What does it mean to say a culture shapes the expression of mental dysfunction? I bungled that question a few days ago in "Batman Movies Don't Kill, But They're Friendly to the Concept," my post about Batman movies and James Holmes. Even friends who got what I was getting at told me I hadn't really made the case well. Heeding that top item on my daily to-do list — "Do better" — I'll try to improve on it here. I'll draw on two brilliant pieces of writing that I hope will make this gin clear.

In the original piece I deliberately referred to "certain unhinged or deeply a-moral people." I left this vague for good reason: Mental health diagnoses are to a great extent social constructs. Their framing and use not only identify traits or behaviors that most observers in a given culture would agree on, but categorize a person in a way that can push that person further out of society and culture. Indeed, such diagnoses explicitly seek to identify what is different about the person – what sets them aside, and to some extent, outside, the rest of society. Good diagnosticians do this because, at least in theory, it can help caretakers help the person. But the resulting sense of alienation can exacerbate the person's problems.

In the case of schizophrenia, for example (and I mean example, since as of this writing we have no reliable diagnosis or description of Holmes's mental state), the very diagnosis can push a person almost instantly into alienation. But it's not that way in every society. In his splendid Crazy Like Us: The Globalization of the American Psyche, Ethan Watters describes research demonstrating that the course of schizophrenia, as well as the actions of those who have it, depends enormously on culture.

Janis Hunter Jenkins and Robert John Barrett, two of the premier researchers in the field, describe the general state of affairs.*"In sum, what we know about culture and schizophrenia is… [that] culture is critical in nearly every aspect of schizophrenic illness experience: the identification, definition and meaning of the illness during the primordial, acute, and residual phases; the timing and type of onset; symptom formation in terms of content, form, and constellation; clinical diagnosis; gender and ethnic differences; the personal experience of schizophrenic illness; social response, support, and stigma; and perhaps most important, the course and outcome with respect to symptomatology, work, and social functioning."*By “course and outcome,” Jenkins and Barrett are referring to that most perplexing finding in the epidemiology on the disease: people with schizophrenia in developing countries appear to do better over time than those living in industrialized nations.

A large World Health Organization study [huge PDF download], for instance, found that "Whereas 40 percent of schizophrenics in industrialized nations were judged over time to be 'severely impaired,' only 24 percent of patients in the poorer countries ended up similarly disabled.' Their symptoms also differed, in the texture, intensity, and subject matter to their hallucinations or paranoia, for instance. And most crucially, in many cases their mental states did not disrupt their connections to family and society.

Watters, curious about all this, went to Zanzibar to see how all this worked. He learned that there, schizophrenia was seen partly as an especially intense inhabitation of spirits — bad mojo of the sort everyone had, as it were. This led people to see psychotic episodes less as complete breaks from reality than a passing phenomena, somewhat as we might view, say, a friend or coworker's intermittent memory lapses.

For instance, in one household Watters came to know well, a woman with schizophrenia, Kimwana,

was allowed to drift back and forth from illness to relative health without much monitoring or comment by the rest of the family. Periods of troubled behavior were not greeted with expressions of concern or alarm, and neither were times of wellness celebrated. As such, Kimwana felt little pressure to self-identify as someone with a permanent mental illness.

This was rooted partly in the idea of spirit possession already mentioned, and partly to an accepting fatalism in the brand of Sunni that the family practiced. Allah, they believed, would not burden any one person with more than she could carry. So they carried on, in acceptance rather than panic. As a result, this delusional, hallucinating, sometimes disoriented young woman passed into and out of her more disoriented mental states while still keeping her basic place in family, village, and work life, rather than being cast aside. Almost certainly as a result, she did not feel alienated, and her hallucinations did not include the sort of out-to-get-me kind that mark paranoid schizophrenics in the West.

This, writes Watters in enormous understatement, "stood in contrast with the diagnosis of schizophrenia as [used] in the West. There the diagnosis carries the assumption of a chronic condition, one that often comes to define a person."

Can we find an example? Someone whose situation was sufficiently relevant to both Kimwana and James Holmes that it can highlight the sort of cultural effect I refer to? Yes we can.

The afternoon after Holmes shot up the theater in Aurora, and three days before I posted my assertion that culture can shape the expression of mental distress, an extraordinary young woman who goes by the pen name N described an experience that eerily parallels the one that Holmes seems to have experienced. Her story powerfully illustrates how the West's definition of and reaction to schizophrenia shapes its course, outcome, and expression. Please, if you care a whit about what happened in Colorado, about madness, about culture, read this:

I suspect it would strike most people as ‘mad,’ particularly perhaps, to those who know me, to identify any sort of kinship, any common bond, with James Holmes, the “Batman shooter,” mass killer, and “psychotic son of a bitch,” as Colorado Congressman Ed Perlmutter has put it. After all, I cry even over the deaths of the small birds my cats carry in from the deck. And yet school shootings, or acts of extreme violence in which the perpetrator is or recently was a college student, have punctuated my life in strange & powerful ways. I was diagnosed with schizophrenia just a month after Steven Kazmierczak (quickly identified as “schizoaffective”) shot six people to death on the campus of NIU, just an hour north of Chicago. Undoubtedly primed by this shooting, wary, uncertain, without enough time to think, my doctoral adviser suspended my graduate assistantship, banned me from the university, and alerted all faculty, graduate students and staff to forward all emails to her and, under no circumstances, respond. It was not until a few weeks had passed that I learned—from the Dean of Students—that she had been operating under the assumption that it had been my plan or intention to bomb one of the buildings on campus. She never apologized.

Why? Because the adviser had concluded that _N _, as she calls herself, was schizophrenic, and that this made her dangerous — a Kazmierczak waiting to happen. The effect was profound and immediate. The diagnosis didn't just marginalize this young woman a bit. It promptly cast her full out of the world that meant everything to her. She writes

Although [the adviser's] (clearly illegal) decision was reversed within a week, it set in motion a chain of events that were to forever change my life, perhaps as profoundly as the “diagnosis” of schizophrenia itself. Friends—my doctoral cohort, as is often the case, were a close and tight-knit group—abandoned me overnight. Students and faculty passed me in the halls, staring ahead blankly as if I were an undergraduate they had never seen and would never see again. Parties were announced, talked about, and I was never invited. Never again. As if the psychosis were not enough, I developed an entirely expectable paranoia about my classmates and former adviser (and other involved faculty). I studied their schedules and timed my entrances and exits from the department with obsessive precision, forced to “hide” in bathrooms and side rooms only on a handful of occasions. I no longer attended departmental events (a fact that, with so many others, would eventually be held against me). I did not, could not, finish any of the papers from courses I had been taking, and the themes of those last lectures—the relationship between the work of Winnicott and Melanie Klein, Lacan’s reading of Antigone—followed me like hungry ghosts for years. For a while I struggled through classes, overwhelmed, perhaps in equal measure, by delusions and this new and unprecedented isolation. Voices took the places of both professors and friends. Following a hospitalization (and consequent withdrawal from a semester’s worth of classes), I descended into a state of the most stunning dysfunction, unable (or simply unmotivated) even to walk from my bed to the bathroom. I could not read, I could not write—words rearranged themselves on the page, and my own thoughts became so hard to follow that I simply could not make it to the end of a sentence; suspended linguistically, suspended in life.

Then, in a harrowing annual review, she is expelled, without any warning she could discern, from her doctorate program; not given time off or compassionately offered help and room to regroup. Expelled, cast out, shunned, made irrelevant in the world that meant the most to her."I only remember bits and pieces" of this review, she relates;> within five minutes, perhaps less, I had to bite down hard, dig my nails into my forearms, to keep back the tears. First, the decision: we are dismissing you, in fact you may not, even as an unfunded student, enroll in any further classes. From a professor I had, until that point, trusted completely: “the decision strikes the committee as simple—you clearly do not have your act together and we have no reason to believe you ever will.” Another professor: “you are a burden on the instructors.” And then some additional reasons, faculty talking more to each other than me: “look at all the withdrawals;” “she hasn’t attended a departmental lecture in almost two years;” “unambiguously uninvolved in the life of the department.” Someone (I’m not looking at them) interjects: “perhaps allowing her just one more term….?” Another “…keeping in mind that if we do this she will immediately lose all her health coverage…” Then: “Absolutely not, but we can discuss the reasons after she leaves.” Clearly she will not succeed. Now or ever.

Me: *Everything I have ever been told was a lie. My one way out—of poverty, desperation, madness—was never more than an illusion. And then disbelief. And then, how will I ever explain this to anyone, to family, to old mentors? *And then betrayal. No language this time, no thoughts; crying, crying for hours. Alcohol, unconsciousness, unbidden dreams. Even there: *repeating their words, over and over and over again. *Isolation so intense, there is no way I will ever bridge it. *I am lost. Days go by, weeks.

*

*Isolation so intense, there is no way I will ever bridge it.*This differs in deeply existential ways from Kimwana's experience. _N_ is not taken in or tolerated. She is, as one commenter at the post noted, ostracized in a way that was "a living death."She responded by fantasizing about inflicting horrid damage on herself and/or her academic mentor.

I fixated on a single vision, me, sometimes hanging, sometimes with gun in hand and a pool of blood on the floor, outside 'her' [i.e., her former advisor's] office.... Suicide, yes, obviously, but also something more: revenge.

Her obsessions and fantasies did not run to mass murder. But others who had committed mass murder in similar circumstances, such as Kazmierczak and Jared Loughner, who was much in the news then, were much on her mind. Her confusion and disorientation and anxiety — her schizophrenia — rose from complex sources. But her anger rose in large part from an alienation that came hand-in-glove with our society's definition of what she experienced – to the mere application of the word schizophrenia. And her ideas about expressing that anger rose direclty from models of action brought to her from the media, and which expressed, in their violence and their repetitive, replicative nature — each bloody rampage imitating others — deep and multiple strains of our culture.

I hope this makes more clear that "culture shapes the expression of mental dysfunction." We see in Kimwana's experience how a different culture shaped what we all agree is schizophrenia in such a way that both its experience and expression take forms that looks foreign to us. And in N's story, we see first a medical and social culture that profoundly shaped the experience of her disoriented mind by giving it a label that cast her aside — and then see our larger culture steer the expression of her resulting anguish toward visions that would seem foreign to Kimwana but horribly familiar to Loughner or Holmes.This is what I tried to get at in my post about Holmes, his SWAT-gear mass-shooting fantasy-turned-reality, and culture.

I'm not claiming this is The Whole Answer (though many commenters virtually insisted on seeing it that way before). This is not something we're going to figure out by finding The Primary Cause, or insisting we must choose A, B, or C. Madness is an endlessly complex phenomenon and experience; mass murder is a stark but enormoously complex act. It is, pardon the language, insane to think we can explain their intersenction with math resembling a x b = c.

We need, as anthropologist Daniel Lende said in his own extraordinary, wider-ranging post about Aurora, to "expand our moral imaginations." His post and N's — the most thoughtful, risky, fully engaged, and truly provocative responses I've read, provocative in the best sense of the term, that of provoking new thought rather than reactive argument — make a good place to start.

Cited:

Batman Movies Don't Kill. But They're Friendly to the Concept.

Amazon.com: Crazy Like Us: The Globalization of the American Psyche, by Ethan Watters

maeror meror (in mourning) « Ruminations on Madness, by _N_

Inside the Minds of Mass Killers, by Daniel Lende

Many thanks to Lende, _N_, Watters, those commenters who actually tried to understand what I was getting at, and to Maggie Koerth-Baker and the commenters at BoingBoing for a rich discussion of the topic there, which provoked my thinking further and generated an earlier version of some of the material above.

Exit-door photo by jennlynndesign, used by permission. Some rights reserved. Other photos by David Dobbs.