SUSAN JAMES

AGONIAS: THE SOCIAL AND SACRED SUFFERING OF AZOREAN IMMIGRANTS

ABSTRACT. Agonias, meaning the agonies, is a culture-specic somatic phenomenon experienced by Azorean immigrants. Although the communitys health providers conceptualize agonias as an anxiety disorder, interviews with community members revealed a more complex phenomenon. For them, agonias is a somatomoral experience where the somatic, the social, the religious and the moral are inextricably linked. Because agonias connects things that, from the traditional medical perspective, should not be connected, such as mind, body, spirit, and community, it dees our psychiatric categorisation and goes beyond disciplinary boundaries. Agonias is a dynamic multivocal symbol that is not just an inanimate signier but also a therapeutic act. On an individual level, it connects the sufferer with others and with God, transforming the interpersonal and divine space. On the societal 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 reect their moral and philosophical ideals (Brandt 1997). In classical antiquity, for example, we encounter a tradition where illness was caused by an imbalance of humours and epidemics were a consequence of miasma impure air. This tradition then spread to countries such as early modern England, where Christianity was rmly in place and people believed that all events were determined by the will of God and that sinners were punished by physical illness, through mechanisms in the body. The result was the coexistence of multifactorial models of disease causation. For instance, the bubonic plague was interpreted as punishment for sins, the effect of corrupt air, and the presence of evil humours; a multiple theory of disease causation with divine providence and Galenic theories being simultaneously invoked (Thomas 1997: 17). Similarly today multifactorial models of disease causation are still commonplace (Rosenberg 1997), but now the causal agents take the form of such ideas as the weather, work stress, difcult relationships, or diet to account for illnesses. The moral causal ontology also continues to
Culture, Medicine and Psychiatry 26: 87110, 2002. 2002 Kluwer Academic Publishers. Printed in the Netherlands.

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coexist contemporaneously. Disregard for health behaviour is a question of personal morality (Thomas 1997) and those who do not have control over their body through restricted food or alcohol consumption or regular exercise are depriving themselves of the good life freedom from disease (Brandt 1997). Given the tremendous complexity, the notion of etiology becomes a socially constructed and often contested domain (Brandt 1997). The complexity is captured by Guseld when he suggests that a condition of the body can be viewed from different points of view or from several at the same time by the same person (Guseld 1997: 203). What one may see as a treatable medical disorder others may see as part of the human condition, or a religious or moral concern (Guseld 1997). This degree of complexity was encountered upon embarking on an ethnographic investigation of agonias, a culture-specic somatic phenomenon of Portuguese immigrants. Although cited as one of the major health problems by community physicians, agonias (meaning the agonies) is surprisingly not documented in the health or mental health literatures. When questioned about agonias, all of the community members replied through their bodies, as words would not sufce. They pressed their hands on their chests and inhaled quickly and suddenly, as if someone had given them a scare. When pressed to verbalise this embodied state a few people said that it is faltando de ar (you are missing air). Some went 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 causes were also as varied as the symptoms which ranged from indigestion to someone literally on the brink of death. Some participants linked agonias to the social context, suggesting that a person can experience agonias from spousal mistreatment or that one can receive relief from agonias by talking about his or her troubles to a friend. Others linked agonias to their religious 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 experience agonias because they are anxious about sin. Thus, after completing several interviews and noticing the diversity of responses, my intentions, albeit reductionistic, of documenting a neatly packaged culture-bound disorder were foiled. Given that informants described a multiplicity of meanings for agonias, it is not surprising that they also described a multiplicity of healing systems for curing agonias. Healing was sought in a number of realms including the medical, the religious, the traditional, and the social. There was little question that all of these realms could be invoked simultaneously and that 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 inextricably linked. The Somatomoral Framework Kleinmans somatomoral framework (Kleinman 1997a) is useful for understanding these interconnections. According to this framework, there is a dialectical connection between the somatic and the moral. Unlike distinctions in modern medicine, there is no difference between psychological, physical, and moral-religious pain. In this integrative view of health, the political, the economic, the moral, and the medical are inextricably linked (Kleinman and Becker 1998). The somatomoral framework also provides an expanded framework for considering suffering. Suffering is no longer seen as situated only within the individual but takes on a socio-religious meaning as well. It connects the sufferer to him/herself by highlighting what is really important for the person. It connects the sufferer to others and to the Divine, transforming the interpersonal and divine space. For instance, in the Judeo-Christian tradition, the suffering body is a place where lay people can meet the Divine (Perkins 1995). Suffering also connects people to prior generations who suffered, such as the ancient martyrs. Suffering is further linked to the past in that, like all cultural forms that mediate our experience, it has a prehistory (Long 1986). Long (1986) suggests that everything from religious intuitions to bodily perceptions is a manifestation of something already there, something given. The Present Study The interconnections between the somatic, relational, religious, and moral domains espoused by the somatomoral framework were supported by the present study. However, these interconnections were not proposed a priori but rather emerged through the interviews and through my resistance to simplifying agonias. By the time that I had completed a quarter of the interviews I realized that agonias was not a neatly packaged culture-bound syndrome. At this point I adopted the somatomoral framework, as it better explained the complexity that I encountered. Members of the Portuguese immigrant community in Cambridge, Massachusetts, participated in the study. More specically, I collaborated with people who had emigrated from the Azores, nine Portuguese islands in the Atlantic Ocean. A semi-structured interview was conducted that addressed the following domains: immigration, employment, family life, 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 specically, the interview also asked about the signicance of symptoms (e.g., What are the symptoms of agonias?, What is the cause of agonias?, and What is the cure for agonias?), whether agonias is normative, whether the informant had ever experienced agonias, and the personal/interpersonal/religious signicance of the symptoms. The interviews were conducted in Portuguese by two clinical psychologists (the author and a research assistant). The interviews were taped and then transcribed into Portuguese and the analysis of the interviews was conducted in Portuguese. The interviews were examined individually, as case examples (of informants with agonias), and collectively by looking at common themes of the experience of the Portuguese immigrant community and meaning of agonias. There are a large number of Portuguese immigrants in the United States. Portuguese immigration to the United States started in the 19th century and had reached sixty-four thousand by 1900 (Bannick 1971). Many of the original settlers were recruited by shing companies as whalers and shers, 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 Health 1994). However, immigrants often nd adjustment difcult because of the disparity between modern urban life in North American and their agrarian or shing communities in Portugal (Moitoza 1982) and because of the discrimination that they face in America. The Portuguese community faces discrimination in various forms. Socially, the Portuguese immigrants are not always welcomed as equals by Americans because of their lack of formal education. Economically, Portuguese workers are often relegated to unskilled labour, such as textile mills, because they do not speak English. In the factories, if the opportunity for advancement occurs, Reeve (1998) argues that the Portuguese are often overlooked because of ethnic bias. This sort of discriminatory sentiment has led to negative stereotyping of the community as a whole. The informants were asked about the differences between the Azores and mainland Portugal. An Azorean-American mental health provider said, Azoreans seem to be more like rural mainlanders, more of a country culture than an urban culture. Its slower, not as fast paced. An informant from the Azores said, Azoreans are more connected to the their homeland and they all came under some kind of hardship conditions at home or at least most of them did. The Portuguese mainlanders are less connected to the homeland and felt less hardship there.

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The informants in the present study had emigrated from the islands of San Miguel, Terceira, Faial, Graciosa, and Santa Maria. On these islands they primarily worked the land/homestead of other peoples farms. Life was difcult there so they came to America to melhorar a vida (improve ones lot in life). Many of them were not sure that they had managed to do that, however, because so many of them face difcult economic conditions in America as well. One woman said
I had to come here. You know, over there we were very poor. The Azores is poor and back when I was growing up; it wasnt like it is right now. We would work, cleaning rich peoples houses, washing clothes, cooking bread, I would come back home very late in the evening because I was washing their clothes. We never had anything. . . . But life over here is also getting hard. The hours at my job are decreasing so I have to get a part time job to help me out.

The informants are from a number of occupations. Due to language barriers and minimal schooling, most informants held lower-paid semiskilled or unskilled positions such as factory workers or cleaners. Often they need to have two jobs to make ends meet, resulting in workweeks of over fty hours. Many described stressors associated with their work such as difculty communicating with co-workers, poor management, unhealthy working conditions, little job security, and few benets. Some also felt that the immigrant employees at their workplace were not treated as well as the non-immigrant employees. One retired man explained,
You know, us, the Portuguese, we didnt know how to speak English. It didnt really matter, Portuguese, Greek or Italians, the boss didnt treat us very well. They would say bad things to us, and all of that, but we didnt understand. The American employees, the ones who knew 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 in the Azores, all of the feasts and community celebrations revolve around religious holidays. All but one of the informants were Roman Catholic and the majority were actively practising Catholicism through prayer or church attendance. The remaining informant was an evangelical Protestant. Sixty-three members of the community, twenty-six men and thirtyseven women, were interviewed through the use of a semi-structured interview about their immigration experience, their family, their health, healing, suffering, and agonias. Informants were contacted through notices at a Portuguese Health Clinic, Portuguese societies, the Portuguese newspaper and the Portuguese-language radio station. The majority of informants lived in Cambridge but there were also some from neighboring districts such as Somerville and Brighton. In all, fty community members, eleven health providers (all of them Portuguese-American; ve of Azorean

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heritage and six of mainland Portuguese heritage), one priest, and one traditional healer were interviewed. It should be noted that the Cambridge community is unique in that there are a number of community services to meet many of the needs of the Portuguese immigrants. The community is maintained through Portuguese churches, social clubs, radio stations, businesses, and banks. In this sense, Portuguese immigrants have a network of available resources even if they do not speak English.

RESULTS AND DISCUSSION In this paper, the experience of the Azorean immigrants is investigated as well as their conceptions of health, healing and suffering. Consistent with the somatomoral framework, the meanings and cures of agonias will be considered from the medical, social, religious, and moral domains. The nal focus is to investigate how agonias sufferers are treated within the medical profession. Social Suffering Similar to studies by a number of medical anthropologists (Becker 1998; Good, DelVecchio Good and Moradi 1985; Kleinman 1995; Lock and Dunk 1987; ONell 1996; Shweder 1997; Young 1995), it was found that symptom 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 ones cross to bear and there is purpose in suffering, it takes on a totally different meaning and it is something that you are not ashamed to share with others. People look for empathy through suffering, empathy from friends and the from the community.

In this community it is difcult for family members to talk openly about their relationships with each other. This all changes, however, if the actions of other family members result in bodily suffering, because physical symptoms are an accepted topic of public discourse. As a Portuguese therapist pointed out, the only legitimate way for them to say that they need a break is if they have physical symptoms along with their suffering. Thus bodily suffering mediates relationships, and it is through suffering that the interpersonal space is created (Long 1986). The social context was also reected in the meaning ascribed to agonias. Some people viewed the causal ontology of agonias as a social phenomenon, such as anxiety regarding a premonition that a catastrophe

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was going to strike another community member. One therapist remarked about the meaning of agonias in her homeland of San Miguel,
People knew it meant something there, it meant something difcult that needed attention but usually the neighbours and the family used the word for more than that. If I told you that I have agonias and if youre my neighbour you would know that my father was beating me 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 agonias was also relational. Although the participants were asked a non-relational question, What is the cure for agonias? many participants responded with a relational narrative, When someone has agonias I give them , and then listed the cure. The cures varied greatly but the most frequently cited remedies were to give water or water with sugar in it, teas, or just listening to others problems. For instance, when one woman was asked, What is the cure for agonias? she responded, When someone is suffering from agonias I give them tea. You know special tea from the Portuguese store? That helps with agonias. At rst the variety of cures was confusing, but later I realized that there was a common thread uniting all of their narratives interpersonal compassion. ONell (1996) found a similar compassionate responsibility among the Flathead Indians that she linked to economic marginality and group survival. This may also be the case for the Azorean immigrants. The Azorean immigrants have faced economic hardships both in the Azores and in America. One informant even made the link between the poor health care 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 the health secrets of others. They probably did this out of necessity because health care was so poor 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, now they discuss health issues because they are trying to discover the secrets of another 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 the Azores and in North America, most cannot afford to call or visit their homeland. Thus, most of the participants had not seen close family relatives, sometimes even children, since the time that they left the island decades ago. In the late 1950s the Azores were under the threat of a volcano, 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 left homeless. Portuguese-Americans initiated legislation necessary to permit more refugees to come to America, resulting in the Azorean Refugee Act of 19581960. After this period, however, immigration policies became much stricter and the number of Azorean immigrants dropped substantially. Most rst generation Azorean-Americans are now senior citizens who arrived before 1961. With these community members passing away, and without a strong ow of new immigrants arriving, the traditions of the community 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 portend to the loss of the [traditional] way of life, and the close interdependence associated with traditional ways (ONell 1996: 119). One woman explained,
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. Our life is more I dont 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 think over here my life is more limited.

For many of the immigrants, their Azorean identity is their primary reference group, so losing traditional ways becomes a loss of part of themselves (ONell 1996). Thus agonias, an everyday term in the Azores, is transformed 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 signicance is compounded; it also represents a loss of a way to express this distress. Moreover, agonias is simultaneously a vehicle for reclaiming relationality and identity by being a plea for compassion and community (ONell 1996). While most community members have proudly held to traditional ways, there was one person who seemed embarrassed by them. One elderly gentleman (who had not completed grade school) rather vehemently said,
This talking about agonias shouldnt happen. Agonias doesnt exist in any books, and it isnt talked about by people who are educated. So this talking about agonias is only for people that never went to school. A lot of things dont exist but people keep saying it. They hear other uneducated people saying it and they keep using it. I didnt study much but agonias comes from people who are very old. And then other people hear the word and they start using it too. They hear it from their grandparents, from their parents, and they continue using the word the same way. But in school, they dont use the word agonias anymore. I didnt go to school much and I sometimes say the wrong thing, but whoever goes to school shouldnt say agonias anymore.

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It seems this is one reaction to using the language of the Azores in America. He speaks as if that language is embarrassing; devalued in his new scientistic society. Agonias, to the extent that he identies with this scientistic society, becomes a very powerful image; an image, as Taussig describes,
illuminating a cultures self-consciousness of the threat posed to its integrity. An image of this sort cannot be tted like a cogwheel into a structural-functional place within society. Instead the [image] is a type of text in which is inscribed a cultures attempt to redeem its history by reconstituting the signicance of the past in terms of the tensions of the present (1980: 96).

In addition to the gentleman described above, the Portuguese clinicians also preferred that the term agonias not be used. In fact, they taught clients to use scientic terms for agonias as opposed to using the folk idiom (as will be explored in more detail later). As members of the Portuguese community are discriminated against because of their level of education, when they use scientic categories, as opposed to local idioms, it challenges the stereotypes of the dominant culture. Perhaps the clinicians taught their clients the scientic nomenclature for agonias in order to save their clients the experience of de-legitimization that the clinicians themselves had experienced in America. Redemptive Suffering Agonias, and the compassion that it evokes, not only links community members 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. Another community member said, As the Great Physician helps His people in a time 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 Divine as Christ indicated when he said, As you do it to the least of these my brethren you have done it unto me (Matt. 25:31,32). Similarly, the way that some community members related to God through the weaknesses of their bodies is reproduced in their societal context. Participants develop a personal relationship with God through their bodily suffering and subsequent prayers for compassion. Similarly, a way to develop close relationships with others is to listen compassionately about bodily suffering, thus paralleling the relationship that they have with God. Often people have reasons for the suffering, known as the causal ontology (Shweder 1997). The interviews suggested that for the participants the causal ontology for illness and suffering was inextricably linked to their religious convictions. One woman, when asked, How is your health? replied, Ive 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. Isnt it my dear? The suffering will last until the day God wants. The day that He says close your eyes and come here with me. Many participants were ill because of their own sins or those of their family members. A Portuguese therapist noted, Suffering is something that happens to you and has to do with forces outside of yourself, like other people or even a higher power, like the devil. The comments of another health provider suggest that there is a predetermined value in suffering.
Suffering is something thats expected, youre expected to suffer because of predetermined values, and those values may be family, they may be church, some moral value thats out there.

This statement echoes Gadamers notion that there is a prehistory in religious traditions that links people to prior generations (Long 1986). It allows a Meaning, always already there, anterior and come from above, to manifest itself to the members of the community that share it (Kristeva 1941: 143). Like suffering, the cause of agonias was explicitly linked to the religious beliefs of community members. Some participants said that a person was aficted with agonias because it was Gods will. One man, when asked, Can both women and men get agonias? replied Women or men get agonias, its for everyone: God gives agonias to anybody. The health providers also suggested that agonias was linked to the faith of the community members: Agonias is a word with a lot of meaning. . . . It would be like somebody believing that theyre going to hell or to purgatory, it involves that sort of intense fear or pain. Its 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 are doing things that are forbidden like divorcing. And for the people its certainly a weight on them and it gives them a tightening feeling, like claustrophobia. . . . Agonias is really anxiety about sins. SJ: So it can be for their own sins or those of others? Priest: Yes, thats the martyr. Its like Christ suffered on the cross for our sins so Im suffering for theirs now.

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

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This type of redemptive suffering is similar to what Long (1986) characterises as opaque theology. It is a theology where the believer identies personally with the suffering Christ, unlike the Protestant theology described by Tillich (1980), the believer is Christ on the cross. Thus, redemption is possible not only through the suffering of Christ but also through the suffering of the believer. Not surprisingly, this form of theology often emerges out of groups that have been oppressed, such as the African-American and Native American communities (Long 1986). Finally, suffering is redemptive for the community as a whole. As they struggle with traditions that are fading, idiosyncratic beliefs revive their identity. Interestingly, the concept of agonias and the value that they place on bodily suffering makes the Azoreans distinct, even from other Portuguese-speaking groups such as the Brazilian and Cape Verdean immigrants. Hence the narrative of the suffering body emerges to represent the group and provide a community identity (Perkins 1995; Kleinman 1997b) for a community losing its identity. Embodied Suffering Within the Portuguese immigrant community a central role is played by religious martyrs. The priest explained, Oh people love the martyrs. They provide models for us because they gave everything they could for Christ. In this community, martyrs are upheld for their ability to imitate Christs suffering and for their repudiation of contemporary society (Perkins 1995). Martyrs provide a connection with the past and tradition not only because of their repudiation of their present society but also because there is an identication with those previously persecuted. Saints also have a central role in this community. As one participant described,
In every village in the Azores, there is a patron Saint and there is a feast to celebrate the Saints day. There is a particular afnity for the Virgin Mary: Were very devoted to the mother of Jesus. I think that is because a lot of people identify with the Virgin Mary, you have to be pure like the Virgin and you have to suffer like the Virgin a woman who sacriced her life.

As there are no gender or class lines of who can become a Saint, women are included as exemplars of how people who are fully human can strive to live 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 shes a human. I mean, Christ is human and divine, but Mary is fully human and so she experienced everything that we experience, from the pain of childbirth to the pain of seeing her son killed. So for them shes more palpable than the Divine.

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For many of the participants, suffering is imbued with power. One woman said, God doesnt respond immediately all the time . . . God wants to see that we really want our faith and our power. Another empowering notion is that the suffering, no matter how difcult presently, will not continue forever but merely exists in the present world. One mental health provider remarked, I think that many women, especially in the reality of domestic problems, like domestic violence, marital issues, and problems with their children are saying, this is my cross to bear . . . They see a purpose in their suffering, if not in this world, then in the other world. According to the metaphysical ontology of the Judeo-Christian tradition, the ability to endure suffering is recast as power and the curative power of pain is recognised. Enduring and dying is domination even for those without power in their contemporary society. Ante Christum, death had power and now this is reversed; the martyrs are rejecting the worlds power and control. As discussed by Perkins (1995), this creates new rules for empowerment. Women and the poor can take active roles in their faith because there is no class or gender distinction in the face of pain. Empowerment is certainly a welcome concept to a group that has often been disempowered in North America and in their home country. One woman remarked,
We are the type of people who fear authority or dont know how to ask for what is rightfully ours. And I think it has a lot to do with the politics of Portugal because we were not encouraged to speak our minds or express opinions. In 1975 there was the revolution and we became more expressive, but before that we were not allowed to speak against the government.

Powerful Healing Within this community, the utilisation of multiple healing systems is commensurable because allopathic and indigenous healers are just extensions of Gods domain. The participants all reported that when they are ill they seek medical care. Besides consulting a health provider, the majority of patients also consult other systems of healing; some pray or consult the priest, 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 didnt tell me to stop the medications from my doctor. He said that it is not bad for me to take both the medications and the tea so I drink one of those teas every now and then.

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

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help beyond the spiritual realm and most of the therapists will suggest that patients pray about issues and go to church if that is something that is meaningful for them. One therapist had recommended that a patient seek traditional healing and another therapist reported seeking traditional healing herself. The majority of therapists felt that it was acceptable for people to seek help in more than one healing system. The physicians, on the other hand, were divided; half were concerned that the herbal concoctions from traditional healers could react with medication that patients were taking while the other half were not worried. One Portuguese physician noted,
There is a connection between the spiritual and scientic that goes beyond both realms. My approach is to tackle the problem in as many ways as possible and make all of the treatments available to the patient. I think that one of the advantages of being Portuguese and dealing with Portuguese patients is that they dont need to hide from me that theyre seeking out other forms of healing.

Some of the healers felt that they were expected to full multiple roles. One physician has noticed that Our medical care has to be allencompassing for this group. I nd myself not only being a physician but a priest and a social worker as well. The priest agreed, A lot of times people will come in with what I would consider psychological, emotional, or deeper problems. The lack of distinction between psychological, physical, and religious pain provides support for the relevance of the somatomoral formulation to this population. Indigenous Healing Although a few of the community members felt that traditional healers were contradictory to religious healing, most participants felt that traditional healing was complementary to their religious beliefs. One woman explained,
By being Catholic, we understand that theres life after death and, therefore, after we die we remain in our spirit form. So its ne for there to be good spirits and bad spirits and if by any chance people made promises, especially to the church, that they never carried out, after they die they wont have peace. They cant go to heaven, hell, or purgatory, and they must remain on earth until they can get people to carry out the things that they were supposed to do while they were living. So there are spirits who are seeking eternal peace, and they cant 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 noises about the missions that they are to carry out. The other possibility is that the patient has his or 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 ofce at his house much like a therapy

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ofce with a waiting room as well as many amulets of saints. People go to see 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 remove evil or anxiety. There are also herbalistas who use a lot of herbs and they prescribe teas and herbal concoctions and oils along with rituals.

When people feel that spirits are causing their symptoms, they will consult a bruxa (witch or medium). A physician explained,
She works as a medium and seeks help from the good spirits, usually the patients relatives who have passed on. They then intercede for the patient and ght the bad spirits. There is usually some praying and a vigil around the house accompanied by cleansing fumes and the ingestion of special beverages.

This petition to the spiritual realm is similar to the way that Puerto Ricans seek healing through espiritismo (Lewis-Fernandez and Kleinman 1994). Within that tradition, mediums (espiritistas) use the spiritual realm to do good for unfortunate people or for souls in purgatory. The rituals entail offering prayer, fruit, owers, 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 cant help us, nobody on earth can. With regards to health, that kind of thing, God is the one who helps us.

Similarly, one woman talking about her condition after she broke her spine said [the doctors] said that I couldnt work or do housework. I was sad because I was very young. But God doesnt sleep. My doctor was God He cured my back. Later, she also mentioned a time in the Azores when a wound on her hand was so infected that her physician said that it had to be amputated:
You know a Saint cured me. Saint Roque, the Saint that takes care of bad things. I pleaded with God, Dont let them cut off my hand. I dont mind suffering, but I didnt want my hand cut off. Please dont let them cut my hand off. And then I felt something really strong, so strong that I fainted. When I woke up I was in the hospital and I was completely cured.

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 didnt go to see any doctors or anyone like that. Another woman had a similar experience,

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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 cold glass of water to help me with my agonias. And I say to God Whats happening? I havent done anything wrong. Why am I so agoniada? Sometimes I ask myself why I am shaking so 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 God as the great physician: If God doesnt intervene and heal the patient, you know it isnt 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 a similar sentiment. When talking about the community she remarked,
They feel that we have the power to help them but the ultimate outcome is dictated by Gods will. If its meant to be, they will get better. On the other hand, they also feel that doctors should be consulted and that we are not trying to take Gods place. God is working through us. If its meant for them to get better, its a way of getting better faster. In other words, going to a doctor is not against their religion.

With this population, even with divine causal ontologies, natural remedies are not to be dismissed. Rather, it is believed that God works through the mechanisms in the body and it is a persons duty to employ natural remedies without relying on them exclusively (Thomas 1997). With regard to agonias, some of the community members connected agonias to illness. One man linked his agonias to indigestion caused by liver problems.
SH: What is agonias? Informant: A person with agonias is a person that is not feeling right in their stomach or the food doesnt sit well and you get anxious. You get agonias, and the food travels up and down and you feel agonias. But this happens because the liver is not functioning well. It is for people that suffer from the liver. I suffer a little in my liver. I cant eat certain things. Pork meat is one of those things. If it is bad for me, I dont eat it. SH: Can people who do not suffer from liver problems still get agonias? Informant: Yes. Even if you dont suffer from liver problems. It can be from a bad stomach. Sometimes we eat something, a food that wasnt good. You get gas and agonias going through your mouth. Agonias is very strange. You dont have to have a liver problem to get it. SH: Can anyone get it? Men, women, children? Informant: Kids can also get it. A lot of times the kids throw up milk, dont they? That milk with a really bad smell. You know that their stomach and intestines are not working well. 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 are suffering from agonias.
SJ: What is agonias? Informant: Agonias. Agonias is, for example, a person who nds themselves in a car accident. They feel agonias. You get agonias when you are behind the wheel without knowing if you are going to die or not. You can also get scared all of a sudden, that is agonias. And there is also the agonias of death. The person gets agonias because they have heart problems. People who suffer from heart disease often get agonias. When the heart 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 informants description of agonias has some similarities to a form of nerves (nervios) that affects women in El Salvador called el calor (the heat). As agonias is a response to a car accident when survival is in question, el calor is a response to a life-threatening environment (of poverty and violence). The symptoms of fright and death agony are also symptoms of el calor. Jenkins and Valientes (1994) argument that el calor is a somatic response to a chaotic environment is a useful framework for thinking about agonias. Although the community members listed a variety of physical symptoms when discussing agonias including gastro-intestinal problems, heart and chest pains, asthma, menopause, indigestion, and being literally on the brink of death, the medical providers conceptualized agonias as anxiety. Thus, if patients had numerous complaints about their agonias, the health providers referred them to the mental health clinic because they were seen as having a psychological disorder. Mental health providers. Unlike the medical providers, some of the mental health providers seemed slightly more critical of Azorean culture. When asked, What is it like to work with Azorean clients?, one AzoreanAmerican provider remarked, A lot of the time it feels like I am treating people from the United States who are in a time warp, from a bunch of years ago. You know, because people may have had less education or more illnesses and poor health care. They are more typical of fty to seventy years ago than they are today. This provider gives an example of an Azorean client that she was working with, She was not very, as one says, psychologically minded. You know, she was very service oriented. She wanted me to get her food, diapers, really concrete things. Some of the providers discussed the struggle of working with people from their own culture and disentangling their personal issues from those of their clients. An Azorean health provider explained,

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I nd being Azorean that I sometimes I have difculty working with Azoreans. I think, I mean Ive actually evaluated this many times, I think its because of over-identication. 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 some psycho-education they just dont value it, they dont do anything about it. They feel like theyre stuck in these situations, so thats very frustrating to see happen. And I think a lot of it is my own issues, you know it goes back maybe to the way I was brought up with my mom and everything you know. A lot of them (and I think I have a little bit of them) are passive aggressive, they dont exactly say what they want so it takes forever to get information from them and they go about it in a roundabout way and they dont directly ask what theyre looking for. So Im not saying that some of the Americans are not like that, but I dont over-identify with them, Im able to separate much more. Im able to detach myself from the issues with Americans. Working with the Azoreans is much more difcult for me.

Some anthropologists have noticed that outsiders of the cultural group with whom they were working labeled the group pejoratively (FavretSaada 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 the positivistic world. Similarly, many of the mental health providers, now that they are educated and enculturated, talked about their Azorean patients as concrete and not psychologically minded. Taussig (1987) also found the colonizers had similar pejorative terms for the Indians in the Andean mountains. Taussigs interpretation that the colonizers projected their antiselves onto the Indians may be useful here. Is it possible that some of the clinicians fear that in the highly theorized world of psychotherapy, where a non-theorized relationship is impossible, they are losing concrete relations with others and the world? Thus by labeling the Portuguese as concrete they are projecting their anti-selves (and in this case previous selves) onto this community. Another possible explanation is that the assumption of universal applicability is implicit in psychotherapy theories. Thus if a patient does not t the paradigm, the generalizability of the theory is not questioned, but rather the ability of the patient to have a valid experience is contested. From the ground of psychotherapy theory, people who do not t the North American prototype, such as many new immigrants, are labeled as concrete and not psychologically minded, suggesting that they are not complex enough to have a valid experience. The judgement that the Portuguese patients are somehow lacking something is paradoxical, however. Just like the backward peasants Favret-Saada (1980) encounters, the Portuguese actually have access to two languages rather than only one. In addition to their relational, moral Azorean dialect, replete with folk categories, they also become uent in the language of psychology under the tutelage of the their mental health

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providers. Consequently, the immigrants learn to speak both languages and they learn when to use each one. Ironically, the patients become bilingual when the providers often limit themselves to only one language. As one Portuguese therapist noted, I teach them the language of therapy so that we have a common language. Although their language speaks to the complexities of their local world, the language of psychology is adopted as the common language as it is the lowest common denominator. Their language connects mind, body and spirit, and community, so to make it more objective the therapist strips away the latter two, making objectivity equal to less than reality. Consequently, the Portuguese patients have at least two ways to describe their experience and can choose which one they will use to voice their experience. Adopting psychiatric nosology and the language of psychotherapy becomes a cultural choice for these patients. Bilingualism provides a choice as to which language they will use to express themselves, but it also allows them to have a choice of which healing system they will use. If they use the medical system, and especially if they are given a diagnosis and medication, they are more apt to receive the support and caregiving of their children and the younger, second generation. If they turn to the indigenous healing systems they receive help from God, the elders, traditional healers, and priests, but these resources may be diminished, discounted or even discredited by the younger generation. Thus, bilingualism optimizes the amount of support that 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 of concerns: agonias was not the neatly bound culture-specic disorder that I had envisioned. Lock and Dunk had a parallel experience when studying a similar phenomenon, nevra (nerves), with Greek immigrants in Canada.
By examining a phenomenon such as nevra in terms not simply of its meaning to individual patients and to their physicians but also as a exible and powerful metaphor, the expression and interpretation of which is modied with time and space, one arrives at a much more dynamic, and less exotic picture than that which is usually portrayed for culture- or areabound syndromes . . . (Lock and Dunk 1987: 299).

Although agonias was a multivocal symbol for community members with various meanings, symptoms and cures, agonias had only one meaning for clinicians, anxiety disorder. Most clinicians only mentioned anxiety, although a couple of them said that it was anxiety and depression. All of the clinicians, regardless of whether they were from the Azores or the Continent, stated that they teach the patients not to use

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the word agonias but rather to only talk about their specic symptoms of anxiety.1 The approaches that the clinicians used for treating agonias were either anti-anxiety medications and/or psychotherapy. All of the clinicians mentioned their frustration with treating agonias because the approaches that they use are often unsuccessful. There are many parallels between agonias and nerves (nervios and ataques 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 rising to the head, fainting, and difculty breathing (Guarnaccia, Rubio-Stipec and Canino 1989). Although agonias is not as dramatic as ataques de nervios, where the sufferer will fall to the ground and either convulse or lie on the ground as if dead (Guarnaccia 1993), both reactions are seen as episodic rather than chronic (Swerdlow 1992). Additionally, sufferers from both groups will seek treatment from traditional (espiritistas), medical, and religious (such as prayer) domains. Like agonias sufferers, ataques de nervios and nervios sufferers are often not well understood by their health professionals (Oquendo, Horwath and Martinez 1992). The transition must seem strange indeed when Azoreans move from the Azores, where agonias is treated by community compassion, to North America where agonias is a psychiatric disorder and community compassion, in the form of health professionals, is commodied and medicalized. Furthermore, the commodied compassion is in a relationship that is asymmetrical and non-reciprocal. The discrepancy between the providers and community members meaning of agonias indicates that our system for diagnosis (the Diagnostic and Statistical Manual, or DSM) encourages a limited understanding of disorders that privileges internal experience and ignores the concomitant cultural and social dynamics (ONell 1996). The DSM has come to be seen as a universal prototype against which the experience of all can be understood and measured. To further substantiate its authority, the categories are disguised as manifestations of the natural and then become a formally instituted source of truth (Taussig 1980; Lutz 1988). Although psychiatric categories appear to clinicians to be natural categories, they are limited when trying to classify idioms like agonias that refuse to be strictly psychological. Consequently, agonias does not t neatly into one of the psychiatric categories because it encircles a broad semantic domain that extends well beyond narrowly dened psychological distress into the realms of moral development, social relations, history and . . . identity (ONell 1996: 8). Ironically, the very God that participants

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claimed redeemed them from having agonias also redeems them from having a psychiatric disorder. A further irony involves the notion of perceived knowledge. As previously mentioned, an elderly gentleman said that agonias is the discourse of the uneducated. However, the community members, most of whom did not graduate from high school, are fully aware of the complexity of meanings, affect, and action associated with agonias. The providers, on the other hand, who are highly educated, have only a unidimensional notion of agonias. They have no idea about the multiplicity of meanings or the power of the discourse, highlighting Foucaults argument that knowledge transforms power and can upset traditional power relations (Taussig 1987). CONCLUSIONS In order to further investigate agonias, an examination of agonias in the Azores presently and historically would provide valuable contextual information. Lock and Dunk (1987) came to similar conclusions in their work with Greek immigrants, suggesting that such an investigation would shed light on the way that migration affects the cultural construction of idioms of distress of immigrants and their offspring. It would also be interesting to explore the meaning of agonias presently and historically in mainland Portugal. This would shed light on how symptoms of distress are shaped by contextual factors specic to the Azores such as poverty, the constant threat of volcano eruptions, or recent political oppression. In light of the ndings of this study, there are a number of clinical implications. The results indicate that treatments for agonias based on the standard diagnostic categories are limiting. Instead, it is important for clinicians to learn about other healers (indigenous and religious) sought by the patient and work collaboratively with them, making referrals when indicated. It would also be helpful for providers to focus on practical aspects of the patients contextual situation, such as family life, work, or schooling of children. Lastly, it is important to work with community organizations to raise awareness about the difculties facing the community, such as poverty, poor working conditions, and domestic violence. As bodily suffering in agonias mediates relationships, patients suffering needs to be understood, not just removed. Thus it is important to take the time to understand the suffering and its network of meaning so that the proper issue can be targeted. Additionally, listening to others suffering is a way to build relationships and therefore an important place for the clinician to start. Friends and God are expected to listen tirelessly

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and compassionately to all of the various physical complaints, and it is assumed that the therapist will do so as well. When patients feel that their suffering and symptoms are taken seriously, only then can they move on to discuss other topics such as their dire economic situation, poor working conditions, or difculties with their spouse. Clinical theories would be signicantly enhanced by incorporating the sociosomatic formulation and the complex religious and socio-cultural awareness that it seeks to privilege. The sociosomatic formulation situates the individual in his or her local world and expands the eld of inquiry in psychology and psychiatry to consider other levels of analysis. We are challenged to move from primarily focusing on the level of the individual to also considering the social, cultural, religious and moral domains, presenting a more complex, integrative and meaningful view of the individual. Agonias is a somatomoral experience where the somatic, the social, the religious and the moral are inextricably linked. Because it connects things that, from the traditional medical paradigm, should not be connected, it dees our psychiatric categorisation and goes beyond disciplinary boundaries. Agonias is a dynamic multivocal symbol that is not just an inanimate signier but also a therapeutic act. It is a call for help and an intervention already in motion. On an individual level it connects the sufferer with others and with God, transforming the interpersonal and divine space. On the community level, it connects a community, losing its way 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 analysis because the provider is neither bilingual nor bicultural. Interestingly, this providers responses to the meaning and treatment of agonias were nearly identical to those of the bilingual/bicultural providers.

ACNOWLEDGMENTS I gratefully acknowledge support from the Social Sciences and Humanities Research Council that supported a post-doctoral fellowship at Harvard University where this research was conducted. Additionally, the Livingston Fellowship Award from Harvard Medical School provided funding for the project. I am indebted to Dr. Arthur Kleinman for supervising this project 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 invaluable input at various phases of the project. Lastly, I am grateful to Dr. Susanne Haskell for her tireless assistance with data collection and Eric Mathias for assistance during the editorial process. REFERENCES
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Department of Psychology Wilfrid Laurier University Waterloo, ON N2L 3C5 Canada