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Inuit Concepts of Mental Health and Illness: an Ethnographic Study

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Inuit Concepts of Mental Health and Illness: an Ethnographic Study Inuit Concepts of Mental Health and Illness: An Ethnographic Study Laùrence J. Kirmayer, MD, FRCPC Christopher'Fletcher, BES Ellen Corin, PhD Lucy Boothroyd, Msc Culture & Mental Health Research Unit Department of Psychiatry Sir Mortimer B. Davis—Jewish General Hospital 4333 Côte Ste-Catherine Road, Montréal, Québec H3T1E4 Phone: 514-340-8210/Fax: 514-340-7507 I Institut national de santé publique du Québec 4835, avenue Christophe-Colomb, bureau 200 Montréal (Québec) H2J3G8 Tél.: (514) 597-0606 Inuit Concepts of Mental Health and Illness: An Ethnographic Study Laiirence J. Kirmayer, MD, FRCPC I Christopher "Fletcher, BES Ellen Corin, PhD Lucy Boothroyd, Msc Culture & Mental Health Research Unit Department of Psychiatry Sir Mortimer B. Davis—Jewish General Hospital 4333 Côte Ste-Catherine Road, Montréal, Québec H3T1E4 Phone: 514-340-8210/Fax: 514-340-7507 I i i TABLE OF CONTENTS Acknowledgment 4 Summary 5 1. Introduction 9 1.1 Outline of Report 10 1.2 The Inuit of Nunavik 10 1.3 Psychiatric Epidemiology Among the Inuit 13 1.4 Traditional Concepts of Illness 17 1.5 Contemporary Concepts of Mental Health and Illness 17 2. Methods 21 2.1 Ethnographic Studies of the Meaning of Symptoms and Illness 21 2.2 Study Sites 22 2.3 Selection of Respondents & Sampling 22 2.4 Procedure for Ethnographic Interviews 25 2.5 Data Analysis 28 3. Symptoms, Signs and Behaviors of Mental Health and Illness 30 3.1 Initial Interviews—Behavioral Registers and Lexicon 30 3.2 General Concepts of Mental Illness 31 3.3 Hallucinations and Delusions 36 3.4 Interpersonal Violence 37 3.5 Suicide : 39 3.6 Social Withdrawal and Isolation 41 3.7 Depression 44 3.8 Anxiety 45 3.9 Mental Deficiency/Learning Disability 47 3.10 Seizures and Convulsions 48 3.11 Memory Lapses, Immobility and 'Running Wild' 48 3.12 Drug, Alcohol and Solvent Abuse ......^.....50 3.13 Demon Possession 52 3.14 Other Problems 57 3.15 Discussion 58 4. Ethnopsychology and Causes of Mental Illness 61 4.1 Role of Traditional Food in Well Being 61 4.2 Environmental Quality and Mental Health 63 4.3 Physical or Organic Causes of Mental Illness 64 4.4 Psychological or Emotional Causes of Mental Illness 65 4.5 Spirit Possession and Mental Illness » 69 4.5.1 Uuttullutaq possession 71 4.5.2 Uitsalik/Nuliatsalik 72 4.5.3 'Satanic' Possession 75 4.6 Impact of Culture Change on Child-Rearing and Mental Health 79 4.7 Discussion 83 5. Social Course & Treatment of Mental Illness 86 5.1 Response to the Mentally 111 86 5.2 The Value of Conversation for Mental Health 88 5.3 Views of Biomedicine and Psychiatry 92 5.4 Name-Soul and the Management of Grief 93 5:5 Discussion .. 97 6. Attitudes Toward Psychiatric Disorders 99 6.1 History of Inuit Responses to Deviant Behavior 99 6.2 Social Responses to Deviance 100 6.3 Measuring Attitudes Toward Mental Health and Illness 102 6.4 Method of Questionnaire Study of Attitudes 103 6.5 Results of Questionnaire Study of Attitudes 105 6.6 Discussion . Ill 7. Conclusion 114 Appendix A. Interview Protocol and Consent Form 120 Appendix B. Glossary of Mental Health Related Terms 124 Appendix C. Attitude Survey Questionnaire 132 Appendix D. 'Concerning Evil Spirits and Fasting' 134 References .r. : 137 TABLES Table 1-1. Psychosocial Comorbidity with Psychiatric Disorders 16 Table 2-1. Distribution of Occupations in the Sample 24 Table 3-1. Behavioral Registers 30 Table 6-1. Vignettes Used in Attitude Survey.. 104 Table 6-2. Sociodemographic Characteristics 106 Table 6-3. Descriptive Statistics for Social Distance Scale 107 Table 6-4. Factor Loadings of Social Distance Scale Items 107 Table 6-5. Descriptive Statistics for Questions 107 Table 6-6. Correlations of Sociodemographics and Attitude Scales 108 Table 6-7. Social Distance Scale by Vignette 109 Table 6-8. Effects of Vignettes on Social Distance Scale ..;... 110 Table 6-9. Multiple Regression Model of Determinants of Social Distance 110 Table 6-10. Effects of Vignettes on Recovery Scale ; Ill FIGURES Figure 1-1. Diagnoses of 100 Consecutive Inuit Psychiatric Consults 15 Figure 2-1. Distribution of Ethnographic Informants by Age Cohort 23 Figure 2-2. Distribution of Interview Informants by Years of Education 24 Figure 2-3. Distribution of Informants' Frequency of Church Attendance 25 Figure 3-1. Signs and Symptoms of Mental Health Problems 35 Figure 6-1. Social Distance Scale by Vignette 109 ACKNOWLEDGMENT This research project was supported by grants from the Kativik Regional Board of Health and Social Services and the Conseil québécois de la recherche sociale. We would like to thank our research assistants and interviewers, Melina Auerbach, Clara Aupaluk, Martha Aupaluk, Michel Elie, Annie Kenuayuak, Nuluki Putugu, Annie Sivuarapik, Robert Watt, and Kate Zimmerman. Dr. André Corriveau and the staff of Inuulitsivik Hospital made the study possible by helping with the many logistical problems. Jimmy Mark, Monica Nashak, Charlie Pinguartuk and Robert Watt translated interviews and transcriptions. Harry Okpik re-translated the Inuktitut lexicon of mental health related terms. Karen Beaulieu, Jennifer Fletcher and Consuelo Quesney assisted with transcription of English and French tapes. Data analysis was conducted by members of the Culture and Mental Health Research Unit of the Department of Psychiatry of the Sir Mortimer B. Davis- Jewish General Hospital. Suzanne Taillefer translated the report summary to French. Laura Freeman, Consuelo Quesney and Louise Veilleux ably assisted with proof reading of the text. This research unit is supported by a team grant from the FRSQ for an équipe prioritaire on "Culture and Mental Health." Christopher Fletcher was the recipient of two student bursaries through this FRSQ team grant program. Laurence Kirmayer is supported as a staff investigator by the Department of Psychiatry of the Jewish General Hospital. We are deeply grateful to all of the people at these institutions who have supported our work both materially and emotionally. Laurence J. Kirmayer Christopher Fletcher Ellen Corin Lucy Boothroyd Montréal October 1994 Inuit Concepts of Mental Health and Illness SUMMARY The concepts of mental health and illness of the Inuit of Nunavik (Northern Quebec) were studied through ethnographic interviews, participant observation and a questionnaire survey. The research involved the participation of the community in the selection of survey sites and the identification of appropnate problems for study. Three communities differing in their existing resources and average level of acculturation were studied. Three types of research interview were conducted, corresponding to distinct parts of the project: (1) problem identification interviews with Inuit health care and community workers identified the range of problems in the community and the usual terminology used to describe them, resulting in a list of specific registers of problematic behavior; (2) problem register interviews with key informants from the community identified the perceived prevalence of problems in the community and the typical signs and symptoms associated with each type of behavior or problem; (3) case history interviews with key informants reconstructed detailed accounts of cases1 with which they were personally familiar. Major findings of the study include: • There is no general term for mental health or illness in Inuktitut. When pressed, informants either used an English term ('mental health problem') or offered two terms with different connotations: Isumaluktuk and Isumaqangngituk. Isumaluktuk implies thinking too much while isumaqangngituk meant having no mind' or not thinking at all. • According to informants, the most prevalent mental health problems-were alcohol and drug abuse, family violence and abuse, and suicidal behavior. • Inuit tended to label behaviors or states of mind rather than individuals. This left open the possibility that someone who had an affliction or troublesome behavior could change and improve. • Most people were not very familiar with mental health problems. Although many had heard of demon possession, only a small number of cases were actually described. • Although some people who completed suicide were described as withdrawn, isolated, depressed, having heavy thoughts, low self-esteem or hating themselves prior to their suicide, in many cases their suicide came as a complete surprise even to close friends and relatives. 5 • Inuit recognized four broad types of causes of mental health problems: (1) physical and environmental; (2) psychological or emotional; (3) demon or spirit possession; and, (4) culture change and social disadvantage. In many cases, multiple causes were offered for the same problem. • The presence of hallucinations or bizarre behavior prompted people to think of mental illness or demon possession. • Violence, drug abuse and suicide were all commonly attributed to abuse and neglect in childhood or to ongoing family violence. • People tended to be very tolerant of others' unusual behavior. This may improve the integration and prognosis for people with psychiatric disorders. It may also, however, delay the recognition of depression, psychosis and suicidality. • Talking with others was widely recognized as a good way to prevent and/or resolve mental health problems. • Religious exorcism was viewed as an appropriate treatment in cases of demon possession by people who believed this was a cause of unusual behavior or illness. From the interviews and survey, a model of indigenous concepts of and attitudes toward mental health and illness was developed. A Inuktitut/English lexicon
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