agonia

SUSAN JAMES

AGONIAS: THE SOCIAL AND SACRED SUFFERING OF AZOREANIMMIGRANTS

ABSTRACT. Agonias, meaning “the agonies,” is a culture-specific somatic phenomenonexperienced by Azorean immigrants. Although the community’s health providers concep-tualize agonias as an “anxiety disorder,” interviews with community members revealed amore complex phenomenon. For them, agonias is a somatomoral experience – where thesomatic, the social, the religious and the moral are inextricably linked. Because agoniasconnects things that, from the traditional medical perspective, should not be connected,such as mind, body, spirit, and community, it defies our psychiatric categorisation and goesbeyond disciplinary boundaries. Agonias is a dynamic multivocal symbol that is not justan inanimate signifier but also a therapeutic act. On an individual level, it connects thesufferer with others and with God, transforming the interpersonal and divine space. On thesocietal level, it connects a community, losing its way of life, to the past and to its identity,preserving its social and religious traditions.

KEY WORDS: culture, immigrant, mental health, Portuguese

INTRODUCTION

All societies develop ways to account for illnesses which reflect their moraland philosophical ideals (Brandt 1997). In classical antiquity, for example,we encounter a tradition where illness was caused by an imbalance ofhumours and epidemics were a consequence of miasma – impure air. Thistradition then spread to countries such as early modern England, whereChristianity was firmly in place and people believed that all events weredetermined by the will of God and that sinners were punished by physicalillness, through mechanisms in the body. The result was the coexistenceof multifactorial models of disease causation. For instance, the bubonicplague was interpreted as punishment for sins, the effect of corrupt air, andthe presence of evil humours; a “multiple theory of disease causation withdivine providence and Galenic theories being simultaneously invoked”(Thomas 1997: 17).

Similarly today multifactorial models of disease causation are stillcommonplace (Rosenberg 1997), but now the causal agents take the formof such ideas as the weather, work stress, difficult relationships, or dietto account for illnesses. The moral causal ontology also continues to

Culture, Medicine and Psychiatry 26: 87–110, 2002.© 2002 Kluwer Academic Publishers. Printed in the Netherlands.

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coexist contemporaneously. Disregard for health behaviour is a questionof personal morality (Thomas 1997) and those who do not have controlover their body through restricted food or alcohol consumption or regularexercise are depriving themselves of the good life – freedom from disease(Brandt 1997).

Given the tremendous complexity, the notion of etiology becomesa socially constructed and often contested domain (Brandt 1997). Thecomplexity is captured by Gusfield when he suggests that “a conditionof the body can be viewed from different points of view or from several atthe same time by the same person” (Gusfield 1997: 203). What one maysee as a treatable medical disorder others may see as part of the humancondition, or a religious or moral concern (Gusfield 1997).

This degree of complexity was encountered upon embarking on anethnographic investigation of agonias, a culture-specific somatic phe-nomenon of Portuguese immigrants. Although cited as one of themajor health problems by community physicians, agonias (meaning “theagonies”) is surprisingly not documented in the health or mental healthliteratures. When questioned about agonias, all of the community membersreplied through their bodies, as words would not suffice. They pressed theirhands on their chests and inhaled quickly and suddenly, as if someonehad given them a scare. When pressed to verbalise this embodied state afew people said that it is “faltando de ar” (“you are missing air”). Somewent on to say that they also felt burning from within from agonias,others lost their sight, while still others could not eat or sleep. The causeswere also as varied as the symptoms which ranged from indigestion tosomeone literally on the brink of death. Some participants linked agoniasto the social context, suggesting that a person can experience agonias fromspousal mistreatment or that one can receive relief from agonias by talkingabout his or her troubles to a friend. Others linked agonias to their reli-gious beliefs; some said that it was God-given so that there was no cure;others said that prayer was the cure; still others said that people experienceagonias because they are anxious about sin. Thus, after completing severalinterviews and noticing the diversity of responses, my intentions, albeitreductionistic, of documenting a neatly packaged culture-bound disorderwere foiled.

Given that informants described a multiplicity of meanings for agonias,it is not surprising that they also described a multiplicity of healing systemsfor curing agonias. Healing was sought in a number of realms includingthe medical, the religious, the traditional, and the social. There was littlequestion that all of these realms could be invoked simultaneously andthat they were additive: in fact, it seemed the more the better. There was

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also little distinction between the four realms; they were all inextricablylinked.

The Somatomoral Framework

Kleinman’s somatomoral framework (Kleinman 1997a) is useful forunderstanding these interconnections. According to this framework, thereis a dialectical connection between the somatic and the moral. Unlikedistinctions in modern medicine, there is no difference between psycho-logical, physical, and moral-religious pain. In this integrative view ofhealth, the political, the economic, the moral, and the medical are inextri-cably linked (Kleinman and Becker 1998).

The somatomoral framework also provides an expanded framework forconsidering suffering. Suffering is no longer seen as situated only withinthe individual but takes on a socio-religious meaning as well. It connectsthe sufferer to him/herself by highlighting what is really important for theperson. It connects the sufferer to others and to the Divine, transformingthe interpersonal and divine space. For instance, in the Judeo-Christiantradition, the suffering body is a place where lay people can meet theDivine (Perkins 1995). Suffering also connects people to prior generationswho suffered, such as the ancient martyrs. Suffering is further linked tothe past in that, like all cultural forms that mediate our experience, ithas a prehistory (Long 1986). Long (1986) suggests that everything fromreligious intuitions to bodily perceptions is a manifestation of somethingalready there, something given.

The Present Study

The interconnections between the somatic, relational, religious, and moraldomains espoused by the somatomoral framework were supported by thepresent study. However, these interconnections were not proposed a prioribut rather emerged through the interviews and through my resistance tosimplifying agonias. By the time that I had completed a quarter of theinterviews I realized that agonias was not a neatly packaged culture-boundsyndrome. At this point I adopted the somatomoral framework, as it betterexplained the complexity that I encountered.

Members of the Portuguese immigrant community in Cambridge,Massachusetts, participated in the study. More specifically, I collabo-rated with people who had emigrated from the Azores, nine Portugueseislands in the Atlantic Ocean. A semi-structured interview was conductedthat addressed the following domains: immigration, employment, familylife, health, religious convictions, conception of suffering and healing,and community leaders contacted for healing (such as health providers,

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priests, and traditional healers). To understand agonias more specifi-cally, the interview also asked about the significance of symptoms(e.g., “What are the symptoms of agonias?”, “What is the cause ofagonias?”, and “What is the cure for agonias?”), whether agonias isnormative, whether the informant had ever experienced agonias, and thepersonal/interpersonal/religious significance of the symptoms. The inter-views were conducted in Portuguese by two clinical psychologists (theauthor and a research assistant). The interviews were taped and then tran-scribed into Portuguese and the analysis of the interviews was conducted inPortuguese. The interviews were examined individually, as case examples(of informants with agonias), and collectively by looking at commonthemes of the experience of the Portuguese immigrant community andmeaning of agonias.

There are a large number of Portuguese immigrants in the UnitedStates. Portuguese immigration to the United States started in the 19thcentury and had reached sixty-four thousand by 1900 (Bannick 1971).Many of the original settlers were recruited by fishing companies aswhalers and fishers, particularly in the New England region. Presently,the Portuguese are one of the largest immigrant groups in Massachusetts,totalling over 650,000 (Massachusetts Department of Mental Health1994). However, immigrants often find adjustment difficult because of thedisparity between modern urban life in North American and their agrarianor fishing communities in Portugal (Moitoza 1982) and because of thediscrimination that they face in America.

The Portuguese community faces discrimination in various forms.Socially, the Portuguese immigrants are not always welcomed as equalsby Americans because of their lack of formal education. Economically,Portuguese workers are often relegated to unskilled labour, such as textilemills, because they do not speak English. In the factories, if the opportunityfor advancement occurs, Reeve (1998) argues that the Portuguese are oftenoverlooked because of ethnic bias. This sort of discriminatory sentimenthas led to negative stereotyping of the community as a whole.

The informants were asked about the differences between the Azoresand mainland Portugal. An Azorean-American mental health providersaid, “Azoreans seem to be more like rural mainlanders, more of a countryculture than an urban culture. It’s slower, not as fast paced.” An informantfrom the Azores said, “Azoreans are more connected to the their homelandand they all came under some kind of hardship conditions at home or atleast most of them did. The Portuguese mainlanders are less connected tothe homeland and felt less hardship there.”


The informants in the present study had emigrated from the islands ofSan Miguel, Terceira, Faial, Graciosa, and Santa Maria. On these islandsthey primarily worked the land/homestead of other people’s farms. Lifewas difficult there so they came to America to “melhorar a vida” (“improveone’s lot in life”). Many of them were not sure that they had managed to dothat, however, because so many of them face difficult economic conditionsin America as well. One woman said

I had to come here. You know, over there we were very poor. The Azores is poor andback when I was growing up; it wasn’t like it is right now. We would work, cleaning richpeople’s houses, washing clothes, cooking bread, I would come back home very late in theevening because I was washing their clothes. We never had anything. . . . But life over hereis also getting hard. The hours at my job are decreasing so I have to get a part time job tohelp me out.

The informants are from a number of occupations. Due to languagebarriers and minimal schooling, most informants held lower-paidsemiskilled or unskilled positions such as factory workers or cleaners.Often they need to have two jobs to make ends meet, resulting in work-weeks of over fifty hours. Many described stressors associated with theirwork such as difficulty communicating with co-workers, poor manage-ment, unhealthy working conditions, little job security, and few benefits.Some also felt that the immigrant employees at their workplace werenot treated as well as the non-immigrant employees. One retired manexplained,

You know, us, the Portuguese, we didn’t know how to speak English. It didn’t really matter,Portuguese, Greek or Italians, the boss didn’t treat us very well. They would say bad thingsto us, and all of that, but we didn’t understand. The American employees, the ones whoknew how to speak English, they would get in good with the boss.

Religion plays a central role in the community to the point that, as inthe Azores, all of the feasts and community celebrations revolve aroundreligious holidays. All but one of the informants were Roman Catholic andthe majority were actively practising Catholicism through prayer or churchattendance. The remaining informant was an evangelical Protestant.

Sixty-three members of the community, twenty-six men and thirty-seven women, were interviewed through the use of a semi-structured inter-view about their immigration experience, their family, their health, healing,suffering, and agonias. Informants were contacted through notices at aPortuguese Health Clinic, Portuguese societies, the Portuguese newspaperand the Portuguese-language radio station. The majority of informantslived in Cambridge but there were also some from neighboring districtssuch as Somerville and Brighton. In all, fifty community members,eleven health providers (all of them Portuguese-American; five of Azorean

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heritage and six of mainland Portuguese heritage), one priest, and onetraditional healer were interviewed.

It should be noted that the Cambridge community is unique in that thereare a number of community services to meet many of the needs of thePortuguese immigrants. The community is maintained through Portuguesechurches, social clubs, radio stations, businesses, and banks. In this sense,Portuguese immigrants have a network of available resources even if theydo not speak English.

RESULTS AND DISCUSSION

In this paper, the experience of the Azorean immigrants is investigated aswell as their conceptions of health, healing and suffering. Consistent withthe somatomoral framework, the meanings and cures of agonias will beconsidered from the medical, social, religious, and moral domains. Thefinal focus is to investigate how agonias sufferers are treated within themedical profession.

Social Suffering

Similar to studies by a number of medical anthropologists (Becker 1998;Good, DelVecchio Good and Moradi 1985; Kleinman 1995; Lock andDunk 1987; O’Nell 1996; Shweder 1997; Young 1995), it was found thatsymptom expression was linked to the social context of the participants.As one clinician noted,

Suffering is a way to build relationships with other people. . . . When suffering is one’scross to bear and there is purpose in suffering, it takes on a totally different meaning andit is something that you are not ashamed to share with others. People look for empathythrough suffering, empathy from friends and the from the community.

In this community it is difficult for family members to talk openly abouttheir relationships with each other. This all changes, however, if the actionsof other family members result in bodily suffering, because physical symp-toms are an accepted topic of public discourse. As a Portuguese therapistpointed out, “the only legitimate way for them to say that they need abreak is if they have physical symptoms along with their suffering.” Thusbodily suffering mediates relationships, and it is through suffering that theinterpersonal space is created (Long 1986).

The social context was also reflected in the meaning ascribed toagonias. Some people viewed the causal ontology of agonias as a socialphenomenon, such as anxiety regarding a premonition that a catastrophe


was going to strike another community member. One therapist remarkedabout the meaning of agonias in her homeland of San Miguel,

People knew it meant something there, it meant something difficult that needed attentionbut usually the neighbours and the family used the word for more than that. If I told youthat I have agonias and if you’re my neighbour you would know that my father was beatingme and that he had done so in the past. You would know what it meant in the social context.When you are in the community, people know the meaning behind it.

The language of the narratives used to describe the cure for agoniaswas also relational. Although the participants were asked a non-relationalquestion, “What is the cure for agonias?” many participants respondedwith a relational narrative, “When someone has agonias I give them –,”and then listed the cure. The cures varied greatly but the most frequentlycited remedies were “to give water or water with sugar in it,” “teas,” or“just listening to others’ problems.” For instance, when one woman wasasked, “What is the cure for agonias?” she responded, “When someoneis suffering from agonias I give them tea. You know special tea from thePortuguese store? That helps with agonias.” At first the variety of cureswas confusing, but later I realized that there was a common thread unitingall of their narratives – interpersonal compassion.

O’Nell (1996) found a similar compassionate responsibility amongthe Flathead Indians that she linked to economic marginality and groupsurvival. This may also be the case for the Azorean immigrants. TheAzorean immigrants have faced economic hardships both in the Azoresand in America. One informant even made the link between the poor healthcare services in the Azores and relational narratives about health.

In the Azores people talk about their health all of the time so that they can learn about thehealth secrets of others. They probably did this out of necessity because health care was sopoor that it was helpful to disseminate health information orally.

This method of sharing health information is not lost in the new context.Whereas before they were trying to discover the secrets of health, nowthey discuss health issues because they are trying to discover the secrets ofanother mystery, negotiating the American health care system.

“A Way of Life Losing its Life”

Due to the economic hardships that the Azorean people face in both theAzores and in North America, most cannot afford to call or visit theirhomeland. Thus, most of the participants had not seen close family rela-tives, sometimes even children, since the time that they left the islanddecades ago. In the late 1950s the Azores were under the threat of avolcano, and the United Sates allowed many Azoreans to take refuge here.

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After the volcano struck Faial in 1957, thousands of Azoreans were lefthomeless. Portuguese-Americans initiated legislation necessary to permitmore refugees to come to America, resulting in the Azorean Refugee Actof 1958–1960. After this period, however, immigration policies becamemuch stricter and the number of Azorean immigrants dropped substan-tially. Most first generation Azorean-Americans are now senior citizenswho arrived before 1961. With these community members passing away,and without a strong flow of new immigrants arriving, the traditions of thecommunity are disappearing.

Consequently, agonias takes on a complex new meaning in America.Agonias, and the loss of language for expressing it, can be said to portendto “the loss of the [traditional] way of life, and the close interdepend-ence associated with traditional ways” (O’Nell 1996: 119). One womanexplained,

Informant: I think that we get more agonias in this land than over there.SJ: People get more agonias here?Informant: Yeah. For me, yeah. Over there our life is more, how am I going to tell you.Over there, we have our houses, our backyard, we get up, and we wash our clothes. Ourlife is more – I don’t know how to explain it, but we do get out more. Where I used to live,it was always the same path. And after I moved here, I only go to visit my mother. I thinkover here my life is more limited.

For many of the immigrants, their Azorean identity is their primaryreference group, so losing traditional ways becomes a loss of part of them-selves (O’Nell 1996). Thus agonias, an everyday term in the Azores, istransformed into a collective representation of “a way of life losing its life”(Taussig 1980: 17). In the Azores, agonias is a common idiom of distress,whereas in America the significance is compounded; it also representsa loss of a way to express this distress. Moreover, agonias is simultan-eously a vehicle for reclaiming relationality and identity by being a pleafor compassion and community (O’Nell 1996).

While most community members have proudly held to traditional ways,there was one person who seemed embarrassed by them. One elderlygentleman (who had not completed grade school) rather vehemently said,

This talking about agonias shouldn’t happen. Agonias doesn’t exist in any books, and itisn’t talked about by people who are educated. So this talking about agonias is only forpeople that never went to school. A lot of things don’t exist but people keep saying it.They hear other uneducated people saying it and they keep using it. I didn’t study muchbut agonias comes from people who are very old. And then other people hear the word andthey start using it too. They hear it from their grandparents, from their parents, and theycontinue using the word the same way. But in school, they don’t use the word “agonias”anymore. I didn’t go to school much and I sometimes say the wrong thing, but whoevergoes to school shouldn’t say “agonias” anymore.


It seems this is one reaction to using the language of the Azores inAmerica. He speaks as if that language is embarrassing; devalued in hisnew scientistic society. Agonias, to the extent that he identifies with thisscientistic society, becomes a very powerful image; an image, as Taussigdescribes,

illuminating a culture’s self-consciousness of the threat posed to its integrity. An image ofthis sort cannot be fitted like a cogwheel into a structural-functional place within society.Instead the [image] is a type of “text” in which is inscribed a culture’s attempt to redeem itshistory by reconstituting the significance of the past in terms of the tensions of the present(1980: 96).

In addition to the gentleman described above, the Portuguese clini-cians also preferred that the term “agonias” not be used. In fact, theytaught clients to use scientific terms for agonias as opposed to using thefolk idiom (as will be explored in more detail later). As members of thePortuguese community are discriminated against because of their level ofeducation, when they use scientific categories, as opposed to local idioms,it challenges the stereotypes of the dominant culture. Perhaps the clini-cians taught their clients the scientific nomenclature for agonias in orderto save their clients the experience of de-legitimization that the cliniciansthemselves had experienced in America.

Redemptive Suffering

Agonias, and the compassion that it evokes, not only links communitymembers with others but it also links them with God. One woman reported,“When I have a lot of pain, I ask our Father to relieve the pain.” Anothercommunity member said, “As the Great Physician helps His people in atime of need, we in turn help our neighbors when they are suffering.”The priest suggested that this is a way for them to serve the Divineas Christ indicated when he said, “As you do it to the least of thesemy brethren you have done it unto me” (Matt. 25:31,32). Similarly, theway that some community members related to God through the weak-nesses of their bodies is reproduced in their societal context. Participantsdevelop a personal relationship with God through their bodily sufferingand subsequent prayers for compassion. Similarly, a way to developclose relationships with others is to listen compassionately about bodilysuffering, thus paralleling the relationship that they have with God.

Often people have reasons for the suffering, known as the causalontology (Shweder 1997). The interviews suggested that for the partici-pants the causal ontology for illness and suffering was inextricably linkedto their religious convictions. One woman, when asked, “How is yourhealth?” replied, “I’ve gone through a lot, a lot dear. God is the one who

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knows. The Saint and God take care of me. Isn’t it my dear? The sufferingwill last until the day God wants. The day that He says close your eyes andcome here with me.” Many participants were ill because of their own sinsor those of their family members. A Portuguese therapist noted, “Sufferingis something that happens to you and has to do with forces outside ofyourself, like other people or even a higher power, like the devil.”

The comments of another health provider suggest that there is apredetermined value in suffering.

Suffering is something that’s expected, you’re expected to suffer because of predeterminedvalues, and those values may be family, they may be church, some moral value that’s outthere.

This statement echoes Gadamer’s notion that there is a prehistory in reli-gious traditions that links people to prior generations (Long 1986). Itallows “a Meaning, always already there, anterior and come from above,to manifest itself to the members of the community that share it” (Kristeva1941: 143).

Like suffering, the cause of agonias was explicitly linked to the reli-gious beliefs of community members. Some participants said that a personwas afflicted with agonias because it was “God’s will.” One man, whenasked, “Can both women and men get agonias?” replied “Women ormen get agonias, it’s for everyone: God gives agonias to anybody.” Thehealth providers also suggested that agonias was linked to the faith of thecommunity members: “Agonias is a word with a lot of meaning. . . . Itwould be like somebody believing that they’re going to hell or to purgatory,it involves that sort of intense fear or pain. It’s a fear of being punished.”The priest also made a similar connection when he described agonias;

SJ: What is agonias?Priest: Children can give people agonias because they are not living with faith or they aredoing things that are forbidden like divorcing. And for the people it’s certainly a weighton them and it gives them a tightening feeling, like claustrophobia. . . . Agonias is reallyanxiety about sins.SJ: So it can be for their own sins or those of others?Priest: Yes, that’s the martyr. It’s like Christ suffered on the cross for our sins so I’msuffering for theirs now.

Many participants spoke of the redemptive quality of suffering. Onewoman pointed out, “You need to suffer to redeem yourself and others.In a Catholic Church suffering is not only for yourself but also for othersand for the world.” Another woman concurred, “Someone, after all, has tocarry the cross like Jesus Christ carried the cross for everyone. Some of usare chosen by God to care for others and pay for their sins.”


This type of redemptive suffering is similar to what Long (1986)characterises as opaque theology. It is a theology where the believer iden-tifies personally with the suffering Christ, unlike the Protestant theologydescribed by Tillich (1980), the believer is Christ on the cross. Thus,redemption is possible not only through the suffering of Christ but alsothrough the suffering of the believer. Not surprisingly, this form oftheology often emerges out of groups that have been oppressed, such asthe African-American and Native American communities (Long 1986).

Finally, suffering is redemptive for the community as a whole. Asthey struggle with traditions that are fading, idiosyncratic beliefs revivetheir identity. Interestingly, the concept of agonias and the value thatthey place on bodily suffering makes the Azoreans distinct, even fromother Portuguese-speaking groups such as the Brazilian and Cape Verdeanimmigrants. Hence the narrative of the suffering body emerges to representthe group and provide a community identity (Perkins 1995; Kleinman1997b) for a community losing its identity.

Embodied Suffering

Within the Portuguese immigrant community a central role is played byreligious martyrs. The priest explained, “Oh people love the martyrs. Theyprovide models for us because they gave everything they could for Christ.”In this community, martyrs are upheld for their ability to imitate Christ’ssuffering and for their repudiation of contemporary society (Perkins 1995).Martyrs provide a connection with the past and tradition not only becauseof their repudiation of their present society but also because there is anidentification with those previously persecuted.

Saints also have a central role in this community. As one participantdescribed,

In every village in the Azores, there is a patron Saint and there is a feast to celebrate theSaint’s day. There is a particular affinity for the Virgin Mary: We’re very devoted to themother of Jesus. I think that is because a lot of people identify with the Virgin Mary, youhave to be pure like the Virgin and you have to suffer like the Virgin – a woman whosacrificed her life.

As there are no gender or class lines of who can become a Saint, womenare included as exemplars of how people who are fully human can strive tolive a divinely inspired life. The priest explained that this community has

a lot of faith and devotion to the Virgin Mary, and I think that that is because she’s ahuman. I mean, Christ is human and divine, but Mary is fully human and so she experiencedeverything that we experience, from the pain of childbirth to the pain of seeing her sonkilled. So for them she’s more palpable than the Divine.

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Powerful Suffering

For many of the participants, suffering is imbued with power. One womansaid, “God doesn’t respond immediately all the time . . . God wants to seethat we really want our faith and our power.” Another empowering notionis that the suffering, no matter how difficult presently, will not continueforever but merely exists in the present world. One mental health providerremarked, “I think that many women, especially in the reality of domesticproblems, like domestic violence, marital issues, and problems with theirchildren are saying, ‘this is my cross to bear . . .’ They see a purpose intheir suffering, if not in this world, then in the other world.”

According to the metaphysical ontology of the Judeo-Christian tradi-tion, the ability to endure suffering is recast as power and the curativepower of pain is recognised. Enduring and dying is domination even forthose without power in their contemporary society. Ante Christum, deathhad power and now this is reversed; the martyrs are rejecting the world’spower and control. As discussed by Perkins (1995), this creates new rulesfor empowerment. Women and the poor can take active roles in their faithbecause there is no class or gender distinction in the face of pain.

Empowerment is certainly a welcome concept to a group that has oftenbeen disempowered in North America and in their home country. Onewoman remarked,

We are the type of people who fear authority or don’t know how to ask for what is rightfullyours. And I think it has a lot to do with the politics of Portugal because we were notencouraged to speak our minds or express opinions. In 1975 there was the revolution andwe became more expressive, but before that we were not allowed to speak against thegovernment.

Powerful Healing

Within this community, the utilisation of multiple healing systems iscommensurable because allopathic and indigenous healers are just exten-sions of God’s domain. The participants all reported that when they are illthey seek medical care. Besides consulting a health provider, the majorityof patients also consult other systems of healing; some pray or consult thepriest, others visit a traditional healer, while others go to all three healers.

One man commented on his experience with the traditional healer,

I went to a curandeiro who said that tea would help my asthma. He didn’t tell me to stop themedications from my doctor. He said that it is not bad for me to take both the medicationsand the tea so I drink one of those teas every now and then.

There are even some referrals between systems. The priest said that hesometimes “encourages community members to seek some professional


help beyond the spiritual realm” and most of the therapists will suggestthat patients pray about issues and go to church if that is something thatis meaningful for them. One therapist had recommended that a patientseek traditional healing and another therapist reported seeking traditionalhealing herself. The majority of therapists felt that it was acceptable forpeople to seek help in more than one healing system. The physicians,on the other hand, were divided; half were concerned that the herbalconcoctions from traditional healers could react with medication thatpatients were taking while the other half were not worried. One Portuguesephysician noted,

There is a connection between the spiritual and scientific that goes beyond both realms.My approach is to tackle the problem in as many ways as possible and make all of thetreatments available to the patient. I think that one of the advantages of being Portugueseand dealing with Portuguese patients is that they don’t need to hide from me that they’reseeking out other forms of healing.

Some of the healers felt that they were expected to fulfil multipleroles. One physician has noticed that “Our medical care has to be all-encompassing for this group. I find myself not only being a physicianbut a priest and a social worker as well.” The priest agreed, “A lot oftimes people will come in with what I would consider psychological,emotional, or deeper problems.” The lack of distinction between psycho-logical, physical, and religious pain provides support for the relevance ofthe somatomoral formulation to this population.

Indigenous Healing

Although a few of the community members felt that traditional healerswere contradictory to religious healing, most participants felt that tradi-tional healing was complementary to their religious beliefs. One womanexplained,

By being Catholic, we understand that there’s life after death and, therefore, after we diewe remain in our spirit form. So it’s fine for there to be good spirits and bad spirits andif by any chance people made promises, especially to the church, that they never carriedout, after they die they won’t have peace. They can’t go to heaven, hell, or purgatory, andthey must remain on earth until they can get people to carry out the things that they weresupposed to do while they were living. So there are spirits who are seeking eternal peace,and they can’t accomplish this on their own so they try to get people on earth to help them.This can cause symptoms for patients because they might have visions and hear noisesabout the missions that they are to carry out. The other possibility is that the patient has hisor her symptoms because of a wicked spirit that is trying to get revenge.

There are three types of traditional healers: curandeiros, herbalistas,and bruxas. The curandeiro has an office at his house much like a therapy

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office with a waiting room as well as many amulets of saints. People go tosee him either alone or with family members for words of encouragement,prayers, or teas. A woman explained,

There are other curandeiros who do special massages and use the art of touching to removeevil or anxiety. There are also herbalistas who use a lot of herbs and they prescribe teasand herbal concoctions and oils along with rituals.

When people feel that spirits are causing their symptoms, they willconsult a bruxa (witch or medium). A physician explained,

She works as a medium and seeks help from the good spirits, usually the patient’s relativeswho have passed on. They then intercede for the patient and fight the bad spirits. There isusually some praying and a vigil around the house accompanied by cleansing fumes andthe ingestion of special beverages.

This petition to the spiritual realm is similar to the way that Puerto Ricansseek healing through espiritismo (Lewis-Fernandez and Kleinman 1994).Within that tradition, mediums (espiritistas) use the spiritual realm to dogood for unfortunate people or for souls in purgatory. The rituals entailoffering prayer, fruit, flowers, incense, or candles.

Redemptive Healing

For this community, many of the members said that they turn to the Divine,“the Great Physician,” for healing. An elderly woman remarked,

I have a lot of faith in God because He is the one who helps us. He is the one. If God can’thelp us, nobody on earth can. With regards to health, that kind of thing, God is the one whohelps us.

Similarly, one woman talking about her condition after she broke her spinesaid “[the doctors] said that I couldn’t work or do housework. I was sadbecause I was very young. But God doesn’t sleep. My doctor was God –He cured my back.” Later, she also mentioned a time in the Azores whena wound on her hand was so infected that her physician said that it had tobe amputated:

You know a Saint cured me. Saint Roque, the Saint that takes care of bad things. I pleadedwith God, “Don’t let them cut off my hand.” I don’t mind suffering, but I didn’t want myhand cut off. “Please don’t let them cut my hand off.” And then I felt something reallystrong, so strong that I fainted. When I woke up I was in the hospital and I was completelycured.

Similarly, community members sought divine healing for agonias.When asked, “What is the cure for agonias?” one woman responded,“Nothing, God is the only one who helped. I prayed to God a lot. I didn’tgo to see any doctors or anyone like that.” Another woman had a similarexperience,


SH: What is the cure for agonias?Informant: Yesterday morning I was feeling like that. Shaking, shaking, shaking and I said“Oh God, what do I have?” Do you know what I do? I get on my knees and drink a coldglass of water to help me with my agonias. And I say to God “What’s happening? I haven’tdone anything wrong. Why am I so agoniada?” Sometimes I ask myself why I am shakingso much. And I hide my head in my hands. I feel bad inside. Shaking, my heart shaking,shaking, shaking. Yes, sometimes I have this here, agonias.

Allopathic Healing

Medical providers. The medical providers also supported the notion of Godas the great physician: “If God doesn’t intervene and heal the patient, youknow it isn’t His will. There is only so much that will be helped by me,not all of it, because I have to have His help.” Another physician echoed asimilar sentiment. When talking about the community she remarked,

They feel that we have the power to help them but the ultimate outcome is dictated byGod’s will. If it’s meant to be, they will get better. On the other hand, they also feel thatdoctors should be consulted and that we are not trying to take God’s place. God is workingthrough us. If it’s meant for them to get better, it’s a way of getting better faster. In otherwords, going to a doctor is not against their religion.

With this population, even with divine causal ontologies, natural remediesare not to be dismissed. Rather, it is believed that God works throughthe mechanisms in the body and it is a person’s duty to employ naturalremedies without relying on them exclusively (Thomas 1997).

With regard to agonias, some of the community members connectedagonias to illness. One man linked his agonias to indigestion caused byliver problems.

SH: What is agonias?Informant: A person with agonias is a person that is not feeling right in their stomach orthe food doesn’t sit well and you get anxious. You get agonias, and the food travels up anddown and you feel agonias. But this happens because the liver is not functioning well. Itis for people that suffer from the liver. I suffer a little in my liver. I can’t eat certain things.Pork meat is one of those things. If it is bad for me, I don’t eat it.SH: Can people who do not suffer from liver problems still get agonias?Informant: Yes. Even if you don’t suffer from liver problems. It can be from a bad stomach.Sometimes we eat something, a food that wasn’t good. You get gas and agonias goingthrough your mouth. Agonias is very strange. You don’t have to have a liver problem to getit.SH: Can anyone get it? Men, women, children?Informant: Kids can also get it. A lot of times the kids throw up milk, don’t they? Thatmilk with a really bad smell. You know that their stomach and intestines are not workingwell. They feel agonias and then they throw up the milk.SH: Is there anything that can be done to help with agonias?Informant: Yes. A cup of water with a spoonful of sugar. A cup of water, cold or warm,with a little sugar. It is good for agonias.

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Another informant suggested that you go to the doctor when you aresuffering from agonias.

SJ: What is agonias?Informant: Agonias. Agonias is, for example, a person who finds themselves in a caraccident. They feel agonias. You get agonias when you are behind the wheel withoutknowing if you are going to die or not. You can also get scared all of a sudden, that isagonias. And there is also the agonias of death. The person gets agonias because theyhave heart problems. People who suffer from heart disease often get agonias. When theheart is beating fast, that is also agonias. You can tell that they have agonias.SJ: What can people do to feel better when they have agonias?Informant: They can drink some water and go to the doctor.

This informant’s description of agonias has some similarities to a formof nerves (nervios) that affects women in El Salvador called el calor (theheat). As agonias is a response to a car accident when survival is in ques-tion, el calor is a response to a life-threatening environment (of poverty andviolence). The symptoms of fright and death agony are also symptoms ofel calor. Jenkins and Valiente’s (1994) argument that el calor is a somaticresponse to a chaotic environment is a useful framework for thinking aboutagonias.

Although the community members listed a variety of physicalsymptoms when discussing agonias including gastro-intestinal problems,heart and chest pains, asthma, menopause, indigestion, and being literallyon the brink of death, the medical providers conceptualized agonias asanxiety. Thus, if patients had numerous complaints about their agonias,the health providers referred them to the mental health clinic because theywere seen as having a psychological disorder.

Mental health providers. Unlike the medical providers, some of the mentalhealth providers seemed slightly more critical of Azorean culture. Whenasked, “What is it like to work with Azorean clients?”, one Azorean-American provider remarked, “A lot of the time it feels like I am treatingpeople from the United States who are in a time warp, from a bunch ofyears ago. You know, because people may have had less education or moreillnesses and poor health care. They are more typical of fifty to seventyyears ago than they are today.” This provider gives an example of anAzorean client that she was working with, “She was not very, as one says,psychologically minded. You know, she was very service oriented. Shewanted me to get her food, diapers, really concrete things.”

Some of the providers discussed the struggle of working with peoplefrom their own culture and disentangling their personal issues from thoseof their clients. An Azorean health provider explained,


I find being Azorean that I sometimes I have difficulty working with Azoreans. I think, Imean I’ve actually evaluated this many times, I think it’s because of over-identification.I get angry at myself, I get angry at them in a way when I see them not doing anything,you know, like coming back always with the same problems. And when I provide somepsycho-education they just don’t value it, they don’t do anything about it. They feel likethey’re stuck in these situations, so that’s very frustrating to see happen. And I think a lotof it is my own issues, you know it goes back maybe to the way I was brought up withmy mom and everything you know. A lot of them (and I think I have a little bit of them)are passive aggressive, they don’t exactly say what they want so it takes forever to getinformation from them and they go about it in a roundabout way and they don’t directlyask what they’re looking for. So I’m not saying that some of the Americans are not likethat, but I don’t over-identify with them, I’m able to separate much more. I’m able to detachmyself from the issues with Americans. Working with the Azoreans is much more difficultfor me.

Some anthropologists have noticed that outsiders of the cultural groupwith whom they were working labeled the group pejoratively (Favret-Saada 1980; Taussig 1980; Taussig 1987). For instance, Favret-Saada(1980) encountered outsiders who felt that witchcraft was something for“backward peasants” who were unable to grasp causal relations in thepositivistic world. Similarly, many of the mental health providers, now thatthey are educated and enculturated, talked about their Azorean patients as“concrete” and “not psychologically minded.” Taussig (1987) also foundthe colonizers had similar pejorative terms for the Indians in the Andeanmountains. Taussig’s interpretation that the colonizers projected their anti-selves onto the Indians may be useful here. Is it possible that some of theclinicians fear that in the highly theorized world of psychotherapy, where anon-theorized relationship is impossible, they are losing concrete relationswith others and the world? Thus by labeling the Portuguese as concretethey are projecting their anti-selves (and in this case previous selves) ontothis community. Another possible explanation is that the assumption ofuniversal applicability is implicit in psychotherapy theories. Thus if apatient does not fit the paradigm, the generalizability of the theory is notquestioned, but rather the ability of the patient to have a valid experience iscontested. From the ground of psychotherapy theory, people who do not fitthe North American prototype, such as many new immigrants, are labeledas concrete and not psychologically minded, suggesting that they are notcomplex enough to have a valid experience.

The judgement that the Portuguese patients are somehow lackingsomething is paradoxical, however. Just like the “backward peasants”Favret-Saada (1980) encounters, the Portuguese actually have access totwo languages rather than only one. In addition to their relational, moralAzorean dialect, replete with folk categories, they also become fluent inthe language of psychology under the tutelage of the their mental health

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providers. Consequently, the immigrants learn to speak both languagesand they learn when to use each one. Ironically, the patients becomebilingual when the providers often limit themselves to only one language.As one Portuguese therapist noted, “I teach them the language of therapyso that we have a common language.” Although their language speaksto the complexities of their local world, the language of psychology isadopted as the common language as it is the lowest common denominator.Their language connects mind, body and spirit, and community, so tomake it more “objective” the therapist strips away the latter two, makingobjectivity equal to less than reality. Consequently, the Portuguese patientshave at least two ways to describe their experience and can choose whichone they will use to voice their experience. Adopting psychiatric nosologyand the language of psychotherapy becomes a cultural choice for thesepatients.

Bilingualism provides a choice as to which language they will useto express themselves, but it also allows them to have a choice ofwhich healing system they will use. If they use the medical system, andespecially if they are given a diagnosis and medication, they are more aptto receive the support and caregiving of their children and the younger,second generation. If they turn to the indigenous healing systems theyreceive help from God, the elders, traditional healers, and priests, butthese resources may be diminished, discounted or even discredited by theyounger generation. Thus, bilingualism optimizes the amount of supportthat they receive from both systems.

Psychiatric nosology. Agonias emerged as what Lock and Dunk (1987)describe as a multivocal symbol used to represent a broad range ofconcerns: agonias was not the neatly bound culture-specific disorder that Ihad envisioned. Lock and Dunk had a parallel experience when studying asimilar phenomenon, nevra (“nerves”), with Greek immigrants in Canada.

By examining a phenomenon such as nevra in terms not simply of its meaning to individualpatients and to their physicians but also as a flexible and powerful metaphor, the expressionand interpretation of which is modified with time and space, one arrives at a much moredynamic, and less exotic picture than that which is usually portrayed for culture- or area-bound syndromes . . . (Lock and Dunk 1987: 299).

Although agonias was a multivocal symbol for community memberswith various meanings, symptoms and cures, agonias had only onemeaning for clinicians, “anxiety disorder.” Most clinicians only mentionedanxiety, although a couple of them said that it was anxiety and depres-sion. All of the clinicians, regardless of whether they were from theAzores or the Continent, stated that they teach the patients not to use


the word agonias but rather to only talk about their specific symptoms ofanxiety.1 The approaches that the clinicians used for treating agonias wereeither anti-anxiety medications and/or psychotherapy. All of the cliniciansmentioned their frustration with treating agonias because the approachesthat they use are often unsuccessful.

There are many parallels between agonias and nerves (nervios andataques de nervios) as described in the Latino mental health literature.For instance, both phenomena have the following symptoms in common:heart palpitations, worrying, stomach disturbance, heat in the chest risingto the head, fainting, and difficulty breathing (Guarnaccia, Rubio-Stipecand Canino 1989). Although agonias is not as dramatic as ataques denervios, where the sufferer will fall to the ground and either convulse orlie on the ground as if dead (Guarnaccia 1993), both reactions are seen asepisodic rather than chronic (Swerdlow 1992). Additionally, sufferers fromboth groups will seek treatment from traditional (espiritistas), medical,and religious (such as prayer) domains. Like agonias sufferers, ataques denervios and nervios sufferers are often not well understood by their healthprofessionals (Oquendo, Horwath and Martinez 1992).

The transition must seem strange indeed when Azoreans move fromthe Azores, where agonias is treated by community compassion, to NorthAmerica where agonias is a psychiatric disorder and community compas-sion, in the form of health professionals, is commodified and medicalized.Furthermore, the commodified compassion is in a relationship that isasymmetrical and non-reciprocal.

The discrepancy between the providers’ and community members’meaning of agonias indicates that our system for diagnosis (the Diagnosticand Statistical Manual, or DSM) encourages a limited understanding ofdisorders that privileges internal experience and ignores the concomitantcultural and social dynamics (O’Nell 1996). The DSM has come to be seenas a universal prototype against which the experience of all can be under-stood and measured. To further substantiate its authority, the categoriesare disguised as manifestations of the natural and then become a formallyinstituted source of truth (Taussig 1980; Lutz 1988).

Although psychiatric categories appear to clinicians to be naturalcategories, they are limited when trying to classify idioms like agoniasthat refuse to be strictly psychological. Consequently, agonias does not fitneatly into one of the psychiatric categories because it “encircles a broadsemantic domain that extends well beyond narrowly defined psychologicaldistress into the realms of moral development, social relations, history and. . . identity” (O’Nell 1996: 8). Ironically, the very God that participants

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claimed redeemed them from having agonias also redeems them fromhaving a psychiatric disorder.

A further irony involves the notion of perceived knowledge. As previ-ously mentioned, an elderly gentleman said that agonias is the discourseof the uneducated. However, the community members, most of whomdid not graduate from high school, are fully aware of the complexity ofmeanings, affect, and action associated with agonias. The providers, on theother hand, who are highly educated, have only a unidimensional notionof agonias. They have no idea about the multiplicity of meanings or thepower of the discourse, highlighting Foucault’s argument that knowledgetransforms power and can upset traditional power relations (Taussig 1987).

CONCLUSIONS

In order to further investigate agonias, an examination of agonias in theAzores presently and historically would provide valuable contextual infor-mation. Lock and Dunk (1987) came to similar conclusions in their workwith Greek immigrants, suggesting that such an investigation would shedlight on the way that migration affects the cultural construction of idiomsof distress of immigrants and their offspring. It would also be interestingto explore the meaning of agonias presently and historically in mainlandPortugal. This would shed light on how symptoms of distress are shapedby contextual factors specific to the Azores such as poverty, the constantthreat of volcano eruptions, or recent political oppression.

In light of the findings of this study, there are a number of clinicalimplications. The results indicate that treatments for agonias based onthe standard diagnostic categories are limiting. Instead, it is importantfor clinicians to learn about other healers (indigenous and religious)sought by the patient and work collaboratively with them, making refer-rals when indicated. It would also be helpful for providers to focuson practical aspects of the patient’s contextual situation, such as familylife, work, or schooling of children. Lastly, it is important to work withcommunity organizations to raise awareness about the difficulties facingthe community, such as poverty, poor working conditions, and domesticviolence.

As bodily suffering in agonias mediates relationships, patients’suffering needs to be understood, not just removed. Thus it is importantto take the time to understand the suffering and its network of meaningso that the proper issue can be targeted. Additionally, listening to others’suffering is a way to build relationships and therefore an important placefor the clinician to start. Friends and God are expected to listen tirelessly


and compassionately to all of the various physical complaints, and it isassumed that the therapist will do so as well. When patients feel that theirsuffering and symptoms are taken seriously, only then can they move on todiscuss other topics such as their dire economic situation, poor workingconditions, or difficulties with their spouse. Clinical theories would besignificantly enhanced by incorporating the sociosomatic formulation andthe complex religious and socio-cultural awareness that it seeks to privi-lege. The sociosomatic formulation situates the individual in his or herlocal world and expands the field of inquiry in psychology and psychi-atry to consider other levels of analysis. We are challenged to move fromprimarily focusing on the level of the individual to also considering thesocial, cultural, religious and moral domains, presenting a more complex,integrative and meaningful view of the individual.

Agonias is a somatomoral experience – where the somatic, thesocial, the religious and the moral are inextricably linked. Because itconnects things that, from the traditional medical paradigm, should notbe connected, it defies our psychiatric categorisation and goes beyonddisciplinary boundaries. Agonias is a dynamic multivocal symbol that isnot just an inanimate signifier but also a therapeutic act. It is a call for helpand an intervention already in motion. On an individual level it connectsthe sufferer with others and with God, transforming the interpersonal anddivine space. On the community level, it connects a community, losing itsway of life, to the past and to its identity, helping to preserve its traditions.

NOTE

1. One other clinician was also interviewed but the data was not included in this analysisbecause the provider is neither bilingual nor bicultural. Interestingly, this provider’sresponses to the meaning and treatment of agonias were nearly identical to those ofthe bilingual/bicultural providers.

ACNOWLEDGMENTS

I gratefully acknowledge support from the Social Sciences and HumanitiesResearch Council that supported a post-doctoral fellowship at HarvardUniversity where this research was conducted. Additionally, the Living-ston Fellowship Award from Harvard Medical School provided fundingfor the project. I am indebted to Dr. Arthur Kleinman for supervising thisproject and for his insightful comments at all stages of the research process.

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I also thank Dr. Joseph Dumit and Dr. Byron Good for their invaluableinput at various phases of the project. Lastly, I am grateful to Dr. SusanneHaskell for her tireless assistance with data collection and Eric Mathias forassistance during the editorial process.

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Department of PsychologyWilfrid Laurier UniversityWaterloo, ON N2L 3C5Canada

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