Attacked by the gods or by mental illness? Hybridizing mental and spiritual health in Okinawa

Notes

• See Kleinman (1980, 1995); WHO (2001).
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• http://www.who.int/whr001/2001/main/en/chapter1/001a.htm
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• WHO estimates that most countries spend less than one percent of their national health budgets on mental health intervention.
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• Lopez's account in the Annual Review of Psychology (2000), problematizes a number of cases, based on the work of Kleinman (1977, 1985, 1995), which cross boundaries between ‘traditional’ states and clinical definitions of psychosis. Many indigenous healers rely on socially and culturally constructed ideas to treat patients who may be identified as suffering from DSM-IV based conditions. See in particular Marsella (1980) and Lebra (1976).
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• World Health Report 2001: Mental Health, New Understanding, New Hope. Available online at: http://www.who.int/whr/2001/main/en/chapter1/001c.htm
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• See Sartorius et al. (1986).
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• See Lebra (1976), for a comprehensive, if dated, look at a range of indigenous forms of healing described in the ethnopsychiatry literature.
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• For an excellent discussion of elements that deal with the cross-culturally informed ideas associated with ‘normality/abnormality,’ Littlewood and Dein's recent (2000) book is particularly useful.
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• Naka et al. (1985), Randall (1990), Nakamura (1992), Nakamura and Suzuki (1994), Ohashi (1998) have all written about this phenomenon.
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• Dr Takaishi remains one of the few psychiatrists in Okinawa who adopts this approach. He believes that the reluctance of psychiatrists to acknowledge the clinical value of indigenous illness categories remains an obstacle to improved mental and spiritual health in the prefecture (interview, 2000).
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• There were more than 800 languages spoken in the Ryukyu archipelago, but the Shuri dialect was, and remains, the most widely spoken.
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• The name ‘Okinawa’ was introduced to provide discursive distance from the previous Ryukyu name, and to reify the new era of formalized Japanese rule. For more on this see Iha (1961).
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• See Allen (2002a), Ota (2000) and Tomiyama (2000) for accounts of the Battle of Okinawa.
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• While the literal meaning is ‘god person’ the term did not denote either gender, but almost always referred to women. Included in the category of kaminchu are noro (nuru), niigan, and other religious practitioners.
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• Ohashi (1998) discusses the relations between yuta and other religious practitioners in some detail.
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• Today many yuta call themselves ‘kaminchu’, signifying their possession by a god, and attempting to appeal to a wider clientele.
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• See Ohashi (1998) for further discussion on the huge range of tasks that yuta undertake.
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• Kaminchu, however, did not prove as resilient as the yuta, largely because of their high public profile, and their accountability to the state. By the early seventeenth century, most kaminchu had dropped out of the public gaze (Ohashi, 1998).
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• Ohashi describes in detail the repression of yuta from the seventeenth century onwards. See also Allen (2002b) for a comprehensive assessment of discrimination against priestesses and religious practitioners in Okinawa, and the need to repress them as symbols of a pre-Japanese existence that was both anachronistic and anathema to Japan's desire to modernize the prefecture.
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• See Tomiyama (2000) for an analysis of the futility of attempting to ‘become Japanese’. Rabson (1999) and Amemiya (1999) have both written of the impossibility of Okinawans being accepted as mainstream Japanese in any historical context.
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• Ota (2000) makes this claim, as do other historians. Other historians have set the figure higher. Some, such as Higa (1995), have said that almost one-third of the population was killed.
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• Lebra (1966) describes in detail the importance of appropriately interring the dead. This has equivalent value in many folk beliefs of Japan, Korea and Southeast Asia.
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• See, among others, Ota (2000), Johnson (1999), Taira (1997).
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• Lebra (1966) estimated that there were more than 200 yuta practising in Okinawa by 1959.
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• See Lebra (1966), Randall (1990), Naka (1982).
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• When a person is identified as saadaka unmarii (born of high spirit birth rank), she will have to undergo examination by yuta or by other spiritually aware people (for example, ogami, or kaminchu). There is a strong expectation that most people in this position come to terms with their importance in the religious life of their family, extended kin group, village or even wider community. It is a spiritual calling that often manifests itself initially in physical discomfort or in psychological problems, referred to as kami daari. In order to accommodate the problems associated with this spiritual attack, the client must placate her ancestors by agreeing to become a yuta, or by choosing an appropriate religious role in the community.
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• See Sered's controversial (1999) work on kaminchu on Henza.
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• Some seventy percent of clients saw yuta over mental or physical health issues, according to Nakamura (1992), who conducted an exhaustive survey of mental hospitals in the 1960s, 70s and 80s.
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• Ohashi's work on the roles of yuta in Bolivia and Peru (1998) emphasizes this perspective. In fact, he goes as far as to conclude that in the expatriate communities yuta played seminal roles in providing comfort, familiar signs and familiar counsel to those who had migrated to other nations.
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• Lebra (1966).
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• By 1998, the nearest recent estimate was that these figures have equalized somewhat, though there is debate about the number of practicing yuta: there were between 300 and 600 yuta in Okinawa prefecture, according to the professional yuta association, the yuta kumiai (shamans’ union), and approximately 100 practising psychiatrists, and around 350 medical doctors.
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• The culture-bound system mentioned above refers to what Lebra (1976) and others have identified as culturally idiosyncratic practices that appear to challenge the epistemological foundations of universality of psychiatric interpretation and intervention.
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• DSM III categories of schizophrenia were those used to inform clinical decision-making in the instances we describe below.
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• For a knowledgeable, English-language set of definitions concerning kami daarii and its effects, please refer to Naka et al. (1985), Randall (1990), and, to a lesser extent, Allen (2000, 2002a). Naka et al. recognized that apart from experiencing vivid auditory and/or visual hallucinations, patients suffering from kami daarii also succumb to some of the following symptoms: loss of appetite, vomiting, nausea, dizziness, vagueness, high blood pressure, genital bleeding, hematemesis, numbness in the hands and feet, anxiety, delusion, blurting out of incomprehensible words and a tendency to go into long monologues (Naka et al., 1985: 268).
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• Increasingly, shamans (and some psychiatrists) acknowledge clear-cut distinctions between mental illness and spirit attack, a situation that strongly influences mental health and spiritual health outcomes. That is, while there are obvious overlaps between disease and illness categories in both systems, religious practitioners and psychiatrists alike employ what they regard as appropriate systemic interventions to stabilize the patient. The intention for both is to enable the patient to function as a socially adept member of society. While psychiatry typically attempts to suppress supernatural ‘contact,’ seeing such behaviour as delusional, Okinawan religious practitioners attempt to encourage their clients to identify their voices, dreams or images, and to harness these to enable them to become religious practitioners themselves. In other words, shamans and priestesses treat the voices and images of clients as real. This revolves around the idea of identity: specifically how one's cultural cosmology accommodates or rejects notions of supernatural intervention in one's life, and how a patient can be rehabilitated to fit into the range of socially acceptable (that is, ‘normal’) behaviour.
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• Dr. Takaishi Toshihiro, of the Motobu Memorial Psychiatric Hospital, was one of the first psychiatrists in Okinawa to take an active interest in the treatment of ‘culture-bound syndromes.’ He has had long experience in dealing with patients who have come to his hospital displaying both psychiatric dysfunctionality and spirit attack (kami daarii). Over the years he developed a diagnosis and treatment paradigm that incorporated indigenous beliefs within the framework of psychiatric, historical, and medical-anthropological knowledge.
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• Women held all religious power in the former Ryukyu kingdom, and within each village a noro/nuru was appointed to look after its spiritual well-being. Yuta, too, coexisted with the nuru, and occupied a powerful margin of society, straddling the living and the dead. In a society in which ancestor worship was widely practiced, those who were seen to be able to communicate with the dead were often feared.
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• Ancestors have had important roles to play in determining ideological structures that in turn influence the nature of social conventions, and social meanings. Ancestors are symbolically housed in the butsudan (shrine) in each home, and lineages (munchuu) are closely scrutinized and meticulously protected. Alongside ancestors dwell kami, who are animist and ubiquitous. Kaminchu and yuta act as mediums, able to communicate with clients, gods and ancestors. There continues to be widespread and populist support for Okinawan religion among Okinawans, with some studies suggesting that more than seventy percent of women and almost fifty percent of men were strongly in favour of retaining ancestor worship and existing worship/counselling structures involving yuta.
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• During the period of American military control of the prefecture (1945–1972) psychiatric facilities were poorly developed, and it was not until reversion to Japanese rule that they were brought more into line with Japanese standards.
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• It should be noted too that shamans were, and in many cases remain, cynical about the value of psychiatry to cure kami daarii and other spiritual conditions.
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• Naka et al. (1985: 271) demonstrated that, in 1984, Okinawans occupied 34.4 psychiatric hospital beds per 10,000 people, while across Japan there was an average of 26.7 beds occupied per 10,000 people.
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• See Ogura Chikara (1996), for a detailed comparison of mental health statistics between Okinawa and other prefectures within Japan.
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• These are the American Psychiatry Association's standard references to mental disorders, the Diagnostic Statistics Manuals, which are frequently reviewed. They are translated into Japanese and widely available, and although American in orientation have strongly influenced Japanese psychiatric practice.
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• We use the term ‘doxic’ here to denote ‘normality’ in the sense that Bourdieu (1990) uses it; that is as a series of known and familiar symbols of the shared habitus.
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• WHO also identifies socio-economic conditions as contributing significantly to the mental health of groups of people.
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• See Naka et al. (1985); Takaishi (1989: 133); Nakamura (1992: 44); Allen (2000, 2002a, 2002b), for discussions on the relationship between schizophrenia and kami daarii.
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• Takaishi Toshihiro, interview, 2000.
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• Naka et al. (1985: 269–270).
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• Naka et al. (1985: 270).
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• Neary (2000).
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• Naka et al. (1985: 268); Takaishi (1994: 133). This is not to suggest that there is no stigma attached to seeking help from yuta. Not all Okinawans regard yuta as upright members of society; indeed a common perception is that they (as a group) prey on gullible or innocent Okinawans. Hence visiting yuta can sometimes be stigmatizing, depending on one's circle of acquaintances.
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• Lebra wrote the seminal volume on Okinawan religion, titled (unsurprisingly) Okinawan Religion (1966). He continued his interest in Okinawan and other forms of East Asian shamanic intervention in contemporary medical and mental health issues over the years, and in 1976 edited a volume on culture-bound syndromes, ethnopsychiatry and alternate therapies. His work was translated into Japanese, and was highly regarded by both medical anthropologists and psychiatrists. Lebra visited Okinawa on a number of occasions to lecture on ethnopsychiatry and Okinawa. The influence he personally exerted on psychiatrists is difficult to assess accurately but there is widespread recognition of the importance of his work among psychiatrists in the prefecture.
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• Yokota (1997a: 172–173) found that 90 percent of a sample of 143 people from an Okinawan village participated in religious rites and traditional events. In a slightly later paper (1997b), he found that from a similar size group, between 50 and 60 percent believed that ancestor worship was a crucial part of Okinawan life, and 70 percent thought that yuta were necessary for the preservation of Okinawan tradition. Moreover, 47 percent of the men in the survey and 72 percent of the women thought that psychosis was something that directly concerned yuta.
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• Kleinman (1980) describes a similar phenomenon in Taipei in the early 1970s.
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• Clinicians and psychiatrists today acknowledge that incidents of kami daarii have increased in recent years, notwithstanding the advances of psychiatric knowledge and facilities (Naka Koichi, interview, July 2000; Nakamura Eitoku, interview, August 2000; Takaishi Toshihiro, interview, July 2000). Moreover, anecdotally, many yuta remain active, and many new yuta are starting to appear.
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• Yokota (1997a, 1997b).
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• Nakamura Eitoku has stated his reservations about yuta actually being able to determine whether a patient is in need of psychiatric care, concluding that the shaman can do considerable damage to a psychotic patient by encouraging her to continue with her psychosis.
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• For a much more detailed discussion of this issue, please see Allen (2002b).
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• Naka et al. (1985) found that shamans provided solid support and counselling networks for clients, which were seen as a positive intervention.
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• See Lopez (2000) for a comprehensive survey of the cultural psychopathology of social impacts on mental health issues globally.
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• WHO (2001).
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