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

Categories: Psychology, Ethics