Book Review

Of Spirits and Madness: An American Psychiatrist in Africa

N Engl J Med 2002; 346:787March 7, 2002

Article

Of Spirits and Madness: An American Psychiatrist in Africa
By Paul R. Linde. 297 pp. New York, McGraw-Hill, 2001. $24.95. ISBN: 0-07-136734-9

First published in the mid-1950s, Robert Lindner's The 50 Minute Hour was a series of lengthy clinical vignettes of romanticized and idealized psychoanalytic psychotherapies. Widely read by psychiatric residents (and others) at the time, it helped us to understand the failures as well as the successes of talking treatments in the era before antipsychotics, antidepressants, and mood stabilizers. It presented us with the therapist as an adventurer in an unknown world but left us feeling that the world of the unconscious and of “crazy” behavior was understandable. Although we realized that this was not easy to accomplish, that it did not always result in a change for the patient, and that there were many failures, we were nonetheless reassured of the meaning and usefulness of the quest.

Linde's Of Spirits and Madness: An American Psychiatrist in Africa is this new century's version of the earlier book. The author recounts 11 vignettes of patients seen at a psychiatric hospital in Harare, Zimbabwe. The hospital is understaffed and undersupplied. The staff labors under difficult conditions. There are inadequate alternatives and few opportunities for continuing treatment or care in the community. Therefore, treatment is usually urgent and brief, requiring rapid diagnosis and administration of medication. Although the setting is foreign and “different,” all this is reminiscent of my inner-city psychiatric training in the 1960s and, strangely, of the current constraints modulated by managed care.

The range of illnesses is also familiar, from delirium and dementia to depression, mania, and schizophrenia. However, the cultural context strongly colors the presentation of each syndrome. We hear nothing of the CIA or FBI listening in, nor of the IRS or INS pursuing the patient (the modern American world seems troubled by acronyms), but rather that “she is being bewitched by her great-grandmother, who may have been a prophet in her time. An important ancestor spirit.” Although the patient is being called “to suffer for her sins,” it is by the spirit of an ancestor rather than a government agency. In Zimbabwe, as in much of the rest of the world, the spirit world looms large, can be both comforting and threatening, and remains an important explanatory set of theses by which one leads one's daily life, including the response to illness. Exorcism, outside of the movies, is a rare event in Western life, but absent a social belief in scientific findings, it and its native equivalents are elsewhere an understandable response to otherwise unexplainable phenomena and to illness, particularly psychiatric illness.

In part because of the social stigmatization of psychiatric illness in Zimbabwe, compounded by the difficulty of finding one's way to the hospital, most patients and their families seek home or local treatments first. These may be home brews, visits to a fundamentalist Christian minister and the laying on of hands, or a visit to the n'anga, a native “witch doctor.” The patient described above, bewitched by her great-grandmother, had had her head shaved in spots to release the ancestor's spirit. As the local nurse pointed out, “If the n'anga's treatment had worked, her family would not have brought her here. Psychiatry is a last resort for most of our people.”

The author and the reader come away with respect for both patients and staff, for their resilience and strength to do what can be done as they struggle with an inadequately funded and ill-supported health care system in an increasingly corrupt and disintegrating society. One must also admire Dr. Linde's ability to adapt, to listen and learn, to empathize with what is foreign to him, and to make friends, sometimes across surprising boundaries: an exemplar of “the good doctor.”

William A. Frosch, M.D.
Weill Medical College of Cornell University, New York, NY 10023