Review: Dissociative trance and spirit possession; challenges for cultures-in-

transition

Author 1: Dr Vishal Bhavsar MSc MRCPsych, Wellcome Clinical Fellow, Institute of

Psychiatry, 16 De Crespigny Park Road, Camberwell, London SE5 8AF, UK.
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Email: vishal.2.bhavsar@kcl.ac.uk. Telephone: 02078480415

Author 2: Dr Antonio Ventriglio MD PhD, University of Foggia, Foggia, Italy

Author 3: Professor Dinesh Bhugra PhD MRCPsych, Emeritus Professor of Mental

Health and Cultural Diversity, Health Services and Population Research, Institute of
Psychiatry, London, UK

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which
may lead to differences between this version and the Version of Record. Please cite this
article as doi: 10.1002/pcn.12425

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 Abstract

The cross-cultural validity of dissociative possession and trance disorders is a matter

of some debate, limiting research and meaningful interpretation of prevalence data.
Intimate to these concerns is the status of spirit possession categories studied in the
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social sciences, particularly anthropology. These two categories are
phenomenologically related and display similar epidemiological associations. In
India dissociative and conversion disorders are fairly common in clinical settings.
There is no doubt that there are true cultural variations in possession and trance
disorders. A new framework may enable clinicians to better understand possession
states and spirit possession.

Introduction

There is no doubt that some diagnoses are easy to understand across cultures,
whereas others need culturally relativist understanding of factors which might
influence presentation and help-seeking. Psychiatry’s vocabulary itself is a historical
product of separate, but interfacing, intellectual schools addressing phenomena with
different approaches and definitions, as a result of their position as experiential and
essentially subjective(1). Clinical work entails an interest in the experiences of our
individual, particular, patients, but also the application of disease constructs that are
meant to apply generally. In other words, the question is raised: how can a single set
of diagnostic definitions do justice to the nuanced experiences of people across the
globe? Furthermore, how can these categories be employed in cultures that are “in
transition”, moving from more traditional and collectivist/socio-centric orientations to
more egocentric and individualist cultures? Generally speaking, in more traditional
cultures, spirit possession and dissociative disorders play a role in communicating
distress to those close to the individual in their kinship or extended family. As this
begins to change, the impact may be reduced and conditions may even disappear.

The peculiar status of dissociative disorders and its origins

Conditions that involve dissociation offer important challenges. Strikingly,

dissociative disorders have resisted clear categorization within psychiatry’s
operationalizing paradigm. Some have even argued that the concept of dissociation

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 lacks any utility as a pathological concept(2). Uncertainty about the term may
originate from vague diagnostic descriptions that refer explicitly to the “psychogenic
origin” of the “loss of psychic integration”. Diagnostic systems have grappled with
dissociative trance and possession phenomena, not altogether successfully(3). The
location of dissociative trance as a dissociative disorder “not otherwise specified” in
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DSM-IV-TR reflected a stark ambiguity in how this form of psychopathology is
defined, and remains thus in DSM-5(4).

Our approach takes a series of steps. Firstly, we look at current diagnostic

descriptions of dissociative trance/possession disorders as they are found in ICD
and DSM-5. The suitability of dissociative trance/possession disorder as putatively
universal disease constructs (validity, cultural and otherwise), depends upon
diagnostic criteria on Western conceptions of selfhood, and the impact of socio-
political influences on disease categories. Only by understanding the processes, and
how they relate to the categories themselves, may we usefully elaborate not only the
variability observed in these disorders, but also the reasons for these variations. It is
important to incorporate social science definitions of spirit possession, in order to
clarify the relationship between a number of salient dimensions of these states,
including distress, cultural acceptability, instrumentality, and the definitions of
disorder. Both categories, one psychiatric and the other anthropological, refer to a
disturbance in agency, a recently reinvigorated philosophical concept.

For clinical psychiatry, trance and possession disorders are defined as states
involving “a temporary loss of the sense of personal identity and full awareness of
the surroundings” in ICD-10 (code F44.3), and are classed as a type of dissociative
disorder. In DSM-IV (TR), a call is made for further research into dissociative trance
disorders before formal inclusion in the dissociative disorders category. Dissociation
refers to the loss of the normal integrative function of the mind, affecting memory,
consciousness, and identity, which map onto different manifestations- amnesia,
trance, and multiple personality disorder(5). Individuals with “dissociative
phenomena” classically experience profound, time-limited disruptions of
consciousness, memory, spatial awareness, and personality. In those with
possession and trance, behaviour are often understood as akin to the replacement of
that person’s identity with another one- manifest in affected individuals speaking with
different dialects, vocal tones, behaving as if they were another personality, or

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 referring to false autobiographical details. Such a conceptualization is not without its
problems however. The first problem is that, like many psychiatric diagnoses,
dissociative trance and possession states display cross-cultural variation - trance
states display variability both in frequency and in attribution- seen as fabricated in
some cultures, pathological or socially accepted in others. Bourguignon(6) found
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spirit possession beliefs present in three quarters of the societies contained with the
ethnographic atlas(7). Islands in the Insular Pacific area apparently had the highest
incidence, with the lowest incidence found among Native Americans in North
America. A large difference was found between the American continent and the Old
World. That no attempts since that time have been made to compare rates indicates
the conceptual difficulties of this undertaking, and its relative neglect in
psychopathological circles. Furthermore, in order to undertake cross-cultural
comparison of any concept, its validity, or truth of its reality, must be taken as a
“given”. To undertake a comparison of the rates of dissociative trance and
possession states between cultures, one must accept that there “really” is something
out there called dissociative trance/possession disorder that may submit to
comparison. Well-argued critiques of the cultural validity and applicability of
dissociative trance /possession (see the previous references, also Alexander(8)) are
counter-balanced by the work of those who have chosen to investigate variation in
dissociative trance/possession disorders between cultures, therein taking as read the
cross-cultural validity of the diagnosis. The extent of this latter work is limited, due to
the small number of reported cases, but During et al suggest that dissociative trance
conditions are probably under-diagnosed in Western countries (9). Although there
are a number of likely explanations, one possibility is that this variation might reflect
culturally influenced diagnostic bias among clinicians. On the basis of a number of
studies, such as those of Wijesinghe(10), Kua(11), and Trangkasombat(12), it seems
that the category is more interesting and deemed more worthy of investigation than
Asian observers; we may also speculate that such states are more frequently
reported in Asia, although John and Das(13) suggest that diagnoses of dissociative
disorder are rarely made in Indian clinical settings; possession did not occur at all in
their two year sample of psychiatric inpatients.

There has been ensuing disagreement about the correct clinical approach to its
aetiology and the relationship with other dissociative disorders, such as multiple

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 personality disorder (MPD, Fahy(14)). Difficulties of this area of nosographic work
originate in the absence of socio-cultural considerations to these definitions, and the
exclusion of non-psychiatric but phenomenologically similar states from our thinking
about dissociative trance.
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Finally, there is the uncertainty regarding the extent to which this diagnostic category
is responsible for the unnecessary pathologisation of normative experiences. The
relationship between experiences diagnosed as dissociative trance/possession and
those which are studied by anthropologist as “spirit possession”, is not clear. In the
social sciences, across the categories of human experience regarded to be
“spiritual”, it is possession, the “seizure of the spirit” by another, which has been the
most arresting for observers. In this regard, dissociative trance states and
possession states have, together, been of interest to both clinicians and
anthropologists interested in the problem of making comparisons of mental illness
between cultures.

It is in our view this latter problem, the relationship between possession states in
psychiatry and spirit possession in anthropological literature which must be resolved
in order to improve the current conceptualization of dissociative trance/possession.
The location of dissociative trance states and spirit possession within a single
explanatory framework may allow for more meaningful comparative investigation of
dissociation and related experiences in culturally different populations.

Cultural validity

There seems to be a consensus that dissociative trance and possession disorder are
a problematic category for psychiatry(3) (15). The problem of cross-cultural validity
has been an ongoing challenge for the dissociative disorders in general, and
possession and trance disorders in particular(3). There is recognition that cultural
factors influence these states, through the cultural shaping of the belief in the
bounded individual self, and dependence on other cultural assumptions. For
example, Castillo(16) points out that the normative-ness of meditative behaviours in
India engenders a lower prevalence of pathological dissociative experiences there.
Whether with culture changing the rates of presentation increase will be worth
observing.

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 It has been argued that Western psychiatry itself is individualised, biologised, and
reductive in its theoretical and methodological approach(17) (18) (19). Such an
approach has often led to diagnostic categories that underplay the role of social
context. This is reflected in the struggle to integrate dissociative trance and
possession disorders into an individualised diagnostic structure. This struggle is
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made more acute by the evidence that mental health professionals in countries
outside the West frequently report spiritual attributions mental illnesses in
general(20). Therefore, states of altered or replaced identity both within and beyond
the clinical interaction must be studied alongside the culturally influenced parameters
of distress, impairment, and thresholds for help-seeking behaviour, in order to
broach questions of cultural variation, and diagnostic validity. Toward this end, we
now discuss the concept of the possession state as it has been dealt with by the
social sciences.

Possession in the social sciences

A commonly-held, broad definition of a possession state in the social sciences is

where an individual’s experience of being taken over or inhabited by an external
force, which then controls or changes that individual’s actions and identity(21). In the
anthropological literature, spirit possession is a wide category referring to a culturally
patterned and accepted mode of being (usually in specific socio-cultural contexts, as
we shall see below). Accounts of spirit possession in the anthropological literature,
such as those of Lewis(22), deal with individual will as fundamentally dyadic in its
relationship with societal structure- that is, it is impossible to understand the
behaviour of the individual with possession without understanding his or her social
context. Furthermore, it is clear that spirit possessions and dissociative trance /
possession disorders share a number of phenomenological and behavioural
characteristics, and may be usefully distinguished along dimensions of
deliberateness, distress, impairment, help-seeking behaviour and idiom.

The relationship between possession states and dissociative trance is a matter of

some debate among clinicians and researchers alike. The universalist position
argues that, by virtue of the phenomenological commonality, the two concepts are
homologous(16). Relativists argue that possession and dissociative
trance/possession must be understood within their respective socio-cultural context,

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 on their own terms(23). Kirmayer(24) notes that diagnostic definitions in psychiatry
tend to reflect the political-economic situation of the disciplinary contexts from which
they arise. Perhaps, stronger emphasis should be placed on diagnostic descriptions
as constructs to foster research and attention on salient issues rather than as
permanent structures(25).
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The development of testable theories of dissociative states must involve an
appreciation of the specific disturbances of attention, arousal, and suggestion that
mark out these experiences, together with their relationship to the socially defined
role of the individual and wider narrative context(2).

Spirit possessions are often interpreted as explicitly and deliberately induced by the
participants themselves, indicating the spirit possessions are not always related to
illness(26). The conceptualisation of possession states as the enactments of
individual or collective strategies represents a key trend in early anthropological
writing(23). Such delineations are not clear; both spirit possessions and dissociative
trance may be interpreted as deliberate. Furthermore, it is unclear whether there can
be a single operational definition for a disorder that is so dependent on local
conceptions of “normative” behaviour.

Questions of cultural acceptability of beliefs are inevitably intertwined with distress;

Lynn(27) suggests a dimensional model of dissociative disorders from normative and
non-distressing to abnormal and distressing as a more useful framework, which
demonstrates the multiple categories involved. Such frameworks are useful, because
they accommodate situations where the relationship between distress and social
acceptability may be under on-going shift; Vecchiato(28) argues that the
development of independent religious movements in Southern Ethiopia have led to
changing conceptions of possession states, indicating that earlier instrumental
models of possession were inadequate to explain the more health-oriented
experiences of afflicted individuals.

Instrumental understandings of dissociative trance disorders, i.e. those that posit that
such states are the expression of hidden social strategies aimed at rectifying,
equalising or otherwise discharging the tensions, processes, and dilemmas of the
group, are superseded in some cases by the reification of these states as illness,
which forms a crucial part of their phenomenology. As such, then, this is even more

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 argument against the development of models that separate “anthropological” and
“psychiatric” interruptions of identity. Seligman(29) points out that spirit possession
has usually been characterised as non-pathological, and hence outside the purview
of the clinical gaze. However, possession states often involve sickness and
competing models of aetiology(30), and Boddy(23) counters this by asserting the
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importance of local possession categories as cultured medical or therapeutic
discourses.

Venkataramaiah(31) in an epidemiological study of the possession syndrome in

West Karnataka in India, found that 91% of sufferers found their spirits troublesome.
These authors asserted that possession was a “socio-culturally induced
phenomenon”, specifically one associated with a belief in possession as a helpful
way of expressing distress. Ng and Chan(32)observed very high rates of
psychosocial stressors in Singaporeans with dissociative trance disorder, and
differences in the type of stressors described between trance and depressed
patients- 38% of trance patients described conflicts over religious and cultural issues
as stressors, compared to 5% of depressed patients. The authors point out the
prominence of spirit possession with Singaporean culture, implying a close
relationship between the two groups of phenomena. From a phenomenological
standpoint, we can suggest that these experiences reflect the displacement or
disruption in individual agency.

The concept of agency

Dissociative trance/possession disorder presents a number of difficulties for

clinicians working with culturally diverse populations. We feel that all these difficulties
may be broached by adopting an approach which relates possession /trance states
and possession states to the concept of agency, or the “ability of an individual to
act”. Agency refers to feeling a sense of being able to do something in the world that
is your own. It may be regarded as the perceived ownership of action (thought,
behaviour, emotion, communication), that a person experiences. Thus, we may use
the term possession as a process wherein an individual experiences a displacement
of their “own agency” by that of another, is normally an unpleasant/unwanted
phenomenon, and is often manifest in stark changes in behaviour, impairment in
functioning, and distress.

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 There has been a resurgence of interest in the concept of agency in recent years,
across a number of disciplines, from studies taking phenomenological and
anthropological perspectives(33) (34) to investigations of its neural and
psychological basis(35) (36). In particular, the structure and representational content
of first person experience has been a matter of some philosophical debate(37). For
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Throop(33) agency involves three experiential components –it is goal-directed,
effortful and owned by the person. There is cultural variation in the descriptive
phenomenology of first person agency; Groark(34) describes multiple categories of
individual volition in the Tzotzil Maya of Chiapas, Mexico. Interviews with Maya offer
up multiple modalities of wilful action, which include, but are not limited to, the
“waking self of everyday social life”. The experience of first person agency in
everyday life may therefore be thought of as involving social and cultural influences.
Against this background then, dissociative/ trance states and spirit possession may
be regarded as socio-culturally shaped disruptions in agency. But how can we
properly understand the relationship between an individual’s experience of agency
and their social world?

Agency and the social world

The tension between individual agency and social context is an on-going argument
within sociological circles(38). In the anthropological literature, the reification of spirit
possession as subject for enquiry owes a great deal to Lewis’ “Ecstatic Religion”(22),
which lays out a heuristic configuration for the explanation of possession states.
Lewis, drawing on religious and contemporary theory, formulates an influential
”social-structural” model of possession using a distinction between central and
peripheral possession- which fit within the prevailing moral systems or marginal
settings respectively. In this way, spirit possession and trance states bring about
benefits for the affected individuals while at the same time maintaining social
structure and working within shared local meanings. The explication of this model by
later writers involved the observation that such systems served to maintain the
“moral order”.

The moral alignment of this model was refined by social scientists who saw the
central-peripheral distinction as also involving distinctions of power and identity(39).
Bourguignon(6, 40) observed a relationship between rates of both trance and spirit

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 possession and concluded that spirit possession might even be regarded as an
expression of the social structure itself. Greenbaum(41) noted that the development
of possession states could relate to the level of societal rigidity- thus, possession
states offer a channel for the expression of emotions and conflicts that would not
otherwise be allowed by the organized social structure.
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Interpretive models

Individuals who were deprived of status could utilise culturally sanctioned behaviour,
including trance/possession to achieve redress(42). Kapferer(43) suggested
demonic possessions among Sri Lankan working class people as communicative of
the otherwise hidden dynamics of class conflict. Obeyesekere(44) suggests that
spirit possession may be interpreted along religious and psychodynamic lines at
once- the symbol of possession(locks of matted hair) are symbols that operate in the
person and social world in parallel.

Across these models, the idea of “instrumentality” is key- possession states “do
something” - exert a strategic influence in the group. Clearly then, the attribution,
phenomenology and healing of spirit possessions are shaped by social context. We
now turn to evidence that the same applies to dissociative trance.

Within psychiatry, the notion that spirit possession could be understood as the
enactment of a hidden strategy, or a goal-directed action, has long history(45, 46).
Possession states have been linked to social change, as well as to the structure of
societies themselves. Igreja et al(47) describe possession states as a focal point for
societal adjustment to the post conflict state in post-civil war Mozambique. Amok, a”
culture-bound syndrome” where an individual commits, or threatens to commit,
indiscriminate acts of violence, exert retributive and negotiatory functions within the
group(21). Skultans(48) described trance in the female care-givers of mentally ill
individuals attending a healing temple in Maharashtra, India. In this study, sufferers
explained trance as a way of channelling suffering away from the afflicted party.
Again states of altered agency appear to fulfil functions located both within the family
and the wider society.

Taking this evidence together, the absolute distinctions between spirit possessions
and dissociative trance/possession states become untenable. Dissociative trance

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 and possession disorders must be positioned within the same conceptual framework
if they are to be usefully made sense of. Agency and structure are in themselves
dichotomies that indicate a deep alignment with duality.

Developing a culturally sensitive framework of agency

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Agency is the human experience of possession of an action or mental state and it
seems that agency exists as a universal, present among all societies of human
beings, and yet it also must be located within an interpersonal context, a relationship
we will now describe. Thus agency as a phenomenological “propensity”, or skill,
even. However, agency must develop within a wider context. Luciano(49) points out
that the development of agency must negotiate a wider system of culturally
accepted conceptions of selfhood.

The idea of a dimension/continuum between individualist societies and collectivist

ones, principally developed through the work of Dumont(50)and Mauss(51),
assumes that it penetrates the real experience of being a person in these difference
cultural environments. In this way the cultural is linked with the cognitive. As cultures
position along this dimension serves as the context to a much narrower and
universal human experiential process, the development of a person’s agency.
Luciano(49) describes the way in which Indian family members develop as
autonomous beings, cognisant of their ability to act for themselves.

In keeping with theoretical discussions on other disorders, it appears that discourse

on Indian populations is more rooted in family-based understandings, and it may be
hypothesised that in more collectivist societies, where the family is the main locus
rather than the individual, contain qualitatively different sorts of
possession/dissociative identity than individualist societies(52).

While it seems evident that all people possess some notion of themselves as
independent persons, or individuals, with possession over their actions and mental
states, this should not be regarded as a commitment to an “individualized Western
concept of the self”. The idea that the concept of the individual may represent a
strong thread in Western anthropology, through the writings of Mauss(51) and
Dumont(50), hints at the notion of agency as something “cultured”. For Dumont, in
Western cultures paramount value lies in the individual, while for non-Western

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 cultures, value lies in the society as a whole. This view has been echoed in the
literature by Shweder and Bourne(53), Marsella(54), Kirkpatrick and White(55),
Sampson(56) and Markus and Kitayama(57), albeit employing differing concepts of
“selfhood” in these(58). In the interview data of Shweder and Bourne, Indian
individuals are more commonly described in terms of their relationships to others (a
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person is “kind to his mother”), while Americans are described in isolation (a person
“is good”). However, while the experience of agency in other cultures has not been
subject to direct ethnographic scrutiny, we may make some general comments
based on previous anthropological work. Firstly, many observers, including Mauss,
have emphasises the importance of interdependence for explanation and location of
the Hindu “self”. In particular, we may consider the Indian family as an example.
Families play a dominant role in the structuring and regulation of behaviour, and
interdependent family relationships are frequently represented in public imagery,
media, folk music, and research.

The idea of a “cultured self” has not gone unchallenged. Insofar as pretty much
anything may be studied comparatively across cultures, it has been argued that
selfhood is a term too difficult to define for observations of cultural variance to have
much use. From a methodological point of view, the concept of the “self” offers too
much confusion when interviewing participants- when they speak about “self” do they
convey their experience of being a self, a personal representation of themselves, or
a culturally acceptable account of themselves, and to what extent are these
connected? Another problem is the empathic barrier; for Western observers a non-
western self-configuration is intimately difficult to understand. A key, or core, deficit
in these explanations is that it is not entirely clear what it is the term “self” describes,
or what function it serves in these models. Considerable variability in selfhood
orientation exists within cultures – for example among Theravada Buddhists in
Nepal, different doctrines of the individual appear to exist. Such dimensional models
which seek to describe whole cultures in terms of how collectivist they are enshrine
the concept of cultures as monolithic bounded containers of cultural material, rather
than dynamic and permeable systems. What “individualism-collectivism” describes is
the collective cultural representation of selfhood, rather than a person’s experience
of their own agency, or possession of action in the world. Morris(59) asserts and
describes differences in Eastern and Western self, noting that the Eastern self is

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 more socio-centric ; individual identity is based on kinship and family rather than
ego-centric or individualistic self which is the Western self and focuses on oneself
and perhaps immediate nuclear family. Similar distinctions have also been drawn by
Hofstede (60). Morris indicates that individualistic concerns in the West are
suggestive of an inflated concern for the self, which, in the extreme, can give rise to
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a sense that there is loss of meaning in contemporary life. The ‘self’ structure of
Western culture has thus been widely described as individuated, detached, separate
and self-sufficient, raising questions about the role of the self in psychopathology
and why and how presentations differ across cultures.

An individual’s agency is intimately related to societal expectations and must

constrain the development of agency over time. This represents a development to
our thinking about dissociative trance and possession states- we can conceptualise
these states as emanating from a destabilisation of agency as it evolves in its socio-
cultural context, a context principally composed of local cultural conceptions of
selfhood.

Developmental agency

This hypothesis is borne out by data on prevalence of spirit possessions and

dissociative disorders in epidemiological studies, where rates appear to be higher
where societies are undergoing rapid change or shifts in cultural makeup, or
communitarian conflict(47). Thus, cultural beliefs about the self serve as a milieu for
the evolution of a person’s agency over time, and conflict between these can
engender disruptions or destabilisations of a person’s agency.

While agency may be characterised as a universal component of usual human

experience, it is at the same time located within a discrete interpersonal context,
which in turn shapes how agency is experienced. Agency may be conceptualised as
something that is realised over time, through cultured processes of socialization
within a specific cultural setting, closely linked to the development of a collectivistic,
interdependent worldview. Rather, individual agency must “negotiate” with an
interdependent social structure through the development of the personality. So, for
any given type of action, the experience of that person’s possession of that action
will be shaped through situational and contextual means. The idea, then, of agency
as a negotiated product of a developing individual phenomenological sense, growing

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 and negotiating itself through a particular configuration of social world, offers
important insights into states where the sense of possession over one’s actions is
lost.

Culture-in-transition
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It is therefore likely that cultures–in-transition may show differential rates and reflect
the destabilisation of individual experiences of agency in the context of shifting
cultural conceptions of selfhood, in the form of rapidly shifting cultural configurations.
In this respect then, modernity and globalization offers up increasing challenges.
Clearly, the concept of cultures as internally consistent containers of symbols or
structures, with independence from other similarly integrated and unitary cultures, is
of limited explanatory value in today’s globalized world. The emergence of
“transnational” studies indicates that cultural dynamics have become much more
interesting than that; not only have cultures become much more permeable over a
short space of time, the temporal and spatial scope of this permeability has
expanded exponentially. Importantly, globalization and resulting urbanisation
changes not only the permeability, inter-penetrance and scope of cultural boundaries
but also the concerns of cultural observers; in a sense, the attempt to bring
dissociative trance/possession and spirit possession together is an endeavour to
make this category “aware” of a complex, globalized culture. Incorporating social and
cultural understandings into a framework for understanding disorders of agency will
be crucial in treating these disorders in an increasingly interconnected world.

As mentioned above, Western psychiatry is seen as the product of an enduringly

individualised theoretical framework(17) (21). Psychiatric disorders by and large are
located in the individual mind-brain, rather than across groups, such as families or
communities.

Beyond conceptual issues, the relationship between dissociative possession and

trance disorders and spirit possession is important in term of the provision of mental
health care outside the West(61) - challenges of resulting unmet need and burden of
distress need to be addressed where views of what constitutes illness compete -
who needs treatment, and where is it best provided? A key argument across
psychiatry and anthropology is how these experiences may represent both

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 generalizable disordered states and also locally patterned idioms open to more
contextualized understandings(3) (62) (21).

Conclusions

The literature on dissociative trance and possession states bears out a deep but
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unnecessary split. By situating both categories of phenomena as disruptions of
agency, we may move towards a common formulation of these experiences that is
oriented within, and shaped by, socio-cultural context, and move beyond some of the
methodological difficulties associated with this arena of psychopathology. The
limitations to current diagnostic definitions of possession and trance states relate
both to psychiatry’s underlying theoretical viewpoint and to historical development of
Western psychiatry. Likewise, the distinction between psychiatric definitions and the
anthropological concept of spirit possession lie in the historical context of both
disciplines, and their respective interests. Among social scientists, possession states
invite, but arguably resist categorisation along multiple lines, including
sought/unsought, real/fabricated, pathological/normative, and distressing/non-
distressing.

We suggest that the development of theoretical models which incorporate socio-

cultural context into descriptions of dissociative trance, a particular type of
dissociative state, by studying dissociative trance states alongside other categories
of experience must involve agency. The paucity of dissociative trance states in non-
Western cultural contexts must be re-assessed in studies that assess the frequency
of dissociative categories alongside indigenous ones; in this way both dissociative
trance and possession states may be understood within a common framework.
Characteristics such as level of distress, degree of “sought”-ness, and cultural
acceptability must be integrated into psychiatry’s understanding of these experiences
if cultural variation is to be understood. Uncertainty over this particular psychiatric
category will continue for as long as diagnostic definitions continue to ignore societal
context.

Disclosure Statement

The authors have no conflicts of interest to declare.

Author Contributions

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 The review was conceived and designed by VB. Analysis of included studies was
done by VB and DB. The manuscript was drafted by AV and VB.

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