Our Most Troubling Madness: Case Studies in Schizophrenia Across Cultures

T.M. Luhrmann and Jocelyn Marrow, editors

University of California Press, 2016, 304 pages

 

A key premise of this volume of ethnographic case studies is that schizophrenia, or the various conditions we label as schizophrenia and related psychoses, varies in crucial ways in terms of experience, prognosis and outcome in different sociocultural contexts. Tanya Luhrmann’s introduction to the volume, which features twelve articles presenting twelve individuals diagnosed with schizophrenia (including three cases presented by Luhrmann), casts doubt on the biomedical model of schizophrenia, or at least the strong biomedical model where an individual’s biology is the determining factor in the pathogenesis of schizophrenia. Support for this critique comes from within the fields of psychiatry, psychology and related disciplines, and not just from anthropology, the disciplinary home base of many of the authors in this compilation. This supports the volume’s efforts to speak to an audience beyond the contributors’ own disciplines and “serve as a positive catalyst for change” in how we treat psychosis, especially in European and North American settings (5).

The introduction also briefly traces the history of theories of schizophrenia in psychiatry and anthropology, including moments when the two fields overlapped as with Gregory Bateson’s theory that schizophrenia results from a “double bind” that develops in a person’s psyche from conflicting social cues. This theory, put forth by an anthropologist, had a significant place in psychiatrists’ understanding of pathogenesis until the rise of the medical model deflected the blame from families toward “random bad genetic luck” (16). Luhrmann points to recent literature that shows correlations between schizophrenic pathology and conditions related to race and class, and recounts the World Health Organization studies which demonstrate that people diagnosed with schizophrenia in developing countries show better outcomes, in terms of recovery and functioning, than people with the same diagnosis in developed countries.

The case studies, which come from India, the US, Ghana, the UK, Romania and Thailand, effectively show the sociocultural environment—in the form of social conditions and adverse events that occur in the lives of the afflicted—to be the driving factor in the development of psychopathology for the individuals profiled. All these individuals come from marginal economic circumstances or suffer some other form of adversity, such as racism. The two individuals from more socioeconomically stable situations are those that show the most stability and the best outcome: Meg, the Yale graduate from Neely Myers’ contribution and Sita, the middle class housewife living in urban South India profiled by Luhrmann and Padmavati. We do not see cases that would indicate that biogenetic pathology creates the problem, where biochemistry suddenly throws off an otherwise stable life. In fact, in Myers’ touching portrayal of Meg’s struggle to cope with her diagnosis and find housing, we learn that Meg’s mental breakdown ensues from her father’s suicide following her parents’ divorce. Of course, the possibility remains in these cases that these individuals may have been more affected by such adverse circumstances due to a biological vulnerability. Still, “schizophrenia is not a genetic lightning bolt” as Marrow and Luhrmann observe in the book’s conclusion. Rather it “is the story of the way that poverty, violence, and being on the wrong side of power drive us mad” (197).

Aside from the more general claim about the importance of sociocultural factors in the development of pathology, several cases show how living in a society where it is assumed that spirits exist and communicate with humans, hearing voices and experiencing other “delusions” do not seem to be as troublesome or as difficult to cope with. This is evident in the case of Charles from Ghana, Poi who lives in Thailand, and Sita, the housewife from Chennai, India, who is highly functional despite her delusions. These individuals have developed insights also promoted in some western settings by the Hearing Voices movement whose members try to improve the afflicted individual’s relations to his or her voices rather than try to eliminate the voices.

In the US examples in this book, voices and delusions are never interpreted as normal or positive—or as relatively “benign” to use Luhrmann and Padmavati’s label in discussing Sita’s case. Instead they are frightening and otherworldly and considered signs of pathology. John Hood, whom Luhrmann worked with in San Diego, said his delusions come from his “diseased brain.” A couple of observations he later added show he almost anticipates some of the anthropological insights offered in this volume. Luhrmann explains “he called himself a shaman throughout our conversation, and he was clear that if he had been born in India he would have been called a holy man” (31), revealing that he did not perceive his delusions merely as symptoms of a diseased brain. The possibility that a schizophrenic person in the West might be a shaman in another society has been raised and debated by anthropologists, and this point rings true to some degree when we consider the case of Sita. Sita and her father interpreted the voices she heard as “emanations and vibrations . . . of the divine stuff that exudes from God” (106). Sita is not a shaman, but she lives in a context where the idea of experiencing such emanations from the divine is not far-fetched. In fact, Sita’s father explains her experience as similar to the experience of darshan, the term for the visceral, sensory encounter with the divine Hindu worshippers seek at temples.

We also see in several of the contributions that religious or spiritual approaches to understanding illness/affliction conveys other benefits. Poi, a Thai woman who suffers psychotic episodes, saw her difficulties as due to spiritual problems, not as a mental illness, and after engaging in religious and spiritual healing, Julia Cassaniti, the ethnographer who tells her story, finds that her psychotic episodes became milder. In the case of a Romanian woman, Alexandra, whose faith is seen as a sign of her madness by her psychiatrist, we learn that an individual can have very different experiences with different religious institutions. Alexandra did not benefit from the views of the Romanian Orthodox church, which was once a primary source of care for the mentally ill but sees mental illness as due to moral failing. However, members of her evangelical Protestant church gave Alexandra invaluable social and psychological support and oriented her toward a positive and loving relation with God and Jesus.

In addition to his comment about shamanism and mental illness, John Hood from San Diego observed that “[i]t is the idea that you have a diseased brain that destroys you” and that “there is no greater stigma” than this (34). This anticipates why, as we see in several of the Indian cases in this volume, psychiatrists in India practice what Amy Sousa calls “diagnostic neutrality.” According to Sousa’s presentation of two sisters in India who are both diagnosed as schizophrenic—but do not both know this—psychiatrists in India usually do not reveal or fully disclose the implications of severe diagnoses to their patients and the patients’ family, focusing their discussions instead on the treatment regimen. Although this move appears paternalistic, it is seen as helping avoid distress that is unproductive, and it leads families to be more optimistic about the future for their ill family member. As anticipated in Hood’s comments, “diagnostic neutrality” also avoids some of the stigma and suggestive power that the idea of having a “damaged brain” seems to impose on the patients in western cases considered in this volume, such as those from the US and UK. Downplaying of diagnostic labels and severity of symptoms, in Sousa’s view, “may guard against exclusion and feelings of worthlessness, which are bad not only for recovery, but for human flourishing in general” (53).

Just as some researchers have suggested that the better outcomes for schizophrenia in developing countries is due to the role of the family in supporting their ill relatives, we see significant family involvement in the cases from India and Ghana, but minimal involvement of family in the US cases, such as in Luhrmann’s depiction of Zaney who struggles to cope with her psychotic symptoms on her own on the streets of Chicago and Myers’ depiction of Meg who lives in shelters and on the streets although her mother lives in the same town. Meg is eventually taken in by her mother when her diagnosis changes from depression to schizoaffective disorder, therefore entitling her to Social Security disability benefits which she is able to use to help pay her mother’s mortgage. Meanwhile, for Alexandra, her home in Romanian “was a place of constant threat and humiliation” (146) supporting studies that claim that (negative) expressed emotion toward the mentally ill in families in the West plays a role in exacerbating illness.

The role of the family however does not seamlessly follow a division between the West and the rest and is not uniformly positive in the Indian context. Sunita, who lives at a the Balaji temple in Rajasthan in northern India and whose experience is depicted in Anubha Sood’s contribution, is seemingly abandoned by family—although we are told that her father originally came to the temple with her and told her she could come home at any time. In addition, Marrow’s depiction of Priyanka shows how the role of the daughter-in-law in her husband’s home can be psychologically damaging due to adverse relations with in-laws. Through Priyanka’s experience, Marrow explains that families in India do not dwell on hallucinations or delusions when describing the problems of their schizophrenia-diagnosed relatives, but show more concern about inappropriate behavior, such as not doing housework or saying inappropriate or offensive things. In a telling moment, Marrow recalls how a hospital staff member was encouraged by seeing Priyanka kneading dough while her mother-in-law cut vegetables in the hospital shortly after Priyanka received ECT. While Priyanka’s relations to her husband and in-laws were problematic during the time Marrow knew her, Priyanka’s in-laws and family were constantly involved in trying to negotiate and improve Priyanka’s behavior and relationships.

While conclusions to edited volumes and anthropological monographs are often unsatisfying, typically claiming that the problem examined is “complex” and requires further study, the conclusion to this volume is quite substantial, following up on the promise made in the introduction to serve as a catalyst for improving the situation. Here Marrow and Luhrmann tie together insights from the various contributions and offer recommendations for improving mental healthcare. This includes “minimiz[ing] diagnosis talk” to avoid labeling, which leads patients to see themselves as broken and incompetent, encouraging family involvement and providing safe and secure housing. Also, given that the WHO studies described in the introduction show a better outcome for schizophrenia in developing country sites and that the nonwestern settings in this volume demonstrated certain advantages in their approaches to coping with psychopathology, Marrow and Luhrmann offer specific “Pragmatic Lessons” people who work with the mentally ill in the West could learn from the cases in this volume. This leads to an endorsement of specific programs and interventions, including the Housing First movement, the Hearing Voices Network and the Open Dialogue approach to working with individuals in conditions of distress. The cases from India, Africa and Thailand seem to attest that care as usual in the US—which Luhrmann argues make an ill person worse—ought to be reconsidered in favor of interventions that target the social situation and how illness experiences are understood by those who are suffering from psychotic symptoms. Hopefully, advocates and clinicians will seriously consider these suggested applications of anthropological insight.

 

Murphy Halliburton is associate professor in the Department of Anthropology at Queens College and the Graduate Center, City University of New York. He specializes in medical anthropology, psychological anthropology and science and technology studies, and has conducted research on treatments for mental illness and recovery from schizophrenia in India.