Ingo Lambrecht
This Mãori greeting is a manner of respect for the space from which one speaks. In an oral tradition, as key notes are, in many cultures, the respect for the land we stand on and the presence of your ancestors is a mindful connecting practice.
In the name of transparency regarding cultural positions taken for this key note occasion, I am German, having trained and practiced as a clinical psychologist in South Africa, qualified as a sangoma, a South African shaman, whilst writing my PhD on trance states, and for the last nearly twenty years, I have been living and working in New Zealand. I shall speak from various positions on psychosis and culture, some psychological, some philosophical, some shamanic, with a bit of a twist in regards to compassion at the end.
Saturation of culture:
It is obvious that psychosis itself s permeated, patterned and modified by culture everywhere all the time. Voices, thoughts and behaviours are transmitted and dominated by gods, ancestors, evil spirits, demons, jinns, angels, telegraph lines, computer code, the matrix, and any other acceptable cultural forms (Larøi et al, 2014). Now transmissions occur via radio waves, television, computer, internet, aliens, etc.. Tomorrow it will be artificial intelligences. We cannot think ‘psychosis’ without culture, nor are we outside of it.
Furthermore, the culture and content of psychosis are very important determining factors when it comes to whether hallucinations or delusions are chronic, whether they are considered normal or abnormal, and even determines the course and outcome of treatment. It is now known, much to the embarrassment of modern western bio-psychiatry that full recovery of psychosis is 10 times higher in traditional versus modern western cultures (Satorius et al, 1986). The assumption first was, well, they’re from agrarian societies, they have simpler lives, they should therefore get better quicker. The issue is still alive in that when they replicated the research, it merely confirmed earlier findings (Hopper & Wanderling, 2000). Importantly and related, in Japan, Hong Kong and Singapore they had better outcomes. Maybe the difference is not just low economic or high economic development but rather what cultural factors are involved (Castillo, 2003).
It could be considered a western scientific delusion that I know ISPS always challenges, namely that psychotic distress is an ahistorical object of science and therapy. The manual of DSM-5 is a very good example of that. Some of the last chapters are dedicated to ‘cultural concepts of distress’ (American Psychiatric Association, 2013, 749-759). This is very curious, because it is as if every diagnosis of mental illness in prior chapters before the ‘cultural concepts of distress’ are free of culture, therefore objective and scientific, although of course these diagnoses and criteria were set up mostly by upper-middle class, white, committee members.
Patterns of the dominant culture:
In order to consider culture, especially other cultures, it is wise and helpful to stand at the edge of one’s own culture, the dominant western culture in a position of critique, here meant in a philosophico-political manner. A common position for a person with psychosis is to be an object of science or the subjective voice of recovery. Foucault’s critique of the modern episteme, so dominant today, is that we are trapped in an “empirico-transcendental doublet” (Foucault, 1994, 318), within two basic epistemological positions, the object or the subject. Thus, we can fall into different positions on psychosis, namely positivism or phenomenology; Cognitive Behavioural Therapy (CBT) or Psychoanalysis; Dialectical Behavior Therapy (DBT) or Mentalisation Based Therapy (MBT); Bio-Psychiatry or Recovery Movement. The positivism of biological and genetic search for the cause of ‘schizophrenia’ finds its partner in bio-psychiatry, whilst the voice of the subject, so revered in phenomenology and the recovery movement creates an antidote, a counterpoint. This is equally true for therapeutic interventions in psychosis, to put it into some sharp relief, the mantle of objectivity is carried by the call of evidence-based and skills orientated therapies such as CBT and DBT, whilst psychoanalytic therapies and MBT seek to formulate subjectively felt inner mental states, and are of course equally evidence-based.
This eternal modernist doublet plays itself out in endless discussions and debates between certain professionals and expert experiencers, between different therapeutic modes, and I think it’s incredible that ISPS can hold that space of critique and inclusion. This is relatively rare. For me it’s a dialectic that occurs within the modernist culture, the specific manoeuvres within these modernist cultural boundaries. Therefore, in western culture on psychosis there is a huge emphasis on the rituals of random control trials, and if the focus or devotion is on the object of knowledge, then RCTs are really appropriate and important. Such knowledge can truly be productive. Equally, the notions of factory efficiencies in hospitals make sense from this cultural stance. We learn from Toyota, a car manufacturer, how to do efficacy better.
However, we cannot totally be reduced to the bleakness of widgets in an organisational machine without subjectivity and values emerging as a necessary resistance or antidote, the other side of the epistemological doublet. Here values and care matter, thus recovery and expert experiencers find their empowered social justice voice. Just as there are diamonds in this voice, there is also the dark side of the subjective experience. Who is more real? Who has more heart? These are the important difficulties to address. The tyranny of subjectivity is not to be underestimated. In the current western academic knowledge, the discursive manoeuvres, as in any culture, have a specific pattern, and in this modern case it is a specific epistemological doublet. Different cultures may hold psychosis differently because they consider rationality and consciousness differently. This is especially evident in indigenous communities, where the master of extreme states of consciousness would be traditional healers or shamans.
Clinical experiences of psychosis in other cultural spaces:
Shamans or traditional healers of indigenous cultures across the world go through an apprenticeship that is often harrowing and distressing with extreme states of consciousness (Winkelman, 2010). Psychoanalysts, psychologists and psychiatrists have viewed this process as quite psychotic (Walsh, 2007). I’ve witnessed such psychotic features in initiates of various shamanic trainings, and I appreciate how, from a western len,s they must seem psychotic. However, not all psychoses in other cultures are the same.
It is worth considering hearing voices as an example. Distressing persecutory hearing voices, together with a withdrawal from socio-occupational functioning would within a western psychiatric framework would be understandably be considered as being hallucinatory, and clearly a form of psychosis. However, in South Africa, the sangoma as a South African shaman distinguishes between voices as distressing spirit communication from ancestors, as very different from those distressing voices of evil spirit possession. For the sangoma in South Africa, the distinction is made between amafufunyana and ukuthwasa. Ukuthwasa is an initiation illness that is the result of the possession of ancestors, and requires training to become a sangoma. Amafufunyana is also a possession, but of evil spirits, and these two states can present quite alike. In terms of western psychiatry, they would appear virtually similar, but for a sangoma, amafufunyana needs healing, whilst ukuthwasa needs training (Ngubane, 1977). This is not unlike psychoanalytic training. In order to become a psychoanalyst, an analysis is necessary in order to challenge our own darkness and processes. Equally, the shamanic training requires its own journey through darkness by training the ancestral or divine voices towards becoming an effective healer. This has also been highlighted by many western thinkers, who define initiation illnesses with psychosis as spiritual emergencies (Grof & Grof 1989), mystical states with psychotic features (Lukoff, 2011) occurring within the hero’s journey (Campbell, 1968).
Very briefly, some of the distressing spiritual states with psychotic features that I have worked with are ukuthwasa and amafufuyna, the Kundalini syndrome, which is often found in the east and now occurring in the west. This is an experience which can occur usually during meditation practices, but at times spontaneously after a traumatic event, , in which the person is overcome by powerful sensations, such as intense hot energy surging through their body, and at times presenting with overpowering grand ideas, voices, and exquisite bliss. Qigong psychosis can be triggered through certain body exercises. Within the traditional Chinese medicine model, it is understood as being the result of an imbalance of chi or energy rushing to the head, which leads to distress, and therefore can evoke psychosis. Similarly, Mate Mãori is an illness that Mãori, the indigenous people of New Zealand, struggle with. Matakite is when distressing visions and voices appear, not all such voices are understood as an illness, but can be a message from the ancestors. Makutu is a form of being cursed, and that can lead to very strong beliefs of persecution. Within such cultures, these conditions are distressing states of consciousness, painful processes that deserve healing and training (Lambrecht, 2017a).
Equally in the east, training of consciousness through meditation is achieved by shifting states of consciousness, and finally arriving at enlightenment. Such training occurs over many years, a life time, and in some Eastern models, many life times. The valuable point to be made here is that, because there is an understanding of different states of consciousness that lie beyond mere waking consciousness, the western science or academia has no understanding of other forms of pathological states of consciousness or madness. In Zen, for example, certain psychoses or pathological states of consciousness on the path to enlightenment may lead to being drunk on states of emptiness, with flights of grandiosity and ego grasping in the attempt to achieve an enlightened experience. Another pathological state is defined as a meaningless and ego deflatedness, in which a person is trapped in a state of endless witnessing with a dissociative, and disconnected ego, never fully grounded in life (Clarke, 2010). So other cultures have other forms of awareness about delusions and stress that are psychotic-like that seem unknown in western scientific academic cultures. This hopefully provides a sense, a little taste, of what other cultures can hold in terms of consciousness and psychosis. Therefore, because they have other ways of understanding consciousness, maybe madness is also different.
However, as these states can shift, these states can also be healed or mastered. The shaman often moves from being a victim of spirits or voices to a master of them (Lambrecht, 2014). Similarly, Debra Lampshire (personal communication 2006) has pointed out that a meaningful relationship with voices shifts a person from being a victim to a master of voices or extreme states.
It is worth mentioning that in regards to research, consumers seek an integration of the best of both worlds, western interventions together with traditional cultural practices (Lambrecht & Taitimu, 2012). Very briefly, my clinical work with the distressing state of psychosis in different cultures, with reference to spirituality, as well as paranormal and exceptional experiences, includes all the therapeutic practices such as normalisation, validation, regulation, and integration. This is placed within appropriate cultural practices true to the person I am working with. I have written elsewhere about applying the term ‘spiritual holding’, which I have adapted from Winnicott (Lambrecht, 2017b). This notion of spiritual holding acknowledges the exceptional experiences with all the therapeutic practices mentioned above. Importantly, this means that also social and political factors need to be taken into consideration.
Concluding reflections:
I wish to just highlight that my work in other cultures has really served me well to hold my own tradition quite lightly, as well as everyone else’s for that matter. I equally want to be very careful to address that, just because everything’s cultural, doesn’t mean that everything it’s right or valuable. This addresses the notion of absolute relativism. For example, is female genital mutilation acceptable because it is a cultural practice? Instead of referencing Western postmodern thinkers such as Derrida or others in this regard, I would like to bring up a Buddhist philosopher Nagarjuna (150-250 CE), just to show that these complex considerations have been addressed in other cultures many hundreds of years ago, very often not acknowledged in western philosophy. Nagarjuna had a lovely way of putting it this way: not too much construction, not too much deconstruction – a middle way. This means holding culture and psychosis lightly, because absolute relativism is as problematic as rigorous essentialism. Even the concept of ‘culture’ as a term is actually quite ‘empty’ (Goode & Sander, 2013). Dialectics or dialogues become challenging for absolutes of any kind, even the absolute of culture.
This is why compassion becomes really important. Not only do compassion exercises modulate the neural circuitry of emotions (Lutz et al, 2008), but they also counterbalance the infinite regress of deconstruction and meaninglessness. Culture is a doorway to hold things more lightly in myself and others but within the light of compassion. My truth is not the only one, nor is it irrelevant. So much suffering because of differences, so much excitement because of differences, so much curiosity because of differences. Compassion allows me to hold such differences. I do just want to end by thanking ISPS for an openness that has always struck me. ISPS has been kind enough to let me speak about strange topics at many conferences, be it about visions and voices with hallucinogens, based on participant research of course, or presenting with Debra Lampshire on shamanic voices versus expert experiences. They have provided space to explore talks on the Kundalini Syndrome, speaking to Mãori mental health and spirituality in Wairua and Psychosis. I believe ISPS holds culture and psychosis really well, and I really want to thank ISPS for providing a compassionate space for different positions to flourish.
This is all summed up in only a few of Rumi’s words, a Persian mystic and poet of the 13. Century:
I have lived on the lip of insanity,
wanting to know reasons,
knocking on a door.
It opens.
I’ve been knocking from the inside.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.
Bourguignon, E. (1973). Introduction: a framework for the comparative study of altered states of consciousness. In Bourguignon, E. (Ed.) Religion, altered states of consciousness, and social change. Columbus: Ohio State University Press, 3-38.
Campbell, J. (1968). The hero with a thousand faces. Princeton: Princeton University Press.
Castillo, R. (2003). Trance, functional psychosis, and culture. In Psychiatry. 66 (1), 9-21.
Clarke, I. (2010). Psychosis and spirituality: consolidating the new paradigm. Chichester: John Wiley & Sons.
Foucault, M. (1994). The order of things: An archaeology of the human sciences. New York: Vintage Books.
Goode, G. & Sander, T. (2013). Emptiness and joyful freedom. Non-Duality Press. Salisbury, UK.
Grof S. & Grof, C. (1989). Spiritual emergency: when personal transformation becomes a crisis. New York: Tarcher.
Hopper, K. & Wanderling, J. (2000). Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: Results from ISoS, the WHO Collaborative Follow up Project. Schizophrenia Bulletin, 26(4), 835-846.
Lambrecht, I. & Taitimu, M. (2012). Exploring culture, subjectivity, and psychosis. In Geekie, J., Randal, P. Lampshire D. (Eds.) Experiencing psychosis: first-person and research perspectives. London: Routledge, 44-54.
Lambrecht, I. (2014). Sangoma trance states Auckland: AM Publishing.
Lambrecht, I. (2017a). The distress of makutu: some cultural-clinical considerations of Māori witchcraft. In White, R.G., Orr, D., Read, U. & Jain, S. The palgrave handbook on global mental health: socio-cultural perspectives. London: Palgrave MacMillan, 549-563.
Lambrecht, I. (2017b). Psychoanalytic reflections on wairua and trauma: spiritual holding at a Māori mental health service in New Zealand. In Ata: Journal of Psychotherapy Aotearoa New Zealand, 151-159.
Larøi, F., Tanya Marie Luhrmann, T.M., Bell, V., Christian Jr, W.A., Deshpande, S., Fernyhoug, C., Jenkins, J., & Angela Woods, A. (2014). Culture and hallucinations: overview and future directions. Schizophrenia Bulletin. 40 (4), S213–S220.
Lukoff, D. (2011). Visionary Spirituality and Mental Disorders. In Cardeña, E. & Winkelman, M. (Eds.). Altering consciousness: multidisciplinary perspectives. Volume 2: biological and psychological perspectives. Oxford: Praeger, 301-326.
Lutz, A., Brefczynski-Lewis, J., Johnstone, T., & Davidson, R.J. (2008). Regulation of the neural circuitry of emotion by compassion meditation: effects of meditative expertise. PLoS ONE. 2008; 3(3): e1897
Moskowitz, A. & Corstens, D. (2007). Auditory hallucinations: psychotic symptoms or dissociative experience? Journal of Psychological Trauma. 6, 35-63.
Ngubane, H. (1977). Body and mind in Zulu medicine. London: Academic Press.
Read, J., Mosher, L.R., & Bentall, R.P. (Eds.).(2004). Models of madness: psychological, social and biological approaches to schizophrenia. New York: Brunner-Routledge.
Satorius, N., Jablensky, A., Korten, A., Ernberg, G., Anker, M., Cooper, J., & Day, R. (1986). Early manifestations and first-contact incidence of schizophrenia in different cultures. Psychological Medicine. 16, 909-928.
Walsh, R.N. (2007). The world of shamanism: new views of an ancient tradition. Minnesota: Llewellyn Publications.
Winkelman, M. (2010). Shamanism: a biopsychosocial paradigm of consciousness and healing. Oxford: Praeger.