YJBM Arts & Humanities: Calming Madness: Transcultural Psychiatry and the Porous Self

Introduction

Schizophrenia is both real and imagined. It has no determined trajectory, nor definitive outcome, yet we claim with certainty that it is one of the most devastating psychiatric illnesses. Schizophrenia can be characterized by a myriad of symptoms, but the most notable symptoms include delusions, hallucinations (visual or auditory), disorganized speech, catatonic behavior, and diminished emotional expression. The rise of biomedicine and the medicalization of psychiatry have contributed to a reductionist understanding of schizophrenia as the poster child of biological mental illness that fails to consider unique trends in the epidemiology of schizophrenia. It is well documented that low-resource, low-income nations have similar rates of schizophrenia as high-income countries, but that those experiencing mental illness in high-income nations have worse rates of recovery [1]. For the purposes of this essay, I define “recovery” as a state of relative stability in which the afflicted individual can participate in norms and behaviors deemed culturally appropriate. I note that recovery does not mean the erasure of internal symptoms such as hallucinations or paranoia, but rather the ability to fulfill one’s role in society, whatever that may be.

I examine two particular aspects of “care-as-usual” that vary in the African context compared to the Euro-American that can better explain outcomes of recovery: 1) diagnostic neutrality and 2) emotional expressivity of an afflicted individual's family. I argue that these two facilitating factors of recovery are manifestations of a “porous self” that reifies itself in the process of recovery while allowing for a more transient and dynamic experience of mental illness that may encourage social reintegration. Moreover, I examine the porous self and its manifestations as multiscalar, exploring its role in the individual, family, and even at the institutional level through an inquiry of the Fann Psychiatric Clinic in its former glory.

I begin this essay with an introduction to the porous self, drawing on ideas and evidence from China Scherz and George Mpanga’s “His mother became medicine: drinking problems, ethical transformation and maternal care in Uganda [2].” I continue to mobilize anthropological perspectives and texts, including T.M. Luhrmann and Jocelyn Marrow’s Our Most Troubling Madness: Case studies in schizophrenia across cultures [3], Ethan Watters’ Crazy Like Us: Globalization of the American Psyche [4], and Katie Kilroy-Marac’s “Speaking with revenants: Haunting and the ethnographic enterprise [5]” to substantiate my argument. I conclude this piece by drawing our attention to two emerging spaces in psychiatric care - generational therapy and pharmaceuticals - and examine how they might create or relieve tension with the porous self and what types of interventions they might open up.

The Porous Self

In “His mother became medicine” Scherz and Mpanga reference philosopher Charles Taylor’s distinction between the modern “buffered self” and the pre-modern “porous self” [2, p.135]. According to Taylor, the buffered self is one that is unaffected by what is beyond the “boundary,” sees itself as invulnerable to the environment, and understands itself as autonomous. The “boundary,” in this case, may be understood as the physical body and environment. Along a similar thread, Schzerz and Mpanga note Lambek’s thinking regarding Western thought that has given rise to a “pure and unitary state of mind,” [2, p.136] that is necessary for accomplishing ethical transformation. This understanding mirrors much of Taylor’s explanation of the buffered self, both of which demonstrate the inflexibility and limitations of such an understanding of self. In contrast, the porous self, as per Taylor’s analysis, is vulnerable to the influence of entities and agents beyond the confines of the body. As the name would suggest, the porous self is permeable, penetrable, and subject to change. This permeability is what allows the porous self to be transformed relationally to one’s social and physical environment. Consequently, while we might push-back on certain dichotomies such as modern/pre-modern, we can use the dichotomy between buffered and porous self as a framework for understanding improved recovery rates of psychosis in Africa. Most notably, through diagnostic neutrality and low emotional expressivity we can see how the porous self is brought to relief, and allows recovery when understood at the individual, familial, and institutional levels.

Porous Individuals and Diagnostic Neutrality

In Luhrmann and Marrow’s Our Most Troubling Madness, the authors offer an overview of the different schools of thought surrounding schizophrenia and present twelve different case studies of schizophrenia across the globe. By comparing the course of the disease and its treatment in Chicago and London to that of patients with schizophrenia in Ghana, Luhrmann and Marrow bring to light a key difference between the Euro-American and African diagnostic neutrality, or the lack thereof. Diagnostic neutrality refers to the lack of emphasis on, or complete absence of, a diagnosis when patients receive psychiatric care. In the US, we are a far cry away from diagnostic neutrality. In Case 1: “I’m a schizophrenic!” Luhrmann follows the story of John Hood, an American patient diagnosed with schizophrenia, who is plagued by the inescapability of his identity as a person with schizophrenia that bars him from recovery. She explains, “To receive care in a society so acutely aware of individual rights is to receive an explicit diagnosis. A patient has the right to know. But the label ‘schizophrenia’ is often toxic for those who acquire it. It creates… an identity framed in opposition to the nonlabeled world” [3, p.27]. Here, we see a clear manifestation of the buffered self that takes priority in the Euro-American worldview of mental illness. The label of schizophrenia assigned to John, as well as to his “diseased brain” (as he puts it), continuously reify the distinction between himself and a “norm.” John’s statement, “I’m a schizophrenic!” epitomizes his own understanding of himself as buffered. His language is pointed, and concise. He does not say, “I live with schizophrenia” or “I am undergoing a schizophrenic episode.” Instead, John fully takes on the label of schizophrenic as indistinguishable from the self that suggests an invulnerability to change. Moreover, by existing in a socio-cultural environment that promotes an immutable “unitary state of mind,” as Lambek puts it, the option of full recovery is not really an option at all.

In contrast, Case 7: Demonic Voices, follows Charles, a young man in Accra, Ghana who hears voices and experiences paranoia as a consequence of a bewitchment. Despite being admitted to a psychiatric ward and prescribed antipsychotic medications, Charles maintains his belief that what he is experiencing is a bewitchment, and that while bewitchment can be entangled with mental illness, he is not yet mad. The authors note that Charles pointed to visibly mentally ill patients in the psych ward (like those talking out loud to themselves and waving their arms) and proclaims that they have succumbed to the bewitchment. Charles' self-proclaimed bewitchment and identification of those who have been bewitched speaks to his understanding of the self as porous. Bewitchment is contingent on the belief that one’s body can be penetrated and influenced by another entity outside oneself. Charles’ case also illustrates a profound benefit of the porous self – diagnostic neutrality. When the self is understood as permeable, illnesses, ailments, and afflictions can come and go – including bewitchment and the voices Charles hears in his head. As Scherz and Mpanga explained in their piece, the porous self presents with it, “elements of unpredictability and contingency” [3, p.136]. Unpredictability in this case may refer to the potentially transient nature of the bewitchment, while the contingency aspects speak most to Charles' ability to still maintain his personhood despite this transformation. Luhrmann and Marrow similarly explain, “As a result [of diagnostic neutrality], they leave many possible ways to imagine the future intact. This may widen the range of possibilities for living in the present” [3, p.42]. Unlike the case of John, where he is condemned to a life fixed within schizophrenia, Charles’ porous self permits a lack of formal diagnosis that encourages an imaginative future free of his illness. As Charles says, “The bewitched can be healed” [3, p.118].

A comparison of the two above case studies reveals the implications of diagnostic neutrality when it manifests on the individual level. John’s identifying with the label of schizophrenia proved damaging for his sense of self and isolated him from his social world. The strict biomedical interpretation of schizophrenia in the US is not only institutionalized but internalized in this way. Consequently, we see the harms of the strict biomedical interpretation in the US that trickle down to buffered individuals that can never be absolved of such labels. On the other hand, Charles’ steadfast belief in his bewitchment, and refusal to internalize a label of mental illness may very well explain his ability to return as a functioning member to society. While it is worth noting Charles lives in a society that holds the bewitched to a greater esteem than the mentally ill [3, p.123], it is also of note that Charles was hospitalized in a psychosis unit. This juxtaposition between his understanding of self and the institutionalization of his affliction demonstrate that Charles, like John, may have been subjected to similar structural forces, but that when the porous self prevails on the most micro-level, within the individual, it serves as protective and promotes recovery.

Emotional Expressivity and the Porous Family

In Crazy Like Us, New York Times journalist Ethan Watters explores transcultural psychiatric trends in anorexia, depression, PTSD, and schizophrenia. While Watters reiterates similar points made by Luhrmann and Marrow, his exploration of schizophrenia in Zanzibar identifies emotional expressivity, or lack thereof, as a facilitating factor for recovery. Emotional expressivity can be likened to taking the “emotional temperature” [4, p.148] of a household. Those families considered to have high emotional expressivity will express criticism, highly charged attention, and emotional overinvolvement toward an ill family member. Watters explains that prior research in the US (and across the globe) has demonstrated that people diagnosed with schizophrenia in families with higher emotional expressivity have relapse rates of hospitalization 3 to 7 times higher than those with low emotionally expressive families. Those with the most severe relapse rates were identified to live in a household with at least one family member that, “routinely criticized and attempted to control the patient’s behaviors” [4, p.152]. Additionally, the three most notable emotional reactions by family that are predictive of a person diagnosed with schizophrenia relapse rate were: criticism, hostility, and emotional overinvolvement. Watters illustrates the intensity of high emotional expressivity through a vignette of an American woman with a son diagnosed with schizophrenia. He describes her as so distraught that she contemplates committing suicide herself due to the second-hand misery of caring for her son. This vignette demonstrates the profound distress and emotional involvement taken on by family members in high emotional expressivity households. While this description of high emotional expressivity, and the associated stress, is quite prevalent in Euro-American families, Watters and McGruder, an American anthropologist, describe a family in Zanzibar that contrast high emotional expressivity despite their ill family members. Here, I explore a familial understanding of and respect for the porous self (as opposed to a more individualistic one) that underpins lower emotional expressivity in African households, and thus, promotes recovery.

Like most Zanzibari families, this family did not consist solely of a nuclear family unit. There was the head of the household Amina (Kimwana’s mother), Hemed (her ex-husband), Kimwana, two of Amina’s married daughter and their children, an unmarried daughter, an unmarried son, Hemed’s half-brother, and the half-brother’s adopted sister and their children. Kimwana, a young woman, and Hemed, her father, were both diagnosed with schizophrenia. While their family unit was both massive and pulsating, McGruder describes the emotional tone of the family as very calm. After spending over a year with them she explains that they had a “remarkably relaxed stance towards Kimwana’s illness” [4, p.149]. This “relaxed stance” is personified in the way the family responded to Kimwana’s ability or inability to fulfill her normal roles such as doing chores. McGruder explains that the family often uses Kimwana’s activities and social interactions to gauge her wellness, but what’s more striking is how the family let Kimwana flow in and out of her responsibilities without judgment. The flexibility of their expectations of Kimwana’s duties conveys a porous understanding of Kimwana and her illness. The family remained emotionally uninvolved in Kimwana’s illness such that bad days were not met with alarm and good days were not met with celebrations. This emotional neutrality permitted Kimwana the flexibility to drift back and forth between a sick role and one of relative health. Consequently, Kimwana’s sense of a porous self was reified and she was able to exist with little pressure to identify as someone living with immutable mental illness, thus opening a revolving door to recovery.

This case study underscores the pervasiveness of the porous self and how an understanding of the porous self at the familial level can serve to fortify it such that recovery for those struggling with schizophrenia is possible. While Kimwana may have perceived herself and illness as porous, it was the family’s shared understanding of porosity that their lack of emotional involvement was predicated on. Through their shared understanding of a porous self, the family was able to exist in relative peace and confidence that Kimwana could come in and out of her state, thus, lowering their emotional stake in it. I believe that this communal understanding of the porous self has profound implications, as the communal understanding both amplifies and substantiates the porous self, such that the individual can embody it as well.

Porous Institutions

The most macro-level at which we might see porosity linked to recovery is at the institutional level. In Kilroy-Marac’s “Speaking with Revenants," she follows two revenants,¹ Demba and Dr. Collomb, in the Fann Psychiatric Clinic in Dakar, Senegal. Fann was seen as an exemplary institution of the newly founded Senegalese state. The institution, run under the leadership of Dr. Collomb, prided itself on its multidisciplinary approach that combined anthropological methods, clinical practicum and the social sciences to create a foundation for a “truly cross-cultural” psychiatry [5, p.256]. While Kilroy-Marac draws our attention to how the past and present might intersect through revenants of different kinds, her discussion of the founding principles and practices of Fann convey an understanding of porosity both at an institution and facility level that may promote recovery.

Most notably, Kilroy-Marac explains that by the mid-1960s Collomb had “opened” the clinic which enabled patients to leave their rooms, walk about different hospital divisions, go outside as they wished, and even have family members come and go. While these freedoms contributed to the social reintegration of patients, thus promoting recovery, they are inextricably linked to porosity at the institutional level. Quite literally, the walls of the institution become porous when patients and family come in and out, detracting from their status or role as a patient. This engages with aspects of both diagnostic neutrality and emotional expressivity, or lack thereof. When patients are allowed to move about freely and their identified role as sick or patients is made flexible, it confers diagnostic neutrality in that their illness is not a constant state of being, but rather a transient, dynamic experience. Furthermore, these freedoms suggest a lack of emotional overinvolvement and/or worrying. Implicit in these privileges is a certain level of trust and autonomy that conveys that the institution is not overtly worried about the patient's safety being threatened in these situations. Consequently, porosity, when observed and mobilized at institutional level, has the potential to reify the porous self on the individual level in ways that promote patient well-being and recovery.

Another noteworthy practice in Fann’s history was that of their weekly town-hall styled meetings. During these meetings patients, doctors, and nurses created a sense of community and had a forum for open exchange. Doctors and nurses often spoke freely with their patients while removing their white coats. This provides yet another compelling instance of the porous self. The action of the doctors and nurses to disengage with their titles in this way personifies a form of professional porosity in which even individuals who are not deemed as sick or patients can act in fluid roles. By extension, this continues to foster an environment in which dynamic understandings of human experience are reconfigured such that those suffering from any form of mental illness, including schizophrenia, may begin to internalize.

Emerging Spaces for the Porous

In “Identified Patient: Apartheid syndrome, political therapeutics, and generational care in South Africa” Stephen McIsaac examines emerging forms of psychiatric therapeutics in a country whose history is rife with racism, economic exploitation, and segregation that brought with it immense violence and intergenerational trauma. McIsaac’s fieldwork brought him to a community mental health clinic in Khayelitsha, South Africa where he observes the therapeutic practices of Black South Africans as they attempt to both heal and liberate their patients from the legacies of apartheid. In this work, McIsaac brings relief to “generational care” as a political therapeutic that challenges Euro-American normative psychotherapeutics. This form of generational care necessitates a recognition and reorganization of a collective history of violence that is shared between therapists and their clients, reproduces violence and trauma, and includes the therapists as a subject. Unlike Euro-American normative therapy, generational therapy draws on the experiences, feelings, and insights of the therapist who shares a past with the client, in order to interrupt the trauma and disorder of the present. What is considered “problematic counter-transference” by a normative paradigm, becomes a profound gesture of political revolution in the South African context. Consequently, therapists, “straddle two registers of knowing: both through memory (of their own histories and presents) and sight (through the disciplined standards of normative psychiatric practice)” [6, p.197].

What allows this methodology to transcend beyond the prototypical normative psychiatry is that it thrusts both therapists and their patients, jointly, into the spaces where past and present collide in family dysfunction. When asked about this type of generational therapeutic, Viwe and Nobhule, two therapists in the clinic, describe how historical resonance between themselves and their clients often “hit” them, and allow them to intervene from both a political and psychiatric vantage point [6, p.205]. In a political sense, the therapists are able to halt the reproduction of family dysfunction, violence, and trauma that plague so many of these communities as the result of post-apartheid legacies. Consequently, healing becomes a political process, one in which patients reimagine and reconstruct family in their own image, and not in the confines of what only an apartheid-era South Africa would permit.

In contrast to past examples of the porous self, porous family, or porous institution, I argue this form of therapy, in which the therapist's own experiences are allowed to permeate, reifies a sense of porosity in the relationship between practitioner and patient, but also a sense of porosity in time. Generational care demands that the past and present be integrated in order to reimagine a liberated future. The distinctions between time frames erode, along with a sense of a buffered self, conveying a vulnerability to the agents and entities outside oneself that parallel a porous self. Generational care demonstrates that with the emergence of a porous therapeutic, a porous self, and porous time, we may be able to reimagine new forms of care that serve as both actions of healing and political resistance.

Lastly, Anita Hardon and Emilia Sanabria’s “Fluid Drugs: Revisiting the Anthropology of Pharmaceuticals,” reveals a final place of tension between psychiatric care and the porous self — pharmaceuticals. Hardon and Sanabria explain, “recent theoretical and empirical work suggests that there is no pure (pharmaceutical) object that precedes its socialization and interpretation,” which would suggest that even a biomedical tool can be reconfigured and reimagined within and through the porous self [7, p.118]. Hardon and Sanabria also explain that studies on methadone found that while the drugs block craving and return the user to a “useful social life,” French researchers deemed the drug “rarely therapeutic; it does not cure but is very instrumental in revealing the psychopathology of the drug user” [7, p.119]. I would challenge the assertion that a drug can return patients to their normal social life, yet not be considered therapeutic; however, this presents a unique tension between the porous self, recovery from illness, and pharmaceuticals. As noted in earlier parts of this essay, the porous self allows a reintegration into social webs and society that can be defined as the goal or state of recovery. Despite this, pharmaceuticals often align with biomedical interpretations of illness that may contradict recovery as a dynamic state, thus discouraging it. In contrast, Hardon and Sanabria reference another scholar (E. Hsu) on the topic who asserts, “the-plant-materials-of-the-environment-in-interaction-with-human-beings form a continuum” [7, p.123]. A more continuum-based approach to understanding the interaction between individuals, their environments, and medications may offer a comprehensive framework for understanding the influence and permeation of pharmaceuticals on the porous self. This more nuanced and flexible interpretation of drugs would allow for more dynamic and fluid understanding of illness than an approach to pharmaceuticals that deems them as inadequate unless they “cure” the illness in its totality. Consequently, pharmaceuticals and psychotropic drugs present an emerging space in psychiatric care that will continue to challenge us to reimagine what recovery looks like and to redefine what deems drugs efficacious.

Conclusion

Transcultural psychiatry presents an opportunity to engage with perspectives, therapeutics, and understandings of self that may underpin differential rates of recovery for mental illness in Africa compared to those we see in the Euro-American context. Most notably, I use the porous self to elucidate certain aspects of “care-as-usual” in Africa such as diagnostic neutrality and low emotional expressivity of families that may contribute to better rates of recovery. An understanding of the self as porous is not only more common in Africa, but also confers upon the individual the power to move in and out of a state of illness transiently. Through case studies of individuals, their families, and institutions, we can see how the porous self can operate across scales and reify the porous self for the individual such that recovery not only seems possible, but well within reach. Finally, the discussion of generational care and interpretations of pharmaceuticals encourage us to question emerging spaces in psychiatric care and what they may allow or disallow. In the case of generational care, we see healing becomes a politically charged act. In the case of pharmaceuticals, we see the push and pull on the porous self and how this might delimit recovery for the mentally ill. These emerging spaces encourage us to continue to observe, question, and assess how we might reimagine psychiatric care moving forward. How might we train porous psychiatrists? What would a porous institution in the US look like? And should biomedicine push on, searching for psychotropic drugs, and redefining our understanding of recovery in the process?

- Matthew Ponticiello, Yale School of Medicine & Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, CT

¹ In this case, revenant refers to two entities that repeatedly revisit the Fann Psychiatric Clinic but in different senses of the word. One of the revenants refers to Demba, a living man and former patient of the clinic, who comes back to the clinic and the other revenant refers to the ghost of Dr. Collomb that people report haunts the hallways of the Fann Clinic. In either case, both are "returning" to Fann. The authors of the article explain it here: "Both Demba and Collomb’s ghost are, in a sense, revenants. In French as in English, the term ‘revenant’, which comes from the French verb revenir, ‘to return’, refers to a person who returns after an extended absence or after death, though the latter usage is more common. The term ‘revenant’ is not indigenous to Senegal and has no direct Wolof equivalent; it comes to Senegal from France, by way of the same colonial encounter that led to the eventual establishment of the Fann Psychiatric Clinic in 1956. The word revenant, then, offers a clue to the kind of haunting Demba and Collomb’s ghost do (they return) while at the same time drawing attention to the space from which they emerge [5, p.255].”

References
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2. Scherz C, Mpanga G. His Mother Became Medicine: Drinking Problems, Ethical Transformation and Maternal Care in Central Uganda. Africa (Lond). 2019;89(1):125–46.
3. Luhrmann, T. M., and Jocelyn Marrow, eds. Our Most Troubling Madness: Case Studies in Schizophrenia across Cultures. Oakland, California: University of California Press, 2016.
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6. McIsaac S. Identified Patient: Apartheid Syndrome, Political Therapeutics, and Generational Care in South Africa. Med Anthropol Q. 2020 Jun;34(2):192–209.
7. Hardon A, Sanabria E. Fluid Drugs: Revisiting the Anthropology of Pharmaceuticals. Annu Rev Anthropol. 2017;46(1):117–32.