Extraordinary Conditions: Culture and Experience in Mental Illness

Extraordinary Conditions

Extraordinary Conditions

Culture and Experience in Mental Illness

Janis H. Jenkins

UNIVERSITY OF CALIFORNIA PRESS

University of California Press, one of the most distinguished university presses in the United States, enriches lives around the world by advancing scholarship in the humanities, social sciences, and natural sciences. Its activities are supported by the UC Press Foundation and by philanthropic contributions from individuals and institutions. For more information, visit www.ucpress.edu.

University of California Press

Oakland, California

© 2015 by The Regents of the University of California

Library of Congress Cataloging-in-Publication Data

Jenkins, Janis H., author.

    Extraordinary conditions : culture and experience in mental illness / Janis H. Jenkins. — First edition.

        pages    cm

    Includes bibliographical references and index.

ISBN 978-0-520-28709-9 (cloth : alk. paper)

ISBN 978-0-520-28711-2 (pbk. : alk. paper)

ISBN 978-0-520-96222-4 (ebook)

    1. Mental illness—Cross-cultural studies.    2. Mental illness—Social aspects.    3. Medical anthropology.    4. Ethnopsychology.    I. Title.

RC455.4.E8J46  2015

    362.196890089—dc23

2015020400

Manufactured in the United States of America

24 23 22 21 20 19 18 17 16 15

10 9 8 7 6 5 4 3 2 1

In keeping with a commitment to support environmentally responsible and sustainable printing practices, UC Press has printed this book on Natures Natural, a fiber that contains 30% post-consumer waste and meets the minimum requirements of ANSI/NISO Z39.48–1992 (R 1997) (Permanence of Paper).

To TC

Contents

List of Figures and Tables

Prelude and Acknowledgments

Introduction: Culture, Mental Illness, and the Extraordinary

PART ONE. PSYCHOSIS, PSYCHOPHARMACOLOGY, AND FAMILIES

1. Cultural Chemistry in the Clozapine Clinic

2. This Is How God Wants It? The Struggle of Sebastián

3. Expressed Emotion and Conceptions of Mental Illness: Social Ecology of Families Living with Schizophrenia

PART TWO. VIOLENCE, TRAUMA, AND DEPRESSION

4. The Impress of Extremity among Salvadoran Refugees

5. Blood and Magic: No Hay que Creer ni Dejar de Creer

6. Trauma and Trouble in the Land of Enchantment

Conclusion: Fruits of the Extraordinary

Notes

Works Cited

Index

Figures and Tables

FIGURES

1. Experiential mélange of person-illness-meds

2. Relationship among factors perceived as critical to improvement

3. Mural of the Virgin and family, New Mexico

TABLES

1. Fundamental aspects of mental illness that are culturally shaped

2. Sociodemographic characteristics of research participants

3. Clinical characteristics of research participants

4. Paradoxes of lived experience for persons taking atypical anti-psychotics

5. Conceptions of the problem by Mexican American and Euro-American relatives

6. Gender and diagnosis among hospitalized adolescents in New Mexico

7. Violence-related problems among hospitalized adolescents in New Mexico

Prelude and Acknowledgments

Anthropology demands the open-mindedness with which one must look and listen, record in astonishment and wonder that which one would not have been able to guess.

—Margaret Mead

This book was born from a long-standing anthropological fascination with the possibilities for being human. These possibilities entail fundamental human capacities and processes; what is fundamental is at the theoretical outset premised on the inextricability of culture, biology, and psyche. Attention to human life as rife with possibilities that are contingent rather than invariant provides the foundation for social, personal, and political transformation. The panhuman possibilities for the development of mental health problems are remarkably common across countries, genders, and social classes. Yet there is substantial cultural variation. Across the board, mental health problems are positioned by social stigma and inequality of care. And because the majority of human populations live under the press of socioeconomic adversity and gendered inequality that significantly affects mental health, the need for social transformation is great.

Along with early anthropological thinkers such as Margaret Mead and Ruth Benedict, my methodological approach involves the identification of patterns. Yet while anthropological analysis is predicated on the identification of patterns, no less impressive are the divergent, the unusual, and the paradoxical. The relation of culture and mental health has been my focal point for the study of fundamental human processes in a series of anthropological studies carried out over two and a half decades. The chapters in this book take up a range of mental conditions, cultural orientations, and geographic locations. The mental health conditions discussed were diagnosed as schizophrenia and schizo-affective disorders, depression, anxiety, and psychological trauma. The cultural orientations include Mexican-descent, Euro-American, African American, Salvadoran, Native American, and Hispano/Hispanic groups. Most of the persons and groups in this book are largely invisible to their fellow citizens. The geographic locations are wide-ranging, spanning the continental United States: the West Coast, the East Coast, the Midwest, and the Southwest. This geographic range reflects my own migratory pattern from the 1980s to the present. Given the scope of the studies incorporated and on the helpful urging of one of the peer reviewers of this book, I came to realize that it may be useful to provide a road map for how these studies came into being as a matter of academic migration and assembly. This led me further to the realization that I could not sketch a road map in the absence of an attempt to mark the indebted grounds for the very possibility of my work.

My early studies as an anthropology PhD student at UCLA in the 1980s in the Department of Psychiatry and Biobehavioral Sciences were conducted according to what I now recognize as a local cultural assumption: I imagined my research environment was representative of simply the way things are. With my anthropology adviser, Robert B. Edgerton, I studied human conditions in a manner that incorporated biogenetic structuralism and cultural conceptions. Edgerton’s 1966 publication in the American Anthropologist, Cultural Conceptions of Psychosis in Four East African Societies, led me to think that comparative cultural study of psychosis was an obvious course of study. While this has certainly been the case for me, I have long since been disabused of the notion that this kind of work was, for most anthropologists or psychiatrists, anything but obvious or standard. With the passage of time came the inevitable observation that my early academic environment was located in a particular historical and cultural moment for the interface of anthropology and psychiatry. That moment and the training environment it generated shaped me as an interdisciplinary researcher among diverse social and health scientists and clinicians. The ethos at that time, one I still subscribe to, is that collaborative groups can get more done. And of course this ethos was made possible by the relatively large-scale research grants that were available. I thank the anthropologist John G. Kennedy for making cultural psychiatry a mainstream topic of sociocultural anthropology and for setting in motion dissertation research with my mentor, the eminent psychiatrist Marvin Karno. It is to Marv that I owe my greatest debt. From him I learned what mattered most: careful, empathic research to determine what makes a difference for improvement from mental illness (chapters 1–3). Together, Marv and I ran several collaborative projects with Spanish-speaking Mexican-descent families. Also at UCLA, I benefited greatly from the methodological training of Tom Weisner. Anthropological fieldwork with him on the Family Life Styles project fostered my abiding commitment to systematic empirical research of kin-based households large (e.g., a sprawling religious commune) and small (tipis, log cabins, huts) in naturalistic splendor (I once sat on a closed toilet seat while interviewing someone in a bathtub). I got the training message: whatever, wherever. It certainly stuck, and many of my own doctoral students who have continued this methodological tack under difficult field circumstances.

In 1986 I accepted an invitation from Byron Good, Arthur Kleinman, and Mary-Jo DelVecchio Good to join as a postdoctoral fellow the Program in Medical and Psychiatric Anthropology at Harvard Medical School, which was funded by the National Institute of Mental Health (NIMH). What was initially to be a one-year post, owing to the need to get back to UCLA to continue a new grant we had received and my reluctance to leave behind a rent-controlled apartment in Santa Monica and beach culture (conceptually foreign if not suspect in Boston), extended to four years. The appeal of the Harvard program proved irresistible given the caliber of the MD-PhD cohort that I trained with in these four years. The intellectual atmosphere fostered by then-peers (now luminaries) Paul Farmer, Jim Kim, Rob Barrett, Tom Csordas, Linda Garro, Pablo Farias, Anne Becker, Paul Brodwin, Lawrence Cohen, and Roberto Lewis-Fernandez was electric. Credit for creation of that exceptional program goes entirely to Byron, Arthur, and Mary-Jo, who together ran the NIMH-funded training grant for twenty-five consecutive years. It remains for me a transformative experience and an intellectual home. I thank Arthur Kleinman for rare gifts of intellectual honesty and depth and the courage of visionary leadership that revolutionized our field. As a deeply thoughtful anthropologist of mental illness, there is no one’s scholarship I admire more than the works of Byron Good. His writings have powerfully influenced my thinking. My work has likewise been made far better than it otherwise would have been by virtue of key theoretical formulations advanced by Mary-Jo DelVecchio Good. Utmost thanks to Byron and Mary-Jo whose limitless energy and generosity of intellectual and social spirit across homes in Cambridge and Maine fostered what we long ago dubbed the FQ (Fun Quotient). Also in Boston, as a member of the Latino Team of the Cambridge Hospital, I was privileged to be part of a stellar team of sophisticated clinicians who welcomed an anthropologist into their midst and helped immensely with my research with Salvadoran refugees (chapters 4 and 5). I thank Mauricia Alvarez, Sylvia Halperin, Pablo Farias, Pedro Garrido, Roberto Lewis-Fernandez, and particularly Marta Valiente, a gifted and generous Salvadoran clinical psychologist.

In 1990 I joined the faculty of the Departments of Anthropology and Psychiatry at Case Western Reserve University in Cleveland. The research support at Case was terrific, and Case was an outstanding environment in which to accomplish a great deal of work (chapter 1), including two NIMH-funded studies on schizophrenia and depression for which I was Principal Investigator. I am particularly grateful to colleagues Milton Strauss, Woody Gaines, Jill Korbin, Jonathan Sadowsky, Jerry Floersch, Jeff Longhofer, and Martha Sajatovic. I thank the many superb graduate students I had the privilege of teaching in seminars and as research assistants. I dare not attempt to list all for fear of omissions. I do, however, wish to extend particular thanks to Elizabeth Carpenter-Song.

In late 2004 I moved back to California, where I am currently a member of the faculty of the Departments of Anthropology and Psychiatry at University of California, San Diego (UCSD). In 2005, along with Tom Csordas, I launched a new study of adolescent mental health in the American Southwest, headquartered in Gallup and Albuquerque, New Mexico. This collaborative effort involved a team of highly dedicated clinicians who generously supported our research. I am grateful in particular for the leadership of the interdisciplinary scholar and medical director David Mullen and the master therapist Sandra Hollingsworth who facilitated the research (chapter 6). This work could not have been accomplished without the research child psychiatrist Michael Stork and the research psychologist Mary Bancroft, along with Elisa Dimas. The UCSD research team included a talented group of PhD students who assisted with complicated fieldwork and data organization, including Heather Hallman, Allen Tran, Nofit Itzhak, Jessica Novak, and Celeste Padilla. My particular thanks go to Bridget Haas and Whitney Duncan for carrying out taxing fieldwork with great skill and dedication. At UCSD, I am fortunate to have as colleagues Steven Parish, Margaret Schoeninger, Katerina Semendeferi, Tom Levy, Guillermo Algaze, Geoff Braswell, Suzanne Brenner, Jonathan Friedman, Paul Goldstein, Joe Hankins, John Haviland, Nancy Postero, Kit Woolard, Shirley Strum, David Pedersen, Steffanie Strathdee, Thomas Patterson, Lew Judd, Igor Grant, Sid Zisook, Dilip Jeste, Fonna Forman, Gerry Mackie, David Mares, Carol Franz, Bill Kremen, Vicky Ojeda, and Monica Ullibari. I appreciate lively interchange among my (former) students Ted Gideonse, Charlotte van den Hout, and Sonia Rackelmann. I have particularly enjoyed teaching with Paula Saravia and departmental organizing with Jorge Montesinos. Carolyn Baratz, Brad Waples, Ellen Kozelka, and Kaylan Agnew provided assistance with manuscript preparation for this book.

I extend thanks for support of my research through invitations to be in residence as a visiting scholar at the Russell Sage Foundation in New York City (1996–1997), a fellow of the American Philosophical Society (2004–5), and a member of the Institute for Advanced Studies in Princeton, New Jersey (2011–12). In addition to sabbatical support, the Russell Sage Foundation generously provided support to convene a conference in New York City organized by me and my dearly departed colleague the anthropologist-psychiatrist Robert Barrett. In addition to spending a year together at Harvard, a decade later Rob and I worked together across a fourteen-hour time difference to produce our coedited volume, Schizophrenia, Culture, and Subjectivity: The Edge of Experience.. I express gratitude also to the School for Advanced Research in Santa Fe, New Mexico, for giving me the opportunity to convene an Advanced Seminar that resulted in the edited volume, Pharmaceutical Self: The Global Shaping of Experience in an Age of Psychopharmacology. Emily Martin kindly invited me to present work, represented in chapter 6, to her interdisciplinary and experimental seminar group Psyences at New York University in spring 2012. Thanks to Monash University and Renata Kokanovic for the invitation to be Distinguished Visiting Professor at Monash University in summer 2013 where pieces of this book were presented to audiences that provided useful feedback, as was also true for the kind invitation from Aaron Denham and Greg Downey at Maquarie University. Work presented in chapter 1 was made substantially better by those experiences. Warm thanks to Angela Woods for the invitation to attend and present work represented in chapter 2 at the annual Hearing Voices conference at Durham University, England, in September 2013.

I wish to acknowledge my gratitude also for comments that I received at invited lectures based on work in progress for chapters presented in this book: McGill University and Groupe Interuniversitaire de Recherche en Anthropologie Medical et en Ethnopsychiatrie (GIRAME) in Montreal; the Friday Morning Medical and Psychiatric Anthropology Seminar at Harvard University; Fundación Granja Taller de Asistencia Colombiana, Fundación Santillana and Departamento de Psicología, Universidad de los Andes, Santafé de Bogota, Colombia; Department of Psychiatry, School of Medicine, Gadjah Mada University, Yogyakarta, Indonesia; International Society for the Psychological Treatment of the Schizophrenias and Other Psychoses at Hospital General Universitario Gregorio Maranón, Madrid, Spain; Ethnografeast conference at the University of Leiden, the Netherlands; Department of Anthropology, London School of Economics; Wissenschaftskolleg, Institute of Advanced Studies, Berlin, Germany; Van Leer Institute, Jerusalem, Israel; European Science Foundation–sponsored conference, Department of European Ethnology, Charité-Universitätsmedizin and Humboldt-University Berlin, Germany; Institute of Social and Cultural Anthropology, Freie Universität, Berlin, Germany; International Conference, Theories of the Body and Anthropology in the Americas, Universidad de Buenos Aires, Argentina; Joint International Conference for the Society for Medical Anthropology (SMA) and Society for European Medical Anthropology (EASA), Fundació Universitat Rovira I Virgili, Tarragona, Spain; the UCLA Mind, Medicine, and Culture Seminar; presentations at the annual meetings of the American Anthropological Association and biennial meetings of the Society for Psychological Anthropology. In the run-up to the final version of the book (December 2014), I am grateful to Olga Odgers Ortiz and Olga Olivas for their gracious invitation to present the overall book project to faculty and graduate students at El Colegio de la Frontera Norte (COLEF), Tijuana, Mexico.

Among persons in the public eye with firsthand experience with extraordinary conditions that concern me in this book, I have been enormously enriched by conversations in London with Jaqui Dillon of the Hearing Voices Network;, with Eleanor Longden, clinical psychologist at the Institute of Psychological Sciences, University of Leeds, UK; jazz luminary Tom Harrell and his wife, Angela, of New York City; and Nobel laureate John Nash, who completed interviews with me in summer 2012 at the Institute of Advanced Study, Princeton. Funding for research reported on in this book was awarded me by the National Institute of Mental Health (NIMH R01 MH 33502, Course of Schizophrenia among Mexican-Descent Families; NIMH R01 MH 60232, Southwest Youth & Experience of Psychiatric Treatment; NIMH MH 60232, Culture, Schizophrenia, and Atypical Antipsychotics) and a Young Investigator Award on culture and depression from the National Alliance for Research on Schizophrenia and Depression.

Over the time that I have collected materials represented in this volume, I have had the good fortune to receive lively input from many additional colleagues and friends I wish to note: Helene Basu, Julia Cassiniti, Gilles Bibeau, João Biehl, Nancy Chen, Ellen Corin, Greg Downey, Aurora de la Selva, Esperanza Diaz, Susan DiGiacomo, Joe Dumit, Stefan Ecks, Javier Escobar, Sue Estroff, Didier Fassin, Angela Garcia, Joe Gone, Peter Guarnaccia, Sushrut Jadhov, Ann Kring, Alex Hinton, Devon Hinton, Ladson Hinton, Douglas Hollan, Michael Hollifield, Kim Hopper, Renata Kokanovic, Donna Kwilosz, Steve Lopez, Anne Lovell, Judith Lusic, Catherine Lutz, Lenore Manderson, Emily Martin, Jonathan Metzl, Juli McGruder, Daniel Lende, Tanya Luhrmann, Hazel Markus, Sheila O’Malley, Angel Martínez-Hernáez, Emeline Otey, Douglas Price-Williams, Jamie Saris, Louis Sass, Nancy Scheper-Hughes, Rick Shweder, John Strauss, Milton Strauss, Charles Swagman, Kimberly Theidon, Jason Throop, Joe Westermeyer, Susan Reynolds Whyte, James Wilce, and Kristin Yarris. At the University of California Press, I thank my exceptional editor, Reed Malcolm, and Stacie Eisenstark.

Portions of chapter 3 appeared in The 1990 Stirling Award Essay: Anthropology, Expressed Emotion, and Schizophrenia, Ethos 19 (1991): 387–431; Conceptions of Schizophrenic Illness as a Problem of Nerves: A Comparative Analysis of Mexican-Americans and Anglo-Americans, Social Science and Medicine 26 (1988): 1233–43; and "Ethnopsychiatric Interpretations of Schizophrenic Illness: The Problem of Nervios within Mexican-American Families," Culture, Medicine, and Psychiatry 12 (1988): 303–31. Portions of chapter 4 appeared in The State Construction of Affect: Political Ethos and Mental Health among Salvadoran Refugees, Culture, Medicine, and Psychiatry 15 (1991): 139–65; The Impress of Extremity: Women’s Experience of Trauma and Political Violence, in Gender and Health: An International Perspective, ed. Carolyn Fishel Sargent and Caroline Brettel (Upper Saddle River, NJ: Prentice Hall, 1996); and "Bodily Transactions of the Passions: El Calor (The Heat) among Salvadoran Women," in Embodiment and Experience: The Existential Ground of Culture and Self, ed. Thomas J. Csordas (Cambridge: Cambridge University Press, 1994). Chapter 6 is an expanded and revised version of an article that appeared as Psychic and Social Sinew: Life Conditions of Trauma among Youths in New Mexico, Medical Anthropology Quarterly 29.1 (2015): 42–60.

To treasured friends of many decades with whom I share great love, humor, and the safe haven: Stacie Widdifield, Holly Hainley, and Teri Hart. Stacie, an art historian, helped with book design issues, but we have long been dedicated to each other for so much more. Without Holly, the richness of chapter 1 could not have come into being; she single-handedly organized the project (and even the clinic that was the site of the study) with her gifts of sheer braininess, brazen creativity, and love of life. Teri, my sister and touchstone for all things, I love you. I could not begin to imagine my life without you at every turn since being teenagers reading Ram Dass’s Be Here Now and going to concerts in L.A. every chance we could.

To my daughter, whose fierce humor, intellect, and love never cease to astound: thanks for the care packages from New York with Agata & Valentina biscotti and teas to fuel the final writing. I thank my son for clever quips, musical innovations, and easy warmth that helps sustain life and work. To my husband and colleague, Tom Csordas, no words could begin to cut it. Approaching three decades together, our life is a fast train of love and creativity. Thanks for being amused by my daily quip, Day in and day out, it’s just one more damn day of anthropology. Despite the intense and near-constant work we are both bent on doing, there is a life and an anthropology that we share and love together, come what may.

Most of all I am profoundly grateful to the many people living with extraordinary conditions who allowed me and my research team entrée to their homes, clinic, and other settings to learn about their lives and what mattered. I am deeply honored to have had these engagements and to have learned from you. In the main, your desire to persist, prevail, and to be is nothing less than extraordinary.

Introduction

Culture, Mental Illness, and the Extraordinary

This book is an anthropological appraisal of life on the edge of experience, based in large part on studies that I carried out over the past three decades. I have come to think that a useful approach to such an undertaking is through the extraordinary conditions that define such life on the edge. My use of the term extraordinary conditions carries double meanings. In the first place, it refers to conditions—illnesses, disorders, syndromes—that are culturally defined as mental illness. However, I also mean conditions—warfare and political violence, domestic violence and abuse, or scarcity and neglect of basic human needs—constituted by social situations and forces of adversity.¹ My notion of the extraordinary emphasizes the nonordinary and spectacular qualities of mental illness in experience and representation. It also recognizes the compelling, impressive, and even heroic quality often evident in life at the edge of experience for both the afflicted individuals and their families. Central to my analysis of extraordinary conditions is the primacy of lived experience not only as possibility writ large but also as human capacity for struggle. I have observed this capacity across a range of conditions of extremity such as unrelenting depression, hearing voices, coming to terms with psychotropic medication, troubled emotional environments in families, flight from warfare and political violence, and children’s lives marked by extreme instability, abuse, and inadequacy of care.

The subtitle of this book, Culture and Experience in Mental Illness, is intended to invoke the enduring relevance of A. Irving Hallowell’s (1934, 1955) formulation of experience as culturally constituted. At the heart of this book is a continuation of my argument (Jenkins 2004) that conditions of mental illness must be understood as engaging fundamental human processes. A short list of these processes—which I take as invariably constituted by an intricate mélange of culture, biology, and psyche—includes self, emotion, cognition, gender, identity, attachment, and meaning. These processes are fluid rather than fixed. Indeed, they are hardly transparent among those not afflicted with mental illness; yet examining their modulations in the most extreme cases can help us understand how they work and why they are fundamental. Moreover, the chapters that follow cumulatively make the argument that perhaps paramount among fundamental human processes is the existential process of struggle. Recognition of struggle goes beyond the useful and increasingly prominent notion of individual resilience in the face of affliction. When we analytically elevate the study of struggle, we see beyond the usual conceptual categories of analysis and see instead a fundamental human process that comes to light as a product of an anthropological approach trained on lived experience.

As I hope to demonstrate, complex processes of struggle are remarkably salient across all the extraordinary conditions that I have had the privilege to engage through my research. Struggle is embedded in the often profound and even courageous social engagement with living, working, and caring for others despite an onslaught of subjective experiences diagnosed as schizophrenia and bipolar, depressive, and trauma-related conditions, along with the social stigma and discrimination that frequently accompany them. This is all too well known by those who live with or are familiar with such conditions. I invite those without such experience to imagine such conditions as the features of one’s daily life. The struggles are formidable: to get out of bed, to confront voices that torment, or to live with memories of the mutilated bodies of loved ones. Superimposed on these are daily life experiences of socially applied stigma meted out by the public for being perceived as different. There is the disdain exuded by a store clerk or fellow patrons when picking up one’s medication at a pharmacy, the sense of exclusion conveyed because one can neither speak nor understand the dominant language, the constant fear that neighbors might call immigration authorities or undertake practices of witchcraft for which one must seek spiritual protection. What it takes to subsist, let alone to prevail, under these conditions cannot be understood without an understanding of struggle. In sum, the studies presented here provide an argument for understanding struggle as a fundamental human process in conditions extraordinary and ordinary alike.

Integral to my anthropological approach is a commitment to understanding and describing human phenomena as distributed along qualitatively defined continua rather than as defined by discrete and distinct categories (Jenkins 2004; Canguilhem 1989).² In adopting this approach, I have found theoretical value in an emphasis on what arguably can be considered extreme or uncommon experience that defines the further ends of such continua, in contrast to comparatively more ordinary or common experience. As I detail in the chapters that follow, taking this methodological tack leads to a variety of instructive observations. For example, in examining situations of mental illness, it has become clear to me that as a matter of lived experience there is no such thing as individual pathology. These situations are invariably constituted by intersubjectivity, social and economic conditions of possibility and constraint, and the shaping of cultural expectations of persons in relation to gender, mental, and political status. My analysis of the interlocking domains of extraordinary conditions can be summarized precisely by the well-known feminist recognition of the reciprocal relations of the personal and the political.

An emphasis on the extraordinary is deeply revealing for an understanding of fundamental human processes and the creation of cultural meaning. The infelicitous manner in which persons with mental illness have been regarded as somehow lacking culture, treated sometimes as footnotes but seldom the primary subjects for ethnographies, has generated a host of anthropological problems requiring attention. In fact, people living with conditions of mental illness (the afflicted; their kin, communities, and healers) regularly create an array of meanings attached to their experiences. A number of these are examined in this book. For example, the examination of extraordinary conditions can reveal cultural processes of anthropomorphosis and personification of illness and pharmaceutical treatment in an experiential mélange of self/medications/illness. Likewise, such analysis shows the inaccuracy of defining people with schizophrenia as somehow less gendered or sexual beings. The ironic and erroneous quarantine in clinical psychology and psychiatry of the abnormal there and the normal here is theoretically and empirically untenable. In short, this book calls out the implicit normative social and health science tendency to ignore the extraordinary. Sequestration of the extraordinary not only does damage to the integrity of nonordinary subjects but also leads to intellectual peril for scholarly fields that indulge in it.

EXTRAORDINARY CONDITIONS IN AN ERA OF NEUROSCIENCE

In the United States, public representations of mental illness have become dominated by images produced by the pharmaceutical industry, on the one hand, and episodes of deranged gun violence, on the other. At once vexing and gripping, stories of mental illness are often accorded center stage in cultural attention. They proliferate in academic texts, newspapers, films, television, magazines, memoirs, pharmaceutical pamphlets, public health billboards, and innumerable Internet sites.³ The New York Times regularly features mental illness as front-page news in relation to recovery, treatment facilities, incarceration, homelessness, or the denial of care for military veterans. Public health campaigns directed at mental health are increasingly common globally, with slogans such as Defeat Depression, Spread Happiness in India, Chains Free in Indonesia, Una nueva comprensión, una nueva esperanza (A New Understanding, a New Hope) in Spain, El silencio no es salud (Silence Is Not Health) in Argentina, and Better Living through Chemistry or A Flaw in Chemistry, not Character in the United States.

In the current biogenetic era defined by the completion of the human genome project, the 1990s Decade of the Brain, and the Obama administration’s 2013 National Institutes of Health (NIH) initiative to map every neuron in the human brain, biologically based neuroscience dominates the research agenda for mental health and illness. The zeal for neuroscience at the expense of social scientific and other approaches raises concern for a variety of reasons. First, despite decades of research and enormous financial investment, neuroscience has not yielded specific markers or diagnostic tests that can differentiate one condition from another. The quest to identify underlying mechanisms has not been, nor will it be, productive any time soon since current studies of neural circuitry, tissue sharing, and genetics hold zero relevance for clinical care or epidemiology (Insel 2014a). Second, neuroscience seeks to understand mental illness as a brain disorder instead of as behavioral disorder. In this view, behavior and symptoms are endpoints of neurodevelopment, and paying attention to these consequences can only lead one astray from the scientific task of identifying causes and mechanisms (Insel 2014b; Insel and Gogtay 2014). While the brain is indisputably a site and source of things gone awry in mental illness, exclusive emphasis on core pathology confined to the brain excludes core pathology that exists in sites and sources that are social, behavioral, and economic. And although there is talk of the social brain, precious few neuroscientists have a basic grasp of concepts, theories, or methods for the examination of social realms. Since psychiatric neuroscience defines basic science largely in the absence of live human populations in real-world settings (Insel and Quirion 2005), the capacity to identify phenotypic or genomic expressions of illness is plainly impossible. Simply put, this is a question of balance, with prevailing scientific priorities gone awry.

Third, there is a lack of agreement on how to define psychiatric diagnostic categories. Prior to the publication of the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual (DSM-V), the current director of the National Institute of Mental Health (NIMH) critiqued the official nosology’s descriptive and classificatory approach as lacking in scientific validity (Insel 2014b). He further insisted that the DSM-V impedes research insofar as it defines disorders by their symptoms rather than by biological and genetic causes, asserting, As long as the research community takes the DSM to be a bible, we’ll never make progress. People think that everything has to match DSM criteria, but you know what? Biology never read that book (Thomas Insel, quoted in Belluck and Carey 2013:A13). This rhetoric of scientific authority offers a rather startling personification of biology. Such rhetorical moves are hardly inconsequential given that a growing number of scientists are convinced that a new paradigm is needed yet have not even a rough idea of what it should be.

Steven Hyman, former director of NIMH, has critiqued what he sees as the underlying model employed in the writing of DSM-V. This model assumes that psychiatric illnesses are discontinuous from the normal, with the result an absolute scientific nightmare. Many people who get one diagnosis get five diagnoses, he continued, but they don’t have five diseases—they have one underlying condition (quoted in Belluck and Carey 2013:A13). The question remains whether this condition is itself radically discontinuous with nonpathological experience. In this respect I again concur with Canguilhem’s (1989) identification of the ontological error in conceptualizing pathology in categorical versus continuous terms. Understanding disorders as entities not only objectifies and alienates them from individual experience but also creates an obstacle to understanding the modulations of experience across a continuum from normal to pathological, ordinary to extraordinary. Moreover, the logic that informs Hyman’s attempt to debunk categorical thinking remains susceptible to reducing the locus of disorder to a biochemical substrate rather than understanding it in terms of the existential totality of an afflicted person’s lived experience. In this situation more rather than less complexity is to the point, and to its credit DSM-V augments that categorical distinction between presence and absence of a disorder by recognizing multiple dimensions in diagnosis as well as degrees of severity (Markon and Krueger 2005; Regier et al. 2013).

It would be a mistake, following a strict interpretation of biological psychiatry, to view the successive iterations of DSM as progressively more accurate representations of an empirically stable domain of psychiatric disorders. Changing social conditions and cultural tendencies affect the manner in which and extent to which psychic distress is manifest in communities and populations. Scientific and clinical perspectives redefine normal as pathological and vice versa, recognize problems that previously existed but were ignored, and ignore problems that previously demanded attention. The field of psychiatry and mental health treatment is subject to a political economy of nosology under the powerful influence of pharmaceutical companies. Neurobiological and genetic factors invariably figure into this complex assembly (Gazzaniga 2011), not as determinants, but as factors that are themselves subject to cultural change and environmental modulation, as is increasingly evident in the recent development of epigenetics.

Likewise, the recent turn toward truly interdisciplinary social and cultural neuroscience provides a welcome challenge to one-sided biological accounts of mind and brain through movement toward theoretical integration of convergent factors (Hollan 2000; Lende and Downey 2012; Choudhury and Slaby 2012; Chiao et al. 2013). Interpersonal neurobiology has identified the process in which attention and social interaction entail neural firing across synapses, which forges new connections and changes in the internal biochemistry of the cell and ultimately cell structure; this neuroplasticity is especially evident in studies of mindfulness and attachment, and it has been invoked to argue for the biological effects of psychotherapy (Siegel 2006; Cozolino 2006; Fosha, Siegel, and Solomon 2009). Finally, there is intriguing speculation that the species-specific creation of the soul can be understood in part as a possibly unique evolutionary adaptation across a range of ecological environments, what Humphrey (2011) has termed a soul niche. Used appropriately, these developments can become part of the anthropological tool kit in the quest for a science of things divine, magical, mysterious, and maddening.

ANTHROPOLOGY AND PSYCHIATRY

Anthropology has a crucial role to play in making sense of mental illness as a feature of contemporary life for a variety of audiences with an interest or stake in psychopathology, as well as in sorting out biochemical, political, economic, spiritual, and cultural dimensions of the phenomenon. The basis for this role is that the study of mental illness is indispensable to anthropological understanding of culture and experience, and reciprocally an understanding of culture and experience is critical to the study of mental illness. As evident in the early writings of Franz Boas, Margaret Mead, Ruth Benedict, and A. Irving Hallowell, cultural anthropology as an approach to the study of humans was developed in full cognizance of mental illness as an existential and social problem, an internal threat to the coherence not only of individual but also collective experience. Similarly, in the field of psychiatry, early observations of mental illness by writers such as Emil Kraepelin and Sigmund Freud exhibited an appreciation of the importance of culture and differences among cultures. In the mid-twentieth century there were highly productive collaborations between anthropologists and psychiatrists like those of Edward Sapir and Harry Stack Sullivan and Clyde Kluckhohn, Alexander Leighton, and Jane M. Hughes. Unfortunately, subsequent attention to the study of mental illness and culture at the intersection of anthropology and psychiatry declined. In cultural anthropology, the primacy and particularity of mental illness as a key domain for theorizing culture goes largely unrecognized. In biomedical psychiatry, the central import of culture to the experience and manifestation of mental illness is similarly underappreciated. Ironically, cultural anthropologists became disappointed with the concept of culture, yet enamored of Foucault’s biopolitics and technologies of the self; and psychiatrists came to think that culture and experience had little or nothing to do with mental illness and became captivated with the neuroscience of biogenetics.

In light of this situation, I want to reassert the importance of research at the juncture of anthropology and psychiatry. Indeed, the extraordinary conditions of mental illness provide limiting cases for anthropological understandings of culturally fundamental and ordinary processes and capacities of subjectivity. The extraordinary sheds light on the ordinary from which it diverges, and the edge of experience (Jenkins 2004) helps define the spectrum of human behavior. By the same token, studies of mental illness shed light on psychopolitical problems of alterity and otherizing in the social rendering of persons diagnosed with mental illness as nonhuman or less than fully human; this is a problem that has never gone away and pertains to the larger group of dangerous others composed of madmen, children, women, savages, and foreigners. Ironically, the social stigma attached to mental illness in communities worldwide is only reproduced when cultural anthropologists relegate such persons and conditions to the status of footnotes, at best of little relevance to theorizing the structure, function, political economic, religious, cultural ecological, symbolic-interpretive, neoliberal, or ethical aspects of indigenous societies, nation-states, or global systems. My point is parallel to Virginia Woolf’s ([1930] 2002: 3–4) sense of wonderment that illness has not taken its place with love and battle and jealousy among the prime themes of literature. After all, illness experience is consuming and enigmatic (Gadamer 1996) and can bring about great spiritual change (Woolf [1930] 2002). While in literature there has since been extensive treatment of illness and the body, the same cannot be said in cultural anthropology or biomedical psychiatry.

This is hardly to say that the stage has gone dark since the mid-twentieth century. The publication in 1980 of Patients and Healers in the Context of Culture by Arthur Kleinman was as a gale force for cultural psychiatry and psychiatric anthropology. There now is a wealth of ethnographic studies on health and mental health showing both the importance of culture and the need to formulate careful accounts of subjectivity.⁴ There are also first-person memoirs of illness that owe much to Woolf’s (2002) concept that the ill actually live in a different world from the well (e.g., Saks 2007).⁵ Hybrid accounts are available, such as Kay Jamison’s An Unquiet Mind (1997), which combines autobiographical and psychiatric scientific accounts of manic-depressive illness, particularly in relation to creativity. Likewise, Emily Martin’s Bipolar Expeditions (2007) presents an in-depth ethnographic study of cultural models of productivity that systematically draws on cultural, historical, and first-person interpretations of bipolar illness experience. Recent accounts from the growing social movement of self-identified voice hearers often eschew the term pathology while also insisting on attention to violations of human rights and social justice (Deegan 1988; Greek 2012; Rudnick 2012; Longden 2012, 2013; Fisher 2014). Literature in phenomenological and existential anthropology offers a valuable platform for close consideration of lived experience and bodily being-in-the-world (Hallowell 1955; Becker 1995; Csordas 1994; Jackson 2005, 2012; Throop 2010; Duranti 2010; Hollan and Throop 2011; Desjarlais and Throop 2011). The analysis of narrative is a methodological locus for understanding subjective experience and transformation of self in a cultural context through stories or descriptions of conditions and events (Bruner 1990; B. Good 1994; Kleinman1988b; Orr 2006; Peacock and Holland 1993; Sacks 1990; Mattingly 1998, 2010). Finally, important work is appearing in the fast-expanding field of global mental health in the twenty-first century (Sorel 2013; Becker and Kleinman 2013; Opakpu 2014; Kohurt and Mendenhall 2015) for which the declaration no health without mental health has been increasingly recognized as compelling (Prince et al. 2007). This recognition is strikingly clear, since overall neuropsychiatric disorders rank number one among noncommunicable diseases and depression is the leading cause of disability worldwide (WHO 2008, 2009).

Against the background of these bodies of work, the concept of culture (and there are many definitions of culture, both inside and outside anthropology) is a critical element in a philosophical and ethnographic approach to an understanding of experience (Hallowell 1955). Culture is not a place or a people, not a fixed and coherent set of values, beliefs, or behaviors, but an orientation to being-in-the-world that is dynamically created and re-created in the process of social interaction and historical context. Culture has more to do with human processes of attention, perception, and meaning that shape personal and public spheres in a taken for granted manner. What do we pay attention to and how? What matters, and what does not? What is remarkable about Homo sapiens is that while the cultures we create can be characterized by a remarkable degree of patterning, they can virtually never be described as uniform within a society. They are often rife with idiosyncrasy and individual variation (Garro 1986, 2002), along with a complexity and diversity and even hyperdiversity (M. Good 2011) of perspectives within institutional settings.

For my purposes, a cultural approach to the extraordinary conditions of mental illness as experience is deeply implicated in the nature of the real or reality. To be precise: (1) reality is culturally constituted; (2) reality is inherently in question in the experience of mental illness on the part of those afflicted and their families; and (3) what is recognized as mental illness or affliction is influenced by culture. In this view, experience is the encounter with the real phenomena of self, others, and the world as this encounter is lived out in the actions and events of everyday life. Subjectivity is the relatively durable structure of experience that is yet subject to transformation based on changing circumstances and modes of engaging the world. A cultural perspective allows identification of the conditions (social, symbolic, material, subjective) under which, for example, a hammer and an ancestral spirit are equally real. In the case of contemporary medicine, symptom complaints are considered meaningful only if they can be identified as real pathology by means of objective evidence of disordered physiology. Moreover, reality and rationality are inextricably intertwined and linked to culturally and historically specific notions of belief, which apply in both religious and secular contexts. Indeed, there is a "close relationship between science, including medicine, and religious fundamentalism that turns, in part, on our concept of ‘belief.’ For fundamentalist