Selfhood and social distance: Toward a cultural understanding of psychiatric stigma in Egypt

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Social Science & Medicine 61 (2005) 920–930 www.elsevier.com/locate/socscimed

Selfhood and social distance: Toward a cultural understanding of psychiatric stigma in Egypt Elizabeth M. Coker Department of Sociology, Anthropology, Psychology and Egyptology, The American University in Cairo, 113 Sharia Kasr el Aini, P.O. Box 2511, 11511 Cairo, Egypt Available online 3 March 2005

Abstract Psychiatric stigma is a concept that is often used uncritically by policy-makers to explain the underutilization of professional psychiatric services in non-Western societies. Stigma, however, is a multi-determined process manifestations and effects of which cannot be viewed separately from the larger social and cultural context. The present paper presents the results of a qualitative study of psychiatric stigma in Egypt from the perspective of lay respondents. A vignette method was used to elicit judgments of social distance and qualitative responses to stories depicting psychosis, depression, alcohol abuse and a ‘possession state’ from 208 respondents recruited through their places of work. The results indicated that while stigma does exist in Egypt, the form that it takes must be understood with reference to Egyptian notions of selfhood that locate behavioral disturbances in the intersubjective rather than intrapsychic realm. On the one hand, individual blame is diffused as responsibility for the illness and its cure is placed in the social, not personal (or biological) realm. On the other, behavioral disorders that threaten the social fabric of society are particularly stigmatized and often met with social rejection. r 2005 Elsevier Ltd. All rights reserved. Keywords: Stigma; Mental illness; Egypt; Psychiatry

Introduction In Egypt as elsewhere, one of the most commonly cited reasons for the under-use of available psychiatric services by the lay-public is the notion of stigma. ‘Stigma’ is frequently blamed for the cultural incompatibility of western-based mental health programs in certain contexts, for the continued reliance on traditional healers and the failure of certain non-western countries (and immigrants from the same) to fall in step with the dominant psychiatric paradigm (Al-Krenawi, Graham, & Kandah, 2000; James et al., 2002; Raguram,Weiss, Channabasavanna, & Devins, 1996). Erving Tel.: +20 2 797 6804.

E-mail address: [email protected].

Goffman’s original formulation of stigma referred to the notion of ‘‘spoiled identity’’ or the devaluation of persons possessing certain socially and/or morally unacceptable traits (or labels) that were revealed by the presence of bodily signs (Goffman, 1963). However, the concept of stigma has widened a great deal since then and now refers to a diverse set of processes that may or may not be related to outwardly observable signs. ‘‘Stigma is creaking under the burden of explaining a series of disparate, complex, and unrelated processes to such an extent that the use of the term is in danger of obscuring as much as it enlightens’’ (Prior, Wood, Lewis, & Pill, 2003, p. 2192). Nonetheless, the term ‘stigma’ is often used in non-western contexts as if it were somehow a homogeneous entity that, once identified, is assumed to exert a predictable effect. The

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increasing popularity of so-called ‘‘culture-free’’ stigma questionnaires raises the question of, first of all, whether stigma is an ‘‘entity’’, and second, whether it could ever be entirely free of culture (Littlewood, 1998). When the stigma construct is used uncritically in research or in policy-making across cultures, then we are in danger of committing something similar to the now-familiar ‘‘category fallacy’’ warned of by Arthur Kleinman (1980, 1988). In other words, searching for stigma in non-western cultures may result in something that fits the original category, but may very well misrepresent or miss the cultural nuances associated with the lived experience of stigma, however defined. The effect of social attitudes towards mental illness upon the experiences of those thus afflicted has been studied extensively under the rubric ‘‘labeling theory’’ (Scheff, 1967). In traditional labeling theory, deviance is produced not in the individual committing the act, but in the interaction between the individual and those who respond to the act (Murphy, 1976; Weinstein, 1983). The labeling of deviant behavior as voluntary or intentional, or the interpretation of symptoms as symbols or as meaningless events is assumed to have a profound effect on the social role that person assumes (Devereux, 1961; Kirmayer, 1989). It is in this way that psychiatric stigma in particular is thought to exert its influence. While the person involved may not possess the ‘‘bodily signs’’ referred to by Goffman, the label itself begins to fulfill this role, becoming the ‘sign’ that produces rejection in the social sphere. The association of stigma with social rejection has led to the common use of ‘social distance’ scales to measure this construct (Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999; Weinfurt & Moghaddam, 2001). These scales offer a quantifiable, ostensibly comparable, way of judging how much distance one would prefer to keep between themselves and a hypothetical person with a given disorder. While the drawbacks of these scales are numerous and have been described elsewhere (Littlewood, 1998), what they offer more than anything is an operational definition of what researchers mean when they discuss the concept of stigma. The present paper will utilize social distance as an operational definition of stigma, but with the understanding that, taken out of context, the construct is virtually meaningless, and measures of stigma as social distance must be heavily contextualized (accomplished here through qualitative analysis) for adequate interpretation (Weinfurt & Moghaddam, 2001). The concept of stigma nevertheless has considerable heuristic value in helping us to understand attitudes and behaviors towards mental illness in different societies. In recent years, many authors have called for a more nuanced understanding of psychiatric stigma through in-depth anthropological and comparative work on mental illness beliefs (Fabrega, 1991; Giosan, Glovsky,

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& Haslam, 2001; Kirmayer, 1989; Littlewood, 1998; Prior et al., 2003; Raguram et al., 1996; Weiss, Jadhav, Raguram, Vounatsou, & Littlewood, 2001). An understanding of cultural concepts of person, social values and norms, experiences with biomedicine and psychiatric treatment, and other factors within a given society is necessary to separate out the different components of that which we have chosen, for the sake of communication, to label as ‘‘stigma’’ (Corrigan & Penn, 1999). For example, Opala and Boillot (1996) used the concept of ‘‘worldview’’ to elucidate stigmatizing attitudes toward leprosy among several different Limba groups in Sierra Leone. What they discovered was that the effectiveness of leprosy control programs in eliminating stigma had more to do with the meanings of stigma within the society and how medical treatment interacted with those meanings than with medical education or particulars of the treatment itself. Among the groups that believed leprosy victims were witches and stigmatized them as such, curing the disease did not reduce the stigma (they were, after all, still witches). However, the groups that saw leprosy as a product of witchcraft welcomed suffers back into the community once the cure was introduced, with no residual stigma at all. This study has implications for psychiatric stigma as well. Public attitudes toward psychiatric disturbances in the West are the product of a worldview that has evolved according to very specific historical, political, and cultural pressures (Jimenez, 1987). Unfortunately, the social stigma that has resulted in that particular society has been treated as somehow unproblematic, a ‘‘natural’’ result of psychiatric labeling, and a catchword for mental health education programs all over the world (Rosenberg, 2002). Psychiatric stigma in the Arab world Many studies have suggested that mental illness is not stigmatized, or at least does not elicit as much stigma in the Arab world compared to other societies, often explaining this with reference to religion (Dols, 1992; Fabrega, 1991). Traditionally, ‘‘idiots’’ were presumed to be blessed by God, and thus endowed with some degree of saintliness, and allowed to wander free and be supported by alms (Lane, 1966). At the very least, a mentally ill or mentally retarded person might be indulgently tolerated as the ‘‘village idiot’’, or the ‘‘silly’’ of the quarter, herding goats or doing whatever other task of which he was capable (Rugh, 1984). However, while tolerance may be the rule in the Arab world when it comes to identified illnesses or mental retardation, other studies suggest that stigma does indeed exist under certain conditions, notably those involving socially unacceptable or out of control behavior, standards of which would vary according to the gender of the person in question (Al-Krenawi et al.,

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2000; Baasher et al., 1983; Bassiouni & Al-Issa, 1966; Younis, 1978). According to Bassiouni and Al-Issa (1966), traditional cultures of the Arab Middle East generally tolerate mental disturbances as long as they do not result in out of control or shameful behavior, and it is usually only in the latter instances that a doctor is sought out. In light of this conflicting evidence, it is particularly important to uncover the underlying cultural belief systems that mitigate stigma toward the mentally or behaviorally disturbed. It is proposed here that aspects of self and identity coupled with the specific meanings given to mental illness in Egypt lead to the unique form that stigma takes in this context. In Northern European Protestant culture (the historically dominant cultural influence in the United States), the person, or self, is experienced as constant, yet alterable through individual effort (Gaines, 1992; Shweder & Bourne, 1982). In this cultural self-conception (also termed ‘‘referential’’), the individual is the source of action and doing, constancy is valued in interactions with others, and the person is considered separately from the social context (Gaines, 1992). Because of this emphasis on the individual, rational being, mental illness strikes directly at this dearly held notion of a controlled, rational self, and as such, may be experienced as highly threatening. In contrast to the Northern European ‘‘egocentric’’ self, the Mediterranean self has been termed ‘‘indexical’’ (Gaines, 1992). That is, the self is constructed and experienced in relation to others in the environment, and in fact, may adapt and change accordingly. In much of the Middle East, not only is the self experienced in relation to one’s social surroundings, but one is evaluated by others in relation to the social context as well (Abu-Lughod, 1986; Bowen & Early, 1993). Differing notions of self and person have been shown to affect representations and manifestations of mental illness in Egypt in other contexts (Coker, 2003). The present paper will demonstrate that psychiatric stigma in Egypt is the product of a unique worldview consisting of indigenous constructions of selfhood interacting with the cultural values and meanings of mental and behavioral disorder in this context.

Method The data used in the present study were part of a larger study examining ‘‘knowledge, attitudes and practices’’ about mental illness and mental illness treatment in Egypt. A total of 208 persons were interviewed for the present project. Participants were recruited through their places of work with the permission of the director or owner (who themselves were not interviewed). The locations were chosen in order to get a cross-section of lower- to middle-class

individuals, and included a private school, a gas station, a textile factory, and an accounting office, among others. Trained Egyptian researchers interviewed 10–20 individuals (excluding owners/directors) from each location, with their informed consent. Of the 208 participants, 184 answered all the questions about social distance for both of the vignettes, and were included in the present analysis. Of these, 34% were female and 66% were male,1 93% were Muslim and the rest Christian; the mean age was 35.1 years (SD 12.29); the majority (57.6%) were married, 5.2% were divorced or widowed and the remainder single; and 10.8% were illiterate, 10.2% had a primary school education only, 27.3% had a secondary school education, and 29% had a university degree or above. The interviews used clinical vignettes to assess lay beliefs and attitudes about mental illness and treatment, a technique used successfully in similar studies (Giosan et al., 2001; Kirk, Wakefield, Hsieh, & Pottick, 1999; Link et al., 1999; Littlewood, 1998). The vignettes consisted of four short (paragraph-long) vignettes (in Arabic) that were developed to represent typical presentations of four different disorders: psychosis; major depression; alcohol abuse, and a ‘‘possession state’’. The first three vignettes were developed through consultations with psychiatrists. They were verified through consensus with several medical professionals as depicting a potentially diagnosable case of the particular disorder. The fourth vignette, the case of ‘‘possession’’, was developed through the author’s own experience observing such cases at a local mosque. Two Muslim religious leaders verified that the latter represented possession. Each vignette type was presented either as a ‘‘male’’ person, or as a ‘‘female’’ person, thus, a total of eight vignettes were used in the study. Each participant was randomly presented with two of the eight vignettes (one at a time), although no one received both the male and female version of the same vignette type. Participants were asked to answer questions about each vignette, focusing on perceived problem, cause, prognosis, characteristics that were considered to be most serious, possible treatment or help for problem, rationality, social functioning, and harm to others. Quantitative measures of social distance were measured on a three-item scale, from ‘‘will accept’’, ‘‘will accept after treatment’’ and ‘‘will not accept’’, for the following four social categories: neighbor, teacher for children, friend, and family member (by marriage). Questions were open-ended, and elaboration of responses was encouraged. Responses were recorded verbatim by hand. The data (315 total responses from

1 Because of the way we collected our data (through place of work) our sample was somewhat biased towards men.

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Table 1 Social distance by vignette type Depression (%)

Possession (%)

Psychosis (%)

Alcohol abuse (%)

Total (%)

Neighbor Will accept Will accept after treatment Will not accept

92.3 1.1 6.6

79.7 5.4 14.9

68.4 5.3 26.3

35.1 8.1 56.8

70.2 4.8 25.1

Friend** Will accept Will accept after treatment Will not accept

78 5.5 16.5

68.9 9.5 21.6

55.3 6.6 38.2

25.7 16.2 58.1

58.1 9.2 32.7

Family member** Will accept Will accept after treatment Will not accept

26.4 39.6 34.1

18.9 33.8 47.3

13.2 30.3 56.6

1.4 17.6 81.1

15.6 30.8 53.7

Teacher** Will accept Will accept after treatment Will not accept

30.8 15.4 53.8

25.7 14.9 59.5

6.6 7.9 85.5

1.4 13.5 85.1

16.8 13 70.2

**

**

Chi-square significant, vignette type by rate of acceptance, po.0001.

the 184 participants2) were analyzed both qualitatively and quantitatively. The qualitative responses were analyzed to ascertain patterns in judgments of illness definition, cause, and treatment suggestion. The coding followed the participants’ own tendency to suggest certain interpretations. For example, many insisted on differentiating between a psychological ‘problem’ (mishkelit innafs) and a psychological ‘illness’ (mareed nafs). Illness definitions revealed by the coding scheme included ‘psychological problem’, ‘psychological illness’, ‘social problem’, ‘demon possession’, ‘madness’ (magnuun), ‘physical illness’, and ‘intentional misbehavior’, while illness causes included ‘family of origin’, ‘personal failure’, ‘trauma’, ‘weak character’, ‘financial problems’, ‘losing faith in God’, and ‘society’. Treatment suggestions included ‘social support’, ‘psychiatrist’, ‘religious practice’, ‘self-treatment’, ‘religious healing’, and ‘medical doctor’, while additional coded variables included ‘is harmful to others’, ‘impaired reasoning’, and the participant ‘feels a moral/religious imperative to help’. For the purposes of the present paper only those variables listed above that were statistically related to social distance for any of the four social categories were included (Chi-square used throughout, alpha o.01). The rest, while interesting, were not found to mediate social distance. Qualitative analysis then concentrated on the variables that were found to be associated with social distance. In-depth responses for each subject that 2 Not all of the participants answered both of the vignettes, which explains the total of 315 responses for 184 participants.

focused on these issues were analyzed for deeper meanings and themes that arose, in order to provide a context to interpret the results.

Quantitative results Social distance Table 1 presents the results of the social distance scale for each vignette type and each category of social distance (neighbor, friend, family member, and teacher). Chi-square analyses for social distance by vignette type were significant for all four social distance categories. As Table 1 shows, social distance collapsed across the four social categories, as indicated by a response of ‘‘will not accept’’, and was greatest for the role of ‘‘teacher’’ (70.2%), followed by family member (53.7%), friend (32.7%) and neighbor (25.1%). Social distance varied significantly across the four vignette types, with ‘‘alcohol abuse’’ eliciting by far the greatest social distance for neighbor, friend, and family member, followed by psychosis, possession disorder, and depression. However, for the category of ‘‘teacher’’, respondents were almost equally unwilling to accept the psychotic person and the alcohol abuser. An analysis of sociodemographic characteristics (gender of participant, marital status, age, religion, and education) by the variables in Table 2 yielded no significant findings whatsoever. The gender of the vignette by social distance by vignette type was significant in only one case (the depressed female was

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Table 2 Illness definitions, perceived causes, and treatment suggestions related to social distance, as percentage of total responses, by vignette type Depression (n ¼ 91) (%)

Psychosis (n ¼ 76) (%)

Alcoholic (n ¼ 74) (%)

Total (n ¼ 315) (%)

4.1

34.2

18.9

14*

33.8 37.8

52.6 59.2

64.9 62.2

41.6* 48.3**

8.1 45.9

18.4 71.1

18.9 50.0

11.4* 51.1

47.3 19.8

51.4 5.4

6.6 10.5

10.8 9.5

29.8* 11.7

79.1

44.6

52.6

66.2

61.6*

60.4

73

64.5

51.4

62.9

Correlated positively with social distance Person is ‘‘magnuun’’ (crazy, lunatic) (all 1.1 4 categories) Harmful to others (all 4 categories) 19.8 Impaired reasoning (neighbor, teacher, 36.3 and family member only) Psychiatric hospital (all 4 categories) 2.2 Psychiatrist or psychologist (teacher and 39.6 family member only) Correlated negatively with social distance Failure (work, love, etc) (all 4 categories) Society/larger social conditions (neighbor and friend only) Social support (teacher, friend and family member only) Feels a moral/religious imperative to help (neighbor, friend and family member only) *

Possession (n ¼ 74) (%)

Chi-square significant po:001: Chi-square significant po:01:

**

more likely to be accepted as a family member than the depressed male), otherwise, the gender of the vignette had no relation to social distance.

worries if the person in the vignette was male (regardless of vignette type).

Variables related to social distance Discussion and qualitative analysis of results Chi-square was used to determine what variables correlated with measures of social distance. Variables were included if they were significantly associated (alpha o.01 used throughout) with at least two social distance categories. As Table 2 shows, higher social distance was associated with saying a person was mad or crazy, harmful to others, had impaired reasoning (significant for neighbor, teacher and family member), and required psychiatric hospitalization or a psychiatrist (significant for teacher and family member). Lower social distance (i.e., less stigma) was associated with citing ‘personal failure’, or social factors as a cause, suggesting social support as a primary treatment, and expressing a moral or religious imperative to help the person. All but three of these variables (moral imperative to help, psychiatrist, and societal causation) were significantly associated with vignette type. Chi-square analyses of these variables by participant gender, religion, marital status, education, and age showed no significant associations whatsoever. Vignette gender showed no relationship to any of the above variables, with the exception that respondents were more likely to attribute the problem to financial

The results of the quantitative analysis highlight the need to look beyond static categories of person toward a more nuanced understanding of cultural meanings in order to unravel the complexities of psychiatric stigma in Egypt. First of all, judgments of social distance were virtually independent of any sociodemographic characteristics of the study sample. At the same time, the present study did not find, in contrast to previous studies, that females are more stigmatized than males for identical behavior (Al-Krenawi et al., 2000; Baasher et al., 1983; Bassiouni & Al-Issa, 1966; Younis, 1978). The one exception to this is the finding that depressed females were more likely to be accepted as a family member than were depressed males, which most likely reflects the differing expectations for males and females and the effect of this on their perceived ability to fulfill the role of spouse. Similarly, there were very few differences in the attributions of problem or causation between male and females respondents, or between male and female vignettes, with the exception that the problem was more likely to be attributed to financial

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factors for males than for females, suggesting that this issue is viewed as more salient for men. Nevertheless, the quantitative results suggest that stigma as measured by social distance does exist in Egypt, and could be quite extreme in certain cases (for example, 85.5% of the sample would not accept the psychotic person as a schoolteacher, and 56.6% would not accept him/her as a family member, as Table 1 shows). What the present analysis revealed is that social distance or stigma in Egypt is a reflection of a series of practical and moral judgments about the person’s ability to fulfill a given role, their moral worth, and their place in the social fabric. Moreover, these judgments are fairly independent of psychiatric labels or other preconceived ideas of ‘‘mental illness’’. The first indicator of this lies in the fact that the category of ‘‘teacher’’ elicited higher social distance than that of family member (followed by friend and neighbor). While it is difficult to directly compare this with other studies due to the unique cultural meanings accompanying these roles, the ordering and the qualitative responses suggested that practical considerations of role-appropriateness took precedence over fears of social ‘‘closeness’’ in these judgments. In other words, far from being concerned about possible contagion from the ‘individual psyche’ in question, respondents were instead focused on the ability of the individual to fulfill the social role implied by the proposed relationship (i.e., marrying a family member carries considerably more social obligations than does being a neighbor, but both are surpassed by the role of teacher). Secondly, it was alcohol abuse, not the strange behaviors and words portrayed in the psychotic vignette, that elicited the greatest need for social distance, a finding that directly contrasts with Western studies (Cormack & Furnham, 1998; Levav, Kohn, Flaherty, Lerner, & Aisenberg, 1990), but correlates with the findings of a similar study conducted in the Sudan (Younis, 1978). Finally, several additional variables mediated the desire for social distance across the vignette types and social categories. These variables, to be discussed below, represent moral judgments concerning the place of the person in the social sphere rather than condemnations of the person as an individual actor. These themes, elicited via qualitative analysis, indicate that the meaning of psychiatric stigma in Egypt differs from that in the West, inasmuch as the nature of selfhood and individuality, both central to the notion of stigma, are constituted quite differently in this context. Normalization and contextualization: stigmamanagement When social distance was low, the respondents tended to interpret the problem presented in the vignette in terms of a series of common ‘‘normalizing discourses’’.

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These normalizing comments centered on the theme that all people are subject to difficulties in life that may lead to various psychological problems which are therefore normal and even widespread in the society. Occasionally, respondents would state that ‘‘he or she is not ill’’, just suffering from an ordinary problem, or they would state explicitly that ‘‘he/she is a normal person’’. Just as often, however, respondents would acknowledge the existence of a psychological illness but normalize it by attributing it to ordinary stress or strain. Consider the following excerpts: (Muslim Female, in regard to possessed man): Everyone is suffering from something that is causing him a psychological illness. Life is like that. The rich are tired, the poor are tired, the married as well. (Muslim female, in regard to psychotic woman): Any one of us could get ill after marriage. Psychological illness has become widespread just like the common cold because of pressures. It didn’t used to be like that. Others insisted that they would not reject the person in question because they already knew someone with a similar problem who coped quite well. Said one Muslim male, when asked if would accept the depressed woman as a neighbor: Of course! And as my colleague as well. My sister is like that and all of those around me. A girl would be holding a bachelor’s degree and she marries a guy holding a diploma [a non-university degree]. My sister is 30 years old and she is like that and is tearing her hair out. In all of these cases, psychological disturbances were be accepted as normal provided that they could be placed in a suitable social framework, a tendency that has been noted in other cultural contexts as well (Jenkins, 1988; Levav et al., 1990; Patel, 1995). This tendency to normalize the presenting problem went along with an equally common tendency to ignore the actual pathological symptoms presented in the vignette in favor of concentrating on the social context provided. While space does not allow us to go into depth on the myriad ways in which the problems were perceived and contextualized, what is important to the issue of stigma is that, in the case of low social distance, problems tended to be localized outside the boundaries of the individual, in the social environment. Moral and religious imperatives to help the sick Many respondents emphasized the moral imperative to care for ill people and people with problems. This moral imperative was, furthermore, a key factor in the mediation of social distance. Several separate themes

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emerged in the interviews regarding the reasons for, and methods of helping unfortunate others. The majority of the respondents (61.6%) believed that social support would be the most effective treatment for the disorders mentioned in the vignettes. Social support was seen as the responsibility of the family, but also of friends, neighbors, and the entire community. Discussions of whether the person would accept the person as a neighbor or a friend thus often led to commentaries on the responsibilities that such a relationship would entail. Said one Muslim Man (in regard to the depressed man): Yes, I would accept him as a neighbor because I might face the same problem that this person is facing. We live in a society where we should help each other get over such situations. If we said that we do not want to deal with him, we will never help him get over his problem. On the other hand, we have to stand by him because we live in the same society. In sum, there appear to be very strong religious, moral, and social imperatives operating in Egyptian society that mediate against stigma, as measured by social distance. Illness is seen as something that comes from God and that can and must be cured through the interventions of the surrounding society, and/or tolerated as a necessary burden (Bassiouni & Al-Issa, 1966; Dols, 1992; Trembovler, 1993–1994). However, this begs the question of how to explain rejection when it occurred, and why the alcoholic persons were so universally reviled. In fact, as will be shown there were very specific factors that intervened to produce high social distance with certain respondents in spite of the very strong mediating factors mentioned above.

Harm to others—contagion A primary concern that was significantly related to increased social distance was that the person presented in the vignette could somehow cause harm to others. Over 41% of the total respondents judged the person in the vignette as potentially harmful to others, and this was significantly related to increased social distance for all four social categories. This potential harm included actual physical harm, disruption to the house or workplace, inability to properly fulfill social or occupational roles, and the danger, expressed by many, that the person in question would somehow transfer his/her disorder to the people around him/her. It was the latter theme that was one of the most common, and the most intriguing. According to some, almost nobody was immune to the negative effects that a psychologically ill person could have on another, but ‘‘weak’’ people and children were particularly vulnerable. Said one woman, in response to the female depressed vignette:

[If that person were my child’s teacher] I would transfer my child from her class. It is a disease that can be transmitted, my son can get a psychological complex from her; [in addition] she might not treat him well. Several others, like the woman mentioned above, talked about a sort of contagion almost like a flu or a cold, and in some cases respondents expressed fear of the hereditary nature of the illness if the person in question were to marry a member of their family. However, most interviews revealed a different notion of contagion that involved modeling and social imitation. ‘‘He will raise a weak generation’’ said one of the psychotic man, in regard to his suitability as a teacher. Others suggested that the person in question could actually transfer their depression or ‘‘strange ideas’’ to the children through direct imitation, as children were thought to be especially influenced by the teacher, whose responsibility to them goes far beyond the transmission of educational materials. Although children were cited as the weakest members of the society and most susceptible to direct influence by a psychologically ill person, respondents also feared for their family members and themselves. ‘‘He will bring depression on the whole street’’ said one man when asked if he would accept the depressed man as his neighbor. In other words, the harm thought to be caused by the mentally disturbed involved direct transmission of negative attributes through social interaction, and several respondents made this danger quite clear. The following proverb was independently mentioned by several respondents: ‘‘If you carry a punctured water bottle it will spill over you’’. In Egypt no individual is immune to the influences of those with whom he/she associates, and these influences are spread through direct contact with one who is breaking social codes and norms. By far the greatest desire for social distance was directed toward the alcoholic vignettes, and by far the greatest potential for harm and the greatest threat of contagion was attributed to this group as well. Almost every respondent requested social distance in the case of the alcoholic man or woman, and of these, a great many gave a reason that suggested the danger of social contagion. Said one man, when asked if he would accept the alcoholic man as a neighbor: If he quits, I’ll accept him. But if he didn’t quit, any member of my family could imitate him. If your neighbor is a blacksmith, you will suffer from his fire. And if you have a happy neighbor, you will become happy like him. This implies that it is not mental or behavioral disorder per se that elicits stigma or the desire for social distance, but the interpretation of the illness in terms of

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its ability to disrupt social relations and ‘‘contaminate’’ those who come in contact with the disordered individual. However, this contamination is not due to a direct contagion but through the powerful influence that people have on their direct associates in this context. This was clear in the case of alcoholism, itself not a contagious illness, but also in the reasons given for excluding those in the other illness categories. Rejection of the other: madness and stigma Many cultures clearly differentiate between categories of ‘‘madness’’, which may be stigmatized, and more ordinary neurotic or somatic presentations, which may not be (Fabrega, 1991; Hutchinson & Bhugra, 2000; Patel, 1995). The label of ‘‘craziness’’ or magnuun was attributed to the case in 14% of the responses, and was in itself highly associated with social distance. The responses demonstrated a clear category of ‘‘mad’’, that was relatively rare, irrational, and completely ‘‘other’’. It was also highly stigmatized and uncurable (‘‘one can cure illness but not insanity’’ said one woman). ‘‘Magnuun’’ as the end result of illness or disease processes was brought up spontaneously throughout the interviews. Often it came up in the form of a warning about the person in the vignette, that he or she should immediately seek medical or psychological help lest the problem develop to the point of insanity. Implicit was the idea that one does not recover from madness, and that prevention is the only cure in this case. For example, one older man suggested that if the depressed man did not get treated immediately, his case would deteriorate and he would end up ‘‘insane or paralyzed’’. Madness was most often defined as a state in which people do not think right, fight with others, and generally are extremely unbalanced in their behaviors, emotions, and reactions. More often than not, the clearest definitions came not when the respondent was defining the individual in question as mad, but when they were illustrating why he or she was not mad. Consider the following excerpt: (Muslim male in response to depressed man): He is rational since he is not pulling out his hair and he is not fighting with people. People would not judge such a person as crazy because he would not be dressed up in rags and fighting with everyone. It is important to note here that ‘‘ordinary’’ psychological problems were carefully contextualized in terms of causes and contributing factors, which were often as not followed by suggestions for appropriate treatment. Madness, on the other hand, was distinguishable not so much by its specific symptom definitions as by its lack of social context, absence of suggested causes and contributing factors (except where it served as a warning

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that urgent treatment was needed) and incurable nature. Once this turning point was breached, then the problem ceased to be characterized in terms of its social components and took on the aura of a true ‘‘disease’’. Cure was not necessarily impossible in this case, but definitely required drastic measures, often involving doctors and psychiatric hospitals. In the case of madness, a person is no longer an integrated social being and therefore can no longer be cured through the careful attention of the immediate social environment. Treatment and stigma To sum up the findings on social distance and treatment suggestion, ‘‘social support’’ was the most common treatment suggestion, and was predictive of low social distance. On the other hand, suggesting a psychiatrist as a first option for treatment was clearly associated with social distance for teacher or family member (but not for neighbor or friend), while suggesting a psychiatric hospital was predictive of high social distance on all four measures. The number of people who suggested a psychiatrist as a possible first option was higher than that found in other areas of the Arab world, suggesting that the role of psychiatrists in treating mental illness is at least beginning to be understood in Egypt (Savaya, 1998). In contrast to psychiatrists alone, however, psychiatric hospitalization was positively associated with the madness label and with increased social distance in all cases. It is a small leap from here to the conclusion that psychiatric hospitals are not viewed as places for the treatment of illness at all but rather as the dumping ground for society’s undesirables (Foucault, 1965). The qualitative analysis bore this out, suggesting that psychiatric hospitals are viewed as places for the hopeless, stigmatizing in and of themselves in their role as isolating the socially unfit. The hospital was almost universally seen as a place where people went when they were dangerous and out of control. It was a place from which people did not return and certainly did not get cured—in sum it was one of the worst places a person could end up. Many respondents used the idea of a psychiatric hospital as a cautionary tale, and warned against the consequences of incarcerating a person there. ‘‘People might take her to somewhere like Abbassia [a famous psychiatric hospital in Egypt] where they treat people with light minds’’ warned a middle-aged woman in regard to the female psychotic vignette. One Muslim man summed this up succinctly as follows (in regarded to the possessed male vignette): If we say right away that he should go to a hospital we should have ruled against him. [Interviewer: What is said about those who go to hospitals?]. People will say that he is crazy.

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Psychiatrists were often spoken of in a similar vein (‘‘She is not insane so she doesn’t need to go to a psychiatrist’’ said one woman). However, psychiatrists were not nearly as strongly associated with social distance as psychiatric hospitals, suggesting that the key factor in the stigma directed toward psychiatric hospitals was their role reinforcing the social isolation that is already seen as characteristic of the mad or insane.

Conclusion: stigma and selfhood To sum up the findings presented here, stigma toward the mentally ill certainly exists in Egypt, but its form varies with the different cultural meanings attributed to person, self, and illness in this context. One of the more interesting findings of the present study was the clear association of social distance not with bizarre behavior or a mental illness label, but with certain specific meanings related to the person’s place and role in the society. Strange words and behaviors did not by themselves elicit social distance as long as the person’s place in the social fabric was assured and the behavior could be understood as a momentary, comprehensible disruption, to be remedied by manipulating the social context rather than the individual psyche or physical body. Increased social distance, on the other hand, was associated with the decontextualized individual (the ‘‘magnuun’’ or crazy person), or the one who can cause harm to others. At the same time, the concept of social distance was clearly associated with practical considerations of role fulfillment. In other words, much of the ‘‘social distance’’ revealed in the present study may have been related as much to common-sense judgments of whether the person could adequately fulfill the social role in question (i.e., teacher or spouse) as to nonspecific fears or desires to avoid the person in question. The commonality here is the centrality of social roles and social context to the mediation of social distance, related to the importance of the social in the construction of selfhood in Egypt. In Egypt, one is part and parcel of the social environment until such time as that contract is breached through extreme antisocial behavior. Because of this, there are strong protective factors against psychiatric stigma, notably in the existence of normalizing discourses and moral and religious imperatives to help the sick and infirm. These stigma-alleviating tactics serve to contextualize the illness in a framework that maintains the sufferer within the realm of meaningful social interaction. From within that realm, the psychic is secondary to the social, and stigma aimed solely at an individual apart from his or her social environment does not make good sense. Behavioral, social and moral disruptions are seen as failures in the social/moral/

religious realm, not in the physical or psychic realm. As long as the problem can be understood in terms of its social and moral implications, then it is understandable and the cure is simple: strengthen the social, moral and religious fabric. While the person may be unfit to fulfill social duties while in this state, there is no lasting associated stigma. In this cultural environment, social isolation is death. No person in Egypt is left alone when they are sick; rather they are surrounded by friends and relatives until such a time as they recover and are able to fulfill their social roles. To have a condition that ends in isolation (i.e., psychiatric hospitalization) rather than recovery is the ultimate stigma. When the social support fails and the only solution is the psychiatric hospital, then the condition has truly become hopeless. In the responses, the reason given for this was the potential to harm the very social environment that would otherwise help them, and the metaphor for the one so marked was magnuun, or madness, a category for the ‘other’ that is most notably free of social contextualization. The idea of madness as stigmatized is certainly found in places besides Egypt. However, the meanings given to madness and selfhood, and the implications of this for stigma and for ‘‘stigma-reduction’’ are arguably different in this context. Fabrega (1991) reviewed the literature on psychiatric stigma in different historical and cultural traditions. He noted that in medieval European societies only ‘madness’ was associated with stigma, as opposed to other more benign conditions more recently added to the psychiatric repertoire. It was when those more benign conditions became associated with madness and insanity that they began to evoke stigma in their own right. He concluded that in the West it is the notion of a core syndrome that exists in the ‘psyche’ that leads to social stigma, a specific construction and concern that would not be found universally. It is argued here that the inherently stigmatizing nature of psychiatric illnesses in the United States and Europe stems from an extreme emphasis on the individual that does not necessarily exist in the same manner in other societies (Kirmayer, 1989). In matters of illness, the individual in the West is considered first and foremost a self-contained biological entity that is fundamentally altered by the occurrence of illness. A ‘diseased psyche’ is a threat to individuality and selfhood that is particularly salient in a society that values the individual self so highly. Psychiatric syndromes do not merely reflect a ‘‘natural reality’’, but rather are comprised of a set of experiences created through meaning and social interaction in a given society (Good, 1977; Kirmayer, 1989). The ability of a syndrome to threaten notions of personhood and lead to stigma is therefore highly dependent on the meanings given to both the person and the illness.

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The notion of selfhood revealed in the present study serves to mitigate psychiatric stigma. Psychological problems, strange behaviors and other manifestations of psychiatric disorders are socially situated in a way that protects the individual from the damaging effects of stigma. The individual psyche is not seen as a bounded entity that can be fundamentally damaged as much as an inherent part of a social entity that is both responsible to, and responsive to, the individual involved. This protects against some forms of psychiatric stigma but not others. Individual behavioral/emotional illnesses are extensions of social illnesses, therefore the responsibility falls on the family and society to provide support and treatment, and little stigma is directed at the person afflicted. At the same time, however, the interconnectedness of individuals leads to the exclusion of those deemed to be socially dangerous or ‘contagious’, and the social isolation of the psychiatric hospital is the virtual equivalent of stigma as it exists in this context. The specific form that stigma takes in Egyptian society therefore reflects the importance of the integral social body, not of the integral individual.

Acknowledgments This research was sponsored by the Egyptian Ministry of Health & Population in collaboration with Ministry of Foreign Affairs, Finland, Mental Health Programme in Egypt.

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