The thickness of being: intentional worlds, strategies of identity, and experience among schizophrenics

In recent years, researchers have explored the subjective experience of patients diagnosed as schizophrenic and its transformation throughout the course of schizophrenia. Experience is a complex, nontransparent reality that escapes direct, empathic understanding. Concepts and methods developed by European psychiatric phenomenology and by Ricoeur's hermeneutics are used for discussing data collected in Montréal with patients diagnosed as schizophrenic. Persons who differ for their rate of rehospitalization during the last 4 years are compared on various indices of social integration and for their subjective "life-world". Data indicate the importance of "positive withdrawal" for nonrehospitalizated patients and enlighten its subjective significance. Patients' narrative reveal how distancing and relating elements are interwoven in their life history. Self-descriptions bring out the semantic and stylistic strategies used to construct a narrative identity. They illustrate the range of strategies patients use to distance themselves from a static, objectified characterization of themselves. Data indicate the importance of understanding patients' experience from the perspectives developed by European phenomenological psychiatry. This invites the reevaluation of the very notion of coping and its expansion on the basis of a broader approach to the notion of experience. Hypotheses are drawn regarding the role of cultural and social factors in shaping a position of "positive withdrawal".

The influence of culture and context on the pre- and post-migration experience of school-aged refugees from Central America and Southeast Asia in Canada

Pre- and post-migration contexts of refugee children from Central America and Southeast Asia were compared. The results suggest that the culture of origin radically modulates the relationship between the pre-migration experience and the developing post-migration universe. In the case of the Central American children, the state-sponsored violence suffered in the country of origin is strongly associated with subsequent family conflicts, whereas in the case of the Southeast Asians, conflict is associated with an active social network in the community of origin, suggesting that there is a delicate balance between the support provided and the burden imposed by the extended family.

Cardiovascular, neuroendocrine, and monoaminergic responses to psychological stressors: possible differences between remitted panic disorder patients and healthy controls

Both clinical symptomatology and stress research suggest that panic attacks might be partially attributable to exaggerated psychophysiological responses to environmental stressors. In the present study, we aimed to explicitly test this idea by measuring the physiological responses to a mild psychological stressor in both healthy controls (n = 8) and fully remitted, medication-free panic disorder patients (n = 8). One hour before the stressor, former patients, compared to healthy controls, exhibited higher diastolic blood pressure. From a blood sample taken 30 min before the stressor, patients, compared to controls, had lower paroxetine platelet binding site densities. During the stressor, patients, compared to controls, had greater increases in plasma levels of cortisol. These preliminary findings suggest that remitted panic disorder patients might have disturbed physiological responses to mild psychological stressors. These disturbances might be related to the development of future episodes.

School performance and emotional problems in refugee children

The relationship between school performance and emotional problems was assessed in a general population sample of refugee children from Southeast Asia and Central America. Results suggested that learning difficulties and levels of academic achievement were associated with emotional problems in both groups but that, despite comparable academic records, remedial measures were more often prescribed for Central American children.

Psychotic symptoms and vulnerability to recurrent major depression

The demographic characteristics and psychiatric course of primary unipolar depressed patients, either with or without psychotic features, were compared in a retrospective study. 15% (25/165) of the patients had had at least one episode of psychotic depression. Compared with the 140 non-psychotic patients, the psychotic patients were more likely to be female, had been ill for significantly longer and endured significantly more episodes of depression. The greater number of episodes was not attributable to the greater length of illness. Various reasons for the group differences are examined. Particular consideration is given to the possibility that a propensity for recurrent psychotic major depression might be related to sensitized dopamine neurons.

From a cultural stance: suicide and aging in a changing world

Beyond its empirical importance documented through epidemiological data, suicide is of symbolic importance due to its close relationship with the values of life and death, privacy and openness, responsibility and reliance, and suffering and resistance. It appears, in daily life circumstances, to reveal or remind us of the limits of our perception of others' intimate world and of our fundamental solitude in the face of life and death. The issues associated with suicide, particularly with elderly suicide, must be confronted. Researchers, clinicians, and planners, among others, must take care not to close the chapter prematurely on suicide by pretending to have discovered “the” final cause of suicide, in a kind of scientific exorcism.

Positive withdrawal and the quest for meaning: the reconstruction of experience among schizophrenics

Psychosocial rehabilitation often remains entrapped within a restrictive definition. It is characterized by a normative orientation, which predetermines the objectives to achieve, and by an approach from outside of the person, which emphasizes the functional aspects of rehabilitation. In this context, marks of withdrawal, lack of involvement, or inactivity are interpreted as signs of passivity or as residual or negative symptoms, which are often associated with a negative prognosis. In parallel, as data regarding the heterogeneity of evolution of schizophrenia begin to accumulate, some authors have defended the idea that studies have to concentrate on the course of the disorder and on the associated processes (Harding et al. 1987; Strauss 1986). They propose going beyond an objective evaluation of signs and behaviors in order to situate them within a larger life-frame. This draws attention to the potential polysemy of symptoms, including the so-called negative symptoms, which can reflect a diversity of influences and therefore possess various psychiatric meanings (Strauss 1989). Yet, the systematic study of "meaning" in psychiatry is still in its infancy and lacks clear conceptual and methodological points of reference (Strauss and Estroff 1989). On another hand, implications for rehabilitation of a meaning-centered approach to psychiatric symptoms have not been fully elaborated. An intensive study conducted in Montreal with patients diagnosed as schizophrenics sought to describe the factors and processes associated with different types of insertion in the community, and particularly to understand the rehabilitative strategies and the specific forms of being-in-the-world associated with an ability to remain in the community. Data collected through open-ended interviews were both quantitatively analyzed and subjected to content and qualitative analysis. The conceptual reference frame was derived from anthropology and from the European school of psychiatric phenomenology. Data indicate that non-rehospitalization is associated with a stance of "positive withdrawal" (Corin 1990); it is characterized by a position at a distance from social roles and social relationships, combined with various strategies for keeping more tenuous links with the social environment. The case study presented here illustrates the complex organization of these various elements in a given life-frame. It also demonstrates the role played by symbols and meanings in developing a new articulation of personal experience.

[Armed conflict and trauma: a clinical study of Latin-American refugee children]

This exploratory research on psychic consequences of armed conflicts has been carried out in Montreal on 30 latin-americans, eight to 12 year-old refugees. The principal objective was to assert the importance of traumas intensity, accumulation and age of occurrence on the level and type of symptomatology (introversion-extroversion). Using two types of methodologies, clinical scales and in a more exploratory way, projective instruments to study the intra-psychic dynamic underlying the symptomatology observed. The children were classified according to trauma intensity and for this purpose, a trauma scale was defined with latin-american informants. ACHENBACH and DOMINIQUE clinical evaluation scales were applied to the measure of clinical symptomatology. These instruments were analysed as a function of the symptoms intensity and type. Among results, the accumulation and intensity of traumas were found to be in significant correlation with anxio-depressive symptoms, as reported by the children with interiorization symptoms in ACHENBACH. The predominance of interiorization is discussed. The analysis of the TAT, based on objective indicators, brought out a light frequency of violent themes in relations with the clinical symptomatology. This research indicates the relevance of projective instruments to the study of traumatic response.

[Anglo-Saxon social research in mental health : tendencies, limits and impasses.]

In this critical review of English-language research on mental health, the authors identify the dimensions and variables taken into consideration in analyzing, on the one hand, social space and, on the other hand, the field of mental health. Three essential aspects of the body of research are analyzed : theoretical frames of reference ; methods and instruments ; and how links are made between social variables and mental-health problems. In a long conclusion, orientations of French-Quebec social research into mental health are compared to those of English research.

[Realities and mirages : psychic and social spaces of reintegration.]

This study, based on a sampling of people who were diagnosed schizophrenic, sought to describe the different types of positive and negative social réintégration. Research combined an anthropological approach with rigid discipline in the gathering of data. The authors examined réintégration from three points of view : social relations, social roles, and utilization of space and time (l'espace-temps). Data shows that people who are constantly rehospitalized feel marginalized and experience rejection, particularly with family and relatives, and that these feelings sharply contrast the relatively normative expectations concerning réintégration. In these cases, the patient's psychiatric environment tends to structure the reintegration process. However, people who have not been rehospitalized are characterized by a dominant type of réintégration that is best described as"posi-tive retreat" ("retrait positif). This characteristic is supported by various psychological, social and cultural hypotheses. Moreover, an intercultural perspective suggests that certain traits in North American societies tend to make people look down on "positive retreat" and view this form of readaptation as negative.

[Questioning the obvious.]

The actual language on mental health in Quebec is founded on a série of premises that generally remain implicit or are introduced as postulates of "good will" with regard to reality. The authors want to question the significance and the real range of those premises by using a comparative analysis. Considering the concept of desinstitutionalization as used in different countries, they detect the ambiguities and the differences due to the context and to the postulates specific to each of those systems. Then, to elaborate our own premises, they utilize a decentralization method: with the help of their knowledge of other cultural ways of reacting to the problems of psychiatry-mental health, on the one hand in Africa, and on the other from data gathered in Quebec from psychiatric patients, ex-patients and friends. This twofold study leads them to express, compare and criticize what they introduce as the three main premises of mental health language in Quebec: to popularize psychiatric-mental health problems and to introduce a standardization of the people and a uniformity of structure in a field that remains very complex. A study of the theoretical character of this model, of its moralizing dimension and of the key-actors who contribute to its definition, allows them to describe the socio-historic context. The authors question the possibility of introducing a new dimension in our ways of thinking, management and action.

[The importance of context. Cultural references and family structure within the Yans society in Zaïre.]

Traditional descriptions of the structure of relations between father, mother and child make difficult a realization of the impact of current transformations of family structure on the development of the child. Referring to the concept of instituted filiation developed by Guyotat, the author proposes that greater importance be accorded to the manner in which positions in present society are in the process of redefining themselves, and that our analytical and observational schemata be "culturally contextualized". Data concerning the manner in which the institution of filiation operates in a society of matriarchal lineage, the Yans society of Zaïre, highlights the influence of cultural context on the mechanism which establishes filiation. Proceeding from analyses of rituals, institutions and beliefs, the article analyzes the way in which Yans society marks, in a specific and differentiated manner, the relation to the mother, to the maternal uncle and to the lineage, the relation to the father, and the relation to the grandfather, and between alternate generations. The analysis sheds light on the mediating role of the two latter relational registers with regard to the hold of the clan, and shows the importance of this mediation in relation to the development of an individual dimension to existence. The text opens itself to a questioning directed at the place of mediation in new forms of family structure.