WORKING DRAFT: Please do not cite without permission of the author

The Impact of Postmodernization on Worldview Construction
and Spiritual Care in Sweden

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Valerie DeMarinis
Uppsala University

The following recently published article, here without diagrams, will be used as the base of my presentation at the 2006  American Academy of Religion Conference: Person, Culture, and Religion Group session.

Publication information:
DeMarinis, V. (2006)  Existential dysfunction as a public mental health issue for post-modern Sweden: a cultural challenge and a challenge to culture.  Holm, B. (ed.) Tro på teatret: essays om religion og teater [Belif and theater: essays on religion and theater]  (Nr.3 in Series: Religion in the 21st Century) Copenhagen: University of Copenhagen.

This article constitutes a critical cultural analysis from a public mental health perspective of existential function and dysfunction in post-modern Sweden. This analysis is not based on one particular research study, but rather on several studies and clinical experience in one cultural context. The cultural analysis approach used here builds from cultural psychology, cultural psychiatry, cultural epidemiology, and psychology of religion.

To begin with a common set of definitions set into theoretical context is needed in this analysis for the terms: culture, post-modern, and existential function. In the field of mental healthcare and cultural psychology, Anthony Marsella, provides the following definition of culture:

Shared learned meanings and behaviors that are transmitted from within a social activity context for purposes of promoting individual/societal adjustment, growth, and development. Culture has both external (i.e., artifacts, roles, activity contexts, institutions) and internal (i.e., values, beliefs, attitudes, activity contexts, patterns of consciousness, personality styles, epistemology) representations. The shared meanings and behaviors are subject to continuous change and modification in response to changing internal and external circumstances. 1

Four important aspects of culture in this definition need to be understood:

First, there is no individual, society nor institution that does not exist in a cultural context. Culture is neither something static nor something reserved only for certain countries or societies. Second, within any society unconscious as well as conscious aspects of culture play a role in the shaping of existing paradigms of health and illness, and most especially of mental health and mental illness. Third, paradigms of mental health and illness, which always are linked to culture, are in coordination with political and social structures implemented into policies of the institutions of the society, i.e., the healthcare structures. Fourth, depending on how a society is organized in relation to power structures, there may be co-existing paradigms in operation or there may be, and this is most frequently the case in Western mental health contexts, a central, dominant, and powerful paradigm in operation that makes claims of universal relevance.

The term post-modern is a conceptual means of providing a vantage point about the nature of how things are and how they are supposed to be approached. This type of functional approach, can be used to describe scholarly traditions, theoretical formations, the differences between traditions, and/or of applications.2  “In the abstract a post-modern vantage point clearly has certain benefits. It stands for critical questioning, innovation, confrontation of absolutes and the necessity of raising suspicions. These are descriptive functions of an abstract process”. 3 

The concrete process of understanding post-modern consequences needs to be understood both on an organizational/institutional level as well as at a group level.  Healthcare philosopher David Levin provides a way of approaching the organizational/institutional impact:

Being on the edge of modernity, postmodern thinking faces into the future. So there is also, in such thinking, a sense of new historical possibilities: in medicine, healing, psychiatry, community networks for health care, living. There are also, of course, enormous challenges and difficulties. The hegemony of the old paradigm is not easily replaced by something better. Practices, routines, and institutions are not easily transformed by critical thinking.4 

Psychologist of religion theorist, David Wulff, brings attention to the challenge for the culture, group, and individual living daily life in a post-modern context:

Those living in the modern age share a confidence that, in spite of the obvious diversity of conflicting beliefs, reality can become progressively known—if not through some religious revelation, then with the aid of human reason and scientific methods. Postmodernism, in contrast, denies the very possibility of knowing reality. All beliefs, religious and scientific alike, are SOCIAL CONSTRCTIONS, linguistic products of negotiation among persons living at a particular time and place.5

In the extreme, living in a post-modern context can result, for an individual and/or group, in the lack of a system of orientation. “In such a case he or she has either no basis for making a decision and so decisions are made haphazardly or in desperation, or the individual is literally paralyzed and cannot make any decision.”6 As postmodern psychological theorist Zygmunt Bauman notes, postmodern men and women, “whether by their own preference or by necessity, are choosers.”7  But choosing in this way is a challenge not faced before by societies, groups or individuals. The result as Bauman cautions, “is the era of experts in ‘identity problems’”.8

Such problems in a post-modern context form the base of a new form of cultural and identity poverty. The consequences of such can be seen on a daily basis in the clinical meeting rooms of mental health care providers. What is at the base of this poverty or dysfunction?  To provide an answer attention needs to be focused on the narratives, rituals, and symbols that constitute how existence is understood and meaning is constructed for societies, groups, and individuals. These narratives, rituals, and symbols, understood from a functional, psychological perspective, are the tools by which an existential or spiritual  worldview is constructed. Together these tools can be grouped under the term existential function. 

Referring back to Marsella’s definition of culture, it is clear that these tools belong to the internal representations of a particular culture and that there needs to be  a strong relationship between these tools and the cultural context’s institutions and other external representations, which shape how these tools are developed and applied.  But can this relationship be assumed in a post-modern cultural context such as Sweden? 

What does existential function and dysfunction look like in post-modern Sweden?

To begin answering this question, an agreed starting point needs to be negotiated, which is that Sweden is a post-modern cultural context.  By evidence of a series of recent academic publications, both theoretical and empirical in nature, the topic is a burning one in Sweden today. In a selected review of these studies for my 2003 volume, an argument there was set forth for the case of Sweden as being a post-modern context when examined through a cultural psychological perspective. Though many Swedish sociologists argue for Sweden as being a late modern cultural context following social theorist’s Anthony Giddens reasoning, many psychologists and psychiatrists are adopting the term post-modern. This difference is both interesting and important from a theoretical as well as applied perspective. 

Sociologists are finding that institutions such as the Church of Sweden, the state church until 2000, are re-inventing their roles and functions in society.9  However, when examining societal existential needs met by such institutions, the picture needs to be framed in a different way.  Two recent dissertations in psychology of religion at Uppsala University illustrate this new need for re-framing. First, in a theoretical study focused on ethnic Swedes and their psychosocial need for existential ritualization, Maria Liljas Ståhlhandske points to the limits and limitations of the institutional church as it currently exists to meet these needs.10 Second, in a study focused on multi-generational acculturation and ritualization in Sweden of Suroyo migrants, Önver Cetrez points to the limits of existing institutions, both of the majority culture and ethnic minority sub-culture, to correctly identify the existential needs and acculturation challenges taking place.11 In relation to acculturation problems for minority groups in Sweden, two commissioned national studies point to the dire need for change in relation to extensive structural discrimination extant in the Swedish cultural context.12

In short, the strongest evidence for an actual post-modern cultural context that these different types of research point to is that the hegemony of the modern cultural context with intact cultural meta-narratives and a well synchronized symbiotic means of relating  between externalized and internalized representations is over. Instead, a period of greater or lesser chaos, not least in relation to existential function viewed from a modern hegemonic paradigm, seems to be upon us in this first decade of the 21st century. Clearly, the paradigm used to examine this chaos will be crucial to what happens or does not happen next. It is here argued that a paradigm shift, after Thomas Kuhn’s model,13 is in order.

A Public Mental Health Paradigm and Existential Functioning in Post-Modern Sweden

The paradigm used here, public mental health with special attention to existential functioning, is one that I initially developed related to a Swedish research study published in 2003.14  This paradigm has as its focus on the mapping of content and function in relation to how persons in a given cultural context are able to make meaning related to both the larger, existential questions of life as well as the impact of this way of making meaning for decisions in daily existence.  Diagram 115 below presents in a continuum format the range of existential public mental health assessment.

(Insert Diagram 1 about here)

Concern for existential health and existential epidemiology in a post-modern framework builds from earlier work in the area of cultural epidemiology, especially that of David Levin.16  In his designation of the term cultural epidemiology, there is a necessary merging between symbolic systems of meaning and the study of the distribution of disease over a population in time and space. “The assumed subject of the epidemiological study can no longer be separated from questions traditionally reserved for humanism and the social sciences.”17

Cultural epidemiology takes place when cultural resources, symbol systems, and ways of living are no longer able to function to promote health. In fact, the opposite may occur, whereby the continuation of such participation may cause harm, leading to a situation of distress, disorientation, and depression. At the heart of cultural epidemiology is existential epidemiology, the lack of function or dysfunction of an existential system, a way of making meaning out of existence. 

To understand existential epidemiology in a post-modern cultural context it is first necessary to understand what typology of existential function exists. What does such a typology look like in Sweden at the beginning of the 21st century? The following typology (see Diagram 2 18), briefly presented here, is built from research and clinical observations.  First, the initial idea for the typology emerged from the national study noted above on the nature and function of pastoral/existential care conducted with priests and pastors in Sweden. 19  Second, the categories in the typology have been applied and refined through different clinical contexts where attempts have been made to map the existential function and the contents of how meaning is made as a part of gaining information on a patient’s or client’s general level of functioning. The typology is a Swedish adaptation of David Wulff’s20 typology. Categories 5 and 6 from the Swedish study are not included in the Wulff typology.

(Insert Diagram 2 about here)

The typology consists of five categories of existential worldview function and one category of dysfunction or absence of an existential worldview. Categories one and four involve an existential worldview that includes a transcendent or immanent power, some force greater than the self. The difference here between transcendent and immanent is primarily that of distance to the source of power as ‘a force out there’ or ‘ a force that comes into.’  In both cases it is something other than and greater than the self that is in focus. For those with a worldview in Category 1, Literal Affirmation, the source of power is often transcendent and the interpretive framework is literal, relying on an exact interpretation of and following of laws and regulations from existing sacred texts.  Fundamentalist believers’ worldviews belong in this category. Category 4, Restorative Interpretation, denotes an existential worldview that uses a symbolic interpretation of both imaging the source of power as well as interpreting sacred texts in cultural and temporal perspectives.   

Existential worldview categories two and three exclude a transcendent or immanent power. These two categories also represent a literal and a symbolic interpretive framework respectively. In Category 2, Literal Disaffirmation, there is a literal approach to how reality is interpreted, where often another system of power or belief such as science, technology, or any extreme movement, function in a fundamentalist manner. In Category 3, Reductive Interpretation, a symbolic framework is operative in approaching reality as lived on different levels. Here there is often a built-in suspicion of any system of power or belief that might be elevated to an absolute, un-criticisable status.

Category 5, Mixed Existential, represents a worldview that either contains elements from two or more of the categories, or contains elements from different traditions. In essence, reality is here divided up into different segments and in these segments different mini-worldviews dominate. Here it is possible to have elements of different belief traditions co-existing within the same individual. In fact, clinical experience shows that this category is the fastest growing among post-modern youth.

From a mental public health perspective set into a post-modern context, categories one through five, are all functional and do not in themselves present a problem, assuming that no one of the categories is permitted, actively or passively, to dominate in society. Religious or existential worldview freedom can operate quite well with all five categories co-existing. To a greater or lesser extent, these catregories all are existing and more or less co-existing openly in contemporary Sweden at the moment. Such a post-modern context therefore needs to be clear about foundational rules of operation and negotiated shared values separated from particular religious or existential systems. 

Assuming that such a negotiation and a separation are understood to be vital and can be achieved, a post-modern society can exist in a state of public mental health. Problems begin with Category 6, Lacking Existential Worldview. The common denominator for all who fall into category six is that there is no functioning existential worldview. Without such, there is a situation of dysfunction and impairment. If the condition does not change, if there is no intervention or if the interventions are destructive, the situation will deteriorate into a more-or-less complete state of existential dysfunction resulting in mental dysfunction and psychological illness.

The thesis proposed here is that existential dysfunction can and should be classified as a mental health crisis. To a limited extent, it can be argued that discussions around the need for cultural analysis and culture-based assessment in diagnosis after the publication of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, including the World Health Organization’s (WHO) International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10),  the dominant system used internationally for the mental health professions, are beginning to work towards such a classification at an individual patient level. 21 

However, when this mental health problem of existential dysfunction is a diagnosis expanding into the cultural, societal context, it is time for a public mental health perspective to come into play. It is time for an alarm to sound that signals the start of an epidemiological warning: that of existential epidemiology. 

The warning signals and patterns of approaching existential epidemiology can only be understood in societal, cultural context. The patterns in post-modern Sweden may resemble those emerging in other post-modern cultural contexts but the comparison will need to be measured by the cultural nearness of the contexts. This is the case both for the understanding of cultural problems as well as in the search for cultural resources.

Two examples are provided here to illustrate the most common patterns of approaching existential epidemiology in Sweden. The first pattern points to the growing absence of existential, meaning-making connections, especially among youth, to once functional and foundational societal and cultural institutions such as family, school, church, or hobby/sport groups. And, the unconscious addressing of this absence is often met by connection to the ‘available institutions’ usually related to substance-use. The following is an excerpt from an interview I conducted with a 16-year old Swedish young man living in Stockholm:

My weekend time looks something like this for me and my friends. Sometimes we cut school on Fridays, but in any case Friday night we are always meeting our contact to get beer and vodka from the state liquor store (Systembolaget).  Then we go to one of my friends’ apartments as the parents are not there.  I guess you can say that we drink until we feel good and then drink more until we don’t really feel anything. I used to get sick but now I’m used to it.  Usually it is only guys but sometimes we bring some girls we know.  They try to drink as much as we do but they can’t handle it. A couple of times a girl I knew got really sick and passed out and went to the  hospital. On Saturdays we do the same thing or just hang out and drink outside in an alley if it is warm. (…)

Sometimes I think about finding something else to do, but this is easy and it feels good for a while and I don’t have to think about anything. I don’t really fit in to any other group or know where to go. I used to play hockey but stopped a while ago. (…)  I don’t think people know how much we all drink and others take some drugs too. I think it’s funny when we have to fill-in those questionnaires at school about how much we drink. I think many of us don’t answer honestly. I’m so used to lying that I can’t really tell what is true. And, I can’t see that anyone really cares to help us do something else.

The second pattern points to the impossible cultural burden of existential dysfunction now being supported by mental health and psychiatric institutions.

The following is an excerpt from my interview with a Swedish consulting psychiatrist in Stockholm:

Over the past decade or so the diagnostic process seems to be more difficult. Following the principle of needing to get as thorough a history of a presenting problem or symptom, I have begun asking questions about the patient’s worldview, cultural resources and his or her way of making sense of things in relation to an illness or problem. When I ask these questions I get much information that can help me in my work with the person. The problem is that there seems to be, for more and more patients, a spiritual or deep-seated aspect of the problem that is not medical in nature. However, I am at a loss as to where to send them for help as most have no contact with religious or that type of organization. So I do my best with the parts of the problem I am responsible for, and give medication when appropriate. But there seems to be missing for many people a connection to the spiritual or whatever it is that helps them to find meaning. Unfortunately but all too often, the person winds up being ‘a perpetual patient,’ making unconscious pilgrimages to the temple of psychiatry.’

These two patterns are not distinct from one another. Over time, existential dysfunction results in illness, and illness can best be understood and addressed through its cultural constructions.22 Without intervention, the signals of existential epidemiology will become stronger. In the midst of the current post-modern chaos, a public mental health initiative that champions the challenge of cultural health promotion and investment in existential health can find inspiration and direction from the World Health Organization’s understanding of the current, third public health revolution: 23

The third public health revolution recognizes health as a key dimension of quality of life. Health policies in the 21st century will need to be constructed from the key question posed by both the health promotion and population health movements. “What makes people healthy?” Health policies will need to address both the collective lifestyles of modern societies and the social environments of modern life as they affect the health and quality of life of populations. 

 How can cultural resources such as The Arts24 play a part in addressing cultural epidemiology and existential dysfunction in post-modern Sweden?

The challenges posed by the third public health revolution need to be brought into and adapted by each cultural context. The Swedish National Committee for Public Health (a parliamentary committee established in 1997) has identified six main areas of strategic intent that set both a health promotion and a health determinants agenda: 1. strengthening social capital, 2. ensuring that children grow up in a satisfactory environment, 3. improving workplace conditions, 4. creating a satisfactory physical environment, 5. stimulating health-promoting life habits, and 6. developing a satisfactory infrastructure for health issues. 25  These areas of strategic intent can serve also as the base for addressing existential dysfunction and the signals of existential epidemiology in the wider public mental health area of cultural epidemiology.

In fact, addressing existential dysfunction is perhaps the most critical area for improved public health in general in the post-modern Swedish context. It is important to note the absence of existential health or any notion related to such in the areas of intent. And, it is not insignificant that no Swedish or Nordic representation has been involved in the initial field testing of the World Health Organization’s new Quality of Life Instrument which includes a Spiritual Assessment component. 26 However, Area 6 of strategic intent, developing a satisfactory infrastructure for health issues, when applied to the post-modern consequences of existential dysfunction, needs to include attention to The Arts as essential cultural resources in the public mental healthcare infrastructure. 

If existential dysfunction is understood as the absence of functioning narratives, rituals, and symbols that engage individuals and groups in a society in a given cultural context, then priority needs to be given to a public mental health agenda that understands how the existential imagination can be developed and/or healed. Psychologist of religion and cultural psychologist Paul Pruyser already in the 1970s argued for an understanding of the role of the artistic and religious systems for developing and maintaining mental health and the ability to hope. 27 Today the post-modern challenges that threaten hope and mental health are different, and the urgency is even greater as the problem spreads and deepens.

If Sweden is to meet its goal of integrating public health with general welfare policy, then attention to interventions addressing widespread existential dysfunction as well as to prevention efforts for the promotion of existential function need to be priorities for building a public health paradigm focused on well-being and quality of life. These prevention and intervention efforts require a paradigm of approach not yet existing. Collective engagement in The Arts, as well as the raising of radical questions to society by The Arts, can provide ways for the cultural imagination to become inspired. As Pruyser knew and every mental health clinician knows, there is the potential for powerful inspiration when one can ‘step outside’ of oneself and see things in a new way. “A new mind-set and professional ethos are proposed for health professionals; their new role is to ‘enable, advocate, and mediate’”.28 And for this new mind-set and ethos to come into being, a respect for the limits of a profession needs to be recognized, as well as a demand for society to take responsibility for the post-modern creation of flexible, empowering, cultural institutions that can provide resources for existential function and for making life-affirming meaning out of the current chaos. 

The emergence of postmodernism and related changes in intellectual thought have taught us in recent years that our realities, including our scientific realities, are all culturally constructed. Knowledge in psychiatry and the social sciences is culturally relative, and as such, it is ethnocentric and biased.  What passes for truth is, in fact, a function of who holds the power. Those who are in power (e.g. Western psychiatry) have the ”privilege” of determining what is acceptable, and those who are not, are marginalized in their opinion and influence.29

In closing, words from the above-cited interview with a Swedish consulting psychiatrist may provide both hope and inspiration for taking the next steps:

Living in and being myself a product of the country that is considered the most secularized in the world, does not mean that spiritual questions or questions about existence are not important. In fact, they may be even more so here because everything is so private around this topic. When people, like my patients, are struggling with these questions, for lack of something else or maybe just because it often works I encourage them to use music, art, or drama as a way of just getting some inspiration. I can also say for myself that I use these methods to combat my own depressive symptoms or when I feel the need to gain perspective. However, what we really need here in Sweden are safe places where people can go and maybe new kinds of groups they can join so that they can feel they belong somewhere and can get renewed. This in my opinion is the function of a ‘sacred place’ today. In my medical office I can provide support, information, treatment, and medication but I cannot and should not try to provide a community of comfort and caring. That is outside my responsibility and competency. How to build such safe and sacred places is another question. I only know the need for such is very great.

Acknowledgements:

For a clinician and mental health researcher it is a rare privilege to have time to reflect on meta-questions such as the ones raised in this article. Such time for reflection has been provided over the last decade through a variety of research project grants from: The Swedish Research Council, The Swedish Board of Health, The European Union, The Swedish Research Council for the Humanities and Social Sciences, and The Swedish National Council on Drug Addiction Research. I am especially indebted to my clinical research colleagues in psychology and psychiatry who have inspired my work through the raising of critical questions and the offering of continual collegial support. Special thanks in this regard to Drs. Anthony Marsella, Leif Öjesjö, and Grace Chang at the University of Hawaii, The Karolinska Institute, and Harvarvard Medical School respectively. Finally, a word of appreciation to the organizers of the Copenhagen conference for the unexpected invitation to provide first a lecture and then this article. I can only hope that these are the beginnings of a much needed dialogue across our disciplines.  

Author information:

Valerie DeMarinis : Professor in psychology of religion and cultural psychology at Uppsala University. Visiting professor in psychiatry at Harvard Medical School. Contact: valerie_demarinis@hms.harvard.edu