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Book Forum: Cultural Psychiatry   |    
Of Spirit and Madness: An American Psychiatrist in Africa
CAROL C. NADELSON, M.D.
Am J Psychiatry 2002;159:1447-1448. doi:10.1176/appi.ajp.159.8.1447
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By Paul R. Linde. New York, McGraw-Hill, 2002, 288 pp., $24.95.

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Linde’s memoir recounting his experience working as a psychiatrist in Harare, Zimbabwe, presents us with a fascinating and important lesson in cross-cultural psychiatry. Linde, an emergency psychiatrist at San Francisco General Hospital, spent a year in Africa. He tells the stories of 11 of his patients, representing a range of familiar psychiatric illnesses with very diverse presentations and conditions, not entirely foreign to those who work in community psychiatry. What is unique is Linde’s description of the complexity of the experience of illness for those afflicted and for their families, especially their understanding of symptoms and causes and their decisions about what to do to obtain help. Interpretations of bewitchment are aspects of practice that take us beyond the familiar views of Western psychiatry. The roles of spirits, ancestors, and exorcism are an important part of the construct of illness and the appearance of symptoms. Linde articulates his recognition that he has to learn the meaning and attribution of symptoms in a culture whose experience he does not share. The shadow of stigma also exists in a different form. It drives the direction of seeking help so that the mental health system is the last resort after other options are exhausted. Fortunately, Linde is able to rely on the knowledgeable and sympathetic "sisters" at the hospital for guidance and support.

Linde’s experience rings very true; it echoes my own briefer visit to South Africa, where I also felt the lack of context with many of the patients I saw and struggled to understand the meaning of illness in a different culture. In his attempt to describe his experiences Linde navigates toward the clinical focus and avoids political references to government policy or practice in Zimbabwe, which resulted in the need for foreign doctors even though they were untutored in the local culture. He also avoids comments on what he found when he arrived—that the doctors were on strike, which had a profound effect on patients. Acknowledging these concerns would have changed his concept of what he wanted to communicate in this book, although it might have offered us greater depth of understanding of the problems he and his patients faced.

At times it is not clear who is Linde’s intended reader. His discussion of sexually transmitted diseases, especially AIDS, and his references to psychotherapy and psychoanalysis are based on his experience in Zimbabwe in 1994 and do not reflect current understanding or practice. Despite these minor concerns, Linde has opened an important door. This presentation of the cases is moving and empathic. Linde asks for a more complex view of culture and an appreciation of the construction of experience, including symptoms and illness, within the context of a culture.

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