Understanding the stakes

in children’s idioms of distress

◊Ria Reis

Leiden University Medical Centre

University of Amsterdam

University of Cape Town

Bergen, Norway, 13-10-2017

Background

Research focus:

- Children and Youth’s health perceptions and strategies

- Trans-generational transmission of vulnerabilities in contexts of inequality

- Supporting (mental) health interventions for populations affected by inequity, epidemics, disasters, conflicts and violence.

- Children’s cultural idioms of distress (IOD)

Aims

Discuss

relation between culture and children’s expressions of distress.

children’s stakes when they show cultural idioms of distress.

Example

Epidemics of mass dissociative illness in schools

Distress and Culture

Psychological distress:

Unpleasant feelings or emotions that interfere with functioning. Sadness, anxiety, and symptoms of mental illness are manifestations of psychological distress.

Culture

Shared and intergenerationally transferred

framework of ideas, perceptions, beliefs, values,

dispositions, norms, rules, and customs that

shape and give meaning to people’s lives

The work of culture in the body/mind

- Culture provides people with guidelines how to deal with

- bodily and emotional sensations and experiences.

- Culture plays a role in determining what is important:

- learn to pay selective attention to certain meaningful processes in the body/mind

- Culture is about ideas and norms:- differences in what is allowed to be felt and

expressed (Kleinman 1980)

- Culture’s work is mostly unconscious:- we experience our body/mind as natural

Learning a language of distress

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DSM 5*: cultural concepts

Considerable differences in the way people perceive or express their distress

may complicate patient-caregiver interaction and hamper effective diagnostic and treatment trajectories

Cultural competences (knowledge, attitudes, skills) needed for accurate diagnosis and adequate referral.

Cultural templates to express suffering and distress.

Cultural Syndromes

Cultural Explanations

Cultural Idioms of Distress

* Diagnostic and statistical manual of mental disorders

DSM V: cultural concepts

Cultural syndromes

clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts and that are recognized locally as coherent patterns of experience.

Cultural explanations

labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress.

DSM V: cultural concepts

Cultural Idioms of distress

Alternative modes of expressing and communicating distress that make sense and invite action in the context of specific complexes of personal and cultural meaning’

Nichter, M., 1981

Shared, culturally distributed sets of symbols, behaviors, language or meanings that are used by people to express, explain and/or transform their distress and suffering.

Hollan, D., 2004

DSM V: cultural concepts

Cultural Idioms of distress

Ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns.

DSM 5

Critique: every expression of distress is cultural, makes the concept superfluous.

Cultural Idioms of distress

an embodied symbolic language for psychosocial suffering that derives its legitimacy from its shared metaphors, meaning and understanding in a group.

due to its multilevel and multi-interpretable nature and its use of condensed symbols it allows the individual to express and communicate suffering caused by different types of stressors

that cannot be expressed in the local socio-cultural-political context due to its inherent threat to the dominant values and structures’

De Jong, J.T. & R.Reis, 2010, Kiyang-yang, a West-

African post-war idiom of distress. Culture, Medicine

& Psychiatry 34: 301-32.

Empirical example Outbreaks of spirit possession in

schools

Case description

1. One child feels unwell

2. From vague physical complaints to violence

3. Seeing/hearing things others can’t see/hear

4. Children’s behaviour installs fear of occult

5. Mounting to collective panic

6. Other children fall prey

Outbreaks occur every year, in different schools

Behaviour known from ritual contexts

Expression of distress - cause of distress

Perspectives and interventions

Heated debates about accountability, related to involvement in the occult

Spiritual interventions backfire

Involvement of parents, community, health & religious services, leadership, media

Children sent home, school closed

No school psychological/psychiatric services, no support in aftermath

Causes are not addressed

Outbreaks continue as (underground) bushfire

Step 1

An embodied symbolic language for psychosocial suffering that derives its legitimacy from its shared metaphors, meaning and understanding in a group

Behaviour is recognised and experienced as meaningful

Violent agency expressed confirms the spirit hypothesis for onlookers

“children are not themselves’

Therefore children are not accountable for the expression of negative emotions

Step 2

Due to its multilevel and multi-interpretable nature and its use of condensed symbols it allows the individual to express and communicate suffering caused by different types of stressors ...

Identification of underlying social causes causing distress by involving children as social actors:

Making sense of and intentionally acting upon themselves and the world

Step 2

Vignette study:

“I don't think they came from a happy family … Because the demons attacked mostly those who came from under privileged families so that it helps them out with their needs … I think the ones that are attacked by demons are the ones that stay with guardians and not their real parents and you find that they abuse them … When you don't stay with your parents, the people you live with sometimes beat you for nothing … “

(focus group, Swaziland, translated from siSwati).

Step 2

Due to its multilevel and multi-interpretable nature and its use of condensed symbols it allows the individual to express and communicate suffering caused by different types of stressors ...

Double orphan Deprivation Poverty & inequity Damaged social fabric

due to HIV/AIDS Weak mesostructures Insufficient & vertical

educational & health services

Step 2

Due to its multilevel and multi-interpretable nature and its use of condensed symbols it allows the individual to express and communicate suffering caused by different types of stressors ...

Sexual abuse Domestic violence Poverty & inequity Damaged social fabric

due to civil conflict Weak mesostructures Insufficient & vertical

educational & health services

Step 2

Due to its multilevel and multi-interpretable nature and its use of condensed symbols it allows the individual to express and communicate suffering caused by different types of stressors ...

Stressors were found on all ecological levels

Problems at macro- and exo-level (humanitarian emergencies) translate to problems at meso- and microlevel.

Step 3

stressors that cannot be expressed in the local socio-cultural-political context due to its inherent threat to the dominant values and structures’

Why do children enact a symbolic mode of expression?

To find answer: Direct our gaze to structural problems/tensions that cannot be directly addressed without endangering children’s stakes

Hypothesis: When suffering can be socially and politically addressed and solved, there is no longer a need for a symbolic mode of expression or IOD that will then dissipate

Step 3

Structural problems/tensions that cannot be directly addressed without endangering children’s stakes

Answer from children & adults:

experiences of abuse and parental neglect lead to anger, loneliness, anxiety, feeling downcast, distrust and disappointment in others.

expressing (strong) emotions by children in the presence of adults is discouraged / considered disrespectful.

To different extent re. gender, ethnic groups, class, family culture

Testifying suffering directly may endanger themselves and their loved ones

Logics of spirit possession

Social problems causing negative emotions

Keeping emotions

inside

Spiritual weakness

Spirit

attack

Logics of outbreaks

A permissive space

Physical, emotional & behavioral experiences as clues for interpretation: a spiritual presence.

Others act on these clues with (re)actions that confirm the interpretation

Reactions feed back into the anxiety of children

Other children’s mild dissociative experiences may also develop into possession trance

An outbreak is born.

Logics of spirit possession

Social problems causing negative emotions

Keeping emotions

inside

Spiritual weakness

Spirit

attack

Conclusion

Possession trance in schools can be analysed as a child idiom of distress

Behaviour that is believed to be caused by external agents is legitimate

Forbidden emotions (such as anger for girls) can be expressed

Children embody own/family/community distress

Children’s stakes are multileveled

Addressing them needs comprehensive interventions

Recommendations

See outbreaks as windows for understanding children’s social suffering and for social change

Help actors understand their role in process leading to outbreak

Do not confront but build on local understandings

Equip all actors with capacities to recognize and mitigate distress

Aim interventions not only at outbreak (spiritual / community/psychological) but focus on and address both individual and collective social suffering

Build structures that enable children to safely tell about their social suffering and enable effective responses

Build meso-structures around children (e.g. parents and teachers) and collaborate cross sectional (Health & Education)

Research template

Chose a case/pattern of (possible) collective expressions of distress

analyse it with three steps of CIOD concept

formulate hypothesis and/or research questions

Haunting spirits of the dead Uganda (cen)

Uppgivenhetssyndrom Sweden

Clusters of attempted suicide (Hindustani schoolgirls)

Binge drinking / substance abuse

Postnatal depression among migrant and refugee

women

Thank You

Literature references

Bronfenbrenner, U. (1979). The ecology of human development.

Cambridge, MA: Harvard University Press.

Hollan, D., 2004, Self Systems, Cultural Idioms of Distress, and the Psycho-bodily Consequences of Childhood Suffering. Transcultural Psychiatry 41(1): 62–79.

De Jong, J. T., & Reis, R. (2010). Kiyang-yang, a West-African post-war

idiom of distress. Culture, Medicine and Psychiatry, 34(2), 301–332.

Nichter, M. (1981). Idioms of distress: Alternatives in the expression of

psychosocial distress: A case study from South India. Culture,

Medicine and Psychiatry, 5(4), 379–408.

Reis, R. (2013). Child Idioms of Distress as a Response to Trauma:

Therapeutically Beneficial, and for Whom? Transcultural Psychiatry

50(5): 623 - 644.

Reis, R.,(2016), Children’s idioms of distress. In: Manderson, L., Cartwright, E. & A. Hardon (Eds), The Routledge Handbook of

Medical Anthropology, case study 2.1, pp. 36-42. Londen: Routledge.

Acknowledgements

Literature reviews and case studies in collaboration with

Joop T.V.M. De Jong

Navaraj Upadhaya & team Nepal (September 2012)

Kamla Nannan Panday-Jhingoeri & team Suriname (October 2012)

Jabulani Shabalala & team Swaziland (November 2012)

Heleen van de Brink & team Sierra Leone (March 2014)

Supported by (travel) grants from:

HCB program AISSR, University of Amsterdam

Foundation Peace Of Mind (POM)

PHEG /LUMC