UNSETTLING MEANINGS OF MADNESS: CONSTRUCTIONS OF SOUTH AFRICAN INSANITY
Carol Long & Estelle Zietkiewicz
University of the Witwatersrand
Post-Structuralist accounts of madness (e.g. Foucault) illustrate that categories of madness are not fixed or objective, but rather participate in productive and exclusionary practices in the exercise of power. Madness in South Africa is often understood to be the realm of expertise of either the biomedical psychiatrist or the sangoma. It is argued that both of these traditions often construct madness as historically static and amenable to non-contradictory categorization. This paper explores constructions of madness in South Africa drawing on analysis of a case study in which these two traditions collide. We explore the intersection of madness with the institution as well as with broader power dynamics, arguing that such constructions elide the workings of power by drawing on discourses of ahistoricity.
The status of indigenous healing in a reformed health system has been the focus of much debate in South Africa (e.g. Freeman, 1990; Seedat, 1997; Swartz, 1986; 1987; 1996). Many writers have called for the inclusion of indigenous healing in mental health considerations (Freeman, 1991; Seedat, 1997; Swartz, 1996), although a recent mental health policy document (see Pillay & Freeman, 1996) is notably silent on the issue of indigenous healing as well as on understandings of the explanatory frameworks (see Kleinman, 1988) clients draw upon in order to make sense of their experiences. The general consensus appears to be that inclusion of indigenous healing into Western frameworks of treatment can only be beneficial (Seedat, 1997; Swartz, 1996), although Swartz (1996) notes that there is little evidence to support the efficacy of indigenous healing and that many have failed to consider the political implications of dialogue between the two paradigms or to approach the debate critically. Studies have suggested that many South Africans draw on both biomedical and traditional taxonomies and treatments in order to address their "madness"(1)
(e.g. Letlaka-Rennert, Butchart & Brown, 1991 in Seedat, 1997; Lund & Swartz, 1998) but, as appears to be the case with biomedical explanations, there has been little critical analysis of what indigenous taxonomies bring with them or on how biomedical and indigenous explanatory frameworks intersect in the lived experience of those drawing upon them. Seedat (1997:264), for example, maintains that "liberatory psychologists will enhance their discourse if they remain sensitive to ordinary, other-than-western discourses of illness" (emphasis added). This elides possibilities that, as post-structuralists have successfully argued is the case in biomedical taxonomies of madness, "other-than-western" discourses are as able to participate in sites of power, constructing such "ordinary" taxonomies as simple, unproblematic and unitary. Such conceptualizations of indigenous discourses contain a host of uncritical assumptions of indigenous healing as pure, natural and, ultimately, nonetheless "Other". Further, the possibility that individuals may incorporate such discourses into their subjectivity in contradictory and conflictual ways has been inadequately explored, particularly regarding experiences of the interface between biomedical and indigenous discourses of madness.
This paper takes as its starting point theories of social constructionism and post-structuralism which undermine truth values in any available taxonomy of madness. In terms of this framework, we argue that taxonomies construct madness in different ways and offer different narratives for people to position themselves within. Further, this construction is not understood as neutral. Constructions of madness set up power relations between "sane" and "insane", allow the justification of certain practices, offer possibilities for inclusion and exclusion, offer constructions of "truth" and "expertise", all of which may be incorporated into subjectivity and lived experience and which support certain institutions (Ff Foucault, 1967). In suggesting that madness is socially constructed, we do not intend to discount the personal pain experienced by those labeled as 'mad', but we do argue that 'madness' does not purely exist in the realm of the personal, unaffected by linguistic constructions and praxis.
Through exploring post-structuralist ideas, it will be argued that neither biomedical nor indigenous taxonomies of madness in South Africa are value-neutral and that both need to be considered in a more critical light. Because of the broad availability of both discourses, we examine more closely the intersection of the two contradictory discourses, drawing on a case study(2)(3)
in order to illustrate the complexities involved in being located at the intersection of competing discourses of madness. The aims of presenting this case study are to deconstruct emergent contradictions of lived experience in relation to discourse and to introduce complex and, no doubt, controversial debates regarding the status of the various taxonomies of madness dominant in South Africa at the present time.
Meanings of madness: A Post-structuralist account
A number of post-structuralist accounts of psychopathology (e.g. Chesler, 1974; Foucault, 1967; Parker, 1995) aim to provide an historical account of the construction of madness in order to problematise the boundaries that separate madness from normality, to undermine static understandings of madness through tracing changes in construction over time and to deconstruct the truth values and power relations implicit in conceptualizations of psychopathology. Deconstruction offers us ways of tackling the inherent contradictions in psychiatric texts. The task of deconstruction is not only to explore medical conceptualisations of mental disorder, but to move beyond them and to offer alternate ways of thinking about mental disorder by locating it in a broader social context and analysis of social relations. One of the aims is to disrupt, unsettle or explode the neat categorization of madness. Post-structuralist accounts (e.g. Foucault, 1967) illustrate that categories of madness are not fixed or objective, but rather participate in productive and exclusionary practices in the exercise of power. Any post-structuralist analysis of the existence of madness, must consider several theoretical strands which emerge from the philosophical and epistemological literature generated from this perspective.
1. THE CONSTRUCTION OF MADNESS IS AN ACTIVE PROCESS
Many critical post-structuralist understandings of madness critique the biomedical psychiatric model's conception of madness as universal, ahistorical and clearly demarcated in terms of neat diagnostic categories (Kaplan & Sadock, 1991; Wetherell, 1996). They argue that current Western conceptualizations of madness as static and definable offer particular constructions which facilitate a web of power relations and institutional claims. Instead, it is argued that madness is an active concept constituted by culturally and socially relative categories whose precise boundaries and meanings vary over time and are highly contested.
The charge that madness is historically located and not universal is sublimely illustrated by Foucault (1967) in Madness and Civilization, where he traces a radical disjuncture between conceptualizations of madness in the middle ages (when it was possible for madness to be constructed as the voice of genius or divine inspiration, and when insanity was in dialogue with sanity) and conceptualizations which influence our current understandings. Foucault (1967) argues that current taxonomies are based on notions of binary opposition between sanity and insanity, oppositions which police the boundaries of society and justify the exclusion of problematic members of society through the compelling logic of scientific truth. Although it is not possible here to provide an exposition of this work that justifies its complexity, this work represents a seminal illustration of the historicity of conceptualizations of madness. The historicity argument has been explored through other work, and is confirmed by the observation that the ICD is in its 10th revision and the DSM in its 4th, and that categories have not remained stable over time (Busfield, 1996).
The argument that madness is culturally specific is stated in its milder form in terms of the notion of "culture-bound syndromes" (DSMIV, 1994; Littlewood & Lipsedge, 1989). The argument here is that madness cannot be universal because different cultures exhibit different manifestations - madness takes on a distinct symptomatology which is only found in a particular culture. A local example would be amafufunyana (e.g. Edwards, Cheetham, Majozi & Lasich, 1982) which has been described as violent, uncontrollable behaviour understood to be caused by spirit possession and often results in the sufferer speaking in languages not their own (Lund & Swartz, 1998). One of the difficulties with this argument is that assumptions of static, clearly definable disorders remain. Interestingly, Lund & Swartz (1998) imply that conceptualizations of amafufunyana are in themselves not static but have been differently described by sufferers and in the literature. A stronger form of the cultural specificity argument would suggest that madness differs culturally not only in terms of manifestation, but also at the level of basic underlying assumptions influencing issues of explanation and treatment. This is often articulated in terms of Western-Traditional differences, in which Western conceptualizations are understood as ostracizing whereas traditional systems include the mad within the system. While it will be suggested later that this version may be simplified, there does seem to be indication that madness is not universal at symptomatic or explanatory levels (Parker, 1995).
A third focus of post-structuralist critique interrogates the contested boundaries of madness. Russell (1995) shows that a major epistemological concern is that the objects of study, namely mental illnesses or mental disorders are by no means conceptually clear. Nor is this epistemological concern diminishing as categories shift and change with each new edition of the major classificatory systems (Russell, 1995). In examining these issues it becomes useful to identify three contested changing boundaries or oppositions to mental disorder: physical illness, social deviance and mental health. Busfield (1996) notes that mental disorder stands in a difficult and precarious position between bodily illness and social deviance, and there is an ongoing struggle between various professionals and social theorists as to where the boundaries should be set.
The location of the boundary between physical illness and mental disorder has long been contested both within the medical profession and without (Ussher, 1996). It has been shown, for example, that whether a particular constellation of symptoms is deemed a mental or a physical illness depends largely on the interests of the professionals and lay people involved (Busfield, 1986). While disputes over the boundary between mental disorder and physical disorder have been dominated by professional rivalries within medicine, the boundary between mental disorder and social deviance has been a matter of rivalry between the medical profession and the law (Smith, 1980; Walker, 1968 in Ussher, 1991). Decisions on cases of this nature are not just a matter of the power and potential of competing discourses and attendant values, they are linked to service provision.
The final boundary of interest is the imprecise and ill-defined distinction between mental disorder and 'normality'. Indeed while the categorical thinking usually involved in medical classifications (and typical modernist thought) has usually presumed a boundary between sickness and health (a binary opposition), many have argued for a dimensional view where there are gradations of health and sickness, and hence only an arbitrary cut-off between the two (Goldberg & Huxley, 1992).
However, shifting systems of classification have shown boundaries to be permeable and fluid
It has effectively been shown (Busfield, 1996) that categories of mental disorder and psychiatric classification constitute practical devices - they serve as intellectual lenses attempting to impose clarity and order on the complexity of human states, structuring thought and practice and providing recipes for action. What is clear is that the constructions of psychiatrists and other mental health professionals change - and that professionals develop and improve their skills to better monopolize the territory.
Therefore, while psychiatrists may find it relatively straightforward to offer a formal definition of the concept of mental disorder via their listing of specific types of disorder, determining the precise boundaries is far from easy in practice. Parker's (1995:4) comment that "notions of madness and abnormal psychology as we understand them are particular and peculiar to our culture and our time" is becoming a more widely accepted and a less controversial view as the precariousness of boundaries around madness becomes more apparent. The theoretical correlate of this point is the slippage between signifier and signified following Derrida. In fact, what this paper hopes to illustrate is a radical disjuncture between signifier and signified in that it seeks to unhinge taken-for-granted meaning from madness.
2. THE CONSTRUCTION OF MADNESS IS PERSONAL AND SOCIAL
Madness has most often been constructed as a personal trajectory that the individual negotiates through a web of social resources - in most of the traditional literature it has been constituted as highly individual, personal and private (Swartz, 1996). Critics of the construction of pathology (e.g. Rose, 1989) have argued that social constructions become incorporated into subjectivity, such that the subject's personal experience is appropriated by the dominant discourse. For example, Swartz (1996) argues that despite the observation that patients are described in stereotypical ways, they may begin to see themselves in ways that conform to institutional expectations. Critics argue that the construction of madness as personal eclipses the workings of the social.
One argument that has been put forward suggests that madness can be understood as a symptom not of personal distress but of social distress. Ground-breaking critical theorist Phyllis Chesler (1972) and later Luce Irigaray (1985) began to argue that the high rates of mental disorder among women could be explained through social repression. Their argument suggested that women were oppressed by their gender roles and that this oppression may give rise to "madness" since women are necessarily alienated from their female role. Irigaray (1985) argued that identity is tied up with sexuality and that under patriarchy women's sexuality has been conceptualised in male terms and that women had not been allowed to speak for themselves about their desire and their pleasure. Further, this silence was held in place by the linguistic and logical processes which structure thought. Similarly, it has been suggested that amafufunyana can be understood as a "symptom" of racial inequality (e.g. Weiss in Swartz, 1986). This is supported by the fact that amafufunyana first appeared in the 1920's when intergroup conflict began to escalate in South Africa (Wessels, 1985).
Simultaneously authors such as Szasz (1974) and later Foucault (1967) ushered even more radical externalist (social) explanations which implied that the mad identity has little to do with the distressed person's own problems, hopes and fears and much to do with the purposes (professional, policing , government) of the groups and agencies wielding the labels. Szasz's particular argument was that socio-economic hardships in life produce stress in vulnerable individuals. In terms of this argument, madness is defined by and controlled by the social. An oft-quoted example of this is the inclusion of homosexuality as a diagnosable disorder up until 1973.
A third understanding of madness is that it forms resistance to the social. Goffman (1961) notes that despite the stereotyping of patients, many still retain a sense of their own uniqueness and are able to resist and form oppositional decodings of institutional structures by choosing when to conform and when not to. Some have su