Review - Schizophrenia, Culture, and Subjectivity
The Edge of Experience
by Janis Hunter Jenkins and Robert John Barrett (Editors)
Cambridge University Press, 2004
Review by Peter Trnka, Ph.D.,
May 30th 2006 (Volume 10, Issue 22)

This major work on schizophrenia brings together psychiatrists, psychologists, anthropologists and one historian to address how culture is manifest in and part of mental illness, specifically and for good reason, schizophrenia.  Let me be clear.  The point is not to show that culture is some variable that has to be taken into account.  This much is known or at least nominally recognized in even the most conservative, i.e., reductive biological or broken brain type, work in and on psychiatry.  The point is rather that culture is inescapable and substantive when it comes to what we know as mental illness and that mental illnesses, including schizophrenia, illuminate our understanding of culture.  In this light the Preface by Arthur Kleinman, bigwig of narrative constructions of illness, is direct and to the point: this volume is "the most serious effort to date to present what is happening in the culture and schizophrenia field" (xvi). 

The short preface is rich with general claims defined precisely and supported cogently.  "Schizophrenia is the defining problem of psychiatry" (xv) and "one of the book's more serious achievements" is "demonstrating that schizophrenia has as much to do with society as it has to do with biology" (xvii).  Now where and how the essays show an equality of influence or constitution of society and biology on schizophrenia is not at all clear.  In fact they don't and the suggestion that society and biology are here something like separable ingredients that can be measured comparatively is misleading.  Kleinman's point, albeit looser, still stands in that the essays here convince the reader that we need to know much more about culture if we are to understand schizophrenia and that more and more knowledge about the brain is leading to diminishing returns in terms of knowledge of schizophrenia.

The primary theoretical orientation of the volume is anthropological although the interdisciplinary collaborations at various stages of this work show throughout.  The majority of essays in the volume contain cases from various parts of the world (and include various discussions of the uneven global development of schizophrenias).  This collection of cases does fairly well in avoiding two common and serious flaws of such works, namely, descriptions without analysis of meaning and collections without principles of collection.  Most of the essays describe well and embed descriptions within theoretical frames partly derived from cases.  Kleinman again captures the essential point in the methodology here when he states that the ethnographic descriptions "challenge the core pathogenetic/pathoplastic ideology of psychiatry and psychology" (xv).  The ideology states that the biological genesis of a mental illness such as a schizophrenia is the same across individuals even though the culture specific to each individual may modify the shape of that illness.  The assumption of an underlying common essence in the absence of evidence and in the face of radically incommensurable cases appears highly suspect.   

Two or three of the essay fall into the trap of description for description's sake.  The bookend sections of the volume offer more explicit theoretical discussions of anthropology and psychiatry and their linkages (including the particular alignment of the psychiatrist Harry Stack Sullivan and the anthropologist Edward Sapir and others in New York City), the meaning of culture, culture and illness, and schizophrenia.  The focus is broad but tight and the contributors include some strong voices from academia and medical practice, among them Byron Good, Louis Sass, and John Strauss.  The volume is published in the solid medical anthropology series by Cambridge, edited by Alan Harwood.    

The Introduction by Jenkins and Barrett is clear, contextual, thoughtful, and focused.  They affirm their work as "perhaps the first systematic effort to advance a cultural approach to the study of schizophrenia that takes the complex phenomenal reality of subjective experience as a starting point" (2).  The editors note that the move to subjectivity is characteristic of anthropology at the same time as there is a mass retreat from subjectivity in psychiatry and psychology (7).  Not shying away from the very difficult, very important, and very easily belittled topic of subjectivity is to be strongly commended.  Nor is this empty praise of a challenge undertaken for the sake of challenge without notion of progress or product.  Whomsoever reads a subset of these essays will understand something more than they previously did concerning the experience of persons and especially persons with schizophrenia.    

The volume is organized in three sections, starting with more general and theoretically inclined, though case supported, essays on culture and experience.  This is a strong start in terms of method and definition of the problem of schizophrenia as a paradigm case for mental illness and indeed human experience.  Schizophrenias are not just one set of cases of mental illness nor is mental illness a separable aberration of normal human experience.  Hence the close affinity between psychiatry, anthropology, and philosophy.  As Jenkins puts it herself forcefully in the opening essay on understanding fundamental human processes: "schizophrenia itself offers a paradigm case for scientific understandings of culturally fundamental and ordinary processes and capacities of the self, the emotions, and social engagement" (29).  It's worth noting that the essays in the volume share a critical and sometimes severe (although not unwarranted) point of view on biopsychiatry they are not antiscientific at all.  By illuminating some of the structures and events of schizophrenias this volume dislocates the assumption that all good science is reductive physicalist science. 

By defining schizophrenia as a paradigm case this volume moves us along to understanding that "in certain ways that can be specified, people afflicted with schizophrenia are just like everyone else only more so" (30).  Jenkins is clear and forthright: "humanity is precisely what is at stake" (43) and the patients know this while their physicians and the normal crowd are secure in their ignorance.  Jenkins is also clear that culture is not a part or an add on to mental illness but a fundamental constitution: "the course of illness is inherently social and cultural, and a matter of intersubjective engagement" (49).      

The second section of the volume is a less successful series of case studies, most of which avoid the problem of description for its own sake but none of which stands out for any particular illumination of the mundane or extraordinary in human experience.

In terms of the conclusion there isn't one, and perhaps this has to do with the aforementioned elision of philosophy.  Instead of a conclusion we have a final essay on emotion which is a weak denouement to the two previous essays, all in the third part of the volume on 'Subjectivity and Emotion.'  Sue Estroff's piece on first-person narratives is personal, honest, and smart: the anecdote here is provided precisely because it is the point – in this case the chasm of mistrust and misunderstanding that exists between professionals and patients (or as Estroff refers to the latter, consumer/survivor/ex-patient or c/s/x) and that makes knowledge of mental illness and the schizophrenias so difficult.  She communicates very well something of the patient's point of view in part because she makes the difficulty of any such communication an issue.  "C/s/x experience themselves as reduced to diseased brains and essentialized into chemicals rather than acknowledged as the perhaps enigmatic, but nonetheless sentient, persons they know themselves to be." (283)  Louis Sass's essay on negative symptoms of schizophrenia argues strongly that the coinage 'negative symptoms' is an imputation and an erroneous misjudgement of schizophrenic affect from the outsider point of view.  "The person with schizophrenia is an anomalous yet exemplary figure: a person who fails to adopt the social practices or internalize the cultural frameworks that are essential to normal social life, yet whose failure to do so can illuminate these very frameworks and processes of internalization, while at the same time typifying some of the most distinctive features of the modern age" (305).  Schizophrenia, as a refusal not of this or that part of culture but of acculturation as such, is a meta-deviation or meta-pathology according to Sass.  Concluding the volume with Sass' panoramic and political writing would have been a bolder choice. 

This foundational critique of establishment psychiatry and psychology is replete with references to Nietzsche, Husserl, Heidegger, Merleau-Ponty, Jaspers, Wittgenstein, and Foucault, among other philosophers.  Yet no philosophers are among the contributors and the specific contribution of philosophy to studies of schizophrenia is left unstated.  The philosophical references appear largely as appeals to authorities and mostly avoid definitions and analyses.  (The overall effect of the long-listing-of-surnames in parentheses reference form is also clunky throughout.  The index is incomplete.)  While I would not want to suggest that philosophy holds some secret key to the whole problem it is odd that the substantial contribution of philosophers to critical work on psychiatry is both recognized and rendered rather mute in this volume.  Amidst the range of contemporary philosophers referenced it is also rather odd that two who have done specific work on mental illness generally and the schizophrenias in particular (and who are also French), Gilles Deleuze and Luce Irigaray, are not referenced.

©2006 Peter Trnka

Peter Trnka, Ph.D., Associate Professor of Philosophy, Memorial University of Newfoundland, Canada