"Chicago's Netherworld: An Ethnography of Psychosis on the Street"
April 6, 2006
Let me begin by introducing you to Zaney. (That’s her real name.) She is a white woman in her middle forties. She is well-spoken, clean, and neatly dressed. This is notable because about half of every month she sleeps on the El, Chicago’s elevated train. It is neither safe nor easy to fall asleep on the train, but it is warm. She came here from Wisconsin in her late twenties when she began to be taunted by an angry but non-existent crowd. They shove her on the street, they shout “slut” and “whore” at her, and they bang on the walls when she tries to sleep. When she arrived in Chicago, the police picked her up and brought her to a hospital where she stayed for a few days, undoubtedly diagnosed with schizophrenia. She was given a referral to a caseworker in a community mental health center, and she kept the appointment. The caseworker helped her find housing and, eventually, a monthly social security check of about $579 a month. Both the housing and the check were available to her only because of her psychiatric diagnosis. Zaney stayed in the housing for about eight years, and then she lost it, either because she left or because she got evicted. Then she stayed in shelters for several years. She said that she was doing a routine chore at the shelter when someone rudely told her that she wasn’t doing it well, and of course, she says, she stuck up for herself and they threw her out. The shelter director remembers that Zaney left the shelter of her own accord. But Zaney remembers that the shelter was full of aggressive, rowdy women who were always fighting and picking on her, and she was relieved to be free of them.
Zaney desperately wants not to be homeless. Two weeks a month she stays at a fleabag hotel, for about $160 a week, but she can’t afford more than that. She comes into the drop-in center every day with the classified ads, looking for apartments and work. She knows that she could get housing again based on a psychiatric diagnosis. Everybody on the street knows how you get housing. One woman even ticked off the options for me on her fingers. “You can get housing if you’re crazy, you’re addicted, or you got a job. I ain’t crazy and I don’t have a job, so I’m working on being addicted.” Zaney won’t accept that housing now because she denies that she is ill. She is very clear that she is not “crazy,” as she puts it. I’ve suggested to her that she just lie, that she “pretend” to hear voices, just to get a safer place to sleep. She always shakes her head. “I’m not that kind of person,” she says.
Zaney’s refusal to accept help is one of the great puzzles of our urban landscape. She exemplifies one of the saddest features of modern psychiatric care in this country, which is that many if not most of all Americans who can be diagnosed with schizophrenia become homeless at some point and spend much of their lives cycling between hospitalization, supported housing, jail, and the street—a relentless, nomadic spiral that the anthropologist Kim Hopper has dubbed “the institutional circuit.”
Perhaps they do get housed—but then they become too disorganized to pay the rent, or their harassed family loses patience with their chaos. Eventually they end up back on the street, evicted or by choice, living in the homeless shelter, ties broken with their families, hospitalized or jailed when their behavior gets out of hand, occasionally getting housed, then leaving or losing housing, and returning to the street again. It is a grim social cycle. These are the people you think of when you imagine the homeless, although they are often cleaner and more organized than you imagine them to be. They aren’t, in fact, representative of the average person who loses housing. As many as 80 percent of all people who become homeless regain housing within a few months, depending on the city and the study. We’ve known for a while that at any one time about a third of those on the street can be diagnosed with serious mental illness. What is shocking about more recent data is that they suggest that the street is where many, if not most, of the Americans with schizophrenia end up for some time. One recent study demonstrated that over the course of a single year in San Diego, one in five of the people with schizophrenia who made contact with the mental health system was homeless. Another study looked at the first two years after a person’s first contact with the hospital in New York; more than one in six of those with schizophrenia were homeless at least once. Both studies undoubtedly underestimate the risk of periodic homelessness over the thirty- or forty-year course of the illness. And as Law School Professor Mark Heyrman has pointed out, as the number of inpatient psychiatric beds has declined our jails have become our largest psychiatric hospitals. A long-time advocate sighed to me, “Look at the figures and weep.”
One temptation is to assume that we do not spend enough money to help those in need. Certainly you can argue that the system needs more money. In Illinois the mental health budget is in the bottom third to bottom tenth, per capita, depending on the way you count, of any in the nation. But many people with schizophrenia end up on the street even when housing is available. In Chicago, the wait for non–disabilityrelated low-income housing (Section 8 housing) is currently seven years. I know people who have been told that if they were willing to see a caseworker, they could get housing in two weeks. Yet many who are eligible repeatedly refuse offers of such housing, in many cases offered by decent, caring people. And they refuse many other offers: of medication, or counseling, or employment, not always consistently and not unambivalently, but often and for years at a time.
This refusal to accept care is probably the most poorly understood dimension of the nomadic psychiatric circuit. The second temptation is to attribute their refusal to the illness, as if people don’t understand that they need housing and psychiatric care. And certainly schizophrenia is a terrible illness that batters thought like a trash can tossed in a storm. We call the most dramatic symptoms of the illness “psychosis,” by which we mean that someone’s judgment is so impaired that they no longer seem within the boundary of human reason. (Figure 1 is a representation of psychosis by someone diagnosed with schizophrenia.) They may speak incoherently, giggle when they talk about something sad, speak furiously to the voices they hear in the empty air. As many as one in a hundred Americans struggle with schizophrenia, the most debilitating and difficult of all the psychiatric illnesses.
Figure 1. John Hood III, artist
But few people with schizophrenia, or for that matter with any of the other psychotic disorders, are psychotic always and in all areas of their lives. Psychosis often comes and goes, flares and dies down, both over the course of a day and over the course of many months. And if you actually enter this netherworld and come to know it as it is experienced by its inhabitants, you realize that they are making choices. They may not be the choices that we would make, but they have a coherent logic in the culture in which these people find themselves.
This is where ethnography can make a critical contribution because it is probably the best method for understanding the complex, shared, but only partially articulated categories and meanings through which members of a social world come to make sense of their daily lives. In their attempt to grasp these meanings, ethnographers immerse themselves in the world they have come to study. Then they pull back to write down, in systematic, regular ways, what they have observed and to look for social patterns. And then after pulling back, ethnographers immerse themselves again to explore those patterns. They go back and forth between immersion and abstraction, between their own data and other scholarship and data, trying to corroborate or disconfirm their hunches, again and again and again. It is a skilled method but not a fast method. The rule of thumb in anthropology is that you should do fieldwork for a year before you begin to draw conclusions. And it is not an easy method, because you are constantly stumbling over your own expectations and unintentionally making mistakes. Precisely because of that, it is a very good method for teaching you about what people in that world hold to be meaningful.
This is important, because there is increasing evidence that even the most apparently organic of psychiatric illnesses may change their appearance as they cross cultural boundaries. The way that mental illness is identified and treated in the social world of those who suffer from it will certainly affect the patient’s experience of the illness. More profoundly, it may affect the illness’s symptoms, course, and outcome. To track the way people experience mental illness in different social settings, you need a genuinely interdisciplinary approach which combines an anthropological attention to local culture and a psychlogical attention to psychiatric science. In the Department of Comparative Human Development we call this approach “clinical ethnography.
And so the National Institutes of Health funded me to do ethnographic fieldwork to understand why psychotic homeless women didn’t seem to want the help they were being offered. For much of the last three years, I have spent afternoons in a drop-in center and evenings at a shelter. I have hung out in single-room occupancy hotels, and I have drunk coffee at the local coffee shops that tolerate the clients. When I started out, no one ever confused me for a client. By the end of last autumn, when I’d been on the street most afternoons for months at a time, they weren’t so sure.
Since the autumn of 2004, I have been joined in this effort by a team of students— Johanne Eliacin, Barnaby Riedel, Amy Cooper, Kim Walters, and Jim Goss.
What we have learned—and this is our principal insight—is that if you actually enter this world and come to know it as its inhabitants do at least to some extent, you realize that the refusal to seek help is also a self-affirming refusal to accept that the street has destroyed you. Clinicians see psychiatric diagnosis as an olive branch of hope, as a sign that the patient has an illness they can treat. Those on the street see that diagnosis as a sign that they have been permanently defeated by the street they have tried to escape.
But first let me introduce you to the neighborhood. Uptown is the general area here, but the focus of the work is around the area carved out by Lawrence, Sheridan, Wilson, and Broadway. It was Richard Taub, the Chair of Comparative Human Development, who first drove me to Uptown when I arrived at the University of Chicago, showing me its crazy quilt of gracious mansions, tree-lined streets, and urban abandonment. In the 1920s, Uptown was the entertainment center for the city of Chicago. Although that has changed, it still has some of the finest architecture in the city. Traces of that era still remain in the theaters and a swing dance lounge, the Green Mill, made famous by the patronage of Al Capone and his men. By their sides loom the big hotels built to house the movie stars and the musicians. By the 1940s, the entertainment industry shifted out west or downtown, and the hotels were filled by white-collar workers who commuted into the city from what was then the last stop on the electric train. By the 1950s, white-collar workers wanted the American dream of the house in the suburbs. The old hotels emptied out. The architecture decayed. When the poor moved to Chicago, they moved here.
Then in 1963, John F. Kennedy proclaimed the Community Mental Health Centers Act. That act transformed the American mental health care system by shifting the primary burden of care from the hospital to the community. In 1955, there were 339 psychiatric beds for every 100,000 Americans, and half of them held Figure 1. John Hood III, artistM AY 2 5 , 2 0 0 6 3 people diagnosed with schizophrenia who stayed for months or years at a time. With the new act, psychiatric hospitals slowly became places for acute, short-term care. These days there are only 22 psychiatric beds for every 100,000 Americans, and the modal length of stay is about three days. We use the word “deinstitutionalization” to describe this transformation. It has an optimistic ring, as if we were removing people from Goffmanesque settings that forced their minds into institutional straitjackets.
Many people who live in Uptown would tell you that the better word is “reinstitutionalization.” By the early 1970s, over 40 percent of all psychiatric patients discharged to supportive housing in the entire city of Chicago were discharged to some facility in Uptown. We know that because that was when the Chicago SunTimes ran a series of sensational exposés on the squalid, rat-infested conditions of the old hotels turned into holding pens for discharged patients. “The Making of a Psychiatric Ghetto,” screamed one headline. The city responded by radically upgrading the conditions, but not by moving anyone out of the neighborhood. The hotels were renovated, a process which continues today. There was much more money, much more oversight. Services for refugees and immigrants were added. Now, the neighborhood is home to Vietnamese, Cambodians, Thai, West Africans, Guatemalans, South Asians, Russian Jews, Bosnians, and members of many other nationalities.
And still the neighborhood has the densest concentration of persons with serious mental illness not only in the city but in the state. The area is packed with supported housing, drop-in centers, substance abuse programs, mental health programs, housing programs, and other social services, funded by a bewildering range of charities and public monies. Each agency has different eligibility requirements and different goals, and there is little overarching organization. Because of this, we do not know the total number of beds allocated to those with serious psychiatric illness, but we know that the beds number in the thousands. You can stand on a single street corner, where Sheridan meets Argyle, one big, old hotel in front of you and another at your back, and see housing for near a thousand psychiatric patients. This is what sociologists call a “service ghetto.” The investment in real estate alone is enormous. Moving the system to some other, poorer neighborhood would be a gargantuan task.
But these days, many people are pushing hard for the move. Uptown is the only Chicago lakefront neighborhood north of downtown that has not been yet redeveloped. Over the past five years—over the past six months—the neighborhood has shifted dramatically. These days you can walk out of supported housing around the corner from Wilson and Broadway, out of a conversation with a woman about how she used to turn $10 tricks for crack, and cross the street to an upmarket store called Soggy Paws, where you can buy artisan doggie water bowls for $100.
In the fight between the gentrifiers and the service providers, the service providers will say that they are there to serve people who are already present; the gentrifiers say that people only come because the services are there. Both are right. There is no conspiracy to send mentally ill ex-inmates and former patients to Uptown, but caseworkers at the jails and hospitals do seem to refer clients there. But the homeless and mentally ill also come to Uptown without referrals. The local park is relatively safe. The reported rate of violent crime is among the lowest in the city. And the residents are tolerant, or at least historically have been so. Three organizations have homeless shelters here, with beds for hundreds of single men, single women, and families. People come here from jail. They come from the hospitals. They eat at the soup kitchens. They get help at the local social services. If they get housed, they often get housed in the neighborhood. When they lose their housing because they get jailed or hospitalized, they return because they know the neighborhood. Most of these people are poor. Many drink. Many use drugs. Many have some experience with prostitution. The most active corner is probably Wilson and Broadway, at the only Chicago train station designed by Frank Lloyd Wright.
The setting for much of our research has been Sarah’s Circle, a drop-in center on the corner of Lawrence and Sheridan. Anyone can come here, as long as they are female. Students collected structured interviews from over sixty women here, pretty much most of the women there on the days we came by. These interviews do indeed tell us that this is the world of the institutional circuit.
- Over 40 percent of the women report six months or more in shelters.
- Over 55 percent report psychiatric hospitalization.
- Over 55 percent have been arrested.
- 43 percent are currently in shelters.
- 29 percent sleep in single room hotels (SROs).
- 11 percent stay on the street. 32 percent are white; 45 percent are African American; 10 percent are Latina; 10 percent are “other”; 3 percent are Asian.
Back in the days when anthropologists studied African villages and parsed their data like intrepid explorers mapping a new domain, they began with the problem of subsistence. The first chapter in those thick, early ethnographies was always about the way people found food and shelter. Later chapters explained the way people organized their social lives to enable themselves to eat and reproduce. Then came the chapters on culture, on the concepts with which people molded their lives. One of the great insights of that early generation was that culture could emerge from the tensions and contradictions in the social world. And if we lay out the analytic story that way here, for those who live on the street whether or not they are psychotic, it will help us to see why certain cultural concepts emerge for these women and why those concepts have such bite for those who struggle with psychosis.
Figure 2. Zaney's social world
From the perspective of the basic task of getting enough to eat and finding a place to sleep, one of the most striking facts is that Uptown is radically different from the desperate world of poverty George Orwell described in Down and Out in Paris and London in 1933. No one need starve today in Uptown. On most days, the women have easy access to four or five meals within a few blocks. It’s pretty good food, too. The food at the drop-in center is cooked by a graduate of the Chicago Culinary Institute. It is easy to get free clothes in the neighborhood, free shampoo, free tampons, and other free toiletries. The largest shelter admittedly looks like an abandoned warehouse. It’s attached to the Wilson Avenue train station, and it shakes with the arrival and departure of each train. More than eightyfive women will spend the night during the cold winter months. There is one shower and three toilet stalls, only two of which have doors. Yet the shelter has considerable charm. There are tables with doilies and potted plants. The fifty permanent beds in the back are piled with comforters and teddy bears. The place feels homier than summer camp.
But it is a stunningly lonely social world. This is hard to see at first because women sit together in more or less predictable patterns, and they talk and joke and clearly enjoy each other’s company. But those patterns are often fragile, particularly for those with psychosis. They change abruptly and often from month to month. Women refer to friends they meet on the street as “shelter friends,” rather than real friends.
Part of this denial of social relationship may be the illness. We asked our structured sample to “draw their social world:” here is Zaney’s (see figure 2).
But part of the denial is that this is a world in which social dependency is replaced by institutional dependency. A woman does not need social relationships with other people like her in order to eat, shower, sleep, and get around. Peers at the shelter hinder her, rather than help her—they are the ones who use the shower when she needs it, or hold up the line for food. Of all the people we interviewed in our structured sample at Sarah’s, over 40 percent said that they did not feel connected to other women there—even though we see them sitting together every day—and 66 percent couldn’t name a single person they regarded as a friend there.
Moreover, a woman in this neighborhood is committed to the view that her time on the street is temporary—even if she has been homeless for years. In this drab world, almost everyone tells you that homelessness is a temporary condition, a matter of months, a period out of normal time. Fully 84 percent of our structured sample said that it was very true that “for them, homeless is a temporary condition.”
They need to believe this, because homelessness is awful. Our second major insight is that to be homeless—whether or not you are psychotic—is to confront what we have come to call “social defeat” daily and on many dimensions. The term is an old one in ethology, the kind of term that is familiar to my colleague Martha McClintock; it is used to describe the actual physical defeat of one animal by another. We use it because it captures a central social interaction on the street, which is the repeated experience of failure in social encounter—failure in an actual social interaction in which one person physically or symbolically loses to another.
The first defeat is simply in being homeless. To be homeless, you must have lost the place you call home, and to end up in a shelter, all your social resources must have failed. The women’s lives are often unbearably painful tales of drugs, prostitution, and violence. The women around them hold up a mirror to their lives they cannot stand, and such people are always present. If you live in a shelter, people are around you all the time. You sleep in public, you shower in public, and you often pee in public. There is little privacy and little control over which people share your space. The very idea of homelessness evokes for these women a crushing sense of shame and failure. Women depict people like themselves with sneering, venomous phrases. One woman said, “You can’t get away from the homeless in Uptown . . . you just can’t get rid of them. You just trip over them when you walk out the door here.” As another woman told me, “Homelessness is hell. You ever wondered what hell is like? This is it.”
The second defeat is daily vulnerability to always simmering violence. Those shelter rooms hold as many as fifty people, with sleeping mats as close together as possible. It is hard to trust your neighbor. Many women are psychotic; many have been jailed. You cannot predict a stranger’s behavior. Even in shelter rooms where the clients earn the right to return day after day, petty squabbles are common and outright fights are not rare. One woman explained:
At the shelter . . . it’s a different experience and everything. They put the mental patients in the shelter and the penitentiary ones in the shelter, and then—you gotta just pray every night that you’re gonna be okay. . . . Last night we had an experience, I mean we had excitement at the shelter. One of the women, she jumped on one of the girls, and then she jumped on another girl, and then she pulled out a knife. . . . I got out of the shower, me and the girl. One of the women said, “Stay in the bathroom because she got a knife. . . . ”
That simmering violence is considerably exacerbated by a quick readiness to fight, which the sociologist Elijah Anderson called, in a different context, “the code of the street.” In the inner city, among nomadic pastoralists, even among ranchers and perhaps their descendants, in social settings where police are unreliable and the law is weak, survival may depend upon an ability to overreact, to defend your turf so aggressively at the first hint of trouble that the trouble slinks away. On the street the women flare quickly, and they flare to protect goods or status that a middle-class housed person might quickly cede. We think that the best way to understand this is as an honor code. In a world in which you have little but your dignity, protecting your dignity becomes paramount. Here is one woman: “I am never going to put myself in a position where [someone] can disrespect me. . . . Just hearing her speak, I was like, ‘You want to make me whup your butt.’ ”
If the conflict were only between those on the street, one would assume that the women were as often victors as losers in these encounters. But the women spend their days moving between institutional settings in which they are supplicants to staff who set the rules and determine the outcome of any encounter. The third form of defeat, then, is between the honor code, the toughness demanded by the street, and what one might call a “middle-class morality,” or what Anderson’s subjects called the code of “decent people.” In this encounter, women on the street always lose. The women sleep at the shelter. They have their morning meal at Salvation Army with many others, coming up in a long line to get the meal. They may stay there for lunch or move on to the library or McDonald’s. After lunch they are at Sarah’s. By nightfall, they are back at another soup kitchen—maybe St. Thomas’s, maybe Ezra’s—and eventually they wend their way back to the shelter by curfew. In each of these settings lie untold possibilities for intended or accidental insults. Over all of this hover the watchful eyes of the staff. If two women fight, even only with words, they are “barred”—dismissed and told not to return for a day, a week, a month, forever if the infraction is severe.
The staff’s goals are eminently laudable. The point of a drop-in center, or a shelter, is to provide safety for clients within their doors. But those same rules can humiliate the women they are set in place to protect. Kathy sat at the drop-in center one afternoon so angry she was nearly in tears. She’d gone to a job fair hosted by one of the agencies. You weren’t allowed to bring a purse into the washroom there; they’d had problems with drugs. Kathy knew the rules. She understood why they were there. But all she’d wanted to do was to brush her hair in private so she would look decent to an employer. They wouldn’t let her take in the bag. Something snapped in her, she said, and she fled.
In this context, one of the most important cultural concepts for the women in the neighborhood is “being strong.” As Zaney explained, “You have to get strong here, really strong.” Once I assembled a group of women over donuts and coffee in the shelter and asked them what “being strong” meant. That morning they were all African American. I suspect that for them, the concept of being strong on the street resonated with the idea of the strong black woman. Melissa Harris-Lacewell reminds us that this is the myth that black women can handle anything life throws at them—that they are independent, selfreliant, and never in need of help. Here on the street, “strong” is used by blacks and whites alike, and vividly expresses a frontier-style commitment to survival. Strong was good. The catch was that you had to be strong in contradictory ways.
In the discussion over coffee and donuts, one meaning of “strong” was being “tough”: standing up for yourself, being able to protect yourself, not letting other people take advantage. As one woman said, “If you are going to survive, you have to smack somebody down.”
And yet the women also said that “strong” was being able to resist the temptation to be tough. As one woman remarked, “Being strong is walking away, you know. We get into it. Little things a person says can set you off. And it’s hard just to stand there.” Here strong has a moral quality. It is about resisting the urge to snap, to hit, to stand up for yourself, to protect your honor—even when honor gets insulted. And being strong also means resisting the lure of the street, and its drugs and drink and freedom from demands. A woman said, “So I was in this facility. . . . Everyone was getting high, they were drinking, they were doing drugs. And at first it didn’t bother me. It didn’t bother me for five to six months. I was real strong.”
“Strong” also meant coming to terms with what you had been, and accepting that you were going to learn to be different. Another woman said ruefully, “When you really seek help, you gonna reveal to the people that you are seeking out who you really are. . . . I had to talk to these caseworkers and reveal the grimy things I did, and I didn’t feel real good. I wanted to fold inside, I wanted to lash out, but I was the author of everything that was done. And I had to be strong and come in here and say, ‘Okay, but that was then.’ ”
The women talked about this other world—this street world, with its drugs and partying and violent toughness—as if it had claws that could reach out and pull you down. One woman said,
You on the top of the world, you get things done, you’re making appointments, then all of a sudden, out of nowhere, out of the blue when you thought it was safe to step into the water here come sharks. You can walk down the street. Someone says, “Hey, how you doing?” The next day, “Hey, how you doing? Want some coffee?” “No thanks.” I mean each day going on, you constantly see this person. Then one day you got time to talk to this person, you thinking this person nice. And then you let them into your life. Then the next thing you know, you start doing things again, you start prostituting again. Then the next thing you know, your rent ain’t paid.
And strong also meant just being able to survive in the face of the shame, the doubt, the sheer difficulty of making it through each day. As one woman put it,
One time I got raped, and I had nowhere to go. I had to get right back on the street and make some money so I could have a room for the night. I couldn’t call the police. I called my mom in Minneapolis. I said “Momma, I’m gonna do something I don’t want to do.” She said, “What’s that?” I said, “Prostitution.” She said, “God bless you, be careful. I’ll pray for you.” That’s what my momma told me. A few minutes later I had to wash up, so I washed up and I had to get right back out there and make some money. And that’s part of being strong too.
Sometimes, in the middle-class world, we have the idea that people end up on the street because they want to be independent, as if urban cowboys. We have not met a single woman who describes herself as choosing to be homeless. These women do not want to be here. They do not want the apparent freedom, and they repeatedly and consistently blame the economy for stripping them of resources. One woman described this, in a way we have heard again and again, as “social cruelty. . . . There’s corporate cruelty going on, and it’s very unreasonable.” Here in Uptown, all the women seem to want to get off the street, to get housed, to get a job, and they consistently say that to do that, you have to be strong.
This is where the culture has its bite, because in the world of this neighborhood, when women use the word “crazy,” they mean the opposite of “strong.” The word “crazy,” of course, is rarely a compliment in middle-class society. But in safer settings, people with serious psychotic disorder can embrace the term with an ironic, grudging familiarity. People with schizophrenia may describe times when they have been delusional by saying, “Yeh, that’s when I was crazy.” My favorite political button was distributed by clients with psychosis at a national meeting: “I’m crazy, and I vote.”
But in Uptown, “crazy” has a meaning more caustic than I have encountered elsewhere. In all our collective fieldnotes and transcripts, there are over a hundred instances where women use the word “crazy” to describe mental illness. In all but two of those occasions, the term is used for other people, and it is used to demean. And if you model the features associated with the word, the data are clear and consistent, suggesting a high degree of local cultural consensus.
The prototype of “crazy” is the flagrantly psychotic person, a woman talking visibly and audibly to people no one else can see. (Figure 3 is a representation of such a woman, drawn by someone with intermittent psychosis.) When you ask people what they mean by being crazy, they point to these women gesticulating to the empty air. And unlike in the safe, healthy world of an upper-middle-class university, you always have such a woman to point to. If you are in a shelter or a drop-in center or a soup kitchen, the flagrantly psychotic are always present. The last time I was in Uptown, I was on Wilson and Broadway, and a woman walked into the middle of traffic and started screaming at the cars. She actually knelt down in front of a van. Then she got up and walked away.
Figure 3. Sharon Pena, artist
There are clearly three features of what we might call the cognitive model, or the local cultural schema, for being crazy. The first is weakness. To be strong is to be not crazy. A woman whose husband had shot himself in front of her some months previously said, “I didn’t think anything was wrong with his head because he was a strong man. I just thought he was this strong man, that that wouldn’t ever happen to him, you know, he would never be crazy, he would never be actually crazy because he was a strong-minded person, strong-minded man, strong, so it wouldn’t happen to him. But I was wrong because it did.” To be crazy is to be someone who is unable to negotiate the demands of this world: unable to care for herself, unable to handle the isolation, unable either to defend herself on the street or conform to the rules of the service setting. Another woman told me, “You know they can’t protect themselves. . . . They are obviously physically vulnerable.”
This is an accurate claim. We know from systematic sociological data that people with serious psychotic disorders are more at risk of assault than other people. Indeed, in the shelters and at the drop-in centers I have seen psychotic women jeered at, teased, and verbally attacked. And that is, in part, because they are genuinely a problem. When you sleep in two rooms with eighty-five people, the woman who talks out loud to herself when others are sleeping is an object for contempt, not for compassion. One woman described such women to me as “time bombs.” They are going to go off, she said; you don’t know when or where, and it just happens. You say “hi” one day and everything is fine, you say “hi” four hours later and they just explode in your face.
The second feature of the model is that those who are crazy are permanently crippled, struggling with what one woman called “something that would never be fixed.” As another woman explained, “It’s something you absolutely cannot control. And a lot of them don’t even take medication. They have retardation, and there’s nothing you can do about it. Alcoholism you can do something about. You can stop drinking. Smoking, you can stop smoking. You can do those things and thereby reverse your situation, but someone who appears mentally ill can’t do that.” Women often speak about mental illness as retardation. As one woman put it, “Half of these people slow up here, you know what I’m saying, half of them got a little problem. They don’t think that well.”
This is a less accurate claim, but not an unreasonable one. The most flagrantly psychotic women on the street are very sick, and change, when it comes, seems to come slowly. Few of the very psychotic women I know in Uptown look much better three years on. That empirical experience seems to impact the decision not to take medication. As one woman caustically remarked, “From what I’ve seen, people who are on medication are worse, not better.”
The third feature of the model is that the street will drive you crazy. Women talk about being crazy as if it is something that happens to those that cannot handle the strain of being on the street. “She’s been on the street too long,” women would say to me about someone else, twirling their fingers or rolling their eyes to show that the person that they were talking about was crazy. “Reality is so overwhelming for them,” one woman explained, “it is like a powerful explosion, they have to go within themselves, they have to create a safer ground. They can’t understand what’s happening, and it’s the only way they can exist because they would otherwise just wither and die.” Another woman whispered, “Some people can’t handle the pressure. . . . They break and become mentally ill.”
The kicker is that this part of the model is probably right. The street may well drive you crazy.
Let me pause on this point. Schizophrenia is famous as the site of the most notorious misuse of psychoanalytic theory in American psychiatry. When psychoanalysis dominated American psychiatry, back before the biomedical revolution, the dominant American perspective on schizophrenia held that the condition was the result of the patient’s own emotional conflict. Often, clinicians blamed the mother. She was “schizophrenogenic,” her own conflicts paralyzed her child. When psychiatry shifted to a biomedical model of mental illness, clinicians began to emphasize the biomedical, organic nature of schizophrenia to parents—as if it were caused by a genetic lightning bolt that swept out of the sky to strike a child.
And certainly there is good evidence for biological causation in schizophrenia. What is striking is that now there is epidemiological evidence, mostly from Europe, that there are specific paths for social causation as well. It’s been known for a long time that schizophrenia is associated with poverty, but until recently, most people thought that this meant that people who developed schizophrenia became poor because they couldn’t hold their jobs. But a recent study, which tracked down father’s job and mother’s address from the birth certificate of the person with schizophrenia, demonstrated that if you are born poor, your risk for schizophrenia increases. If you live in an urban area, your risk for schizophrenia increases. And if you have dark skin, your risk for schizophrenia increases as your neighborhood whitens—a remarkable, disturbing finding called the “ethnic density” effect.
Most strikingly, when dark-skinned people emigrate to the United Kingdom or to the Netherlands (the only places where the studies have been done), their risk of schizophrenia rises sharply. This effect has now been shown in so many papers by so many researchers with such methodological care that it cannot be explained away by clinicians’ racial bias. Those who arrive in England from the Caribbean have around seven times the incidence of schizophrenia and of other psychotic disorders than whites, even after adjusting for social class and age.
Meanwhile, one of the most interesting puzzles in culture and mental health today is the difference in the outcome of schizophrenia in developing and developed countries. In an old World Health Organization study, researchers had found that two years after an initial diagnosis of schizophrenia, patients looked better in Africa and India than they did in sites scattered throughout the West. The study was redone and done more carefully, and the results still held. No matter whether you look at symptoms, disability, clinical profile, or the ability to do productive work, roughly 50 percent more people do well after a diagnosis of schizophrenia in the developing world (really, in India) than they do in the developed world. So in some sense the causal account of schizophrenia has at long last circled back to the old psychoanalytic explanation. Much is different. The mother is no longer the villain. Complex ideas about unconscious motivation and defense are no longer to blame. But the fundamental insight seems right: individuals are caught in webs of human relationship that can strangle the biologically vulnerable. To read this new epidemiology is to confront the social dimension of our bodily experience in a manner as arresting as when Freud first suggested that illness was intrapsychic and interpersonal.
Many people look at this data and wonder what India is doing right. They speculate that it is because in India, there is more single-episode psychosis; the family remains fully involved in the treatment; patients often live in joint families; entry-level work may be less stressful; fewer families are critical and emotionally intense than in America; and so forth.
I look at these data, and I see Uptown. If I am right that the nomadic psychiatric circuit is common in the lives of those who struggle with schizophrenia, the explanation of this outcome data may be that in the richest country in the world we subject people with psychosis repeatedly to a culture of consistent social defeat, in which they face failure in social encounters again and again and again.
The paradox that I am describing today is that I think these women see this too, and their very attempt to escape it may damn them to greater illness through their reluctance to accept care.
These women live in a world in which to be “crazy” is a sign of absolute failure, a sign of weakness, an admission that you are not strong enough to escape the world you loath. Their decision to refuse any help they associate with “being crazy” is not an arbitrary symptom of their illness, but a coherent decision that is appropriate in their culture. They see flagrant psychosis as the consequence of being defeated by the street, and their judgment is not only shared by other people like them but is also probably accurate. They see little value, in the social world in which they find themselves, in taking medication. They see that people who are flagrantly psychotic are vulnerable and at risk. And they are terrified that the street might in fact drive them crazy, and they will be caught—permanently crippled in a world they regard as damnation. As my colleague Rick Shweder points out, this is an instance where what looks like stigma is in fact good sense. Here, for example, is an exchange with a woman who has just announced that dignity is all she has left, and that she’s certainly not accepting housing offered on the condition that she accept a psychiatric diagnosis.
“Just the fact that they even wanted me to go to [mental health services] made me like . . .” (her voice trails off)
Interviewer: “Why were they saying you should go there?”
“To qualify for the housing. [But] whatever it was, I didn’t want it. Why should I say I’m not competent?”
It is not the case that women like this always refuse services. Certainly when they get sick enough, they have no choice. But many of those who refuse are, like Zaney, among the smartest and most competent women with psychosis on the street. They have to be, almost by definition. They wouldn’t survive otherwise.
Yet when they refuse that help, they put themselves at risk. To sleep on the El is probably more stressful, and certainly less safe, than to sleep behind your own locked door. To sleep in the shelter is probably more stressful, and probably offers more opportunity for social defeat, than to sleep in your own place. To refuse antipsychotic medications may bring you closer to flamboyant psychosis, and clinically speaking, to go in and out of hospitalization, and on and off of medication, probably makes your psychosis worse. I don’t have any romantic illusions about Zaney’s freedom. The more she sleeps out, the worse she looks, and the greater her chance of getting raped, getting beaten, and getting really, really sick.
So this is a decision in which if you choose what you know to be morally right—in this case, to be strong—you may bring yourself closer to what you morally condemn and profoundly fear. For these women, psychosis is not an abstract fear. It stares them in the face every day. They are like Leonard Bast, in E. M. Forster’s Howards End, a poor clerk perched on the edge of poverty, desperately clinging to respectability and with each reasonable judgment sliding closer to the edge of the abyss. They are like those in the 1930s who refused public assistance because to do so would be to admit that they were poor—and because they knew what poverty looked like. Some of those people did, with sheer luck and determination, scramble back into the middle class. Many of them did not. Zaney may be lucky. But the last time I saw her, I thought that she would be dead or hospitalized within the month.
A woman like Zaney is willing to take a terrible risk to protect her dignity, her identity, and her sense of what it is to be a decent person. We ought to respect that. Intellectuals like to think that we can talk someone out of what we think are bad ideas by giving them better ones. I don’t see that working here. I don’t see holding an anti-stigma campaign for these women and expecting them to change their minds about accepting a psychiatric diagnosis. They hold these ideas about being crazy because those ideas spring directly from their social experience. If we want to help them solve their problems, we need to grasp how that social experience has led them to think, and we need to reach out to them in their terms, not in ours. All our technical skills in biomedicine and pharmaceuticals avail us nothing if we ignore the social context in which people make their fundamental choices. At the least, in this case, we should stop making help contingent on an explicit psychiatric diagnosis, because to them the very concept of being crazy evokes a visceral moral disgust. And this, to end on a University of Chicago note, reminds us that Emile Durkheim taught us that an image that arises out of social experience can acquire a moral quality which can feel more real that reality itself. If we ignore the moral vision of women like Zaney, those women will continue to suffer and die on the street. As a woman remarked one afternoon, shaking her head, “To be mentally ill and homeless . . . you really can’t get much worse off than that.”
About the Lecturer
Tanya Luhrmann is the Max Palevsky Professor in the Department of Comparative Human Development and the College, and Associate Member in the Department of Anthropology.
She received a B.A. in folklore and mythology from Harvard University in 1981 summa cum laude, and an M.Phil. in 1982 and a Ph.D. in 1986 in social anthropology from Cambridge University. Luhrmann was a research fellow at Cambridge from 1985 to 1989. She then taught at the University of California, San Diego, for eleven years before joining the University of Chicago faculty in 2000.
A social anthropologist, Luhrmann studies the social construction of psychological experience and the ways that social practice may affect psychological mechanism. Her specific research interests include witchcraft, religion, trauma, and people with serious mental illness.
Her Persuasions of the Witch’s Craft: Ritual Magic in Contemporary England (1989) is a detailed study of how apparently reasonable people come to believe apparently unreasonable beliefs. In The Good Parsi: The Fate of a Colonial Elite in a Postcolonial Society (1996), Luhrmann explores the seemingly irrational selfcriticism of a postcolonial Indian elite, the result of colonial identification with the colonizers. Of Two Minds: The Growing Disorder in American Psychiatry (2000) analyzes the contrasting cultural logic implicit in the biomedical and psychodynamic models of mental illness. Of Two Minds won the Victor Turner Prize for Ethnographic Writing, the Bryce Boyer Prize for Psychological Anthropology, and the Gradiva Award from the Association for the Advancement of Psychoanalysis.
Luhrmann was elected to the American Academy of Arts and Sciences in 2003. Her numerous grants for fieldwork include a 1990 Fulbright Senior Research award for work in India. Her 1989 essay “The Magic of Secrecy” received the Stirling Prize from the American Anthropological Association.