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2014 51: 829 originally published online 26 February 2014Transcultural Psychiatry William Sax
Ritual healing and mental health in India
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DOI: 10.1177/1363461514524472 tps.sagepub.com
Ritual healing and mental health
in India
William Sax
South Asia Institute
Abstract
Ritual healing is very widespread in the Indian state of Uttarakhand, and is by far the
most common option for those with serious behavioral disturbances. Although ritual
healing thus accounts for a very large part of the actual health care system, the state and
its regulatory agencies have, for the most part, been structurally blind to its existence. A
decade of research on in this region, along with a number of shorter research trips to
healing shrines and specialists elsewhere in the subcontinent, and a thorough study of
the literature, suggest that such techniques are often therapeutically effective. However,
several considerations suggest that ritual healing may not be usefully combined with
mainstream “Western”psychiatry: (a) psychiatry is deeply influenced by the ideology of
individualism, which is incompatible with South Asian understandings of the person; (b)
social asymmetries between religious healers and health professionals are too great to
allow a truly respectful relationship between them; and (c) neither the science of
psychiatry nor the regulatory apparatus of the state can or will acknowledge the validity
of “ritual therapy”—and even if they did so, regulation would most likely destroy what
is most valuable about ritual healing. This suggests that it is best if the state maintain its
structural blindness to ritual healing.
Keywords
effectiveness, global mental health, India, ritual healing
In this essay, I ask whether ritual healing can fruitfully be combined with the
official mental health care system in India. The question is difficult to answer for
many reasons, one of which is that there is no single, widely accepted definition of
“ritual.” After more than a hundred years of observing, documenting, analyzing,
and theorizing about rituals, scholars of ritual still cannot agree upon a definition
of their object. Despite this lack of agreement, specialists in this field are
Corresponding author:
William Sax, South Asia Institute – Anthropology, INF 330 Heidelberg 69118, Germany.
Email: william.sax@urz.uni-heidelberg.de
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surprisingly quick to identify rituals and, as Lukes pointed out nearly three decades
ago (1975, p. 290), what they identify as “rituals” usually turn out to be sets of
formal actions, often with religious elements, that are assumed to be inherently
ineffective and nonrational. The assumption that ritual is not efficacious is rarely
acknowledged or discussed in the literature, but as I have argued elsewhere (Sax,
2007, 2009a, 2010a, 2010b, 2010c), it is fundamental to both popular and learned
understandings of the topic, and particularly important in the discussion of ritual
healing. According to our meteorological theories, dancing cannot really make it
rain, and so when someone performs a rain dance, we call it a “ritual.” According
to our theories of human development, one cannot alter a person’s fundamental
nature by making him fast and then cutting his body, and so when people do this in
the course of an initiation, we call it a “ritual.” According to our medical theories,
diseases cannot be cured by worshiping ancestors, and so when people do so, we
label it “ritual.” In short, the problem of ritual is nothing other than the old
rationality problem (cf. Hollis & Lukes, 1982) linked to the assumption that rituals
are inherently ineffective.
Problems defining ritual have proven to be so intractable that the two most
recent and influential books on the topic (Bell, 1992; Humphrey & Laidlaw,
1994) eschew the term altogether, focusing instead on processes of “ritualization.”
Most actions can be ritualized to a greater or lesser degree (for example eating,
speaking, and journeying are ritualized as Eucharist, prayer, and pilgrimage) and
so, rather than asking whether or not an action or set of actions “is” or “is not” a
ritual, these theorists instead seek to describe the processes whereby, and the degree
to which, human actions become ritualized. This shifts the definitional problem
from the noun “ritual” to the verb “ritualization,” that is, from object to process,
of which both theories have highly recondite discussions.
1
But the problem of
efficacy remains, lurking in the background, since both of these theories (like
nearly all those that have gone before them) assume that whatever efficacy rituals
possess is purely social and expressive. Thus, they have little to contribute to a
discussion of the efficacy of ritual healing.
But for those performing the rain dance, or the initiation, or the healing, “rit-
uals” do indeed fit into a cosmology in terms of which they are rational and
effective means for attaining certain ends. That is why participants typically refer
to them not as “rituals” but rather as dancing, or healing, or simply as “work.”
2
What we label ritual, they regard as technique. And who is this “we” who decide
what does and does not count as ritual? It is the transcultural and post-
Enlightenment community of scientific moderns, disproportionately represented
in the universities and the educated classes. Foucault defined the modern episte
´me
as the conditions of possibility for what counts as scientific. But “ritual” is precisely
the negation of this episte
´me, and that is what makes it such a fascinating category.
It is a “leftover” category, designating a set of practices defined in terms of what
they are not: not modern, not rational, not medical, not scientific, not mainstream,
not recognized, and above all, not effective. That is why the integration of ritual
healing with modern, scientific psychiatry is so deeply problematic, as I hope to
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demonstrate in this essay. Ritual healing is the original non-evidence-based
medicine.
But rather like clinicians stubbornly insisting on the effectiveness of their thera-
peutic methods despite the lack of acceptable “evidence,” numerous scholars (espe-
cially anthropologists) have provided accounts of ritual healing which suggest that
it really does relieve distress, increase wellbeing, and sometimes even reduce symp-
toms. Many of these reports have to do with forms of healing that we might
broadly call “behavioral,” “psychological,” or “mental.” So if ritual healers can
effectively address such problems, why not incorporate them into the health
system? Why not encourage them to work more closely with psychiatrists, clinical
psychologists, and their patients? In this essay I seek to address that question: first,
by providing a summary of a particular tradition of ritual healing that I studied for
10 years, together with my hypothesis about how it “works”; second, by making
some observations about ritual healing in general; and finally, by providing an
answer to my question.
To anticipate: my answer is “No, one should not attempt to integrate ritual
healers into the health system,” for at least three reasons. First of all, because
mainstream medicine canonizes the dualism of mind and body by relegating non-
somatic problems to psychiatry, which in turn is so deeply influenced by the ideol-
ogy of individualism that it is incompatible with, and perhaps even damaging to,
certain non-European understandings of the person, including most of those found
in India. Second, although some scientists and intellectuals have a tolerant and
even respectful attitude towards ritual healers, the social asymmetries between
them and health workers “at the coal face” are too great to allow a truly respectful
relationship between them. And third, neither the science of psychiatry nor the
regulatory apparatus of the state can or will acknowledge the validity of ritual
healing; moreover, even if they could (and did), state regulation would destroy
what is most valuable about it. Therefore, I suggest that it would be best for the
state to continue to ignore ritual healing.
A healing cult in the Himalayas
In 1993 I began investigating a cult of ritual healing in the Western Himalayas of
North India (Sax, 2002, 2004a, 2004b, 2009a, 2009b, 2009c, 2010c). In this cult,
diagnosis and healing are clearly distinguished: when one has an illness that cannot
be diagnosed or cured, one typically visits an oracle to find out the cause of the
problem, and only later seeks out a healer. Typical afflictions include fever, stom-
ach ache, lack of energy, sleeplessness, sexual problems, and behavioral disturb-
ances like involuntary possession, bouts of fear and panic, or excessive strife within
the family. People also turn to local oracles for information about runaway chil-
dren or stolen property, for help with problems connected to livestock (cows that
do not give milk, barren sheep or goats, etc.), because of economic difficulties, or
simply from a persistent run of bad luck. Already, we see an important difference
between modern medicine and ritual healing, since the latter deals with all facets of
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the person, and not just somatic problems. In other words, the medicalization of
human suffering has not yet taken hold in the Western Himalayas. The oracles,
most of whom have undergone an initiatory illness,
3
become possessed by local
deities, and answer clients’ questions while in trance.
Clients are often impressed by the accuracy of the oracles, who seem to possess
intimate knowledge of their lives that could only be obtained by supernatural
means. But when I carefully examined transcripts of oracular consultations, it
became clear that the oracles were eliciting information from clients, who were
usually not aware that this was occurring. I think that the oracles too were unaware
of it; that is, that they did not consciously exploit the credulity of their patients.
Rather, they believed themselves to be engaged in a conversation with the client; a
mutual attempt to discover the causes of suffering.
4
The entire edifice of oracular
consultation rests on the assumption that it is only the body of the oracle that is
present, his “self” or “personality” having been temporarily replaced by that of the
possessing agent. Elsewhere I have called this the “ideology of absence” (Sax,
unpublished manuscript) and without it, the entire oracular edifice would crumble.
Most clients believe that oracular diagnoses are not always reliable, and so they
typically “triangulate” them by consulting more than one oracle. Only if they
receive a consistent explanation for their troubles from several different oracles
do they take the next step, and seek out a healer. These healers are called gurus,
not because they are spiritual masters, but rather because they are masters of the
spirits. By dint of certain magical and liturgical practices, they are able to control,
and if necessary to exorcize, afflicting spirits and deities.
In a very large proportion of the cases I documented—perhaps 70%—the oracle
located the cause of affliction in episodes of strife within the family: the client had
quarreled with someone and been cursed by them; or perhaps it was a parent, an
uncle, or aunt, or even the grandparents or their antagonists who had quarreled
and uttered the curse. Cursing took a standard form, in which one’s personal deity
was asked to “see to” the victim, usually by making them ill. Clients often denied
having cursed anyone, or insisted that their parents or grandparents were not
involved in such bitter quarrels. But the fact is that here as elsewhere in the
world, harsh words and threats of violence are rather common. Tension and
strife within the family often led to physical and psychological affliction.
Quarrels over land, jealousy at another’s success, abuse and exploitation of
young wives, conflict between the generations, pressure on young people to do
well in school, demands from newly married couples to have children—such
forms of intrafamilial tension were regularly identified in oracular consultations
as the root causes of affliction, having led one family member to curse another, with
illness and misfortune being attributed to the curse. They were also understood to
be symptoms of affliction: many clients complained of family disharmony, and were
visiting the oracle precisely in order to discover its underlying causes.
Because the family was the locus of so much conflict, one of the very first
questions asked by an oracle was, “Is the family united?” If the client answered
“No,” then the oracle could reasonably infer that the affliction had something to do
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with family discord, so that the next question was likely to be, “Can the family be
united?” If the client still said “No,” then the oracle could be fairly certain that
there was serious conflict within the family. Such cases were usually associated with
deep intransigence on the part of the quarrelling parties, with sorcery and black
magic, and ultimately with tragedy and death. On the other hand, if the client
replied that the family could indeed be united, the oracle usually prescribed a
healing ritual obliging relatives to pull together and cooperate closely. Funds
had to be collected, the guru summoned, ritual articles like lamps and oil and
colored powder purchased, along with sacrificial animals and rare plants.
Animals and insects had to be collected from the forest or the river, the house
cleaned, and food and drink prepared, along with a hundred other tasks, large and
small. Everyone contributed in a way that was appropriate to his or her gender,
age, and position within the family. Close kin who had been absent for months or
even years returned to the village, while nearby friends and relatives gathered to
participate in the ritual and the feast with which it concluded. Family unity was
emphasized, strengthened, and created anew in the preparation for, as well as in the
performance of, the ritual, which involved numerous collective acts, for example
tying the family together with a grass rope in order to demonstrate its unity.
Elsewhere I have argued that in the very act of cooperating and working together
to perform a ritual, families began to heal themselves (Sax, 2009a, Chapter 5,
2009b, 2010c). Family unity was thus not only a diagnostic principle: it was also
a ritual principle, a therapeutic principle, and a moral principle. As a diagnostic
principle, the presence or absence of family unity helped determine the cause of the
affliction. As a ritual principle, such unity was a necessary condition for conducting
the ritual in the first place, and was embodied and performed at several points
during the proceedings. As a therapeutic principle, family unity was taken to be the
result of a successful healing ritual, and a sign of health. Finally, family unity was a
moral principle, the violation of which could have deadly effects. In my 2009
monograph (Sax, 2009a) on this healing cult, I provide numerous examples of
how symptoms were reduced or eliminated following such ritually mediated
forms of what one might call “intrafamilial rapprochement.”
Does ritual healing work?
This explanation of how ritual healing “worked” in one cult cannot be extended to
ritual healing in general because the great diversity of ritual healing practices makes
it exceedingly difficult to generalize about the entire class. In the cult that I studied,
oracular diagnosis is common, but other forms of ritual healing make use of other
techniques such as dreams (Quack, 2010), prayer (Csordas, 1994), and the “read-
ing” of bones (Turner, 1968). According to my hypothesis, collective ritual action
was the therapeutic “core” of the healing cult, but other scholars suggest other
therapeutic methods: persuasion (Frank & Frank, 1973/1991), aesthetics
(Desjarlais, 1992), narrative (Bellamy, 2011), the “placebo effect” (Kaptchuk,
2002), memories (Krauskopff, 1999), social support networks (Pakaslahti, 1998),
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herbal medicines (Press, 1971), and surgery (Wall, 1996). Empirically, the myriad
techniques that we label “ritual healing” are so diverse that we shall be lost if we try
to develop a definition based on essential traits. As I argued above, the very cat-
egory is little more than an artifact of the linked discourses of science and
modernity.
Most forms of what we call “ritual healing” have rather different aims than
psychiatry and medicine, and require different standards of evaluation. It is not
just that healing rituals are employed to remedy many kinds of misfortune other
than illness. More importantly, much ritual healing does not seek the elimination of
symptoms so much as the restoration of social relationships. In many if not most
cases, ritual healing does not repair or replace a body part or heal a disturbed mind,
but rather restores a cosmology; or better, it restores the suffering person to an
appropriate place within his or her cosmology.
5
In other words, ritual healing tends
to be holistic: it treats mind, body, and spirit altogether. While this observation is
trite, even hackneyed, it bears constant repetition because mind–body dualism is so
persistent and deep-rooted in the culture of academia in general, and medicine and
psychiatry in particular.
The point is underscored by the language we use; for example, the Indo-
European root kailo, which means “whole” and “uninjured,” and is the root of
English “health” and “healing,” as well as German Heil and Heilung. To be healthy
is to be whole, and healing is the activity of making a fragmented, sick person into
a whole person once again. From this root, an entire semantic field develops, which
includes a number of closely related concepts: “health”; “whole”; “the holy.” To be
healthy is to be complete, whole, and holy. No wonder then, that the World Health
Organization defines health as “a state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity.”
6
Health and well-
being is not just a bodily state; it also involves social and interpersonal relation-
ships. From the perspective of ritual healing, to rigidly distinguish physical from
mental health is to repeat the false dualism that separates mind (and spirit) from
body. The practice of healing does not focus merely on parts of the patient’s body
(or in the case of psychiatry, on the “mind” as separate from the “body”), but
rather integrates those parts into a healthy person, and further, integrates that
person with his or her society, and perhaps even with the cosmos. That is why,
as several scholars have pointed out, the term “healing” is embarrassing for
modern, scientific medicine: its goals are much too lofty. Better to stick with the
more limited agenda of curing a diseased part (Kleinman, 1979; cf. Scheper-
Hughes, 1990).
It is important to emphasize how successful this limited agenda has been.
Medicine continues to fragment the human body into smaller and smaller parts,
so that there are specialists for eyes, ears, teeth, heart, liver, womb, bone, and skin,
and this specialization has resulted in powerful advances in medical science. But
such knowledge has come at a price, which is that few medical doctors specialize in
human beings any more, but only in parts of them. Ideally, one should be able to
weigh, measure, and analyze these parts with the greatest possible precision, and it
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is precisely this fragmentation that is responsible for the “miracles” of modern
medicine (cf. Latour, 1993, pp. 112–113).
Psychiatry and psychology, the sciences of the mind, cannot lay claim to the
same kinds of miracles, because their object resists the weighing and measuring
techniques of a purely somatic/materialist paradigm. Early hopes for a psycho-
pharmaceutical “silver bullet” for the treatment of schizophrenia were dashed
(Luhrmann, 2012; McNally, 2011, p. 37) and initial enthusiasms for a genetically
based theory of mental disease have proved to be naı
¨ve (McNally, 2011, Chapter
6), because most mental disorders are at least partly constituted by historical and
cultural factors that are difficult or impossible to quantify. It seems likely that
factors such as social support, family structure, and perhaps the frequent use of
traditional (ritual) healing are crucial in accounting for the fact that Indians
respond so much better to psychiatric treatment than Europeans; and that wide-
spread racism explains why dark-skinned migrants to Europe develop schizophre-
nia roughly 10 times more often than White Europeans do (Luhrmann, 2012).
As McNally puts it,
Cognitive and emotional symptoms are constitutive of psychiatric disorder, and cul-
tural and social factors affect how we think and feel. Therefore, social factors may
become part of the very fabric of psychiatric disorder whereas they cannot for infec-
tious disease. Unlike other medical conditions, psychiatric disorders may not be
stable, ahistorical entities whose essence is invariant irrespective of cultural variation.
(2011, p. 130)
Of course there are many important schools of psychiatry that attempt to incorp-
orate such insights; for example systemic therapy (Schweitzer & von Schlippe,
1998; cf. McDaniel, Hepworth, & Doherty, 1992; see especially Sax, 2010c), psy-
chosomatic medicine (Fava & Sonino, 2000, 2005; Lipowski, 1986), integrative
medicine (May, 2011), community-based psychiatry (Donaldson, 2005; Druss
et al., 2006; Mosher & Burti, 1989; Wells, Morrissey, Lee, & Radford, 2010),
and George Engel’s conception of human bio-psycho-social unity (Engel, 1977),
to name just a few. But the fact remains that as a branch of modern medicine,
mainstream psychiatry privileges somatic etiologies over cultural and historical
ones, that Indian psychiatry relies very heavily indeed on the administration of
psychopharmaceuticals, and that from the patient’s point of view, this is the only
branch of psychiatry that counts (Ecks, 2005; Jain & Jadhav, 2009; Nunley, 1996;
cf. McNally, 2011, pp. 36, 55).
Ritual healing, on the other hand, very often focuses its attention on social and
cultural factors. Its subject is usually the family rather than the individual person.
People in many societies exhibit forms of personhood that differ from those of
secular, modern intellectuals. Geertz famously wrote that the idea of the individual
is a “rather peculiar idea within the context of the world’s cultures” (1983, p. 126).
I would go even further, and argue that individualism is better characterized as an
ideology than a description. Others see things differently, for example Charles
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Taylor who, in his recent and influential book A Secular Age (2007), hypothesizes a
long-term development in Europe, from the “porous self” of the middle ages, sus-
ceptible to numerous outside forces and thus vulnerable to possession, to the “buf-
fered self” of the current, secular age. But whether individualism is ideology,
universal fact, or historical process, it is certainly not universal.
Nearly all anthropologists who have studied ritual healing in India have noted
that the subject of therapy is not the “individual” but rather the family. This is clear
in studies of Hindu healing temples (Dwyer, 2003; Kakar, 1983; Pakaslahti, 1998,
2009; Skultans, 1987), Muslim healing shrines (Basu, 2009; Bellamy, 2011;
Pfleiderer, 2006), popular healing practices amongst Buddhists (Kapferer, 1983),
Hindus (Nabokov, 2000; Sax, 2009a) and Muslims (Flueckiger, 2006), and is also
the case in many other cultures around the world (e.g., Balzer, 1983; Dow, 1986;
Waldram, 2000; Worsley, 1982).
The centrality of the family in ritual healing is consistent with widely accepted
characterizations of Indian notions of personhood, family, caste, and society. As is
well known, Louis Dumont (1966/1970) argued that there is no place for the indi-
vidual in the ideology of caste, which he took to be the defining feature of Hindu
society. Although McKim Marriott (1990) and his circle at the University of
Chicago were critical of Dumont’s approach, they agreed that “the individual”
was an inappropriate category of analysis for Hindu society and that “individual-
ism” was an artifact of Western ideology, deriving from Western historical experi-
ence, rather than the universal category it is sometimes assumed to be. Marriott
and his students sought to identify and analyze fundamental “cultural assump-
tions” informing many areas of Hindu life, from traditional sciences such as astrol-
ogy and Ayurveda to contemporary social practice, and to ensure that their
theoretical terms were consistent with these “indigenous” assumptions. Several of
the pervasive assumptions identified by Marriott and his circle have been confirmed
by scholars working on Indian culture, because they do indeed seem to accurately
describe some of the basic parameters of life there. For example, the idea that
people’s natures are continually altered through transactions of substance has
won general acceptance. One of the main kinds of such transformative transactions
is that between persons and their physical and social environments (Daniel, 1984;
D. P. Mines, 2005; Moore, 1985; Sax, 2009a). Ultimately, Marriott and his students
assert that it is better to think of Hindu persons as “dividuals” who are constantly
being transformed by the multiple transactions of life, than as “individuals” with
some enduring and changeless essence.
7
In a peasant society like the one where I
conducted my research, most transactions and exchanges take place within the
intimate confines of the family. Continual transactions of food and other resources,
along with words, touch, and other actions create persons who are subsumed in, or
subordinated to, the family, to a much greater degree than in the cultures of
Western Europe and North America. In brief, contemporary psychiatry’s focus
on the individual patient, and its goals of fostering that patient’s individual auton-
omy and agency, may be deeply inconsistent with some fundamental ideas about
personhood in South Asia and elsewhere.
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My final point about ritual healing in general is that according to a great deal of
anecdotal evidence, it often seems to work rather well. Of course, one must be very
careful about this assertion, upon which so much depends. In medicine, one dis-
tinguishes between the efficacy of a treatment or drug under artificial laboratory
conditions, and its effectiveness in actual practice. If it is true that some forms of
ritual healing “work” by redefining social contexts, then it is impossible to subject
them to randomized, double-blind experiments in a laboratory setting where such
social contexts are deliberately ignored. But there is also a serious problem evalu-
ating effectiveness, because the criteria of success vary so enormously. Psychiatric
criteria for effective healing are radically different from shamanic criteria, and these
in turn are different from the criteria of an Ayurvedic doctor, a Christian mission-
ary, a clinical psychologist, etcetera. One cannot assume that the various systems
share a single definition of illness, healing, or efficaciousness. In fact, it is clear that
they do not (Janzen, 1978; Weiss et al., 1986). The fact that some patients express
satisfaction with ritual healing while maintaining their symptoms (or even dying!)
points to “fundamental conceptual difficulties in the very definition of outcome”
(Csordas & Kleinman, 1990, p. 16). Above all, one should be careful not to evalu-
ate the efficacy of one system by the criteria of another: ritual healing may well be
ineffective according to psychiatric criteria, but the opposite is also true: patients
might be successfully treated by administering psychopharmaceuticals, but not
healed according to the criteria of a traditional healer. Certainly it is true that
not all patients benefit from ritual healing, but neither do all patients benefit
from psychiatric treatment. One of the few studies to compare the two concludes
that their “success rates” are roughly similar (Pakaslahti, 1998).
What evidence do we have for the effectiveness of ritual healing? Since ritual
healing is so widely used, and because it presents such a fundamental challenge to
mainstream medicine and psychiatry, it seems to me that the epidemiological study
of its effectiveness is a scientific desideratum. But this has never been attempted on
any significant scale, at least not in India. On the one hand, there is a trickle of
epidemiological and psychiatric evidence, based largely on self-reporting by men-
tally ill patients at healing temples and mosques, which suggests that ritual healing
compares favorably with standard psychiatric therapies (Dwyer, 2003; Pakaslahti,
1998; Raguram, Venkateswaran, Ramakrishna, & Weiss, 2002), and on the other
hand a great deal of observational and anecdotal evidence from around the world
illustrating beyond any reasonable doubt that such techniques are widely perceived
to be powerful and effective (Bellamy, 2011; Csordas, 1994; Desjarlais, 1992;
Dwyer, 2003; Fallot, 1998; Frank & Frank, 1973/1991; Halliburton, 2003;
Haram, 1991; Incayawar, Wintrob, & Bouchard, 2009; Kakar, 1983; Kaptchuk,
2002; Kirov, Kemp, Kirov, & David, 1998; Koenig, 2008; Le
´vi-Strauss, 1963;
Moerman, 2002; Mullings, 1984; Pfeifer, 1994; Press, 1971; Puckree, Mkhize,
Mgbobhozi, & Johnson, 2002; Sloan, Bagiella, & Powell, 1999; Sloan et al.,
2000; Turner, 1968).
“Based on the material we have presented,” wrote Arthur Kleinman in an early
article, “we draw the perhaps startling conclusion that in most cases indigenous
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practitioners must heal” (1979, p. 24). Their healing is effective, Kleinman sug-
gested, because of the kinds of disorders they treat: chronic conditions where the
management of the disease is more important than clinical treatment, problems
related to social stress, and self-limiting conditions. “The equally startling corollary
of this argument,” continued Kleinman, “is that in most cases modern professional
clinical care must fail to heal” (1979, p. 24), because the physician is systematically
trained to ignore the subjective experience of the patient in favor of his external
symptoms, something that has been true of psychiatry ever since Jaspers’s work on
the symptomatology of mental illness (Langenbach, 1995, p. 209).
Ritual healing and psychiatry
If ritual healing sometimes works, and if this often has to do with the fact that it
addresses the whole person in his or her cultural and historical context, then why
not incorporate it into the health care system? Why not employ ritual healers to
work cooperatively with medical professionals, including psychiatrists? Why not
recruit them to help disseminate important public health information, encourage
them to treat the disorders for which their techniques are appropriate, and train
them to refer patients with problems that they cannot address to the appropriate
professionals?
Informed discussion of such questions is hindered by the fact that the state and
its regulatory agencies in South Asia—and no doubt in many other places as
well—are structurally blind to the existence of the myriad ritual healers in their
midst. This became clear to me when I visited Sri Lanka in 2002, and was discuss-
ing that country’s health system with colleagues from the medical school. They
boasted to me of how thorough their health statistics were. They said they had data
on virtually every visit to a doctor or a dentist throughout the country: the socio-
cultural background of the patients, the reasons why they made these visits, the
health outcomes, and so on. All of this was possible, they said, because they had
inherited an excellent health bureaucracy from the English, and Sri Lanka was after
all a small island, relatively easy to administer. But when I asked them if they knew
the number of visits that had been made to ritual healers, they shook their heads in
puzzlement. Government departments of health don’t count such things! This is
what I call “structural blindness”: the state’s inability, because of its conceptual
paradigms and epistemic practices, to “see” ritual healing. And this is so, despite
the fact that the vast majority of those who seek psychiatric help are, at the same
time, consulting ritual healers (the figure usually quoted is 80%, see Quack, 2012,
p. 3), not only in remote rural areas, but also in urban centers (Pakaslahti, 1998,
2009).
The widespread use of ritual healing is by no means unique to India. A quick
glance through the medical and psychiatric journals suggests that around a quarter
of psychiatric patients in the USA use prayer and other religious techniques to deal
with their problems; the figure for prayer (and exorcism!) jumps to 30% in
Switzerland. In the early 1990s, more than 30% of 343 patients interviewed in
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Switzerland used ritual prayers and exorcism to counteract their diagnosed psychi-
atric problems (Pfeifer, 1994); a similar study in the USA in the 1990s came up with
a figure of 25% (Eisenberg et al., 1993); other studies show a very high incidence of
using religion for “coping” with mental illness (Kirov et al., 1998; Koenig et al.,
1992; Tepper, Rogers, Coleman, & Malony, 2001). A study published in The
Lancet showed that “79% of the respondents believed that spiritual faith can
help people recover from disease” (Sloan et al., 1999, p. 353, quoting from
McNichol, 1996). In another study of 157 hospitalized adults with moderate to
high levels of pain, prayer was second only to medication (76% vs. 82%) as the
most common self-reported means of controlling pain (Mueller, Plevak, &
Rummans, 2001). Nevertheless, mainstream psychiatry is reluctant to incorporate
into its methods anything that smacks of “religion” (Fallot, 1998; Kaiser, 2007;
Koenig, 2008; Mueller et al., 2001; Sloan et al., 2000).
One would think that mental health professionals in India would be quite aware
of the ubiquity of ritual healing, and they often acknowledge it informally. When I
suggested to a clinical psychologist in Dehra Dun that perhaps 75% of her patients
also sought the help of ritual healers, she smiled and wagged her finger at me,
saying, “Oh no, Prof. Sax. One-hundred per cent!” But as Johannes Quack has
pointed out, most of the scientific literature on mental health care in India simply
assumes that for people with mental problems, there is nowhere to go other than
hospitals and psychiatric clinics; in other words, that an absence of psychiatrists
and mental hospitals equates to an absence of mental health care. This kind of
rhetoric is found elsewhere as well, for example in the concluding chapter of a
major recent work on interactions between psychiatrists and ritual healers, written
by one of the collection’s editors:
The majority of the 450 million patients with mental disorders around the world
are not receiving even the most basic mental health care. In developing countries,
76.3–85.4% of serious cases receive no treatment. (Incayawar, 2009, p. 252)
Quack suggests that the mental health community (and professional psychiatrists
in particular) can be roughly divided into three camps, depending on their atti-
tude towards what he calls “folk healers.” The first group seeks to abolish
such therapies altogether. In India, their case was greatly strengthened by the
“Erwadi tragedy” of 2001. Erwadi is a Sufi shrine in South India, famous for the
ritual healing of persons with mental disorders. It receives so many pilgrims seeking
help that special accommodation had to be built for them nearby. On August 6,
2001, a fire broke out in one of these hostels, resulting in the death of some
30 persons, many of whom were physically restrained at the time and thus
unable to escape. The tragedy resulted in calls for the outlawing of such shrines
(even though critics pointed out that fires in hospitals do not result in calls for the
abolition of hospitals). But where would those needing help for mental disorders
go, if the numerous Hindu temples and Muslim shrines specializing in such
things were no longer available? Would the crammed and unhygienic wards of
Sax 839
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Indian hospitals really be a better alternative than these supportive religious
environments?
A second group of scholars “may be critical or even hostile to such practices, but
at the same time, acknowledges the advantages of using the folk healers as means
to the end of spreading psychiatry” (Quack, 2012, p. 4). For example, in the dava
aur dua project documented by Helene Basu (2009), where psychiatrists opened a
small clinic in a prominent healing shrine in the Western Indian state of Gujarat,
the aim was to train people in the folk sector “to identify mental health problems,
provide counseling and refer appropriate cases to the closest mental health facility”
(Bhat, Maheshwari, Rao, & Bakshi, 2007, p. 211). Such statements disguise the
underlying perspective on the folk sector: folk practitioners do not count as a
“mental health facility.” It would be more appropriate to speak of such cases as
“utilization” rather than “collaboration” (Quack, 2012, p. 9).
The notion in this model of integration is that the healers should be identified
and inducted into the system so that they may practice their skills under the watch-
ful eye of the state, or so that their cooperation can be enlisted for disseminating
information, and referring sick persons to “real” doctors. Such a position is wide-
spread, and by no means confined to India. It is for example explicit in Incayawar’s
article (cited above), where much of the rationale has to do with cost-cutting: given
the shortage of psychiatrists, ritual healers can usefully function as a kind of stop-
gap measure.
According to Quack, a third group of scholars and practitioners aim at collab-
oration rather than utilization (2012, p. 4). One example is an article appearing in
the pages of this journal (cf. de Jong, 1987, 1997), another is the collection edited
by Incayawar et al. (2009), some of whom seek collaboration between psychiatrists
and traditional healers. But this appears to be a minority position, and I want to
conclude this essay by arguing that the state’s structural blindness to ritual healing
should be maintained, at least in India. There are several reasons for this.
The first reason is that the individualism informing mainstream psychiatry is
incompatible with South Asian understandings of the person. Above, I discussed
the “nonindividualism” of Indian culture, which contrasts strongly with individu-
alism central to the western sciences of the mind. Whereas individuation is often the
goal of western psychotherapy (Blos, 1967; Doctors, 2000; Franz & White, 1985;
Mahler, 1968) it is more likely to be regarded as the problem in India. This was
brought home to me during my own research on healing rituals, when I discovered
the concept of hamkar.Hamkar refers to a dead person’s anger and jealousy,
emotions that are sometimes so strong that they afflict the living, and transform
the dead person into a ghost. The term derives from the Sanskrit ahamkara, liter-
ally “I-ness,” which is associated with egoism, self-interest, and identification with
the body (see Desai, 1989, pp. 44–46). I think it is significant that this abstract
philosophical term is very widely used in such a context to designate egotistic,
“individualistic” emotions that are at the same time dangerous and destructive
supernatural forces, and I infer that there is a kind of incommensurability between
South Asian notions of the person, which form the basis of ritual healing practices,
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and western psychiatric ones. When the latter are operationalized, they might even
do more harm than good.
The second reason why the state should maintain its structural blindness to
ritual healing is that in India, and probably in many other countries as well,
social asymmetries between ritual healers and health professionals are so great
that it is difficult to imagine how a truly respectful relationship between them
could develop. This is because such professionals belong to the “transcultural
and post-Enlightenment community of scientific moderns” that I mentioned at
the beginning of this essay—or at least, they aspire to belong to it. Although
some of the ritual healers I met were sophisticated and highly educated, their
education was in Sanskrit not science, and they would almost certainly be regarded
by health professionals as deficiently modern, all the more so because the majority
are low-caste women or farmers.
8
We must remember that in many settings, ritual healing is not rejected on sci-
entific grounds, but rather in order to keep up appearances. Mullings has shown
how in Ghana, family-based ritual therapy gave way to individual therapy under
the modernizing influences of capitalism and Christianity, and the transformation
of villages into towns (1984, pp. 121, 133–185). To be “modern” and scientific is to
reject the theories and practices associated with ritual healing, because they lie
outside contemporary paradigms of science, modernity, and development. Those
who seek to defend or preserve ritual healing thus risk marking themselves—and
perhaps even coming to understand themselves—as “non-modern and deviant”
(Nandy & Visvanathan, 1990; cf. Pigg, 1995), and this is as true of the
“modernizing” cultures of Africa and Asia as it is of Europe and North
America: perhaps even truer, since local elites in such cultures are surrounded by
ritual healing practices, and must therefore work harder than their western col-
leagues to distinguish themselves from those who engage in ritual healing. Kendall
(2001) cites cases from Cypress and Sri Lanka illustrating
the middle class’s identification with “science” or with more “rational”-seeming reli-
gious practices as a means of asserting and naturalizing class domination .... The
point here is not that the new elites’ posture toward popular religion is an inevitable
consequence of “modernity” so much as it represents the self-conscious inhabiting of
new class positions. (2001, p. 30)
A third reason why, in my view, it would be best for the state to maintain its
structural blindness to ritual healing is that neither the modern sciences of the
mind nor the regulatory apparatus of the state can or will acknowledge the validity
of ritual or religious therapy for “mental illness.” The inability of most Indian
health professionals to take ritual healing seriously, or to do anything other than
disparage it, was brought home to me the first time I ever gave a public lecture
about the topic, at the Institute for the Study of Human Behavior and Allied
Sciences in Delhi (informally known as the “Old Madhouse,” because an asylum
was previously located there). I had only just begun the research, and was glad to
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have the chance to discuss it with other academics. I told my learned audience of
doctors, psychologists, and psychiatrists about the system of oracles and gurus,
showed them a brief video clip, and advanced a preliminary version of the thesis
with which I began this article: that ritual healing sometimes “works” by address-
ing the social causes of stress-related disorders. After concluding my talk,
I expected an enthusiastic round of applause and a stimulating discussion. What
I got was outrage. “How dare you conduct research on such a topic?” they asked.
“This is nothing more than primitive, superstitious nonsense! You should be spend-
ing your time stamping it out, not conducting research on it!” Perhaps I should
have expected such a reaction. After all, these were men of science, and the idea
that ritual healing might have therapeutic benefits comparable to those of biomedi-
cine seemed ridiculous to them, perhaps even insulting. They were like the Nepali
doctors discussed by Adams, who were exposed for such a long time to modern
critiques of ritual healing that they began to regard such practices as evidence of
backwardness (1998, p. 12).
Practices of ritual healing are characteristic of specific cultural and historical
niches, to which they are well adapted, otherwise they would not persist. Very
often, their strength lies in their particularity. They are not especially systematic,
and are therefore recalcitrant to standardization. But an official health regime
requires the standardization of practices, so that they can be monitored, controlled,
and improved (Hoff, 1995; Puckree et al., 2002; Weiser, 1999). Worse, with the
introduction of “modern” biomedicine, traditional knowledge systems are defined
as inferior, nonscientific, and superstitious; in short, as forms of ignorance, as the
title of Hobart’s (1993) influential study of the development industry implies. Ritual
healers often adjust to such blindness by taking on the appearance, accoutrements,
or language of biomedicine (Greene, 1998; Press, 1971; Whyte, 1989, pp. 294–295).
Meanwhile, the World Health Organization claims to be interested in traditional
healing techniques, and even encourages research on them; however, its interest is
limited to those kinds of healing that can be accommodated within a biomedical
model: massage, diet, bone-setting, and above all herbalism (World Health
Organization, 1978, 2002). Ritual healing is definitely not on the list. Meditation
and related practices are popular components of health programs, and are increas-
ingly subject to scientific trials of various sorts, (Majumdar, Grossman, Dietz-
Waschkowski, Kersig, & Walach, 2002; Ospina et al., 2007; Speca, Carlson,
Goodey, & Angen, 2000), but similar studies of ritual healing are practically non-
existent. I suspect that this is largely because methodology and class reinforce each
other here. While it is indeed possible to measure the effects of meditation on those
middle and upper class persons who practice it in the West, it is much more difficult,
perhaps even impossible, to do similar measurements with traditional forms of ritual
healing with their ecstatic trances, bloody sacrifices, and oracular diagnoses.
In the end, the paradigms of biomedicine and ritual healing are incommensur-
able, and so are their criteria of effectiveness. On the one hand, a worldwide web of
doctors, hospitals, universities, clinics, journals, experiments, and professional
associations works to ensure that practices are standardized, and that efficacy is
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evaluated according to universal criteria, purified of their social and historical
context: a classic example of Latourian modernization in practice. On the other
hand are the thousands of isolated traditions of ritual healing that attempt,
through a myriad of techniques and a veritable Babel of idioms, to reintegrate
afflicted persons with their families and communities. They do so in terms of cul-
tural contexts, which are, by definition, local. Ritual healing resists the normalizing
practices of the state and of biomedicine—and so it must, or else lose the very
context sensitivity that defines it. That is why, in my view, the Indian state should
retain its structural blindness to ritual healing.
Funding
This research was funded by the German Research Council’s Collaborative
Research Centre 619, “The Dynamics of Rituals”.
Notes
1. For Humphrey and Laidlaw, the “ritual stance” or “ritual commitment” is of central
importance. This is a kind of “nonintentional intentionality” according to which, in
effect, ritual actors subordinate their own agency to that of the ritual, agreeing to follow
its prescriptions. “Instead of being guided and structured by the intentions of actors,
ritualized action is constituted and structured by prescription, not just in the sense that
people follow rules, but in the much deeper sense that a reclassification takes place so that
only following the rules counts as action” (1994, p. 96). For Bell, ritualization is “a matter
of various culturally specific strategies for setting some activities off from others, for
creating and privileging a qualitative distinction between the ‘sacred’ and the ‘profane,’
and for ascribing such distinctions to realities thought to transcend the powers of human
actors” (1992, p. 74).
2. Hence the title of Raymond Firth’s influential monograph on Polynesian ritual, The
Work of the Gods in Tikopia (1940). In the Western Himalayas as well, what I call “rit-
uals” are often referred to as devakaarya, “the work of the gods.”
3. The term “initiatory illness” refers to the extensively documented fact that many shamans
and other ritual healers (and all of the oracles whom I studied) are inducted into this
vocation only after they themselves have undergone ritual healing.
4. For an explicit discussion of this issue, see Sax (2009a, Chapter 3) and Le
´vi-Strauss’
discussion (1963, pp. 175–185) of the Kwakiutl shaman Quesalid who, despite his self-
conscious use of various techniques to “trick” patients and thereby increase their faith in
his methods, nevertheless retained a strong belief in the efficacy of shamanism.
5. This is why traditional healing in general is highly conservative, insisting that persons in
subordinate positions and especially women, conform to social expectations as a mark of
successful healing (see Okwaro, 2010; Polit, 2011; Sax, 2010c).
6. Preamble to the Constitution of the World Health Organization as adopted by the
International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946
by the representatives of 61 States (Official Records of the World Health Organization,
no. 2, p. 100) and entered into force on 7 April 1948.
7. The Cambridge Anthropologist Marilyn Strathern adapted Marriott’s term “dividual” for
her own research on Melanesian concepts of the person (see Strathern, 1993, pp. 41–52).
8. Haram (1991) has described a very similar situation in Africa.
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William S. (“Bo”) Sax studied at Banaras Hindu University, the University of
Wisconsin, the University of Washington (Seattle), and the University of
Chicago, where he earned a PhD in Anthropology in 1987. He has taught at
Harvard, Christchurch, Paris, and Heidelberg, where he is Chair of Cultural
Anthropology at the South Asia Institute. His major works include Mountain
Goddess: Gender and Politics in a Central Himalayan Pilgrimage (1991); The
Gods at Play: Lila in South Asia (1995); Dancing The Self: Personhood and
Performance in the Pandav Lila of Garhwal (2002); God of Justice: Ritual Healing
and Social Justice in the Central Himalayas (2008); and The Problem of Ritual
Efficacy (2010).
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