Unfortunately, this analysis does not help us very much. In later chapters, we will see that processes similar to those described by Sperber can be seen at work in the beliefs of many Western psychiatric patients. Some delusions, like West African beliefs about the mind, seem to be patients’ rational attempts to explain their experiences. Others, like the Bororo males’ identification with red macaws, may be metaphors. (As I write this passage, I am reminded of a young black man I once saw who had been raised by white adoptive parents and
who claimed that he was an abandoned visitor from another planet who would one day be rescued by a flying saucer.) Others do not seem to be statements of fact at all, as witnessed by patients’ failure to behave accordingly (for example, the patient who asserts that his food is poisoned but who can easily be encouraged to eat it).40
The standard psychiatric response to this conundrum is to rule the beliefs of other cultures non-delusional by definition. For example, the definition of delusions given in DSM-IV notes that ‘The belief is not one ordinarily accepted by other members of the person’s culture or subculture.’41 Others, for example Roland Littlewood and Maurice Lipsedge, have argued that there is a spectrum of beliefs running from widely held religious convictions, through the beliefs of obscure sects, to individual psychotic delusions.42 Both of these moves seem to make the answer to the question, ‘Is this a delusion?’ a matter of consensus. (If enough people locally share the belief it is not a delusion.) Although they have been proposed in order to allow psychiatrists to distinguish between ‘true’ delusions and unusual but culturally determined beliefs, they seem to let cultural relativism in by the back door.
The evidence on cultural variations in the acceptability of hallucinations is more clear-cut. Anthropologist Erika Bourguignon found that hallucinations played a role in the ritual practices of 62 per cent of the 488 societies for which she was able to obtain adequate data. For example, Mohawk Indian hunters are forbidden to eat their own game, and are visited by spirits if they do so.43 American psychologist Ihsan Al-Issa has suggested that cross-cultural differences in hallucinatory experiences reflect culturally embedded beliefs about the boundaries between imagination and reality, so that experiences that would be regarded as imaginary in one culture are regarded as real in another.44
Failure to appreciate the cultural context may prevent clinicians from responding appropriately to the distress experienced by their patients. An example of this kind of mistake has been reported by Scott McDonald and Chester Oden, two clinical psychologists practising in Hawaii, who have described their misdirected efforts to help two men who suffered from hallucinations of dead relatives. They later discovered that this kind of experience, known as aumakua, is quite common among Hawaiians of Polynesian ancestry, and usually occurs when someone has violated a cultural taboo. Instructing their patients
to make amends for their transgressions was sufficient to bring the hallucinations to an end.45
Some social scientists have suggested that experiences that would be regarded as psychotic in the West are afforded a normal status in the activities of traditional healers and shamans (holy people who experience altered states of consciousness).46 For example, Robert Edgerton has discussed the work of Abedi, in Tanzania:47
Abedi’s specialization in mental illness began during his apprenticeship when he first hallucinated (‘hearing voices of people I could not see’) and ran in terror to hide in the bush. He was discovered and returned to his father’s care, but lay (‘completely out of my senses’) for two weeks before being cured. The cause was diagnosed as witchcraft and since the cure, Abedi has never been sick again. The experience initiated Abedi’s interest in mental illness, and the subsequent mental disorders of his sister and his wife reinforced it. At different times, both women became violently psychotic, but Abedi cured them both. These two cures not only heightened Abedi’s interest in psychiatric phenomena, but they led to his reputation as a skillful psychiatrist.
Similarly, of ten Ugandan traditional healers interviewed in depth by Joanna Teuton as part of her Ph.D. research, two had clearly been inspired to take up their vocations by psychotic episodes. For example, a woman from the Luganda tribe said that she had become a healer after a difficult period during which she had heard voices and entertained paranoid beliefs, experiences that she described with great lucidity.
Nor is this phenomenon restricted to the developing world. Historical figures from the West who might justifiably be regarded as shamans because their claims to religious leadership were associated with psychotic experiences include Francis of Assisi, Joan of Arc, John Bunyan and Ann Lee (the founder of the Shaker Movement in the United States), all of whom experienced hallucinations. Even today, some citizens from the developed world are able to pursue shamanistic careers on the basis of such experiences, as the following case-vignette from Holland demonstrates:
A 42-year-old divorcee, mother of two children, who has a private practice as a psychic healer, has heard voices for as long as she can remember. She hears the voices via her ears. The voices are located both inside and outside her head. One voice began in childhood and is still present, but she also
hears other voices. The initial voice talks to her in the second person. She communicates with this voice, consulting it for the benefit of her clients. Her voices also talk amongst themselves. Although her voices are not actual voices she has heard in daily life, she is not afraid of them and does not feel restricted by them. Rather, she feels that they are protective: they give her advice, comfort and care. She considers her voices as protective ghosts. She also regularly experiences visual, tactile, and olfactory hallucinations.48
Anthropologists have often rejected the suggestion that many healers and shamans are psychotic, perhaps because this idea seems to devalue the contribution that they make to their own cultures.49 They have argued that the healer’s role requires a degree of organization that would be difficult to achieve by someone suffering from a full-blown psychotic illness, that most societies clearly distinguish between shamanistic states and behaviour believed to be evidence of madness, and that the experiences of shamans and Western schizophrenia patients are not so similar on close examination.
American anthropologist Jane Murphy of Harvard University studied local psychiatric concepts in a village of Yupik-speaking Eskimos on an island in the Bering Sea, and among Yorubas living in rural Nigeria.50 The languages of both cultures included words for madness. Among the Eskimos, nuthkavihak refers to a sickness of the soul or spirit in which sufferers talk to themselves, and scream at people who do not exist. Among the Yoruba, were refers to a condition involving hearing voices, laughing at nothing in particular, picking up leaves for no purpose, throwing off clothes and defecating in public.
Another American anthropologist, Richard Noll, compared reports of altered states of consciousness, mainly collected from Native American shamans, with the description of schizophrenia in DSM-III.51 He argued that, ‘By far the most important distinction between shamanic states and schizophrenia is that the shaman voluntarily enters and leaves his altered states of consciousness while the schizophrenic is the helpless victim of his.’ Moreover, according to Noll:
The phenomenology of schizophrenia contained in DSM-III… indicates clearly that the shamanic state of consciousness… cannot be mistaken for schizophrenic states if the current diagnostic criteria of the latter are assumed to be reliable and the experiential descriptions of the former are accurate.
But, of course, as we have seen in previous chapters, the current diagnostic criteria for schizophrenia are not reliable, and give a biased picture of psychosis. As the majority of people in Western societies who experience psychotic states never come into contact with psychiatric services, many must be capable of the degree of organization necessary to be a healer.
Perhaps the dispute about the relationship between psychosis and shamanism approaches our question about the boundaries of madness in the wrong way. Rather than ask whet
her psychotic experiences can be valued in some circumstances, we should step backwards and ask why certain types of behaviour and experience are singled out as evidence of insanity. As Horacio Fabrega points out, human behavioural breakdowns are nearly always recognized when individuals are unable to participate and function in social life.52 The apparent consensus between different cultures about madness therefore concerns behaviours and experiences that are associated with an inability to cope with the demands of living. There seems to be an equal lack of consensus about how to describe similar behaviours and experiences when the individual is nonetheless able to lead a fruitful life and get along with others. According to the Kraepelinian paradigm embraced by psychiatrists in the developed world, such people are nonetheless psychotic or schizophrenic. Other cultures, in contrast, allow such people to find valued roles that prevent them from being dismissed as crazy.
Moving the boundaries of madness
Fortunately, we do not have to rely on cross-cultural studies for evidence that the boundaries of madness are culturally determined. Disputes about the positioning of these boundaries have been fought between Western psychiatrists since the earliest days of their profession.
Not many people today would take seriously a suggestion by Dr Samuel Cartwright, published in the New Orleans Medical and Surgical Journal of 1851, that dreapetomania (an uncontrollable urge to run away observed in American Negro slaves) should be regarded as a medical disorder.53 More recently, the psychological problems of combat veterans have been variously described as evidence of low
moral fibre, nostalgia, shell-shock, battle fatigue, brainwashing or post-traumatic stress disorder (the currently favoured diagnosis) in response to changing attitudes towards warfare.54 Psychiatric theories about minority sexual preferences have shifted even more dramatically. Homosexuality was listed as a psychiatric disorder in DSM-II but was removed from the diagnostic manual following a referendum of members of the American Psychiatric Association in 1974.55 Although it might be thought that the psychoses involve such a clear break from reality, and such obvious disability, that they would be immune from similar attempts to redraw the boundaries of psychiatric disorder, a recent experiment in Holland has shown that this is not the case.
Maastricht, a charming city of cobbled streets surrounded by thirteenth-century battlements, was catapulted into the limelight in 1992, when it hosted the signing of the European treaty that now bears its name. In addition to being a venue favoured by European bureaucrats, it is home to the University of Limburg where, until his recent retirement, Marius Romme was a professor of social psychiatry. A tall, white-haired and gentle man, Romme developed his unusual approach to helping people suffering from hallucinations after attempting to treat a 30-year-old female patient whose ‘voices’ gave her orders, forbade her from doing things, and dominated her life.56 Severely distressed, she had been diagnosed as suffering from schizophrenia. Neuroleptic drugs had no impacton the voices, but marginally reduced her anxiety. A course of psychotherapy was similarly ineffective. Her attitude towards her hallucinations was unexpectedly transformed, however, by a chance encounter with a book written by an American psychologist, Julian Jaynes.57
The book (something of a cult classic in psychology) is called The Origins of Consciousness in the Breakdown of the Bicameral Mind, and has a strikingly original thesis. Jaynes proposes that self-reflective consciousness is a recently evolved faculty of the human mind that did not exist in Ancient Greece. According to Jaynes, because the Greeks lacked a concept of ‘I’, or the self-as-agent, the things they said to themselves when engaged in verbal thought were experienced as being said by gods (which is why they had so many gods).58 Jaynes noted the similarity between the Ancient Greeks’ experiences, and the experiences of modern-day schizophrenia patients, and it was this aspect of
the book that had such a dramatic impact on Marius Romme’s patient. Embracing the view that hearing voices was an entirely normal experience for the Ancient Greeks, she no longer saw her own experiences as pathological.
Romme and his patient appeared on a popular Dutch television programme and invited viewers who had experienced voices to write to them. Approximately one third of the 450 people who responded said they had little difficulty coping with their voices. As might be expected from the epidemiological evidence that we considered earlier, many had never received psychiatric treatment. When those who had avoided becoming patients were compared with those who had not, the two groups appeared to be remarkably similar. The main difference was that the non-patients saw themselves as stronger than their voices, whereas the patients saw themselves as weaker.59
Working with his partner Sondra Escher, a journalist, Romme has organized a national network for Dutch people who hear voices. This provides a forum in which they can meet to discuss their experiences and share ideas. The organization, known as Resonance, encourages people to accept their voices as part of normal human variation rather than as manifestations of disease, and encourages independence from psychiatric services whenever this seems possible.
This startling and quite deliberate attempt to move the boundaries of madness demonstrates that even the experiences normally attributed to schizophrenia do not have to be considered pathological. It may be true that hallucinations and delusions are found throughout the world, but whether or not these experiences are seen as evidence of illness appears to vary according to local customs and beliefs.
The NeoKraepelinian Paradigm as a Cultural System
Not surprisingly, anthropologically minded psychiatrists often objected to the picture of psychiatric disorders embodied in early editions of the DSM, not necessarily because they perceived its classification system to be invalid, but because it barely acknowledged the influence of cultural factors on mental health. In response to these kinds of criticisms, the US National Institute of Mental Health set up a task force to develop proposals for including cultural information in
DSM-IV.60 As a consequence, the fourth edition of the manual contains notes on how culture can influence the expression of psychiatric disorders, and an appendix listing some culture-bound syndromes reported in developing countries. However, many of the recommendations made by the task force were not incorporated.61 There is very little discussion of the way in which differing social norms can influence the experience and interpretation of symptoms, and the inclusion of culture-bound syndromes in an appendix appeared to give them a marginal status within the system as a whole. The task force’s suggestion that two diagnoses widely used in the West, anorexia nervosa and chronic fatigue syndrome, should be described as culture-bound was not taken up.
However, even if the editors of DSM-IV had followed the advice of the task force to the letter, it is not obvious that they would have produced a manual that would be entirely satisfactory from an anthropological perspective. Indeed, the evidence that we have considered in this chapter suggests a radical reappraisal of the entire DSM enterprise. We can now see that this enterprise is, itself, culture-bound. It represents the efforts of members of one particular culture to make sense of human behavioural breakdowns.
In an insightful analysis of the relationship between medicine and culture, Arthur Kleinman has argued that medical concepts are always embedded within a cultural system, so that theories of disease (maladaptions or malfunctionings of biological or psychological processes) and illness (the individual’s experience of disease) can never be separated from the cultural background.62 On Kleinman’s view, the health care systems of different cultures serve functions that are common to all. They enable individuals to communicate about their experiences; they sanction certain types of behaviour (for example, staying away from work when ill); they guide the choice of health care interventions; and they influence health care practices per se (for example the use of herbs, manufactured drugs or psychotherapy).
Kleinman points out that the explanatory models that are used to account for disease and illness often vary between different social groups occupy
ing the same location at the same point in time. In African countries, for example, discrepancies often arise between the explanatory models of ordinary people, traditional healers and a professional elite trained in Western medicine. Kleinman believes that
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