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 suggested that a diagnosis may offer spaces for resistance previously not available to a person, and as such may have adaptive qualities. For example, ukuthwasa, a form of ancestor possession that signifies a calling to become a healer, may offer the sufferer opportunities to change role and to ensure wider support from one's family network (Mills, 1985). When one examines the restrictions placed on a thwasa sufferer (most of whom are women), one can understand that it may represent a way out for women in oppressive situations. She must remove herself from public life and live away from her home with the igqirha(4)
. This means an unhappy home life or an abusive husband can be left behind. Because she removes herself from her previous social setting, many of the restrictions of that setting fall away. For example, the system of hlonipha, whereby a woman may not say any word containing the name of her husband or any word that sounds like it or has a similar meaning or any word relating to procreation (Buhrmann, 1977) restricts a woman's speech markedly. By taking on a new and superior role, this system falls away. A further restriction placed on a thwasa sufferer is that she must avoid all sexual contact in order to remain 'clean'. A woman who suffers from thwasa can thus legitimately leave her husband's house, kitchen and bed without fear of retribution. Additionally, many black women have limited participation in the economy and few opportunities to earn a living. Ukuthwasa may hold financial advantages. Being a sufferer may thus be empowering, as one of O'Connel's (1980:21) respondents implies: "A female diviner can do anything a man can do. She is a man. I am a man".
3. THE CONSTRUCTION OF MADNESS IS RELATED TO SOCIAL INSTITUTIONS
Parker (1992), following Foucault, stresses the need to analyse the relation between discourses and social institutions. Western conceptualizations of madness have increasingly become the domain of the psychiatric institution and of medical discourse, but also participates in penal institutions as well as other interest groups such as various mental health care professions and the psychopharmacology industry (see Breggin, 1992 for an extended discussion). Similarly, it could be argued that indigenous belief systems keep indigenous healers in business and also contribute in complex ways to the survival of cultural distinctiveness. Understandings of madness are thus not value-neutral but constructed in line with the needs of institutions, including the need to take ownership of areas of knowledge in order to promote professional survival (Rose, 1989).
In South Africa, psychiatrists, as medical experts, still have prime responsibility for the care and treatment of the 'mentally disturbed', although the world of community care and other professionals compete with them for influence and power. As such, several authors (e.g. Busfield, 1996) would argue that psychiatrists still monopolise the formal construction of the dominant social discourses through which mental disorder is constructed and imbued with meaning. Busfield (1996) shows that from a medical perspective mental disorder is viewed as a distinctive type of illness to be understood, as with other types of illness, first and foremost in physical terms, and is to be treated through physical intervention. It can be argued that these strong although varying emphases on physical causes and treatments of mental disorder are indicative of assimilatory tendencies (Rose, 1989). Foucault (1967) and others have argued that this trend can be traced historically and that psychiatry survived the nineteenth century by laying claim to mental disorder as distinctive.
4. THE CONSTRUCTION OF MADNESS IS RELATED TO POWER
In many ways it is artificial to proclaim a separate point that the construction of madness is related to power, since the workings of power operate at many levels of explanation. The relation between power and madness thus forms an overarching theme of this paper. Theories of the relation between madness and power have a long history. Three issues will be highlighted here: the relation between madness and political/professional power, between patriarchy and power and finally, following Foucault (1967) between knowledge and power.
Psychiatry, psychology and the study of the abnormal is one of the primary ways in which power relations are established in society. When abnormality and its corresponding norms are defined it is always the normal that defines the abnormal. It has been argued that political and professional power serves to police those who do not conform (e.g. Foucault, 1967) and to separate deviants or misfits from the rest of society (e.g. Rose, 1989). The workings of professional power, it has been argued, exercise power through calling upon the subject to participate in forms of (often scientific) knowledge which is constructed as truth. Thus Swartz (1996:150), for example, argues that the professional practice of rendering patients' histories as linear sequences of events which produce current symptoms is not a neutral technology. Through this, "patients are narrated into spaces which psychiatric knowledge has the power to explain". Other arguments regarding the relation between politics/professionalism and power have called upon Marxist arguments that western psychiatric practices participate in capitalist forms of control (e.g. Szasz, 1974). In the case study presented below, it could be suggested that professional institutions vie for markets (both monetary and ideological) through laying claim to bases of expertise and world view.
The relationship between patriarchy and madness has been noted by a number of feminist authors (e.g. Chesler, 1974; Ussher, 1991), who argue that patriarchy wields madness as a form of control and as punishment for those women who transgress patriarchal norms. Ussher (1991), for example, notes that, historically, women have been labelled as mad for being witches, rebels or heroines - for offering a challenge to patriarchal balance. Madness has similarly been used to excuse rape, although studies have shown that the vast majority of rapists are not 'pathological' (Scully & Marolla, 1984) and to pathologize race (Terre Blanche, 1997).
Foucault's (1967) historical exploration of madness has been drawn upon elsewhere in this paper. One of his central arguments is that the separation of 'reason' from 'unreason' into binary opposition is a fairly recent phenomenon, and that the division of 'reason' has become associated with 'normal' in a way which becomes increasingly difficult to deconstruct. He argues that the sequestration of 'unreason', partly through technologies of subjectivity (Rose, 1989), has highlighted normality through obsessive study and thought about the division between mad and sane. He suggests that the link between madness and unreason is not a logical, natural one, but one in which a number of troublesome groups in society can be labelled as mad. Ingleby (1982:128) expresses this view:
If we go back to first principles, what the 'mentally ill' have lost is not their bodily health, nor their virtue but their reason, their conduct simply does not make sense. Insanity ascriptions, on this view, are made when behaviour does not seem accountable to any plausible motive, or it seems to be quite unfounded: they may be ruled out simply by providing a credible motive for action or a reasonable ground for belief.
We have discussed four interrelated issues through which it may be said that madness is a social construction: that it is an active and changing concept, that it is not purely located within the individual, that institutions are influential in forming and maintaining conceptions of madness and that processes of power imbue every aspect of the construction of madness. A case study will now be introduced in order to illustrate some of these ideas and to provoke thought regarding broader use of taxonomies of madness in South Africa.
Case Study: Ancestors and aetiology
X, a young university student, presented at a local psychiatric hospital requesting therapeutic intervention after a confusing experience he was struggling to make sense of. The previous year his family had pressured him to undergo ritual circumcision. He felt this conflicted with his Christian beliefs and thus refused, triggering family conflict. At about the same time, he failed his university exams.
Soon after this he left on a journey to his home village. Before he arrived, he found himself naked in a misty forest on a hill. He relates that he could see figures and shapes, but no more detail than that. These figures spoke to him but he could not understand what they were saying. He remembers feeling confused and then does not remember anything else until he found himself bruised and sore in a village near his own. Apparently he had arrived at this village and been aggressive and incoherent. Some of the villagers had beaten him up, after which a friend of his family had taken him in. This friend then sent him home to his family.
His parents understood that these events had been caused because X had angered the ancestors in some way. According to X, they forced him to go to a sangoma, who confirmed the diagnosis and prescribed circumcision. He resisted the sangoma and eventually managed to return to his university town. Once back, he says he felt completely normal, ceased hearing voices, but was plagued by conflict regarding how to understand his recent experience. He felt that perhaps God had been trying to communicate with him, but was also plagued by guilt for having experienced something that might have been related to his ancestors. In this sense, he concurrently interpreted his experience in terms of his religion and in terms of his family's explanation. He decided to approach the biomedical institution for answers.
This case evoked heated debate in a subsequent case conference. Initially, this was centred around how to deal with 'cultural explanations' of X's experience coupled with a reluctance to label him as 'schizophrenic'. It was suggested that he be allocated a black therapist who would be able to understand his world view. Little reference was made to his fragmented relationship to his '"world view'. Discussion then shifted to focus on what 'precipitated' his 'breakdown'. It is suggested that the availability of this biomedical language framed as a universally important question opened space for a slippage into biomedical discourse. This may have facilitated the next discursive manoeuver. One person stated that, since this had clearly been a schizophrenic and possibly dissimulating episode, the probability was high that he would remit, and that therefore it was dangerous for him not to be maintained on drug therapy. This became the focus of the rest of the case conference. His complex experience had been reduced to psychopharmacology.
Interestingly, X only attended a few sessions of therapy and then left. No information is available about his subsequent experiences.
Unsettling meanings of madness
X's complex experiences and understandings present rich possibilities for a post-structuralist discursive analysis. He is graphically positioned within and between contradictory and powerful discourses which have strong institutional bases with which to hail him. It is not possible here to undertake a full analysis. Rather, the case study will be used to briefly highlight sites of conflict and contradiction and the relation between discourse and subjectivity. Issues of power and resistance will then be addressed in order to explore broader relations between biomedical and indigenous discourses.
VOICES COMPETING FOR DISCURSIVE SPACE: DISCOURSE AND SUBJECTIVITY
Three dominant and competing discourses can be identified relating to biomedical, religious and indigenous institutions. Each offers alternative opportunities for creating meaning and different possibilities for action. X's reason for referral can be related to him being caught between the various discourses and unsure where to position himself in relation to their contradictions. It is possible to understand his experience as a symbolic expression of his conflict regarding the different requirements of religious and indigenous discourses. Religious discourses require him to reject traditional values and thus the values of his family while indigenous discourses require actions and belief systems he feels unable to incorporate into his subjectivity exactly because of the requirements of religious discourse. Within this interpretation, it is interesting to note that his experience in the forest could be drawing on the indigenous discourses he is trying to reject. This particular geographical location is culturally accepted as a burial ground for the ancestors and thus a holy place in indigenous discourse. Conversely, then, religious discourse may locate this as a place of 'evil'. This provides some indication of how discourses may vie for power, not only at the level of language and institution, but also at the level of subjectivity.
An examination of the truth claims offered by indigenous versus biomedical discourses punctuates the different constructions of the person and different production of 'facts' offered by each. Positioned in relation to Christian religious discourses, X felt unable to participate in indigenous discourses but nonetheless experienced conflict between competing demands. His attempt to cohere his experience (approaching a psychiatric hospital) represented an invocation of biomedical discourse as a channel for reaching truth. It may be argued that this discourse required an equal refutation of religious discourse. In order to accept the truths offered by biomedical discourse, X would have needed to re-story his experience in terms of illness and deficit. Perhaps it underlines the power of biomedical discourse that X turned to science for answers to a question about the meaning of his experience. In the ultimate analysis, he was given a simplified answer (schizophrenia) but it could be argued that this foreclosure could not adequately account for all his subject positions. While he turned to biomedicine for answers, he also exited biomedical discourse once answers had been given, possibly as a result of the label's lack of explanatory power.
For X, the argument presented by some South African authors that biomedicine and indigenous taxonomies should be used in conjunction would not have been satisfactory. X did not incorporate either discourse unproblematically. This case may highlight how both discourses require self-policing and management of subjectivity. Both require discursive action which implies subjugation to the truth claims of the discourse. Prescription of drugs in biomedicine is akin to prescription of circumcision in indigenous taxonomies in the sense that both treatments demand that the subject submits to the truth claims at work. While this may be so for discourse in general (and thus not any more problematic than many of the discourses we participate in), the absolute commitment demanded of X was problematic for him. This illustrates how simple claims of whether indigenous or biomedical taxonomies should be used discount the conflict and complexity of experience.
This brief analysis of the discourses operating for X raises a number of points regarding theoretical conceptualizations of madness discussed above. His personal experience of madness was clearly mediated through a number of social expectations and practices. It could even be argued that his experience in the forest was a form of negotiation with social expectations involved (to be a good son; to be circumcised; to be a good Christian; to be a good student). Further, his personal experience became subject to social meanings and requirements. It is important to stress that it was not merely a case of different stakeholders offering him different explanations. Each explanation came with a social imperative to participate or to suffer the loss of subjective rewards offered by each discourse. While X describes feeling these imperatives on a subjective level, however, he also clearly illustrates that people are not passive to the social demands of the category of madness. In line with theory arguing that madness is a form of resistance, X's experience may have been an enacted resistance to the contradictory demands placed upon him.
For X, the claim that madness is an active process was experienced at the level of subjectivity, as he struggled to negotiating the available discourses to make sense of his experience. Definitional boundaries were fluid for him and not static. The claim that psychiatric labels are reductive, for example, was possibly experienced by him in relation to the inadequacy of the term 'schizophrenia'. A number of more general points seem to arise from this case study. We witness, in action, the contestation of boundaries between the realm of indigenous taxonomies (which place his experience in the realm of the spiritual) and biomedical taxonomies (which call upon the realm of the physical). It could be said that the two discourses compete for legitimacy and commitment, and that the requirements of each require an exclusion of participation in the other. Biomedical discourse may tolerate indigenous explanations, but is much less likely to tolerate 'non-compliant' drug use. Similarly, indigenous taxonomies may not openly exclude biomedical taxonomies, but require commitment which more insidiously excludes participation in both discourses.
The fiction of cultural and temporal universality is further highlighted by this case, raising pertinent questions regarding understandings of the various taxonomies in South Africa. We suggested earlier that a trend in South Africa is to uncritically romanticize indigenous taxonomies as natural, fixed and wholesome. Critical psychiatric literature (e.g REF) has similarly noted a reification of psychiatric taxonomies as static, transhistorical and imbued with scientific truth. The case study highlights that understandings are not even shared within a particular culture, even less between cultures. While it is more accepted that biomedical taxonomies ignore cultural specificity and historicity, it could be argued that so too do indigenous taxonomies. Indigenous discourses may imply that there is one culture that is shared by all those sharing ancestors. This is unable to account for the varied experiences of people. Further, indigenous discourse may call upon a notion of timeless wisdom passed down in untainted form from many generations ago. To think that indigenous taxonomies have not been influenced by the profound social changes of the last century seems to be naive and dismissive of the influence of current social configurations on presentation, understanding and treatment of madness.
THE ROAD TO TRUTH: POWER AND RESISTANCE
Issues of power have been highlighted through the case study and the paper; such issues are central to a post-structuralist analysis of madness. A Foucaultian analysis of power emphasises the bidirectional and pervasive nature of power and reconceptualizes power as productive rather than oppressive (Foucault, 1975; Parker, 1989). This framework examines the intersection between power and issues of subjectivity, discourse and the institution. The case study has been analysed in terms of contradictory discourses competing for power and, concurrently, different stakeholders exercising power in different ways. We can thus analyse power on a number of levels. For example, the power of the sangoma to hold X against his will is linked with the power of his discourse to give legitimacy to his prescriptions and actions in the eyes of X's family. Similarly, members of the medical profession have the power to commit X to an institution, but here power also works at the level of the case conference through which his experience can be transformed into a medicalised category through medicalised language. On a more diffuse level, it is noted that, while X was relatively clear on which discourse he wanted to position himself in relation to, the power of indigenous, biomedical and a range of other (e.g. family) discourses were such that he experienced conflict on the level of subjectivity. A Foucaultian explication of power has the further advantage of avoiding the portrayal of X as a helpless victim. His resistance first to the sangoma and then to the psychiatric team represented an important and shaping exercise of power, although it appears to have been gained at some cost to himself.
Thus some of the dominant institutions involved participated in the power matrices that emerged: indigenous healing system; psychiatric team; church (of which we know little - it could be speculated that X's next choice would be to approach the church for meaning). Many more institutions are at play (e.g. institutions of the family and of education) and we have illustrated the complex interactions between institutions and subjectivity on the level of lived experience. Focus on the two institutions most clearly represented in this case study - the biomedical and the indigenous - and their systems of discourse highlights their conflictual relationship. In conjunction with available literature, this case study illustrates their competing relationship and competition for legitimacy on the level of discourse as well as on the level of subjectivity. The final task of this analysis will be to examine this relationship more carefully, returning to Foucault's (1967) historical analysis of madness.
At first glance, it might be said that western and traditional taxonomies represent co-existing correlates of Foucault's historical analysis of differences in world view between modernity and pre-modernity. Such notions have entered popular discourse through metaphors such as the "noble savage". In this (naive) understanding, it might be said that biomedical taxonomies represent the pinnacle of the binary and valued division between reason and unreason (Foucault, 1967) where unreason is vilified and constructed as "to be fixed" by those who possess reason. Indigenous taxonomies, then, may be seen as a harkening back to pre-modernity where reason and unreason were in dialogue and the language of the mad stood to hold meaning. Thus we might say that the psychiatric staff aimed to chemically straight-jacket that which is not acceptable in society and label it as 'chronic' while the indigenous healer's aim was to prescribe a way to enter into dialogue with the social (in the form of appeasing the ancestors) with the aim of reincorporation.
Besides for the paternalistic overtones of this formulation, it appears problematic when one explores the implications of the fact that both metaphysics are linked by shared historical location and cultural availability. Such a formulation would only hold if the two were completely ostracized from each other. Further, because intersecting social discourses and practices overlap between the two metaphysics, it becomes possible that they are both, at least in part, subject to similar social imperatives. Upon reflection, this implies a new binary opposition between the biomedical and the indigenous, an opposition in which both are constructed as transhistorical. In this way, both conceptions resist change and therefore constrain the subject through the terms of participation in that discourse. Both are also competing for legitimacy. We have aimed to illustrate that both participate in power relations and that both demand conditions of inclusion and exclusion. If one is positioned in relation to possible access to either, the binary opposition (which implies that values are attached to each taxonomy) undermines the option of a simple choice between them. By calling on one discourse, one must also negotiate the other discourse set in relation to it. Both taxonomies are important and dominant in the lives and meanings of many South Africans, and we suggest that to sequester the one from the other or to accept either uncritically is to ignore the complexity of the issues at play.
This paper has called for a more critical approach to all available explanatory frameworks of madness and has focused particularly on the complex relations between biomedical and indigenous frameworks. The case study drawn upon portrayed a person caught between competing discourses and struggling to find meaning. Other people may have very different experiences. We have hoped to show through the case study and theoretical discussion that to understand constructions of madness, it is necessary to understand the person's narration of self as well as the intersection of this with available discourses and power dynamics. We call particularly for a recognition that the narration of meaning is not a categorical process nor one removed from broader discursive struggles and networks.
Deconstructive approaches have been criticized as nihilistic and paralysing (Burman, 1990), leaving few strategies to negotiate a way forward. Our aim has been to demonstrate the usefulness of deconstruction in critically examining taken-for-granted knowledge in order to open opportunities for more sophisticated understandings which are able to recognize discourses at play. This has practical utility for South Africa at a point of transition nationally and, more specifically, at a point where mental health policy is being radically reformulated. Deconstruction offers opportunities for reconstruction, which in turn offers opportunities for movement and change.
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1. The term "madness" is used in this paper in order to avoid drawing on either biomedical or traditional taxonomies and in order to highlight the problematics and shifting meanings of this term.
2. Details have been changed in order to preserve confidentiality. It should also be noted that the author (Long) gained access to this case study through the secondary source of participating in the case conference referred to in the paper. As such the interpretations offered rely heavily on the subjective experiences and reconstructions (from clinical notes) of the author. The case study presented here has been offered for verification to fellow participants at this case conference. This paper does not claim to offer objective truths (of which the author, along with others (e.g. Giddens, 1976; Hollway, 1989; Parker, 1992) regards as an unattainable methodology for the social sciences). Rather the aim is to enter debate around interpretations, using these as a starting point for future critical thought around the issues raised in this paper.
3. The purpose of using this case study is to use a specific example to discuss broader issues of discourse and the broad interaction between discourses and institutions. The authors in no way wish to imply that the specific clinicians involved in the case were inappropriate. The focus is on the case and not on the specifics of intervention.
4. A Xhosa word signifying a type of indigenous healer.
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