Depressive Illness and Navajo Healing Author(s): Michael Storck, Thomas J. Csordas, Milton Strauss Source: Medical Anthropology Quarterly, New Series, Vol. 14, No. 4, Theme Issue: Ritual Healing in Navajo Society (Dec., 2000), pp. 571-597 Published by: Blackwell Publishing on behalf of the American Anthropological Association Stable URL: http://www.jstor.org/stable/649721 . Accessed: 27/07/2011 18:43

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http://www.jstor.org MICHAEL STORCK Department of Psychiatry and Behavioral Sciences University of Washington School of Medicine THOMAS J. CSORDAS Department of Anthropology Case Western Reserve University MILTONSTRAUSS Department of Psychology Case Western Reserve University

Depressive Illness and Navajo Healing

What is the experience of Navajo patients in Navajo religious healing who, by the criteria and in the vernacular of contemporary psychiatry, would be diagnosed with the disorder called depression? We ask this question in the context of a double dialogue between psychiatry and an- thropology and between these disciplines' academic constructs of illness and those of contemporary Navajos. The dialogue is conducted in the arena of patient narratives, providing a means for observing and expli- cating processes of therapeutic change in individuals, for illustrating variations in forms of Navajo religious healing sought out by patients demonstrating similar symptoms of distress, andfor considering the heu- ristic utility of psychiatric diagnoses and nomenclature in the conceptu- alization of illness, recovery, and religious healing. From among the 37 percent of patients participating in the Navajo Healing Project who had a lifetime history of a major depressive illness, three are discussed herein, their selection based on two criteria. (1) all metformal psychiatric diag- nostic criteria for a major depressive episode at the time of their healing ceremonies, and (2) together, their experiences illustrate the range of contemporary Navajo religious healing, including Traditional, Native American Church (NAC), and Christian forms. We suggest that, despite the explicit role of the sacred in religious healing interventions available to Navajo patients, differences between biomedical and religious healing systems may be of less significance than their shared existential engage- ment of problems such as those glossed as depression. [depression, psy- chiatry, religious healing, narrative, Navajo]

MedicalAnthropology Quarterly 14(4):571-597. Copyright ? 2000,American Anthropological Association.

571 572 MEDICAL ANTHROPOLOGY QUARTERLY

ur goal in this articleis to contributeto an understandingof illness experi- ence among Navajos who have participatedin the three forms of healing examined in the Navajo Healing Project(Csordas, this issue). We do so in the contextof a doubledialogue between psychiatry and anthropology (the first author is a psychiatrist)and betweenthese disciplines'academic constructs of illness and those of contemporaryNavajos. Central to the firstdialogue are the repeatedefforts by Westernpsychiatry to define reliableand valid categoriesof psychiatricdisor- der, as evidencedby threeupdates since 1980 of the AmericanPsychiatric Associa- tion's Diagnostic and Statistical Manual of Psychiatric Disorders. These efforts have been subjectto critiquefrom the standpointof both anthropologyand cultural psychiatryon the grounds that they unduly reify disease categories as biological entities and thattheir generalization is an ethnocentricimposition of Westerncate- gories that suppressescross-cultural variations in illness (Gaines 1992; Kirmayer 1997; Mezzich et al. 1996; Taussig 1992). In our view, the most productivestance has been expressed by Byron Good (1992), who suggests that along with concep- tual critique, psychiatric diagnostic categories be taken seriously by subjecting them to systematiccross-cultural investigation, at the same time criticallyexamin- ing the anthropologicalhypothesis about the cross-culturalheterogeneity of psy- chiatricdisorder. Our work in the Navajo Healing Project embraces this approach.Further, while recognizingthe limits of dialoguebetween anthropologyand psychiatry,we also recognize anthropologyand psychiatryas sister sciences and grant at least heuristicvalue to psychiatriccategories as provisionaletic formulationsof distress for comparativepurposes. This approachis centralto the second of our dialogues, thatbetween academicand indigenousunderstandings of illness experience.How- ever, we do not frame this dialogue as a comparisonof "Western"and "indige- nous"diagnostic categories as such: in that case the analysis might juxtapose de- pressionand what Navajos recognize as hochxoo'ji (illness requiringtreatment by the Evilway ceremony), which is frequentlyassociated with the emotionalconse- quences of bereavement.Neither do we offer a comparisonof the diagnosticprac- tices of psychiatristsand those of Navajohealers: issues pertainingto Navajodiag- nosis are taken up separately in the contributionby Derek Milne and Wilson Howard(this issue). Instead,our methodis to ask the following question:what is the experience of Navajo patientsin Navajo religious healing who, by the criteria of contemporarypsychiatry, would be diagnosed with the disordercalled depres- sion? Formulatedin this way, the dialogue is between those data that allow for a psychiatricresearch diagnosis and those datathat allow for an ethnographicunder- standingof illness experience. Our interest in whetherdepressive symptoms are factors in Navajo patients seeking religious healing originatedin part with the observationthat depressive disordersare prevalent,though often undetected,in Westernmedical primary care (Coyne et al. 1994; Wilson et al. 1995). In addition,depression may be an espe- cially salient psychiatricdisorder for ethnographicstudy, given its biological, psy- chological-existential, and sociocultural determinants. Kleinman and Good (1985), in concluding their essential collection of psychiatricand anthropological essays on depression,ask for cross-culturalresearch that seeks to (1) addressfun- damentalquestions of validity regardingcategories of depressive illness, (2) ex- plore the role of emotions and cognitions in depression,(3) discern how somatic DEPRESSIVE ILLNESS AND NAVAJO HEALING 573 symptoms and anxiety relate to constructsof depression,and (4) characterizethe connection among social relationships,power, and the developmentand mainte- nance of depression. The accepteddiagnostic coding systems in psychiatryare found in TheInter- national Classification of Diseases-Tenth Edition (ICD-10) (World Health Organization1991) andthe AmericanPsychiatric Association's (1994) Diagnostic and StatisticalManual of MentalDisorders, Fourth Edition (DSM-IV). Both posit that depression,as a discreteillness, is a cross-culturallyvalid construct.For a di- agnosis of depression,both the ICD-10 and DSM-IV requirethat a patienthave low mood and/orloss of majorlife interestsfor at least two weeks. An individual must also be experiencing several of the following symptoms: appetite change, sleep cycle change, poor concentration,and fatigue. In the Navajo HealingProject, we used the DSM-IV criteriafor depressionand other psychiatricdisorders (see Figure 1). The ICD and DSM classificationsystems both claim to be purelydescriptive and "non-etiologic"and to advocate no specific treatmentstrategies. But though thereare advantagesto tryingto make internationallyapproved diagnostic nomen- clature systems lean and reductionistic,there are risks, too. Gary Tucker(1998), himself renownedfor explicatingbiological dimensions of psychiatricillness, re- gardsDSM and ICD manualsas tools for "doingpattern recognition." At the same time, he lamentsthat "theDSM diagnosis has almost become a thing itself-a cer- tainty of 'concrete' dimensions"(1998:159). The diagnostic process can lead, ac- cording to Tucker,to the loss of "thepatient and his/her story."Even if diagnoses can be reliably and validly obtainedcross-culturally, it can be arguedthat for the healerto be effective, he or she must drawon somatic,psychological, cultural, and historicalperspectives obtained from the patient(Engel 1980). Clinical as well as researchinquiry about symptoms may elicit culturallyme- diated complications from the outset due to several factors. First, some standard lines of questioningabout depressive symptoms can be unacceptablein some cul- tural groups. Robins (1989) notes that Chinese patients, when interviewedabout depressivesymptoms, are quite reluctant to answerquestions about sexual interest. There may be general response biases characteristicof ethnoculturalgroups, too. For instance,Iwata and associates(1989) found thatJapanese patients make efforts to avoid extremes in their answersto diagnostic questions. Second, typical symp- tom clusters and indigenous labels for them may vary cross-culturally,as Klein- man (1980) has shown in comparingneurasthenia and depressionin China and as Manson and associates (1985) have shown in discussing depressive experience among American Indians.Third, culturally distinct patternsof co-morbiditymay blur the boundariesbetween diagnostic categories, as in the case of depression, anxiety, and substance abuse among American Indians and Alaska Natives dis- cussed by contributorsto Maserand Dinges 1992. Standardizedclinical researchtools have limitationsin characterizingpsychi- atricproblems of ethnicallydiverse peoples but nonethelesshave helped illustrate problemsfaced by AmericanIndians. Shore and colleagues (1987) utilizeda struc- tured instrument,the Schedule for Affective Disorders and Schizophrenia-Life- time Version (SADS-L), to study depressive phenomena across several tribal groups and found special unifying featuresamong AmericanIndians with depres- sion. Perhapsto help demonstratethe possible complementarityof DSM constructs 574 MEDICALANTHROPOLOGY QUARTERLY

* Criteria for Major Depressive Episode A. Five (or more) of the following symptomshave been presentduring the same 2-week period and representa change from previous functioning;a least one of the symptomsis either(1) depressedmood or (2) loss of interestor pleasure. Note: Do not include symptomsthat are clearly due to a generalmedical con- dition, or mood-incongruentdelusions or hallucinations. (1) depressed mood most of the day, nearlyevery day, as indicatedby either subjective report(e.g., feels sad or empty) or observationmade by others (e.g., appearstearful). Note: In childrenand adolescents,can be irritable mood. (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearlyevery day (as indicatedby eithersubjective account or observationmade by others) (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month),or decreaseor increasein appe- tite nearlyevery day. Note: In children,consider failure to make expected weight gains. (4) insomniaor hypersomnianearly every day (5) psychomotoragitation or retardationnearly every day (observableby oth- ers, not merely subjectivefeelings of restlessnessor being slowed down) (6) fatigue or loss of energynearly every day (7) feelings of worthlessnessor excessive or inappropriateguilt (which may be delusional)nearly every day (not merelyself-reproach or guilt aboutbe- ing sick) (8) diminishedability to think or concentrate,or indecisiveness,nearly every day (eitherby subjectiveacount or as observedby others) (9) recurrentthoughts of death(not just fear of dying), recurrentsuicidal idea- tion withouta specific plan, or a suicide attemptor a specific plan for com- mittingsuicide B. The symptomsdo not meet criteriafor a Mixed Episode (see p. 335). C. The symptomscause clinically significantdistress or impairmentin social, oc- cupational,or otherimportant areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drugof abuse,a medication)or a generalmedical condition (e.g., hypo- thyroidism). E. The symptomsare not betteraccounted for by Bereavement,i.e., afterthe loss of a loved one, the symptoms persist for longer than 2 months or are charac- terized by markedfunctional impairment, morbid preoccupation with worth- lessness, suicidal ideation,psychotic symptoms,or psychomotorretardation.

FIGURE 1 Criteriafor Major Depressive Episode. (Source:Diagnostic and StatisticalManual of MentalDisorders Fourth Edition. Washington,DC: AmericanPsychiatric Association, 1994, p. 327.) DEPRESSIVE ILLNESS AND NAVAJO HEALING 575 and patientascriptions, O'Nell (1993, 1996) utilized structuredinterviews as well as more open-endedinterview techniquesto help patientsprovide narrativesum- maries of their difficulties. She was able to provideDSM diagnoses while illumi- nating the personaland social meanings of such problemsas depressionand sub- stance dependencewithin a community.Manson (1996) has noted some signs of shift in the "diagnosticculture" of the DSM-IV, which now suggests that mental health providersshould consider culturalinfluences on the phenomenology and experience of such psychiatricdisorders as depression.Nevertheless, from an an- thropologicalperspective this is hardlymore than a token shift (see the contribu- tions to Kirmayer1997). Research that integratesqualitative (ethnographic) and quantitative(structured clinical) interviewmethods can help informcontroversies about the natureand prevalenceof DSM disordersand how they may have differ- ent social meaningsin specific communities. With respect to validity issues for depression, there has been debate about whetherdepression is best regardedas a disease, a constellationof distress symp- toms ("dis-ease"),or both. The strongfamilial risk for depressionand evidence of genetic diathesesfor depressivedisorders are a bedrockof the disease model, as is the effectiveness of somatic treatments(Whybrow et al. 1984). Carrand Vitaliano (1985) favor a distressrather than disease model for depression,positing that the symptomsare manifestationsof a coping responseand shouldnot automaticallybe construedas pathological.Manson (1996) arguesthat regardless of primarycause, all symptoms,perhaps, especially, depressivesymptoms, cannot be regardedor ap- preciatedout of context of the patient's psychosocial matrix.Depressive experi- ences may even be positively valued by the individualand also be seen as having some value to the communitygroup. Obeyesekere(1985) describesefforts by Sri LankanBuddhists to derive meaning and transcendencefrom distress that is only inadequatelycaptured by the categoricalnotion of depression. Depressionmay also hold meaningfor individualsregarding the role of emo- tional processes in the organizationand regulationof the self. Schieffelin (1985) describeshow emotions such as anger,grief, anddepressive experiences are tied to effective negotiationof social expectation within a community.Emotional states and emotion regulationare posited by Jenkinsand associates(1991) to be the inte- grationof bodily experiences, social forces, and communicationdemands for the individual.Nesse (2000) discusses evidence thatdepression and its characteristics of pessimism and lack of motivation, ratherthen being purely pathological and dysfunctional,may have an adaptive function in certain circumstances,such as when a person is faced with an unreachablegoal or has insufficient internalre- sources to allow action withoutdamage. So it could be proposedthat regardless of the origin of depressivestates, as individualsexperience a depressiveillness, they may acquireuseful new vantagepoints vis-a-vis themselvesand theirroles in their social matrix. In psychiatry,the last decade has seen rapidgrowth in pharmacologicalinter- ventions to address Western constructs/medicalized symptoms of depression. The utilization of such therapies has helped advance the notion that depression is a discrete and biologic pathologicalprocess in an individual'slife. Placing reli- gious healingpractices such as those of the Navajoalongside these biomedicalinter- ventions can help advance the alternativenotion that depression is also a multi- plex social process in intersubjective(community) life. If depressionis a complex 576 MEDICAL ANTHROPOLOGY QUARTERLY intertwiningof biological, existential,and social processes, then healing practices thataddress these dimensionsmay be especially salient for psychiatricand anthro- pological investigators. Accordingly, we offer our ethnographicevaluations of Navajo patientsand their experiencesin a non-Westernhealing system to the dis- cussion of depression.

Studying Navajo Illness Experience The Navajo populationwas less than 7,000 in 1868 after the people barely survived removal from ancestrallands during the U.S. government'scampaigns againstthe Indiantribes of the AmericanWest following the Civil War.However, the Navajo provedremarkably resilient, and the contemporaryNavajo reservation, a 25,000-square-mileregion of high desert and mountainforests centeredin the Four Cornersregion of the United States, is home to nearly 200,000 Navajo peo- ple. A centralfeature of modernNavajo life is the availabilityof multiplehealing systems. The first hospitals on the Navajo reservationwere established around 1900 (Kunitz 1983). Today, there are six IndianHealth Service hospitals and nu- merousclinics regionallylocated near Navajo population centers that together pro- vide a full rangeof medical services. OverallNavajo morbidity and mortalityrates for many health indicatorshave come to closely approximatethe U.S. averages. Some notableexceptions at presentare the continuedhigh rates of diabetes,tuber- culosis, and serious injuries. Navajos have lower rates of such illnesses as most cancers and HIV infection (U.S. IndianHealth Service 1997). Meanwhile,Tradi- tional Navajo healing, providedby a medicine man or medicine woman, has con- tinuedto serve a majorhealth care role for Navajos. The Traditionaldiagnostician determinesa patient's disease and disharmonythrough conversationand hand- tremblingor crystal-gazingtechniques. He or she then typically refers the patient to a chanter(hataali) who performsor coordinatesthe performanceof intricate ceremonialchants, prayers,dances, and sandpaintingsto addressthe dysfunction or distress that broughtthe patientto the healer.In the last half century,the NAC and Christianreligious healing systems have also become essential providersof healing interventionsfor Navajos. NAC healing is derived from Plains Indian spiritualityand centers on a ceremony characterizedby ingestion of sacramental peyote and night-long prayerand singing coordinatedby the road man (healer), with the patientand his or her family seated aroundan earthenfireplace. Navajo Christianfaith healing, usually based in communalprayer groups, weekly church services, or seasonal revival meetings, has been providedby Navajo Pentecostal ministersfor decades.There appears to be an increasingprominence in Navajoland of religioushealing by otherChristian denominations, too. Hospitalsand clinics may be perceivedby Navajo patientsas intimidatingor unsettlingenvironments compared to the ceremoniallyprepared hogan for Tradi- tional healing,the tipi for the NAC meeting,or the churchor revival tent for Chris- tian services. Especially when experienced in a Western hospital, illness may threatena Navajo patientand his or her family in ways thatcannot be ameliorated by the Westernhealing system alone (Griffin-Pierce1997). Hence, many patients and families utilize both medical and Traditional/religioushealing systems. In our study, we found thatreligious healers,alongside Western medical providers,have helped patientscope with the majorpublic healththreats faced by Navajo families DEPRESSIVE ILLNESS AND NAVAJO HEALING 577 in the last half century.Most of the patientsin our study had, on multipleoccasions in theirlives, turnedto religious healingto addressa wide varietyof symptomsand such major illnesses as tuberculosis,diabetes, cancer, ulcers, infant diarrhea,and psychosocially mediated health problems including stress disorders,depression, and substance use disorders. Though mental health services are offered at all IndianHealth Service sites, religioushealing also providesa primarycare resource to patientsto addressproblems often conceptualizedin Westernmedical traditions as emotionalor psychiatricin nature(Navajo Health Systems Agency 1985). In the Navajo Healing Project,four teams, each consisting of an ethnographer and an interpreter,were assigned to the four quadrantsof the Navajo reservation. Their goal was to enlist healers (representingTraditional, NAC, and Christian practices) as participantsin an ethnographyof the practice of religious healing. Healers who agreed to participatein the study were interviewed regardingtheir healing methods and explanatoryconstructs related to illness/distressand healing. Patientswere typically approachedto join the study by the ethnographicteam after being recommendedfor participationby theirhealers. Other patients were referred by fellow patientsor recruitedthrough social networksof the projectstaff. The ma- jority of patientsin the study soughthealing for symptomsnot directlyclassifiable as psychiatric.Patient concerns upon referral to a religious healerincluded such ill- nesses as gastrointestinaldisease, cancer,diabetes, renal failure, heart disease, der- matological symptoms, and dizziness. For this study, Western medical healers were not contacted,and patientmedical records were not reviewed. For each patient, a psychiatricinterview was completed after the religious healing interventionsand after the ethnographerand interpreterhad interviewed patientsin detail abouttheir life history,current illnesses, and healingexperiences, and had observedan event of ritualhealing conducted for the patient(Csordas, this issue). Many of the patients were monolingual Navajo speakers, and approxi- mately half of the interviews were conductedwith the assistanceof a Navajo lan- guage interpreter.The ethnographicteam occasionallyattended the psychiatricin- terview to help provide contextual informationand, in some cases, to facilitate patientcomfort. Transcriptsfrom the ethnographicinterviews were not available until afterthe psychiatricinterview. Psychiatricinterviews were conductedby a psychiatristor psychologist, us- ing the StructuredClinical Interviewfor DSM (SCID) (Spitzer et al. 1992). The SCID is a semistructuredinterview for makingdiagnoses from the catalog of psy- chiatricdisorders as defined by the AmericanPsychiatric Association (APA). The interview consists of an open-ended,information-gathering component (which is used to elicit a lifeline narrative)and separate,algorithmically structured modules exploringmood, thought,anxiety, and substanceuse disordersymptoms across the patient's life span. We used the SCID-NP, an interview format specifically for nonpsychiatricpatients. The SCID facilitatesassessing patientsacross four of the five dimensions(axes) of psychiatricclinical status: AxisI-primary psychiatric disorders AxisIII-relevant medical disorders AxisIV-severity of psychosocialstressors' AxisV-level of adaptivefunctioning (can receive a scoreof 1-100)2 SCID questionsdo not addressdevelopmental and personality disorders (Axis II). 578 MEDICAL ANTHROPOLOGY QUARTERLY

The SCID is seen by its designersas a tool for eliciting psychiatricdiagnoses and generally is not used to providedescriptive, qualitative, or narrativeinforma- tion about patientfunctioning. In our study, the SCID interviewtook from one to four hours to complete dependingon language and patienthistory factors. In the midst of the SCID interview,we also asked patientshow they understoodtheir ill- ness and theirreligious healinginterventions.3 In the first phase of The Navajo Healing Project, ethnographicinterviews were conductedwith 95 religioushealers from among the threesystems. Religious healers were asked by the ethnographicteam to offer perspectiveson methods of practiceand the natureof illness-healing.These findings will be presentedin sub- sequent publications.Eighty-four patients, with the permissionof their religious healers, elected to participatein the ethnographicinterviews, sharing their life and illness histories and their beliefs relevantto their religious healing interventions. At the time of the ethnographicinterviews, 33 of the 84 patientswere involved pri- marily with Traditionalhealing ceremonies,21 with NAC meetings, and 30 with Christianhealing ceremonies.SCID interviewswere successfully completedwith 79 of 84 patients.Two patientsdropped out of the ethnographicstudy before com- pletion, two patients declined the SCID interview after completing the ethno- graphic interviews, and one patient died in a motor vehicle accident. The SCID findings will be presentedcomprehensively in a futurepublication. Demographiccharacteristics of the patientsare reported in the tablesincluded in the introductionto this issue, but for conveniencecan be summarizedas follows: 60 percentof the patientswere female, and 60 percentof the patientswere married at the time of the interview.Patients ranged in age from 16 to 84 years, with nearly half (49 percent) age 50 or above. The Navajo populationas a whole is younger thanthe United States, with a medianage of less than25 years (U.S. IndianHealth Service 1997). Our populationreflected a substantialdiversity of educationalex- perience, with 30 percentof patientscompleting less than six years of formaledu- cation and 27 percent completing more than two years of college work. Over a third(38 percent)of the patientsspoke only the Navajo languageduring the inter- views, with another10 percentspeaking both Navajo andEnglish.4 Only 22 percentof the patientsin our studyhad no historyof a psychiatricdis- orderper SCID criteria.Thirty-seven percent of the patientshad a historyof a ma- jor depressive illness in their lifetime.5 Thirty-fourpercent had lifetime occur- rences of anxiety disorders(primarily post-traumatic stress disorder).Forty-five percent had lifetime histories of substance use disorders (primarilyalcohol re- lated). Twenty percentof our patientshad lifetime historiesof depressive,anxiety, and substanceuse disorders.We found that25 percentof the patientsin the Chris- tian healing group had a lifetime historyof a depressiveillness. Forty-twopercent of the Traditionaland 45 percentof the NAC patientshad historiesof depression. Sixteen patients(19 percent)had significantdepressive symptoms at the time of theirreligious healing intervention,which in some cases precededthe SCID by threeto six months.Depressive symptoms had remitted for seven of the 16 patients between the time of their healing ceremonyand their SCID interview.The preva- lences of currentdisorders at the time of SCID interview were 11 percentfor de- pressive disorders, 10 percent for anxiety disorders,and 5 percent for substance use disorders. DEPRESSIVE ILLNESS AND NAVAJO HEALING 579

Narratives of Illness and Healing We discuss three patients selected on the basis of two criteria:(1) all met DSM criteriafor a majordepressive episode at the time of their healing ceremo- nies; and (2) together,their experiences illustratethe broadestrange of treatment acrossthe threeforms of religioushealing. We use thesecase studiesto helpexemplify the nexus of culture, psychiatric illness, and healing interventions.Information from ethnographicand SCID interviews is then combined to present patient life stories, family traditions,and illness and healing system experiences.We explore each patient'sattributions related to his or her symptomsand healing interventions.

Patient #1-Eleanor W.

EleanorW. is a 64-year-oldmarried woman who is the motherof ten children and grandmotherof 35 children.She is the oldest child of a renownedTraditional medicine man. She is highly regardedin her community and outside the Navajo Nation for her rug-weavingskills (as are several of her daughters).She grew up nearher currenthome andhad no formalschooling. She tendedfamily livestock as a teenageruntil she marriedher currenthusband at age 17. Her husbandis a Tradi- tional healer (a Blessingway chanter).He is also a road man (ceremonyleader) in the NAC. Eleanoris a monolingualNavajo speaker.A Navajo-Englishinterpreter facilitatedall interviews. In both the ethnographicand SCID interviews,Eleanor shared many recollec- tions from her childhood.Since she is the daughterof a Traditionalhealer, she has sought to understandher illness symptomsin Traditionalways throughouther life. She spoke with pride and satisfactionas she reviewed her life. She believed that she developed a strongand resilient spirit as a child and gave creditto the practices she was taught.She recalled being awakenedby her parentsearly in the morning and being sent outside to run. Even in cold weather,she and her younger siblings were requiredto jump into water or snow to wash themselves. She felt this ritual played a protectiverole in preventingcoughs and colds and lamentedthat children raised today seem more susceptibleto illnesses because they do not have the same rigorousmorning habits. Eleanor also recalled learningabout loss at an early age. As an eight year old, she was caughtin a stormwith a cousin and swept down a col- lapsing sandbank.Her cousin did not survive. Eleanornoted thatshe and her family had been active in the ChristianChurch when she was a young woman, though she had not been active for years. She has participatedin Traditionalhealing interventionsand helped with Traditionalcere- monies throughouther life. She andher family also have long been membersof the NAC. She sharedher view thatthere is significantoverlap in Traditionaland NAC healing practices. In addition,Eleanor described lifelong participationin the Westernmedical system. She lamentedthat doctors in past decades seemed to have a betterunder- standingof patients'illnesses thanthey do now. She reported,with apparentpride, that Traditionaland NAC interventionshad positive effects on her medical prob- lems. At the time of the SCID interview,she was receiving medical treatmentfor diabetesmellitus, arthritis,and high blood pressure.She also creditedher family's knowledge of medicinal herbs as helping to provide symptomaticrelief for these 580 MEDICAL ANTHROPOLOGY QUARTERLY problems.She sharedher belief thatdiabetes is a problemthat was not experienced by her elders and, thus, that it was probablycaused by contact with "Anglos"and Anglo lifestyle and dietaryinfluences. Eleanornoted that she and her family still seek treatmentin the Westernmedical system, though she has never been referred to a mentalhealth provider. She also noted thather husbandis asked from time to time to visit patientsin the hospital and provideTraditional healing interventions to augmentthe Westerncare. Eleanoragreed to join this study aftera TraditionalNavajo diagnosticianrec- ommendedthat she participatein a TraditionalShootingway ceremony. The nine- day ceremony(her first majorceremony in 30 years)involved herb-inducedsweat- ing andemesis, intensivehealer-led singing, sandpainting,and ceremonial dancing to addressknee pain, numbnessin her feet, burningin her stomach,dizziness, sleep problems, and difficulty concentratingon her work as a weaver and caretakerof her grandchildren.During the ceremony she learnedthat her symptoms were due to an accumulationof disharmonyand distressrelated to multiplelife events. She was told she had been exposed to risk in uterowhen she had been too close to her fatheras he led ceremonialhealing. Also, she had eaten corn that had been struck by lightningand a sheep that had been bittenby a venomous snake, and as a child she had been "hit by a rainbow."She explained that her family had seen her en- gulfed by the end of a rainbow.She felt this could have been a positive influence for her but still needed to be addressedin her ceremonyto help restorethe healing effects that a rainbowcan engender.She was told duringthe ceremonythat a rain- bow could also affect the soles of the feet, causing problemslike arthritis.Of the ceremony,Eleanor commented, "It helped me remembercompassion for my body because I walk in it. It helps me live and I want to walk in beauty."During the SCID interview,Eleanor reported that the ceremonybrought relief of her arthritic, gastrointestinal,and sleep problems. The ethnographicfield team met with Eleanorseveral months after her Tradi- tional ceremony. The team had learned in the interim that Eleanor's father had died. After herfather's death, she experiencedthe rapidonset of disablinggrief and a nearcomplete abandonmentof her roles within her family. Eleanorexplained to the field team that in her grief she was restless and moved aroundto the homes of her children to try to escape her distress. "I stayed with them at each place. I couldn't get comfortableanywhere. I would thinkmaybe if I sat down in a flat area and let the wind blow dirtaround me I would feel better.I couldn't handleit. I lost interestin everything."The profounddistress continuedfor nearly three months. Then, at the requestof her brother(who was worriedabout her withdrawalfrom the family), she participatedin an NAC ceremonylasting from Eastereve into Eas- ter morning. Eleanor's family was mindful of the spiritual meaning, from the Christianperspective, of the timing of this ceremony.She reportedthis effected a significantchange in her mind: "I attendedthe meeting and cried my heartout for my late father.I felt like somethingwas crushingmy chest and thatit was wrapped all aroundmy chest as hardas you could tightenit, but at this meetingthe tightness softenedup and then I settleddown and thatis how I am today." The SCID interview took place eight months after the Shootingway cere- mony, five months after Eleanor's fatherdied, and two months after the Easter- time NAC meeting. The following lifetime and currentDSM diagnoses were ob- tainedand relevanthealing systems identified: DEPRESSIVE ILLNESS AND NAVAJO HEALING 581

DSM Diagnoses Axis I. Majordepression, in early remission Agoraphobia,without panic disorder Axis II. No diagnosis Axis III. Non-insulin-dependentdiabetes mellitus Axis IV. Moderateto severe psychosocialstressors in previoussix monthsre- lated to healthconcerns and deathof father Axis V. Global Assessment of Functioning:85 (good functioning) PrimaryHealing System Relatedto DepressiveSymptoms NAC OtherHealing Systems Traditional,Western medicine

Eleanorreported no history of psychiatricdisorders until the months preced- ing her father's death, when she developed significantsymptoms of agoraphobia (fear of being alone, fear of being away from home). She understoodher fear of solitude as relatingto her worry over the decline in her abilities. She continuedto have symptomsof agoraphobiaat the time of the SCID interview. Eleanorhad experiencedeight of nine featureslisted in DSM-IV as criteria for a majordepressive illness (only five symptomsare requiredto make the diag- nosis). The symptoms lasted three months. DSM-IV stipulatesthat if depressive symptoms and functional impairmentpersist two months beyond the loss of a loved one, the bereavementepisode shouldthen be regardedas a majordepressive episode (see Figure 1; CriterionE). She reporteda persistentloss of appetite,en- ergy, concentration,motivation, and outlook. She acknowledgedrecurrently imag- ining her own deathbut did not contemplatetaking her life. She commentedduring the SCID interviewthat she had "walkedthe hills" aroundher home for hours at a time due to a sense of restlessnessand anxiety.During this three-monthperiod she spoke aloud to her deceased father,telling him, for example, that "you left us feel- ing alone down here." In the SCID interview, Eleanor expressed her appreciationof her brother's and husband's efforts in setting up the Easter-timeNAC meeting. During that meeting she saw herself as able to "questionthe spiritsthat linger afterdeath and ask them, 'Why do you botherme? You went into the earth.I'm supposedto be liv- ing on the earthand in the sky and being healthy.' " Duringthe SCID, though, she lamented not yet having fully returnedto her formerenergy and vigor. She was worried that she was progressively losing her strength.This was a particularly troublingthought, given her commitmentto weaving projectsand her sense of re- sponsibilityto her childrenand grandchildren. There were ample signs during the SCID interview of Eleanor's recovery from her bereavementand depressive illness. She used her hands in an expressive fashion to help illustratesomatic and spiritualstruggles during the three months following her father'sdeath. She smiled broadlyas she discussedher excitementat recoveringmuch of her energy and interestin life again. She describedthe impor- tance of againbeing able to spiritedlywalk amongthe hills aroundher home as she had throughouther childhoodand adultyears. Eleanoralso noted that duringher periodsof deepest sadness she triedto im- prove her low appetiteby drinkinga lot of waterand eating oranges.When she lay down on the groundand contemplateddying, she felt remindedof special powers 582 MEDICAL ANTHROPOLOGY QUARTERLY she felt she had acquiredthrough years of helping her husbandand her fatherwith ceremonies. She explained her despondencyas an inevitable existential struggle following the loss of a beloved parent.When asked during the SCID if she had beenbothered by thoughtsthat did notmake any sense, she explained,"When relatives are lost or people die the dead spirits always know how to get back to the people thatare still alive." She notedthat her NAC ceremonyhad given her the strengthto speak out against the "spirits"that had come back to haunther duringher time of loss. Eleanorshared her sense of pleasurethat she has been able to resumecaring for her nearly 80-year-old motherand regain most of her otherroles as the oldest child in the family. At the end of the SCID interview,she showed the interviewers a 5x7-foot rug that she had resumedweaving. Navajo weaving is a highly skilled and labor-intensivetraditional activity, and her resumptionof the unfinishedpro- ject signaled re-engagementin a productivelife. The rug's intricatedesigns, for which Navajo weavers from hercommunity are renowned, could not butremind us that to help her throughthe somatic, psychological, and existentialdistress of the precedingyear she had woven together,to a greateror lesser extent, elements of four healing systems:Traditional, NAC, Christian,and Western biomedical.

Patient #2-Rita T.

Rita T. is a 47-year-old woman who was interviewedin her home, which she shareswith threechildren and two grandchildren.She is fluent in both Navajo and English, though all interviews with the clinical and ethnographicteam were con- ducted in English. Her childhood was markedby separationfrom her parentsfor many years. Her mother was diagnosed with tuberculosiswhen Rita was three years of age and spent six years in a TB sanitariumon the Navajo reservation.Rita was placed in a boardingschool for most of her schooling years. She recalled a spartanlife, feeling abused in the boardingschool and neglected duringthe sum- mers living with relatives."It was hard,but I thinkI learneda lot from all the disci- pline."She spoke in some detailabout specific punishmentsat the boardingschool, including being forced to stand in a closet with several other children all night long. She recalled harsh hygienic interventionssuch as chemical treatmentfor head lice thatled to chronicsores on her scalp. Rita marriedat the age of 19 afterbecoming pregnantby her boyfriend.Her marriagewas markedby her husband'songoing abusivenessand threatsof death, until he himself died 20 yearsago fromillness. A second marriageended in divorce priorto her involvementin this study. At the time of the SCID interview,she was working towarda baccalaureatedegree and expected to graduatewithin 12 to 18 months.Rita reportedthat she had gottencloser to her fatherand her motherin the last decadeand deriveda good deal of supportfrom them, particularlyfrom her fa- ther,who is a Traditionalhealer. Rita was diagnosed with cancerjust priorto her divorce. She regardedthis as "theshock of my life." Thoughshe regardedthe surgicaland chemotherapeuticin- terventionsas successful, she was left with some physical limitations.For exam- ple, she was less able than she had been to tend the family livestock. At the time of the SCID interview,she reportedthat her cancerwas in remissionand thatshe was pleased with her extensive medical care. She joked at one point, "Thedoctor told me thatmy recordsare aboutas big as the Old andNew Testament." DEPRESSIVE ILLNESS AND NAVAJO HEALING 583

Rita was raised in the TraditionalNavajo healing system. Her second hus- band, though, had been quite active in the NAC. She regardedthis as a source of conflict, given her Traditionalvalues. She also notedthat her cancerdoctor had ex- pressedhis concernabout the possible negativeinfluences of peyote (used in NAC ceremonies)on her cancer treatment.In the midst of her quandaryregarding NAC versus Westernhealing interventions,she began to spend time with an elder in the communitywho introducedher to a Christianprayer group. Her Christianfriend encouragedher to join Pentecostalprayer services but was also supportiveof Rita having a TraditionalNavajo Blessingway ceremonyto help her throughthe cancer treatment.The same friend was quite opposed to Rita staying active in the NAC. Rita's husbandleft her soon aftershe was diagnosedwith cancer. At the time of the SCID interview, Rita was involved with her Christian prayergroup several times a week. She was actively raising grandchildrenin her home, working outside the home, and enrolled in upper-level baccalaureate coursework.She was continuingmedical follow-up for her cancer.She sharedwith the interviewteams that she could not yet regardherself as a cancer survivor.She understoodthat she needed to be free of the cancerfor five years before she could call herself a survivor. The following lifetime and currentDSM diagnoses were obtainedand relevant healing traditionsidentified: DSMDiagnoses AxisI. Majordepression, current, moderate Alcoholabuse, sustained remission (subthreshold:Post-traumatic stress disorder features) AxisII. No diagnosis AxisIII. Carcinoma, possibly remitted AxisIV. Moderate to severepsychosocial stressors related to parent,grand- parentresponsibilities, health concerns, and abuse exposure AxisV. GlobalAssessment of Functioning:68 (symptomscause mild impairment) PrimaryHealing System Related to DepressiveSymptoms Christian OtherHealing Systems Western,Traditional Rita's lifetime psychiatrichistory is remarkablefor her having had intense symptoms of posttraumaticstress disorder(PTSD) during much of her first mar- riage. Her hypervigilance,nightmares and flashbacksof the abuse, and nihilistic outlook on life at that time might betterhave been construed,though, as a protec- tive responseto ongoing trauma.Rita reported being beatenby her husbandduring her first pregnancy."I couldn't fight back, if I opened my mouth I'd get hit."Rita acknowledgedsymptoms of alcohol abuse duringher first marriage.She reported resortingto drinkingwith her husbandbecause she couldn't get him to stop abus- ing her. "I was a punchingbag for him."She recalledthat their fighting intensified due to her drinking and that at one point she attempted to attack him. "After that, I stopped drinking." Her PTSD symptoms largely remitted soon after the loss of her first husband. Rita reportedfour periods in her life when she experiencedsymptoms of ma- jor depressionfor at least two weeks. Two occurredafter the diagnosis of cancer. She recalled"being down and depressedand crying a lot" and also being unableto 584 MEDICALANTHROPOLOGY QUARTERLY eat, think,or get out of bed in the wake of her husband'sdeparture. She consulteda social workerand met with a psychiatristfor several sessions, and found this help- ful "for a shorttime." As stated above, she also creditedher fatherand her Chris- tian friends with helping her endure her stresses. Nonetheless, she had felt sad, lonely, and anxiousfor much of the two years following the diagnosis.She also re- porteda resurgenceof post-traumaticstress symptomsin the form of flashbacksto the violence of 20 years ago. She acknowledgedtrying to "fight off" chronic de- pressive feelings by focusing on the needs of her childrenand grandchildren.She triedto see herselfas "adifferent person" as she struggledto get throughher cancer and to earna bachelor'sdegree. At the time of the SCID interview,Rita endorsedseven of nine criteriafor an episode of major depression, which, for her, included having "burned-outfeel- ings," low mood, loss of interest,weight loss, insomnia, agitation,and difficulty concentrating.However, she denied having any suicidal ideation or feelings of self-reproachor worthlessness.Rita had not sought any medical or psychiatric treatmentfor her depressivefeelings and also notedthat she had not requestedhelp specifically for depressivefeelings from her minister. Rita reportedthat she had been encouragedto have a prayermeeting in the weeks precedingthe SCID interview."I neededhelp to let things go smoothlyand I put thatrequest out for a prayermeeting because I really neededhelp in school. I was really burnedout. I hadheadaches and body aches and I guess my body knows I was really putting a lot of pressure on myself." She referredto her healing throughthe PentecostalChurch as somethingthat brought a sense of belonging to and acceptanceby her community."God's word is healing, and the most powerful word is love. The churchpeople are here to love. The healing power has brought me innerpower deep inside, andI know thatGod has healedme, the canceris heal- ing, and even though there is still emotional pain, I know I am strong enough to keep going." She regardedherself as "a newbornchild of the Lord still trying to find myself, tryingto climb the stepladder." When asked how her ministerwould explain the health effects of her faith, Rita stated, "He would say that throughprayers the Word comes to you and you learn that the Lord cares for you. The Lord knows you're suffering ... and can bring you salvation.... I used to be greedy and mean and selfish and now I've changed.Now I can reachout." She sharedwith the ethnographicteam her experi- ence of conversionto Christianity(two years before the SCID interview)."When I went to churchit was with a heavy load on my back, but when I walked out I felt real light like I was walking on the clouds. When I got saved I had to say my own prayerfrom my heart,from my innerself to just give everything,all my problems back to the Lordand let Him takecare of it."The idea thatthrough prayer she could gain relief and lighten her burdensseemed to be a centralhealing theme for her. Rita sharedno sense of conflict about having three healing systems (Traditional, Christian,and Western medical) contributing to her care.

Patient #3-Jimmy Y. Jimmy Y. is a 62-year-oldmarried man, fatherof threechildren, grandfather of nine, and great-grandfatherof one. He is one of seven children,and his mother lives in a nursinghome in a nearbyvillage. Jimmyhad no formalschool education. DEPRESSIVE ILLNESS AND NAVAJO HEALING 585

He has retiredfrom full-time carpentrywork but continuesto be active, as he has been for 40 years, as a leaderof ceremoniesin the NAC. FromJimmy's home one of the four sacred Navajo mountains is visible 40 miles away. His wife Helen was presentfor most of the ethnographicand SCID interviews.She often offered supportive and clarifying comments. Both Jimmy and Helen are monolingual Navajo speakers, and a Navajo-Englishinterpreter therefore facilitated all inter- views. As a child, Jimmywas raisedto tend to his family's livestock. His fatherdied when he was young. He recalledlearning from his motherand grandmotherto ap- preciatethe needs of others.His grandfatherintroduced him to TraditionalNavajo principles of healing. He began to integrateNAC practiceswith Navajo healing practicesas a young adult.Jimmy's wife was chosen for him by family elders when he was a teenager.He recalled not fully appreciatingHelen as a companion until they had raisedseveral children together. He acknowledgedlong-standing stresses within his extended family relatedto issues of jealousy between family and com- munity members.Individuals seeking NAC healing have often broughtproblems relatedto jealousy to Jimmyand Helen for theirhelp. Over the years, Jimmy had been treated by Western medical providers for such problems as skin rashes, fainting spells, an episode of facial paralysis, and for diabetes mellitus. Though he has continued to get medical care in a nearby clinic, Jimmy expressed disgruntlement with Western medicine: "You don't often see the same (Western) doctors, so they don't know who you are. When you see a medicine man you see the same one. The medicine man really gets to know what's going on with you." He credited Traditionalhealing with helping his diabetes. "Anyone with diabetes needs a Snake Bite Way. Now that I've had all these ceremonies done my diabetes is much better, I don't have to do shots anymore." Jimmyreported seeking Traditionalhealing in the weeks precedinghis SCID interview to addressproblems with weakness, faintingspells, skin rashes, and be- cause he was feeling "wornout." He reported,and his wife stronglyconcurred, that his role as an NAC healerput him at risk for these illnesses as he triedto help others with theirproblems. Jimmy had a protection/shieldTraditional Navajo prayer ceremony per- formed for him two and a half weeks before the SCID interview.His family had come to believe that his symptoms were signals that someone was wishing him harm.He noted that the medicine man correctlydivined that his vehicle had been sabotagedby those who wished him ill. He had felt similarly at-riskin previous years and soughtsimilar help from the Traditionalhealer. Duringthe SCID interview,the following DSM diagnoses were obtainedand relevanthealing systems identified: DSMDiagnoses AxisI. Majordepression, current, mild AxisII. No diagnosis AxisIII. Diabetes mellitus, non-insulin dependent AxisIV. Mild to moderatepsychosocial stressors related to healthdifficulties andfamily pressures AxisV. GlobalAssessment of Functioning:75 (symptomsassociated with slightimpairment) 586 MEDICAL ANTHROPOLOGY QUARTERLY

PrimaryHealing System Related to DepressiveSymptoms Traditional OtherHealing Systems NAC,Western For the monthpreceding his Traditionalceremony and continuingto the time of the SCID interview,Jimmy endorsed six of the nine DSM criteriafor depression, including low mood most of the day for most of the month, disturbedsleep with hypersomnia,restlessness observable by others,chronic fatigue, ruminations about wrongdoing,and significantproblems with concentration.Jimmy did not endorse the more classically cognitive symptomsof despondencyor feelings of worthless- ness but found himself wonderingwhere he had gone wrong and what caused his sadness. He and his wife concluded that witchcraft,jealousy, and family stresses were likely the causes for his distressand physicalproblems. He reported"feeling worn out" from being a healer:He regardedhimself as having been limited in his ability to functionas a fatherand a healerduring the precedingmonth. Jimmyhad no previoushistory of majordepressive or otherpsychiatric symp- toms otherthan fleeting periods of feeling stressed.Once duringthe last few years he had turnedto alcohol consumption.He recalledat thattime feeling undergreat work and family pressureand drankheavily for several days. The medicine man believed he'd starteddrinking because he had been "witched." Jimmy and Helen discussed the specific interventionprovided by the medi- cine man in the precedingmonth to addressJimmy's distress.It was a "protection ceremony"wherein the family's possessions were blessed, including their house, furnishings, automobile, livestock, and their NAC ceremonial tools (feathers, herbs, stones). According to Jimmy, the ceremonyaddressed "contagion" issues: "Whenwe performa ceremonywe get in the way of whateverproblem the person may be having. If we do a ceremonyfor him, we will end up getting involved with his problems."Jimmy also noted, "Ifyou experiencepainful hurts with yourphysi- cal body, throughthat you will be able to understandthe problems of your pa- tients."Speaking as a healer, and discussingjealousy as a causal factor in his dis- tress, Jimmy stated, "It [jealousy] is like a disease, that's what they call heart-mind-ache."In the ceremony, Jimmy and his wife both received prayers from the medicine man. Prayerswere directedby the medicineman towardcertain deities (the "Holy People"in Navajo cosmology) and reportedlyalso targetedthe jealous parties. Helen remindedJimmy (and the interviewteam) that he must recurrentlyat- tend to the stresseshe faced as a healer:"If you do four overnightsings [NAC cere- monies] in a row then you will have to have one overnightsing for you." Jimmy noted that if a person becomes a patientin the correctTraditional ceremony, then the problem (his symptoms) goes away "by itself' in accordancewith "the Holy Beings." "It's really sacred,so I think of it in a beautifulway and I will be healed by it and everythingwill (then) be back in harmony:my children,my wife, even my car, and then I will continueto live on in harmony."Jimmy's specific healing ceremony involved arrangingarrowheads on the ground and pointing them out- wardto help protecthim from those who wished him ill. Jimmyrecalled that he be- came exhaustedduring the ceremonyand was told by the medicineman to rest for four days "of reverence"before beginning to be active again. He acknowledged DEPRESSIVE ILLNESS AND NAVAJO HEALING 587

that the rest period was very helpful for him. "During this time you watch to see if your mind is becoming at ease ... little by little it goes away ... all of the sudden you realize that you feel fine, that's how it works." Jimmy and his wife work together in the NAC ceremonies and thus share risks of contagion from the problems they help others address. They commented that their stress problems (largely experienced as physical symptoms) can go back and forth between them. If one gets better, the other gets sick. When they spoke during the SCID interview, they were hopeful that their strong connection and their persistence would get them through his problems. During the SCID interview, when asked to speak about the best times in his life, Jimmy stated, "My wife and I have been together supporting each other through illnesses. We've gone through the tunnel and overcome turmoil and tribulations. We have come up against all these obstacles, sometimes suddenly, but come out of the tunnel. It's like we've made it into a beautiful place or a beautiful pasture." Jimmy demonstrated a persistent effort in his interviews to anchor his distress in his own experience as a healer. He seemed almost to welcome distress or at least to see illness as, in part, an opportunity.

When you are a personwho performsall these ceremoniesfor people, you become awareof the entire areaof illness, being sick thatis partof your treatment.You're totally exposed to everythingthat affects people. I think that is how you get sick. Everytime you get sick you are made awareof whatit meansto be sick or be well. You thenuse this experiencein your treatmentof people. You use certainherbs or certainceremonies to overcomethese illnesses andin turnyou have addedknowl- edge how curing and healing is possible throughthe use of herbsand ceremonies. It's like you gain for your patient.You study how being sick can affect people. You have actualpractical experience to help yourpatients and help you treatthem, that's how I look at it.

Experience, Diagnosis, and Therapeutic Change

The Navajo people are renowned for their belief in the integration of physical, mental, and spiritual functioning (Farella 1984; Griffin-Pierce 1992; Lamphere 1977; Levy 1998; Witherspoon 1977). For centuries Navajos have turned to Tradi- tional ceremonies to treat symptoms of disease, distress, and social disjunction. A half century ago, Frank Waters observed the work of the surgeon Dr. Clarence Salsbury, who had provided health care for Navajos for many years. Dr. Salsbury understood that for Navajos "health and religion are inseparably tied up" (Waters 1950:386). In the last five decades, the strong link, for Navajo people, between health care and spiritual path (living in harmony) has provided a fertile medium for the sustenance and growth of three major religious healing systems (Traditional, NAC, and Christian) that complement Western medical care. The patient stories presented here are intended to show that patient ascriptions of illness and healing expressed in religious forms can provide a means for observ- ing and explicating some processes of therapeutic change in individuals, and to il- lustrate experiential processes in Navajo religious healing for patients demonstrat- ing (by Western psychiatric constructs) similar symptoms of distress. We have not sought to assess the validity of the diagnostic categories, the nature of the diagnos- tic process, or the efficacy of the interventions but, instead, to characterize the 588 MEDICAL ANTHROPOLOGY QUARTERLY experienceof making use of the threehealing systems. Ourfindings are not meant to suggest that Navajo patients are especially prone to depressionor psychiatric disturbancesbut, instead, to describehow they understand,experience, and come to terms with problemsthat would be categorizedas depressionaccording to psy- chiatriccriteria. We are aware,too, thatthe patientsin this study may not be repre- sentative of all groups of Navajo individualswho might meet criteriafor depres- sion. Our patient group may represent (as evidenced by their willingness to participatein many hours of ethnographicand clinical interviews)a more expres- sive, optimistic, and socioculturallysecure group than many others experiencing depressiveillnesses. None of the threepatients discussed here was seen as suffer- ing fromcultural alienation, at least duringthe periodof our study. We entered the study with some apprehensionabout how Navajo patients would experience the StructuredClinical Interviewfor DSM-IV (SCID). Given concerns about the palatabilityof a lengthy structuredpsychiatric interview proc- ess (especially when translationwas necessary),we were appreciativeof and de- pendentupon patientand interpreterpatience in completingall the modules of the SCID. Though ethnographicand psychiatricinterviews may be time-consumingfor patients, we have not assumed that researchinterviews are necessarily aversive. We noted that many patients seemed to be reflective and curious, and some ex- pressed appreciationfor the opportunityto review their lives. Scarvaloneet al. (1996) observed in their study of HIV patients that many individuals reporteda diminishmentin feelings of distress by participatingin a SCID interview.At the end of theirSCID interviews,many Navajo patients in our study offeredtheir hope thattheir answers would help Westerndoctors (such as the SCID interviewer)and traditionaland religious healerslearn from each other. Our inquiry has taken us into the heartof questions about the concepts and constructsof depression.For the threepatients presented here, the SCID interview discernedsymptom clusters that depicteddiscrete distress experiencesassociated with arguablysimilar cognitive and somatic difficulties and impairmentin social and occupationalfunctioning. All threepatients endorsed six or more of the nine symptoms constituting a fundamentalDSM diagnostic criterionfor a major de- pression (at least five are requiredto meet the criterion).All three acknowledged sustainedsadness, self-doubt, and pervasive loss of interestin importantlife activi- ties priorto theirreligious healing ceremonies.Each patientidentified him or her- self as unableto adequatelyperform his or her social and family duties duringthe distress. Though the Diagnostic and Statistical Manual for DSM-IV does not re- quire or stipulatethat specific biological or psychosocial factorsare causal or nec- essarilycontributory for a diagnosis of depression,our patientseach identifiedfac- tors they felt generatedtheir symptoms.These factors,though in partsomatically manifested,seemed to emanatefrom the patient's psychosocialmilieu. Our patients' distress experiences were socially monitoredif not mediated. Family membersand/or communitysupporters were vital in encouragingthe pa- tients to seek help. For three months,Eleanor's husband and brotherwatched her progressivelyabandon her usual competencies.Noting her enduringinertia, they arrangedthe NAC meeting. Rita's fellow churchmembers enjoined her to ask for a prayer meeting when she felt herself to be overwhelmed and drifting from her DEPRESSIVE ILLNESS AND NAVAJO HEALING 589

Christiansupport group. Jimmy's wife served as his sentry and symptommonitor to detect when he was overduefor a protectiveintervention. Neither the patients nor their healers appearedto label the symptom cluster "depression"per se-and thereis no reasonthey shouldhave.6 There is no Navajo term that fully correspondsto the English notion. Navajos we interviewedsome- times used yiniil to denote that someone is worried, sad, or distraught(see also Young and Morgan 1987:769). A recent dictionary for health care providers glosses depressionin two ways. The first is, doo bc 'aits'ida,or "lonely and sick." The second and more elaborateapproximation is yee'iind 'ill' iidoigai d66 yee hodi ' adoigii bee bich 'i nahwii'nd, roughly, "something is not rightthat is giving you a problemmaking a living and takingcare of yourself."In the latterphrase, the "something"is implicitly evil. Moreover,subtleties of both vocabularyand phras- ing create inevitable ambiguity at the linguistic frontier between English and Navajo (in particular,questions in the Mood Disordermodule of the SCID were difficult to translate).7Neither is there a complete concordancebetween Navajo and psychiatric understandingswith respect to what falls within the domain of symptoms-in Navajo experience, a negative event, setback, or obstacle is as "symptomatic"as a pain, depressedaffect, or inabilityto stop drinking. Though each of these observationsin itself points to a methodologicalissue, their global importcan be summarizedby saying that Navajo healerstreat the pa- tient ratherthan the disorder,guided by the patient'sspecific alienationfrom safety and security. This does not necessarilyinvolve extensive interviewingor elicita- tion of the patient's narrative,but it often includes ceremonialtreatment custom tailoredto the patient's needs. Throughthe religious healers' interventions,the pa- tients come to understandwhat we call their depressive symptoms as signals. Eleanor perceived her religious ceremony as a guidepost signaling when it was time for her to rejoin her lifelong roles in the family. Rita learnedthat her distress was a result of takingon her problemsalone and forgettingthat "the Lord will take care of it." Jimmy's ceremony taught him how to see his symptoms as lessons aboutstress management and perseverancein the face of ongoingrisk. Each patient felt that his or her healer offered personalizedinterventions that were targetedto his or her own somatic, psychological, and social-existential distress and that helped to re-securethe patientin the community. The DSM provides a nomenclaturefor labeling, but most of its diagnostic constructs are specifically avowed to be free of etiologic implications.Further- more, there are no specific treatmentrecommendations offered in the manual.If we make a diagnosis of depression,then what have we identifiedand for whatpur- pose do we identify it? What is the benefit of linking these or any patientswith a specific diagnosis? The "non-etiologic"DSM, becauseit aspiresto neutralitywith respectto cau- sation and treatmentimplications, may allow for less controversialand less so- cially stigmatizing labeling. On the other hand, the diagnosis, the label, the "stigma,"the reductionistprocess inherentin all healing is a beginningpoint for the patienttransformation. The DSM categorizes"disorders" but does not address the logical implication of using the term disorder by suggesting pathwaysfrom "disorder"to "order."For Navajo religious healers and their patients,the attribu- tional matrix,grounded in life context and narrativethemes, provided the template for change, the direction out of the distress. Presumably,the healers were poised 590 MEDICAL ANTHROPOLOGY QUARTERLY with theirdiagnostic knowledge to truly guide the patientfrom "disorder"or "dis- harmony"(in Navajo conceptsof disease) to improvedorder or harmony. The perspectivesprovided by these three patientsdemonstrate the interplay between anxiety, somatic distress, cognitions, and social efficacy. It appearsthat these patientsutilized the many facets of theirdistress as signals to guide them to- wardthe help of the healer.As has often been observedin studies of ritualhealing (Bourguignon1976; Csordasand Kleinman1996; Csordasand Lewton 1998; Dow 1986; Frank and Frank 1991), throughthe therapeuticprocess all three patients seemed to experience a transformedsense of meaning about their symptoms that helped themput theirdistress, and perhaps their life as a whole, into a richergrid of personaland social meaning.Specifically, each patientwas able to reconnectwith experiences helpful to him or her earlier in life. Eleanorreaffirmed the value for her of "walkingthe hills" to gain strengthas she had done as a young child. Rita could see thatsome degree of stoicism (as modeled by the life of Jesus) would help her throughher hardships.She had learnedin boardingschool how to be tough and strong.Jimmy was thankfulthat he had learnedas a newly marriedteenager how to deal with the personaland family problemscaused by jealousy. Navajo healing, and religious healing in general, has for decades been com- paredto psychotherapy(Csordas, 1990, 1994; Frankand Frank1991; Janet 1925; Leighton and Leighton 1941). Indeed, though none of the threepatients we have discussed had recourseto Westernmental health systems for treatmentof the de- pressive disorder,the threereligious healing systems appearedto offer therapeutic strategiessimilar to such contemporaryWestern psychotherapeutic modalities as psychodynamic, cognitive-behavioral, and narrative/solution-focusedtherapy. Each patientwas encouragedinto a cognitive life-reframingprocess to recontextu- alize his or her problems.Jimmy had to reassess his notions of self-vulnerability and figure out how to improve his habits of self-protection.Rita worked to clear old pains and threatsfrom her currentrelationships, put cancerfears into perspec- tive, and resolve some of her anxieties aboutre-engagement in the world. Eleanor had perhapsthe most profoundhealing task: reworkingher sense of family posi- tion following the life-centralloss of her father. For our three patientsdiagnosed by SCID with a majordepressive disorder, the narrativeinterplay between patient and healer gave rise to apparentlyuseful constructsof causation.The religious healing system constructsand patientsymp- toms and attributionalnotions were meshed by the healersto yield contextuallyde- rived solutions and healing paths to help guide the patient out of distress. Thus, common elements in the experiencesfor our threepatients (beyond their meeting DSM diagnosticcriteria for depression)were that (1) their"idiom of distress"was recognizableby theirhealer, (2) somatic, cognitive, and spiritualissues were seen as interrelated,(3) theirillness/distress was linked to variablesin theirlife stories, (4) theirtools for regaininghealth/harmony/grace were latentwithin them, (5) their problemswere addressedin a personalizedfashion, and (6) healing was facilitated in a community/familycontext. These considerationssuggest that if thereis a dis- tinctively Navajo patternof depression,it does not consist only of a constellation of depressivesymptoms somewhat different from thattypical among non-Navajos, but also of culturalattributions and interpretationsof depressinglife situationsand culturalpatterns of reorderingand reintegrating the lives of distressedpeople. DEPRESSIVE ILLNESS AND NAVAJO HEALING 591

Conclusion All formsof healingare based on a conceptualscheme consistent with the pa- tient'sassumptive world. The scheme prescribes a set of activitiesand helps suf- ferersmake sense out of inchoatefeelings, thereby heightening their sense of mastery.[Frank and Frank 1991] We have predicatedthe precedingdiscussion of Navajo illness experienceon understandingdepression as an etic categoryof distressconceptualization, derived from the Western psychiatricdiagnostic method, that endeavors to validate the clustering of symptoms for the purpose of comparingpatients' functioning.The Diagnostic and StatisticalManual was bornin the post-WorldWar II era as a clas- sificationsystem to collect statisticalinformation. The DSM-I, publishedin 1952, recognized the role of multidimensionalcircumstance in determiningdiagnoses. "The use of the term reaction throughoutDSM-I reflectedthe influence of Adolf Meyer's psychobiologicalview that mentaldisorders represented the reactionsof the personalityto psychological, social, and biological factors"(American Psychi- atricAssociation 1994:xvii). Thus, historically,the DSM is rootedin the view that context and personal meaning matterin diagnosis (patternrecognition) and con- ceptualization(formulation) of disorders.Disorders need not and should not be re- gardedin the absenceof etiologic or treatmentimplications. It has takena few dec- ades in psychiatric diagnosis for the idea that psychiatric illnesses and existential/contextualfactors are inseparablylinked to regain prominence. Psy- chiatristGary Tucker concluded his recentappeal to his fellow psychiatrists,"The time has come to mergethe empiricalpsychiatry of DSM-IV with the story and ac- tual observationsof the patient.Accurate observation and the story of the patient must be included in our diagnostic processes. All are necessary for the effective care of patients,which, in the long run,is what it is all about"(1998:161). Indeed, our patientsfaced both similar symptomaticdistress experiences, as identifiedby the SCID, and similaritiesin their treatmentinterventions that pointed beyond the heuristicreduction of theirdiagnosis to a rich matrixof somatic,psychological, so- ciocultural,and existential-religiousvariables. Stated in terms of a more general conclusion, the specificity of symptomsexpressed in formaldiagnosis contributes to our understandinginsofar as it is complementedby what Byron Good (1994) calls the subjunctivityor existential open-endednessof experience expressed as narrative. Diagnosing is a process common to healing systems. Indeed, the etymology of the termdiagnosis takesus to the Greekprefix dia-, meaning"through, between, across"and gnosis, meaning"knowledge" or "knowledgeof spiritualthings, mys- tical knowledge" (Webster's 1989). The results of the ostensible non-etiologic SCID, as with any diagnosticscheme, includingthose utilized by Navajo religious healers(see Milne and Howard,this issue), areused to place a patient'sdistress in a nexus of causal vectors. The healerideally comprehendsthe idiom of distress,the somatic and psychological manifestationsof disjunction,the metaphorsof aliena- tion, and the patient'splace on the grid of social-existentialconnections and guides the patientto a re-securedsense of self-efficacy andreframed sense of purposeand hope. All healers must addresscomplex variableswith their treatmentstrategies and interventions.Medical doctors and traditionalreligious healers are often re- ferred to in the Navajo language by the same noun: azee' it "ini, which can be 592 MEDICAL ANTHROPOLOGY QUARTERLY translated"medicine maker." Navajo patientsexpect both kinds of healerto make diagnoses and conduct treatmentinterventions, to "make medicines" that lead from dis-ease to ease and from dis-orderto order,thus deliveringthem from their specific distress. As in much of the literatureon medicalpluralism and ritualhealing (Brodwin 1996; Csordas and Garrity 1994; Csordas and Lewton 1998; Leslie 1980; Ro- manucci-Ross 1969; Rubel 1979), we found that the vast majorityof Navajo pa- tients in our study utilized multiple healing systems to address their distress. Though they reportedthat they were cautious and often reticentin revealing their involvementin one system (for example, a religious healing system) to the healer of anothersystem (such as anotherreligious healer or a Westernmedical provider), they generally did not regardthe systems as mutuallyexclusive. Many, perhaps most, patientsregarded their religious healing involvementas an activity that had served or could have served a complementaryand collaborativerole with their Western medical care. This observationis especially relevant if these religious healing systems are conceptualizedas additionalforms of "primarycare" to which patientsbring problems such as depressivesymptoms to the providerfor treatment. In the last decade, the Indian Health Service, a branch of the U.S. Public Health Service, has also come to appreciatethe complementarityof healing sys- tems availablefor AmericanIndian patients. Regarding his agency's commitment to effective collaborationbetween healers, Dr. MichaelTrujillo, Assistant Surgeon General and Director of the Indian Health Service (1994) has offered this state- ment:"The Indian Health Service (IHS) recognizesthe value of traditionalbeliefs, ceremonies,and practices in the healing of body, mind,and spirit.The IHS encour- ages a climate of respectand acceptancein which traditionalbeliefs are honoredas a supportfor purposefulliving, and an integralcomponent of the healing process." Despite the explicit role of the sacredin religioushealing interventions available to American Indian patients, differences between biomedical and what we have called religious healing systems may be of less significancethan their sharedexis- tentialengagement of problemssuch as those we gloss as depression.

NOTES

Acknowledgments. We wish to thank the following Navajo Healing Project staff membersfor theircontributions to the work reportedhere: Mitzie Begay, Wilson Howard, Derek Milne, VictoriaBydone, ElizabethLewton, Nancy Maryboy,David Begay, Sharon Rose, and ElizabethIhler. Special thanksare due to Loma Rhodes for her careful reading and helpful comments on an earlierdraft of the article.This article was reviewed and ap- provedby the NavajoNation HealthResearch Review Boardon October12, 1999. Correspondencemay be addressedto the first authorat Departmentof Psychiatryand BehavioralSciences, University of Washington,Children's Hospital and Medical Center, CL-08, P.O. Box 5371, Seattle,WA 98105-0371. 1. "Axis IV is for reportingpsychosocial and environmentalproblems that may affect the diagnosis,treatment, and prognosisof a mentaldisorder (Axis I andII )" (AmericanPsy- chiatricAssociationAmerican Psychiatric Association 1994:29). Problemsare groupedinto a rangeof categories,including those associatedwith primarysupport group, social environ- ment, educational,vocational, economic, legal, and healthcare systems, and so on. Clini- cians and researchersrate net severity of psychosocial stressors as none, mild, moderate, severe, or catastrophic. DEPRESSIVE ILLNESS AND NAVAJO HEALING 593

2. Axis V is for reportingthe clinician's or researcher'sjudgment of the overall psy- chosocial and occupationalfunctioning of the individual.A score of ten representsgrave disability, with 30 representinggross impairment,50 serious impairment,70 mild impair- ment, and 90 or above minimalor no impairment. 3. Ourquestions included: a. Can you tell me what kinds of difficulties you were having that caused you to see a healer?How did you know you were ill? b. How do you understandor explain the cause of your illness/difficulties?Do you think there were emotionalfactors in these difficulties? c. Did other people in your family or communityknow you were sick/ill/having difficulties?What did they say? Whatdid they think was wrong with you? d. Did you see a physician, nurse, psychiatrist,mental health worker, substance abuse counselor, minister,road man, medicine man ... ? e. Would you feel comfortabletelling me about the healing ceremony that you had? f. How do you understandyour illness now thatyou have had a healingceremony/ prayermeeting ... ? g. How would your healerexplain your illness or difficulties? 4. These proportionsinclude patientsacross a wide age range.Although to ourknowl- edge comprehensivefigures on monolingualismand bilingualism are not availablefor the general populationof Navajos, it is safe to say that the majorityof monolingualEnglish speakersare underage 20 and the majorityof monolingualNavajo speakersare over 50. In our experience,it was not uncommonfor participantsin theirforties to choose Navajoas the languagefor at least a portionof theirinterview. 5. This is well above the lifetime prevalencefor mood disordersdiscerned in a large samplenon-patient epidemiological survey of U.S. householdsin the early 1980s (Robinset al. 1984). 6. Since two of the patients and two of the healers were monolingual or primary Navajo languagespeakers, we must explore the translationprocess in the ethnographicand SCID interviewsto discernthe specific patientand healersemantics. 7. In subsequentpublications, we will discuss the linguistic challenges posed by our interviews,including explicit comparisonof ethnographicand diagnosticinterviews.

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Acceptedforpublication August 26, 1999.