Abstract
Experiencing the continued presence of the deceased is common among the bereaved, whether as a sensory perception or as a felt presence. This phenomenon has been researched from psychological and psychiatric perspectives during the last five decades. Such experiences have been also documented in the ethnographic literature but, despite the extensive cross-cultural research in the area, anthropological data has generally not been considered in the psychological literature about this phenomenon. This paper provides an overview aimed at bridging these two areas of knowledge, and approaches the post-bereavement perception or hallucination of the deceased in cultural context. Ongoing debates are addressed from the vantage point of ethnographic and clinical case study research focusing on the cultural repertoires (in constant flux as cultures change) from which these experiences are labelled as desirable and normal, on the one hand, or as dangerous and pathological, on the other.
Introduction
During and after the grieving process, the bereaved frequently describe hearing, seeing, or feeling the presence of the person who died. These experiences have been extensively narrated in the folk, historical, and ethnographic literatures and, during the last five decades, have received increased attention from the psychological and medical disciplines.
Research in this area, in both psychology and psychiatry, is divided terminologically. On one side are those who refer to post-bereavement hallucination (Rees, 1971; Grimby, 1993; Castelnovo, Cavalloti, Gambini, & D’Agostino, 2015), grief hallucination (Baethge, 2002), or hallucination of the deceased (APA, 2013). On the other, and primarily due to the pathological connotation of the term hallucination, some prefer to refer to experiencing or sensing the presence of the deceased (Steffen & Coyle, 2010; Keen, Murray, & Payne, 2013; Hayes & Leudar, 2016).
To avoid adopting either side of this polarised debate, and merely for convenience in this paper, we will refer to these experiences as a bereavement-related perception or hallucination of the deceased (BPHD) On our definition, a BPHD involves perceiving (hearing, seeing, touching, smelling) or feeling (the presence of) the deceased person. They are mainly felt as pleasant, comforting, and welcome, and they are experienced by 30% to 60% of the bereaved (Keen et al., 2013; Castelnovo et al., 2015), happening to those identifying as both religious and non-religious. 1 BPHDs are most frequently a felt presence (39% to 52%), followed by auditory (13% to 30%) and visual (14% to 26%) experiences (Rees, 1971; Grimby, 1993), although experiences involving several (or all) sensory modalities have been also reported in the literature (Castelnovo et al., 2015).
In contrast to the common over-reliance of psychological research on Western samples (Henrich, Heine, & Norenzayan, 2010; Rad, Martingano, & Ginges, 2018), this reported prevalence is based on a breadth of cross-cultural data. The initial empirical studies on BPHDs were conducted in Japan, by Yamamoto, Okonogi, Iwasaki and Yoshimura (1969), and in Wales, by Rees (1971). Studies have followed across European, American, and Asian countries (Castelnovo et al., 2015). However, these rates should be approached with some caution: BPHDs are believed to be underreported due to fears of rejection, stigmatisation, or ridicule (Rees, 1971, 2001; Grimby, 1993, 1998), and there are clear phenomenological difficulties in isolating these experiences from similar ones, such as waking-nightmares during sleep paralysis (Cheyne, 2001, 2003) and hypnagogic and hypnopompic hallucinatory experiences.
Despite BPHDs being predominantly experienced as welcome, a minority of people find them disturbing. Although data on the valence of BPHDs is considerably limited, 5% to 30% seem to be experienced in a distressing, unwelcome or ambivalent way (Hayes & Steffen, 2017). In discussing the reason(s) for the varied valences of BPHDs, several authors have noted the importance of sociocultural-sanctioning and suggested that distressing BPHDs could be non-existent (Yamamoto et al., 1969) or less disturbing (Chan et al., 2005) in cultures where perceiving the deceased is culturally accepted and expected. Steffen and Coyle (2010) and Keen and colleagues (2013) have also discussed the particular role of spiritual-religious belief in the sociocultural-sanctioning of these experiences.
Whilst cross-cultural research has had an impact on discussion of BPHDs, the lack of integration between the psychological and anthropological literatures has caused the richness of ethnographic data to be frequently overlooked. Arguably, at the same time, the attention to phenomenology in psychology and psychiatry has had little impact in the anthropological realm. Although this is probably due to the foundational disconnection between both disciplines (Fish, 2000; Greenfield, 2000), terminological issues have not helped in establishing bridges: whilst psychologists have coined a myriad of etic terms for these experiences 2 , anthropologists have mainly relied on emic descriptions (such as possession or haunting).
By contrast, the wider field of hallucination research, besides specific research on BPHDs, has shown an integrative trend between psychology and anthropology in recent decades. Non-clinical voice-hearing is now known to be frequent among the general population (Beavan, Read, & Cartwright 2011) and to be culturally malleable (Luhrmann, 2011). Psychosis also varies in hallucination content (Suhail & Cochrane, 2002) and sensory modality (Bauer et al., 2011) across countries. Reviewing the ethnographic and clinical literatures in the area, Larøi et al. (2014) concluded that culture influences the experiencing, understanding, and labelling of hallucinatory experiences. In their view: An ethnographic approach to hallucinations therefore becomes essential in understanding how members of particular societies identify and understand sensory events that would be recognised by secular observers as hallucinations and how they distinguish between unusual sensory events they regard as appropriate and those they identify as signs of illness. The richness of the ethnographic method captures meaning that experimental approaches will miss. (p. 213)
Method
A keyword-based search was conducted in three databases (Social Sciences Citation Index, PsycINFO, and Google Scholar) to identify pertinent studies. In each database, keywords from the database were selected that addressed potential BPHDs (presence, hallucination, apparition, haunting, possession), combined with keywords addressing loss (bereavement, grief, mourning) and with ones addressing the research area (ethnography, cultural, cross-cultural). Only experiences fitting the definition of BPHDs provided above were included in this review. Exclusion criteria, therefore, were experiences occurring outside complete wakefulness, and those not experienced directly but mediated by somebody else (e.g. by a shaman or a priest). Studies assessed as being outside the aforementioned research area were also excluded. The initial search was supplemented with manual searches in selected articles: forward by citation tracking, and backward from references, in order to identify additional papers that had been missed through the database search. The search was conducted in both English and Spanish. The resulting studies are reviewed according to their main framework: (1) medical anthropological and cultural psychiatric research, (2) family-based participant observation, (3) Psychotherapy case studies, (4) interview-based psychological and psychiatric research, and (5) socio-historical research. The reader is cautioned regarding the heterogeneity of these studies, ranging from single case (n = 1) to fieldwork-based (n > 100) studies.
Overview of the literature
Medical anthropological and cultural psychiatric research
Almost simultaneously with the foundational studies of Rees (1971) and Yamamoto and colleagues (1969), three cases of BPHDs were documented by Matchett (1972) in his fieldwork among the Hopi Indians of northern Arizona. The three were elderly Hopi women, diagnosed as non-psychotic and suffering from depression, whom “during a period of mourning, clearly and repeatedly hallucinates the presence of a recently deceased family member” (Matchett, 1972, p. 185). These experiences were audio-visual (a vision for two of them, a vision and a voice for the third one) and clearly unwelcome for all of them. For one woman, her visual experiences evolved from being welcome to become highly distressing: She described how she would sit alone in her room in the evening and draw all the shades, and then, almost nightly, a vision of her deceased husband would appear before her chair. He would say little to her. At first she found this experience a very comforting one, and looked forward to his presence. Later, he began quite persistently to say things like: ‘I’m gone now, don’t bring me back any more; I don’t want to come back’. In the last month before her hospitalisation, the apparition stood in front of her chair, caressed her hair, then softly touched her check. She could distinctly feel his fingers move gently from her cheek to her neck; then suddenly he began to strangle her. She sprang to her feet in terror, ‘struggled free’, threw on the light, and ‘he was gone’. Gradually, the apparition began to show signs of physical decay. She reported that flesh on his hands and arms was turning to ‘skin and bones’ and that his clothing was deteriorating (Matchett, 1972, p. 189).
Another case, of a bereaved woman experiencing the presence of her deceased father, was described by Putsch (1988) among the Coast Salish, a group of tribes inhabiting the North American (mainly Canadian) Pacific coast. The Salish believe that chronic illnesses during wintertime are caused by spirit possession, an illness that is only treatable through singing and dancing the spirit’s song. The woman described a vision of her father giving her a song, after which her mother began “hallucinating her father all the time, refusing to believe that he was really gone” (Putsch, 1988, p. 14). The daughter developed arthritis, which she related to the spirit’s influence, and both women came to believe that she was about to die. A memorial service, during which the daughter was able to sing his father’s spirit song, was successfully conducted as a treatment.
Nagel (1988), moreover, documented another three cases of distressing BPHDs in his fieldwork among the Navajo. All of them, suffering from a traumatic loss, received psychotherapy and pharmacotherapy (antidepressant medication) in addition to culturally-bound rites and ceremonies. As Matchett (1972) did with the Hopi, Nagel (1988) connected these experiences to the worldview of the Navajo. Loss and mourning were surrounded with fright and avoidance, since they believed that most of the deceased return as malevolent ghosts that haunt their relatives. As a measure of prevention, no emotional expression of grief is condoned in the community after the four-day period of mourning. Nagel presented “haunting” as a culturally-sanctioned outlet of the grieving distress, providing a solution to the mourning processes that go awry: the advice of “star-gazers” and the “Enemy Way” ceremonies that offer both diagnosis and treatment. Nagel finished his article reflecting on how: Culture shapes and patterns these processes and interprets and judges significant aspects of the individual’s experience. The intensity, frequency, and affective response to dreams and hallucinations seems to lead to a determination as to whether these experiences are deemed ‘normal’ or ‘pathological’ in a given cultural context (Nagel, 1988, p. 39). The most immediate concern for all members of the local group is, quite literally, losing the deceased, forcibly separating them from their living relatives. When a person dies or is killed, his image (wakan) remains in the vicinity to harass the living: either vengefully, in the shape of a murderous ghost called muisak (emesak in Shuar) intent on causing accidental death in the household of the killer, or nostalgically, in the shape of a blind ghost prone to upsetting pots and banging things during the night. The dead are acutely lonely and they are also sightless and perpetually hungry; hence their reluctance to part with the living (Taylor, 1993, p. 662).
Yet another description of this mourning taboo can be found in the ethnography of Shepard (2002) among the Matsigenka, a third Amazonian tribe. They believe that, after a sudden death, the deceased can return to life (in the form of a beast) to attack their own loved ones, either when they are dreaming or when they are walking alone in the forest. Bereft families are invaded by a mortal fear after the loss, and the mourning rites of the Matsigenka mirror this concern over the power of the dead. “The dead seek out their loved ones for companionship,” describes Shepard, “not fully aware of their own dangerous, liminal status. It is their nostalgia for life that makes the dead so perilous to the living” (Shepard, 2002, p.211). This defensive mourning involves, for the bereaved, laying quietly in the house for three days, avoiding both the forest and hunting, and painting their head with the ghost-repellent red annatto, a tincture. The nostrils of the corpse are plugged with tabor, a resin, to smother the aggressiveness of the beast. The Matsigenka differentiate between dreaming about a dead person, on the one hand, and seeing them while awake, on the other: tsavitetagantsi, “to become confused, to see something that latter vanishes or is not there” (p. 213). The latter is seen as a serious illness frequently leading to death, and kamatsirivenki, a sedge frequently infected by psychedelic-producing ergot fungi, is used as a treatment.
So far, this section has outlined three case studies among North American tribes and three ethnographies among Amazonian tribes. All of them have described people reporting BPHDs that were interwoven with the surrounding socio-cultural and spiritual-religious framework. The predominant sensory modality was visual, followed by auditory, and the experiences were mainly distressing.
An exception to this trend, regarding both the modality and the valence of the experiences, is the ethnography conducted by Gondar-Portasany (1989) in coastal Galicia (Spain). Interviewing 1,873 people with BPHDs as part of his fieldwork, besides the usual visual and hearing experiences, he also documented the belief that the deceased return as a dove or as a dancing light in the night, experiences reported by 21% and 15% of his sample, respectively. He connected these experiences to the societal changes in Galicia and in Western societies during the last century: The fear of death is making us forget the dead: those that were first expulsed from the centre of the village and kept in peripheral cemeteries. We are now trying to expulse them from our memory: because they symbolise our own death (which we seek to avoid), because they are our past, because we are only interested in our future. The problem is that the deceased are taking revenge coming back to perturb the unconscious of their reckless children […]. As we destroy ritual symbolism without providing a substitute system, we are witnessing the exclusion of an anarchic imagination almost bordering the pathological (Gondar-Portasany, 1989, p.14, translation by the first author).
Family-based participant observation
Whilst the ethnographies of Kracke (1988), Taylor (1993), and Shepard(2002) documented instances where BPHDs were culturally avoided and feared, the fieldwork of Doran and Downin-Hansen (2006) provided evidence of the opposite situation. Conducting participant observation among Mexican American families living in the United States who had lost a child, they documented a situation where BPHDs were not only accepted, but culturally sought-after. The families maintained a bond with the deceased children through a shared felt presence, experienced collectively (and in a welcome way) as a family system rather than as an individual, and stated that it would be “inconceivable not to maintain such a bond” (Doran & Downin-Hansen, 2006, p. 209). Rites and storytelling were in place, such as the use of the flower zempasuchil, which is believed to attract the spirits of the deceased. They concluded: The cultural influences on the grief process were clearly evident in the interview data. For example, the preparation of the deceased’s favourite food as part of the Day of the Dead celebration, the use of certain flowers to entice the spirit of the deceased to return home, and the dressing of dolls in the deceased’s clothes on home altars all illustrate the powerful role of Mexican American culture in the grief process […]. Death is a prevalent motif in Mexican culture, perhaps because of the intertwining of similar Aztec and Catholic beliefs that death is not the end, but rather an entry into a new way of life […]. Psychotherapists, when working with similar Mexican American families, might prudently focus more on engaging extended family and community support for the bereaved rather than emphasizing the centrality of the counselling relationship (Doran & Downin-Hansen, 2006, p.209).
Doran and Downing-Hansen (2006) and Steffen and Coyle (2017) have showed the relevance of family-based research on BPHDs. Besides participant observation, future research could focus on the interactional and linguistic issues involved in the family system experiencing BPHDs, either in dissension and individually (as in Steffen & Coyle, 2017) or in agreement and collectively (as in Doran & Downin-Hansen, 2006).
Psychotherapy case studies
The first paper on psychotherapy for distressing BPHDs was published, to the best of our knowledge, by Aguilar and Wood (1974). The intervention was held in a mental health clinic in California that provided psychotherapy to patients of Latin American (and mainly Mexican) origin. Among other techniques, they described the use of a drama-ritual with Mexican symbolism as an intervention for grief difficulties. The case was of an adolescent girl suffering from distressing visual BPHDs of her deceased father. Aguilar and Wood connected the distress to unresolved business with the departed, and described how the girl was able to express her grief and anger during the drama-ritual, confronting her father (“You were bad, you drank, you left us alone”; Aguilar & Wood, 1974, p. 13) before making amends, and saying goodbye.
Three years later, MacDonald and Oden (1977) published a clinical case series on three young Hawaiians suffering from distressing visual BPHDs. All of them interpreted these experiences as visits from aumakua, departed loved ones that appear to their family members in the form of spirits. They were initially treated with behaviour therapy (systematic desensitisation) but, after the intervention failed, a Hawaiian cultural practice was used instead: they were told to relax, bring forth the image of their aumakua, and ask them what messages they had for them. This latter intervention was quickly successful, decreasing their suffering and making the visions disappear. In the three cases, the aumakua (the grandmother of the boys, in the first two cases, and the brother of a girl, in the third one) communicated moral messages to them: to behave ethically, to stop his violent behaviour, and to obey her family, respectively. The authors connected these phenomena with the Hawaiian respect for their elders, and explained them from an etic perspective as the externalisation of a cognitive expectation that “seems to serve as solution to the dilemma posed by belief in the importance of voluntary adherence to group standards and, at the same time, belief in the need for independent control” (MacDonald & Oden, 1977, p. 193).
Shimabukuro, Daniels and D’Andrea (1999), also in Hawaii, published the case study of an 11-year-old Filipino boy whose mother had died and who frequently experienced her continued presence. These BPHDs were both auditory and visual and were experienced as comforting (“She’s always there to protect me”; p. 227), and were experienced by the boy while in the therapy room (“She is over here […], she’s kneeling down next to me”; p. 227). The authors connected the experiences with the particularities of the Filipino culture, both a religious belief in the power of the dead over the of the living and a sanctioning of BPHDs. Confronting “some of her own ethnocentric views about death and the afterlife” (p. 235), and refraining from diagnosing, the clinician reflected how, if using a traditional approach, she: …would have likely concluded that this student was suffering from pathological reactions to this mother’s death. By arriving at this type of conclusion, the youngster would probably have been referred for more intensive and ongoing psychotherapeutic services that would have included prescription medication to help ameliorate his reported hallucinations of his mother’s spirit and assist him in readjusting to school (p. 235).
To summarise, these psychotherapeutic case studies have described an intervention for BPHDs guided by normalisation and cultural-awareness. All of them reported successful outcomes, as assessed by the clinician. In those cases were the BPHDs were unwelcome, the distress was hypothesised to be connected with either unfinished business with the deceased (Aguilar & Wood, 1974) or with a deviation from socio-cultural rules (MacDonald & Oden, 1977).
Interview-based psychological and psychiatric research
Cross-cultural psychological research on BPHDs began, at the end of the nineteenth century, with the publication of the census on hallucination by Sidgewick (1894) and colleagues. The inquiry involved the interviewing of 17,000 people, across European and American countries, on the “spontaneous hallucinations of the sane” (p. 25). A total of 1,684 people (9.9%) responded affirmatively to having experienced a hallucination, of which 275 (1.6%) reported having experienced the presence of a deceased person via a vision (n = 127), a voice (70) or both (48).
Research then lapsed for seven decades, until the discrepancies between the investigation of Yamamoto et al. (1969), in Japan, and the studies conducted by Rees (1971) and Marris (1958) in Britain, triggered replication studies in in China, Sweden, Norway, Denmark, Germany, United Kingdom, Canada, and the United States (see Castelnovo et al., 2015). Yamamoto and colleagues interviewed 20 Japanese (and mostly Buddhist) widowed women in Tokyo, and found that 90% of them felt the presence of their deceased husband. None of the women worried about their sanity. They connected this with an acceptance and encouragement in Japanese culture around the idea of the presence of the deceased, and highlighted the butsudan (the family altar) in this sanctioning: In Japan the deceased become ancestors who are fed, watered, given gifts, and talked to, and so the tie between the widow and the dead husband remains through the concrete medium of the husband’s photograph on the family altar. The family altar is almost universal and is a cultural cultivation of the idea of the presence of the deceased (Yamamoto et al., 1969, p. 79)
These latter two studies, together with the majority of the cross-cultural research conducted in the area during the last two decades, were framed from the perspective of continuing bonds (Klass & Steffen, 2017). The continuing bonds theory is an emerging framework in bereavement studies that, briefly stated, asserts that not every grieving process should conclude with the detachment from the deceased (“let go for the past, and move on”; Klass & Steffen, 2018, p. 3): the ‘breaking bonds hypothesis’. A continued bond with the lost loved one, is argued, is a normal aspect of grief. A continuing bond can be a BPHD (an ‘externalised bond’), but also ‘internal bond’, such as keeping the personal belongings of the deceased and praying to them. In the case of this review, the amalgamation of these phenomena under the same terminological umbrella is a difficulty when extrapolating from cross-cultural data on continuing bonds to our understanding of BPHDs. An example of this is the investigation of Foster and colleagues (2012) among bereaved Christians in Ecuador, in which 14% of the sample reported feeling the presence of the deceased and 10% reported perceiving (hearing or seeing) them. A full 55% classified these continuing bonds as discomforting, but the researchers did not specify whether these belonged to the latter category.
A counter-example is the study conducted by Chan and colleagues (2005) among 52 bereaved people in Hong Kong. Nine of their participants (17%) reported that their deceased loved one coming back as an insect, and “some of the bereaved also described how these insects rarely flew away, as insects normally do, allowing the bereaved the chance to talk to the insects as if they were talking to the deceased” (Chan et al., 2005, p. 939). They interpreted this from the Chinese belief that the deceased relatives can return in insect form, usually as a moth, butterfly, or dragonfly, and fly around the family altar. Another Chinese belief, belonging to Taoism, is that the spirit of the deceased will return home on the seventh day after death. Nine of the participants reported having such an experience, and one reported distress that this prediction did not occur. In total, 17 participants (33%) reported perceiving (hearing or seeing) or feeling the deceased after the death. As Yamamoto et al. (1969) did in Japan, Chan et al. (2005) highlighted the sanctioning of a prolonged connection with the deceased in Chinese culture, connected with the ritualistic use of the family altar and the coexistence of (Buddhist, Christian, and Taoist) religious beliefs in the afterlife.
Socio-historical research
Stroebe, Gergen, Gergen, and Stroebe (1994) contrasted the contemporary perspective on bereavement in Western European culture, based on the 'breaking bonds hypothesis', with a pre-existing ‘romantic’ perspective in 19th-century Europe, when grieving was meant to signal the importance of the relationship with the departed. From this latter perspective, a complete detachment from the deceased would categorise both the relationship and the bereaved as superficial, making “a sham of a spiritual commitment and undermining one’s sense of living a meaningful life” (Stroebe, et al., 1994, p. 1208). Their analysis, based on previous research on 19th-century personal diaries, highlighted how common it was for people either to narrate visions of the deceased or to describe a striving to perceive (or feel) their presence. An example of their perspective in Victorian Britain is, precisely, the case of Queen Victoria after the death of Prince Albert who, according to the newspapers of the time, had: … a firm conviction that Prince Albert is always present with her, and that she can hold communion with him […]. In some of her moods she will converse with him for an hour together, conducting her own share of conversation aloud and with the vigour and interest of old times […] she imagines that her husband looks on, well pleased. At times, when she is more than ordinarily depressed with a sense of his presence, the poor, fond woman will order a knife and fork to be placed on the dinner-table for him, and cause the attendants to place every course before the empty chair as if the master still occupied it. (Sacramento Daily Union, 1871, October 10)
Discussion
BPHDs seem to be a common feature of bereavement in several cultures. Cultural research, nevertheless, has repeatedly documented cultural variation in the way that BPHDs are anticipated, experienced, and evaluated. Whilst the psychological and psychiatric literatures indicate that they occur regardless of nationality, age, and creed (Keen et al., 2013; Castelnovo et al., 2015), the anthropological literature suggests that they are strongly shaped by social, cultural, and historical influences.
Anthropological remarks
From an anthropological perspective, in the light of the reviewed literature, the psychological hypothesis connecting the valence of these experiences (welcome versus unwelcome) with the presence or absence of a (mainly religious) sociocultural-sanctioning seems over-simplified. Researchers have documented distressing BPHDs in those cultures where perceiving the dead is accepted (Matchett, 1972), as well as in those where it is feared (Nagel, 1988; Taylor, 1993). Kracke (1988), moreover, documented welcome BPHDs in a cultural environment of avoidance and repression. All occurred in cultures with a firm religious worldview. What can be concluded is that, although the cultural framework may not establish whether they are welcome or unwelcome for the bereaved, it definitely shapes the way in which the distress is suffered, expressed, and treated when BPHDs are disturbing. As Nagel (1988, p .33) stated, “in any culture these processes can go awry and one might expect there to be a cultural prescription for diagnosing and treating pathological outcomes”. The singing and dancing ceremonies of the Salish (Putsch, 1988) and the Navajo rites (Nagel, 1988) are good examples of this.
Another anthropological remark can be made regarding the phenomenological boundaries of BPHDs. We believe that meticulous attention to the subjective experience of people can add value to the anthropological exploration of BPHDs, helping distinguish rather different types of experiences. 2 Such phenomenological attention can differentiate BPHDs from other hallucinatory phenomena, such as a voice heard when falling asleep (hypnagogic hallucination), during sleep paralysis (waking-nightmare), or when waking up (hypnopompic hallucination). However, even here, caution is needed: Putsch (1988) and Shepard (2002) highlighted the difficulties in extrapolating the implicit Western European dichotomies (mind versus body, dreaming versus awakening, the living versus the dead, individual versus community) into some cultures to which they are alien, and the ethnographic literature provides us with more examples of these porous boundaries. Putsch (1988), for instance, has described two cases of BPHDs situated between the dreaming and waking state, which the patients (a Navajo woman and a Laos refugee) perceived as ontologically real (“the dead calling for, or returning for, the living”, p.17) and which caused not psychological but psychosomatic difficulties. He defended the equivalence of these experiences to the waking ones, involving perception, and categorised them as a culture-bound “ghost illness”. As Walker and Thompson (2009) have highlighted, dreaming and wakefulness are not mutually exclusive in American Indian culture.
Psychological remarks
From a psychological perspective, is compelling that several cultural researchers (ethnographers and non-ethnographers) saw BPHDs as idiosyncratic and as specific to the cultures they studied, connecting them with either their worldview, their rites, or their historical past. This has been the case even when psychological research had already indicated that BPHDs are common, and welcome, for the majority of the bereaved across countries. Matchett (1972), for example, analysed his clinical cases from the lens of the Hopi religion. Similarly, Shen (1986) even considered “mourning hallucinations” to be a pathology specific to the Hopi culture. Gondar-Portasany (1989) connected the phenomenon to the cultural and societal changes occurring in both Galicia and in Western societies during the last century, considering them as problematic, if not bordering on the pathological. In a clinical location, Sluzki (2008) saw the audio-visual BPHDs of his patient as reflecting the magical realism of Latin American culture, assuming them to be more common in “cultures where the boundaries between the inner and the outer world are fuzzy” (p. 379). A similar conclusion was reached by MacDonald and Oden (1977) and Shimabukuro and colleagues (1999) regarding the Hawaiian and Filipino cultures, respectively. Without wishing to minimise the distress of the protagonists in these reports, we do not see a convincing argument to classify these experiences as a pathology arising from the surrounding socio-cultural environment. We attribute the need to understand BPHDs in this way to the classical disconnection between the mental health and anthropological literatures that was already discussed. 3 Exceptions to this trend, nevertheless, are the studies of Kracke (1988), Putsch (1988) and Nagel (1988), who neither pathologized these experiences, nor framed them as specific to a given culture.
The proscription and pathologisation of BPHDs is clearly not the sole province of psychology and psychiatry. However, the literature suggests that, in Western European societies, the management of the divide between the bereaved and the departed relies increasingly upon mental health practitioners. In other cultures, where the therapeutic and the religious roles are not necessarily divided (Calabrese, 2008), this border-keeping function seems to have been frequently allocated to a shamanhood or a priesthood. We wonder to what extent changes in the status of religion in Western European societies, over the last 150 years, are linked with the transfer of a gatekeeping function to these mental health professions.
Psychopharmacological remarks
Another theme underlying the reviewed literature is the use of psychoactive substances, as part of this cultural proscription, either to treat or to suppress BPHDs. An example is psychedelic use among the Matsigenka, as described by Shepard (2002), but also the use of anti-psychotic medication, within the psychiatric realm, as mentioned by Sluzki (2008). Given that psychosis is sometimes described as “simply the presence of hallucinations and/or delusions” (Semple et al., 2005, p.176), and that some distressing BPHDs could meet criteria for a brief psychotic disorder within DSM-V (APA, 2013), this use of medication to manage BPHDs is an unsurprising possibility. We believe that the danger is considerable, potentially involving an unnecessary pathologisation or an ethnocentric medicalisation, and that such use of medication should be a last line of resort when BPHDs are highly distressing. In the presence of additional and severe difficulties (e.g., delusional experiences) that predate the bereavement, nevertheless, the balance of advantages to disadvantages may be different. In those instances, a cautious exploration of a psychopharmacological intervention could be warranted.
When viewed from an anthropological perspective, however, psychoactive substances have been widely linked with the management of BPHDs across cultures. What is interesting is that they are not only used to suppress BPHDs, but also to promote such experiences, as psychedelic substances have been used to loosen the boundaries between the dead and the living as well. Taylor (1993), for example, describes how communication with the deceased is sought-after among male Jivaro, when transitioning from childhood to adulthood, through a vision quest. The liminal rite involves entering in the forest for days, fasting alone, and finally consuming datura (an anticholinergic psychedelic) to materialise the arutam, a vision, which is addressed as ‘grandfather’. The ancestor is identifiable as such, but not recognisable as a concrete person: the mourning rites have distanced them from the living, and they have been forgotten. Similar pharmacologically-caused experiences have been also documented arising from the ritualistic use of ayahuasca (or ayawaska) in the Amazon basin (Shanon, 2010), a serotonergic psychedelic brew that etymologically means liana (or vine) of the dead in Quechua.
Conclusion: Implications for clinical practice
We have identified, analysed and contrasted perspectives of bereavement-related perceptions or hallucinations of the deceased in the psychiatric, psychological and anthropological literatures, and have outlined some potential avenues for future research. A point of agreement between both the psychological and anthropological literatures, when working clinically with distressing BPHDs, is recommending awareness of the patient’s cultural resources. There is a danger, as highlighted by Shimabukuro and colleagues (1999), for the clinician to “pathologize behaviours that, although appearing unusual to the culturally incompetent practitioner, are very appropriate from the client’s own cultural perspective” (p. 225). This is especially pertinent considering the absence of a clear psychological framework to draw from when making sense of these experiences (Hayes, 2011), and that a failure in accommodating a culturally-bound belief may easily derail the assessment or the intervention (Putsch 1988). Two of the clinical cases, the ones presented by Shimabukuro and colleagues (1999) and Sluzki (2008), have described a psychological intervention for BPHDs that were not experienced as distressing. Consideration should be given to whether these experiences were unwelcome for the patient or for the external observer, and normalisation is needed in those instances when BPHDs cause no distress (Hayes & Steffen, 2017).
In an era of increasing migration and globalisation, intercultural psychotherapy is becoming more the rule than the exception. In such a context, there is a need to build stronger bridges between the clinical disciplines of psychology and psychiatry, including close attention to phenomenology, and anthropology, recognising the value that ethnographic research has to bring to this area.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was financially supported by the University of Roehampton.
Notes
) and has published widely. His research interest has always been in how it is that we think we know what we think we know, but particularly what it is we think we know about the changes people achieve in psychotherapy.