The International Journal of Psychosocial Rehabilitation

Western and Indigenous Conceptualizations of

Self, Depression, and its Healing




 Dr. Tony B. Benning  MSc   MRCPsych   FRCP (C)

 Consultant psychiatrist

 Maple Ridge Mental Health Centre

Benning TB. 
(2013).Western and Indigenous Conceptualizations of Self, Depression, and its
International Journal of Psychosocial Rehabilitation.  Vol 17(2)  129-137

Dr. Tony B. Benning    MSc   MRCPsych   FRCP (C)
 Consultant psychiatrist
 Maple Ridge Mental Health Centre
 Suite 500
 22470 Dewdney Trunk Road
 Maple Ridge, BC,
 Canada       V2X 5Z6

Taking a comparative, cross-cultural perspective, this paper examines indigenous and western conceptualizations of depression and its healing, in relation to Indigenous and Western concepts of self and selfhood. What emerges from the review of relevant literature from anthropology, cultural psychiatry as well as cultural psychology is that the concept of an extended self, which is seemingly common to many Indigenous cultures, is reflected in the presentation of depression and in the way in which its healing is conceptualized in these cultures. Similarly, Western conceptualizations of depression and its treatments reflect Western concepts of the self. The implications for Western mental health researchers and clinicians working with individuals, who identify with Indigenous world views, are discussed.

Key words:  cross cultural aspects of depression, Indigenous and Western self-concept, Culturally congruent therapy, Etic and emic concepts of depression

The purpose of this paper is to examine the concept of depression from a cross cultural perspective, by taking a comparative approach to Western and Indigenous cultures. A particular focus is to show how Western and Indigenous conceptualizations of depression, as well as its healing, are inextricably linked and intertwined with their respective concepts of self and selfhood. Such an understanding of the manner in which culturally relevant notions of self under pin  notions of health and illness is of particular importance for Western mental health clinicians practising in a setting where their patients identify with Indigenous worldviews. This paper draws on anthropological literature as well as the literature of cultural psychiatry and cultural psychology. Given the space constraints, it is necessary to state at the outset that this paper does not aim to provide a comprehensive review of the literature on this potentially vast subject but merely to highlight major themes as a possible basis for more detailed future exploration. This paper also acknowledges from the outset that terms such as ‘Western’ and ‘Indigenous’ are rather oversimplified and  that they are themselves, rather dichotomizing and essentializing-and that for these and other reasons, are imperfect. Yet, this paper proceeds on the basis that these terms do have value in orientating a discussion.

Indigenous Conceptualization of the Self Identity is very much an inalienable feature of an inter-dependant world. Personal identity
is holistically defined in terms of kinship, ritual, spiritual relationships, and responsibilities, all of which are inseparable from each other and the land, that is, nature
itself.  (Morgan, Slade, & Morgan, 1997, p.598).

The above quote suggests that the Indigenous self can justifiably be characterised as an ‘extended’ self, and one of the reasons why this is the case, is the importance accorded to a sense of family or the collective. As Yeo (2003) states, the aboriginal sense of self is derived from kinship ties (including ancestry and communal bonds) and individual attributes are not as important as are kinship bonds and country etc.  In much the same vein, Morgan et al. (1997) conceptualize the Indigenous self as an extended, plural self-emphasising too, the strong bonds of social inter-dependence. Of significance too, for the understanding and conceptualizing of the Indigenous sense of self, is the observation, reported by Mills and Slobodin (1994) that Indigenous conceptualizations of the self, endorse notions of past lives and reincarnation – and this implies a very different understanding of the relationship between the past, present and future than is familiar to the Western mind. The element that is central to the Indigenous self-concept is that of connectedness. The self is constituted by and related to other people, the land, and animals- a characteristic that Kirmayer (2010) describes as ecocentric.
 Indigenous Conceptualizations of Depression and its Healing
As Jilek-All (1976) notes, supernatural factors are often considered to be of aetiological relevance in causing and explaining illness by Indigenous people. This suggests, I would argue, the fact that an extended concept of self is reflected in theories or ideas of causation. The word supernatural itself has a negative connotation in the West and its use , as an etic construct, runs the risk of Westerners imposing meaning (from an outsider’s perspective) in a way that deflects from a true understanding of the Indigenous person’s subjective experience. What in Western terms might be called supernatural and worthy of  special signification, refers to concepts which are considered as merely part of the extended self-concept in the Indigenous worldview-not requiring any special linguistic or conceptual distinction.

Okello and Ekblad (2006) show that  the choice of  treatments  that are considered to be appropriate to severe depression amongst the Baganda people in Uganda are understood  in the light of  the putative causes of the depression in that cultural group. There is a clear and direct relationship between the assumed cause and the assumed most appropriate treatment in that the word to describe depression (eByekika), also conveys that the suffering individual has forgotten to honour their ancestors, remedy for which is to undertake a ceremony in which a connection to the ancestors can be re-established. 

In  O’Neill’s (1992) research with the flathead Amerindians, depression did present with classical symptoms such as sleep and appetite disturbance, but the  ‘symptom’ that was considered by the community to be indicative of severe depression was the loss of feelings of compassion for another’s’ wellbeing. O’Neill’s narrative research also showed that depression was also considered to have positive meaning for it equipped the sufferer to have an appreciation for the suffering of others.

In Jilek’s (1982) research on the Coast Salish of British Columbia, one of the key therapeutic factors in the treatment of depression was held to be the reinforcement of a sense of collective identity, community spirit, and sense of cohesion in the winter ceremonials, and Moylan (2009), in her research on indigenous conceptualizations of depression articulates the role in healing, that a re-connection with one’s land or country has. This is conveyed in the following quote from an aboriginal health worker:

           " I think the first part of any healing process is to know who you are and where you come 
            from and to further that healing, you need to go back to that place once you find where
            you belong. You go because part of that healing would be that spiritual connection to the
            land. And it is not just the land, it is also the water, or there are other things that are part
            of where you come from that gives you back some sense of belonging (Moylan, 2009, 

The relevance of the role of disconnectedness in a qualitative study by Brown, Scales, Beever, Rickards, Rowley, and O’Dea (2012). This study of Australian Aboriginals revealed a lack of an equivalent word for depression but as is the case with the Ugandan concept of eByekika (which conveys a judgement about the cause of illness), the Australian Aboriginal term Watjilpa, which is loosely translated as homesickness, strongly alludes to a cause (in this case, a disconnectedness from home and family) in which there is an implicit strategy for healing (in the form of reconnection with home and family).  Any form of disconnectedness or displacement is thought to contribute to a weakening of the spirit (kurunpa) which is considered both as a cause and consequence of depressive state. The indigenous healer (Ngunkari tjuta) is able to diagnose, manipulate and heal this.  An interesting finding from Brown et al.’s study is an absence of the articulation of hopelessness and perceptions of self-deficit in their participants’ narratives-and one of the interpretations of this is that the Australian indigenous sense of self is defined by and grounded within the wellbeing of others. Also suggestive of this notion of self was that the focus of one’s aspirations was never oneself but others.  The observation that culture may influence symptom profile was also made in Sethi, Nathawat, and Gupta’s (1973) paper, reporting a study of depression in India, in which it was found that the theme of guilt was not very commonly seen amongst Indian depressives. It was speculated that this is due to the relative lack of emphasis on guilt in the  Hindu religious belief system as well as by the fact the Indian sense of self locates  depression not as arising  out of the individual but as arising from an extended self-one that is intimately and  metaphysical connected  to others and to  the universe.  A prominent theme then, in Indigenous conceptualizations of depression, is that of recovering some previously broken connection-be it to ancestors or to nature or to land or country. A reflection of this is the fact that, in healing rituals and ceremonies in many indigenous cultures, it is quite typical for the entire family to be present. This was Peters’ (2007) observation in his ethnographic study of shamanic healing rituals amongst the Tamang people of Nepal,  and the Nigerian psychiatrist Thomas Lambo, in developing therapeutic communities appropriate to the worldview on Nigerians, acknowledged the need to make adequate provisions for the families to stay throughout the period of treatment (Oyebode, 2004).

Western Conceptualization of the Self
The Indigenous self, as has been demonstrated above, may be justifiably conceptualized as an extended or connected self. This contrasts with the Western self which is characterised as placing stress on values such as self-efficacy and individuality  (Kirmayer, 1989; Kirmayer , Brass, & Tait, 2000) and competitiveness, assertiveness and self-assuredness (Kirmayer et al., 2000).  Kitayama and Markus (1994) characterize the Western self as entities that are independent and self- contained, adding that the much objectified view of self, which separates the individual from the context, is rooted in the Western philosophical tradition and especially to the influence of Cartesianism. Shweder and Bourne (1984) noted this absence of reference to context, when Americans were asked to comment on their personalities. Markus and Kitayama (1991), in elaborating on their notion of the independent construal of the self, prominent in the West, list alternative terms which they consider to be reflecting similar ideas: individualistic, egocentric, ideo-centric, autonomous, and self-contained. Johnson (1985), in his description of the evolution of individualism in the West, emphasises the fact that value is accorded to verbal disclosure as well as to the ethos of self-actualization.

Western Conceptualizations of Depression and its Healing
Paykel (2008), in overviewing the history of the concept of depression, views modern concepts of depression, with its emphasis on psychological feelings, as peculiarly Western. This, the ‘compartmentalized’ conceptualization of depression in  psychologized  terms arguably reflects a Western, Cartesian distinction between psyche and soma  which introduces a cleavage in the self that is not seen in Indigenous cultures-as a later part of this essay will go on to show. According to Dowrick, Peveler, Katona, and Lloyd (2005), this undue emphasis on psychological symptoms of depression on standard Western medical history taking and diagnostic checklists often overlooks physical or somatic symptoms.

Theories of depression reflect Western concepts of self. This is seen in  Freudian theory’s over emphasis on personal or biographical factors in the causation of  psychopathology (Grof , 2012) and it is also the case with other very prominent and influential theories such as the theory of learned helplessness (Seligman, 1975). The bias here is towards a Western style sense of self which places emphasis on autonomy , individuality and self- interest and I would argue that this can be appreciated and understood in the context of Neki’s ( 1976) assertion that Western psychiatry and psychotherapy reproduce and reflect  such ‘culture bound’ Western values such as  independence and  individual freedom (as cited in Fabrega, 2009,  p.650) , Joseph Gone (2009) states that “psychology as an academic and professional discipline is grounded in Western ways of knowing” ( p.426 ) and  Smye and Mussell (2001) bring attention to the individualistic ethos  of Western psychiatry. The overwhelming emphasis in Western approaches to the treatment of depression is on individual treatments- including cognitive behaviour therapy, interpersonal therapy, psychoanalytical based therapies (Moylan, 2009) but as Corsini, Wedding, and Dumont (2000) state, these are firmly rooted and embedded in a Western culture that is primarily individualistic and secular. Robertson (2010) argues that Cognitive behaviour therapy reflects the values of stoicism in championing the role of self -mastery and self-discipline in overcoming of self-defeating thoughts and distressing emotions. Kantrowitz and Ballou (1992) argue from a feminist perspective, that whilst cognitive behaviour therapy is often assumed to be universally applicable, and value-free, this is far from the case. In this respect, I am in agreement both  with Hays and Iwamasa’s (2006) contention that CBT prizes the values of rationality and scientific method as well as the observation of   Kantrowitz and Ballou (1992) that CBT tends to reinforce a  worldview that is Euro-American, and masculine, and  that it tends to undervalue spiritually orientated worldviews and  cooperative interactive styles. Petchkovsky’s (2000) elegant empirical demonstration of a very externalised locus of thought attribution among central Australian Aboriginals seems to conflict with the ethos of Cognitive behaviour therapy which promotes the values of autonomy in its therapeutic aim of internalizing the locus of control (with respect to one’s thoughts and behaviours) to the individual and in encouraging the individuals’ mastery over thoughts and behaviours. For the Aboriginals studied in Petchkovsky’s research, ownership of thought was not attributed to the person but externalized to ‘the dreaming’ (tjukurpa). This concept, again, demonstrates how Western ideas (and ideals) of agency (reflected in Western modes of therapy) are not congruent with notions of agency found in the Indigenous extended self.

Whereas Western psychotherapy values introspection, verbalization and working through, Kennedy (1967) commented on the conspicuous absence of these features in Nubian Zar healing ceremonies in Egypt. Yet, it is worth stressing, firstly, that some authors have determined that therapeutic modalities, such as cognitive behaviour therapy, may be successfully adapted to the needs of Indigenous communities (Jackson, Schmutzer, Wenzel, & Tyler, 2006) and secondly, that that not all Western modalities of psychotherapy have been considered to be incongruent or incompatible with Indigenous values. A case in point is certain types of group therapy. In this respect, Jilek (1982), in describing aspects of shamanic healing amongst the Coast Salish in B.C. in Canada, argues that therapeutic components of group therapy, namely acceptance, stimulation, support, protection are very much operant in some aspects of the healing ceremonials. Peters (2007),  in his explication of  those aspects of Western psychotherapeutic theory and practice that are relevant  to shamanic healing in Nepal, identifies  therapeutic concepts such as catharsis, naming an illness, symbolic communication and identification with others who have a similar illness experience.     

As Paykel (2008) states, referring particularly to African cultures, a lack of awareness of another culture’s languages and metaphors to describe depression have resulted in an under-detection and therefore underestimation of the prevalence of depression in these settings. This is a point also made by Patel, Abas, Broadhead, Todd, and Reeler (2001), who, based on fifteen years of epidemiological studies of depression in Zimbabwe, conclude that the most common presenting symptoms of what in the West is called ‘depression’ are fatigue and headaches, adding that this tendency for Zimbabweans to express the equivalent of depression in somatic forms has resulted in an underestimation of its prevalence. A diagnosis of depression cannot depend on the complaint by a Shona speaking Zimbabwean person that he or she is feeling ‘depressed’ as no such word exists in the Shona language. The somatic nature of the presentation of depression amongst indigenous populations (as opposed to cognitive manifestations) was also demonstrated by Yusim et al. (2010) in a Latin American setting. Again, as has been previously stated in this paper, the existence of distinct psychological language in the West may itself reflect Western Cartesian commitments and it is on the basis of an awareness of such issues that Patel (1996), in an editorial in the British journal The Lancet questioned the very use of the term ‘mental’ in his work specialising in mental health in a primary care mental health setting in Africa. Western mental health clinicians should also keep in mind the fact that an indigenous person’s extended self-concept might be their greatest resource in terms of providing the ontological container within which to cope with their of their distress and explain suffering-and A Western clinician should be careful not to automatically disregard (or pathologize) this even though their  frame of reference may predispose them to construing it  as an example of fatalism or as an expression of an external locus of control (Bhui, King, Dein, & O’Connor, 2008).

Hodge, Limb, and Cross (2009) call, with particular relevance to contemporary Indigenous (Amerindian) populations, for a greater appreciation amongst clinicians of the incongruence between several Western therapeutic approaches and the worldviews of Indigenous people. Hodge et al. call for greater provision, in these communities, of culturally appropriate therapies that acknowledge the holistic paradigm of health and healing that honours and seeks to restore balance between the areas of mind, body, spirit and context.  These authors also call for the rehabilitation of specific therapeutic approaches such as story telling/remembering and ceremonies-all approaches that enhance relatedness, to strengthen and enhance social bonds.

Gone (2008) argues that given the importance to Aboriginal peoples of space and land, consideration should be ways in which these issues could be incorporated in to the delivery of mental health care.

Arguably, another manner in which a Western, rational bias is reflected in the dominant treatment modalities of depression, is in the dominance of talk therapies at the expense of body oriented therapies. Even though there is increasing evidence for the efficacy of body orientated therapies in depression as well as in other psychiatric disorders, such research findings have made very little impact in terms of mainstream treatments (Rohricht & Priebe, 2006; Shannahoff-Khalsa, 2008).

Conclusions and Discussion

Western concepts of self can be said to be ‘nuclear’ in that values such as individualism, autonomy, assertiveness and independence are prized. This contrasts with the values of inter-dependence, harmony, cooperation and collectivism-which are relatively prized in Indigenous cultures. Not surprisingly, such understandings of the nature of self, underpin concepts of mental illness, including depression and its treatments. Recent studies on Indigenous conceptualizations of depression in Uganda and Aboriginal Australia, (note the reference earlier in this paper to the concepts , respectively of  eByekika  and  Watjilpa) suggest that some sort of putative theory of  causality is often conveyed in that word which best approximates to the western term depression (with the putative cause being some sort of rupture or severance between the person and an aspect of their extended self; be this their ancestors or homeland etc.). Such ideas about cause have immediate and obvious implications for healing-with some sort of effort towards reversing the disconnection invariably being prescribed. The degree to which Western concepts of depression are couched  in, and the degree to which they are reflective of Western notions of self and selfhood, often remains understated. In other words, there is an assumption of universality. This can be understood and contextualized against a background tendency of Western psychiatry to assume that it has universal relevance and therefore relevance for indigenous cultures and in patients who endorse or identify with non- Western worldviews.  Such an assumption- of the suitability and relevance of its own constructs and treatments for Indigenous people- amounts, arguably, to a colonial attitude. My further contention here is that there is yet another way in which divergent self-concepts play out at in the encounter between the Western mental health clinician and the Indigenous world in that a Western clinician may underestimate the damage to the Indigenous self that has been brought about by his or her separation from context. Unless there is greater awareness of such factors, the Western mental health clinician will be inclined to underestimate the pathogenic potential inherent in the rupture of an Indigenous person from the context that forms their lived world and which underpins their sense of self. When such factors are examined, then issues of colonial trauma, of the separation of peoples’ from their land come to be appreciated more.
Western psychiatrists should be cognizant of the culture specific nature of psychiatry’s own epistemic and ontological commitments, particularly when working with Indigenous people. The Western mental health professional, when assessing and treating a patient from an Indigenous background should take into consideration, the patient’s extended sense of self, which, as has been shown, is likely to heavily underpin and influence indigenous concepts of depression and likely to influence the indigenous person’s idioms of  distress,  symptom profile, and  treatment choices. The Western clinician’s assumption that depression will present according to a universal idiom risks under-detection of the extent of morbidity amongst Indigenous people. It is also evident that despite the fact that Indigenous mental health is attracting increasing interest amongst Western researchers and clinicians, the area still remains vastly under-researched. The last word concerns the difficult question of the universal applicability of Western categories of psychiatric disorder-including depression. Most of the studies reviewed do not engage with this thorny question in great detail yet it is an important one. The statement: depression in indigenous cultures presents with somatic symptoms arguably assumes a universalism of the concept of depression which, after all, is Western. This Western concept of depression is assumed then to be some sort of valid category, or reference point. 

There is an outstanding and unresolved question about how to determine if any given Indigenous presentation of distress (that  resembles depression to a Westerner) is justifiably conceptualized as a form of depression or whether it is better thought of as belonging to a separate category. A review of the anthropological and psychiatric literature concerning two so called ‘folk psychiatric disorders’ or ‘culture bound syndromes’: ataque de nervios and susto (both common in Latin America) shows that learned opinion on this question has varied- with some researchers over emphasising the distinctiveness of these syndromes on the one hand and others, overstating their proximity to western concepts of anxiety and depression (Guarnaccia et al., 2007). This suggests that there is an ongoing need to address an as yet unresolved issue concerning the cross-cultural validity of Western concepts of psychopathology. My own view is that in the hitherto cross cultural research on psychopathology, there has been an excessive reliance on Western psychiatric concepts-as frames of reference, and this has prevented  Western researchers from engaging with and honouring the emic categories of experience  of  different, non-Western cultures.


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