Keywords

Concern about culture, within the psychopathology field, is not a new task in contemporary research (Kirmayer, 2006a, 2006b; López & Guarnaccia, 2000). Historically, research in this area became necessary, to the extent that globalization processes began to intensify. The motivations that supported these investigations seemed to revolve around the following question: how do we understand the disease process (or better yet: how to identify if this process is occurring) in others, with life experiences so different from ours, contemplating a different cultural context? This question has been studied in different ways, pointing to several paths of understanding.

One of the problematic routes of this issue focuses on the field of phenomenology. Phenomenology is understood herein as the development of a component that is based on the philosophical perspective created by Husserl, and continued by authors such as Merleau-Ponty, Heidegger, and Sartre, among others. Within the clinic, psychiatrists such as Binswanger, Minkowski, and Tatossian, to name a few, have appropriated philosophical phenomenology as a means of inspiration to build a clinical perspective and a proposal for psychopathology (Moreira, 2009; Tatossian, Moreira, Chamond, & Collectif, 2016). Thus, the ballast of phenomenology extends and enables discussions, not only in the field of philosophy, but also in terms of the clinic and psychopathology, which are the focus of this chapter.

Increasingly, researchers (Csordas, 1990, 1993, 2008; Felder & Robbins, 2011; Sam & Moreira, 2012; Telles & Moreira, 2014) have proposed to discuss the issue of cultural psychopathology from this perspective. Among the many phenomenologists that could be remembered in this endeavor, we cite herein the phenomenology of Maurice Merleau-Ponty, French philosopher, who developed his works through constant reflections on the relationship between man and the world, inevitably passing through the issue of culture.

Still with regard to the discussions influenced by phenomenology, now in the clinical context, we emphasize the movement of phenomenological psychopathology that, from 1920, undertakes a look at psychopathology which focuses on lived experience and its meanings. Representative of contemporary phenomenological psychopathology, Arthur Tatossian, a French psychiatrist of Armenian origin, contributed significantly to discussions involving culture and psychopathology from a phenomenological perspective. He recognizes the important role of culture in disease processes and the fecundity of a phenomenological look of culture in psychopathology—the axis of this chapter.

This paper aims to discuss the relationship between psychopathology and culture through the lenses of philosophical phenomenology, by Maurice Merleau-Ponty, and clinical phenomenology, by Arthur Tatossian. Therefore, it is divided into three parts, as follows: (1) a brief presentation of the phenomenology of Merleau-Ponty, focusing on his discussions of man, the world, and culture; (2) an introduction to the phenomenological psychopathology of Tatossian, especially regarding his developments dedicated to the relationship between culture and illness; (3) a brief discussion of case studies in cultural psychopathology, along with a critical reflection on how to think about the contribution of these two phenomenologists to current research in the area.

The Philosophical Phenomenology of Merleau-Ponty and the Ambiguity of the Relationship Between Nature and Culture

The phenomenology of Merleau-Ponty is marked by an ambiguous perspective, proposing a radical overcoming of dualities such as indoor–outdoor, subjectivism–objectivism, and natural–cultural (Matthews, 2010). This question is important for us to understand the concept of man in Merleau-Ponty, as well as the conceptions of psychopathology and culture. Now, if it were not possible to understand what is exclusively natural or cultural, we begin from the idea that thinking man, and his disease processes, necessarily imply that we contemplate cultural issues.

In this sense, to investigate and intervene in the field of psychopathology, under a phenomenological bias, requires the understanding that biological and cultural issues are intertwined with each other. This discussion is not new in the field of cultural psychopathology,Footnote 1 but it is here that it becomes necessary to define what is the specific design of phenomenology—philosophical and clinical—in this harvest.

Regarding the specificity of the Merleau-Ponty discussions, the philosopher, in The Phenomenology of Perception (1945/2000), presents the notion of man as a situation constructed ​​mutually with a cultural world. Thus, the importance of understanding man beyond a physical and natural order is highlighted. In The primacy of perception and its philosophical consequences, Merleau-Ponty (1947/2007) writes that “but in reality the ideas which we give our assent are valuable only for a period of our lives or for a period in the history of culture” (p. 89). This quote points to the understanding that man in his relationship with culture implies in assuming that this is a dynamic operation. In the field of psychopathology, what is considered a disease today may be a part of a common organization mode tomorrow, and vice versa. In other words, in addition to understanding man from his physical character nuances, both natural and cultural, it is necessary to understand that the way these nuances interact are not given statically, but in mutual relationship with political, historical, social, and ideological issues, among others (Moreira & Sloan, 2002), which puts us in a constant state of questioning, with respect to the features previously attributed to illness modes, without considering this dynamism.

This perspective is in line with recent discussions about how culture is contemplated in diagnostic manuals, which mostly comprise psychopathology as a result of a number of factors that would not be within what is considered normal. However, these normal parameters are graded in a Western culture, among other aspects that could come to mind. In other words, that is, one is considered ill that is not within the parameters of normality of a given society, and not from the lived experience of the patient. It is in this sense that the Tatossian discussions contribute a great deal, as we shall see in the following pages.

Merleau-Ponty (1969/2010) discusses the impossibility of understanding culture without considering history, speech, and gestures. One might think that there might be two equal gestures, for example, by ignoring the condition in which they occur, since history, culture, and language are interconnected. In an ambiguous perspective, the expression is never purely the same, but not purely different because

With regard to this particular gesture that is the word, the solution consists in recognizing that in the dialogue experience, the word of the others touches our meanings, and our word, as attesting the answers, touches their meanings, invades each other, since we belong to the same cultural world and the same language, and my acts of expression and those of the other emerge from the same institution. (Merleau-Ponty, 1969/2010, p. 1533)

It is in this intersubjective aspect that, despite the differences between our experience and that of the others—mostly on a cultural level—a common understanding is possible. In other words, language is closely related to culture, which allows for different understandings of human expression, but also the existence of an institution, as a common background, that enables the structural understanding of a certain experience, which is described. The Merleau-Ponty notion of institution does not reflect a static character but is characterized as a movement, action, capacity for the new (Chauí, n.d.). It is in this context that it is appropriate to think of expression and culture, in the phenomenology of Merleau-Ponty, as belonging to the same soil, but that is dynamic, always in motion. Each person may have different nuances, even with respect to the same common base.

In this context, the description of symptoms or experiences reported by the patient will be related to their lived experience and, therefore, words and gestures that are able for him/her to use at that time will be in fact used. However, since there is an intersubjective relationship, it is possible for the caregiver (whether a doctor, psychologist, etc.) to have an understanding of what is being said, because there is a common background that allows for this dialogue to happen. This is observable, working in several different inter-human relations.

In the words of Merleau-Ponty (2001/2006), “culture can be defined as the set of attitudes tacitly recommended by society or by different groups in which we live, attitudes that are inscribed in the material order of our civilization” (Merleau-Ponty, 2001/2006, p. 377). This quote is a rare moment in which Merleau-Ponty, throughout his works, directly defines the concept of culture. Although we realize the conceptual definition, we can also read the need to understand it in motion, linked to multiple contours (Moreira, 2009), such as social and personal factors, among others. In addition, in the same work, Merleau-Ponty says that “between the psychic life and the collective or social life there is a mediation, a means: it is culture” (Merleau-Ponty, 2001/2006, p. 378). We can understand the notion of culture while allowing for the ambiguous relationship between man and world, psychic and social life, inside and outside.

Merleau-Ponty (1956/2000) considers geographical, social, political, and economic conditions in relation to culture. He questions the possibility of considering autonomy, for example. The phenomenologist regains his sense of engagement and considers that we have a certain autonomy, since we conduct ourselves ambiguously in the making of the world and, therefore, with regard to the other and to culture. This engagement perspective differs from the notion of man as totally autonomous, which would conduct his/her decisions based only on him/herself, without considering the weight of culture and the other in his/her choices.

These discussions do not stop us from thinking about the promotion of autonomy; when we refer to mental health, however, a critical eye is needed, through the concept of engagement. Merleau-Ponty treats the way we situate ourselves in the world and problematizes that we are nothing but ‘can-bes’, conceptualizing the notion of engagement: “A sane conception of engagement seems to be one in which autonomy is not separate from relationships with others” (Merleau-Ponty, 1956/2000, p. 189).

In this perspective, we can realize the lack of pure autonomy or freedom, since choices are always tied to culture and to others with whom we live (Moreira & Telles, 2016). It is in this sense that we can think with a more critical look at cultural psychopathology.

We remember that Merleau-Ponty emphasizes the importance of understanding man in the intertwining of culture—nature, stating that:

The distinction of the two plans (natural and cultural) is, in fact abstract: everything is cultural in us (our Lebenswelt is ’subjective’) (our perception is cultural-historical) and everything is natural in us (even the cultural rests on the polymorphism of the wild Being) (Merleau-Ponty, 1964/2007, p. 229).

Here, Merleau-Ponty (1964/2007) explains that only ambiguously can we understand the relationship between man and culture, where both are mutually constituted. Thinking the natural is to think of what is culturally constituted and vice versa, and only then can we understand the notion of culture in Merleau-Ponty (Weiss, 2008). The Merleau-Ponty phenomenology allows us to contemplate, beyond the ambiguous interweaving of nature and culture, the constitution of man and the contingencies that surround him, since he is always in a conditioned freedom incarnate in situation. The subject exists only in his/her mutual constitution with each other and with the world, structured in language, on a culturally inherited basis. Nature and culture, man and the world, are ambiguous relationships, situated bodily, continuously expressed in an always conditioned and engaged freedom.

But after all, what does it mean when we refer to the field of cultural psychopathology? In short, these discussions seem to point to the understanding that not only continuing the development of research that emphasizes the links between culture and nature in the field of psychopathology that phenomenology rescues the understanding that this relationship is constitutive of man and is also understood ambiguously, making it impossible to think of nature and culture separately, since it also requires a committed way of thinking about the issue of autonomy.

Phenomenological Psychopathology and Culture: The Contribution of the Clinical Phenomenology of Tatossian

The theme of culture, in its relationship to psychopathology, can be considered a central theme in the clinical phenomenology of Arthur Tatossian. With four specific texts on the subject and a constant reference to the culture theme in other texts on phenomenological psychopathology, Tatossian undertakes a critical perspective that finds in phenomenology a fruitful source, able to avoid the constant determinisms, dichotomies, and excessive oversimplification that the discussion about culture in psychopathology assumes constantly. Culture cannot be limited to one way of relativizing the notions of normal and pathological and justifying the development of psychiatry for each culture, because it is, in itself, able to provide clues for the understanding of the different ways of illness, necessarily beholding the world in which it is inserted. So, considering culture does not mean either the rejection of the consideration of subjectivity or its restriction, but does imply in thinking of it in its interweaving with the culture in which we operate.

Tatossian (2001a, 2001b) considers that, since the eighteenth century, the relationship between psychiatry and culture is confrontational and of opposition, defending the approach to this issue in its practical and theoretical character. In practice, it is urgent that the patient’s understanding imply a “cultural neutrality,” taking culture as part of his/her experience, and also that he/she consider the subcultures within the same culture, an idea supported by other contemporary authors (Kirmayer, Rousseau, Jarvis, & Guzder, 2008). In theory, he differentiates classical transcultural psychiatry, where there is the prevailing idea that psychiatric nosologies are universal and culture would be an external modifier from recent transcultural psychiatry, which would threaten the validity of research conducted with a more classical approach. Tatossian alerts us to the risk of cultural relativism in psychiatry, in general, and recognizes the need to seek the authentic psychopathological experience that reaches both the singular and the universal, by recognizing the mutual constitution between man and the world (Bloc & Moreira, 2016).

Therefore, it is necessary to go beyond the symptom, aiming at the phenomenon as a global way of being of the subject that necessarily includes the meanings of behaviors and lived experience (Tatossian, 1986). Thus, the direction of the symptom from the phenomenon is searched for, in that the symptom of what is the index of that which is not shown, that is hidden—the phenomenon. Thus, phenomenology aims precisely to reveal this phenomenon, which is also cultural. To think based only on symptoms would consider only what is observable, reducing the psychiatric clinic to facts. However, to consider the lived experience and the understanding of psychopathology, as a phenomenon, implies contemplating the cultural horizon, which is a constituent of the meaning of lived experience (Tatossian, 1981, 2001a, 2001b).

When positioning culture as constitutive of the subject, Tatossian recognizes the importance of defining what would be normal or pathological. This is about going beyond the deviation concept, since a “behavior is not pathological by its low frequency or social maladjustment, but its significance and, more precisely, its individual significance, in other words, more by living experience than structure” (Tatossian, 1981, p. 341). Thus, he claims “the only acceptable pathological definition is undoubtedly that of Blankenburg, who argues that a behavior or experience are pathological when the-subject-cannot-present this behavior, or cannot-submit-to-this-experience” (Tatossian, 2001b, p. 144). That is, it is about understanding a psychopathological process when there is a stiffening in the relationship between man and the world, where there is only one way of being in the world. This definition includes cultural aspects, because it is not a moral or normalizing concept, in that psychopathology would be seen as something out of the rule, disregarding cultural issues in this pattern, and has great emphasis on lived experience as a possibility and movement that, in this case, would be stagnant and restricted (Bloc & Moreira, 2016). This bias has as axis in the issue of freedom to consider the disease as the inability to make choices or even the consideration that such experience is the only possibility of the subject, characterizing, thus, a lived experience as psychopathological.

The distancing of the symptom as a priority and superficial parameter, far from what is considered more important, the phenomenon, is seen by Tatossian as an initial step toward what he calls a psychiatry and psychopathology metaculture. This is a hermeneutic movement that may have as basis, among other possibilities, phenomenology. With an eminently phenomenological orientation, Tatossian (1994) recognizes and even emphasizes the potential of phenomenology to the understanding of culture, conceiving of it as a method that, as such, “forbids the separation of the subject and the object, the individual and the world, and, more specifically, the human world. The phenomenological lived experience inseparably connects external behavior and meaning” (Tatossian, 1981, p. 342). In addition, he further states that the “analyses of the lived time and space, corporeality and the world, in the phenomenological sense, are always implicitly cultural analyses, because culture is, a priori, present and because subjectivity is always intersubjectivity and historicity, or, in other words, culturality” (p. 342).

Tatossian (1981, 1994) uses the term culturality to emphasize this rooting and traversal of man, by culture, in its historical immersion. This is a culturality that constitutes us and at the same time we also contribute to its institution. Furthermore, we understand that this term seeks to establish a movement in the understanding of culture that should not be seen as static, but as part of human existence and, as such, is always in (re)construction.

It can be said that to phenomenologically understand culture means, for Tatossian, to incorporate the description and analysis of the Lebenswelt (world lived or the world of life) in its everyday dimension, as lived culture (Bloc & Moreira, 2016). In other words, to seek “to understand the human being in its original sociality and its mandatory culturality” (Tatossian, 1981, p. 343), which would be the condition for a metacultural psychiatry. It is common to find, in his writings, the emphasis on the need for constant contact with the subject and his psychopathology, stepping into his lived world and seeking to approach their experience as much as possible; unthinkable immersion without the consideration of culture as constitutive, of both the clinical itself and the patient, who lives the sickening in such a manner.

With an ambiguous cultural lens in psychopathology (Bloc & Moreira, 2016), Tatossian denotes the interlacing, in the same phenomenon, of biological and cultural aspects. He recognizes the existence of a similar experience, even if patients are part of different cultures. It is a common experience, which is essential, for example, in the categorization of certain psychopathology frames. However, he also identifies that, with cultural variations, forms of expression and their meanings are potentially variable according to culture, and this aspect is also of fundamental importance. So, one can observe an ambiguous understanding toward both conceiving an intersubjective dimension traversed by a lived culturality and in developing a psychopathology model able to “escape” the cultural influence, presenting in its common dimension as a phenomenon present in different cultures, which could also be seen above, in the philosophical phenomenology of Merleau-Ponty.

By proposing, under a phenomenological bias, the understanding of many psychopathological conditions such as, for example, schizophrenia and depression, Tatossian seeks to return to experience, focusing on the possibility of these experiences. A discussion about the time lived in depression, for example, seeks to understand how the changes of the lived time can create conditions for a stagnant time experience. This lens seeks to go beyond the cultural dimension, considering that there is a way of being depressed, which is common to patients who live this experience. However, culture will always be taken into account, inasmuch as the insertion of the subject in the world also passes through the constitution ways and, above all, the meaning of the experiences.

This understanding makes us emphasize the importance of cross-cultural studies. On the one hand, an experience of illness, as in the cited case of depression, has common points that allow us to name it as such. But, on the other, recognition of the different meanings produced is essential, according to the culture where it is inserted, in addition to the possible impact of culture itself in the production of suffering and its consequent illness. It is important to also note that contemporary tools, such as the internet, have profoundly changed the contact modes and access to different aspects that were unique, and even characteristic, of certain cultures.

Ambiguity, a common dimension of the phenomenology of Merleau-Ponty and of the phenomenological psychopathology of Tatossian, is an indispensable mechanism to break the usual dichotomies when we enter the field of psychopathology. Individual and society, nature and culture, cannot be classified as opposite poles. It is about conceiving of our rootedness in the world and the illness modes of a subject, with its particular aspects, but which are marked by their worldliness, by their culturality, as Tatossian entails.

Current and Future Prospects of Cultural Psychopathology from the Phenomenology of Merleau-Ponty and Tatossian

As examples of cross-cultural research in Brazil, we highlight two investigations: the first attempted to explore the theme of schizophrenia in Brazil and Chile (Moreira & Boris, 2006), while the second was held to study the depression phenomenon in Brazil, Chile, and the USA (Moreira, 2007). They both used the phenomenological perspective, inspired by the philosophy of Merleau-Ponty, as a methodological tool.

With regard to the research on schizophrenia, 50 patients were interviewed in São Paulo and Santiago. The results found that in both countries “1. The schizophrenic experience is lived as an experience of oppression and lack of power; 2. The description of the experience made patient refers largely to the fact that they feel trapped in psychiatric hospitals; 3. Their description constantly refers to the fact that they are taking strong drugs; 4. Patients feel lonely and suffer because of the stigma of mental illness” (Moreira & Boris, 2006, p. 10). However, with specific regard to Brazil, we see the strength of the religious issue, so there is mutual relationship between the spiritual and psychopathological components in the expression of the schizophrenia experience. With regard to Chile, there was a close collaboration with historical and political issues, some showing the relationship of this disease process with other issues—such as religion, in the case of Brazil.

As another example of a cross-cultural study, we present a survey conducted by Moreira (2007), about the meaning of the lived experience of depression in Brazil, Chile, and the USA. The authors interviewed 72 patients in Fortaleza, Santiago, and Boston. In this research, it is possible to observe that the forms of expression and their meanings can vary according to the cultural environment in which they manifest. However, with respect to the presented symptomatology aspects, no significant variation was observed.

Issues such as family, work, unemployment, loneliness, and stigma appear strongly in the respondent answers, although each of these topics are presented in line with the cultural processes of each country, which led to further studies (Moreira & Callou, 2006; Moreira & Telles, 2009). Specifically, it is emphasized that, in Brazil, urban violence and religiosity were prominent points. In the USA, racism and the need to be productive and in the labor market has emerged as a source of suffering, linked to lived depression and, in Chile, elements of the dictatorship the country lived in previous decades can be found. Thus, we conclude that, even if the symptoms are similarly present in different cultures, it is essential to consider the culture as constitutive pathway of the lived experience. It is about designing the subject’s condition in the world, inserted in their culture as constitutive of the meanings of their experience.

After exposing these studies as an illustrative means of a phenomenological lens of culture in psychopathology, we consider that the significant contributions of Merleau-Ponty and Tatossian open perspectives for the development of this bias. Although there are peculiarities in their considerations, given that the former is in the field of philosophy, and the second, in the clinical field, we could observe convergences throughout this chapter that assert the constitutive nature of culture and its implication in the illness modes. Culture marks the subject’s state of being in the world and, in a phenomenological perspective, allows us to envision the current and future discussions of cultural psychopathology.

Among the current perspectives, Moreira (2002), by understanding the lived experience in disease processes, recovers studies in cultural psychopathology and proposes a critical psychopathology. With the Merleau-Ponty lens, critical psychopathology suggests that man must be seen in a worldly way, seeking to overcome man-world, indoor–outdoor dichotomies.

This proposal includes a non-individualized notion of psychopathology, considering cultural, historical, social, ideological, biological, and political issues, among others, as constituents of psychopathology. This is not to relativize the notion of man, but to contemplate him in his different dimensions, necessarily, as present and intertwined. This attitude also collaborates for the refusal of a look overly focused, for example, on the biological or, on the other hand, purely relativistic.

Another major discussion held in the proposal by Moreira (2002) is a de-ideologizing understanding of psychopathological processes, understanding the ideology as a way to exert power over others. Tatossian emphasizes the importance of daily life, the constant contact with the patient and the recognition of their movement. It is necessary to recognize the interests involving these relationships and that the developed modes of care are also traversed by culture and power. If we currently live governed by a logic dedicated to the biological, for the use sometimes excessive of drugs, this bias follows interests that need to be recognized and deconstructed. However, it is important not to fall into too relativistic an understanding, so that there may be a specific attention for each illness mode.

To think critically of culture and psychopathology, an inherent dimension of a phenomenological method, is without doubt a fruitful way of deconstructing these political wards governed by our economic dynamics and the illusion of a quick cure, which should turn only to the subject who gets sick when, in fact, we may be living in a sick society. On the other hand, this process of construction cannot occur fully, because we believe that there is the possibility of a common background shared between illness experiences, which aids in the understanding and proper care of specific psychopathologies.

Further corroborating the understanding of the psychopathology of Tatossian (1981, 2001a, 2001b), Moreira (2009) considers that psychopathology can be identified when a stagnant existence is present, without the construction movement of this existence. Both in psychosis and neurosis, in an analogy with Cezanne’s paintings,Footnote 2 the lived experience of psychopathology is the absence of color. This is a sharp reduction of the possibilities of the subject in the world, a limit that does not allow him/her to live, using the expression of Tatossian (1993/2014) as subjectivity or possibility of subjectivity. A distinct understanding of a purely nosological understanding—common in psychiatric manuals—is thus observed in the identification and attention of disease processes. From a phenomenological perspective, this recognition is given from the lived experience of the patient.

Sam and Moreira (2012) conducted a discussion on cultural psychopathology, comparing the lived experience of illness in culturally different situations. Researchers resume studies on cultural psychopathology and claim that cross-cultural studies show noted critical potential, that is often lost by a movement of ‘psychologizing’ culture, by psychologists who give priority to research that is restricted to measuring symptoms, merely to compare them between cultures. Culture is not only something that influences mental illness, but is an essential part of psychopathology: “to understand mental illness is to understand culture and understanding culture makes mental illness comprehensible” (p. 6). As a mental health constituent (and of sickening modes), culture must be addressed in a dimension covering its political, historical, social, anthropological, and ideological aspects, avoiding a naive look at the cultural phenomenon (Sam & Moreira, 2012). Psychopathology should be understood through a mental disease experience that will always be reciprocally incorporated with culture.