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Of Spirits & MadnessReview - Of Spirits & Madness
An American Psychiatrist in Africa
by Paul R. Linde
McGraw-Hill, 2001
Review by Sumter Carmichael, M.D.
Jan 20th 2003 (Volume 7, Issue 4)

    Of Spirits and Madness describes one young psychiatrist’s journey into the world of medicine in Zimbabwe in 1994.  Largely a personal story reflecting the author’s search to find for himself a place in the world, Paul R. Linde describes his encounter with Shona culture and it’s impact on psychiatric illness and practice in Zimbabwe.  Linde’s personal digressions and brutal frankness about his laziness, selfish disregard of others and dangerous disregard for the safety of his patients leaves the reader wondering if the author is even aware of his monstrous self-centeredness.

Having chosen Emergency Psychiatry as something that could overcome his “ennui,” but failing to find it his niche, he turned to writing as a way out.  He admits to being at loose ends as he follows his pediatrician wife into Africa. “I envisioned myself alone, sweating, drinking potent “crash” coffee in the morning and African lager in the afternoon, pecking away at the keys of a rickety typewriter…”  Thrust into work when there is a general strike among physicians in that country, Linde describes various encounters during his stay at Harare Central Hospital on the psychiatric unit.  All the while struggling with his own demons, Linde stumbles through one case after another, trying to fit his American-trained psychiatry into a setting in which his experience and knowledge are inappropriate and inadequate.  He admits over and over his own cowardice and laziness in the face of difficult situations. His inability to meet these challenges contrasts vividly to the amazing heroism and courage of his patients.  While the African system seems strange to Linde and he wants to remonstrate with his patients for not seeing things through “American eyes," he uncovers again and again the underlying stability and resilience that Shona beliefs and traditions provide, even in the face of overwhelming disasters in the wake of the AIDS crisis.     

Chapter One starts with a description of the young adventuring doctor/writer’s introduction into a new culture during his first day “at work”.  “Visualize a misplaced Bedlam: a dusty court yard in Africa, its perimeter marked by a chain-link fence topped with barbed wire; the scene set under a canopy of blue sky and the muscular arms of a Baobab tree standing guard over Dante’s inferno.” His descriptions well convey his fascination with the setting and the rituals of the Shona Culture. In the absence of doctors, the nurses or “Sisters,” as they are called, run the hospital and mete out most of the treatment.  He relies heavily on their knowledge of their patients and the cultural biases as he tries to unravel problems. 

Linde’s first patient is a psychotic man who has already been seen by a “n’anga,” or traditional healer.  The n’anga thought the illness was a bewitchment Linde explains. In the Shona culture, those who show symptoms of madness often are heralded as traditional healers and are treated with special respect. Though many Shona people are devout Christians, they simultaneously hold traditional, culturally sanctioned beliefs in ancestor spirits and witchcraft.  Traditional healers are called on at times of family conflicts, legal disputes, marriage troubles, major decisions, matters of faith as well as at times of physical and mental illness.  Therefore, the medical doctor or psychiatrist is only the last resort in that culture.  Linde found himself absorbed with his patient. “I had become bored with the day to day practice of psychiatry in America,” he says, “where I sometimes felt like a Pez dispenser of medications instead of a voyager into the lives and existential realms of my patients… On a personal level I was desperately seeking a greater sense of personal fulfillment from my life and my work.”  He began to see with his first patient that, while American biomedicine would help his patient recover from his episode of illness, it could not answer the questions of “why me?” or “Why now?”  “Already, I was beginning to understand, “says Linde, “these could only come from the spiritual and existential realm…within his traditional culture.” 

Even though he managed to grasp this concept in the abstract, he appears unable to adapt his practice to it. Linde continues to struggle with his own cultural biases about people and about how things should be run.  Feeling personally overwhelmed with the task of treating a very sick patient with delirium, callously he abandons him and the patient dies.  “Surprisingly, I was able to put Mr. M out of my mind.”  Linde says of himself.  “Most psychiatrists, at least those who choose to retain their sanity, learn early on to compartmentalize their work from other areas of their lives.  Otherwise they’d go crazy…”

When asked to evaluate a twelve-year old girl who has been raped, so that the perpetrator’s sentence might reflect the “dastardly nature of his crime,”, Linde exaggerates in his report the damage done because he thinks the crime is so terrible. He admits to ignoring the law in order to follow his own feelings in the matter.  Throughout Linde struggles with the system that does not follow American Medical guidelines.  He is surprised that the Africans, rather than using medicine to prolong the life of someone dying of AIDS, would think it better to allow the sufferer to be off with his ancestors.  “I needed to deprogram myself from …reliance on deductive reasoning to solve medical problems while in Zimbabwe.  I needed to unlock my intuitive mind, opening it to the mysterious realms of subculture and spirituality in order to work as a psychiatrist in this new culture.”

Again applying his American prejudices, Linde is critical of the medical students at the hospital for abandoning the care of their patients by late morning until he discovered they were moon lighting to support their whole extended family.  Still he describes himself as “miffed and sanctimonious” when at the same time he describes himself as repeatedly lax in the treatment of his own patients.

One day a patient came in after a suicide attempt. It had been discovered that she was HIV positive, and was being ostracized by her family. Her husband refused to be tested, even though it was believed that he had had other women. Though she had symptoms of depression, according to the DSM-IV, Linde decided to wait until her return visit to prescribe medication. But when she returned to the clinic, she appeared happy.  She had returned to her husband satisfied that he would give up other women. “I was stunned,” Linde says. “How could I argue with generations of misogyny?… I came up against one of my foibles as a clinician; I only wanted to help people I had a chance of… influencing. EJ’s denial and blind allegiance to her husband and her traditional culture were stupefying to me, particularly to my American medical twentieth-century mind. I couldn’t go on some futile search and rescue mission here. This situation frustrated me and filled my heart with sadness.” Linde “half-heartedly reviewed the checklist for clinical symptoms of depression… In her mind, order and stability had been restored to her life….” The patient responded,  “It is better that I have a husband and a home. If I am going to get sick and my child too, it is better to be with a family.”  Her position seems very understandable, but Linde didn’t seem to get it.  Reflecting his own American biases and training, he appears incapable of accepting a different set of values.

Linde’s continuingly self-serving egocentric point of view renders him unable to adapt to and come to terms with the circumstances of African life. He occasionally sees the irony of the tragedy and triumph of Africans decimated by HIV. “The typical Zimbabwean’s laid-back perspective and seeming stoicism is laudable, for it helps him to be resilient and accept the suffering and hardship that is particular to the life of a spiritually-rich but economically-poor African.” While his patients manage to accept life and trudge on, Linde finds himself less and less able to cope with situations unfamiliar to him. Even when he returns to the United States to practice Emergency Psychiatry.  his inability to handle work and relationships continue.

He hopes that writing will be the answer: “ Telling stories can be healing.” He quotes,  “We all have within us access to a greater wisdom and we may not even know that until we speak out loud….”

Of Spirits and Madness contrasts the cultural differences between Zimbabwe and the United States. Because his inflexible Americanness is so extreme, Linde becomes almost a caricature of the worst in American culture. His story allows us to see how our own denial of death and promotion of the rights of the individual over what is best for the community permits incredibly self-centered behavior in the name of individual freedom.  Without honoring the past or being willing to sacrifice for the good of others (family, community), we can only become obsessed with the pursuit of our own pleasure and lose the very influences that bring about our maturation and growth.  Our cultural shortcomings have produced a psychiatric system devoid of its connection with the body and the soul. What we have is a healthcare system driven by money that reduces the body to a machine. We have created a society that must find enemies at all turns to blame for its plight (personal injury suits, high tech wars).  While Linde tries to portray the superstitiousness and backwardness of an overly ritualized and polite African society, instead he has shown us the arrogant and solipsistic attitude that pervades our own American society.


© 2003 Sumter Carmichael

Sumter Carmichael is a psychiatrist working with medical patients and teaching medical residents. His interest is in the interface between medicine and psychiatry, psychotherapy, patient interviewing and the interface between psychiatry and religion.


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