MicSem Publications

In Search of the Social Roots of Mental Pathology in Micronesia

by Francis X. Hezel, SJ

1986 Health

I was asked to address the relation of social change to mental health in Micronesia in this paper, but I admit to doing so with some serious misgivings. Let me then begin in true Micronesian fashion by apologizing in advance for the inadequacies of this short presentation. In the first place, I am neither a clinical psychologist, much less a psychiatrist, nor am I a professional social scientist. I am simply an interested American who has spent twenty years in that part of the world and has a potpourri of information and observations on the run, so to speak. The observations are probably no worse than anyone else's, but it is a serious disadvantage not to be conversant with the theoretical assumptions that are commonly accepted and the issues that are being contested in the fields of cultural anthropology and clinical psychology.

Not all the shortcomings, however, are my own. It appears that the area of social change is something of a "black box" even for social scientists. The theory of social change is itself subject to change, as the numerous revisionist studies of anthropologists and sociologists in recent years attest. When we look at area studies on Micronesia, we find anthropologists in increasing numbers going beyond the traditional land and kinship studies to investigate new institutions such as schools, alcohol use, land sales, modern food raising and consumption patterns, and US Federal Programs as these have been engrafted into Micronesian societies. Yet these studies are usually long on descriptive ethnography, particularly in showing the altered forms that these institutions have taken in their Micronesian milieu, and short on defining the impact of these innovations on other features of social landscape. That should not surprise us, of course, for the description of the impact on other institutions is both an ambitious undertaking and one doomed to imprecision almost by definition. But if it is hard enough to measure the effect of change on other social institutions, it is all the harder still to gauge the impact of such changes on the inner workings of people's minds.

Mental health has been a formal object of attention in Micronesia only since 1974 when a psychiatrist and a clinical psychologist were first recruited for the Trust Territory Headquarters staff. It was in the years shortly after this, as the Division of Mental Health took shape, that the first serious attempt was made to collect data on mental disorders. From 1977 through 1980 monthly reports were submitted to headquarters by the mental health personnel working in each of the states. Rates of mental illness for the years 1978-1980 were culled from these monthly reports and case files and published by the then staff psychiatrist (Dale 1981). A more limited but considerably more detailed study of schizophrenia in Palau was done by three psychiatrists from Loma Linda Medical School, one of whom had worked in Palau for several months (Hammond et al 1981). A second study by the same authors tried to explain the dis proportionately high incidence of male schizophrenia in the same island group (Kauders et al 1982). To these can be added several recent reports written by visiting social scientists and professional health care personnel on the state of mental health and the health care systems in Micronesia. These include reports by H B M Murphy (1978), Cooper et al (1981), Tseng and Young (1981), White (1982), and Robillard (1983). Finally, there is an excellent review by Howard (1979) of the development of psychological theory in literature on the Pacific and its various applications.

Mental Illness in Micronesia

The mentally disturbed are a highly visible phenomenon in almost every part of Micronesia. Nowhere, however, are they more visible than in the towns where these wandering psychotics roam the streets, sometimes in a partial state of undress, begging cigarettes and engaging passersby in bewildering conversation. Frequently enough they deliver religious exhortations to any who may be within earshod; at other times they busy themselves picking up trash in public places or even directing traffic on main roads. There are still others who skulk in their homes far from the eyes of any but their most intimate relatives. Most of the victims are males, many of them in their 20s or 30s. A good number speak English well and many have spent a period of time away from their island, usually in order to attend high school or college. A Trust Territory Health Services count in 1980 (White 1982:94) showed about 240 persons diagnosed as suffering from some form of psychosis, but the true incidence may well have been over 300, when allowance is made for under-reporting.

The rates of mental illness, as tabulated from the Trust Territory case registry, vary widely from one part of Micronesia to another (Table 1). Schizophrenia, the most common form of psychosis throughout the islands, ranges from a high of nearly 13 per thousand adults in Yap, to 8.4 in Palau, to 4.9 in the atolls of the central Carolines, to 0.5 in the Marshalls. Even allowing for differences in the effectiveness of the mental health care programs and the thoroughness of reporting methods from one island group to another, there is still undeniable evidence that the incidence of mental illness is markedly higher in some places than in others. The Palau and Yap rates at the high end of the spectrum are comparable with those in industrialized nations, while the rate of 2.1 for Truk and that of 1.4 for Ponape are similar to those recorded in other Pacific island communities (Murphy 1978:5-9). On the other hand, an intensive survey of Polynesians from Nukuoro and Kapingamarangi, whether living on their home island or abroad, failed to turn up a single case of schizophrenia (Dale 1981).

The statistics gathered by the TT Mental Health Division have their weaknesses, as do most government statistics in Micronesia and elsewhere in the Pacific. The 60 cases of schizophrenia reported for Palau are notably fewer than the 73 cases of this illness reported by Kauders during the same time period (Hammond et al 1981). I have therefore compiled from the monthly mental health reports and patient lists covering the years 1978 to 1983, where these were available, my own rough table of the number of psychotics under treatment during these years (Table 2). Not all those listed were active patients in 1983, the end of this period, but there were no doubt also a good number who never came to the hospital for treatment and thus were never recorded in this tabulation. Since we did not have access to such mental health reports for Truk, we conducted an extensive three-month study of the Truk area with the help of two Xavier High School seniors to identify the persons labelled by their own community as severely mentally impaired. The figures in Table 2, then, give a rough idea of the number of psychotics in each island group together with their age-sex distribution, although the data were inadequate for identifying the different forms of mental illness.

The most striking fact revealed in Table 2 is the significantly higher number of males over females seeking treatment for serious mental illness in Micronesia. Palau and Ponape show more than a 2:1 ratio of male patients to female. Kauders' (1982) study indicates an even more lopsided ratio of nearly 4:1 among the schizophrenics studied in Palau. Mental health tabulations done by Dale (1981) support the heavy prevalence of male mental illness over female. Everywhere except in the Marshalls, according to TT figures, the male-female ratio varies from about 2:1 to 4:1. We can dismiss out of hand the possibility that this ratio merely reflects the greater willingness of males to seek treatment for mental illness, since the Truk data, derived from a community survey rather than from patient records, show an even higher ratio of male to female psychotics at 7:1. Could it then be that the female rate of serious mental illness is undercounted because female symptomatology is muted while that of males is exaggerated for cultural reasons? Although there is no doubt that the symptomatology can be affected by the socio-cultural environment, it is hard to believe that the symptoms in females can be so attenuated in a cognitive disorder like schizophrenia that they could pass unnoticed. If we discount these two explanations, we are left with the fact that the male rate of schizophrenia, and other forms of mental illness as well, is simply much higher than that of females. This is a point to which we will return later in the paper.

In the absence of reliable baseline data, we are unable to demonstrate that mental illness rates have increased in recent years, although this certainly seems to be the case. We will simply have to assume that this is so, just as we must assume that the rapid social change that has swept Micronesia in recent years has played a significant role in the increase of mental illness in the islands. All of this, I admit, makes for a rather loose argument. The rate of mental illness, which is assumed to have risen in recent years, is also assumed to be due in some way or other to social change. While this bit of conventional wisdom may be widely accepted in most circles, it is liable to be quite unconvincing for a scientific community that is trained to rely heavily on quantifiable data and the isolation of variables. Yet this simply underscores the limits of our knowledge on mental illness in Micronesia. It also necessitates a change in direction in our attempt to show the relationship between mental disorder and social change in the Pacific.

A Model of Social Disruption and Stress

It is a commonly held postulate that rapid modernization, along with the social dislocation and anomie that invariably accompany it, almost always results in some degree of personal disintegration. Levy and Kunitz (1971) and others have suggested that a middle term is required between social disintegration and personal disintegration; this middle term is stress. The authors are well aware of the danger of circular reasoning here — viz, our observation of certain forms of individual pathology lead us to conclude that the society must be disintegrating — and they propose establishing an independent measure of stress. Indeed, the past two or three decades have seen an enormous amount of research on stress, but the multiplicity of approaches and the resultant conceptual confusion has frustrated the attempts to achieve this goal. Yet the suppposition that continues to be shared by these authors and many others, a supposition that is rooted in the classical sociological theory of Merton and Durkheim, is that social change often produces stress, which will generally manifest itself in a higher incidence of breakdown of health, whether somatic or psychic or both.

The pathway leading from social disruption (whether due to modernization or other forms of change) to a state of personal stress is more complex than was formerly imagined, as newer models show (Marsalla and Snyder 1981). Stressors such as confusion over roles or conflict in expectations do not in themselves produce high stress states in the individual. The frequency, intensity and duration of the stressors, among other things, must be taken into account, not to mention the number of areas in life on which they impinge and the depth at which they touch the person. Also essential in the calculus of stress is the support system upon which the individual can call to withstand the negative effects of these stressors. Supports could include such different items as personal friendships, codes of belief, and level of personal achievement. Only as both stressors and support systems are considered and their interaction weighed can we determine the true stress state of the individual.

The stress state itself is not undifferentiated; it is not a simple general state of arousal that can manifest itself in any number of idiosyncratic ways, ranging from a case of the hives to paranoid schizophrenia. The stress state experienced by individuals differs according to degree of arousal, whether this is positive or negative, and whether it results in overload or underload on the system. These factors, which determine the quality of the stress state, may well also play a large part in determining the form in which the stress manifests itself.

In the interactional model that we are describing, the response of the individual to the stress state is adoptive. That is to say, the individual experiences changes in behavior and perhaps also in other levels of functioning that are patterned to accommodate and relieve the stress state. Sometimes these adaptations are so strikingly variant from usual patterns that they are judged abnormal, or even pathological. Whereas earlier models tended to view the pathologies resulting from stress states as simply a breakdown in the organism, the interactional model sees the quality of the stress state as a partial determinant of the pathological behavior that is exhibited as a response to this state.

This is by no means an entirely new idea. After all, expansions on classical social dislocation theory have for years maintained that the ways in which stress is displayed in persons will vary depending on genetic and cultural factors. Thus, the response of the individual to stress will frequently be patterned along cultural lines: through suicide in certain societies, for instance, rather than by running amok. In fact, Levy (1965) finds that acculturated communities among the Pueblo Indians show a suicide rate three times as high as that in more traditional communities. On the other hand, he finds no correlation between suicide rates and acculturation among the Navajo, although he does note a shift towards a higher incidence of suicide among the young. Howard (1979:125) notes that the violent response to stress that American Samoans sometimes exhibit may well have its roots in the physical punishment that is frequently administered during early child rearing. Conversely, societies that favor withdrawal as a strategy for coping with conflict may well tend to display anomic stress in similar ways. The familiar culture- bound syndromes of latah, windigo or koro are merely extreme examples of the ways in which cultural patterning can determine the manifestations of stress in the individual.

In addition, it has long been recognized that the particular genetic and environmental makeup of the individual can also greatly affect the way in which stress is displayed. Much attention today is being paid to the genetic factors that account for various stress-related health problems. Some social scientists, meanwhile, continue to seek to explain different forms of socio-pathology — among them homicide, assault and rape — in terms of the environmental conditioning of persons to these anti-social ways of exhibiting stress (Levy et al 1969). It seems to be readily agreed that the psycho-physical constitution, then, plays a large part in determining whether the stress will exhibit itself in the form of peptic ulcers, hypertension, or even schizophrenia.

The interactional model would readily allow for the importance of genetic factors as well as social patterning in mediating the response of the individual to the stress state. This model, however, would emphasize the dynamic interrelationship between all these elements, the support systems and stressors as well, in calculating what the adaptational response to stress will be.

In summary, then, acute social disruption can under certain conditions bring about a stress state, which can translate into any of a number of ills for the individuals affected. Which particular pathological response is made will depend on various factors, including the genetic constitution and the menu of response patterns that one's culture and background offers the individual.

Which of the many particular forms of social change that occur during a period of rapid modernization are generally the most potent stressors? Although the interactional model attempts to speak to this question, it does so in a complex fashion and yields answers that are invariably ambiguous. There are times that we can demand and obtain a good measure of precision in our analysis of social change without recourse to the quantification of stressors and stress states demanded by the interactional model. Relying on observation and field study, we can map specific changes that have occurred and trace their links to certain forms of personal disintegration (or adaptive responses, if you will) commonly witnessed in a society. This is what I would propose to do in the remainder of this presentation. We will examine the startlingly high Micronesian suicide rates in recent years, especially among young males, and identify a few of the most critical social changes that have been responsible for the increase in suicide today. Here I must beg your indulgence for once again taking up the topic of suicide, a subject that I have studied for the past eight years and one that is trotted out at conferences and in articles like this with what must be tiresome frequency. My purpose here is not to rehearse once more the findings of our long-standing study of suicide in Micronesia, but to offer a possible paradigm for the understanding of a similar increase in other pathologies, particularly psychosis, that are to be found in the area.

Suicide in Micronesia

Suicide has long been a feature of Micronesian cultures, as European visitors to the islands during the last century noted in their writings (Hezel 1984:193). Suicide is consistent with the Micronesian preferences for dealing with serious interpersonal problems by withdrawal rather than confrontation. Since the late 1960s, however, the number of suicides throughout Micronesia has risen sharply. Slightly more than 400 cases have been recorded for the Trust Territory (exclusive of the Northern Marianas) since that time (Rubinstein 1985). In more recent years the number of suicides throughout Micronesia has averaged 34 a year, with Truk alone responsible for 15 of them. Truk is the most populous of the island groups in the Trust Territory and it is the one in which we have done the most thorough research of this problem. Don Rubinstein, an anthropologist now affiliated with the East-West Center, has been engaged in fieldwork on suicide in Truk for the past three years. He and I have amassed a significant amount of data on the life histories of suicide victims since 1960 throughout Micronesia.

Without reviewing here all that has been written elsewhere on this problem, we might briefly consider some of the characteristics of Micronesian suicide. The victims are generally young males between the ages of 15 and 25, with the rate for this age-sex group in Truk approaching 200 per hundred thousand (Rubinstein 1985). In some of the other island groups the median age of the victims is somewhat older. Everywhere there is a strong preponderance of male suicides over female, with the ratio for the entire area running 10:1 in favor of males (Rubinstein 1983:658). The victims tend to be young men with a fairly traditional upbringing, although not usually from the outlying coral atolls, the communities least touched by change. Most of the victims have had no serious delinquency problems, and many of them are regarded as hardworking and dutiful young men; only a very small percentage (except in Palau) show any evidence of psychological abnormality. Their educational achievements and occupational status tend to be rather modest, although they are not notably clustered at the low end of the scale (Hezel 1985). Suicide victims in Micronesia do not constitute a group of incompetent or socially inept young people who could be classified as "losers."

Certain distinctive cultural patterns can be observed in Micronesian suicides (Hezel 1984). These patterns have wide application throughout the area, although they vary to some extent from one island group to another, particularly in Yap and Palau at the western extreme of Micronesia (Table 3). Suicide is not a general response to any sort of setback or serious disappointment. It is a culturally embedded response to particular situational difficulties. Virtually all suicides in Micronesia are brought on by conflicts, actual or anticipated, with one's own family or spouse. Conflicts with others outside the family, no matter how embarrassing or painful, will very seldom provoke suicide. They will be met with other responses, often involving more direct forms of rataliation. The three major patterns into which Micronesian suicides fall are anger suicides, shame suicides, and psychotic suicides (Hezel 1984). Table 3 gives a breakdown of all Micronesian suicides within the past 25 years according to island group by these three major patterns.

The first pattern, anger suicides, embraces the overwhelming majority of suicides in virtually every part of Micronesia. So predominant is this type, especially in eastern and central Micronesia, that upon hearing news of another suicide local people will invariably ask what made the victim angry. These suicides characteristically occur shortly after the victim is scolded, denied a request, or otherwise rebuffed by parents or an older sibling. In some island groups an altercation with a spouse also frequently triggers a suicide. Although there is undeniably a strong impulsive element to such suicides, a good number of case histories show evidence of more long-standing difficulties between the victim and his family or spouse. The introverted form of expressing anger in such situations, although sometimes regarded as pathological by American mental health personnel, can in fact be explained by strong cultural restrictions on the expression of anger towards parents, older siblings, and others in the family with a superior social status. It should be noted, however, that suicides prompted by anger at a spouse are more difficult to explain in these terms, for direct and sometimes violent displays of anger at spouses are commonplace occurrences everywhere in Micronesia. In the psycho- dynamics of this type of suicide, the victim seems to experience the refusal of a request or scolding as a rejection by someone in the family with a claim to both his love and respect. His emotional response is seldom blind rage; it is usually a milder and more plaintive form of anger tinged with melancholy and self- pity, sometimes accompanied by tears of frustration. His suicide, therefore, cannot be seen so much as a purely vindictive and defiant gesture as a plea for understanding and restoration to a place of regard in the eyes of his family, even after his death.

The shame suicides that comprise the second pattern are far less common than the first and represent the obverse side of the first. The victim, again typically a young man, takes his own life not because he has been offended by someone, but because of the shame or fear he feels at having done something offensive to the family. He may have struck or insulted an uncle during a temper tantrum or drinking spree, or he may have become aware that a misdeed of his had just come to public notice and would invariably bring shame on his family. The clearest example of this are the suicides that follow close on the heels of the discovery of an incestuous relationship in which the victim has been involved. In brief, the victim recognizes that he has done something that will bring disgrace upon his family and very likely disrupt his own normal relations with others in the family. His response to the shame that he feels is classic withdrawal in the form of suicide, perhaps in the hope that when his presence is removed criticism of his family will diminish and he will eventually be forgiven his misdeeds.

The third category of suicides are those committed by persons who are seriously mentally disturbed, many of them diagnosed as schizophrenics. Most of this handful of victims have undergone treatment at some time in their life for their mental illness. Although these suicides can be attributed to the victim's mental condition, it is noteworthy that in many cases victims perceived the deterioration of relationships with family members prior to their death. Sometimes the event that occasioned the suicide was very similar in nature to what might be found in the other two suicide patterns. As is evident in Table 3, this category accounts for a very small percentage of suicides everywhere except in Palau, where 29% of all suicides were committed by psychotics.

Suicide and the Changing Trukese Family

While our survey of the patterns of suicide may help us to appreciate the social context in which suicide occurs and the social meaning that it carries, it does not explain why suicide rates should have risen so greatly in the past 25 years. In order to answer this question satisfactorily, we must take a closer look at those elements in the social environment, particularly in the family, that have been affected by recent change and might have an adverse effect on young people today. Since this will require a closer examination of particular features of the culture and their alteration in the course of modernization, we will reduce our focus in this part of the presentation to the single culture area of Truk, undoubtedly the best studied of the island groups in Micronesia.

There are a number of features in the Trukese cultural environment that encourage suicide among young males today: the indifference to death that young men are expected to cultivate as an indication of bravery, the tendency of Trukese males to advertise and almost display pride in their sufferings, and the acceptance that suicide has gained as a serious option for the young (Hezel 1985). The obvious contagion effect of youth suicides on others in the community represents another feature in the social landscape that may have contributed to the increase of suicide in the past two decades. Likewise, there are certain value changes on the part of both youth and adults that make communication more difficult between them and increase the likelihood of more severe conflicts between parents and children. Among the better advertised are the tendency of young people today to appeal to their "rights," something unknown in the traditional society, and the increasing tendency of adults to judge their sons' performance in terms of the ability to provide a cash income rather than simply the usual assistance in food- production and family chores. All of these, and other factors, play some part in the rising rates of suicide in Truk, but they are in all probability only secondary causes. Suicide in Truk is so intimately related to the family that it is there that we must now turn in order to examine structural changes in the Trukese family that might explain the rising rates.

The basic Trukese kinship unit has traditionally been the matrilineage, and the English loanword faameni meant primarily the lineage group. At marriage a couple would ideally take up residence with the woman's lineage, and her husband, while retaining obligations to his own lineage mates, worked in a subservient role on behalf of his wife's kin group. At birth their children became members of the mother's lineage and were socialized more fully into the group as they grew up. All of the normal resources (food and other produce) prepared by the couple were distributed through the entire matrilineage group, usually by the wife's older brother or whoever of her relatives had been designated the lineage head. Meals were shared in common with other members of the lineage. Authority in family matters followed the same patterns as the distribution of resources. While the father was granted considerable authority over his younger children in day to day matters, they were still subject to the general supervision of older members of his wife's lineage. The father's brother-in-laws, for example, exercised the right to assign work tasks to his children. As the young men grew to adolescence, they were required to sleep outside of the house in which their sisters stayed, usually sleeping in the lineage gathering house, or uut, together with other male lineage mates. Increasingly during this period they were brought under the supervision of older lineage members, usually their maternal uncles, and participated in a wide range of lineage activities that reinforced their corporate sense of identity with their lineage. When the young man reached the age of marriage, he usually sought not only his father's permission but that of his mother's brothers as well.

This admittedly idealized picture of the way in which the traditional Trukese family worked has changed in some important respects during the past two or three decades. The catalyst for this change seems to have been, more than anything else, money and the goods that it buys. As a cash income has become available to the husband, the family structure has changed to accommodate a type of wealth that did not emanate from the land and was not subject to the traditional lineage distribution system. The money and store-bought goods that a husband has remain his possession; they are not turned over to the lineage authorities as traditional goods were, even though lineage members may make considerable claims for a share in these resources.

As the father retains ownership over an increasingly important share of the resources, the authority system will invariably be altered in such a way as to reflect this fact. In fact this has been the case. The father, with his control over a significant part of the means of livelihood, enjoys more autonomy from his wife's lineage and a greater degree of authority over his own wife and children. From a different perspective, however, he now finds himself burdened with responsibilities — principally involving the care of his children — that he once shared with several of his wife's lineage mates. While his own father had turned him over to the control of his uncles when he was young and so avoided the onerous task of having to supervise an adolescent boy singlehandedly, he is no longer able to rely on this same support in raising his own children. His task is made still more difficult if he has more surviving children than his own father had, something that is very probable, given the lower mortality rates and better medical attention today.

In response to the heavier demands that are made on him, demands that he is poorly prepared to face, the father often turns over considerable responsibility to his eldest son, or even to one of the younger ones if they have a cash income. While this is meant to free him from some of the demands of authority, the increased tendency to delegate authority has the potential for aggravating conflict between older and younger siblings, particularly if their traditional age-ranking is disrupted. Meanwhile, as the social network of the lineage weakens together with its economic and political functions, the lineage commensal unit (fanang) tends to disappear. Children will turn increasingly to peers as friends and playmates, lineage work activities will fall off, and young members will come to depend more and more on their nuclear family as their point of identity.

In brief, the father today has taken on a larger and rather novel role vis-a-vis his children. Whereas in the past his adolescent sons might have gone to their maternal uncles to make special requests, or at least have sought their help as intermediaries, today these uncles are reluctant to interfere in the affairs of the nuclear family. This can be critical when the young Trukese feels that he has been denied his rightful share of food or other kinds of gifts, for these continue to symbolize for Trukese personal acceptance and a secure place in the family group much as a hug or affectionate squeeze would for an American youth. Such symbols are perhaps even more important today than in the past as adolescent roles undergo change and lead to increased insecurity about the place these young people have in the family.

Overall, we can see that the changes in the distribution mechanism and authority in the family can easily have the effect of increasing the likelihood of tension within the family circle. Moreover, the same changes make it more difficult to resolve conflicts once they have arisen since the young man (or woman) does not have recourse to older lineage members to intervene. Thus, these changes in the structure of the family not only increase the probability of friction, but also greatly diminish the effectiveness of the "safety net" that once served to help offended young people who were experiencing troubles with their family. When we add to all this the fact that young men's traditional roles in the family are being undermined and hence their place in the family is no longer as secure as formerly, we can begin to understand why suicide may have increased in Truk within the past two decades.

We can assume that similar dislocations have occurred in the familial structures in other parts of Micronesia, even though these have not been delineated as fully as those in Truk. The same forces are at work everywhere to weaken the traditional family structures, which in most islands were founded on matrilineage groups. One of the most prominent mental health personnel in Palau commented on the prevalence of suicide and mental health problems among those who have been adopted and those living in single-parent families — both of these phenomena having become more common than formerly due to a complicated set of social changes that have occurred in recent years (Polloi 1984). Suicides throughout Micronesia are clearly related, in the great majority of cases, to family problems. If the suicide epidemic that the islands have seen since the late 1960s is attributable in large part to changes in family structures and roles, as appears to be the case, then Rubinstein may well be correct in suggesting that the wave of suicides is probably a single-generation phenomenon (Rubinstein 1985). As those young people raised in families in which the father holds primary authority themselves become parents, we can expect that they will handle their new roles more comfortably and the incidence of suicide will fall off sharply.

Social Dimensions of Mental Illness

The above description of social changes and their possible effect on suicide rates, while accounting for the presence of added stress on youth in Truk, has omitted any mention of the interplay between stress and personality factors in the victims. Our description has ended, in other words, just at the point at which psychiatrists and their colleagues usually begin. This omission is not intented to downplay the obvious importance that personality factors play in Micronesian suicides. The very incomplete data that we have collected on profiles of victims suggest at least two common personality syndromes: the quiet-but- explosive youth, and the spoiled child (Hezel 1985:120). The psychological autopsies of victims are still too thin to allow us to speak with much confidence on this point, but this may well represent a fruitful direction for future research on Micronesian suicide.

You have the right to ask at this point how the long discussion of suicide is related to mental illness, especially since in all but a handful of cases suicide victims did not show any mental pathology. To establish the relationship let us return to the stress model presented earlier. If the incidence of severe mental disorder among Micronesians has risen sharply in the past decade or two, as is believed to be the case, then this would constitute a social phenomenon like suicide and would suggest the possibility of a higher stress level caused by social disruption. In that event, the approach taken in our inquiry of suicide would illustrate both a line of inquiry and a methodology that might yield comparable results if applied to mental illness. Indeed, if the ultimate purpose of the study of mental illness is the cure and prevention of these disorders, a cultural analysis of the underlying social causes of increased stress could well prove more effective than a case-by-case psychological study.

There are some strong indications that mental illness, like suicide, is in part a product of social disruption brought about by recent change. As we have mentioned earlier, there is insufficient baseline data with which to compare present rates to demonstrate conclusively that the psychological morbidity rate is higher than in the past. Nonetheless, the fact that the 1978- 1980 schizophrenia rates recorded for Yap and Palau approach the rates of Western societies would seem to suggest that a considerable increase in incidence has already occurred in those places (Table 1). The rather low rates registered for other parts of Micronesia, rates comparable to those of rural island communities elsewhere in the Pacific, may indicate that only a slight, if any, increase in overall rates has yet taken place. Even in island groups such as Truk and Ponape, however, where rates of mental illness are still comparatively low, we find the startling predominance of male cases over female that has been noted earlier. All figures for Micronesian mental illness show the same heavy skewing towards males, even though the distribution varies somewhat from one island group to the next (Tables 1 and 2). There is evidence, however, that this is a recent phenomenon and that the sex ratio was roughly 1:1 as recently as fifteen years ago (Kauders et al 1982). The age distribution of mental cases favors younger men, particularly those in their 20s and 30s, although one cannot construct a real argument on this since schizophrenia, the most common form of psychosis, appears only after the middle teens and is often attenuated by middle age.

It is undoubtedly more than coincidence that the age-sex group at highest risk for mental illness in Micronesia, as revealed in our figures, is the same group that runs the highest risk of just about everything else: males from their late teens through early 30s. This is the same group that shows the highest incidence of alcohol-related problems, arrests and imprisonment, and suicide (Kenney 1976, Rubinstein 1980, Hezel 1981). It seems altogether safe to assume that the stress upon this group is considerably higher than on any other in virtually all Micronesian societies. This is not entirely the result of social change, it should be noted, since in age-ranked societies that are structured to assure women a security that is often denied men, it stands to reason that young males would be considerably less stable than others. Nonetheless, the role of young males everywhere in Micronesia has probably been subject to more change in the past generation than that of any other cohort of the population. This only makes them all the more likely targets for whatever pathologies are to be found in the islands.

If mental illness in Micronesia is to be studied in the future — and there is a good chance that it will be — the social factors that tend to put young males at an even higher risk than in the past should be examined. Just as the loosening of traditional family structures has been to a great extent responsible for the escalation of suicide rate among young men, similar changes may well underlie the increasing incidence of mental illness among the same group. Despite the time and effort that such social research requires, it may be the least costly and most effective means of prevention.


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Table 1: Mental Disorders Diagnosed inTrust Territory of the Pacific Islands, 1978-1980 avg.


  Schizophrenia Manic Depressive Paranoid state Anxiety state

Psychotic depression

























































































Note: Numbers in parenthesis represents the rate per thousand adults.
Source: White 1982:94.

Table 2: Total Severe Mental Patients Treated, 1978-1980


  Total Male Female 10s 20s 30s 40s 50s
Yap 73 41 32 3 20 19 11 17
  (100%) (56%) (44%) (5%) (27%) (27%) (16%) (25%)
Palau 128 88 40 6 37 42 9 23
  (100%) (69%) (31%) (5%) (32%) (36%) (8%) (20%)
Ponape 63 45 18 10 22 6 9 13
  (100%) (71%) (29%) (17%) (36%) (10%) (15%) (22%)
Truk 80 70 10 2 31 12 5 9
  (100%) (87%) (13%) (3%) (53%) (20%) (9%) (15%)

Source: Figures for Yap, Palau and Ponape are compiled from Mental Health reports for 1978-1980; figures for Truk are from a community survey in March 1985.

Table 3: Micronesian Suicide by Pattern, 1960-1984

  Anger     Shame Mental Unknown Total
Truk 90 83 7 15 6 25 136
  (81%) (75%) (6%) (13.5%) (5.5%)    
Ponape 37 28 9 4 2 0 43
  (86%) (65%) (21%) (9%) (5%)    
Kosrae 5 3 2 2 0 1 8
  (71%) (43%) (29%) (29%) (05)    
Marshalls 46 30 16 2 2 32 82
  (92%) (60%) (32%) (4%) (4%)    
Carolines 3 3 0 1 1 0 5
  (60%) (60%) (0%) (20%) (20%)    
Yap 15 13 2 4 2 15 36
  (71%) (62%) (9%) (19%) (9%)    
Palau 22 12 10 5 11 17 55
  (58%) (32%) (26%) (13%) (29%)    

Source: Author's case file on suicide, 1984.