Racism and Immigration

Arguably the most important discovery in the recent social epidemiology of schizophrenia is that the illness does not occur at a fixed rate across the globe as researchers used to believe, but at variable rates. One of the best documented cases is among the African Caribbean community in Britain, where the risk for schizophrenia is as high as fifteen times the rate for the local white community. Rates among the African-Caribbean British are much more elevated than rates among African-Caribbeans living in Jamaica. The author argues that there are five features of social experience within the community that may contribute to these increased rates: social inequality, racism, social fragmentation, increasingly fragile cultural identity, and community “expressed emotion.” This chapter describes a British African Caribbean woman living with schizophrenia.

Introduction

The introduction lays out what we know about the social context of schizophrenia from the epidemiological literature: that risk of schizophrenia is particularly high for immigrants from predominantly dark-skinned countries to Europe; that risk increases with lower socioeconomic status at birth and even at parent’s birth; that risk increases with urban dwelling and seems to increase the longer time is spent in cities; that risk increases as ethnic density in the neighborhood declines. The chapter presents a history of the way schizophrenia has been understood in the United States, and the diagnostic complexities of serious psychotic disorder. It then discusses what ethnographers have observed so far about the social conditions which may shape the experience of psychosis: the local cultural interpretation of mental illness; the role and presence of the family; the structure of work; and the basic social environment. This becomes the ground for our case studies.

Demonic Voices

Charles is a young man living in Accra who hears voice that he interprets as those of witches and demons. This is not bizarre or unusual in the context of the local cosmology in which spiritual attack by malevolent others is not uncommon; Charles’ social world consider it plausible that he may be under spiritual attack. However, when he confronts his father’s tenant—who is bewitching him in order to seduce him—his father thinks that there is something more. This results in Charles’ first hospitalization. Supported by Ga religious beliefs and Pentecostal Christianity, Charles’ direct experiences of gods and demons transform his everyday existence into a constant battle between forces of good and evil, where his protection is Christian prayer and the strength of his spirituality.

Voices That Are More Benign

Persons with schizophrenia and other serious psychotic disorders often experience a wide range of auditory events. We call them “voices,” but in fact, people hear scratching, buzzing, bells. They hear voices inside their heads and voices that seem to come from outside, from the world. Sometimes the voices are clear; sometimes, indistinct. Sometimes they make kind and even admiring remarks (“You’re the one. You’re the one I came for.”) Sometimes they are horribly mean. Sometimes they command, and sometimes they comment. In general, on average, people with schizophrenia in India are more likely to experience their voices as people they know or as gods, and in general the voices are more benign than they are for many patients in the US. That may make it easier to live with them. This chapter considers the voice-hearing experience of a Chennai housewife with schizophrenia.

Faith Interpreted as Madness

Alexandria is a poor Romanian woman who obtains solace and support from a community of evangelical Christians. Alexandria lives with delusional guilt that she is responsible for many evil crimes. Having borne a son out-of-wedlock while living with her impoverished mother in her village, Alexandria is hospitalized for mental illness. With the compassion and fellowship of her new Christian friends, Alexandria finds acceptance and hope. However, in the context of post-socialist Romania—formerly Eastern Orthodox and currently striving for all that is modern—evangelicalism is so unfamiliar as to seem bizarre. The psychiatrist treating her at the publicly-funded psychiatric hospital where Alexandria lives is baffled by her religious experience and thinks of them only as signs of mental illness. Alexandra’s story illuminates the way fledgling religious movements (here, evangelical Protestantism) may collide with established religious sensibilities and biomedical protocols for treating schizophrenia.

Madness Experienced as Faith

Spirit possession is what anthropologists call a common “idiom of distress” in India. That is, anthropologists observe that spirit possession is a way of behaving that signals emotional trouble. Spirit possession in India often begins with intense distress to the afflicted. However, through negotiation and attention to its desires, possessing spirits may be transformed from malevolent to beneficent. Sumita is a devotee and long-term resident of the Balaji temple in Rajasthan, India. After her marriage, demands for dowry, domestic violence, and Sumita’s growing awareness of the destructive spirits living in the walls of her husband’s home, her in-laws expel her from their home. After numerous stays in publicly-funded psychiatric facilities, she is brought by her father to the temple of Balaji, where she begins to hear the voice of the deity. Sumita manages to eke out a marginal existence by passing on the divine revelations of Balaji to worshipers at the shrine. In this way, her spirit possession may participate in the construction of a valued social identity in which voices and visions are signs of the divine and not solely associated with a permanent, crippling illness.

Diagnostic Neutrality in Psychiatric Treatment in North India

In India, doctors deemphasize diagnoses and the biomedical specificities of what are essentially grave conditions, like schizophrenia. They don’t talk about diagnoses or treat diagnoses as important, at least when interacting with their patients. As a result, they leave many possible ways to imagine the future intact. This may widen the range of possibilities for living in the present. This chapter describes the way two sisters who each meet criteria for schizophrenia understand their problems.

Conclusion

Schizophrenia is a disorder with causes that are endogenous to the body including genetic vulnerability and the decay of neuronal connections. However, there is evidence that individual vulnerability to psychosis is increased by the experiences of discrimination, despair, trauma, and failure. Drawing upon epidemiology and animal biology, this chapter argues that repeated social defeat increases the risk of developing psychosis. Further, social defeat, especially in the United States, is a regular experience of those who who live with a serious mental illness. The case studies of persons with psychosis in this volume illustrate the social and cultural factors that may be responsible for outcomes. How psychosis is understood, whether available work can accommodate the ill individual, the type of family involvement, the social and cultural backdrop, and the meaning of symptoms are factors that mitigate or exacerbate illness. The final section of this chapter presents some recommendations for how the lives of those with psychosis might be improved.

A Fragile Recovery in the United States

After her father’s suicide, Meg’s distress intensifies until she can no longer do her work and she is fired from her job. She loses her apartment and ends up on the “institutional circuit” of shelters, half-way houses, and public services for the indigent mentally ill in a large city. Meg experiences the arbitrary-appearing rules and grinding despair of this life until she began receiving disability benefits for schizoaffective disorder. While Meg did not work for pay, she is able to create a meaningful life with friends and family, and her interests in art and music. As such, she has achieved the outcome envisioned by the Recovery Movement. Yet the chapter also illustrates the social factors which make this recovery difficult.

Return to Baseline

Ta is a school teacher living in Bangkok. She suffered episodes of debilitating psychosis during which she is so completely caught in an evil spirit world that she cannot interact with other persons or even take care of herself in basic ways. However, what was remarkable is that between episodes, she is completely free of any symptoms of schizophrenia. Over the course of ten years, Ta’s lucid periods have become less lucid and her episodes of “spirit sickness”—as she calls them—less separate from reality. This development has allowed Ta more control over her hallucinatory experiences. Now, she can sometimes force demonic spirits to go away, or summon beneficent spirits to help herself or others. The chapter illustrates a form of psychosis that appears to be more common outside of western settings.