The role of sensorial processes in Q’eqchi’ Maya healing: A case study of depression and bereavement

Case study: The story of Serena

In the early months of the dry season the death of a grandmother in a large Santa Cruz family in southern Belize left her children and grandchildren in various stages of bereavement. For some this was seen as a natural transition from the earthly world to the spiritual; their emotional, psychological, and social functioning during mourning remained interpretably “normal.” These family members participated in typical Q’eqchi’ burial ceremonies and community gatherings. Shortly thereafter they returned to daily routines, occasionally reflecting on the life of their mother and grandmother—successful cultural processes in the “work of mourning” (Desjarlais, 1992, p. 143). For others in the village, however, the adjustment to the change in social dynamics was more difficult, and the initial period of “normal” bereavement began to negatively impact day-to-day activity.

This is the story of Serena. For several months after the burial and family ceremonies honouring her mother, Serena remained sad and depressed. This negative mood eventually turned into a more serious, generalized anxiety that began to restrict Serena’s regular household routines and social activities. Eventually, she also developed stomach pains and poor appetite. At that time, Serena’s husband contacted Emilio, a local Q’eqchi’ healer, explaining what was occurring in the family home. After only a brief investigation of Serena’s case, involving a description from her husband and an initial meeting with Serena, Emilio promptly identified her disruptive experiences as rahil ch’ool, a Q’eqchi’ illness reflective of a form of depression with causal connections to forms of bereavement and loss (Hatala, Waldram, & Caal, 2015).

Early one morning our research team accompanied Emilio on the slow winding trek from his home in Jalacte to the village of Santa Cruz and Serena’s home. We waited patiently outside for several minutes while Serena prepared her home for guests. Upon entering, Emilio sat on a wooden bench that wrapped around the perimeter of the home. The floor was hard-packed dirt, firm and smooth, resembling soft cement. The main entrance space of the home was an area roughly four square meters, and was divided by a wooden wall that came about three quarters of the way across the room. On the other side of the divide was the cooking area with fireplace and hearth as well as the sleeping area where several hammocks were tied up to clear the way for daily activity. A young child peeked around the dividing wall as Serena finished up some household tasks. While waiting, Emilio requested a small bucket filled with water. Serena dropped it off silently. Emilio then ripped up a few medicinal leaves from his healing sack and placed them in the water to prepare for the treatment. In most Q’eqchi’ healing encounters with women, the healers proceed only when a male representative of the family is present. With a young child at home and our research team present, however, Emilio decided it was culturally appropriate to begin the healing session.

After a few moments, Serena returned with a small wooden stool and sat in front of Emilio. Without warning, Emilio immediately began his healing prayer. Saying nothing, Serena’s eyes remained open, sitting slightly hunched with shoulders curled in towards her chest. The small child sat beside Emilio on the same bench, seemingly attentive to his quiet words. Left hand on his forehead, right arm bent across his knees, Emilio continued his praying for several minutes, his focus broken every few seconds only by his right hand indicatively making subtle gestures toward Serena as if talking with a third party about her. Emilio then dipped his hand into the bucket and gently flicked a tiny bit of the liquid on Serena. Her disposition changed little. Following this, Emilio gently took hold of Serena’s wrists, grasping them carefully with his thumbs, to read her pulse; Emilio’s eyes closed as he continued with his healing prayer. After several moments, he dipped his hands in the bucket of medicinal liquid and grasped the tops of Serena’s feet, reading the pulse again, while continuing his prayers. After a brief pause, Emilio again dipped his hands into the medicinal liquid and flicked it gently towards Serena’s face. Starting at the top of her head, he swiftly ran his hands over and across his patient’s body, keeping them about 1 centimetre from her face, her shoulders, arms, and down to her legs, never making contact—a process referred to as jilok or “spiritual massage” (Hatala, 2014; Waldram, 2015; Waldram & Hatala, 2015). Emilio then placed his hands gently on Serena’s feet again while continuing to softly pray. The small child sat patiently beside Emilio on the bench. After twice more sprinkling the medicine and massaging her spirit, Emilio signalled with his hand that this stage of the healing was complete.

Emilio began discussing the medicine she required. He moved the bucket close to Serena and pointed to it several times, never making eye contact. “I was telling her how to wet her head, bathe with it and also drink some of the medication,” Emilio explains in a later interview, “She will continue this for about two days and three times a day.” After he detailed the treatment regimen, Serena acknowledged with a nod and left the room.

Emilio opened his healing sack and pulled out a different medicinal herb and a small lump of copal pom (a form of Q’eqchi’ incense made from copal tree resin) and laid them out on the bench where Serena had been sitting. He requested something he could use to burn the pom, Serena retrieved a small metal pan into which Emilio placed the herbs and the waxy lump of copal pom. Serena then took her seat beside Emilio as he set the herbs and pom on fire in the metal tin. Thick, black smoke began to fill the small room. Emilio placed the pan on the floor between them and let the rising smoke envelope his patient. While the smoke filled the room, he again placed his left hand on Serena’s forehead and began uttering his words of prayer. Loosely making a fist, he moved his right hand from one side to the other of Serena’s head. Emilio removed another small piece of copal pom from his sack, placed it in his hand and continued to pray. He grasped his head with his other hand. During the prayers, he moved the copal pom close to the burning herbs and then back to Serena’s head. While the prayers continued, the smoke whirled up between them and escaped out the side of the wood paneled home.

After about two minutes of praying with the copal pom and holding Serena’s head, Emilio let go of Serena, picked up the metal tin, and fanned the smoke into her face. Prayers continued. Another brief moment passed before Emilio placed the metal tin in the corner of the room and came back to his patient. He then removed a small bottle of agua de florida (often called “spirit water” by the healers) from his back pocket, a tincture of scented flowers, spices, and alcohol designed commercially to be used as a cologne. Emilio took a small amount of agua de florida into his mouth, then sprayed it onto Serena’s face and body. He repeated this twice, after which the room smelled slightly of perfume and copal incense.

Emilio signalled with his hands that his work for today was complete. He further explained the medicinal plants to Serena as she picked up the small bucket containing the medicinal liquid. Again there was no eye contact made between them. Emilio packed up his things and wiped the sweat from his forehead before leaving.

Rahil ch’ool and the ontology of Q’eqchi’ illness

The illness known as rahil ch’ool means “sadness of the soul,” but is often glossed as “depression” when translated. Central to the changes of one’s internal disposition with this illness is a style of thinking or “thinking too much” involving a preoccupation with a negative situation in such a way as to subsume one’s being with negative mood and affect. “Thinking too much,” or numtajel nak’a’uxlak in Q’eqchi’, is an idiom frequently used by the healers to signify a general state of unhealthy patterns of thinking that involves or begins with some kind of social misfortune, like problems with a spouse or a boyfriend or girlfriend, economic troubles or poverty, or the death of a close family or community member (Hatala, Waldram, & Caal, 2015; Yarris, 2014). More generally, “thinking too much” is presented as one of nine cultural concepts of distress in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013, pp. 834–835) and has been outlined as a common way of expressing mental illness and distress or “idiom of distress” in over 100 studies across cultures and world regions (Brown et al., 2012; Hinton, Hinton, Eng, & Choung, 2012; Hinton, Reis, & de Jong, 2015; Kaiser et al., 2014). In Q’eqchi’ contexts, the patterns of “thinking too much” about a certain kind of social misfortune often engender mood and emotional disturbances, as notions of “mind” and “heart” are closely related in Q’eqchi’ metaphysiology, and “thinking” can be expressed in both (Groark, 2008; Hatala, 2014). The symptoms of rahil ch’ool are also similar to Western conditions like Major Depressive Disorder (MDD) outlined in the DSM-5, as both involve an overwhelming degree of sadness, debilitating lethargy, listlessness, suicidal ideation, fatigue, significant loss of energy, and diminished cognitive ability (Hatala, Waldram, & Caal, 2015). As one healer explains, “The person with this illness [rahil ch’ool], their blood will be really sad or moving slow, and the person will not be feeling well but he will be feeling sad that he had something in his mind.”

In Q’eqchi’ theories of metaphysiology, moods and emotions are not solely the “psychic” property of individuals alone (cf. Groark, 2008; Gossen, 1999). In their descriptions of several illnesses, Q’eqchi’ healers often suggest that the experience of a negative mood is the consequence of an “evil spirit” within the body and blood. The negative moods and emotional states that are interpretable as “abnormal” are often caused by “thinking too much,” which can become a fault or “sin” in the vernacular of a “moral causal ontology” (Shweder, 2003), that, to a great extent, opens the way for the “evil spirit” of depression and “thinking too much” to envelope or consume, and occasionally enter, the person. In other words, although “thinking too much” conditions often begin with an event of social misfortune, they endure due to rumination about such misfortunes or negative life events, like, in our case, thinking about and missing a deceased family member, which permits an illness or “evil spirit” to manifest (Hinton et al., 2015). In a sense, then, “thinking too much” can be considered both a genre of Q’eqchi’ “mental” disorder and its cause (Hatala, Waldram, & Caal, 2015).

Spirits in Q’eqchi’ “cosmovision” (a term likely derived from Spanish typically used to describe the worldview and ethos engendered in Maya communities) can function as external agents who “take over” or seize control of the mood, behaviors, or emotional states of a person: “it is the spirit that brings the anger,” one healer explains. In this way, emotions (xch’ool) involve the ethereal qualities of the soul (ch’ool) or human spirit, and these notions are closely related as witnessed in the similarities of the Q’eqchi’ terminology. The “x” here in Q’eqchi’ spelling is used to transform the noun of soul or spirit (ch’ool) into a verb or to express the active quality of emotional states (xch’ool). Thus, emotions are often seen as the actions of the soul or spirit in the world. In this way, moods and emotions are understood as unseen forces that can operate on human experience in complex ways.

Unlike cases of susto or fright “narrative genres” where the spirit is generally trapped or “lost” (Hatala, Waldram, & Caal, 2015; Weller, Baer, Garcia de Alba, & Rocha, 2008), discourses of emotional distress, “thinking too much,” or extreme sadness like the case of Serena, are often coupled with notions of “presence”—an additional spirit or “otherness” that is with the person (Groark, 2008; Harvey, 2006; Hatala, 2014). In this way, moods, like various spirits, are thought, under certain conditions, to envelope or overpower a person, taking control and becoming all-consuming; they can alter someone’s “normal” behavior and their ability to effectively perform daily activity. Moods and emotions, again like spirits and souls, can occupy individuals as well as social spaces, lingering in abandoned buildings, uninhabitable homes, dark corners, or individual minds and bodies where “thinking too much” seems to abound.

“Presence” in Q’eqchi’ discourse also reflects a notion of agency. Illness disturbances of various kinds are often described by healers and Q’eqchi’ community members as a volitional force or “other” that acts on the person from the outside or intrudes into the body, and thus needs to be “taken out,” “taken away,” or removed. A similar logic is expressed for thinking and emotional illnesses or “mood disorders” such as rahil ch’ool. The sadness that is experienced is thought to have a force and agency, and correspondingly the healers’ discourse centers on the need to “take out” the spirit of the sickness. “To take out the bad spirit,” one healer describes, “I use a medicinal plant… I smoke the person, and I blow in the face to take out the spirit and fix his life.” “You would tell them [evil spirits] to leave the patient alone,” another healer outlines regarding the use of healing prayers, “so that they [evil spirits] go away in the name of God… When the evil spirit comes out, the person is cured.”

For Serena, the family and social dynamics in her village changed suddenly due to the passing of her mother into the spiritual worlds. Serena then began “thinking too much” about this situation while having trouble adjusting to the interpersonal loss. Her mind and heart became “weighed down,” “slow,” or “heavy” due to the social misfortune experienced—all common idioms or metaphors used by the healers and translators to communicate her experience. Mood and affective disorders like Serena’s are thus thought to involve a force beyond the control of the individual that impacts the person’s thinking, mood state, and behavior. Serena experiences particular thoughts, behaviors, and emotional states coloured by sadness and grief that impact her ability to effectively be-in-the-world (i.e., rahil ch’ool). Her mood alterations are not felt as part of the “normal” intentional actions she performs on a day-to-day basis. Instead, the ongoing and lingering “presences” of these moods and dispositions are interpreted as unwelcome “evil spirits” that eventually lead her and her family members to request assistance from a local Q’eqchi’ healer. And it is in this way that “evil spirits” are sensed and “sensible” as empirical entities in their own domain, “just as are viruses in the somatic and emotional traumas in the mental domains” (Csordas, 1997, p. 39–40).

Martin Heidegger (1996) argues that unlike the acts of perceiving, believing, desiring, or remembering, a mood (stimmung) is not an intentional state directed at something within the world. Rather, moods and emotions are neither “cognitive” in the traditional sense nor mere “affects,” but, as Heidegger suggests, a background that binds us to the world, anchoring us in a context of goals, projects, and relevant environmental patterns. Moods and emotions constitute a sense of “belonging” or “attunement,” a basic feeling of orientation and being without which explicit cognition could not occur. Thus, from this perspective moods are not conceptualized as “subjective” or “psychic” phenomena that are part of an individual’s mind and thoughts, but instead are part of the “preobjective” or “withdrawn” embodied background of being relative to which the world and the manner in which we are situated within it is disclosed to us or rendered intelligible. Heidegger (1996) indicates that moods operate in the ontological background of our dispositional (befindlichkeit) character, and in this way he suggests that they carry with them a certain kind of experiential “presence” or “otherness.”

Like Heidegger’s formulation that moods operate at a “preobjective” background to our being-in-the-world, so too we have seen in Q’eqchi’ cosmology that moods possess a certain agency of affect interpreted by Q’eqchi’ healers as a “presence” of volitional evil spirits. In other words, “thinking too much,” as in the context of rahill ch’ool, can cause embodied changes in one’s being or disposition, changes interpreted as the presence of volitional “spirits.” In this way, Q’eqchi’ therapeutic attention for rahil ch’ool specifically, or conditions that involve perceptual or experiential changes in “thinking too much” generally, do not centre on or involve the patient’s individual cognitive “self” to any significant degree. Rather, the main actors in the therapeutic drama—from a naturally logical and rational perspective—are the spirits or “moods” that impact or cause the change in the person’s behavior, and the blood which is the seat of these spirits in the body and the vehicle for “thinking too much” conditions. As Waldram (2015) also observes, the patient in Q’eqchi’ therapeutic encounters is secondary or even superfluous to the treatment process and while “communication” does occur, it primarily involves a dialogue between the healer and the “spirit” of the sickness or the blood, and rarely the patient. As Waldram (2015) further notes, marginalizing the patient in this way is not uncommon to various diagnostic processes throughout the world (Finkler, 1994; Good, 1994), yet what we further explore here is how this “marginalization” is ontologically connected to a Q’eqchi’ illness conception and etiology that involves the “presence” of spirits and cosmological forces. Indeed, this medical vision further shapes or directs healer attention to the “preobjective” or “withdrawn” level of being-in-the-world, that is, to the existential immediacy of the lived body (Csordas, 1990; 1994; 1997).

Q’eqchi’ healing, sensation, and the body

In describing processes of healing from rahil ch’ool in particular and other conditions within the “thinking too much” narrative genre in general (Hatala, Waldram, & Caal, 2015), Q’eqchi’ healers commonly invoke a notion of “stabilizing” or “settling” a person’s mind or thoughts. As in Serena’s case, this process occurs through a confluence of several therapeutic techniques revolving around the logic of extracting the “evil spirit” of the sickness. Few words are exchanged between Emilio and his patient in this process, leaving Serena, to a great extent, as a mere witness of the unfolding medical drama. The “stabilizing” or “settling” of the mind in such cases of excessive sadness or depression occurs not so much through a kind of linguistic or discursive “talk therapy,” nor even through the presence of a strong therapeutic relationship or shared “assumptive world” between patient and healer (Frank & Frank, 1993; Waldram, 2015), instead, what we observe and detail here is a performative healing encounter robust with sensorial modalities, with therapeutic attention directed primarily toward the “preobjective” level of embodied experience and the body’s phenomenological engagement in the world.

One of the main elements of Q’eqchi’ healing involves the burning of copal pom or other kinds of incense. During Serena’s treatment, Emilio spends much time burning the copal pom, saturating Serena’s humble abode with the strong scent of Q’eqchi’ incense. In a later interview, Emilio suggests that it is through the inhalation of the smoke that Serena’s mind is “stabilized” and the illness or “spirit” of the depressed mood state will leave or be “taken out” from her body and blood. “Before I do anything,” Emilio explains, “I make sure that I pray first then I continue the medication. I use a special prayer to settle the person’s mind so that the sickness can stop affecting the person.” “The person would then inhale the smoke of the incense,” Emilio suggests, and “that smoke would let the sickness fade away.” “The scent helps in the thinking of the person,” Emilio later describes, “It’s the scent that impacts the person.” In Q’eqchi’ healing, we observed, the ceremonial aspects of burning copal pom operate directly on the person through their senses, through inhalation: “The scent goes to the blood, mind and spirit. That is why it helps the mind,” Emilio reasons.

Odours play a unique and pivotal role in the sensory experience involved in Q’eqchi’ healing practices. Through performative and sensual healing activities, a range of bodily experiences are elicited, exploited, and altered. Regarding the practice of “smoking” a patient with copal pom, another healer states, “It helps [the patient] so that she has more confidence and more self-esteem. The pom brings happiness and health.” Although Waldram (2015) observes that Q’eqchi’ healing primarily occurs without any obvious efforts to create a sacred or special healing space, there can be small and localized sacred spaces created within a larger secular family or home environment, which can include a distinct vividness or heightened experience that sets the ritualistic elements of clinical time apart from routine day-to-day activity. This is not solely attributed to the burning of copal pom, but also to other scented elements in Q’eqchi’ therapeutic encounters including certain kinds of flowers, alcohols, and herbal medications. As one healer explains, “some flowers help someone’s thinking and feeling. It’s used for making a person feel good and happy. Sometimes a patient doesn’t feel good and we collect some pretty and sweet scented flowers.” “It’s the scent that helps,” the same healer continues regarding his herbal medications, “If the medication is sweet scented the person would feel relieved and feel good.” Another healer agrees, “Plants have different scents, and they help a patient as well. We borrow the beauty and sweetness of the flower.”

As Serena’s body and senses are saturated by the cogent smell of copal pom and other medicinal herbs, she is directly impacted at the preobjective level of corporeal practice. As Howes and Classen (2014) and Meyerhoff (1986) argue, these kinds of sensual or ritualistic elements in therapeutic encounters engage the entire body as a sensing and perceiving organ in a very different manner from “just talk.” From this perspective, direct sensorial experience (i.e., touch, smell, taste, sight, sound) may bypass language, narrative, and conscious cognition while being embedded directly into the lived experience of the body. This direct engagement with the body, through the olfactory vehicle in particular, can transform illness experience and a way of being-in-the-world that is preconceptual, preobjective, and precognitive, that is, avoiding and bypassing the conscious mind. “Our senses are naturally persuasive,” Meyerhoff (1986) again argues, “convincing us of what the mind will not indulge” (p. 268).

Emotional responses to odours have both ethnographic exemplification and a foundation in biological processes and principles. As Ross (2012) notes, “long before becoming one of the most popular forms of alternative therapy, the use of aromatic plants, extracts, and essences played an important role in all great medical traditions” (p. 144), and “it is the sense of smell that provides the most direct link to the brain, through the olfactory nerve” (p. 125). The hypothalamus and amygdala, for example, the parts of the brain most closely linked to emotional disposition, feelings, and mood, is greatly affected by changes in odours inhaled (Howes, 2003; 2005; Parkin, 2007). There is an important physiological link between smell and emotion or mood, providing a pathway to embodied transformation in Q’eqchi’ healing encounters. The transformation of the body through odours experienced in healing performances like Serena’s is actual in this sense, not simply symbolic or dependent on a shared meaning system. Speaking to this notion in the context of charismatic Catholic healing, Csordas (1996) outlines how sensorial experiences provide persuasive messages at the “preobjective” level of embodied practice that can impact or alter memories, emotions, or moods states of individuals. “Efficacious healing,” Csordas (1996) argues, “is predicated not only on a cultural legitimacy that says healing is possible, but on an existential immediacy that constitutes healing as real” (p. 108). “The immediacy of the imaginal world and of memory,” Csordas continues, “have their common ground in embodiment. The moods and motivations evoked upon this ground in ritual performance are indeed uniquely realistic” (1996, p. 108).

The hippocampus is another related olfactory centre in the brain, known for its links to memory processes. Memory, like emotion, is an important factor in ritual or healing experiences, helping to induce phenomenological alterations at the level of embodied experience and practice (Hinton et al., 2008; Turner, 1983). Howes (2003) and Parkin (2007) also suggest that odours have the potential to transcend or dissolve the dualistic categories of mind and body through the manner in which odours resist objective definition and classification, neither seeming material nor immaterial. These dissolutions of the separation of mind and body can be critical for understanding ritually induced bodily healing practices which have historically been explained as simply symbolic or psychological in their effects (Ots, 1991; Turner, 1983). Through a discussion of the logical, psychological, and social levels on which odours operate, Howes (2003) contends that odours effectively bridge the bounded spheres of mind and body and have the potential to blur such dualistic notions. This blurring of boundaries further facilitates and reinforces the liminal phase identified as critical to the process of ritual healing and transformations of bodily experience (Turner, 1983). The ambiguous nature of odours is commonly exploited and particularly useful for participation in these periods of transition and change. This liminal status attributed to smell is exemplified in its association with spirits, as studies across many societies illustrate how spirits are often identified by their odours and clear associations are made between particular smells and their effects on the health of individuals (Hinton et al., 2008; Howes, 2005; Howes & Classen, 2014). Spirit expulsion, invocation, or pacification is often the objective of many healing rituals (Parkin, 2007) and scents are identified for their specific function of pleasing or driving away the spirits. In Q’eqchi’ cosmovision and healing practice, this is routinely observed as the healers commonly use the idiom of “scent” (b’ook) as synonymous with the “spirit” (muhelej) of the sickness.

In addition to the use of odours, touch is another ubiquitous sensorial medium in Q’eqchi’ healing. In every healing encounter observed in southern Belize, the Q’eqchi’ healers, in some manner and to some extent, “touch” the patient by making both direct and indirect contact with their body or “spirit.” In the case of Serena, Emilio begins by gently holding her wrists for several moments while uttering his words of prayer. Following this he moves to touch her forehead and then to her feet. At each location on her body, Emilio is attentive to the subtle, “pulsing” movement of blood within Serena’s arteries. Beyond having a diagnostic and prognostic purpose, however, touch of this kind during Serena’s case, we argue, also has a therapeutic potential, contributing to shifts in “embodied metaphor, memory and self-image” (Hinton et al., 2008, p. 154; see also Hinton & Kirmayer, 2013).

This kind of physical contact during healing episodes was also explored by Waldram (2015) as intercorporeality—and a form of intersubjectivity—that can invoke a kind of radical empathy between patient and healer. Connection and communication between patient and healer through touch allows the healer to feel the “spirit” of the sickness within the patient most vividly through the medium of the blood, through its quality, speed, and texture as it passes through the patient’s veins. A key element that explains the effectiveness of this gentle “touch” from a patient perspective is “passive catharsis,” which, according to Finkler (1994) is “when a patient experiences a sense of release and relief without having said anything” (p. 180). By connecting with the patient through the immediacy of the lived body, radical empathy and “passive catharsis” a healer can facilitate shifts in the lived experience of the patient, shifts that occur in absence to any direct engagement with the patient’s cognitive self or “talk therapy.”

In addition to direct touch, Emilio also moved his hands over and across Serena’s body on several occasions without making contact with her body. This therapeutic movement is referred to in Q’eqchi’ as the jilok, generally translating as a kind of “spiritual massage.” Although the body is not directly or lightly touched, jilok can make direct contact with the person’s “spirit” through the delicate and rhythmic movements of the healer’s hands over and across the patient’s body, substantiating a non-material-based “massage.” This process is described as a “sweeping” or “cleaning” of the person’s spirit, aiding the extraction of the unwanted mood dispositions and illness “spirit.” Jilok is also at times coupled with a gentle blowing, a light movement of air over and across the body. “After I’m done with the prayer,” Emilio remarks regarding Serena’s healing encounter, “I blow the sickness away so that she is cured.” This practice of “massaging the spirit” was seen in nearly every healing encounter observed with the Q’eqchi’ healers (Waldram, 2013; 2015).

Mindfulness and “body psychotherapy” based therapeutic approaches further suggest that subtle “touch” by a healing practitioner can help patients “stay mindfully in contact with their body” which, for individuals experiencing depressive symptoms in particular, results in “less rumination and fewer depressive symptoms” (Michalak, Burg, & Heidenreich, 2012, p. 194). Correspondingly, these authors also suggest that “the ability to mindfully stay in contact with the body might be an antidote to rumination” (p. 194). Furthermore, in their study of “mindfulness” techniques in refugee and ethnic minority populations with post-traumatic stress disorder (PTSD), Hinton, Pich, Hofmann, and Otto (2011) note that maintaining a “mindful” state involving a present-oriented being and a mind-set attentional shift towards sensorial experiencing, can decrease negative rumination and psychological inflexibility associated with depression and anxiety. In this way, we see that as Emilio gently grasps Serena’s wrists, forehead, and feet for his pulsing activities, he is aiding her ability to become grounded within and mindful of her bodily disposition, and in this he is impacting her rumination, or her “thinking too much.” This kind of mindful grounding in the body through the light touch of a healer, or spiritual-based massage as in the jilok process, occurs primarily at the preobjective, and prereflective level of the patient. In other words, from the perspective of Emilio and the other Q’eqchi’ healers, a patient need not “know” or associate a particular meaning with the touch, scent, or therapeutic gestures of the healer that arise during a clinical encounter, as the bodily alterations in experience occur at these preconscious and preobjective levels of embodied practice (Csordas, 1990; 1994).

Overall, what we observe here is a logical association in Q’eqchi’ healing between the presence of unwanted illness states, “moods” and “evil spirits,” on the one hand, and a therapeutic focus on the existential immediacy of the lived body and its sensual engagement with the world, on the other. By addressing the level of bodily disposition through the performative and sensorial aspects of Q’eqchi’ healing, alterations in mood and a decrease in “thinking too much” can occur. In other words, the extraction of an unwanted “spirit” or entity, which in Serena’s case is a state of depression or rahil ch’ool, occurs not so much through a kind of narrative engagement or “talk therapy,” but rather through a general “cultural saturation of experience” (Good, 1994, p. 143) and resultant alterations to a “preobjective” or “withdrawn” aspect of bodily disposition or historicized way of being-in-the-world (Kahn, 2006). What we propose, then, is that the invocation of “spirits” in Q’eqchi’ healing discourse and medical treatment is ontologically and epistemologically associated with an analytic focus at the preobjective level of bodily practice. The “spirits” in this context, as well as during notions of mood states discussed earlier, become the locus of therapeutic intervention insofar as “spirits,” like the embodied dispositions and ways of being-in-the-world, are invisible and “withdrawn” from everyday life and social interaction (Heidegger, 1996). Conceptualizing the level of preobjective bodily practice to be ontologically associated to the world of “spirits” ultimately allows us to more fully understand why there are limited verbal exchanges between patient and healers during Q’eqchi’ medical encounters. As we have seen, the patient is almost entirely passive in the healing process, and there is no clear or strong development of a therapeutic relationship (Waldram, 2015). The healers rarely attempt to involve the patient’s individual “self,” including their beliefs, meaning-making processes, or “mind,” to any significant degree, nor is there any serious attempt to “name” the illness or communicate its diagnostic significance or interpreted etiology to the patient. The patient is typically a mere witness to the medical drama. Indeed, Serena does not “participate” in the healing encounter in the true sense of the word. Rather, it is the “withdrawn” and embodied, preobjective level of “evil spirits” and cosmological forces that captures Emilio’s medical attention. This engagement with the body and sensations of scent and touch in Q’eqchi’ healing encounters, coupled with the near absence of verbal communication, reliance on a shared “mythic world” or narrative discourse, forces us to reach beyond models of symbolic healing to understand how healing might prove effective.

Sensorial processes and symbolic healing

What we have briefly outlined here regarding the sensorial mediums of smell and touch in Q’eqchi’ therapeutic encounters departs from accounts of “symbolic healing” in previous literature (Dow, 1986; Luhrmann, 2013; Moerman, 1979; Waldram, 1997). Symbolic healing generally assumes that patients play a conscious role in the healing process, that they are aware of and “know” the different evocative healing metaphors or symbols manipulated during the ceremony. “Symbolic healing,” then, is understood to operate through the “mind” of the patient. Indeed, Dow (1986) argues, “we assume that there are psychological processes in which symbols affect the ‘mind,’ which in turn affects the body,” and that “this is the rough manner in which symbolic healing works” (1986, p. 59). The “psychological processes” of patients must then involve a kind of knowing or understanding regarding certain aspects of what Dow frames as the “mythic world,” a model of experiential reality that is culturally substantiated and shared by patient and healer. As Dow (1986) further suggests,

In the curing process the healer particularizes part of the general cultural mythic world for the patient and interprets the patient’s problem in terms of disorders in this particularized segment. In particularizing the cultural mythic world, the healer forms transactional symbols to which the patient attaches emotions. (p. 60)

Both Dow (1986), and Moerman (1979) before him, privilege the way patients consciously interpret or derive meaning from the healing encounter over other ways of knowing, including those of bodily-engaged processes of experience and knowledge. Yet, regarding what is often referred to as the “placebo response” in healing encounters, Thompson, Titenbaugh, and Nichter (2009) identify an undue emphasis on “belief,” “conscious knowledge,” and “meaning-making” and instead contend that “the body can directly respond to sensory or affective stimuli and it does not require meaning in any consciously cognitive sense to catalyze a placebo response” (p. 131) such that “direct embodied experience may take precedence over meaning-making in the healing encounter” (p. 140). Similarly, Briggs (1994) also demonstrates previous limitations in symbolic healing ritual theories which place “undue emphasis on the meaning of the narrative incantation,” and argues that “curing processes operate beyond the patient’s cognitive interpretations of the text—which may not even be accessible to the patient” (p. 128). Desjarlais’s (1992) reflections are insightful on this point: “We have lost an understanding of the body as an experiencing, soulful being before and beyond its capacity to house icon and metaphor” (p. 29).

For the Q’eqchi’ healers, their engagement at the level of preobjective bodily practice cuts across the conscious awareness of the patient; that is, the patient need not fully “know” about the symbolic and metaphorical power associated with copal pom, but rather when it saturates the room with its powerful scent the patient’s experience is “persuaded” at the preobjective level of bodily sensation. This process more closely exemplifies “restorative healing,” in which the goal is to eliminate pathology and return the patient to a presickness state, and therefore a need for meaningful communication between healer and patient is minimized (Waldram, 2013; 2015). Hence we argue that the direct engagement with sensorial experience observed in Q’eqchi’ healing practice can occur in the absence of a common understanding of Q’eqchi’ cosmovision or “mythic world,” or the patient’s ability to interpret meaning, “believe” in, or consciously “know” what is occurring in the embodied and sensation-centered healing encounter. This conclusion is not to suggest that meaning-making processes in healing are irrelevant or invalid. Rather, what we bring attention to here is perhaps an overemphasis on rationality, cognition, and the mind’s ability to manipulate a cultural “mythic world” in contemporary literature at the expense of analytic attention towards direct embodiment and a sensorial or phenomenological engagement in subjective experience and healing encounters.

Hinton et al. (2008) do remind us, however, that “sensory meaning is never simply a question of physiology; it is always mediated by culture” (p. 143). Through their treatment of the “cultural elaboration of sensation” these authors point out errors that can arise from assuming that “sensations belong to some pre-cultural, universal biological level of the person, with no appreciable differences across cultures” (2008, p. 155). Every culture, these authors propose, has unique ways in which sensations are configured, interpreted, experienced, and expressed. Each unique sensation elicited in different contexts is coupled with a certain kind of cultural meaning or “sensation script” that “leads to certain social actions” or serves to “construct and position the self in terms of specific forms of (bodily) experience and identity” (2008, p. 151). From this view, “Every culture (and each individual) has available various sensation scripts or stories that are activated by specific social contexts and that embed sensation in a larger web of meanings and expectations” (2008, p. 153). With this in mind, it is interesting to note how Q’eqchi’ healers in this study make no explicit attempt to communicate to their patients the various meanings associated with a particular sensation, nor do they suggest that a patient need to know anything in order to be “cured” or to engage in a processes of “restorative” healing (Waldram, 2013). Indeed, the Q’eqchi’ healers are comfortable treating patients of entirely different cultural backgrounds or presumably different “sensation scripts” under the assumption that a shared mythic or cultural world is not necessary for healing to occur. What emerges from this analysis and the case study of Q’eqchi’ healing, then, is that questions of meaning and cultural interpretation of various bodily sensations that arise in therapeutic encounters may be secondary to the existential immediacy of the experience those sensations can elicit at the site of the lived body (Briggs, 1994; Csordas, 1994; Howes & Classen, 2014; Ots, 1991).

The Q’eqchi’ healers demonstrate such a therapeutic focus toward the existential immediacy of the lived body. As opposed to Dow’s treatment of symbolic healing that allows “unconscious and somatic processes to be controlled by symbolic communication” occurring largely in the “mind” of the person (1986, p. 62), what we see in the work of the Q’eqchi’ healers is how attention at the preobjective level of embodied practice can impact psychological and social processes at higher levels in Dow’s “hierarchy of living systems” (1986, p. 62), composed of somatic, molecular, self, social, and ecological levels. Thus, the body and preobjective aspects of being-in-the-world, and by proxy the realm of “evil spirits,” rather than symbols and narrative myth, become the communicative links between the social and self systems in Q’eqchi’ healing. This formulation ultimately allows Q’eqchi’ healers to objectify or “medicalize” social and spiritual forces that may negatively impact a person and interact with them at the level of engaged embodied experience. As we observe in Serena’s case, she suffers from a kind of depression or rahil ch’ool due to the loss, bereavement, and a form of “thinking too much” on the social misfortune of her mother’s death. Rather than confront the social or interpersonal aspects of Serena’s mood and emotional disturbance, Emilio “medicalizes” the problem and thereby directs therapeutic attention towards extracting the “spirits” at the level of embodied engagement with the world. There is no talk therapy or psychotherapeutic engagement, and little or no direct communication with the parties involved, as the body, and not the level of conscious narrative construction, is the communicative medium between the self, social, and cosmological levels of living systems. While Fabrega and Silver (1973) also suggest that the general practice of Maya medicine must be conceptualized as a social phenomenon, where the body is understood to be “spread out” in a larger interpersonal, environmental, and cosmological context (1973, p. 91), and illness is understood as a failure or disharmony in an individual’s psychosocial adaptation to some form of social misfortune, illness is manifest and made known to the self and others through bodily infirmities (Fabrega & Silver, 1973). Indeed, illness in these contexts, or personal experiences of negative affects, such as emotional suffering or pain, sadness, anger, or envy particularly, are rooted in social occurrences and yet mediated through or connected with individuals through specific manipulations of bodily states and sensorial experience. In this way, complex social, cultural, and spiritual problems, such as poverty, the loss of a loved one, or even unemployment, can be therapeutically addressed by attending to the “evil spirits” and a bodily engagement with the world. Future research in these areas could explore patients’ perspectives and understandings of various healing encounters and means of efficacy in more detail.

Based on this analysis, a model of Q’eqchi’ healing may be the inverse of a “symbolic” perspective: sensorial processes which directly affect the lived experience at the existential immediacy of the body can, in turn, impact the mind and “thinking too much” of a person, producing a plethora of illness narratives that accompany these embodied alterations as the preobjective is made objective. Indeed, “what is initially embodied and sensorial may, over time, become cognitive, as narrative, explanation and meaning become attached to the experience” (Thompson et al., 2009, p. 114). It is the body, then, and a rich conceptualization of how sensorial processes can induce alterations in illness experiences that have been marginal or limited in previous models of “symbolic healing.” And it is the body, as a site of experience, transformation and “communication,” that should be considered in attempts to understand healing efficacy, both transformational and restorative (Waldram, 2013; 2015), especially in contexts of Indigenous healing where discourses of “evil spirits” and the cultural saturation of sensation can abound.