Wednesday, November 18, 2009

Ethnography of a Psychiatric Ward: The Meaning of Psychosis

“What’s the point?” she asks. She looks fragile as she sits in that chair, her shoulders drooping and her face nearly hidden by the pink hoodie she’s pulled over her hair. She looks at the doctor with a bit of frustration in her eyes, her hands digging themselves deeper into her hoodie’s pockets.

“It’s gone, and I feel good. Isn’t that all that matters?”

Doctor Mourad leans back, and lets out a subtle sigh. Then he responds:

“But it’s important that we talk about this, you and me, so that I can help you.”

The consultation is suddenly interrupted when the door swings open and another resident walks in. She shares this consultation room with Dr. Mourad, and she’s here to pick up her bag. As the two physicians exchange a few pleasantries, I notice the patient’s head sinking lower and lower, until it is cradled by her hands. Rhythmic tremors running through her shoulders betray that she is crying.

But she has not given in. After the female resident leaves, Dr. Mourad tries again, to no avail. He is hoping to convince his patient to talk about her experience of possession by what she calls a diable, a devil (or, in Arabic, a shaitan*). I cannot help but think that he’s doing so in part for my benefit; ever since the doctors on this ward have learned about my research interests, they are constantly calling me in to observe their interaction with patients who claim to have been possessed or cursed – an experience the doctors categorically define as a particular kind of hallucination. None have been as unwilling to discuss the subject as this young woman, and I am struck by her defensiveness.

Her next argument calls on notions of expertise and authority, as she hopes to excuse herself from the responsibility of having to explain what happened to her:

“You shouldn’t ask me,” she says. “I don’t know anything about jnoun, diables or shaitans. All I know is what it says in the Qur’an. If you want any explanations, don’t ask me. You need to talk to an expert, some kind of scholar.”

The doctor tries to explain that he’s not interested in theory; he just wants to know what happened to her. But it’s no use, and a few minutes later we escort the patient back to her room. She’s staying in the closed women’s ward: a dreary concrete courtyard where about twenty five very sick women spend their days doing little more than wandering around. Paint flakes off the walls and ceilings, there is little more than a few rusty old hospital beds to sit on in the recreational room, and a stale smell of abandonment hangs in the air. It is a far cry from the state of the art facilities where I spent my first week at the Clinic. Having moved on to a third ward at the time of writing, I’ve learned that this closed ward is by no means representative of the rest of this hospital. Nevertheless, it struck me in its sadness, and I think the difference in environment between this and other wards is worth exploring.

The dreariness of this ward is matched by a complete lack of stimulation or activity for the patients. Doctors tell me that a hair dresser comes to the ward to do the patients’ hair once in a while, and nurses will sometimes hang out with the women, listening to music or dancing a little. But there is no exercise equipment like there was on the addiction ward, nor are there musical instruments, books, or a television. Nothing is allowed on the ward; in their psychosis or suicidality, a fair amount of these women cannot be trusted not to do something harmful. On the one hand, I wonder how these women make it through the day, with nothing to do. On the other, even I can see that the majority of these patients are too sick to be able to participate in any kind of activity.

Most of the patients on this ward suffer from a psychotic disorder. They are heavily medicated: each morning, the nurses enter the ward with a tray full of Haldol, Largactil,** and other anti-psychotics and tranquilizers. The medication is often administered by injection – pills can be refused, I guess. There is no privacy; each room accommodates five to six women. Without curtains or doors to hide behind anywhere, patients are injected right there on the courtyard, en plein public.

Despite this medication, the women seem truly sick. Many of them spend their days walking around the courtyard, talking animatedly to the voices in their head. They slur their speech when they talk, and jump from one subject to the next. They crowd around the locked glass door that separates the ward from the nurses’ area, and sing famous Sherine songs.*** When they notice me, sitting there with the staff, they blow me kisses, and call out that I’m trop belle. A few of them even begin to recite the Fatiha, the first verses of the Qur’an. I’m struck by this ‘strange’ lack of inhibition, and take it as a sign that these women are really sick. Nevertheless, when that glass door opens and they all come in to greet me, they are friendly, and normal, and simply curious. They just want to know my name, where I’m from, how I’m doing. The next day, I see genuine recognition in their eyes as they greet me again.

A lot of the patients, the doctors tell me, believe they have been possessed, or cursed. One of the residents tells me, almost self-consciously, that for a psychiatrist, this is a hallucination. An anthropologist might feel differently, she adds, but for her, it is part of a psychotic symptomatology. I don’t have time to respond – she’s in consultation with a patient at the moment, and simply turns to me once in a while to ‘translate’ what the patient is saying into psychiatric terms. But it makes me realize that I need to come up with a ready answer for questions such as these. I am so often asked these days if I believe in possession, or in the effectiveness of countercurses. Regardless of how I might feel about these issues, I think I’ll say “I don’t know.” True objectivity is an illusion, I know that, but I think it’s a better idea not to weigh in on these questions with the people who are participating in my research, and try to maintain some kind of neutrality.

A central question in my research, however, is what happens when two different theories about mental illness meet. What does it do to a person’s experience of being sick, when his or her belief about possession is explained (dismissed?) by a psychiatrist as a ‘hallucination’? I cannot help but wonder if this has anything to do with that young woman’s unwillingness to tell Dr. Mourad about her experience. As we talked about her reticence, Dr. Mourad explained that she might worry that her diable will come back if she talks about it. Alternatively, she might be afraid that talking about devils will lead doctors to conclude that she warrants longer hospitalization. Dr. Mourad, however, feels that she will not truly be well enough to leave until she is able to talk openly about her experience. I can see his point; I tend to believe in the idea that talking – externalizing – provides a necessary kind of catharsis. Nevertheless, I wonder what it’s like for a patient like this young woman; to be asked to open up about a very traumatic experience to someone who might not agree about what that experience meant, and who has no more than twenty minutes a day to speak with you.

All of it makes me wonder about the nature or definition of ‘pathology’. Who has the right to define what’s normal and what’s not, and who gets to decide what it all means, or what should be done about it? I’m thinking here not just about the meaning of possession. Aside from these beliefs, another problem most of the patients had in common was a history of prostitution. Nearly every patient I met on the ward had, according to the doctors, engaged in some kind of prostitution at some moment in time. This behavior was often seen as a symptom of illness: a sign of mania, or psychosis. Some patients talked openly about it all, while others denied ever having sold their bodies – a sign, for the psychiatrist, of that patient’s impaired judgment. I couldn’t help but wonder, though, whether it might not be at least a little understandable that a woman might deny having engaged in something considered to be so shameful?

In addition, I wonder how much cultural beliefs and social expectations have weighed in on the high occurrence of ‘prostitution’-as-pathology among these patients. Morocco is a modernizing country, but extramarital sex is still, and will probably long remain, highly unacceptable for a woman. Does that mean, I wonder, that the definition of ‘prostitution’ here in Morocco is broader than ours? Once, when discussing an alcoholic male patient’s extramarital affairs with girls, a resident insisted that he must have slept with prostitutes. Anything else was simply not possible, she said; any girl who has extramarital sex is by definition a prostitute. Perhaps some of these female patients had engaged in behavior that, by Western standards, would not necessarily be termed prostitution? And in the same way, I wonder if the particular unacceptability of extramarital sex might mean that doctors here are more likely than elsewhere to label promiscuous behavior as ‘pathological’? Excessive promiscuity is often included on lists of the kind of reckless behavior that the DSM-IV lists as a possible symptom of mania, or various personality disorders. Nevertheless, I wonder if cultural mores weigh in here to create this particular tendency to label people with deviant sexual behavior.

I spent a lot of my time on this ward in a chair in the nurses’ lounge, observing the women on the ward through that glass door. And as they crowded up against that door to wave or sing to me, I began to wonder: what really is the difference between me and them? Aren’t we both curiously and unabashedly observing the other? I am as interested in them as they are in me. As a foreigner I, too, don’t always behave according to the social rules. Aren’t I, then, as abnormal as they are? When the nurse pulls a screen in front of the door, I am not sure whose gaze she is trying to avert – theirs, or mine.

I had hoped to do my research on this ward, but the level of pathology might pose a problem. I can interview only those who are capable of understanding the goals of my research, and of providing informed consent for participation. I did not meet a single patient who would have met those criteria – an observation later corroborated by most of the residents. I haven’t yet visited the open women’s ward, but hope this may be a better fit. Part of me is relieved, not to have to spend a few months on that dreary, tragic ward. But the other part of me continues to think about the women I’ve met there, wondering how they’re doing now, half a week since I last saw them, wondering also where they might end up, once they leave the Clinic.

* though curiously, this woman argued that a diable is not the same thing as a shaitan. It was one of the few things she was willing to explain – though she couldn’t tell us what exactly the difference was. I continue to be intrigued by the way in which Moroccans mix French and Arabic - and her distinction between these two concepts interestingly contradicts the idea that the two languages are conceptually interchangeable...
** Largactil is known as thorazine in the US, I believe.
*** Sherine is a famous middle eastern singer. Egyptian, most likely.


Anonymous said...

Love your posts Charlotte. Especially when you give your insights when you are watching the patient and you feel she is obsevering you as much as you are her. Then they put the screen and you ask if its to protect you or the patient. Regards Irfan.

Charlotte said...

Thank you so much, Irfan!