BOOK REVIEWS Schizophrenia, Culture, and Subjectivity: The Edge of Experience

As Arthur Kleinman notes in the Preface of this volume, the current dominance of biological psychiatry has relegated social factors in schizophrenia to the back burner. While acknowledging the importance of biological investigations, Jenkins and Barrett have compiled an edited volume that attempts to advance a cultural approach to the study of subjective experience in schizophrenia. It seeks to understand the relationships among an illness, a person, and a person’s lived world; in the process, it provides mental health professionals with new approaches to considering the relevance of culture and context to the experience of illness, expression of emotions, sense of self, and family interactions. The volume is organized into three sections that elaborate an analysis of schizophrenia based on cultural theory from contemporary anthropology. The chapters in the first section, “Culture, Self & Experience,” attempt to open up the black box of culture and how it shapes the experience and expression of illness. Jenkins (chapter 1) suggests that schizophrenia offers a unique opportunity for studying culturally fundamental and normal social processes. She notes that the experiences of people with schizophrenia can be quite ordinary, but also warns of negating their extraordinary and intense experiences. While Jenkins’ chapter and many others in this book suggest that contrary to common belief, people with schizophrenia have both ordinary and extraordinary experiences, the title of the book suggests otherwise. While catchy, it unfortunately suggests that schizophrenia exists only at the edge of experience. The remaining chapters in this section examine the vague and careless notion of culture employed in much of the schizophrenia research and illustrate how culture shapes the subjective experience of illness as well as how people with schizophrenia use culture to accommodate their symptoms and experiences. Interestingly, Barrett (chapter 3) found that culture not only influences how schizophrenia is experienced, but also what symptoms people experience. While investigating the experience of first rank symptoms, he encountered difficulties translating the Present State Examination into the language of the Iban of Malaysia. The Iban people could relate to the items about auditory hallucinations; however, they found questions about the subjective experience of thought disorder nonsensical. Barrett discovered that the Iban had no cultural model of thoughts being read or broadcast, and thus reported these symptoms significantly less often than a comparison group in Australia. Barrett suggests that rather than assuming this difference is a result of the methodology of translation, psychiatric research would be wise to explore culture as a mediator of subjective experience in schizophrenia. He emphasized that “comparative cultural phenomenology requires ethnographic underpinning” (p. 107). The second section of the book, “Four Approaches for Investigating the Experiences of Schizophrenia,” juxtaposes ethnographic, sociolinguistic, clinical, and historical approaches and each perspective’s contribution to the understanding of the lived experience of schizophrenia. For example, Wilce (chapter 7) employs frame-by-frame analysis of videotapes of family interaction in Bangladesh. He demonstrates the disruption in intersubjective communication and the attempts by family members to mend it. More clinically oriented, Diaz, Ferguson, and Strauss (chapter 8) use life story narratives of individuals participating in a rehabilitation program for persons with mental illness who are homeless in Columbia to examine the subjective experience of recovery. They note how illness explanations change over time to allow for definitions of illness as treatable. The authors also highlight the significant survival skills that patients developed while homeless, and the importance of meaningful work to their recovery. The final section of the book, “Subjectivity and Emotion,” contains four chapters examining dimensions of emotion in schizophrenia. Using different approaches, Sass (chapter 12) and Kring and Germans (chapter 13) challenge the notion that negative symptoms represent a diminishment of subjective experience and higher or more selfaware forms of conscious life. Contrary to this belief, Sass suggests that these symptoms are a response to “hyperreflexivity” and “loss of natural self evidence. ” In effect, people with schizophrenia may lose their commonsense orientation to reality, which normally allows one to ignore many details taken for granted and attend to new and novel information. Thus, the person must attend to every minute detail. This will “disorganize the normal goal oriented quality of experience,. cause fatigue, but also detach a person from the normal sources of emotional and instinctual engagement with the world” (p. 308). Kring and Germans’ final chapter provides evidence that persons with schizophrenia experience at least as intense emotion as others, both in response to emotionally evocative material and in everyday life. The illness does not rob them of emotional experience but prevents them from displaying emotions outwardly. The authors note the tendency to discount as inaccurate patients’ reports of symptoms if they do not coincide with clinicians’ judgments. Consistent with this observation, Estroff (chapter 11) found themes in the narratives of consumers/survivors/expatients related to feelings of having their experiences of illness invalidated by mental health professionals. While it is difficult to acknowledge that researchers and clinicians who have not experienced schizophrenia personally can never completely “get it,” we can-