Introduction

Like many other Indigenous groups throughout the world, the Q’eqchi’ Maya of southern Belize have maintained distinct conceptions of mental illness and disorder, as compared to Western psychiatric nosology, despite increasing availability of state- and church-sponsored biomedical and psychiatric services. There are tensions regarding how these “ethnic” conceptualizations of mental illness and disorder relate to biomedical categories, however, which affect the delivery of both traditional and Western services. In this article, we suggest that in-depth research documenting Indigenous conceptualizations can mitigate these tensions by outlining the “windows of compatibility” (Dickinson 2008) between medical systems that provide focal points for discussion and collaboration. What we present here is a way to view Q’eqchi’ mental illness and disorder in narrative terms, a perspective, we argue, that not only highlights important aspects of Q’eqchi’ medical nosology, but also augments dialogs across the cultural divides of biomedicine and Indigenous medical epistemologies.

As Jerome Bruner (1986) observed, narrative offers a way of “ordering experience, of constructing reality” (p. 11). Through narrative, people make sense of how things have come to pass and how their actions and the actions of others have helped shape their history. Narratives “emplot” or “domesticate” experience by rendering it recognizable within a familiar cultural world (Becker 1997; Mattingly 1998, 2010). Narratives also enable a meaningful vision of the present based on a set of cultural relationships with a constituted past and an anticipated future (Ricoeur 1981). Thus, narratives not only order and recount experiences or events, they also project activities into an imagined future, organizing strategies and desires teleologically, “directing them toward imagined ends or forms of experience which our lives or particular activities intend to fulfill” (Good 1994, p. 139).

Regarding various forms of illness experiences, several authors note that illness can disrupt the “normal” day-to-day functioning of an individual, bringing into question his or her imagined endings and the cultural meanings previously derived from routine activities (Becker 1997; Kirmayer 2000; Mattingly 2010). Illness experiences often create an “unmaking of the life world” as Good (1994) observed, moments that stand out or interrupt common everyday experiences. Illness can also bring into question the moral values underlying one’s concept of personhood and challenge one’s culturally laden concept of self (Hatala et al. 2013). Narrative in the contexts of various forms of illness experiences, or what Good (1994) termed “narrativazition,” can foster a “re-making of the lifeworld,” not only assisting people to make sense of the potentially troubling and disrupting illness experience, but also helping to re-construct a morally valued and conceptually coherent concept of the self or personhood. In this way, Bruner (2008) argued that narrative is often “about violations of the shared ordinary, and about how such violations are resolved” (p. 36) and about how these “deviations from shared ordinariness” are culturally and morally rendered “both conventional and manageable” (p. 35).

Most narrative research of illness and healing in cultural psychiatry, psychology, and medical anthropology has been about patient experiences. Indeed, a wealth of research into the social contours of illness and health has been conducted within a framework often referred to as a “narrative turn” in health-related research (Becker 1997; Charon 2006; Garro and Mattingly 2000; Garro 1994, 2010; Hatala 2011; Kirmayer 2000; O’Nell 1996; Waldram 2012). To look at, talk about, and interpret the structure of medical epistemology—especially that of Indigenous peoples—through a narrative lens, however, is somewhat unique.

Based on our research with Q’eqchi’ healers in Belize, we argue that narrative is not only a form in which experience is represented, ordered, and recounted, in which events are presented as having a meaningful and coherent order (Bruner 1986; Garro and Mattingly 2000), but also a medium through which the epistemological structure of Q’eqchi’ medical reality can be understood. In this way, the different mental illnesses and disorders recognized by healers represent alternative narrative structures, genres, or plot forms allowing the healers to, as Ricoeur (1981) said, “extract a configuration from a succession” (p. 278). Patients or family members who request assistance from the Q’eqchi’ healers sometimes describe the story of how or why an illness condition may have begun and how the patient feels as a result. More significantly, the healer also “communicates” with or “reads” the various “texts” of the illness through diagnostic techniques to fill in or explicate the unfolding drama. From the confluence of the healer’s diagnostic techniques and the patient’s story, healers interpret, “emplot” and configure the patient’s illness experiences in the context of already-known structures or plot forms of illness narrative (Hatala 2014; Mattingly 1994, 2010).

A narrative formulation of psychiatric nosology is not solely of use for understanding Indigenous or ethnic conceptualizations of mental illness and disease, however, as the Diagnostic and Statistical Manual (DSM) of mental disorders—the accepted diagnostic coding systems of mental disorders upheld by the American Psychiatric Association’s (APA) and Western clinical psychology—has also been explored as a “narrative framework” specific to Western contexts and cultural systems (Kirmayer 2006). Working with physicians in Western medical settings, Montgomery (2006) argued that “Narrative accounts of disease mechanisms or pathological processes are the principle means of organizing symptomatic clues and their interpretive syndromes” (p. 64). While drawing on the descriptive imagery of esthetic genres Montgomery (2006) further suggested, “Like Victorian turrets beneath a cloud-draped moon, the details of illness, its signs and symptoms, reveal to a clinical audience the kind of situation it is and what is likely to happen next” (p. 64). Similarly Wood (2004) observed in her study of the “diagnostic narrative within the DSM casebook,” that any “medical diagnosis itself is both an interpretation, which thus holds hidden in its own shadow multiple alternative interpretations, and a trace marker for larger narratives with their own multiple histories, vocabularies, writers, and audiences” (p. 196). Psychiatric diagnosis, Wood (2004) continued, is “based on the reading and writing of patients through narrative” and “is a fraught, highly subjective process that draws on a wide range of culturally specific histories and contexts, some scientific, some popular, some literary” (p. 200). Thus, Wood (2004) concluded that psychiatrists, as Hunter (1991) and Montgomery (2006) have observed with Western physicians, “are being trained as critics who must interpret a text. The text is the patient” (p. 218).

Based on the research presented here, we argue that a narrative conception of mental illness and disorder can aid our understanding of the Q’eqchi’ Maya conceptions as well as Western psychiatric nosology contained within the DSM-5. Both systems in effect read the patient as a “text.” The narrative genres recognized by the Q’eqchi’ healers have important qualities and characteristics, plots and actors, significant events, and props, that signal to the healers what story they are in, what they are likely to encounter, and what the resolution should look like. In a similar fashion, DSM illness categories can be articulated as “larger developing narrative structures” or “canonical genres” that biomedical practitioners “actively seek to impose upon clinical time” (Mattingly 1994, p. 811; Mattingly 2010). A narrative view of Q’eqchi’ mental disorder allows us to see the inherent flexibility and adaptability that often accompany the illness narrative and allows for descriptive, etiologic, and explanatory formulations to work together in the overall diagnostic process. Seen this way, our argument pertaining to the narrative structure of Q’eqchi’ mental disorders should ring familiar to biomedical practitioners and open the door to a fruitful discussion between them and the traditional healers. While the narrative structure itself as well as constituted genres may seem different—comprised of culturally contextualized content—the fundamental clinical process is essentially the same.

Building on previous research in southern Belize (Bourbonnais-Spear et al. 2005; Waldram 2013; Waldram et al. 2009; Waldram and Hatala 2015), the purpose of the current study then is to discern and interpret the Q’eqchi’ nosological system of mental disorders involving the factors—spiritual, cultural, social, historical, cosmological, or otherwise—implicated in their articulation and construction. What we observe in the Q’eqchi’ nosological system are narratives that structure and organize illness epistemology, narratives that are unique to Q’eqchi’ cultural contexts while also relating to previous cross-cultural work in mental illness conceptualizations and selected biomedical categories. How this nosological system intersects with that of biomedicine and especially DSM-5 diagnostic categories is of particular interest for pragmatic reasons, as we seek points of parallel compatibility in epistemology that support healer initiatives toward greater collaboration and dialog between medical systems. The intention here is not to present DSM or biomedical perspectives as validation for the Q’eqchi’ understandings of mental illness and disorder. Rather, select DSM-5 categories are explored throughout as a loose “heuristic” to promote a common language for cross-cultural conversations and dialog.

Research Context

Maya peoples comprise some 31 distinct cultural groups inhabiting Mexico and several countries in Central America. The Q’eqchi’ represents nearly 10 percent of the total population of Belize, living primarily in the southern district of Toledo. The Q’eqchi’ people maintain a rich “traditional” system of healing despite centuries of colonization and more recent intrusions by North American evangelical groups (Bourbonnais-Spear et al. 2005; Watanabe 1992). Yet, despite this “traditional” way of life, globalization has provided access to new forms of technology, media, and neo-liberal ideologies (Hatala 2013; Kahn 2006). As such, younger generations, even in what could be considered the most remote Maya villages, are becoming less interested in the often arduous work of aj ilonel, the “bush doctors” or local healers.Footnote 1 Acquisition of subsistence knowledge, once the primary means of survival and base of “traditional” life, including that of localized medical practices, is simply less of a priority for younger generations as urbanized life increasingly becomes normalized (Zarger 2002). More broadly, despite a rich network of traditional or Indigenous healing services in the country, there are also growing trends within many Maya communities away from the utilization of local healing services in favor of available biomedical services (Hawkins and Adams 2007; Kahn 2006; Watanabe 1992). In response to these cultural changes, several local and grassroots Indigenous groups have formed as part of the ongoing “ethnic revitalization” of Maya communities generally and the Q’eqchi’ of southern Belize specifically (Waldram et al. 2009; Wilson 1993, 1995).

One such grassroots Indigenous organization is the Maya Healers’ Association (MHA) (formerly the Q’eqchi’ Healers’ Association), that emerged in 1999 in response to growing concerns over the erosion of Q’eqchi’ cultural practices, especially those related to local medical knowledge and care. The MHA has since created a medicinal plant garden called “Itzamna” (i.e., the Maya god of the sky and of medicine, science, and the arts) to preserve and protect medical herbs and plants and provide space for research activities and educational tours (Arnason et al. 2004; Pesek et al. 2010). The MHA has also embraced a professional ethos to support and, in a sense, help legitimize its work. In this they have created certificates of competency and identification cards declaring each aj iloneleb’ to be a “certified member of the Q’eqchi’ Healers Association of Belize” and a “fully qualified traditional healer and herbalist” (Waldram et al. 2009). Official membership in the MHA is regulated entirely by the healers themselves and between 2000 and 2011; there were 12 healers in the association.

Amidst a backdrop of globalization, modernization, and cultural change, the MHA members are asserting their legitimacy as medical practitioners and knowledge experts. They do so not only by appeals to “traditional” ways and knowledge as a means of legitimizing their work, but also through research and collaboration with bioscientists, biomedical practitioners, and medical anthropologists. These healers are drawing on both ancient traditions and modern technologies to substantiate themselves as “active agents” in the ongoing cultural reconstruction of their identities as Q’eqchi’ traditional healers or aj ilonel (Wilson 1993, p. 136).

Ethnographic fieldwork among Q’eqchi’ healers in southern Belize describes a complex network of relationships informing their vision of reality that is far from anthropocentric. Rather, the cosmos or spiritual worlds are often the key referent. Thus, “cosmovision” is the term typically used to describe the worldview and ethos engendered by Maya communities; a vision underpinning psychological, medical, ontological, epistemological, moral, and esthetic realities and where an intimate connection is observed between Qaawa’ (creator God), Tzuul taqa’ (spirits of the Mountains and the Valleys), and humanity. Q’eqchi’ cosmovision is not only a medium of perception; it is a medium of experience, a mode of engagement with the world in which human and spiritual reality are deeply interrelated (Hatala 2014; Kahn 2006; Molesky-Poz 2006). Q’eqchi’ cosmovision also shapes culturally distinct conceptions of personhood, where spirit, heart, mind, body, environment, and one’s maatan (a preordained destiny or vulnerability linked to one’s day of birth according to the Maya calendar), coalesce to shape a persons traits and characteristics (Hatala 2014; Groark 2008). In this way, Q’eqchi’ cosmovision formulates a vision of reality and a “context” within which narrative expressions of mental illness and disorder are interpreted, conceptualized, and understood (Good 1994; Hatala 2014; Waldram and Hatala 2015).

According to the MHA members, the mental health scenario in Belize, including health intervention at the community level as well as official Ministry of Health policy and regulation, is currently lacking attention to Q’eqchi’ patients, epistemology, and healing methodology. The mental health legislation in Belize was, until recently, based on the British model dating back to 1965—a model of psychiatric care closely associated with “asylum psychiatry” as an early colonialist enterprise (Kirmayer and Minas 2000). In advocating for a comprehensive mental health program in Belize, Claudia Cayetano, chief psychiatrist and technical advisor to the Ministry of Health, has helped to establish a strong community mental health care program. In 1991, the first training program for Psychiatric Nurse Practitioners (PNPs) was established under the auspices of the Pan American Health Organization (PAHO) and the World Health Organization (WHO) in collaboration with Memorial University in Newfoundland, Canada (PAHO 2007). Today, there are eight mental health clinics spread across the country, one in every district that is maintained by PNPs under Cayetano’s supervision and guidance.

Since the first training program for PNPs in 1991, the DSM and related diagnostic interview tools (i.e., Diagnostic Interview Schedule (DIS)) have been the primary means by which mental illness and disorder are conceptualized and diagnosed by the Belize Ministry of Health (Hatala 2014; Killion and Cayetano 2009). There are currently no significant efforts in the country to provide language translation for non-English speakers and no attention is given to cultural sensitivity regarding local illness conceptualizations. Most rural Belizeans first seek medical assistance from one of the several different types of local herbalists or traditional healers before going to a government-sponsored biomedical practitioner (Bonander et al. 2000; Killion and Cayetano 2009; Staiano 1981), yet the World Health Organization (WHO) observed that in Belize “there is no interaction between mental health facilities or personnel and alternative/traditional practitioners” (WHO-AIMS 2009, p. 25). Additionally, the current edition of the National Mental Health Policy in Belize 2010–2015 remains entirely silent on the issue of local or traditional healers (Government of Belize 2010). Thus, conceptual and cultural gaps are rising for Q’eqchi’ patients as biomedical and psychiatric services in the country are still lacking in cross-cultural training and cultural competence regarding local conceptions of and treatment practices for mental illness and disorder.

Research Methods and Analysis

Collaborative research with members of the MHA has been ongoing for almost a decade. As part of their broader goals, the healers requested that research into their healing practices be undertaken with the goal of demonstrating their effectiveness to the health officials in the Belize government, medical practitioners in their region, and to their own people, many of whom are impacted by forces of modernization and globalization. The research has involved extensive interviewing of both healers and patients, and documentation of healing practices through video recording (Waldram 2013; Waldram et al. 2009; Waldram and Hatala 2015).

The current research details the epistemology and nosological system of mental illnesses and disorders of five male Q’eqchi’ aj iloneleb’ who were active members of the MHA during 9 months of fieldwork in 2011 (Hatala 2014).Footnote 2 During this time, 94 semi-structured interviews into “ethnosemantic” categories occurred to elicit lexicon taxonomies of Q’eqchi’ mental illness and disorders (Manson et al. 1985, p. 336). Interviews began by asking aj ilonel to name illness categories: “what are the illnesses that can impact the mind, heart or spirit of a person?” Further questions related to cause, severity, or duration of the illness, behavioral, affective or cognitive descriptions, demographic characteristics, help seeking behavior and potential approaches to treatment. Each interview lasted approximately 1.5 h and occurred in the Q’eqchi’ language through a local Q’eqchi’ translator. The third author served as the main translator, language expert, and cultural guide for the duration of this research project and accompanied the lead researchers (first and second author) during all interviews. Importantly, he also served as a cultural broker and ethical advisor to the research project by ensuring respect for the traditions and patients’ privacy, and adherence to local ethical protocols (Waldram et al. 2009). For the current research, the standardized version of the Q’eqchi’ language approved by the Academia de Lenguas Mayas de Guatemala (ALMG) (Guatemalan Academy of Mayan Languages) is used throughout. Secondary translations of interviews by five additional Q’eqchi’ language experts also occurred, and these English language texts are also presented here, edited for readability.

The entire interview, translation, and transcription process generated over 900 pages of textual data from the 94 healer interviews. Initial themes were highlighted and separate analytic files were constructed (Denzin and Lincoln 2008; Rothe 2000). The analytic files included any data detailing specific areas of interest (i.e., Q’eqchi’ cosmovision, diagnosis, etiology, treatment approaches, different mental illness conditions, and case studies of each healing encounter). The data were examined several more times to capture the main ideas, highlight them in the margins, and create concise phrases that encapsulated, as much as possible, the essential quality of the section, theme, or concept being expressed. This first stage of analysis ultimately transformed the entirety of the analytic files into a series of interrelated themes.

The analysis further examined the frequency with which healers mentioned an item that fit logically within one of the particular categories explored during the interviews (i.e., etiology, symptomology, demographic, or treatment approach). As such, care was taken to ensure that all healers were given the same questions and relatively the same amount of time to answer. Although this process is not free from limitations, it allows us to present data (i.e., Tables 1, 2, 3, 4) related to the frequency with which the healers mentioned a particular cause, symptom, or treatment approach for a particular condition within the interviews (Hatala 2014). This frequency count was collapsed across the healers and represents the number of times an item was mentioned during the 94 interviews and targeted conversations.

A final phase of analysis examined the compiled list of emergent themes and analytic files to identify connections among them. Analytic and theoretical ordering of super- and subordinate themes then helped to make sense of the connections between and among the emerging illness conditions (Denzin and Lincoln 2008; Manson et al. 1985; Rothe 2000). What emerged from this analysis was a way of conceptualizing Q’eqchi’ mental illness and disorder in narrative terms.

Narrative Genres of Q’eqchi’ Mental Disorders

The analysis of interview data first revealed superordinate themes that were common to all conditions and across all healers. These broad themes, such as morality, esthetics, spirituality, and social relationships, are aspects of Q’eqchi’ cosmovision that punctuate and pervade the various descriptions of mental illness and disorder. In this way, Q’eqchi’ cosmovision provides the provisional overarching cultural structure that characterizes the telling and interpreting of medical stories (Garro 2000, 2010; Kleinman 1988; Mattingly 2000).

Six structural elements of narrative also arose from the interviews. These include as follows: the inciting incidents of the illness episode or how the plot of the condition begins; the major tensions around the complicating factor or disruptions in the plot; the resolutions of the complicating factors; the temporal aspects or how long and drawn out the process of tension and resolution takes; the central actors that are implicated in the onset and treatment of the condition; and the “directedness,” teleology or outcomes of the treatment. Based on differences of content across these structures, four broad Q’eqchi’ narrative genres were evident: (1) “Thinking too much”; (2) “Fright”; (3) Maatan or Days of birth; and (4) Spirit “attacks.”

These “narrative genres” signify a “common stock of stories” that are part of the Q’eqchi’ healers’ visions of the world (Mattingly 2000, 2010). They involve a similar story, an unfolding course of events that could be described as general “narrative types” (Frank 1995) or “prototypical plot forms” (Good 1994). According to Frank (1995), “a narrative type is the most general storyline that can be recognized underlying the plot and tensions of particular stories” (p. 75). These narrative types are seen as a repertoire of cultural scripts or cognitive tools that provide, however modestly, models for social action and drama. Similarly, Good (1994) argued that “‘an illness’ has a narrative structure,” a structure that involves particular “prototypical plot forms” which give stories coherence and order through which experiences and events are joined together to create meaning in the overall story (p. 164). In other words, “narrative genres” are interpretive tools to apprehend medical and social reality, enabling aj iloneleb’ to recognize, create meaning from, and “enact cultural scenarios” with which they are familiar (Good 1994; Mattingly 2000, p. 197).

The concept of a “genre” began as an absolute classification system where literary categories (i.e., poetry or prose) and theatrical categories (i.e., comedy or tragedy) had specific and calculated styles related to the theme, form, and content of esthetic expression (Devitt 2004). Speech patterns and behaviors in one genre were considered inappropriate in another, unless the intent was such as in a tragic-comedy. As Devitt (2004) noted, genre later became a more dynamic tool to help the public make sense of unpredictable artistic expressions. In this way, genres are understood to be culturally formed by social conventions that change over time as new genres are invented and the use of old ones discontinued. The concept of genre remains useful in artistic disciplines insofar as it provides, however loosely, an initial interpretative framework within which meaning may be produced during an esthetic encounter. The four recognizable “narrative genres” function for the Q’eqchi’ healers in a similar way. They provide an initial epistemological framework within which medical reality is meaningfully approached and interpreted.

At a final level of analysis there emerged 17 distinct yet related stories of illnesses known to negatively impact the “mind” of a person in some way. Each of the 17 “mental” illness conditions can be grouped together under one of the four broad “narrative genres” on the basis of subordinate themes that run through the healer’s descriptions. These include as follws: how the onset of the illness is understood (i.e., etiology); how the temporal unfolding of the illness plays out in the patient’s life (i.e., symptomology and prognosis); the severity of the condition; the demographic population most afflicted by the condition; the main idioms used for its expression; and the interpretive logics underlying the therapeutic process. In other words, the 17 distinct mental illness conditions can be understood as variations on the superordinate themes contained within the “narrative genres,” allowing the healers to constitute them as separate conditions yet having commonalities with the other conditions in the same genre. In some cases, as in many “thinking too much” conditions, the variations within the genre are described as distinct stages along a progression of severity. In other cases, the variations within a genre are related more by the demographic most effected or by etiology. Finally, all of the 17 conditions discussed throughout this work can be classified under the broad Q’eqchi’ rubric of “mental” illness insofar as they deal directly with the mind, heart, soul, or spirit of the person, narratively engender a set of mood conditions (i.e., anger, fear, sadness, jealousy, worry, etc.), and can be distinguished from illnesses that “only” impact the body (i.e., malaria, skin and skeletal conditions, diabetes, various localized pains, etc.).Footnote 3 Figure 1 outlines the relationships among these three levels of analysis.

Fig. 1
figure 1

Epistemological taxonomy of Q’eqchi’ mental illness and disorders

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Following Fig. 1 are four additional tables for each narrative genre. The numbers in brackets within each table represent the frequency with which the healers mentioned that cause, symptom, or treatment approach during the interviews. This number is summed across the healers and represents the number of times that item was mentioned during the 94 interviews and directed conversations. For each condition, the healers attribute multiple causes, symptoms, and treatments, and hence overlap is evident.

“Thinking Too Much”

Seven of the seventeen “mental” illness conditions recognized by the healers fall within the broad narrative genre of “thinking too much” and are depicted in Table 1. For the seven illness conditions under this “narrative genre” there are 13 different causes identified: thinking too much; changes in temperature; in the air; from other conditions; spirit “attacks”; maatan or day of birth; witchcraft; already in blood (i.e., heredity); death of loved one; marital problems; financial troubles; and fright. In total, these 13 causes were mentioned 77 times, 47 (61 %) of which were connected directly to “thinking too much” or related etiological factors such as witchcraft, death of a loved one, marital problems, family problems, or financial troubles. In terms of treatment approaches, another important pattern for this narrative genre is that all of these conditions use the prayer “k’ochob’ank,” translating roughly as “the prayer to stabilize the person’s mind and thinking.” In addition, these are the only conditions that use a kind of therapy involving an array of flowers. It is said that the scent of various flowers can help “stabilize” the thinking of the person and are therefore useful for “thinking too much” conditions.

Table 1 “Thinking too much” narrative genre of mental disorders
Full size table

The term “thinking too much” or numtajel nak’a’uxlak in Q’eqchi’, is an idiom frequently used by aj iloneleb’ to signify a general state of unhealthy thought or patterns of thinking that are negative or harmful to an individual. These are the only conditions recognized by the healers to be illnesses of “thinking.” However, the Q’eqchi’ notions of “mind” and “heart” are closely related, and often the “thinking” of the individual is expressed in the heart as well (Groark 2008). “The heart and the mind are both related,” one healer suggested, “Everything starts in the mind then it goes to the heart. These two organs in the human body go together for a person’s thinking (k’a’uxl).” In Q’eqchi’ parlance, emotions (xch’ool) are expressions of both the heart (aam) and soul (ch’ool), recognized as an external communication of the internal spirit, and also the way in which one behaves in the world. In this way, these “thinking too much” conditions also closely reflect a Q’eqchi’ notion of “mood” disorders insofar as pathological thinking can alter one’s mood or emotional well-being. It is not surprising then that many descriptions of the various conditions within this narrative genre engender a wide range of emotional idioms such as anger, frustration, or excessive sadness. With the exception of “fear,” the sole emotional idiom of the “Fright” narrative genres that is rarely invoked for “thinking too much” conditions, all “mental” illnesses within this genre involve emotional expression.

The origins of illness within this narrative genre begin with a problem or event that is understood to trigger the onset of “thinking too much.” There are many etiological pathways that can lead an individual to this illness state. Notably, “thinking too much” is described as both a state that leads to illness and a symptomology of illness conditions. Thus, we could say that it is the “content” of the “thinking too much” or the negative thought patterns that are relevant when attempting to understand the different conditions within this narrative genre and the primary reason why each of the seven conditions is given a different name.

The cognitive content of “thinking too much” generally involves or begins with some kind of social misfortune, like problems with a spouse, a boyfriend, or girlfriend, economic troubles or poverty, or the death of a close family or community member. The primary tensions within this genre involve the dealings with a kind of pathological thinking or mood state, an excessive dwelling or rumination on the event that captures or begins to control one’s patterns of thought. The temporal dimensions of this genre are slower and more gradual compared with other conditions, often characterized by a slow accumulation of risk factors. Even when the cause of the condition is the loss of a loved one or community member, as is often the case for rahil ch’ool, understood as a kind of depression, the symptomology is not recognized to begin right away but may take time and the confluence of other factors before a person’s state becomes interpretable as pathological, thereby warranting therapeutic intervention. The main actors involved are community members, friends, and family or other social events or broad structural processes such as employment rates or poverty. The symptomology can range from descriptions of psychosis and hallucination, to mild forms of depression and sadness. Children are not typically able to suffer from these illness conditions since they involve general misfortune and complex social affairs. “Kids don’t really get it,” one aj ilonel explained regarding rahil ch’ool, “Maybe from 14-16 years and older they can get this illness. Once you’re not worried about anything you won’t get this sickness but if you’re worried, of course you can get it.” Only adults are thought to understand complex social relations and processes involved with these conditions and so they are the only ones susceptible to “thinking too much.” The therapeutic interventions here are typically marked by a longer initial onset and recovery time as compared to other genres and conditions. The resolutions often involve acceptance of one’s situation, or the changing of one’s situation through the repairing of disrupted social relationships, including relationships to the spirits of the Mountains and Valleys or the other-than-human realm (Hallowell 1960), or addressing, in some way, broader structural factors such as poverty, unemployment, or a general lack of upward social mobility and opportunity.

Conditions like tib’l jolom and chiqwual xjolom are roughly translated as “pain in the head” and “heat in the head,” respectively. This heat is semantically related to emotional states such as anger or frustration, patterns of thinking that, when carried to excess, lead to pathological states. The “content” of thinking too much here is usually based on the stress of the headache and less on social or environmental stressors. However, these conditions can also be the result of “thinking too much”—worrying or being preoccupied—about one’s financial situation, marriage, infatuations, or general community life. As one healer described tib’l jolom, “let’s say that a person wants to be with a woman so he will start to think about that woman too much and he eventually gets a headache.” Or as another stated, “whenever somebody has a bad attitude toward others they are more susceptible to getting a headache, because all they think about is negative things. The blood temperature rises and the person’s face turns red.” As shown in Table 1, the symptoms and patient experiences often involve “high blood pressure,” fever, nausea, difficulty in sleeping, and in extreme cases, a kind of dangerous aggressiveness that can endanger oneself and the community.

The illness rahil ch’ool translates as “sadness of the soul” or “depression,” ra signifying the emotional state of sadness and ch’ool referring to soul, while also signifying their emotional state as in how the soul is socially expressed to others. Po’ol k’a’uxl translates as “spoiled mind,” and although the symptomology is similar to rahil ch’ool, it is caused by the ill intentions of another or by “witchcraft,” and is thus given a separate name. Aj ookil translates as a “person who remains awake,” as in insomnia, and is closely related to rahil ch’ool and po’ol k’a’uxl. In some instances, it is described as a symptom of these conditions rather than a separate condition. As one aj ilonel described regarding a patient who became ill due to the loss of a loved one, “Maybe this person is sick. His worries get too much and he might say, ‘why hasn’t he [family member] died yet? He gets sad and his sickness is getting worse and then it turns to this sadness. He gets sleepy because of worries.” Notably, the symptoms for conditions like rahil ch’ool and po’ol k’a’uxl are nearly identical to conditions such as Major Depressive Disorder (MDD) presented in the DSM-5. Both involve an overwhelming degree of sadness, debilitating lethargy, listlessness, suicidal ideation, fatigue, significant loss of energy, and diminished cognitive ability. “The person with this illness [rahil ch’ool], their blood will be really sad or moving slow, and the person will not be feeling well but he will be feeling sad that he had something in his mind,” remarked one aj ilonel.

Wax ru and waxk’ay are more serious and dangerous than the other conditions within this narrative genre. The Q’eqchi’ term wax reflects behavior that is “crazy.” The term can also be used for someone who is in a hurry or who, for example, comes into a house during a storm and is frantically searching around for their rain boots. The term “ru” signifies the face of the person. Together, wax ru translates as “the person who is acting crazy,” or “the person who has crazy on their face.” The Q’eqchi’ term “k’ay” translates as “the person who wants to sell something.” In the context of mental illness, waxk’ay signifies a person who is “selling craziness,” as in acting in such a way as to make others witness their crazy actions. Wax ru is considered to be the more serious variant of waxk’ay.

The “content” of thinking too much with these two conditions is characterized by a kind of chaotic thinking and an inability to communicate or follow a conversation properly. These conditions can also involve severe hallucinations and feelings of wanting to “run away” from others, notions related to the “running taxon” of the “culture-bound syndromes” (Simons and Huges 1985). Describing wax ru one aj ilonel stated, “The person acts as a drunkard. The person might kill or hurt you because he is not conscious of what he’s doing. It’s really dangerous and he is stronger than everybody. The person can talk and get angry or they could even bite you.” Similarly, another healer argued, “wax ru is really dangerous because this person won’t allow you to get hold of him. All he wants is to run into bushes, he screams and makes weird sounds.” “The person gets crazy,” he continued, “starts to talk to himself without sense, fights with family members, and shouts at people.” Regarding waxk’ay another healer noted, “The person will have a headache, and will be thinking too much craziness, and the heart starts to have pain. Eventually the person will start to think of running away in the forest. That is the way this sickness occurs.”

These descriptions reflect an array of conditions presented in the DSM-5, specifically those referred to as “Schizophrenia Spectrum and other Psychotic Disorders.” These involve abnormalities in one or more of five domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms (APA 2013, p. 87). Indeed, both wax ru and waxk’ay involve, to greater or lesser degrees, varieties of delusions, hallucinations, disorganized speech, and grossly disorganized behavior. As such, wax ru and waxk’ay are described by the Q’eqchi’ healers to be among the most serious and dangerous cases to treat, requiring “special” knowledge and techniques in order to properly return the person’s thinking to “normal.” As opposed to the biological and neurological discourse in the DSM, however, aj iloneleb’ outline a wide range of etiological factors known to induce these forms of pathological thinking (see Table 1).

In addition to the DSM conditions, this genre also relates to research in other cultural contexts exploring the idiom of “thinking too much” as related to mental or emotional illness. Indeed, “Thinking too much” is presented as an idiom of distress in DSM-5 (APA 2013, pp. 834–835) and has been outlined in over 100 studies across cultures and world regions as a common way of expressing mental distress (Brown et al. 2012; Hinton et al. 2012; Yarris 2014). Like the Q’eqchi’ aj ilonel argue, many of the research in other cultural context describe how “thinking too much” occurs when someone ruminates on a particular problem, often social, economic, or structural in nature, and where the thinking is not directed to any particular solution. For Yarris (2014) working with grandmothers in Nicaragua, “thinking too much” was an idiom reflecting wider social and cultural disruptions in family continuity via transnational migration and “a means of expressing locally salient cultural ideals of solidarity in family life” (p. 477). In related research “Thinking too much” has also been linked with other conditions such as depression, anxiety, or severe psychosis and outlined as being more of a spectrum or constituting part of a spectrum of mental disorder rather than a specific condition (Kaiser et al. 2014). What we see among the Q’eqchi’ healers is a similar story, as the content of “thinking too much” generally involves some kind of social misfortune. The formulation of “thinking too much” as a narrative genre is somewhat unique, however, as it allows us to appreciate a spectrum of related conditions within the same genre.

Therapeutic intervention and post-condition temporal points within the generalized “thinking too much” narrative structure are similar to the “restitution” or “restorative healing processes” we will observe later among the genre of “Fright” conditions (Frank 1995; Waldram 2013). However, they are marked by longer onset and recovery times. The treatment is known to completely dissipate the illness state if done properly and under the right conditions. Multiple treatment encounters are the norm, however, as symptom relief can take significant time. There are some instances where, if a condition be severe enough, the healers recognize that a complete “cure” may not be possible and instead a kind of coping or “acceptance” must ensue. A softer ending to this plot structure can be observed, as stabilization of one’s thinking occurs slowly over several cycles of treatment. In most cases during our research, this was observed to be 1 or 2 months as opposed to the weeks mentioned for conditions within other narrative genres. Overall, however, aj iloneleb’ agree that a “cure” is possible even for complex cases of wax ru in which the patient is extremely aggressive, dangerous, and constantly running into the forest. Even for these situations, aj iloneleb’ suggest that a complete elimination of the illness condition is possible and a return of the individual to normal day-to-day functioning can occur.

“Fright”

Three of the seventeen “mental” illness conditions recognized by the Q’eqchi’ healers fall within the broad narrative genre of “Fright,” depicted in Table 2. For the three illness conditions under this “narrative genre,” there are eight different causes identified: fright; maatan or day of birth; thinking too much; spirit “attack”; changes in temperature; already in blood; witchcraft; and actions of parents. In total, these eight causes are mentioned 26 times, 13 (50 %) of which are directly related to “fright.” Some of the causes listed here, such as “maatan/day of birth,” “actions of mother/parents,” or “already in blood,” are better described as pre-condition factors which predispose an individual to have and/or succumb to frightening experiences in the face of other etiological factors. Another prominent pattern within this illness narrative genre is that the symptomology of these conditions also involves fear, worry, or some kind of excessive paranoia. Indeed, one of the primary means by which aj iloneleb’ diagnose these conditions is through the blood pulsating in a “fearful” manner. Finally, these conditions involve the unique healing approach of “smoking” the patient and “calling back the spirit” of the patient, two therapeutic techniques described to alleviate the worry and fearful symptoms of the patient and which are unique to this narrative genre. The prayer called “b’oqok mu,” translating roughly as “the prayer that calls back the spirit of the person,” is also uniquely used for these conditions (although the treatment approach for the conditions under the spirit “attack” narrative genre occasionally include this prayer).

Table 2 “Fright” narrative genre of mental disorders
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All of the conditions classified under the narrative genre of “Fright” emerge as a result of some kind of frightening experience. In aj iloneleb’ descriptions, however, there are also many subtle allusions to a pre-condition state, such as the risk and protective factors that contribute to the onset of the illness. It is here that aspects of Q’eqchi’ cosmovision come to bear most directly on the plot of the fright illnesses (i.e., the individual’s relationship with spiritual worlds, the moral contours of their personhood, and their maatan or day on which they are born). The multiple ways in which these “pre-condition” factors coalesce in a particular individual, family, and community life determine, to a great extent, whether or not they will, at some point in their lives, become ill due to fright.

The fright episode is the point around which the plot of this narrative genre unfolds. It is the inciting incident or catalyst that propels and shapes the illness narrative. The Q’eqchi’ aj iloneleb’ recognize many ways in which an individual can become frightened, the general term for which is xiwajenak, translating as the state or condition of being frightened. Within this broad term are several distinct conditions that depend on the way in which the person is frightened. Kaanil, for instance, which is likely the most common illness within this narrative genre, specifically refers to someone who has fallen by a river and become ill as a result. Kaanil can also be used as a general term for fright illness conditions synonymous with xiwajenak. More specifically, we could say that the root “kaan” here is synonymous with xiwajenak, both signifying the state or condition of being frightened.

Oksinb’il kaan is a condition closely related to kaanil, except that it is caused specifically by being frightened from behind by another person or animal. Aj iloneleb’ also described cases where individuals have become afraid at the sight of seeing the ghost of a relative that had passed on. Thus, this condition can occur as a result of “supernatural” events as well as natural. Xib’emb’il is another Q’eqchi’ term that is used to describe this fright condition, a kind of fright induced from another person or community member who does something unexpected. Different illness names are attributed to different etiological agents, and although kaanil and oksinb’il kaan are nearly identical in symptomology, they are recognized as separate conditions requiring slightly different healing approaches based solely on how the person became frightened (i.e., etiology).

The last condition that falls within this narrative genre is xiw xiw, and is etymologically related to xiwajenak. Although involving fright as a core aspect of the illness narrative, this condition is slightly different from kaanil and oksinb’il kaan insofar as it is more chronic and severe in nature. The onset of xiw xiw is not described as sudden. Rather, it comes on gradually and then impairs the individual to such an extent that he or she becomes afraid of nearly everything (i.e., other people, animals, leaving the house, loud noises, or travel). This condition is reminiscent of Generalized Anxiety Disorder (GAD) in the DSM-5, although, as can be expected, the cultural undercurrents and interpretive aspects of the condition are distinct. Xiw xiw can also have an onset related to the “attack” from a spirit. In this way, it resembles the narrative genre of spirit “attacks,” yet is distinctly characterized with the state of being afraid. As a result of this connection, xiw xiw is the most serious condition within the narrative genre and the most difficult to treat.

After the “fright” episode, it generally takes between one and three weeks for an individual to become ill. This is because the individual’s mu or muhelej (i.e., spirit), that is trapped at the location where the fright occurred, is outside and away from the person. This separation between the person’s spirit and body gradually creates the symptoms associated with this illness condition. “The person falls down and gets frightened,” one aj ilonel explained. “The spirit is lost and it causes fever. It’s in the river/streams that the spirit is lost.” “The person will be experiencing lots of frights and the blood will re-circulate with frights as well and that person will have fever and loose stools” another described regarding kaanil. “The kaanil affects the blood and the person will begin to get frightened and then the person will start to vomit, will be shamed, and will be tired” added another aj ilonel. Because the spirit is trapped at the site where the fright incident occurred, their actions and ability to perform normal behaviors slowly declines. What is “lost” in these conditions is not only the spirit as it is trapped outside the body, but also a generalized way of being-in-the-world, a normalized and moralized mode of action-in-place (Kahn 2006; Watanabe 1992).

These fright conditions reflect categories presented in DSM-5 resembling, at times, the general notion of “Anxiety Disorders,” or, more specifically, GAD for xix xix, or Post-Traumatic Stress Disorder (PTSD) for kaanil and oksinb’il kaan. According to the DSM-5, anxiety is defined as “the apprehensive anticipation of future danger or misfortune accompanied by a feeling of worry, distress, and or/somative symptoms of tension” (APA 2013, p. 818) and involves “features of excessive fear” related to “behaviour disturbances” (APA 2013, p. 189). Although there are some similarities in “Fright” narrative genres and anxiety-type conditions, there is distinction insofar as anxiety primarily involves anticipated future threats and fear involves emotional responses to real or perceived threats. As opposed to this formulation, fright conditions presented here involve a preceding frightening episode followed by an illness state and change in behavior. As such, the “Fright” narrative genre is perhaps more closely related to “Trauma and Stressor-related Disorders” in the DSM-5 wherein “exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion” (APA 2013, p. 265).

In addition, these “Fright” conditions are also reminiscent of the general narrative structure of “susto” as presented in the DSM’s “Glossary of Cultural Concepts of Distress.” As a “folk illness” prevalent among Latinos in the southern United States, Mexico, Central America, and parts of South America (Klein 1978; Rubel et al. 1984; Weller et al. 2008), susto involves an illness that is associated with “a frightening event that causes the soul to leave the body and results in unhappiness and sickness, as well as difficulties functioning in key social roles” (APA 2013, p. 836). This description in the DSM, although brief and somewhat essentialist in its language, is similar to the narrative structure of Q’eqchi “Fright” genres, especially the condition of kaanil. Indeed, the term “susto” is occasionally used by the Q’eqchi’ healers and translators to describe these “fright” conditions, having learned the term from their Spanish compatriots and other social science researchers working in the area. In some literature on Latin American healing, susto is presented as a single condition (Weller et al. 2008). However, here we present “fright” (xiwajenak) as a broad “narrative genre” harboring several other “fright-related” conditions.

Therapeutic interventions within this narrative genre center on restoring the patient to the pre-illness condition. For kaanil and oksinb’il kaan, this is generally a straightforward therapeutic intervention involving the “calling back of the spirit of the person” in a healing ceremony involving, prayers, candles, and herbal medications. For xiw xiw, the treatment and therapeutic narrative is slightly more complex and based on the severity of the condition, in some cases involving elaborate attempts to retrieve some hair from the animal that caused the frightening event. Overall, however, the healers’ descriptions of these conditions center on a notion of “cure.” All aj iloneleb’ recognize that the condition of being afraid, even when driven to pathological levels, can be cured through strategic intervention and healing techniques. Thus, the resolution of this narrative genre is generally clean and simple when compared to the multiple plot endings within the “thinking too much” or “Maatan or Days of birth” genres. In this way, the general plot structure of the fright conditions is more cyclical than linear; the goal is to return to the pre-fright episode state. Generally speaking, it is a relatively easy and fluid “restorative” healing process (Waldram 2013).

Maatan or Days of Birth

Three of the seventeen “mental” illness conditions recognized by the Q’eqchi’ healers fall within the broad narrative genre of “Days of birth” or xyajel maatan, meaning sicknesses related to the day of birth and are depicted in Table 3. For the three illness conditions under this “narrative genre,” there are eight different causes identified: maatan or day of birth; actions of parents; changes in temperature; already in blood (i.e., heredity); thinking too much; failure to seek permission; spirit “attacks”; and spontaneous. In total, these eight causes were mentioned 32 times, 23 (72 %) of which are related to the maatan or day of birth of the individual, actions of the parents during prenatal stages of development, or the condition of being already in the blood during the time of birth. The other prominent pattern within this genre is that each of the conditions begins in early childhood or at birth and remains with the individual throughout life unless interventions at an early age occur.

Table 3 Days of birth genre of mental disorders
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The general structure of this genre involves an inciting incident that occurs before the birth of the individual, usually related to an action or behavior, typically contextualized as a moral infringement of some kind, that the mother or family has done. The inciting incident then impacts the prenatal development of the individual and their day of birth, aspects of Q’eqchi’ ontology that are characteristically sensitive to the cosmic and spiritual forces of the universe: “It all depends on the moon and the stars on which you were born,” one healer suggested while describing the onset of awas. Similarly with ch’i’ chi’i’ il another described, “That comes from birth, they have a negative mind. Some born in like [the months of] Tijax and Imox.Footnote 4 It’s the day of the sea and the seas have rough and big waves. It’s the same as a person. He will have some difficult times, some roughness like the waves.” Thus, various occurrences of moral infringement can impact the day in which a person is born (i.e., maatan), and in the case of ch’i’ chi’i’ il where an individual is born on Tijax or Imox, days which reflect the tidal qualities of the sea, the child will take on those characteristics and be temperamental and miserable, moving in and out of turbulent behaviors.

The main tensions within this genre involve questing for answers as the parents seek assistance regarding their child’s developmental and neurological abnormalities. The temporal aspects of this genre are long and drawn out over the course of childhood and early adolescence and occasionally throughout one’s entire life. The central actors in this condition are the parents and family members, with the child and mother having a particularly strong role in the plot development. The symptoms experienced by the patient vary, but primarily involve disturbed cognitive ability, loss of memory, and the inability to control one’s body. The resolutions of the plot primarily involve acceptance and/or forgiveness on behalf of those who committed some type of moral infringement before the birth of the individual suffering from this condition. This is facilitated through various ceremonies and healing sessions. The treatment outcomes, however, can widely vary depending on the severity of the condition. The most severe conditions, which involve brain damage or neurological abnormalities, are presented by aj iloneleb’ to be the most chronic. In this plot, the parents are forced to adapt to the condition and after the initial search for a cure, the family and the individual come to accept, to varying degrees, what has been given to them. In a sense, acceptance or searching for the positive aspects of the situation is their therapeutic intervention. In the less severe cases of these conditions, the individual will need constant maintenance throughout their life, including periodic visits to healers or spiritual guides, to ensure their inherent susceptibility for these conditions is under their control and does not manifest in a debilitating manner. In the least severe of these cases, the healers suggest that a full “cure” is possible through the intervention of “restorative”-based healing (Waldram 2013), in which case the condition is eliminated and the patient’s symptoms entirely abated.

The Q’eqchi’ term “sachk” refers to the condition of being “lost,” as in being lost in the jungle and in need of a guide. While the term “ch’ool” refers to the “soul” of the person, sachk ch’ool does not signify a concept like the “spirit” as in “spirit loss.” Rather, it references a generalized notion of “life,” a way of being that is “lost” or meaningless when experiencing this condition due to the improper functioning of the mind. Indeed, Q’eqchi’ translators often used the term “retarded” to describe this condition. Within sachk ch’ool, “The person will not be talking properly or he will be acting like a drunken person because he had lost his mentality. They will be totally lost (sachk) or at times when they speak it doesn’t make any sense,” one aj ilonel described. In a similar way, another observed that “anybody can get it [sachk ch’ool], sometimes the children are born retarded,Footnote 5 whereby the mind would not be functioning properly, the face would be down, and they will have difficulty in learning at school.” In addition, although the main discourse of this condition was centered on children, there were also occasional suggestions that sachk ch’ool can develop among elderly people. “Sometimes you can get it when you are old and sometimes kids are born with it,” another aj ilonel described. In these cases, “sachk” referred more specifically to the “memory loss” of a person and, thus, suggests possible connections with narratives related to Alzheimer’s or dementia, conditions described as the degenerative capabilities of the brain due to “age-related” concerns. Although this research reveals a “narrative genre” clearly focused on “childhood” conditions or “days of birth,” it is interesting to note that no specific narrative genre focused on the elderly emerged from this research.

Ch’i’ chi’i’ il and awas are closely related to sachk ch’ool, yet are still recognized as distinct conditions. The Q’eqchi’ term “ch’i’ chi’i’” signifies a bodily state of irritation or being miserable, when the body (cha’al) is not happy. The term “il” simply means the person who is experiencing this state. The term awas has no direct translation in English but can be understood as a form of mimesis, in which one or more properties, characteristics or traits of an object are taken on by another. This is a kind of mystical transference or bonding of properties between objects, animals, or people in the local environment. Signifying the influence of cosmic forces and the day in which someone is born, awas is typically translated as the “illness of the moon.” The “illness” aspect of this condition, then, reflects the state in which negative or undesirable characteristics are taken on, bonded to, or manifested within a particular individual. In a similar way to sachk ch’ool, awas is described as a kind of generalized difficulty in cognitive ability. “Sometimes with this condition it is just the way we are born,” one healer noted, “for instance if you are sending one of your children to school they may not have interest in doing work in class, may have difficulty learning.” In ch’i’ chi’i’ il the child “won’t be feeling well, he’s always stressed out,” another aj ilonel explained. “The child is just stressful, crying, fighting and won’t be able to eat,” yet another added, “like when he sees his food, he would just reject it and cry.” Again, another healer suggested that “When it’s [ch’i’ chi’i’ il] in a child he or she will just be crying and crying, because the child will be feeling heat in the body.”

What emerged during aj iloneleb’ descriptions of this “narrative genre” was a story that blurred across DSM-5 categories of “Neurodevelopmental Disorders.” These conditions are defined in the DSM as “disorders that manifest early in development, often before the child enters grade school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning” (APA 2013, p. 31). Such conditions typically include Autism Spectrum Disorders (ASDs), a generalized notion of intellectual or learning disorders, motor disorders, Down Syndrome (DS), or Mental Retardation (MR). Both the healers’ descriptions and DSM categories narratively relate insofar as they begin at birth and are, therefore, usually chronic, neurological conditions lasting throughout life.

There are also powerful moral discourses that are not centered on the child, but rather the roles of the parents, family, or community members. Such personalistic notions of etiology are common to many healing traditions around the world (Foster and Anderson 1978; Erickson 2008), and the focus on morality is often central (Shweder 2003). According to the Q’eqchi’ healers, children are largely outside the realm of moral responsibility, not having yet been moralized and socialized into the community (Kahn 2006). Thus, when children are born with certain conditions resembling mental disability, it is the parents, and particularly the mothers, who are morally responsible for the onset of the condition. “That [sachk ch’ool] illness happens when the mother is a bad woman or she may hate other people,” one healer outlined. Another reasoned, “When the child gets awas it’s because the mother doesn’t like the scent of such things and hates something or someone. Then the baby would directly be born with that effect.” As another healer further described for ch’i’ chi’i’ il, “Sometimes they get that sickness when they are born because when a woman is pregnant they might like go for a walk at night and that is what causes them to get that sickness.” In this way, how the parents, and particularly mothers, behave and treat others in the community, and how they react to situations during conception and gestation periods, are risk factors for the onset of the illnesses in the child. Whether parents start a conflict with a neighbor, walk late at night, or are frightened by an animal, the child will be born on a particular day that bestows specific characteristics onto the child. The mother’s sins, aj iloneleb’ often remark, are shown in the child.

The three conditions within this “narrative genre,” more so than any others, are understood to be chronic neurological conditions that are with a person through life, a kind of narrative framework for interpreting why some children are born with mental disabilities and others are not, with the locus of moral causation situated in the actions of the mother and close family members. Although views of chronicity of these conditions do vary by healer and can range in severity, one important aspect of the therapeutic encounter is commonly to restore the moral order by ceremoniously placating the spirits and asking for forgiveness on behalf of the mother or family members. If this is done properly, and of course depending on the severity, the child may at least partially recover from whatever debilitating condition is inflicting them and a “restorative” healing process can result (Waldram 2013).

Spirit “attacks”

Four of the seventeen “mental” illness conditions recognized by the healers fall within the broad narrative genre of spirit “attacks” and are depicted in Table 4. There are 14 different causes identified for the illness conditions under this “narrative genre”: spirit “attack”; in the air; already in the blood (i.e., heredity); thinking too much; fright; failure to seek permission; from other conditions; falling down; witchcraft; changes in temperature; maatan or day of birth; actions of parents; physical impact; and spontaneous. In total, these 14 causes were mentioned 34 times, 27 (79 %) of which are related directly to spirit “attack,” a failure to ask for permission, or something in the “air” that “hits” the person, all of which are related to the ideology of spirit “attack.” It is important to note that k’axum xul (i.e., snake bite) is also included in this narrative genre of mental illness since its description by the healers closely resembles rilom tzuul and eet aj yahel. Sikirk is also included in this narrative genre due to its related narrative structure involving contact with “spirits” or supernatural forces, yet this condition is somewhat separate from the others insofar as its symptomology primarily involves neurological or sensory-motor defects as opposed to direct “mental” disturbances. In this way, it is included under this narrative genre for similar reasons as k’axum xul.

Table 4 Spirit “attacks” narrative genre of mental disorders
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For the illness conditions classified under the spirit “attack” or tyajel xiilik’ narrative genre, aj iloneleb’ focus on the situations that led to the onset of symptoms and to the risk or protective factors. The medical gaze, therefore, seeks out external agents, intentions, or events that provide insight to the agents’ pathogenic intentions, a kind of “sociopsy” (Nash 1967). The logic of inquiry is moral and sociological, concerned with the motives, desires, and grievances of the individual or family. Common idioms invoked when discussing these conditions include permission, duty, obligation, sin, or proper conduct, which reflect a broad Q’eqchi’ typology of morality (Hatala 2014; Kahn 2006). Spirit “attack” is understood primarily to occur to an individual who has broken the normal moral code or transgressed a social obligation, especially concerning the other-than-human realm and the spirits of the “Mountains and the Valleys.” “It could be when you don’t pray to God for guidance and protection, to ask for permission, that’s your fault to Him,” one aj ilonel said when describing the onset of eet aj yahel. “Because of the person’s faults,” another added, “it’s the evil spirit that could get into the person, like the Mountain Spirit. It would hit the person and make them go unconscious.”

Throughout the healer’s descriptions of these conditions, the concept of “permission” is common and expressive of the factors leading to or determining the likelihood of an “attack.” The attack of a spirit is seen as a kind of punishment for one’s sins, either by omission (i.e., failing to placate the spirits and request permission), or by commission, (i.e., where an individual wronged another). In either case, the plots of spirit “attacks” all begin and are colored by an understanding of a “moral economy of permission,” a core aspect of Q’eqchi’ cosmovision (Hatala 2014).

Another prominent feature of this narrative genre is the degree to which the onset of the illness symptomology is sudden or rapid. The patient here is described to fall down suddenly, in some cases clench teeth, foam at the mouth, and roll their eyes in the back of their head. Along with conditions closely related to epilepsy or epileptic seizure disorder, snake bite or k’axum xul, is included in this narrative genre because of the similar plot structure and the semantic relation often held by the Q’eqchi’ healers between snakes and “evil” spirits.Footnote 6 Snake bite is clearly a sudden and shocking event that can be conceptualized as an “attack” of some kind. As with the sudden onset of symptoms of snake bite, eet aj yahel and rilum tzuul are described to occur in a similar fashion. “When the spirit hits you,” one aj ilonel stated, “you go down.” “The spirit hits the person and they go unconscious, they begin to shake and their eyes roll back in their head,” another noted regarding rilum tzuul. The plot here is characterized by its dramatic nature, and its sudden and disruptive onset. Whether hit by a spirit of the Mountains and Valleys, or bitten by a snake, these spirit “attack” conditions are instantly debilitating. Thus, the temporal sequencing of events for these conditions is somewhat compressed when compared to the other narrative genres, allowing little time on the part of the healer to treat the condition. These conditions are also more dangerous and are treated with enhanced respect and recognition of their power. It takes a well-trained healer to properly attend to rilum tzuul and k’axum xul or snake bite.

In Q’eqchi’, yahel is a general term that translates as “illness.” The Q’eqchi’ term “eet” signifies being irritated or stubborn, or very moody, unfriendly or angry. The phrase eet aj yahel is difficult to translate into English, but is commonly understood as “epilepsy” due to the symptoms of falling down, uncontrollable tremors, and an inability to listen to others or interact socially while experiencing the illness episode. As one Q’eqchi’ healer described, “they scream or they might look back with their neck twisted with their eyes rolling back in the head.” Similarly, another observed, “with this condition the teeth are clenched together and when it starts the person might fall to the ground and be unconscious.”

Rilum tzuul is described similarly, except it is more severe with a violent characteristic of the “attacks” and greater resistance to treatment. The Q’eqchi’ word “tzuul” roughly translates as Mountain spirits. The term “rilum” signifies a kind of “seeing.” Rilum Tzuul, then, translates as the “illness of the mountain spirit”, or, more literally, “the mountain spirit came and looked at the person and they got ill.” Both rilum tzuul and eet aj yahel likely describe different kinds of seizure activity, perhaps reflecting differences between the symptoms of tonic–clonic seizures and complex partials seen in epilepsy.

The Q’eqchi’ term k’axum xul refers to the physical case of snake bite and is reflective of this narrative genre due to its relation to the stories, narrative structure, and plots of eet aj yahel and rilom tzuul. K’axum xul phenomenologically manifests the same as the other two conditions and is thus treated with the same degree of care and respect.

The Q’eqchi’ term sikirk translates as “numbness,” and reflects a kind of temporary paralysis in the limb or nerves of the individual, as the individual loses mobility or sensitivity in the infected area. As one aj ilonel described, when affected by sikirk, “The person cannot walk with his foot and when it’s his hand he cannot get hold of anything. He isn’t happy because he isn’t capable of doing anything. His body part affected would be numb and not work properly.” There are multiple causes recognized for this condition, but one of the most common is the “attack” of a spirit. “To get this type of sickness [sikirk] the person is resting in an old house or a place where the spirit of the devil rests. This spirit will attack the person and get into them,” one aj ilonel explained. Another healer similarly suggested, “It’s the animal that passes through the wind and leaves bad spirit behind and when that breeze hits you then you’ll get that sickness [sikirk], making you numb and not able to move.” Sikirk is less severe than the three other conditions within this narrative genre, but is placed here based on the similarity of etiology, narrative structure, and treatment approach.

The final stages of the plot for this narrative genre, or “resolution,” center on the extraction of the “spirit” that is attached to or inside the individual due to the “attack.” When the person is “attacked” by one of the spirits, there remains an aspect of the spirit within the individual that causes them to remain ill in some instances, or to continue having regular, smaller attacks in others. The “evil” spirit is described as “feeding” on the patient causing the illness symptoms. This is opposite to the “Fright” narrative genres in which the individual’s spirit is “lost” or frightened out of the body. In these cases, there is an extra spirit within the person continuing to “feed” on them, causing serious harm. Thus, the healing drama unfolds around the complex and careful work of extracting the foreign entity out of the body, whether the lingering venom from k’axum xul or the “evil” spirit from rilum tzuul. Extracting the “evil” spirit from within the person usually involves a kind of sacrifice or offering (awas). This procedure lures the spirit out of the person and enables aj iloneleb’ to take it deep into the forest. The extraction of the spirit, therefore, involves making sacrifices and offerings, which are typically various kinds of animals on which the spirit can feed instead of the patient.

Once this work is complete, the healer focuses on asking for forgiveness of moral transgressions on behalf of the patient, and that they suffer no more future “attacks.” This aspect of the awas healing ritual is similar to the permission ceremonies oftentimes conducted before the collection of plant medicines or hunting in the jungles. These ceremonies, coupled with the extraction of the evil spirit, if done under the proper conditions, will allow the patient to fully heal from their condition and return to a pre-condition state. This genre therefore has a similar cyclical plot form as with “Fright” narratives, in which patients return to a pre-illness state.

Nevertheless, a subtle difference can be seen. Due to the strong moral rhetoric invoked with these spirit “attack” conditions, the individual is often brought to reflect on their actions and come to a “new” place once symptoms have subsided. More so than any other narrative genres, these illnesses are understood as a “lesson” from the spirits. They provide a mode of spiritual and existential education and help the individual live in harmony with social and spiritual forces that govern Q’eqchi’ notions of morality, ontology, and community life. A kind of “transformational” healing is observed here (Waldram 2013); the punishment of the “attack” now corrects their behavior and forces the patient to grow and learn from the experience. The plot is in some sense cyclical, but resolves at “new heights” of moral awareness. The patient experiencing snake bite or an “attack” has grown in some existential way, living life more “attuned” to the underlying cultural ethos engendered through their moral visions of the world (i.e., cosmovision).

Toward a Narrative Nosology

With their sophisticated narrative genres of mental illness and disorder, the members of the Maya Healers’ Association are quite adept at recognizing and ordering a set of events and patient symptoms as a therapeutic story with a coherent temporal ordering, teleological structure, and plot. This is a form of “therapeutic emplotment,” which, as Mattingly (1994) outlined, “involves making a configuration in time, creating a whole out of a succession of events.” “What we call a story,” she continued, “is just this rendering and ordering of an event sequence into parts which belong to a larger temporal whole, one governed by a plot” (p. 812). The early onset and chronic nature of the days of birth conditions, the frightening event, the “thinking too much” from social misfortune and structural limitations, or rapid “attack” of a spiritual nature requiring an exorcist-like intervention, all reflect a broad notion of Q’eqchi’ mental disorders, their “larger developing narrative structures” that aj ilonel “actively seek to impose upon clinical time” (Mattingly 1994, p. 811). Table 5 summarizes the six structural elements of narrative that emerged to make distinctions across each narrative genre.

Table 5 Comparing narrative genres of Q’eqchi’ mental disorders
Full size table

Although research from both Western and Indigenous epistemologies include narrative in its approaches and methods, most narrative research of illness and healing in cultural psychiatry and medical anthropology has been about patient experiences (Becker 1997; Garro and Mattingly 2000; Garro 1994, 2010; Kirmayer 1996, 2000; Waldram 2010). To examine how stories or narratives are recognized or constructed by the Q’eqchi’ healers to guide, as part of their healing epistemology, the interpretation and treatment of mental illness and disorder is, however, somewhat unique. Throughout our research, narrative forms of representing reality have provided insight into the synthetic processes through which Q’eqchi’ “mental” illnesses are constituted, shaped, and treated.

The detailed interviews with the members of the Maya Healers’ Association reveal that narrative is not only a form in which experience is represented and recounted, in which events are presented as having a meaningful and coherent order (Bruner 1986; Garro and Mattingly 2000; Waldram 2010), but also a medium through which the epistemological structure of Q’eqchi’ medical reality is revealed and understood. It was argued throughout this article that Q’eqchi’ “narrative genres” signify a “common stock of stories” or “canonical genres” that enable aj iloneleb’ to recognize, create meaning from, and enact cultural scenarios with which they are familiar (Mattingly 2000, 2010; Good 1994). It is the way in which clinical time and patient experiences are “domesticated” or “emploted” by aj iloneleb’ narrative genres that concerned us throughout this research (Becker 1997; Mattingly 2010). And it is in this way that the different mental illnesses recognized by the Q’eqchi’ healers represent competing narrative structures, genres, or plot forms.

It is clear that the narrative genres of mental illness are informed by contemporary forms of Q’eqchi’ cosmovision and cultural practices. The objects of Q’eqchi’ medical reality and narratives of disorder are culturally situated and in dialog with other ideological systems and modes of practice such as biomedicine or various forms of Christianity. This research demonstrated that contemporary nosological perspectives of the Q’eqchi’ aj iloneleb’ comprise a relatively stable core of illnesses known to impact the mind of an individual. This is not to say, however, that Q’eqchi’ medical knowledge is static or hermetically sealed. Rather, like Lock and Nichter (2002) observed with medical traditions such as Ayurveda and Chinese medicine, Q’eqchi’ medicine is open, dynamic, and is capable of creative synthesis as contact with other medical traditions. Seeing illness as narratively constructed allows us to appreciate that cultural influences are implicated in the articulation and construction of illness categories while acknowledging their flexible nature to adapt and respond to new situations and contexts. Previous research attests to this notion, for instance in the adaptation of local medical systems to the relatively “new” illness condition HIV/AIDS (Mogensen 1997; Thomas 2008; Waldram and Hatala 2015).

The Q’eqchi’ healers also rely on the ultimate casuistry of narrative amidst clinical encounters, a judgment or reasoning process that is shared with biomedical practitioners. Several important studies conducted over the last few decades have delineated the narrative reasoning that underlies clinical work in Western biomedical settings (Charon 2006; Flemming and Mattingly 2008; Hunter 1991; Hurwitz 2000; Kirmayer 2006; Mattingly 1994, 2000, 2010; Montgomery 2006; Waldram 2012; Wood 2004). Indeed, Hunter (1991) concluded that “as a human enterprise, medicine speaks primarily through the narratives its practitioners construct as hypotheses about a patient’s malady, the stories that convey the medical meaning they have discerned in the text that is the patient” (p. 26). The different processes of this kind of “narrative reasoning” were highlighted and reflected within the healing practices of Q’eqchi’ aj iloneleb’ (Hunter 1991; Montgomery 2006). This points to a perhaps unsuspected parallel in clinical judgment in the practice of biomedicine and “traditional” Q’eqchi’ healing. Both biomedical and Q’eqchi’ medical practices are engaged in a clinical reasoning process that is empirical and rational in nature and employs the casuistry of narrative. Indeed, recognition of the rational and empirical principles present in many forms of traditional healing can be an essential step toward a more fruitful partnership between them and biomedicine (Craig 2012; Lock and Nichter 2002).

Conclusion

Q’eqchi’ healers often conceptualize the physiology of “mental” disorders by including other aspects of the human person, for example, the heart, spirit, blood or body. With one exception (i.e., tib’l jolom), all “mental disorders” involved these other human aspects in some way: spiritual, cultural, and historical notions are integrated in Q’eqchi healing epistemology with those of a material nature. Thus, Q’eqchi’ notions of “mental” are broader than the physiological undercurrents of disorder found within biomedical and psychiatric categories, a finding often reflected in other Indigenous communities (Waldram 2004; Kirmayer 2007; Alarcón et al. 2009). This being said, however, it is also relevant to observe the similarity between several Q’eqchi’ conceptions of “mental” disorder and those detailed in the DSM-5. For example, the symptomology and prognosis of rahil ch’ool and xiw xiw seem to correspond closely with the categories of MDD and GAD, respectively. This would support the notion that some mental illness conditions may occur in “cross-cultural” contexts, with local variations and idioms, and that therefore some “traditional,” empirically based, localized, and culturally grounded approaches to treating them may remain salient and effective. Accepting these observations should aid potential dialogs between the MHA members and the Belizean Ministry of Health and promote a collaborative approach to mental health service delivery for Q’eqchi’ and other Maya people.