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Views of mental illness in Morocco: Western medicine meets the traditional symbolic
A July morning in Casablanca. The hot buzz of a city bursting at the seams. And the sense that most of the world meets here. I'm here to learn about psychiatry in a cultural context that is new to me. For a Canadian medical student interested in the crossroads between medicine and culture, the Centre Psychiatrique Universitaire Ibn Rochd (CPU) is a fascinating place. Here, the shift from traditional to Western modes of care is illustrated in a resident's report at morning rounds. A young man had been admitted because he had become delusional and violent, threatening his mother with a kitchen knife. His family had taken him to a traditional healer, a fquih (feki), who believed him to be under the spell of a maleficent spirit, a djinn (jin). The fquih had prescribed ritual fumigation with herbs — b'khour (pkhor) — to expel this unwanted guest. But the patient's condition had deteriorated, and his family now saw the CPU as their last hope. The resident had started him on a course of haloperidol, hoping to keep this first episode of psychosis in check. That July morning I was reminded of Arthur Kleinman's argument in Rethinking Psychiatry1 that healing, especially in the realm of the psyche, is enacted through the symbols of the surrounding culture. The psychiatrist and the shaman alike heal by manipulating the symbolic framework that they share with their respective patients. A large part of the resident's work that morning would be to introduce a new set of symbols to the patient and his family, setting in motion a healing process in line with the tenets of scientific medicine. As I would learn in my weeks in Casablanca, the Moroccan perception of mental illness is informed by 2 monolithic symbolic frameworks, the secular and the sacred. A colonial legacy
Western psychiatry arrived in Morocco on the coattails of French military and tropical medicine, whose first priority was a war against the infectious diseases endemic to the country. The French presence in Morocco became a political reality in 1912 with the signing of the Treaty of Fez, which removed power from the reigning sultan and established French and Spanish protectorates. Initially, France's main concern was the welfare of about 300 000 new settlers who had slowly established themselves: modern colonial cities, each with its own hospital, were built alongside Morocco's ancient medinas. In the 1930s, the French military doctors Mazel and Pierson were given the responsibility of providing the first psychiatric services in Morocco. Thus began the era of "Berrechid," a sprawling asylum that strictly segregated French from Moroccan patients.2
When the Moroccans achieved self-governance in 1956, they took over French institutions, and the psychiatry that is practised today is by Moroccan physicians for the Moroccan population.2 Most psychiatrists, in both the public and the private sectors, are concentrated in large urban centres, particularly Casablanca. Two faculties of medicine, one in Casablanca and the other in Rabat, train students in the specialty. Strongly rooted in Western medicine, Moroccan psychiatry views mental illness as a medical condition amenable to medical intervention. The psychiatry I saw practised at the CPU was pharmacologically driven, aside from the more psychodynamic approach taken by a handful of psychologists. The "changing of hands" of this specialty from the French to the Moroccans has not included an attempt to incorporate traditional approaches in the treatment of mental illness. Physicians have certainly shown an interest in traditional therapies3,4,5 but, on the whole, psychiatry (and medicine in general) has kept its distance from traditional modes of healing. Berber beginnings
In Morocco, popular approaches to mental illness are rooted in the traditions of the country's indigenous population, the Berbers, who inhabited the mountainous and desert regions of Morocco well before the arrival of the first "foreigners," the Phoenicians, in the first millennium BC. Traditionally, the Berbers were animists who attributed magical or spiritual powers to much of their natural surroundings. It is easy to see how the concept of sorcery, sHour (seHour), so integral to the Moroccan understanding of mental illness, could have either arisen from or been adopted by the Berbers. As one psychiatry resident explained to me, "C'est le mal palpable." That is, it is evil in a form that we can touch, taste and feel. SHour can be anywhere — in a stone lying in the grass, in the henna painted on a woman's hands, in the orange juice sipped at a local café. It can be "placed" in these and countless other objects by malicious people bent on revenge, or it can simply be a natural property of the objects themselves, waiting patiently for some innocent person to stumble upon them. People who walk over, touch or swallow sHour are not themselves; they suffer from a range of chronic physical and mental disturbances. One patient at the CPU, a young man with a history of alcohol abuse, had been admitted with delirium tremens. Whereas the residents explained his hallucinations and bizarre behaviour in terms of clinical dependency and withdrawal, a local fquih viewed the symptoms as a clear case of accidental ingestion of sHour. His response to the young man's complaints had been to prescribe a strong emetic. To take another example, the mother of a young woman experiencing a psychotic episode stated that she suspected tretat to be the cause. Loosely translated as "to take a step," this meant that someone had thrown sHour under her daughter's feet as she passed. Stepping over the sHour (no doubt some innocuous-looking object such as a stone), she had fallen ill.
A small part of some village economies in Morocco is devoted to the making and breaking of sHour. The seHara is typically an older woman with experience in the magical arts who, for a fee, will imbue objects with evil for use against one's enemies. Victims of tretat or other encounters with sHour seek out the local fquih and pay for an antidote. When this fails, they may find themselves in a psychiatrist's office, grappling in desperation with a new set of healing symbols.
Evil can also attack without direct physical contact, simply from the ill will or jealous intentions of others. Berbers have, in common with many Mediterranean cultures, a concept of the "evil eye" (Al Ein [al ayn]). Someone presenting with chronic pain or limb paralysis, for example, is as likely to have been a victim of the evil eye as of sHour. Either of these capricious forces can strike anyone — in the words of Gita El Khayat, "parce qu'on est jeune, ou beau, ou heureux, ou prospère, ou fecond, ou ... simplement tranquille!"2 The djnoun: Islam's legacy
Islam, which was introduced to Morocco by the Arabs in the eighth century AD, has also coloured the Moroccan view of mental illness. The Koran teaches that Allah populated the universe with 4 types of beings: humans, angels, Iblis (Satan) and demons, or djnoun (jenoun). (Djinn is the singular form.)2 Only humans are visible, but the others are not merely imaginary or symbolic: they coexist with humans, guiding and interfering with their efforts to follow the way of Islam. In fact, the djnoun closely resemble humans in having the same needs. They eat, drink, procreate and die; they form families, communities and entire societies. Their activities are nocturnal, ending at dawn with the muezzin's call to prayer.
In Morocco as elsewhere, an entire folklore surrounding the djnoun has arisen. For example, they are believed to inhabit particular areas. They like moisture and tend to set up camp alongside creeks and under trees, in washrooms and old ruins, as well as in cemeteries, garbage dumps and slaughterhouses.2 They are sensitive creatures, and care must be taken when intruding on their territory. One patient at the CPU could pinpoint the exact time of onset of her symptoms of depression: it was the night she inadvertedly scalded a djinn living peaceably in the bathroom pipes. Enraged, the djinn entered her body and took his revenge on her psyche. Another patient, a teenager, believed that his problems began when he stepped on a djinn living under a nearby bush. At the CPU, the djinn's vengeful possession was interpreted as the beginnings of schizophrenia. A medical student who took clomipramine to manage obsessive–compulsive disorder had also visited a fquih, who read from the Koran and performed b'khour. In his opinion, her obsessions were the non-Muslim thoughts of some pagan or Jewish djinn who possessed her. The patient herself was unsure of the reason for her affliction (which she summed up as "pensées qui n'arretent pas"); straddling 2 worlds, she found the medical and religious interpretations of her illness equally unconvincing. The marabouts
Sufism, a mystical strain of Islam, arrived in Morocco in the 12th century AD. An attempt to democratize Islam and make it accessible to poor and illiterate segments of the population,6 it was both embraced and transformed by an indigenous population that was already slowly becoming Arabized. Sufi brotherhoods cropped up throughout the country, with holy men, the marabouts, espousing a simple and devotional life and acting as intercessors between human and divine beings. Claiming direct lineage from the Prophet, the marabouts were community leaders who led exemplary lives. More importantly, they were imbued with baraka, which might be loosely translated as "divine blessing." This concept appealed to the once-animist Berbers: special powers, once the domain of inanimate objects, were now invested in people themselves.2 Today, the term "marabout" denotes the tomb and surrounding shrine of one of these holy men, a site of pilgramage for those seeking baraka.2,4 For people suffering from mental illness, the marabout of Bouya (Father) Omar, close to Marrakesh, holds particular sway. Omar gained a reputation in the 16th century for his ability to communicate with the djnoun and settle their grievances against humans.3 In return for some kind of compensation (e.g., visits to a marabout, readings of Koranic suras or the sacrifice of animals), the djinn would voluntarily leave the person's body, thus ending the psychological torment. Today, the search for a cure through Bouya Omar's intercession rests on the same concepts of justice and compensation for wronged djnoun and involves a complex set of rituals, including prayer, trance, animal sacrifice and taking up long-term residence (sometimes years) close to the shrine.3,7
The importance of marabouts in Moroccan culture can be gauged by their sheer number. Travelling around the countryside, I grew accustomed to the sight of the koubba, the white-domed structure that shelters the marabout's tomb. In Kelaa es Sraghna, a town of around 100 000 people near Marrakesh, no fewer than 50 marabouts occupy an area of 10 square kilometres.2 Marabouts tend to be simple, square and compact, settling unobtrusively into the landscape; similarly, they tend to be incorporated quite naturally, sometimes almost imperceptibly, into daily life. Very close to the CPU, in downtown Casablanca, lies the marabout of Sidi (Saint) Mohammed. As one walks along a city street apparently like any other — with pale ochre buildings, dusty shops and mopeds buzzing past at every turn — one comes across the shrine almost by accident. It appears suddenly, its small koubba peeking over a narrow courtyard. Very close to the entrance, a group of women sell wax candles as offerings, as well as baskets brimming with the herbs, bark and seashells that form the necessary ingredients for b'khour. Inside the courtyard, visitors mill about, reading the Koran and conversing quietly. From here one can peer into the entrance to Sidi Mohammed's tomb: inside, some people pray in silence while others shuffle around the coffin. The concerns that bring people to Sidi Mohammed are diverse. One visitor seeks a husband; another hopes to improve her marks in the coming school term; another seeks relief from a painful, suppurating eye. At the CPU, the personal histories of patients invariably included visits to marabouts. The fquih
If the marabout represents the physical institution of traditional healing for mental illness, the fquih is its living practitioner.2,3,5 Literally translated as "religious scholar," the fquih fulfills the role of holy man, sage, seer and sorcerer. The details of his education are mysterious; it may include some schooling in the occult, but the fquih is also well versed in the Koran. His most important credential is his baraka. Like the marabouts of yore, these healers are viewed as having a special gift that allows them to navigate between the human and spirit worlds. Their role as exorcist, whether this entails the removal of sHour or the eviction of Djnoun, is perhaps the one called upon most often.4 Their tools include b'khour, herbal remedies and amulets, as well as Koranic readings and magical incantations. More extreme methods include beating the client to frighten away a djinn and animal sacrifice.
Although many of the psychiatrists I spoke to at the CPU considered most fquihs to be charlatans who exploit people's suffering for monetary gain, there were certainly some fquihs who made the well-being of their clients a priority. One physician related to me an encounter with a young man and his family who had arrived at the hospital accompanied by a fquih, whom they had consulted on numerous occasions about the man's alarming behaviour. The fquih had become convinced that his client's problems were not related to possession by a djinn, but represented an organic mental illness. In fact, it was the fquih who suggested that he consult a psychiatrist. The patient seemed greatly comforted by the fquih, who calmed him down with Koranic verses and incantations. The psychiatrist suggested that the fquih could play a part in the patient's care by ensuring that he took his medication. Conclusion
Almost all of the patients I encountered at the CPU appeared to have a great deal of confidence in their psychiatrists and medications, and many had abandoned the "traditional symbolic" in favour of a medical or psychodynamic interpretation of their symptoms. However, it would be misleading to suggest that the beliefs and practices I have described are confined to the fringes of Moroccan society. There appears to be no Moroccan who is unaware of indigenous healing practices or is without an opinion about them. As in the case of the young man whose fquih helped him to comply with medical treatment, many Moroccans are faced with the challenge of finding a middle ground between 2 powerful symbolic frameworks.
To a foreigner, the dissonance between these frameworks is striking. My visit to Morocco coincided with Pfizer's introduction of Viagra in that country. I was invited to attend the drug's unveiling at a major hotel in downtown Casablanca. It was an impressive affair with expert talks on erectile dysfunction and a lavish buffet. As I left the festivities that night, wondering when Viagra would arrive in Canada, I was struck by the strangeness of my situation. Behind me, at the hotel, physicians discussed the "magic pill," answered cell phones and sampled smoked salmon and white wine. Ahead lay the moonlit walk to my residence: the thrum of voices joined in night prayer, the lit mosques and the anticipation of enjoying, before bed, a written account of Bouya Omar.7 Perhaps it was the age-old romance of Westerners with the "Orient" at work, but to me the city reverberated with an echo of Berber Islam. It will be interesting to see where the interplay between secular and sacred frameworks will lead the Moroccan people. The medical profession knows its own tenets, but from what point on the spectrum will patients draw the symbols they use to define mental illness? Time will certainly tell.
Competing interests: None declared.
Acknowledgements: I thank the staff and residents at the Centre Psychiatrique Universitaire Ibn Rochd for their guidance and insights into Moroccan perspectives on mental illness.
The author received a University of Toronto International Health Program Scholarship, funded by the University of Toronto Medical Alumni Association. Debra Stein is a fourth-year medical student at the University of Toronto, Toronto, Ont. This article has been peer reviewed. Correspondence to: Debra Stein; fax 416 968-0957; debra.stein@utoronto.ca References
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