the process to Maybury-Lewis, while ticking the months off with his fingers: "Copulate. Copulate, copulate, copulate, copulate a lot. Preg­nant. Copulate, copulate, copulate. Born" (1967:63).

Similarly, the Western theory of equal male and female contributions to con­ception that spans the reproductive biologies of Galen to Theodore Dobzhansky (1970) probably owes more to the theory's compatibility with the European ex­tended and stem bilateral kinship system than to scientific evidence, which was lacking until relatively recently. The principle of one father, one mother, one act of copulation leading to each pregnancy was part of the Western tradition for more than a thousand years before the discovery of spermatozoa (in 1677), the female ova (in 1828), and before the actual process of human fertilization was fully understood and described (in 1875) (Barnes 1973:66). For centuries the theory of

20 MEDICAL ANTHROPOLOGY QUARTERLY

equal male and female contributions to conception was supported by the erro­neous belief that females had the same reproductive organs and functions as males, except that, as one 6th-century Bishop put it, "theirs are inside the body and not outside it" (Laquer 1986:3). To a great extent, talk about the body and about sexuality tends to be talk about the nature of society.

Of particular relevance to medical anthropologists are the frequently en­countered symbolic equations between conceptions of the healthy body and the healthy society, as well as the diseased body and the malfunctioning society. Jan-zen (1981) has noted that every society possesses a utopian conception of health that can be applied metaphorically from society to body and vice versa. One of the most enduring ideologies of individual and social health is that of the vital balance, and of harmony, integration, and wholeness that are found in the ancient medical systems of China, Greece, India, and Persia, in contemporary Native American cultures of the Southwest (Shutler 1979), through the holistic health movement of the 20th century (Grossinger 1980). Conversely, illness and death can be attributed to social tensions, contradictions, and hostilities, as manifested in Mexican peasants' image of the limited good (Foster 1965), in the hot-cold syndrome and symbolic imbalance in Mexican folk medicine (Currier 1969), and in such folk idioms as witchcraft, evil eye, or "stress" (Scheper-Hughes and Lock 1986). Each of these beliefs exemplifies the link between the health or ill­ness of the individual body and the social body.

The Embodied World

One of the most common and richly detailed symbolic uses of the human body in the non-Western world is to domesticate the spaces in which humans re­side. Bastien has written extensively about the Qollahuaya-Andean Indians' in­dividual and social body concepts (1978, 1985). The Qollahuayas live at the foot of Mt. Kaata in Bolivia and are known as powerful healers, the "lords of the medicine bag." Having practiced a sophisticated herbal medicine and surgery since AD. 700, Qollahuayas "understand their own bodies in terms of the moun­tain, and they consider the mountain in terms of their own anatomy" (1985:598). The human body and the mountain consist of interrelated parts: head, chest and heart, stomach and viscera, breast and nipple. The mountain, like the body, must be fed blood and fat to keep it strong and healthy. Individual sickness is under­stood as a disintegration of the body, likened to a mountain landslide or an earth­quake. Sickness is caused by disruptions between people and the land, specifically between residents of different sections of the mountain: the head (mountain top), heart (center village), or feet (the base of the mountain). Healers cure by gathering the various residents together to feed the mountain and to restore the wholeness and wellness that was compromised. "I am the same as the mountain," says Mar celino Yamahuaya the healer, "[the mountain] takes care of my body, and I must give food and drink to Pachemama" (Bastien 1985:597). Bastien concludes that Qollahuaya body concepts are fundamentally holistic rather than dualistic. He suggests that

The whole is greater than the sum of the parts. . Wholeness (health) of the

body is a process in which centripetal and centrifugal forces pull together and

THE MINDFUL BODY 21

disperse fluids that provide emotions, thoughts, nutrients, and lubricants for members of the body. [1985:598]

Possibly, however, the most elaborate use of the body in native cosmology comes from the Dogon of the Western Sudan, as explained by Ogotemmeli to Marcel Griaule (1965) in his description of the ground plan of the Dogon com­munity. The village must extend from north to south like the body of a man lying on his back. The head is the council house, built in the center square. To the east and west are the menstrual huts which are "round like wombs and represent the hands of the village" (1965:97). The body metaphor also informs the interior of the Dogon house:

The vestibule, which belongs to the master of the house, represents the male part of the couple, the outside door being his sexual organ. The big central room is the domain and the symbol of the woman; the store-rooms each side are her arms, and the communicating door her sexual parts. The central room and the store rooms together represent the woman lying on her back with outstretched arms, the door open, and the woman ready for intercourse. [1965:94-95]

We could multiply by the dozens ethnographic illustrations of the symbolic uses of the human body in classifying and "humanizing" natural phenomena, human artifacts, animals, and topography. Among some of the more well-known examples are the western Apache (Basso 1969), the Indonesian Atoni (Cun­ningham 1973); the Desana Indians of the Colombian-Brazilian border (Reichel-Dolmatoff 1971); the Pira-pirana of the Amazon (Hugh-Jones 1979); the Zina-cantecos of Chiapas (Vogt 1970); and the Fali of northern Cameroon (Zahan 1979). In such essentially monistic and humanistic cosmologies as these, princi­ples of separation and fusion, imminence and transcendence influence interpre­tations of illness and the practice of healing.

Manning and Fabrega (1973) have summarized the major differences be­tween most of these non-Western ethnomedical systems and modern biomedicine. In the latter body and self are understood as distinct and separable entities; illness resides in either the body or the mind. Social relations are seen as partitioned, segmented, and situational—generally as discontinuous with health or sickness. By contrast, many ethnomedical systems do not logically distinguish body, mind, and self, and therefore illness cannot be situated in mind or body alone. Social relations are also understood as a key contributor to individual health and illness. In short, the body is seen as a unitary, integrated aspect of self and social relations. It is dependent on, and vulnerable to, the feelings, wishes, and actions of others, including spirits and dead ancestors. The body is not understood as a vast and complex machine, but rather as a microcosm of the universe.

As Manning and Fabrega note, what is perhaps most significant about the symbolic and metaphorical extension of the body into the natural, social, and su­pernatural realms is that it demonstrates a unique kind of human autonomy that seems to have all but disappeared in the "modern," industrialized world. The confident uses of the body in speaking about the external world conveys a sense that humans are in control. It is doubtful that the Colombian Qollahuayas or the Desana or the Dogon experience anything to the degree of body alienation, so common to our civilization, as expressed in the schizophrenias, anorexias, and

22 MEDICAL ANTHROPOLOGY QUARTERLY

bulemias, or the addictions, obsessions, and fetishisms of "modern" life in the postindustrialized world.

Existential psychiatrists have expounded at length on the contemporary themes of self-alienation, estrangement, and its pathological consequences (see, for example, May, Angel, and Ellenberger 1958). The alienation may be ex­pressed by patients as a sense of a disembodied self, or a selfless body, or to use R. D. Laing's term, a divided self (1965). The loss of the sense of bodily integrity, of wholeness, of continuity and relatedness to the rest of the natural and social world is surely the cumulative effect of forces we have discussed above: the Carte­sian legacy and the materialism and individualism of biomedical clinical practice.

However, the mind/body dichotomy and the body alienation characteristic of contemporary society may also be linked to capitalist modes of production in which manual and mental labors are divided and ordered into a hierarchy. Human labor, thus divided and fragmented, is by Marxist definition "alienated," and is reflected in the marked distortions of body movement, body imagery, and self-conception that E. P. Thompson (1967), among others, has described. Thompson discusses the subversion of natural, body time to the clock-work regimentation and work discipline required by industrialization. He juxtaposes the factory worker, whose labor is extracted in minute, recorded segments, with the Nuer pastoralist, for whom "the daily timepiece is the cattle clock" (Evans-Pritchard 1940:100), or the Aran Islander, whose work is managed by the amount of time left before twilight (Thompson 1967:59).

Similarly, Pierre Bourdieu describes the "regulated improvisations" of Al­gerian peasants, whose movements roughly correspond to diurnal and seasonal rhythms. "At the return of the Azal (dry season)," he writes, "everything with­out exception, in the activities of men, women and children is abruptly altered by the adoption of a new rhythm" (1977:159). Everything from men's work to the domestic activities of women, to rest periods, and ceremonies, prayers, and pub­lic meetings is set in terms of the natural transition from the wet to the dry season. Doing one's duty in the village context means "respecting rhythms, keeping pace, not falling out of line" (1977:161) with one's fellow villagers. The slovenly housewife, the lazy or the overly eager peasant violates the fundamental virtue of conformity, which is expressed in a kind of organic solidarity rather like a piece of choreography. Although, as Bourdieu suggests, these peasants may suffer from a species of false consciousness (or "bad faith") that allows them to misrepresent to themselves their social world as the only possible way to think and to behave and to perceive as "natural" what are, in fact, self-imposed cultural rule, there is little doubt that these Algerian villagers live in a social and a natural world that has a decidedly human shape and feel to it. We might refer to their world as em­bodied.

In contrast, the world in which most of us live is lacking a comfortable and familiar human shape. At least one source of body alienation in advanced indus­trial societies is the symbolic equation of humans and machines, originating in our industrial modes and relations of production and in the commodity fetishism of modem life, in which even the human body has been transformed into a com­modity. Again, Manning and Fabrega capture this so well:

In primitive society the body of man is the paradigm for the derivation of the parts and meanings of other significant objects; in modern society man has

THE MINDFUL BODY 23

adopted the language of the machine to describe his body. This reversal, wherein man sees himself in terms of the external world, as a reflection of himself, is the representative formula for expressing the present situation of modern man. [1973:283]

We rely on the body-as-machine metaphor each time we describe our somatic or psychological states in mechanistic terms, saying that we are "worn out" or "wound up," or when we say that we are "run down" and that our "batteries need recharging." In recent years the metaphors have moved from a mechanical to an electrical mode (we are "turned off," "tuned in," we "get a charge" out of something), while the computer age has lent us a host of new expressions, including the all-too-familiar complaint: "my energy is down."

Our point is that the structure of individual and collective sentiments down to the "feel" of one's body and the naturalness of one's position and role in the technical order is a social construct. Thomas Belmonte described the body rhythms of the factory worker:

The work of factory workers is a stiff military drill, a regiment of arms welded to metal bars and wheels. Marx, Veblen and Charlie Chaplin have powerfully made the point that, on the assembly line, man neither makes nor uses tools, but is continuous with tool as a minute, final attachment to the massive industrial machine. [1979:139]

The machines have changed since those early days of the assembly line. One thinks today not of the brutality of huge grinding gears and wheels, but rather of the sterile silence and sanitized pollution of the microelectronics industries to which the nimble fingers, strained eyes, and docile bodies of a new, largely fe­male and Asian labor force are now melded. What has not changed to any appre­ciable degree is the relationship of human bodies to the machines under 20th-century forms of industrial capitalism.

Non-Western and nonindustrial ized people are "called upon to think the world with their bodies" (O'Neill 1985:151). Like Adam and Eve in the Garden they exercise their autonomy, their power, by naming the phenomena and crea­tures of the world in their own image and likeness. By contrast, we live in a world in which the human shape of things (and even the human shape of humans with their mechanical hearts and plastic hips) is in retreat. While the cosmologies of nonindustrial ized people speak to a constant exchange of metaphors from body to nature and back to body again, our metaphors speak of machine to body symbolic

"

equations. O'Neill suggests that we have been  put on the machine " of biotech nology, some of us transformed by radical surgery and genetic engineering into "spare parts" or prosthetic humans (1985:153-154). Lives are saved, or at least deaths are postponed, but it is possible that our humanity is being compromised in the process.

The Body Politic

The relationships between individual and social bodies concern more, how­ever, than metaphors and collective representations of the natural and the cultural. The relationships are also about power and control. Douglas (1966) contends, for example, that when a community experiences itself as threatened, it will respond

24 MEDICAL ANTHROPOLOGY QUARTERLY

by expanding the number of social controls regulating the group's boundaries. Points where outside threats may infiltrate and pollute the inside become the focus of particular regulation and surveillance. The three bodies—individual, social, and body politic—may be closed off, protected by a nervous vigilance about exits and entrances. Douglas had in mind witchcraft crazes and hysterias from the Salem trials through contemporary African societies and even political witch hunts in the United States. In each of these instances the body politic is likened to the human body in which what is "inside" is good and all that is "outside" is evil. The body politic under threat of attack is cast as vulnerable, leading to purges of traitors and social deviants, while individual hygiene may focus on the main­tenance of ritual purity or on fears of losing blood, semen, tears, or milk.

Threats to the continued existence of the social group may be real or imagi­nary. Even when the threats are real, however, the true aggressors may not be known, and witchcraft can become the metaphor or the cultural idiom for distress. Lindenbaum (1979) has shown, for example, how an epidemic of Kuru among the South Fore of New Guinea led to sorcery accusations and counteraccusations and attempts to purify both the individual and collective bodies of their impurities and contaminants. Mullings suggests that witchcraft and sorcery were widely used in contemporary West Africa as "metaphors for social relations" (1984:164). In the context of a rapidly industrializing market town in Ghana, witchcraft accusations can express anxieties over social contradictions introduced by capitalism. Hence, accusations were directed at those individuals and families who, in the pursuit of economic success, appeared most competitive, greedy, and individualistic in their social relations. While Foster (1972) might label such witchcraft accusations a symptom of envy among the less successful, Mullings argues that witchcraft accusations are an inchoate expression of resistance to the erosion of traditional social values based on reciprocity, sharing, and family and community loyalty. Mullings does not, of course, suggest that witchcraft and sor­cery are unique to capitalist social and economic formations, but rather that in the context of increasing commoditization of human life, witchcraft accusations point to the social distortions and dis-ease in the body politic generated by capitalism.

When the sense of social order is threatened, as in the examples provided above, the symbols of self-control become intensified along with those of social control. Boundaries between the individual and political bodies become blurred, and there is a strong concern with matters of ritual and sexual purity, often ex­pressed in vigilance over social and bodily boundaries. Individuals may express high anxiety over what goes in and what comes out of the two bodies. In witch­craft-fearing societies, for example, there is often a concern with the disposal of one's excreta, hair cuttings, and nail parings. In small, threatened, and therefore often conservative peasant communities, a similar equation between social and bodily vigilance is likely to be found. For example, in Ballybran, rural Ireland, villagers were equally guarded about what they took into the body (as in sex and food) as they were about being "taken in" (as in "codding," flattery, and blar­ney) by outsiders, especially those with a social advantage over them. Concern with the penetration and violation of bodily exits, entrances, and boundaries ex­tended to material symbols of the body—the home, with its doors, gates, fences, and stone boundaries, around which many protective rituals, prayers, and social

THE MINDFUL BODY 25

customs served to create social distance and a sense of personal control and se­curity (Scheper-Hughes 1979).

In addition to controlling bodies in a time of crisis, societies regularly repro­duce and socialize the kind of bodies that they need. Aggressive (or threatened) societies, for example, often require fierce and foolhearty warriors. The Yano-mamo, who, like all Amerindian peoples living in the Amazon, are constantly under siege from encroaching ranching and mining interests, place a great pre­mium on aggressivity. The body of Yanomamo males is both medium and mes­sage: most adults' heads are criss-crossed by battle scars into which red dyes are rubbed. The men's mutilated crowns are kept clean and shaved for display; their scars are endowed with a religious as well as a political significance—they rep­resent the rivers of blood on the moon where Pore, the Creator-Spirit of the Yan-omamo, lives (Brain 1979:167-168). In creating a fine consonance among the physical, material, political, and spiritual planes of existence, many Yanomamo men are encouraged to put their bodies—especially their heads—in the service of the body politic. In many societies (including our own) the culturally and politi­cally "correct" body is the beautiful, strong, and healthy body, although the meanings given to obesity and thinness, to the form and shape of body parts, to facial and dental structure, as well as the values placed on endurance, agility, fertility, and longevity (as indicators of strength and health), vary.

Body decoration is a means through which social self-identities are con­structed and expressed (Strathern and Strathern 1971). T. Turner developed the concept of the "social skin" to express the imprinting of social categories on the body-self (1980). For Turner, the surface of the body represents a "kind of com­mon frontier of society which becomes the symbolic stage upon which the drama of socialization is enacted" (1980:112). Clothing and other forms of bodily adornment become the language through which cultural identity is expressed. Nudity may serve as sexual advertisement or as display of strength and vitality, a public warning to potential enemies. The Nuba of the Sudan, a people known for their elaborate body painting, shun clothing which conceals the body in prefer­ence for body paint that celebrates and exaggerates the human form. Clothing is reserved for the old, the infirm, and the deformed (Farris 1972).

In our own increasingly "healthist" and body-conscious culture, the politi­cally correct body for both sexes is the lean, strong, androgenous, and physically "fit" form through which the core cultural values of autonomy, toughness, com­petitiveness, youth, and self-control are readily manifest (Pollitt 1982). Health is increasingly viewed in the United States as an achieved rather than an ascribed status, and each individual is expected to "work hard" at being strong, fit, and healthy. Conversely, ill health is no longer viewed as accidental, a mere quirk of nature, but rather is attributed to the individual's failure to live right, to eat well, to exercise, etc. We might ask what it is our society "wants" from this kind of body. DeMause (1984) has speculated that the fitness/toughness craze is a reflec­tion of an international preparation for war. A hardening and toughening of the national fiber corresponds to a toughening of individual bodies. In attitude and ideology the self-help and fitness movements articulate both a militarist and a So­cial Darwinist ethos: the fast and fit win; the fat and flabby lose and drop out of the human race (Scheper-Hughes and Stein 1987). Crawford (1980, 1985), how­ever, has suggested that the fitness movement may reflect, instead, a pathetic and

26 MEDICAL ANTHROPOLOGY QUARTERLY

individualized (also wholly inadequate) defense against the threat of nuclear hol­ocaust.

Rather than strong and fit, the politically (and economically) correct body can entail grotesque distortions of human anatomy, including in various times and places the bound feet of Chinese women (Daly 1978), the 16-inch waists of an­tebellum Southern socialites (Kunzle 1981), the tuberculin wanness of 19th-cen­tury Romantics (Sontag 1978), and the anorexics and bulemics of contemporary society. Crawford (1985) has interpreted the eating disorders and distortions in body image expressed in obsessional jogging, anorexia, and bulemia as a sym­bolic mediation of the contradictory demands of postindustrial American society. The double-binding injunction to be self-controlled, fit, and productive workers, and to be at the same time self-indulgent, pleasure-seeking consumers is espe­cially destructive to the self-image of the "modern," "liberated" American woman. Expected to be fun-loving and sensual, she must also remain thin, lovely, and self-disciplined. Since one cannot be hedonistic and controlled simultane ously, one can alternate phases of binge eating, drinking, and drugging with phases of jogging, purging, and vomiting. Out of this cyclical resolution of the injunction to consume and to conserve is born, according to Crawford, the current epidemic of eating disorders (especially bulemia) among young women, some of whom literally eat and diet to death.

Cultures are disciplines that provide codes and social scripts for the domes­tication of the individual body in conformity to the needs of the social and political order. Certainly the use of physical torture by the modern state provides the most graphic illustration of the subordination of the individual body to the body politic. Foucault (1979) argued that the spectacle of state-mandated torture of criminals and dissidents—brutal, primitive, and utterly public—was compatible with the political absolutism of the French monarchy. A more gentle way of punishment (through prisons, reform schools, and mental institutions) was more compatible with republicanism and a "democratization" of power. Torture addressed the soul through the vehicle of the body; contemporary psychiatry, medicine, and "corrections" address the body through the soul and mind of the patient or in­mate. Both, however, serve the goal of producing "normal" and "docile" bodies for the state. Torture offers a dramatic lesson to "common folk" of the power of the political over the individual body. The history of colonialism contains some of the most brutal instances of the political uses of torture and the "culture of terror" in the interests of economic hegemony (Taussig 1984; Peters 1985). Scarry suggests that torture is increasingly resorted to today by unstable regimes

" "

in an attempt to assert the incontestable reality  of their control over the popu­lace (1985:27).

The body politic can, of course, exert its control over individual bodies in less dramatic and mundane, but no less brutal, ways. Foucault's (1973, 1975, 1979, 1980c) analyses of the role of medicine, criminal justice, psychiatry, and the various social sciences in producing new forms of power/knowledge over bod­ies are illustrative in this regard. The proliferation of disease categories and labels in medicine and psychiatry, resulting in ever more restricted definitions of the normal, has created a sick and deviant majority, a problem that medical and psy­chiatric anthropologists have been slow to explore. Radical changes in the orga­nization of social and public life in advanced industrial societies, including the

THE MINDFUL BODY 27

disappearance of traditional cultural idioms for the expression of individual and collective discontent (such as witchcraft, sorcery, rituals of reversal and travesty), have allowed medicine and psychiatry to assume a hegemonic role in shaping and responding to human distress. Apart from anarchic forms of random street vio­lence and other forms of direct assault and confrontation, illness somatization has become a dominant metaphor for expressing individual and social complaint. Negative and hostile feelings can be shaped and transformed by doctors and psy­chiatrists into symptoms of new diseases such as PMS (premenstrual syndrome) or Attention Deficit Disorder (Martin 1987; Lock 1986a; Lock and Dunk 1987; Rubinstein and Brown 1984). In this way such negative social sentiments as fe­male rage and schoolchildren's boredom or school phobias (Lock 1986b) can be recast as individual pathologies and "symptoms" rather than as socially signifi­cant "signs." This funnelling of diffuse but real complaints into the idiom of sickness has led to the problem of "medicalization" and to the overproduction of illness in contemporary advanced industrial societies. In this process the role of doctors, social workers, psychiatrists, and criminologists as agents of social con­sensus is pivotal. As Hopper (1982) has suggested, the physician (and other social agents) is predisposed to "fail to see the secret indignation of the sick." The med­ical gaze is, then, a controlling gaze, through which active (although furtive) forms of protest are transformed into passive acts of "breakdown."

While the medicalization of life (and its political and social control func­tions) is understood by critical medical social scientists (Freidson 1972; Zola 1972; Roth 1972; Illich 1976; deVries 1982) as a fairly permanent feature of in­dustrialized societies, few medical anthropologists have yet explored the imme­diate effects of "medicalization" in those areas of the world where the process is occurring for the first time. In the following passage, recorded by Bourdieu (1977:166), an old Kabyle woman explains what it meant to be sick before and after medicalization was a feature of Algerian peasant life:

In the old days, folk didn't know what illness was. They went to bed and they

died. It's only nowadays that we're learning words like liver, lung . intes‑

tines, stomach . . ., and I don't know what! People only used to know [pain in] the belly; that's what everyone who died died of, unless it was the fever.

Now everyone's sick, everyone's complaining of something . . . Who's ill nowadays? Who's well? Everyone complains, but no one stays in bed; they all run to the doctor. Everyone knows what's wrong with him now.

Or does everyone? We would suggest the usefulness to the body politic of filtering more and more human unrest, dissatisfaction, longing, and protest into the idiom of sickness, which can then be safely managed by doctor-agents.

An anthropology of relations between the body and the body politic inevit­ably leads to a consideration of the regulation and control not only of individuals but of populations, and therefore of sexuality, gender, and reproduction—what Foucault (1980a) refers to as bio-power. Prior to the publication of Malthus 's An Essay on the Principle of Population in 1798, there existed a two-millennia-old tradition of interpreting the health, strength, and reproductive vigor of individual bodies as a sign of the health and well-being of the state (Gallagher 1986:83). Following Malthus, however, the equation of a healthy body with a healthy body politic was recast: the unfettered fertility of individuals became a sign of an en­feebled social organism. The power of the state now depended on the ability to

28 MEDICAL ANTHROPOLOGY QUARTERLY

control physical potency and fertility; "the healthy and, consequently reproduc­ing body [became]. . . the harbinger of the disordered society full of starving bod­ies" (Gallagher 1986:85).

In short, the healthy human body, including its appetites and desires, became problematized beginning in the 19th century, and various disciplines centering around the control of human (especially female) sexuality have come to the fore. B. Turner (1984:91) suggests that the government and regulation of female sex­uality involves, at the institutional level, a system of patriarchal households for controlling fertility; and at the individual level, ideologies of personal asceticism. Thus, late marriage, celibacy, and religious ideologies of sexual puritanism were a structural requirement of European societies until the mid- 19th century (Imhof 1985) and of rural Ireland through the late 20th century (Scheper-Hughes 1979).

Biomedicine has often served the interests of the state with respect to the control of reproduction, sexuality, women, and sexual "deviants." A particularly poignant illustration of medical intervention in the definition of gender and sexual norms comes from Foucault's (1980b) introduction to the diary of Herculine Bar-bin, a 19th-century French hermaphrodite. At that time it was the opinion of med­ical science in Europe that nature produced in humans (unlike other animals) only two biological sexes. Once discovered to be sexually ambiguous, Herculine was forced in adulthood to conform to a medically and legally mandated sex and gen­der transformation, based on her "deviant" sexual preference for female part­ners. Although fully socialized to a healthy personal and social identity as an adult female, Herculine was forced to accept a medical diagnosis of her "true" sex as male, which resulted in her suicide a few years later.

Emotion: Mediatrix of the Three Bodies

An anthropology of the body necessarily entails a theory of emotions. Emo­tions affect the way in which the body, illness, and pain are experienced and are projected in images of the well or poorly functioning social body and body politic. To date, social anthropologists have tended to restrict their interest in emotions to occasions when they are formal, public, ritualized, and "distanced," such as the highly stylized mourning of the Basques (W. Douglas 1969) or the deep play of a Balinese cock fight (Geertz 1973). The more private and idiosyncratic emotions and passions of individuals have tended to be left to psychoanalytic and psycho­biological anthropologists, who have reduced them to a discourse on innate drives, impulses, and instincts. This division of labor, based on a false dichotomy between cultural sentiments and natural passions, leads us right back to the mind/ body, nature/culture, individual/society epistemological muddle with which we began this article. We would tend to join with Geertz (1980) in questioning whether any expression of human emotion and feeling—whether public or pri‑

vate,) individual or collective, whether repressed or explosively expressed is

ever free of cultural shaping and cultural meaning. The most extreme statement of Geertz's position, shared by many of the newer psychological and medical an thropologists, would be that without culture we would simply not know how to feel.

Insofar as emotions entail both feelings and cognitive orientations, public morality, and cultural ideology, we suggest that they provide an imporant miss

THE MINDFUL BODY 29

ing link" capable of bridging mind and body, individual, society, and body pol­itic. As Blacking (1977:5) has stated, emotions are the catalyst that transforms knowledge into human understanding and that brings intensity and commitment to human action. Rosaldo (1984) has recently charged social and psychological anthropologists to pay more attention to the force and intensity of emotions in motivating human action.

Certainly, medical anthropologists have long been concerned with under­standing the power of emotion and feelings in human life, and it is time that their specific contributions were recognized beyond the subdiscipline and the impli­cations of their findings brought to bear on general theory in the parent discipline. We would refer in particular to those phenomenological, ethnopsychological, and medical anthropologists whose stock-in-trade is the exploration of sickness, mad­ness, pain, depression, disability, and death—human events literally seething with emotion (e.g., Schieffelin 1976, 1979; M. Rosaldo 1980, 1984; Kleinman 1982, 1986; Lutz 1982, 1985; Levy and Rosaldo 1983; Kleinman and Good 1985). It is sometimes during the experience of sickness, as in moments of deep trance or sexual transport, that mind and body, self and other become one. Anal­yses of these events offer a key to understanding the mindful body, as well as the self, social body, and body politic.

Elaine Scarry claims to have discovered in the exploration of pain (especially pain intentionally inflicted through torture) a source of human creativity and de­structiveness which she refers to as the "making and unmaking of the world" (1985). Pain destroys, disassembles, deconstructs the world of the victim. We would offer that illness, injury, disability, and death likewise deconstruct the world of the patient by virtue of their seeming randomness, arbitrariness, and hence their absurdity. Medical anthropologists are privileged, however, in that their domain includes not only the unmaking of the world in sickness and death, but also the remaking of the world in healing, especially during those intensely emotional and collective experiences of trance-dance, sings, and charismatic faith healing.

John Blacking (1977) refers to the "waves of fellow-feeling" that wash over and between bodies during rituals involving dance, music, movement, and altered states of consciousness. These "proto-rituals" occur, Blacking suggests, in a spe­cial space that is "without language, without symbols," drawing upon experi­ences and capacities that are species specific. The language of the body, whether expressed in gesture or ritual or articulated in symptomatology (the "language of the organs") is vastly more ambiguous and overdetermined than speech. Black­ing's insight is reminiscent of Jean-Paul Sartre's observation (1943) that lan­guage, insofar as it represents above all a being-for others, presupposes a prere-flexive relationship with other human beings. We might, perhaps, think of those essentially wordless encounters between mother and infant, lover and beloved, mortally ill patient and healer, in which bodies are offered, unreservedly pre­sented to the other, as prototypical. In collective healing rituals there is a merging, a communion of mind/body, self/other, individual/group that acts in largely non­verbal and even prereflexive ways to "feel" the sick person back to a state of wellness and wholeness and to remake the social body.

"Belief kills; belief heals," write Hahn and Kleinman (1983:16), although they might as accurately have stated it "feelings kill; feelings heal." Their essay

30 MEDICAL ANTHROPOLOGY QUARTERLY

is part of that tradition in psychiatry, psychosomatic medicine, and medical an­thropology that seeks to understand human events in that murky realm (close to religion and parapsychology) where the causes of "sudden death" or of "mirac­ulous cure" cannot be explained by conventional biomedical science.' At the one pole for Hahn and Kleinman is "culturogenic" death involving voodoo, bone pointing, evil eye, sorcery, fright, "stress," and other states involving strong and pathogenic emotions. These they label "nocebo" effects. At the other, and ther­apeutic, pole are unexplained cures attributed to faith, suggestion, catharsis, drama, and ritual. These they label placebo effects. Moerman (1983), reporting on remarkable improvements in coronary bypass surgery patients (in which the surgery was a technical failure), attributes cause to the powerfully metaphoric effects of the operation as a cosmic drama of death and rebirth. His analysis strikes many chords of resonance with previous interpretations of the "efficacy of sym­bols "  in shamanic and other ethnomedical cures (e.g.. Levi-Strauss 1967; Ed­gerton 1971; Herrick 1983). What is apparent is that nocebo and placebo effects are integral to all sickness and healing, for they are concepts that refer in an in­complete and oblique way to the interactions between mind and body and among the three bodies: individual, social, and politic.

Concluding Observations

We would like to think of medical anthropology as providing the key toward the development of a new epistemology and metaphysics of the mindful body and of the emotional, social, and political sources of illness and healing. Clearly, bio­medicine is still caught in the clutches of the Cartesian dichotomy and its related oppositions of nature and culture, natural and supernatural, real and unreal. if and when we tend to think reductionistically about the mind-body, it is because it is "good for us to think" in this way. To do otherwise, using a radically different metaphysics, would imply the "unmaking" of our own assumptive world and its culture-bound definitions of reality. To admit the "as-ifness" of our ethnoepis-temology is to court a Cartesian anxiety—the fear that in the absence of a sure, objective foundation for knowledge we would fall into the void, into the chaos of absolute relativism and subjectivity (see Geertz 1973:28-30).

We would conclude by suggesting that while the condition may be serious, it is far from hopeless. Despite the technologic and mechanistic turn that orthodox biomedicine has taken in the past few decades, the time is also one of great fer­ment and restlessness, with the appearance of alternative medical heterodoxies. And, as Cassell (1986:34) has recently pointed out, there is hardly a patient today who does not know that his mind has a powerful effect on his body both in sick­ness and in health. We might also add, with reference to our combined experience teaching in medical schools, that most clinical practitioners today know (although often in a nontheoretical and intuitive way) that mind and body are inseparable in the experiences of sickness, suffering, and healing, although they are without the vocabulary and concepts to address—let alone the tools to probe—this mindful body (Lock and Dunk 1987).

In our experience, most clinicians today know that back pain is real, even when no abnormalities appear under the penetrating gaze of the x-ray machine. And many are aware, further, of the social protest that is often expressed through

THE MINDFUL BODY 31

this medium. Most surgeons know not to operate on a patient who is sure she will not survive what may be a rather minor surgical procedure. And, while most psy­chiatrists know that the effectiveness of tricyclic antidepressants has something to do with their effects on brain transmitters, few believe that chemical abnor­malities are the sole causes of depression. Therefore, they invariably explore the painful life events and difficulties of their patients.

Consequently, physicians are increasingly looking to medical anthropology and to the other "softer" disciplines of cultural psychiatry, medical sociology, and psychiatric epidemiology for the answers to the ultimate and persistent exis­tential questions that are not reducible to biological or to material "facts." Why this person, of all people? Why this particular disease? Why this particular organ or system? Why this "choice" of symptoms? Why now?

What we have tried to show in these pages is the interaction among the mind/ body and the individual, social, and body politic in the production and expression of health and illness. Sickness is not just an isolated event, nor an unfortunate brush with nature. It is a form of communication-the language of the organs-through which nature, society, and culture speak simultaneously. The individual body should be seen as the most immediate, the proximate terrain where social truths and social contradictions are played out, as well as a locus of personal and social resistance, creativity, and struggle.

NOTES

Acknowledgments. This article is based on a chapter of our forthcoming book, The Anthropology of Affliction: Critical Perspectives on Medical Anthropology (New York: Free Press). We wish to thank Elizabeth Colson, George Foster, Stephen Foster, David Mandelbaum, Anne M. Lovell, Gail Kligman, Aihwa Ong, Vincent Sarich, and various anonymous reviewers for their careful and critical readings of earlier drafts.

'See, for example, Bateson and Mead 1942; Hewes 1955; Belo 1960; Hertz 1960[1909]; Merleau-Ponty 1962; Darwin 1965[1872]; Strauss 1966a; Brown 1968; Schilder 1970[1950]; Hinde 1974; Needham 1973; Davis 1975; Englehardt 1975; Black­ing, ed. 1977; Daly 1978; Polhemus 1978; Betherat 1979; Bateson 1980; Rieber 1980; Kunzle 1981; Konner 1982; Johnson 1983.

2Mary Douglas refers to "The Two Bodies," the physical and the social bodies in Natural Symbols (1970). More recently John O'Neill has written a book entitled Five Bod­ies: The Human Shape of Modern Society (1985), in which he discusses the physical body, the communicative body, the world's body, the social body, the body politic, consumer bodies, and medical bodies. We admit that this proliferation of bodies had our decidedly nonquantitative minds stumped for a bit, but the book is nonetheless a provocative and insightful work. We are indebted to both Douglas and O'Neill but also to Bryan Turner's The Body and Society: Explorations in Social Theory for helping us to define and delimit the tripartite domain we have mapped out here.

'We do not wish to suggest that Hippocrates's understanding of the body was analo­gous to that of Descartes or of modern biomedical practitioners. Hippocrates's approach to medicine and healing can only be described as organic and holistic. Nonetheless, Hip­pocrates was, as the quote from his works demonstrates, especially concerned to introduce elements of rational science (observation, palpation, diagnosis, and prognosis) into clinical practice and to discredit all the "irrational" and magical practices of traditional folk heal­ers

'This article is not intended to be a review of the field of medical anthropology. We would refer interested readers to a few excellent reviews of this type: Worsley 1982; Young

32 MEDICAL ANTHROPOLOGY QUARTERLY

1982; Landy 1983. With particular regard to the ideas expressed in this article, however, see also Taussig 1980, 1984; Estroff 1981; Good and Good 1981; Nichter 1981; Obeye sekere 1981; Laderman 1983, 1984; Comaroff 1985; Devisch 1985; Hahn 1985; Helman 1985; Low 1985.

'See also "The Surgeon As Priest" in Selzer (1974).

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===

The impact of spirituality on mental health A review of the literature

mht_spirituality.indd

The impact of spirituality on mental health A review of the literature

Contents

 Executive Summary 2

1. Background 6

 1.1 Definitions of spirituality 6

 1.2 Spirituality and mental health 7

 1.3 Aims of report 8

2. Consequences of spiritual activity for mental health 9

 2.1 Spirituality and depression 10

 2.2 Spirituality and anxiety 12

 2.3 Spirituality and PTSD 14

 2.4 Spirituality and schizophrenia 15

 2.5 Spirituality and suffering 16

3. Factors mediating the relationship between

 spirituality and mental health 18

 3.1 Coping styles 18

 3.2 Locus of control / attributions 20

 3.3 Social support 21

 3.4 Physiological impact 22

 3.5 Architecture and the built environment 23

4. Limitations of the research 25

 4.1 Over-reliance on quantitative research 25

 4.2 Lack of distinction between religion and spirituality 26

 4.3 Population biases 26

 4.4 Divine intervention? 27

5. Implications and Recommendations 28

 5.1 For Practice 28

 5.2 For Research 30

6. Conclusion 32

7. Further information and support 33

8. References 34

===

Executive Summary

Background

In the past decade or so, researchers across a range of disciplines have started to explore and

acknowledge the positive contribution spirituality can make to mental health. Service users and

survivors have also identified the ways in which spiritual activity can contribute to mental health and

wellbeing, mental illness and recovery. This report reviews the evidence and explores the impact that

some expressions of spirituality can have as part of an integrative approach to understanding mental

health and wellbeing.

Mental health problems

Anecdotal, quantitative and qualitative evidence all point to a positive (although often modest)

relationship between spirituality and mental health in relation to a number of mental health problems.

Depression is the most common mental health problem in the UK and has been the focus of much of

the research exploring the relationship between spirituality and mental health. The evidence shows

a positive association between church attendance and lower levels of depression amongst adults,

children and young people. It also shows that belief in a transcendent being is associated with reduced

depressive symptoms.

Similar research has examined the relationship between spirituality and anxiety or stress. Quantitative

research demonstrates reduced levels of anxiety in a number of populations, including medical

patients in later life, women with breast cancer, middle aged people with cardiac problems and those

recovering from spinal surgery. Qualitative research also demonstrates that yoga and meditation are

also associated with improvements in mental health and reductions in anxiety.

There is an emerging literature examining the association between spirituality and post-traumatic stress

disorder (PTSD). One review found 11 studies that reported links between religion, spirituality, and

trauma-based mental health problems. A review of these 11 studies produced three main findings. First,

these studies show that religion and spirituality are usually, although not always, beneficial to people

in dealing with the aftermath of trauma. Second, they show that traumatic experiences can lead to a

deepening of religion or spirituality. Third, that positive religious coping, religious openness, readiness

to face existential questions, religious participation, and intrinsic religiousness are typically associated

with improved post-traumatic recovery.

Similarly, the evidence exploring spirituality with schizophrenia is also relatively scarce. However, one

review of the literature concluded that “religion plays a central role in the processes of reconstructing

a sense of self and recovery”. Another found that for individuals who share the same religious values as

their family, religiosity can be a cohesive and supporting factor. Others have found that people with a

diagnosis of schizophrenia find hope, meaning and comfort in spiritual beliefs and practices.

Not all research exploring the association of spiritual or religious activity and anxiety shows a beneficial

effect of the former on the latter. Rather, it seems to depend to some extent on the way in which

spirituality is expressed. For example, increased mental health problems are often found amongst those

with a strict religious upbringing.

Some also find that their religious or spiritual beliefs are not understood or explored within mental

health services. For many, clinicians either ignore an individual’s spiritual life completely or treat their

spiritual experiences as nothing more than manifestations of psychopathology.

Mechanisms

Some of the research exploring the association between spirituality and mental health attempts to

understand the mechanisms through which potential benefits may occur. Mechanisms most often

discussed are:

coping styles

locus of control

social support and social networks

physiological mechanisms, and

architecture and the built environment

Findings show that a collaborative approach to religious coping (i.e. the individual collaborates with

‘God’ in coping with stress) is associated with the greatest improvement in mental health.

Similarly, perceiving negative events as externally caused and positive events as internally caused is

widely regarded as an ‘optimistic’ attributional style and is generally associated with better mental

health. One review of the literature has suggested that religious beliefs may allow a person to reframe

or reinterpret events that are seen as uncontrollable, in such a way as to make them less stressful or

more meaningful.

The support individuals derive from the members, leaders and clergy of religious congregations

is widely considered one of the key mediators between spirituality and mental health. As with

other forms of social support, spiritual or religious support can be a valuable source of self-esteem,

information, companionship and practical help that enables people to cope with stress and negative

life events or exerts its own main effects.

Some researchers have argued that certain expressions or elements of spirituality may positively affect

various physiological mechanisms involved in health. Emotions encouraged in many spiritual traditions,

including hope, contentment, love and forgiveness, may serve the individual by affecting the neural

pathways that connect to the endocrine and immune systems.

A final mechanism that may mediate the relationship between spirituality and mental health is the

environment. As well as specific ‘spiritual’ buildings and architecture – such as churches, temples or

mosques – nature, art and music may all have an impact upon mental health.

In short, the proposed benefits of the association are probably the result of a collection of inter-related

and interacting factors, some of which have been addressed in the literature and some of which may

yet need to be discovered. These may well interact with a number of individual factors, including a

person’s pre-existing mental health status, their age, their gender or their cultural background.

Limitations

Although the evidence generally supports the notion that spirituality is beneficial for mental health, the research does have limitations.

One of the key shortcomings in the field is that it relies almost exclusively on quantitative measures,

which may not fully access the meaning spiritual activity has for the individual. Quantitative research

tends to try and isolate the impact of one activity (e.g. church attendance) upon another (e.g. level of

depression), which may not always capture the rich and complex interactions of other factors on any

association found.

A further methodological limitation of the research is that it focuses on the effects of spirituality on

mental health problems. Few studies address the mechanisms through which spirituality may promote

good mental health and wellbeing in populations without those problems.

A conceptual limitation of the field relates to definitions used. Whilst there is recognition that there

are differences between religion and spirituality, the distinction between the two is often blurred, with

much of the research using measures of religious practice as a proxy.

In summary, research exploring the association of spirituality with mental health generally displays a

range of methodological and conceptual shortcomings. These need to be addressed before we can

deepen and extend the evidence base. Methods need to be combined and sample selection should

reflect the diversity of spiritual expression that exists in the UK, in order that the maximum potential

benefits of spirituality are available to as many individuals as possible.

Recommendations

Those working in mental health services should:

ask service users about their spiritual and religious needs upon entry to the service and throughout

their care and treatment

help service users to identify those aspects of life that provide them with meaning, hope, value

and purpose

ensure that all service users including those who do not regard themselves as spiritual or religious

are offered the opportunity to speak with a chaplain or other spiritual leader if desired

provide good access to relevant and appropriate religious and spiritual resources

offer or make available safe spaces where users can pray, meditate, worship or practice their faith

provide opportunities for service users to discuss their spirituality or religion with others

build strong and effective links with religious and spiritual groups in the local community

avoid pathologising, dismissing or ignoring the religious or spiritual experiences of service users.

Further research should:

acknowledge the socio-demographic, social and health factors that are known to be risk factors for

certain mental health problems

ensure that the methodologies employed are those most appropriate to answer the questions

being addressed

include service users, wherever possible, in the design, conduct and analysis of research projects

be sufficiently well designed to identify mediating factors that are exclusive to spiritual or religious

activity and how they relate to other dimensions of being human (emotional, psychological, social,

intellectual)

take into account the range of demographic variables that could moderate or mediate the

relationship between spirituality and mental health

develop measures of religion and spirituality that cut across a range of religious traditions without

robbing those traditions of their distinctive and substantive characteristics

consider using spiritual or religious activity as an outcome measure and to explore the impact of

mental health on different expressions of spirituality

explore the impact and effectiveness of the ‘healing’ dimensions of different spiritual activities