Schizophrenia, culture and the person

Schizophrenia exists in ‘all corners of the earth’ (Lin & Kleinman, 1988, p. 555). We find patients with the symptoms of schizophrenia in Western and non-Western societies, in urban and rural areas, in small, isolated villages upon the mountains and in extremely isolated island societies. ‘This mental illness is no myth’ (Kleinman, 1991, p. 35). A still unexplained finding however is the more favorable course and outcome of schizophrenia in developing countries compared to Western countries as demonstrated in several WHO studies of schizophrenia (Jablensky, Sartorius, Ernberg et al., 1992; Hopper & Wanderling, 2000; Hopper, 2004). Lin and Kleinman (1988, p. 563) even speak of this as ‘the single most important finding of cultural differences in cross-cultural research on mental illness’.

Although we are not sure how this difference in outcome can be explained, social isolation is regarded as one of ‘the few strong predictors of the outcome of schizophrenia’ (Lin & Kleinman, 1988, p. 561). ‘Most developing societies are “sociocentric” with an emphasis on social relations … that make isolation unusual even for the disabled. In contrast, Western societies are “egocentric”. In these societies, relationships are more likely to be bilaterally defined … and subject to constant re-evaluation’ (Lin & Kleinman, 1988, p. 561). For example, in India there are many more married people with schizophrenia compared to Western countries (Hopper, 2004). Marriage seems to be associated with good outcome. Most marriages in India are still arranged. The institution takes over the responsibility of the individual.

Findings like these cannot be translated easily in our Western society. It is not credible to ‘prescribe’ marriage as a remedy for an unfavorable course of schizophrenia. A prearranged marriage is at odds with our value of free will. But we cannot ignore the fact that the most vulnerable individuals in our society have trying times with the fierce competitiveness that forms the other side of personal freedom. In the way schizophrenia manifests itself through the individual in Western society, it is not only symptoms of the disease that are reflected but also the inherent values of modern times.

In research carried out in Montreal, Corin compared a group of men with schizophrenia who were regularly re-hospitalized with a group who had been without hospitalization for four years. ‘Unexpectedly’, she finds, ‘that the group of non-rehospitalized patients is significantly characterized by features indicating a position “outside” of the social world’ (Corin & Lauzon, 1992, p. 269). Both groups lived a marginal life. There were some contacts with relatives. Now and then they visit a friend. But the difference was that the more regularly hospitalized group felt excluded while people from the second group experienced the social distance as a positive thing.

This research teaches us to look at the meaning of symptoms in a different way. The socalled ‘negative symptoms’ express themselves in the form of a withdrawn and apparently flattened existence. We can regard these negative symptoms as a part of the disease, but we can see them also as an expression of how a vulnerable individual with a history of psychotic episodes relates to the world. In this way so-called negative symptoms are in fact a positive construction that enables a vulnerable individual to stand their own ground in Western society. Corin (1990, p. 172) speaks of a positive withdrawal. The prevention of relapse seems to be connected with keeping the world at an appropriate distance.

Each person has their own way of being-in-the-world. We all look for a meaningful relationship to the world. The kind of relation depends on who we are, the culture we are brought up in, and the world we are living in. The same goes for people with schizophrenia — apart from the fact that, at the beginning of their adult life, they suffered one and usually more psychotic episodes that destroyed their original way of relating to the world. They are faced with the task of forming a new connection. Corin (1990, p. 182) speaks of secondary relating elements, building a new bridge to the world.

It is about very concrete matters, like visiting a friend now and then — frequenting small, anonymous restaurants (like MacDonalds), with superficial but recognizable contact with the waitress — doing little jobs — making preparations for a large project (which will never get off the ground) — reading for hours and hours in an etymological dictionary — trying to link up with a religious group. Corin claims that two trends are conspicuous in ‘the positive withdrawal’. Firstly, ‘withdrawal is described as enabling the person to find inner peace, to settle things with oneself; in solitude’. Second is the important role of religion: ‘reference to a broadly defined religious frame borrowed from marginal religious groups allows them in someway to inhabit their private world, to protect and reinforce their withdrawal by giving it a positive value’ (Corin, 1998, p. 139).

At first sight, living in the margins seems to be in contradiction with the lifestyle of Western culture. However, Corin (1990, p. 183) claims that this way of being-in-the-world reflects the most important values of our Western culture: autonomy and self-reliance. These people are too vulnerable to function autonomously in the usual way. In the absence of the social institutions of non-Western societies, where people with schizophrenia can find support, they have to find another way to keep at pace with the culture they are brought up in. By keeping the necessary distance from society, which they bridge over with these peculiar secondary relating elements, they can stand their ground in their own autonomous way.

In our Western society there is little room for difference. You are in or you are out. We strongly value freedom and self-realization, but subsequently they have to be realized in an equal manner. ‘In such equalitarian treatment difference is disregarded, neglected, or subordinated and not “recognized”’ (Dumont, 1986, p. 266). Apparently we are tolerant towards each individual, but as soon as the individual is leading a truly different life, as a person with a mental disorder, there are only two possibilities. You participate (after hospitalization) in a psychosocial rehabilitation program where you learn to recover according to the uniform values (a regular job, sufficient social contacts, compliance to treatment) or you are forced to live a marginal life. Being different is tolerated but not valued.

People with schizophrenia in Western society are more at risk of developing a chronic course. ‘Industrialization, capitalism and the shift to different socioeconomic work conditions paralleled the creation of ever more individualistic and autonomous selves’ (Fabrega, 1989, p. 45). There is an intensive individualism (Lin & Kleinman, 1988) that ‘may interfere with recovery for many schizophrenic patients’ (Kirmayer, Corin & Jarvis, 2004, p. 213). The self is singled out in Western society. ‘A consequence of this was a change in the appearance, interpretation and treatment of disease states like schizophrenia’ (Fabrega, 1989 p. 45).

A psychotic experience questions the fundaments of self. People with schizophrenia are searching for more than a causal explanation of their illness (Corin, Thara & Padmavati, 2004). Problems are ‘seen as a sign of something involving their fundamental identity, for example, a sense of a mission that might remain enigmatic, or a sign of their devotion to lord Shiva’ (Kirmayer, Corin & Jarvis, 2004, p. 217). Cultures other than our Western culture and subcultures might provide ‘meaning systems that allow people to positively reframe frightening or disturbing experiences’ and to integrate these experiences in their lives (Kirmayer, Corin & Jarvis, 2004, p. 212).

Schizophrenia ‘challenges fundamental notions of who and how we are’ (Estroff et al., 1991, p. 332). A person-centered approach should reckon with two visions of schizophrenia. On the one hand there is the work of Davidson and Strauss, in which the person and the sense of self are considered crucial factors in the recovery from schizophrenia. This approach aims for an improvement in the sense of self for a person with schizophrenia. On the other hand there is the social and cultural anthropology which shows that an unfavorable course of schizophrenia might be connected with too much emphasis on the self-reliant person. A person-centered approach should look for ways to embed the self at risk in a larger whole, in a way that is acceptable for the person.