List of Illustrations
ONE. ENTERING THE SCENE: THE WALLS
1. On the Tightrope of Culture
2. Decolonizing Treatment in Psychiatry
TWO. ENTERING THE SCENE: THE IMMIGRATION OFFICE
3. Ambivalent Inclusion: Psychiatrists, Nuns, and Bureaucrats in Conversation
THREE. ENTERING THE SCENE: THE POLICE OFFICE
4. Denuncia: The Subject Verbalized
FOUR. ENTERING THE SCENE: THE SHELTER
5. Paradoxes of Redemption: Translating Selves and Experimenting with Conversion
FIVE. REENTERING THE SCENE: THE CLINIC
6. Tragic Translations: "I am afraid of falling. Speak well of me, speak well for me"
EPILOGUE: OTHER SCENES
"A fresh look at ethno-psychiatry, human trafficking and the politics of recognition in contemporary Italy. Informed by philosophy, Italian history and critical psychiatry, Giordano’s ethnographically-grounded and nuanced analysis goes to the heart of the contradictory relations between psychiatrists, Catholic nuns, police and women migrants, and between the production of exclusion and the dream of practical utopias." —Anne M. Lovell, National Institute for Health and Medical Research (INSERM), Paris
"With great sensitivity and theoretical acuity, Giordano lays bare the challenges of cultural mediation and the political tangles at the heart of mental health work with refugees and asylum seekers. This is an important work for advancing cultural psychiatry and responding to the needs of marginalized groups." —Laurence Kirmayer, M.D., McGill University
Boyer Prize, Society for Psychological Anthropology
On the Tightrope of Culture
The potential [of ethno-psychiatry] lies in the possibility of getting closer to the experience of the other, . . . not with the aim to "understand" . . . him, but to recognize his discourse . . . as irreducible to dominant paradigms, something that clinical work with the local population rarely shows; the risk lies in potentially encouraging projective mechanisms of representation where the pain of the other appears as circumscribed and distant and the suffering of the migrant as exotic and culturalized.
Simona Taliani and Francesco Vacchiano, Altri corpi
Mary was in her early thirties when social services referred her to the Centro Fanon. She wore an open expression on her face, often smiling and always willing to talk about her experiences and concerns, but she also looked sad. I met her on a late November afternoon at the Centro. She had migrated from Nigeria approximately three years before we met, and she was still undocumented. Over this period, she had gone back to Nigeria once. When she returned to Italy, she was pregnant and had just lost her husband in a car accident in Nigeria. She went to the hospital for a prenatal visit, where she was diagnosed as HIV-positive. Social services subsequently placed her in a locally funded program for pregnant HIV-positive foreigners. She lived with her sister in what social workers described as very precarious economic conditions, in a small, dark apartment where a lot of people of all ages, mostly Nigerians, cycled in and out. Her sister was probably involved in prostitution, but it was unclear whether Mary was as well. She gave birth to an HIV-positive son who became negative after several months of retroviral treatment. A year after giving birth, the social workers thought that she was "depressed"; she was crying a lot and felt guilty about her health and her son's future. They referred her to the ethno-psychiatric center, where the doctors knew, as one social worker put it, "how to deal with cultural difference."
A short time after the initial referral, Mary became one of Dr. L's patients. I sat in on her therapy sessions for several months, often conversed with the practitioners in charge of her case at the Centro, and spent some time with her outside the clinic, at the apartment she shared with her sister. Three people participated in Mary's sessions: Dr. L, a trainee, and me. In this case, no Nigerian mediator was available to assist in the consultation, but Mary spoke enough Italian and the doctor enough English for them to understand each other. In general, ethno-psychiatrists at the Centro would meet patients together with a cultural mediator who helped with issues of translation or cultural interpretation when necessary. Dr. L had a lot of experience working with Nigerian patients and had conducted several years of ethnographic research in West Africa on curing techniques, childhood, and witchcraft. Like other practitioners at the Centro, she held degrees in both psychology and anthropology and was committed to bridging the practices of both in her clinical work.
Over the course of several consultations, Mary spoke of her difficulties in Italy: she did not have a residence permit; she was afraid of getting caught by the police and sent back to Nigeria; she feared for her life and her son's future; and she was terrified at the idea that other Nigerians in Italy might find out about her HIV status, which felt like a death sentence to her. She was haunted by dreams about her dead husband and could not talk about him without ending in a desperate cry. The threat of death was a refrain in her stories. Although Dr. L explained to her that her illness did not mean imminent death and that retroviral treatments could make a great difference, her fears persisted. She once said, "If I take the medicines here, I will heal, but if the police send me back there, I will die." Because she referenced death in different ways, I wondered whether she was alluding to different kinds of death, not just corporeal. In this clinical context, patients often voice or express through symptoms the fear of social death (both in Italy and back home), the shame of returning home without proof of success, concern about family members' jealousy and envy, and the threat of revenge. Death also speaks to ruptured relationships, to symbols that no longer grant meaning to experience, and to the failure of her migratory process.
We spent a lot of time speaking about which social program could grant her a residency permit. Because she was the mother of a minor who was born HIV-positive in Italy, she could qualify for the "health reasons" that the state uses to recognize parents of offspring affected by life-threatening conditions. At first, the stories that emerged in our discussions were mostly about Mary's life in Italy and the pressing concerns she had about her health and legal status. As another ethno-psychiatrist pointed out to me:
It is easier to collect accounts of migrants' lives in Italy than to find out about their lives before they migrated; when you try to get to those stories, they are often impenetrable. In these cases, you gently try to reorient them to their cultural background by establishing connections with family members, practices, and rituals, so that slowly another story can be told.
People's premigration stories are impenetrable for various reasons. Many patients who are referred to the Center have experienced different forms of violence and abuse. Some have been persecuted and tortured in their countries, have experienced war, and have sought political asylum elsewhere. Stories about "home" often resist narration because they recall an inhospitable place, one that is impossible to reinhabit, both physically and symbolically. At other times, "home" is an opaque reality that has been overshadowed by the urge to assimilate, integrate, and become other in ways that live up to the receiving society's standards of behaviors and of desiring. Italian institutions that grant legal status to foreigners often require clear narrations of their migration trajectories and countries of origin. Such pressure often results in confused accounts that are symptomatic of an impossible encounter between bureaucratic language and the complexity of people's histories. For instance, how does one translate the desire to escape from poverty by accepting prostitution as a lucrative activity? Or understand the desire to use the body as a powerful tool that brings wealth outside of the discourse of trafficking? "Home" can also become an object of impossible desire that exile has turned into a fantasy. There is often a gap in patients' language that points to an impossibility to remember and to speak. It can be understood as the response to trauma that disrupts language and consciousness (Agamben 1998). In all these cases, the accounts concerning life before migration take time to shape in the clinical encounter, which thus becomes the scene where experiences that cannot be communicated in language are nonetheless forced into the open.
During one consultation, Mary recounted a dream. Her husband had come to see her to tell her that he had died because his family had done voodoo on them and that she and their son were in danger. She had to go back to their house in Benin City, Nigeria, to find a wire and then return to Italy. If she could not find it, something bad might happen to them. On this occasion, Dr. L told Mary not to fear her husband's visits at night: "If he comes back in your dreams, talk to him, try to find out why his family turned their backs to you." Later, when we were alone, the therapist commented, "In her context, dead people are not just memories or dreams, they are real." She further explained that dreams were "an instrument of the present," an experience that provided memories from the past and reworked them in light of the present.
To me, the doctor's reflection was an invitation to the participant to take her dreams seriously and address them in their ghostly reality. I was also reminded of the fact that dreams can offer a space of doubling, where people who are dead in life are alive in dreams, where the boundaries between life and death are blurred. Dreaming of a dead person may signify that her influence in the dreamer's life is still present or that her death is real only in waking life. In this sense, the therapist was not just alluding to Mary's experience in which dead people could come back to life in dreams, but also to a quality of dreams that makes them not only a screen onto which images and symbols are projected but a moment in which existence is articulated in different forms (Binswanger and Foucault 1986). Or so I interpreted it. The clinical encounter provided a space for her memory, where past and present, death and life became blurred in dreams and where the impossibility to remember could be faced so that the subject may access a different kind of speech.
Mary's dream brought up other stories. Her husband's family was, in her words, from a village where "they did a lot of voodoo." His family was very envious of the couple because they did well financially and were able to buy a house in Nigeria and emigrate to Europe. Moreover, they imagined she had made a fortune during her time in Italy, and now her son would inherit all his father's money and the house. She was afraid of them and the harm they could do. She said they killed her husband, or that they did not protect him enough-"They did voodoo on him"-and that her HIV was the consequence of a spell. She also spoke about the bad worms inhabiting her body. They were red because they sucked her blood. She got them because "bad people had cast a spell" on her when she was pregnant. She almost died, but then she saw a native doctor in Nigeria who helped her; even so, the worms were still in her body. She also heard an ongoing echo in her ears and head that caused her a lot of pain.
She wanted some drugs because she had problems sleeping, which was why she had agreed to come to the Center in the first place. Dr. L, however, did not prescribe any medicine. First, she listened to the other symptoms that Mary presented: she had a strong pain in her ears, and the worms went from her head to her feet, through her shoulders and breast, and then all the way down her spine. Her knees were hurting, too. Mary had seen her cousin, a healer, who poured a powder made of pepper and other things from Nigeria into her ear. Along with suggesting that she undergo further medical tests, Dr. L attempted to go beyond the initial diagnosis of depression. She asked Mary if she could speak to the spirits who were causing her and her family pain. She also inquired if the presence of worms in Mary's body resulted from a failure to perform some rituals as part of her worship of gods and goddesses. In this way, the therapist was letting the patient know that she was familiar with and understood that rituals had powerful meanings and that spirits could speak and be spoken to. Mary explained that the pain had to do with something else. The doctor then asked Mary about her family back in Nigeria: "Do they know about your medical problems? What do they make of them?" Her mother knew, and her father died after she told him about it. She felt tremendous guilt.
Mary referred to her husband by his African name, Osaliato. Dr. L asked Mary what her other name was, and what it meant. "Osatuame," she replied. "It means 'God has pity on me.'" Prompted by Dr. L's questions, Mary said that her father had given her the name. When Mary's mother was pregnant with her, a woman from their village did voodoo, putting her at risk of losing the child. But Mary was nonetheless born healthy, and thus her father named her "God has pity on me." When Dr. L heard this story, she reformulated it by saying, "Your father was right because you are strong, otherwise you would not have been born. You are still strong now." As she later explained to the trainee and me, asking about the name in Edo-Mary's mother tongue-was a way to create a relationship of trust in which Mary could feel comfortable evoking parts of her life in Nigeria and know that the therapist could attend to it. She specified that it was important to know when to ask these types of questions; the purpose is to let the patient express herself in her own terms and let her know that her references are not completely foreign to us and that she can bring them to the therapeutic space.
A couple of months into therapy, Dr. L asked whether Mary talked to her son about his dead father. No, she responded, not without falling into despair. She feared that her son might be doomed to a similar tragic destiny. While discussing the case with me, Dr. L had admitted that it was difficult for her to deal with how the memory of Mary's dead husband played out in the therapy sessions. We knew Mary's sister had gotten rid of any objects related to him in order to protect Mary from her sadness. But he appeared in her dreams and claimed that his family remembered and sometimes helped or protected him. "Why don't you put a picture of him in a corner of the house and build an altar to him?" asked Dr. L.Mary started crying. She felt unable to do it. The therapist reassured her she did not need to rush it but insisted that it would be beneficial to her and to her son. Maybe she could also recite a prayer in Edo, she added. Mary asked if she should light a candle and suggested that maybe it should be white. Sure, the therapist replied, as long as she did it. Mary cried hard but said she would do it and thanked us.
At the end of the same consultation, in a therapeutic/pedagogic way, Dr. L suggested that Mary go to the exhibition of African art currently showing at a museum in town, as a way to reconstitute some connections with "home." Mary answered with some hesitation, asking, "What is an art exhibit?" Dr. L explained that there were life-sized statues from Nigeria and other parts of Africa that represented kings and queens of ancient times. "I don't want to see other people from Nigeria. I don't want them to find out about my illness," Mary replied. Dr. L explained that the statues were not human beings but a kind of object that resembled kings and queens and other humans. I added that she did not need to talk to anyone at the museum; it was a space just meant to exhibit objects. Later I asked myself whether this was an instance of the misunderstandings that could lead to a comedy of errors, where each group's uncertainty about the other confirms preexisting anxieties and misconceptions (Obeyesekere 2005). When Mary said she did not want to see other Nigerians, did she mean other Nigerians visiting the museum? Did Dr. L, and I along with her, instead assume that she did not know what an exhibit or a museum is based on the understanding that they are a Western construction? Perhaps Mary truly did not know what an art exhibit was; or maybe statues are more than mere museum artifacts and can act upon us and see through us, like the gods, goddesses, kings, and queens that they stand for. It is hard to know.
In the context of ethno-psychiatric clinical work, practitioners are engaged in finding an "intermediate space"-a space of mediation-between the therapist's theories and techniques and the patient's ways of expressing suffering in an attempt to avoid reducing symptoms to biomedical diagnostic criteria. At the same time, they encourage patients to maintain relations with their respective backgrounds in forms that range from being in contact with family members, performing rituals, or speaking their mother tongue to attending groups or churches with their fellow nationals.
This intermediate space can also be understood as a space of transference. In psychoanalytic treatment, transference is the term used to describe how the relationship between the analyst and the analysand is translated by and through the lens of the analysand's past relational experience. In the therapeutic setting, old memories and experiences are reenacted and emotions are projected onto the analyst. Through the process of unconscious reenactment, the patient assigns the analyst specific roles that resemble relationships in the patient's life. For example, the patient may transfer feelings of hate and frustration onto the therapist in ways that resonate or coincide with the feelings she may have toward a parent. The setting thus becomes a theater of the unconscious where the patient can act out past traumatic experiences and, with the analyst's support, work through past traumas by revisiting the relationship that caused it. In other words, if the patient had experienced an abusive relationship with the mother, through transference that relationship might be reconstituted to such an extent that its effects can be worked through differently. Thus, transference is a form of mediation-a space of translation-that rearticulates intersubjective relations and the meanings attached to them. Although the ethno-psychiatric setting is not a psychoanalytic one, when ethno-psychiatrists talk about the clinic as a "space of mediation," they are alluding to the process whereby the patient's painful motives and affects are transformed into publicly accepted symbols and meanings. Obeyesekere (1990) called this process "the work of culture," and Winnicott (1967) spoke of cultural experience as that third area between the inner or personal psychic life and the world in which the individual lives as a space of creation.
Through Mary's case I became interested in the question of when and how cultural material opens up, or closes down, the space of therapy. In many ways, I had to shift my focus to approach the issue of culture from a clinical/therapeutic angle and to ask what work "culture" does in this context. In the discussion that follows, I trace some of the ways in which "culture" is identified, at different moments in the therapeutic space, through diverse symbols, practices, words, and techniques. The contours of what counts as the patient's cultural background are in flux; they take shape as the result of a set of relationships the clinical context enables. I, for example, was curious about the ways in which Dr. L evoked Mary's "culture" in relation to the African art exhibition, or to praying in Edo, or to referring to her African name. What counts as her "culture," and in relationship to what? My anthropological desires to understand what mattered as cultural often coincided with those of the ethno-psychiatrists, trained in both anthropology and psychology or psychiatry. I shared with the ethno-psychiatrists the sense that this latter angle was sometimes at odds with the anthropological discussions on culture as a construction with indefinite boundaries. As I show in the rest of the chapter,in clinical work the anthropological and therapeutic takes on culture can become incommensurable, and yet it is precisely this untranslatability that produces encounters and spaces where categories are undone and a different listening can take place. This way of listening is a response to the new speech that emerges in the discourse of patients. As Dr. L suggested, the purpose of evoking cultural identifications was not to identify the patients' cultural background but to enable them to find a language and a memory that was lost in the process of migrating. I also began to understand the clinical use of cultural material as a way to reintroduce the political dimension of suffering, not just in the language of psychiatry, but also, more broadly, in the state's politics of recognition and integration of foreign others.
Walking the Tightrope
The process of naming cultural material as part of therapy was in part inspired by Tobie Nathan's clinical work with foreigners in the outskirts of Paris. In 1979, Nathan, a psychologist and psychoanalyst of Jewish Egyptian descent, opened the first ethno-psychiatric clinic and designed new treatment techniques for foreign patients that included healing practices from the patients' background and used cultural material as a therapeutic tool. In his early work,Nathan (1996) used the metaphor of the womb to refer to a reassuring and structuring envelope framed by culture that provided holding and healing within the ethno-psychiatric setting. He assumed that the structure that culture provided could get lost in the experience of migration, and that therapy could help reconstitute it. Both Nathan and ethno-psychiatrists at the Centro often refer to culture as a "therapeutic lever." When the term lever is applied to culture one is apt to think about an actual object or a series of identifiable symbols that stand as cultural references and that have an effect on the patient's state. In this sense, cultural identifications are conceived of as tools to lessen pain, to lift the weight of suffering by activating a mechanism of healing that can only be triggered through certain words, allusions, and gestures. The image of the lever thus evokes something in and of itself simultaneously static and transformative.
The therapeutic process designed by Nathan is ambivalent and complex, as I learned through the ethno-psychiatrists' work at the Centro. Practitioners there have rearticulated Nathan's early influence and departed from it. They do not assume culture to be an original set of meanings and practices left untouched and protected by the membrane of the maternal womb. Rather, they understand it as both a reassuring and violent set of symbols, simultaneously providing coherent and incoherent meaning to patients' experiences; for them, "culture" can be a tool in flux, a set of antagonistic and threatening practices.
It was never clear from Mary's accounts whether the people she feared seeing belonged to a prostitution network or whether she had ever worked in the sex industry at all, and if so, for how long, even though she once said she worked in the streets for a short period but never declared it to the institutions. Her account was opaque. What made it even more elusive was the layered process of translation at play in the therapeutic setting. In order to understand the nature of her symptoms and start a quest for a cure, Dr. L referred to the possibility that Mary was a devotee of Mami Wata, goddess of the waters, dispenser of wealth and abundance, to whom many Nigerian women are tied by promises of loyalty and worship and to whom they are offered as brides before migration. Failure to fulfill the duties of devotion may result in the goddess taking revenge and in the manifestation of bodily symptoms, like strong headaches or the worms inhabiting Mary's body. Nigerian women in Italy often talk about the difficulties of maintaining worship of the goddess. For some of them, resuming their devotion to her has led to feeling better. Ethno-psychiatrists may suggest this return to a form of devotion as a therapeutic strategy, to observe whether the patient benefits from it. In the cases I observed, acknowledging the existence of the goddess on the part of the therapists made women feel acknowledged, or even validated to a certain extent, in a sphere of their lives that other institutions (e.g., the state, the hospital, Catholic NGOs) classified as superstition. This acknowledgement was effective in reducing some of the symptoms they experienced.
If we understand symptoms not just as an index that signals the existence of an illness or disturbance but rather as a sign or a symbol formed in the interface between the unconscious and the conscious, and in which something of the illness is incarnated and manifested-the anger of the goddess, or the sense of guilt of the devotee-then the therapeutic work revolves around interpretation, not decoding symptoms into diagnostic categories. This process of interpretation is a form of translation that I understand through Benjamin's (1968) idea of translation as a way to abide and provisionally come to terms with the difference and multiplicity of languages. The symptom is in and of itself a translation of sorts. In the context of ethno-psychiatry-a practice and theory positioned at the thresholds of different knowledges (psychiatry, psychoanalysis, anthropology, philosophy)-various forms of translation are at work. Patients and doctors translate between their different understandings of suffering and cure; doctors translate between various medical languages (psychiatry, ethno-psychiatry, spirit possession, magic) and what may count as healing at different moments in the clinical work. Misunderstandings-like the one about the African art exhibition-are produced by complex encounters and negotiations (translations) and are themselves forms of understanding.
The misunderstanding occurring in this clinical context-just as in translation-can be a productive moment. In the relationship between therapist and patient (and in translation between one language and another), misunderstanding can help the therapeutic process and produce new meaning in language. The French psychoanalyst Jacques André has argued, "Agreement and understanding of the protagonists in the analytic situation . . . [signal] more of a hindrance to the analytic process than the mark of its dynamic" (2006, 567). This can be said of both the clinical and the ethnographic encounters, where various forms of foreignness meet. To reach an exhaustive understanding of the other implies having reduced difference to sameness. In translation, this would suggest that it is possible to achieve transparency of meaning through exact equivalents of words in every language. Yet Benjamin points to the fact that transparency is not the ultimate goal of translation. For him, that which resists literal transposition produces an epiphany in both languages. Translation thus creates newness. To translate is simultaneously to betray and to be faithful to an original meaning; it produces both understanding and misunderstanding. I interpret the processes of translation at work within the ethno-psychiatric setting as forms of acknowledgment that have surrendered the certainty of diagnostic categories as tools of recognition and can pay attention to the interruptions and enigmas of the patient's speech. Translation, here, does not produce agreement but rather dis-agreement.
In Mary's case, it was clear that what the doctor presented as a source of support and reconnection to a familiar context was only sometimes perceived as reassuring. When I later conversed with Dr. L, I discovered that she herself was ambivalent about her suggestion that Mary visit the African art exhibition. This instance created a conundrum, or at least I saw it as such. How patients respond to references to cultural material can vary greatly. In some cases, it proved effective. Other patients at the Centro responded very well when ghosts and spirits, djinns, and gods and goddesses were evoked and invited in the clinic. The vocabulary of "magic" and "witchcraft" is translated into superstition and belief in the public hospital, where biomedicine translates symptoms into psychiatric diagnoses regardless of the patients' backgrounds. For instance, practitioners at the Centro usually do not assign the diagnosis of schizophrenia or depression unless they are dealing with patients who have previously received such diagnoses from clinicians at the public hospitals before being referred to them. In these cases, they may refer to psychiatric diagnoses to question them or to continue the pharmaceutical treatments associated with them. Or they may use diagnoses instrumentally when they write psychological assessments for asylum seekers or victims of torture or trafficking (knowing that some psychiatric categories speed up the bureaucratic processes of obtaining documents). In the ethno-psychiatric setting, on the contrary, at any given time the ambivalent ways in which patients-and therapists-position themselves with regard to homes, mother tongues, techniques of cure, and what counts as "cultural material" can be expressed. In trying to recuperate what psychiatry excluded from its field of understanding, ethno-psychiatry creates a space-both therapeutic and political-that aims to include difference (cultural and experiential) as a fundamental variable in therapeutic work. In so doing, one of the ways in which ethno-psychiatrists work is by translating practices, experiences, ways of expressing suffering, rituals of cure, and symptoms into the language of culture. Instead of a fixed notion, "culture" is a vehicle of translation, a concept that enables different types of interpretation in the clinical encounter. In this context, culture also takes on a political meaning, because it introduces a difference that the state (in its various forms) can only recognize as belief and thus classify as unreal or untrue (Farquhar 2013).
Writing about his clinical practice, Roberto Beneduce (2007), founder of the Centro Fanon and leading figure in the contemporary field of clinical intervention with foreign patients in Italy, has defined ethno-psychiatry as a "clinic of ambivalence." I read this as referring to different layers of ambivalence: on the one hand, the patients' ambivalent positions with regard to their cultural identifications that shift in the course of life and migration; on the other, the ambivalence of the ethno-psychiatric practice itself, which emerges at the juncture of different-and often contradictory-etiologies and ways of conceiving what counts as normal, pathological, and, ultimately, as human.
After this consultation, I asked Dr. L why she suggested that Mary go to the museum: "What do you mean by 'culture' when you evoke the African art?" With other Nigerian patients I had heard therapists suggest that they attend Pentecostal churches if that could provide them with a network on which to rely. I was also curious about how Dr. L would go about assessing whether patients perceived cultural references as either persecutory or therapeutic. Her response captured the complexity of her position and the challenges inherent in it:
Sometimes in the clinical encounter we present patients with pieces of their culture. At times, you have to reify culture to make things happen. By using a certain reified idea of culture, you can see how patients respond to it and how they themselves use it. In this way, we understand better what culture means to them. One strategy is to reimmerse patients in what is persecutory in order to become stronger. In the clinic, you use culture as if you were a tightrope walker: you reify [it] without mummifying it. It is a fine balance, and you create a dialectic among the participants.
She continued, explaining that a complex process of reification, manipulation, creation, and simplification of what comes to be seen as culture takes place in the therapeutic space. There are moments during treatment when it is important to essentialize and present patients with a possibly stereotyped or homogenized idea of culture, followed by other moments in which that same idea is questioned, deconstructed, and further manipulated. This is a complex process, "something that can slip from your grasp," Dr. L added, if you do not know how to handle all the different phases of therapy and the various configurations that cultural references can take in the course of therapy. The idea here is not to reconnect patients to their cultural backgrounds but rather to produce the conditions for the subject to speak and find ways to be in the world.
For now, I want to reflect on the process of reifying culture that Dr. L mentioned as the actualization of a means of communication that is identified as "culture"-or our understanding of "their culture"-and that has the potential to become a shared field of understanding between patients and doctors. Her words reminded me of the experience of transference in the psychoanalytic setting that I mentioned earlier. For the therapist, the patient's transference of old patterns onto the therapeutic relationship is a way to get a better feel for the patient's experience and to relive certain memories with the patient. For the patient, transference provides a space where the play of the unconscious can be acted out differently. Similarly, in ethno-psychiatry we can understand culture as a transitional space wherein patients and therapists negotiate their positions vis-à-vis symbols and practices (Winnicott 1967). As Dr. L explained, by using certain ideas of culture and observing patients' responses, we learn about their experience of the world. Transference can thus be understood as a controlled misunderstanding wherein roles and meanings are unconsciously assigned and produce self-knowledge. In this sense, misunderstanding is not the sign of failed therapy but quite the opposite. It allows an encounter that occurs through various detours and crossings wherein subjectivity is produced and cure unfolds.
In regard to the art exhibition, Dr. L was aware that a misunderstanding may have taken place; she had wanted to evoke Africa as a geographic space, not as a cultural one, she explained to me. Her intention was to create an occasion for Mary to remember where she came from and to start putting together different pieces of her story, before and after migration. She agreed that at that moment she had taken on a more pedagogical position vis-à-vis Mary, a role she played with some discomfort. She herself was voicing and struggling with one of the dilemmas inherent in evoking cultural material in this setting. She pondered what other therapeutic strategies she could have used, what other ways could have served the purpose of creating a supportive space for Mary, who was experiencing a strong sense of alienation and fear.
The ethno-psychiatrists' strategy of relying on cultural material and/or practices that they understand as familiar to the patient in order to create a sense of belonging and recognition leaves room for a series of questions about the status of what is therapeutic. Is there persecutory potential in this approach, and can it influence therapy's outcome? Or, as Dr. L suggested, can being reimmersed in what the patient perceives as threatening, and reexperiencing haunting presences within this setting, fulfill a therapeutic promise? What counts as therapeutic in such a clinical ethos? Why does culture matter?
Allowing for words from patients' different contexts to circulate in the clinical setting, to talk about symptoms, to name suffering, is a way of creating a space of mediation and translation (or transference) where the unsaid of the patient's story can be articulated, or at least can be heard as silence or seen as bodily signs. Within this practice, acknowledging the legitimacy of cultural interpretations seems to unblock both the patient's and the family's speech (in those cases when family members are present in the consultations or contacted by patients to discuss symptoms) and to release associative chains that resituate symptoms within a personal and collective history (Corin 1997). I understand this form of acknowledgment as therapeutic. This framework prevents the patient from getting caught in one hegemonic discourse of suffering and enables a different kind of listening on the part of the doctors. The cultural approach provides a space of critique of dominant techniques in clinical work and repoliticizes the issue of difference. For instance, I began to understand Dr. L's suggestions to pray in Edo and her listening to Mary's references to voodoo and native doctors not only as part of a therapeutic approach but also as a political gesture that creates dissonance with the apparatus of biomedicine and the state, which relegate cultural, historical, and economic difference outside of its purview.
A Matter of Invention: Conundrums of Culture
"But what happens if and when the tightrope walker falls from the rope?" I later asked myself. I was struck by how well the image of the tightrope walker captured the tensions that therapists see in their work. What happens in the clinical setting when what figures as culture fails, is ineffective, or gets contested? Do these moments count as therapeutic as much as those in which patients identify with and respond positively to what Dr. L referred to as a "reified idea of culture"? Put otherwise, what practices of making, remaking, translating, recognizing, and undoing the temporary and fleeting object of "culture" are at play in this clinical space? Moreover, who is the tightrope walker? Is it the therapist, the patient, or the cultural mediator who translates for them? Or does everyone share equally the challenges of falling and remaining in balance while walking on a tight rope of culture, anthropologist included?
This clinical moment showed me one of ethno-psychiatry's conundrums, and my own conundrum as an anthropologist. At stake here are not only the different layers of translation embedded in this therapeutic practice and in my task as an anthropologist (also a sort of translator) but also the various meanings-concrete, elusive, and shifting-of what, through processes of translation, is identified and invented as "culture" or "cultural material" at different moments and for different purposes. When it is invoked in the form of rituals, prayers, beliefs, etiologies, and practices, what kind of work does culture do? How can the work of culture inform the therapeutic process (Obeyesekere 1990) and posit a new kind of politics for clinical work?
Roy Wagner (1981 ) has argued that anthropology as a discipline invented "culture" as a kind of illusion, or "false object," in order for the researcher to arrange and understand his or her experience of alterity. In this view, "culture" is a mediating term that allows the anthropologist to make sense of his or her experience of otherness and commensurate the sense of disorientation that accompanies any encounter with what is radically different from one's self. What the construct of culture shows is its kinship with the anthropologist's worldview and ways of rationalizing experience. In inventing "another culture," the anthropologist not only invents his own; he also reinvents the notion of culture itself (4). As an explanatory concept, culture makes difference translatable and therefore knowable. Along these lines, Wagner warns us that for the purpose of understanding, we must proceed as if culture existed as a monolithic "thing," but for the purpose of demonstrating how as anthropologists we attain our comprehension of the other, it is necessary to realize that culture is an invention, a tool-in other words, a prop (8-9).
The relation that the anthropologist builds between two cultures-which, in turn, objectifies and hence "creates" those cultures for him-arises precisely from his act of "invention," his use of meanings known to him in constructing an understandable representation of his subject matter. The result is an analogy, or a set of analogies, that "translates" one group of basic meanings into the other and can be said to participate in both meaning systems at the same time in the same way that their creator does. This is the simplest, most basic, and most important consideration of all; the anthropologist cannot simply "learn" the new culture and place it beside the one he already knows. Rather, he must "take it on" so as to experience a transformation of his own world (Wagner 1981 , 9).
Understood from a linguistic perspective, this kind of translation does not leave any of the languages involved unchanged. Translation is the way in which words travel from one language into another and back; it is a movement into the elsewhere of another language and the coming back transformed into the language of departure. Words are not simply dislocated into another linguistic dwelling, but are called to reshape the space in which they are transported and transformed (Heidegger 1975).
Dr. L seemed to be moving in and out of the different registers outlined by Wagner: at moments she needed to operate as if culture exists as a discrete set of practices (praying in Edo, referring to voodoo rituals, being in contact with family members, visiting the museum) in order to produce a response in Mary and to create a means of understanding of the patient's experience outside of psychiatric diagnostic criteria. In line with a phenomenological approach to mental illness, the ethno-psychiatrists at the Centro agree that to enter the lifeworld of the patient one has to break free from the apparatuses of control of the medical institution, beginning with its classificatory language. They argue that the diagnostic apparatus prevents one from exploring what is behind the patient's symptoms and from listening to the radical difference of what Foucault (1988) called the voices and experience of madness. At other moments, on the other hand, Dr. L implied that over the course of the therapeutic relationship objectified ideas of culture could also be undone, contested, and discarded as not useful for understanding. At the epistemological level, ethno-psychiatrists realize that the evocation of cultural ties is also an invention and a creation. I interpreted it as that intermediate space where translation as a form of relation occurs and produces something new. In this context, translation transfers the subject to an origin from which she has been alienated and which now appears as a completely different reality, a new world. Moreover, when the tightrope walker makes the journey without falling, cultural interpretations allow for other epistemologies and ontologies to be part of the therapeutic encounter.
What the exchange with Dr. L taught me was that the concept of culture at play in this kind of therapy is the result of an encounter, or a series of relations, not only between patients' representations of their experiences and the ethno-psychiatrists' own interpretations of them but also with homes, spirits, and invisible presences in the here and now of the therapeutic consultation. What emerges from these sets of relations is a constantly shifting context where cultural identifications simultaneously allow for understanding, misunderstanding, and the invention of meanings.
The ethno-psychiatrist's imperative is to provide culturally sensitive clinical services by focusing on the different ways in which patients' cultural backgrounds shape their expression of suffering and how forms of identification shift-sometimes dramatically-in the experience of crossing borders, as I suggested in the story of Favor in the introduction. This practice-as with anthropology-tends to recognize difference through the construct of culture, which becomes a shared construct, done and undone within the encounters. In a way, culture works as a signifier onto which difference can be translated and thus signified. When ethno-psychiatrists work as if culture is a tool, the underlying idea is that cultural referents can hold a space of difference and suffering that does not stigmatize the patient's experience in the way a psychiatric diagnosis can. Culture-understood in this case as rituals, prayers, magic, possession, spirits, djinn, and other meaningful cultural signifiers-may have the capacity to alter the patient's experience or simply reinscribe it in a world that holds meaning. How different contexts allow for experiences that escape coherence and meaning plays an important role in understanding patients' experiences of what lies at the margins of cultural codes (Corin 2007).
Because of their interdisciplinary training, the ethno-psychiatrists at the Centro bring to their practice a complex understanding of culture and recognize the problems entailed in the therapeutic strategy of reanchoring migrants in their own cultural backgrounds. They know well that the anthropological critique has undone the concept of culture by revealing it as a flexible and conflictual construct, encompassing norms and their transgression, rules and their opposites, and that the self emerges between adherence to existing codes and the constant creation of new ones. In this sense, our approaches to culture were very similar. In my work with them, I was intrigued not only by the ways in which cultural material was evoked and used in the clinical setting and its effectiveness as assessed by clinicians but also by those instances in which patients resisted identification with their mother tongues or etiologies that were too close to them and tainted by unresolved ties. What counts as therapeutic in these moments of identification and dis-identification is a central question. This issue is made even more complex by the fact that what figures as therapeutic in ethno-psychiatry is often in conflict with Western psychiatric practices. The use of culture is thus political in the sense that it creates an interruption, a disturbance, with the dominant discourse of biomedicine. What is important in ethno-psychiatry is how it recuperates the concept of culture after anthropology's deconstruction of it and repoliticizes it by showing its potential to create another discourse on difference.
Within this alternative space, the issue of what counts as human and its relationship to invisible presences and other ontologies is ultimately called upon. The Belgian philosopher Isabelle Stengers-who collaborated with Tobie Nathan on his first experiments in ethno-psychiatry in France-said that every technique needs some kind of invisibles (Stengers 2009). Invisible forces populate our therapeutic traditions, and not just the traditions and techniques of others. Among them, she counted the unconscious, which is irrational, repeats itself, possesses and acts upon us, has a force of its own that is unknown, and appears in the analytic setting before the analyst as a sort of sorcerer. Our Western sense of being human is in part defined by this "invisible," just as Mary and other patients at the Centro defined their experiences as influenced by invisibles. Ethno-psychiatry can thus be understood as a self-reflective practice that constantly reminds us that all therapeutic techniques are culturally and historically situated. In this sense, it functions as a medical anthropology that is attuned to the rituals and invisibles not only of others but of us as well.
Juggling Words, Translating Worlds: The Work of Mediation
I met Grace when she entered the rehabilitation program for victims of human trafficking and was referred to Emancipazione Oggi (Emancipation Today), a Catholic NGO that supported women filing criminal charges against their exploiters. She looked very young, although her actual age remained unknown. She had arrived in Italy from Benin City (Nigeria) with a fake passport. On paper she was eighteen. She and I spent a lot of time together over the course of several months. The staff at the NGO asked me whether I was willing to accompany her through the different steps of the program. At first, this meant going with her to the police station to file charges, to the hospital for medical checks, and attending to other needs she may have. When we met, she lived at a shelter for victims run by Catholic nuns in a secret location at the periphery of town. She was in a protected site because she had just entered the program and was in the process of collaborating with the police. Grace's life took some complicated and painful turns over the course of our relationship, some of which led her to attend the Centro Fanon, where she was eventually taken in as a patient.
Following Grace through various institutional settings allows us to look at the ways in which her story is rendered and made intelligible and how different languages and logics translate her into various categories of recognition. I argue that in the ethno-psychiatric setting, what the state hears as a lie or a missed narrative is received as a different kind of truth. In this context, the role of the cultural mediator becomes central; it embodies yet a different kind of translation that enables a relationship of care among all the participants in the therapy. Usually members of migrant communities, cultural mediators translate between migrants and Italians in institutional settings such as hospitals, prisons, schools, Catholic shelters for migrants, and courtrooms. The mediators' role in ethno-psychiatry helps develop a shared therapeutic frame between patients and doctors.
Let me start from the first time I encountered her story, at the police station on the day she filed a denuncia against her traffickers. I had accompanied her there and sat next to her as she recounted her story to a police officer with the help of a Nigerian cultural mediator who translated from Edo into Italian. Grace spoke broken Italian and needed a translator to understand and answer the officer's questions. The story that resulted from that day of interrogation and that came to constitute the official text of the denunciaruns as follows (this is my paraphrasing of the official document):
Grace is eighteen as she enters the rehabilitation program for victims of human trafficking. She left Nigeria when she was fifteen. In Nigeria she had never had sexual intercourse with a man. Her brother arranged for her to travel to Europe, with the promise that she could pursue her studies there. Grace completed primary school but dropped out of secondary school, as the family had little money. Her parents are divorced. Her father has twenty-five wives and more than fifty children and is completely absent from her life. Her mother has a small seasonal business in the local market in Benin City. She never knew where Grace was taken and what she was doing. She knew only that Grace was in Europe. Her brother's friend traveled with her to Italy and sold her to Edith, the woman who became her madam. Edith told her that her travel from Nigeria to Italy cost them 200 million lire (the equivalent of $100,000) and that in order to pay her debt quickly she had to work as a prostitute. Grace thought that being a prostitute meant wearing heavy makeup and had no idea that she actually had to have sex with men. Her madam told her to put on a miniskirt, a wig, high-heeled boots, and a tight shirt and sent her on the streets with the other young Nigerian women who worked for her. She was told that from that moment on, her name was Juliet, and if someone asked her age, she should say she was twenty years old. After her first sexual intercourse with a client she was taken to the hospital for constant bleeding. Once she was discharged from the hospital, the madam forced her to go back to the streets, even though the bleeding continued. She worked from 8:00 A.M. to 9:00 P.M. every day and gave all the money she made to Edith. She was not able to save any for herself or her family in Nigeria. A month after arriving in Italy, her madam performed a voodoo ritual. As part of it, she made Grace take an oath not to betray her and said, "If you don't pay your debt, you will die. If you tell anyone about what is happening to you, you will become crazy. I bought you with the money I earned from my own prostitution, and now you have to return the money with yours. If you don't respect the pact, you will die in Italy." The police caught Grace several times but never repatriated her. Her madam used to hit her with a belt or punch her in the stomach. She used to slam her face against the wall every time she came home without having earned enough money. One day, she escaped from her madam's house and lived with another Nigerian woman for a few months. During this time, she continued to work as a prostitute, to pay her debt to Edith, but also kept some money for herself. One night, three Italian men raped her. She was taken to the emergency room, and social workers approached her to explain about the possibility of entering the rehabilitation program for victims of human trafficking. In the denuncia, she declared that she had made a conscious decision to join the program.
Right after filing criminal charges, Grace had several crises at the shelter where she lived with the nuns. During these episodes, she would tremble with fear, at times ending up in uncontrollable fits and seizures, being completely unresponsive to the nuns, and becoming physically rigid and stiff. She was afraid to sleep in her bedroom by herself. In more dramatic moments, she would run to the kitchen and grab a knife, saying that she wanted to kill herself. She reported hearing a voice telling her to kill herself. It was the voice of Edith, her madam. For days the nuns did not know what to do, aside from stopping her from harming herself. They described her crisis as follows: "She crawls on the floor as if she was a snake; her body becomes as heavy as a piece of wood that weighed 200 kilos; we can't lift her even if the four of us together try. She says she wants to die." The nuns described her crises as "epileptic convulsions" and justified them as consequences of the subjugation she experienced during what the nuns understood as "voodoo rituals."
Before hospitalizing Grace, they called her pastor from the local Pentecostal church. He performed rituals with water, sprinkling drops of it all over her body, which reduced her to crawling on the floor. He suggested that the nuns contact her madam to tell her to stop performing rituals on Grace. "Otherwise," he told the nuns, "she is going to die in seven days." None of these rituals worked. After another crisis on Christmas night, Grace was hospitalized. Her diagnosis showcased the overlapping languages and criteria that are not usually combined in a single diagnosis: "psychotic syndrome linked to her prolonged exposure to serious psycho-physical traumas." The psychiatrist at the public hospital, Dr. M, explained her "post-traumatic psychotic syndrome" as a consequence of being forced into prostitution at a young age, being raped twice, and being reduced by her madam's voodoo rituals to a state of psychological subjugation. He concluded that she was likely to die or go mad if not treated. The psychiatrist reported her symptoms as "hallucinatory voices of a persecutory type, delirious and persecutory interpretations, anxiety attacks, nightmares, and insomnia." Dr. M was not familiar with ethno-psychiatric practice, but he was trained in psichiatria democratica-democratic psychiatry-and had a particular interest in social medicine. He volunteered as a psychiatrist at the local jail and was the only doctor at the hospital who was interested in seeing foreign patients. With Grace, he attempted to translate the symptoms into a language that reinterpreted psychiatric categories. Post-traumatic stress disorder is not a syndrome and does not belong to the spectrum of psychosis. In diagnosing her with "post-traumatic psychotic syndrome," the doctor was rearranging the categories at his disposal to signify a series of symptoms untranslatable to one specific psychiatric category as he knew it.
Apparently, Grace's last crisis started immediately after she found out that the police had not yet arrested her madam. "If she is free, she can do rituals on me," she thought. Moreover, Grace feared that the madam would send someone to threaten her family in Nigeria, thereby disclosing the fact that she was working as a prostitute and had lied to them. As the stories in the following chapters show, the larger networks of prostitution that move between Europe and Africa and the social relations back home have a strong impact on women's experiences, often haunting their imaginary and psychic life.
Meanwhile, the nuns were always with Grace and, at the suggestion of the psychiatrist, tried to collect information about her life before she came to Italy and while in Italy. Nuns, psychiatrists, ethno-psychiatrists, and cultural mediators collaborate at different moments of the rehabilitation program for victims and often share the fragments of a woman's story that each collects in the effort to grasp the larger context of their lives. But Grace's story seemed impenetrable to the nuns; it constantly eluded their attempts to grasp some truth about her past that would explain her current suffering. She often contradicted herself: sometimes she would say that her brother had sent her to Italy; sometimes she denied it. Sometimes she said he was a native doctor, a magician, who tricked her into prostitution, but in other versions of her story he was a craftsman who lived far away from the family and had lost contact with her. She said her mother knew she was a sex worker but then claimed her mother did not know and had not talked to her in a long time.
During one consultation with the hospital psychiatrist, one of the nuns said, "Each time, she tells a different story. It is as if she did not have a center, an identity that could hold, a story to which she could adhere, a culture that could sustain her." Even the Nigerian cultural mediator who worked in the Catholic shelter complained that Grace always lied about her past: "She never gives me the same version of the story." She didn't want to contact her family in Nigeria, especially her mother. "But she is still her mother, after all," lamented one of the nuns. "Why shouldn't she forgive Grace for what had happened to her?" I wondered whether forgiveness was what Grace wanted or if that was just what the nun wanted for her-her language to imagine Grace's project of emancipation and healing. The story she told the nuns did not have the same coherence as the one she told at the police station when she filed criminal charges, although the nuns were looking precisely for that same logic in the account of her life. They wanted to make sense of her difference and what they perceived as her madness.
Dr. M reflected on the nuns' concerns: "The different versions of the story could be a strategy of survival, a defense. If she told the true story she would probably die; she is not able to handle the truth of her own story." He alluded to a dangerous truth that can only be approached through multiple lies, fearful and timid attempts to touch it and own it again (or maybe own it for the first time), with the risk of being annihilated by it. Grace's migration, her exile, can therefore be seen as a possibility to occupy her story differently, in a way that could make healing possible. But this story could not emerge within the hospital through biomedical language, or in her interactions with the nuns.
The hospital psychiatrist's interpretation shows how various actors reacted differently to Grace's numerous narratives. The lack of coherence in each fragment of Grace's account confused attempts to rehabilitate her as a "victim" and free her from subjugation to make her an autonomous subject. Foreign women are recognized and taken on by social services as victims. Without the narrative of the victim, recognizing the other is fraught with the danger of losing one's own center, or, following de Martino (2000 ), of losing one's own presence. For de Martino, the "crisis of presence" refers to the individual's existential fear of being threatened by situations that challenge his or her ability to handle external and internal realities. Foreigners and Italians alike share this danger when their mutual incommensurabilities cause conflict. This is how I interpreted the anxiety and fear I heard in the nuns' concerns about Grace's "psychotic episodes," their discomfort about hearing of the complicity of family members in her choice to migrate, and the impossibility of grasping some coherent narrative that could then be labeled as her story.
As for Grace, she did not have many prefabricated stories at her disposal within the Catholic shelter,other than the story of the "victim" provided by the denuncia, which, as I show in chapters 4 and 5, found its raison d'être in the Catholic rhetoric of confession and redemption. Approached as a victim within the frame of the rehabilitation program, she responded as a victim. Grace's experience also points to something I have observed in other foreign women's lives. They come to inhabit the category of the victim for particular periods of their migration trajectories. While they often have that category ascribed to them, they are never completely subsumed within it, even at critical moments when all other reference points are lost. Hence the confused versions of the past that creep into their narratives are a way of redeeming a story that cannot be told as it attempts to make itself heard. I saw Grace's suffering as an account in and of itself, a way of telling an ineffable story in institutional settings that represent, to her, multiple alterities and that inhibit the production of a single narrative. Her elusive stories could also be interpreted as ensuing from trauma: did they point toward dissociation, a missed narrative-as Western psychological and psychoanalytic theories of trauma would cast it-or were they an account of life in its own right? In the various institutional settings where her stories were heard, the gaps and discrepancies were interpreted as holes in the account, as lacks preventing Grace's narrative from becoming whole. In contrast, in the ethno-psychiatric space, as I show below, discrepancies would be treated as forms of truth, contradictions would hold meaning more than coherence, and silence would contain not the absence of speech or the vacuum of sense but a narrative itself.
When she was discharged from the hospital, she worried about what would happen to her once she had fully recovered: "I don't know how to do anything. What will I do when I get better? I am nothing, I can only go back to the street." Her concern, apart from practical ones such as finding a job, speaks to her fear of being recognized solely as a victim. Being labeled in this way contains the foreigner in a moment of loss, outside of which the risk of experiencing a crisis of presence re-presents itself with full force. The story of victimhood provides a singular fixed narrative-a kind of anchor for some-and also adds another possible version to the other stories women tell in different institutional settings and/or according to various contradictory paths of memory.
After her first hospitalization, I told the nuns and Dr. M at the hospital about the ethno-psychiatric clinic where I was conducting my research. They decided to consult with the ethno-psychiatrists and cultural mediators at the Centro Fanon, and eventually Grace was accepted as a patient. When asked at the Centro about her crises, she responded with frustration and anger at the fact that she had yet to receive her residency permit. She had been in the rehabilitation program for four months, and she had filed criminal charges before that. When she met Dr. A, one of the ethno-psychiatrists at the Center, she refused to talk to him. A Nigerian cultural mediator, Charity, was present during the consultations and spoke Edo with her. They were both from Benin City. Over the years, Dr. A had treated many Nigerian women and had come to be recognized as an expert on issues concerning their treatment; he consulted with the Immigration Office, social services, and mental health practitioners. After a few consultations, he asked Grace whether she was in contact with her mother in Nigeria or with the brother who had sent her to Italy without warning her about prostitution. He was relying on a version of the story that the nuns had reported to him and that mirrored the one she gave when she filed criminal charges. Other questions were more directly about the specific symptoms she experienced. I wondered how she would talk about the voices she heard in her head now that she could speak in her mother tongue. What words would she use to describe her bodily sensations during her crisis?
At first, Grace responded with "yes," "no," or long silences. Eventually, however, Grace started telling a story about the time she had arrived in Italy. It sounded just like the storyarchived at the police station, with the same coherent rhythm and empty words, caught in the speech accepted by the state. And then she burst into a long list of grievances:
I am tired of telling the same story over and over again. I gave them my story, and I still don't have a residency permit or a regular job. I am going crazy because my madam knows I reported her to the police. I live with Catholic nuns who pray day and night, and I am still sick and without papers. Why don't their prayers work? If I go mad, it means voodoo works here in Italy as well. This man can't do anything about my papers. What's the point of telling him my story anyway?
Charity not only translated the ethno-psychiatrist's questions for Grace, but, as is common practice at the Centro, was given the space to ask her own questions and collect Grace's story in her own way without specific instructions from the therapist. The idea is to create a space where patients can use their own words and language to express what they are experiencing, and the aim of the cultural mediator is to facilitate this process so that the patients can resort to different etiologies and techniques of cure and borrow from both those of the receiving country and those of their country of origin. In this context, the cultural mediator is asked to be much more than an interpreter, an expert at finding equivalences between languages. Rather, she becomes a juggler of words and a translator of concepts, adept enough at the task to make the words and concepts resonate and reverberate in the language of the other, whether the patient or the therapist.
Even so, for several weeks during the consultations Grace met any question or reference to Nigeria with complaints about not having papers, the denuncia not helping her get legal status, not having money like she did when she worked on the streets, and so on. The ethno-psychiatrist did not make a new diagnosis. In fact, he suspended the previous diagnosis in his attempt to let another story emerge. Dr. A encouraged her to slowly get back in touch with her family in Nigeria and, more generally, with her life there. He suggested that she read African literature-if that was something she used to like to do. But Grace was still very vulnerable, and she resisted all attempts to draw her life and story back to where she came from. She refused to contact either her mother or her brother. Hers was a broken biography, splinters of stories jutting in divergent directions.
When Grace filed criminal charges she was asked to provide a chronological narrative in which the past was recounted with linear transparency. In the therapeutic setting, another kind of memory was invoked: a traumatic one that repeats itself in symptoms and regressions, punctuated by multiple temporalities and interruptions, and that resists direct access. As Dr. A explained, what in part characterizes traumatic memory is that the subject ignores the existence of a past traumatic event in the sense that she does not hold a distinct rational memory of it. Nonetheless, this memory makes itself visible in repetitions, in acting out old patterns of behaviors, and it operates despite the subject's awareness of it. In a way, the patient is possessed by this memory; it has a life of its own and cannot be reduced to a single narrative (Beneduce 2010). There is no coherence. In this clinical space, fragments of memory provide an account that defies categorization. This memory encompasses all the invisibles that the ethno-psychiatric setting can reconvene (Stengers 2009).
Before Grace left the session that day at the Centro, Dr. A told her to write down all the words she heard in her head and urged that if the voices told her to kill herself, she should cry out, "The doctor forbids it!" This imperative seemed to reassure her. Someone was standing up for her against the threatening voices in her head. Through transference, the doctor occupied the position of the healer who speaks directly to the persecutory voices, as a shaman or native doctor would do. Dr. A explained to me that evoking concepts such as witchcraft or the existence of invisible agents as the root causes of the patient's suffering resembles the revelation of a secret. Thus, the therapist needs to position himself as the patient's defense against damaging forces that can bring about illness, madness, and danger. The first step for a therapist is to take the patient's fear seriously and not reduce it to belief. Next the therapist needs to insert himself in the network of power relations that cause the patient's suffering so as to take on the role of the one who can break the spell (Beneduce 2007). In this clinical context, it is not a matter of evoking the magic of the patient's cultural background but rather of making her speak to it in order to free her from its effect. This is how I understood what Dr. A enacted on that day. He occupied the position of the protector-or, rather, he let the logic of the voices in Grace's head assign him this position-who could counteract the malignant forces. But as Dr. L had warned us in the case of Mary, things can slip from your grasp if you do not know how to position yourself in the field of magic, where accusations and counteraccusations become powers that assign positions to those who find themselves in their presence (Favret-Saada 1980).
Eventually, after several consultations, mostly spent talking about the residency permit, a different kind of story seemed to creep into the usual exchange of words. Charity, the cultural mediator, evoked the possibility that Grace belonged to a secret society in Nigeria, which would explain why she resisted revealing the details of her life back home. On that day, Grace had a bad headache that made it more difficult for her to talk. The therapist put his hands on her head and asked her to tell him about her past in Nigeria. "You are safe here, the doctor protects you from the people who want to harm you," he said. She remained silent, with her eyes closed. "Do you have another name, an African name?" "Yes?" "What is your African name?" "Ivié," Grace replied. Slowly she started revealing more. She was worried about going mad because she had not paid her debt to her madam, and she had broken the oath. "My madam will do anything to destroy me, to make me go mad." The ethno-psychiatrist asked Charity what the expression "to go mad" is in Edo. "Iwaré." "Is it a general term or is it linked to voodoo rituals?" he asked. "It means that the people who do magic to you make you become a cadaver without a body; you become a slave, useless, the living dead, at the threshold of life and death," Charity explained. At that point, Grace started to complain about back pain and her legs being very heavy, as if full of water. She had experienced these symptoms before but had never revealed them to the therapist. He then asked her if she had ever participated in the worship of Mami Wata, the goddess of water, wealth, abundance, and success. After a while, she recounted that her mother had brought her to one of Mami Wata's ceremonies and that for a long time she had worn an anklet as a symbol of her devotion. When she came to Italy she joined a Pentecostal church and ceased worshipping Mami Wata. The interaction was a flurry of words: those spoken by Grace, then translated by the cultural mediator, then taken up by the doctor, and finally bounced back by Grace.Her symptoms seemed to resist any reduction to a clinical record; they pointed instead toward confused relations, opaque memories, and ruptured belongings that exceeded psychiatric diagnosis and could not be made intelligible through biomedical logics.
How could Grace's experience and multiple affiliations be translated in a clinical context that did not use psychiatric categories to find meaning in what exceeded the domain of normality? Could "culture" be used to understand these moments of incommensurability when stories follow different temporalities and categories no longer hold their logic? The ethno-psychiatrist as tightrope walker had to create an encounter with the patient that would produce meaning for both patient and doctor. This meaning, however, could be fleeting and illusory. As one psychologist at the Centro explained, when women speak of voodoo in the clinical space the therapist might assume an understanding of what cultural trait they refer to, but in reality what the patient presents is an element whose contours are very opaque. Voodoo is sometimes called "culture," though it eludes any definition of what culture is. Ethno-psychiatric practice is thus articulated through the making and unmaking, appearing and disappearing of meanings, objects, rituals, and concepts. Moments of commensuration/reification are followed by moments of incommensurability, when "things slip from your grasp." And just like misunderstandings, things that slip through your fingers and accounts that are not linear become important elements of a cure.
Patients often arrive at the Centro after having been diagnosed at the hospital. They are usually referred by other health services or by public and religious institutions. The referral takes place when institutions recognize that the person needs a different kind of treatment and when social workers, mental health practitioners, and volunteers feel powerless and unprepared to manage the patient's request for help. Because ethno-psychiatry is intertwined with practices of cultural and linguistic mediation, at the Centro patients can turn to cultural mediators from the same linguistic group to help. In this context, mediators are asked to explain and clarify symptoms according to the cultural idioms of the country of origin of the patient, and they can also participate in the process of formulating diagnoses and administering a cure (Nathan 2001). Their role is to mediate between the cultural content of the patient's idioms and the explanatory models of the doctors (Kleinman 1988). This allows for a different telling and a different listening.
The stories that resist being told are not necessarily about prostitution or other events that are usually represented and experienced as traumatic; often they concern the time before migrating: stories about homes and family members with whom ties have become more precarious, tense, and persecutory after migration. For example, one of the psychologists at the Centro explained to me that in the ethno-psychiatric setting, a considerable number of women who according to the law qualify as victims of human trafficking do not talk about prostitution as a traumatic experience. They have a more complex relationship to sex work, which at the moment of migration they might see as an entrepreneurial adventure, for lack of better choices. In women's accounts sexuality is mentioned and experienced in multiple ways: in some cases it serves the purpose of migrating, earning money, and supporting family members; in other instances it is thought of as sinful and shameful, especially if perceived through the gaze of the receiving society's institutions; in yet other cases, all these aspects are experienced at once. Women are often caught in these polarized logics, seen as either victims or prostitutes, either traumatized or pathological. In reality, in their experiences these polarities are blurred. They do talk about the crude reality of street violence and sexual abuse that often accompanies prostitution, but this is only one of various ways in which women position themselves and are positioned by others in relation to prostitution.
The Play of Diagnostic and Cultural Interpretations
One way in which translation works in the ethno-psychiatric setting is through the formulation-or suspension-of diagnosis, a kind of translation itself. Therapists are very cautious about using diagnoses based on the criteria of diagnostic manuals. Yet they are aware of the patients' need to have a name for their suffering. In the consultation, all participants share the process of naming the experience of suffering. Practitioners view the formulation of a diagnosis as an exploratory process during which patients can explain what they experience in their own terms; family members are involved in naming the moments of crisis (often from afar by phone calls made by cultural mediators or patients themselves), and ethno-psychiatrists juggle their own explanatory models and cultural explanations and are conscious of whether or not they resonate with the patient's representation and experiences. In the words of one ethno-psychiatrist, "Coming up with a diagnosis is an open process of exploration, not a process of labeling and fixing. It takes into account multiple voices, and it aims at serving a purpose for the patient, such as being able to name his/her suffering in a way that can be heard and shared by family members and people back home." The assumption is that any diagnosis that claims to have recognized and identified symptoms within an explanatory model is paralyzing. The aim is to have composite diagnoses that draw from plural epistemologies and taxonomies and speak specifically to the patient's situation.
In a context where matters pertaining to gods and spirits are put in dialogue and tension with the language of secular psychiatry and psychoanalysis, clinical practice is fundamentally reshaped and "enchanted" by logics that escape the language of secular time. Diagnosis is thus less a process of direct translation of causes and symptoms into categories and more a form of acknowledgment of a fluid situation where the subject is to be understood not only in psychoanalytic terms but also as defined and constituted by external invisible agents. As in the experience commonly referred to as "possession," these external agents fundamentally position the subject by putting it in relation with forces, spirits, and presences that are constitutive of it-not separate from it, but copresent with it in forms of intersubjectivity that go beyond the Western idea of what counts as human. Just as acknowledging the presence of invisible agents in the clinical encounter decenters the idea of the subject as it is framed in psychological and psychiatric terms, ethno-psychiatric theory and practice decenter psychiatry itself (Beneduce 2006). Ethno-psychiatry produces a rupture within psychiatric practice. On the process of diagnosis, Dr. L explains:
We often deal with people who don't adhere to a single system of classification; they are suspended in between various possible ways of making sense of the causes of their suffering. . . . Our practice should facilitate the person's exploration of all the etiologies available to them . . . , in order to make space for their difference to emerge. . . . A diagnosis is . . . a classification, a homologizing labeling that completely misses the patient's difference. . . . Our effort is to look at the migrant's difference and not to put suffering into the box of a diagnostic category.
Naming symptoms and suffering in this setting implies the combination of multiple approaches, languages, categories, and ontologies. Beyond the diagnostic logic of psychiatric and psychological paradigms, the explanation of the patient's symptoms results not from an either/or process (either psychiatric or cultural) but from a process that attempts to blur the boundaries of psychiatric and cultural categories. The suspension of diagnosis represents the attempt to make the space of the clinic receptive to other ways of understanding suffering and open to difference. In ethno-psychiatry, both prognostic and therapeutic efforts aim to allow the patient's difference to express itself and not to reduce it to the homologizing effect of a diagnosis. Approaching diagnosis as a multivocal process resonates with a practice of translation that recognizes a certain degree of incommensurability between languages and ontologies and does not attempt to reduce them to equivalences.
Recognizing the patient's difference is considered a therapeutic act in and of itself. In my fieldwork at the Centro Fanon, I often observed this approach. However, the benefits of demedicalizing suffering had its exceptions. In some cases, evoking cultural material in the therapeutic setting can provoke anxiety in the patient. The attempt to invoke values and cultural material that resonate with the patient's original context can cause distress rather than a sense of holding or a reassuring sense of familiarity. In Mary's case, for instance, Dr. L was aware that the dead husband and his family's magic powers had a persecutory effect on Mary, but she also believed that even if certain aspects of culture are perceived as threatening, working through them can bring healing.
I was caught in another set of questions regarding the failure of culture as a concept that could heal. Or, rather, I understood cultural interpretations as a vehicle of mediation that at times need to be suspended and bracketed, just like psychiatric diagnoses. In one of our conversations, Dr. A told me about the case of Joy, a Nigerian woman who complained about hearing voices and feeling the presence of spirits inside her head. In particular, she had reported a dream in which a spiritual husband sat on her head and ejaculated. Devotees of the possession cult of Mami Wata are married to a spiritual husband (another way to refer to Mami Wata), but their devotion is often discontinued or tainted with ambivalence once they leave Nigeria. Nonetheless, women may experience that the ties with the divinity cannot be completely severed and thus feel haunted by her presence. Joy felt persecuted by the spirit. During one consultation at the Centro, one of the practitioners made a reference to the presence of the spiritual husband in Joy's dream, to which she responded with a high level of anxiety: she stood up and started walking fast in a circle while speaking to the spirits. Dr. A intervened because he realized that the spirits were threatening to Joy, and at that point in the treatment the therapeutic team was not capable of handling such forces. He commented to me that if you invite spirits into the consultation, it is like inviting a ghost: "You must know both how to let them in and how to send them away." In that instance, he reassured Joy that the medications she was taking would help her get rid of the voices and feel better. He therefore resorted to what he defined as an "allopathic-exorcist treatment," not because the presence of the spirits was something to deny (on the contrary, he emphasized), but because he believed that the patient was too vulnerable and the therapeutic team ill equipped to face the spirits.
This further explains how in ethno-psychiatry identifying the patient's positioning with respect to their culture has important implications for the diagnosis and kind of treatment chosen. The patient's suspension between different etiologies can at times mean that he or she may benefit from naming the suffering with a psychiatric diagnosis, precisely the diagnostic domain contested and challenged by ethno-psychiatric practice. Moreover, medications can also figure as part of the treatment if they help the patient cope with unsettling presences and threatening voices. This is what Dr. A described when he discussed Joy's case and the difficulties the therapeutic team encountered dealing with the invisibles that the patient evoked. In this case, the doctor did not use the language of culture to communicate with the patient. Therefore, in the context of migration, as in a postcolonial situation, it becomes impossible to fully inhabit the diagnostic categories or the references that culture provides (Pandolfo 2008). This kind of clinical work suggests and enacts a conversation-an encounter, a translation-between different worlds (and languages) that construct a plurality of meanings, objects, interpretations, and understandings.
Within this setting, not only are there competing and overlapping etiologies at play, but there are also discrepancies between how the ethno-psychiatrists and the cultural mediators approach the question of translation. Leaving room for multiple interpretations of symptoms can coexist with the therapeutic need to name difference through criteria framed in the register of culture rather than that of a psychoanalytic diagnosis. Acknowledging the existence of differences, singularities, and the process through which they constantly reshape each other is not the only practice at play in ethno-psychiatric clinical work. The tendency to explain symptoms through what is recognized as cultural material points to the need-for both ethno-psychiatrists and patients-to name suffering and make it commensurable, understandable, and manageable. This leads me to ask whether cultural explanations can, in this context, become a substitute for psychiatric diagnoses and thus have the same fixing and paralyzing effect of the language of biomedicine.
The Reverse of Culture as Therapy
What if, from the patient's point of view, exile from one's own world rather than cultural references can provide a therapeutic opportunity? While participating in therapy sessions at the Centro-and later as I started transcultural therapy myself, in the context of my own migration-I often wondered whether departure from one's mother tongue and from what counts as home may allow the subject to rearticulate life in different forms and imagine experience anew in ways that can be considered therapeutic. The ethno-psychiatrists shared this question with me. They often talked about culture as conflictual and violent as well as therapeutic, as a shifting signifier that carries different connotations. They often avoided using the concept of culture but instead referred to "a noncoherent set of cultural and social references that influence patients' ways of experimenting the world," as Dr. P once explained to me. What figures as a reference to patients' background and tradition can also be "poisonous knowledge" (Das 2000), pointing to experiences of suffering that are enmeshed in social relations and not necessarily tied to a specific traumatic event. When Mary referred to her husband's family and the fear of being the victim of their spell, she is referring to social relations that she perceives as dangerous. Frantz Fanon, too, has talked about the practice of tradition as "a disturbed practice" (1965 , 130), and of the impossibility of a return to the past, to a culture that has been tainted and erased by the experience of colonization. For him, the "quest for dis-alienation"-or emancipation-can happen by acknowledging the fracture that violence produces, becoming untangled from the influence of the colonizer's gaze and starting anew (Fanon 1967 ).
For instance, at the Centro, in some cases when the language of sorcery, possession, or witchcraft is evoked to provide a context to a patient who is hearing voices and feeling haunted by other forces, ethno-psychiatrists noticed that patients and family members (who are not necessarily present in the consultation) may react with distrust and disbelief. As Beneduce (2003) explained, people express this kind of distrust in regard to theories and etiologies in order to distance themselves, not because that world has ceased to be meaningful, but precisely because that world is still present and associated with unresolved ties, relations, and debts. In such moments, cultural interpretations appear to be persecutory rather than healing. Here I am referring to the persecutory aspect of cultural references that could lead to a foreclosure of the cure, and not, as Dr. L earlier suggested, a necessary step in the healing process. In this sense, both cultural and psychiatric diagnoses can turn out to be stigmatizing and paralyzing, closing down the possibility of exploring suffering and instead enabling it. Thus, when practitioners describe their practice as a "critical ethno-psychiatry" they refer to the importance of bracketing both cultural and psychiatric diagnoses and allowing interpretations to emerge in the space in between.
In the context of migration to Europe, the psychoanalyst Fethi Benslama (2000) points to the fact that in the sociology of migration, migrants are often portrayed as victims rather than agents. They are passively moved by the need to leave, attracted by the illusion of the wealthy north that alienates them from their cultures. This argument classifies all kinds of migration as banishment (banissement), and it completely effaces the question of desire: the desire to exit, to exile one's self from a context that may have become unbearable. Such is the desire to inhabit another culture and speak the language of the other as an experience of emancipation. Benslama further argues that migration creates a rupture in the course of the life of the subject who has become a foreigner, to himself or herself and to others. This experience puts in question the very sense of being in the world, and the psychoanalytic setting can help the subject inhabit this rupture, tolerate the loss, and thus find a more authentic sense of self.
Benslama's critique of ethno-psychiatry is directed at Nathan's clinical use of culture in the French context. As I explained earlier, while Nathan's model inspired the early phase of the Centro Fanon, practitioners there have also questioned it and developed a critical approach to it. Benslama (2000) argues that by encouraging foreign patients to address their cultural backgrounds, ethno-psychiatry may risk reducing the specificity of the individual to the anonymity of the group. Thus, contrary to a use of culture as a tool of recognition of difference-which counters the universalizing perspective of biomedical knowledge-this approach might produce precisely the opposite effect. Thinking about Dr. L's explanation of what it means to reify certain aspects of patients' backgrounds in order to create a relationship, I understand reification not as the reduction or translation of experience into fixed meanings but on the contrary as a mean to create a therapeutic relationship. Reification in this clinical context, then, does not fix patients in abstract representations but emerges from the relationship between patients and therapists and enables the circulation of speech and associations. As Dr. L specified, a patient's response to a therapist's use of cultural material reveals what resonates with the patient as a meaningful interpretation. In this sense, reification is a social relation (Strathern 1999) that produces certain effects.
My question about exile-as a way of thinking about the rupture produced by migration and as a potentially healing place-emerges from spending time at the Centro, where cultural representations and identifications are both evoked and suspended and symptoms can interrupt the flow of memory and beg for another listening. In line with a psychoanalytic perspective, this therapeutic choice allows the subject to be in touch with the rupture produced by crossing borders and with the resulting self-inquiry that is peculiar to the individual as such and not as a member of a group. To live in this break means to stutter in one's own language and in the language of the other. Experiencing this uncertainty in a clinical setting-instead of reanchoring the patient in what is represented as his or her culture of origin-can be therapeutic. At the same time, it is essential, in my view, to understand ethno-psychiatry's contribution beyond the Western psychoanalytic conception of the subject as the expression of a singular voice that emerges at the juncture of individual experience, unconscious desires, and the work of memory. Some of the therapeutic choices in ethno-psychiatry position the patient in the frame of external and collective forces that, while being other from the subject and operating beyond his or her will, are constitutive of his or her subjectivity. These invisibles coexist with what in Western terms is understood as the individual, and they blur the distinctions between self and other, knowledge and belief, as we know them. Ethno-psychiatry thus troubles Western assumptions not only about mental health but also about subjectivity and what counts as human.
What is "therapeutic" and what stands for "cultural identification" at different moments in the ethno-psychiatric treatment shift and are in tension. Whenever cultural material is represented as a possible therapeutic tool, or lever, anthropologists raise their guard and denounce its objectification. In the contemporary heated debates about ethno-psychiatry in Europe, psychoanalysts have joined the classic anthropological critique of this practice, which they claim can stigmatize and further the risk of creating cultural ghettos and exotic representations of the other (Benslama 2000; Fassin 2000; Fassin and Rechtman 2005). I believe the anthropological critique of ethno-psychiatry needs to be turned upside down. As the clinical moments I have recounted in this chapter show, clinicians may reify cultural references, but they do so with the awareness of creating a tool in order to produce an effect that in turn produces a therapeutic encounter. The clinical setting becomes a theater of alterity where cultural meanings are produced and shared by the different characters. To apply anthropological theory to the clinical use of culture is misleading and risks missing the point of the political valence of the use of culture in this specific context. The kind of reification I am referring to here is only a temporary tool of recognition, an attempt to translate difference in terms that are intelligible to patients and doctors. It is a means (a technique) that has the potential to go beyond the logic of recognition and blur the distinctions between various classificatory systems and translations. This reminds me of James Clifford's (1997) ways of talking about culture in terms of travel and as a set of circuits to exemplify the complex cultural formations that cannot be contained in the term culture and that contemporary anthropology theorizes.
The question about what counts as cultural material that I-as an anthropologist-and ethno-psychiatrists-as both therapists and anthropologists-ask points in directions that are sometimes similar and sometimes different. I am mostly interested in how the play of cultural references takes definite boundaries in the clinical setting (in the form of rituals, languages, prayers, places, voices heard, spirits, invitations to join local Pentecostal churches, to visit exhibitions, to recuperate memories and maintain ties with home) and how those very boundaries are done and undone in the therapeutic encounter. Different intertwined layers of culture and translation are at play. Sometimes aspects of the patient's world constitute the subject; at other times they dissolve it. At some times cultural representations provide containment for the individual; at others they create dangerous identifications. In a way, "culture" resists closure; it works-for both anthropologists and doctors-as a floating signifier. In this context, reifying cultural material does not imply a closure. Therapists make and undo reifications in order to create a relationship with the patient. Perhaps, in this relationship, cultural material may also make the subject depart from, rather than fix her in, certain identifications.
As practitioners, ethno-psychiatrists use "culture"-not merely to observe or theorize it (although they do so in their theoretical writings)-as if it existed and experiment with what has therapeutic traction. They do not know with certainty what cultural identifications are or what they mean to the patient. They work through intuitions, definitions, constructions, and translations. Moreover, they pay attention to the work that cultural references do, to their effectiveness on the bodies of patients and in their lives (Lévi-Strauss 1968). What is "therapeutic" from the practitioners' point of view also seems in flux: in some cases cultural material is seen as healing because it provides a positive environment, a set of symbols that would re-create meaning in the patient's world. On the other hand, as in Mary's case, being reimmersed in cultural material that the patient perceives as dangerous can be, in Dr. L's words, a way to make her stronger. Ethno-psychiatrists suggest that provoking disruption has the potential to be both healing and ineffective. Continuity with one's cultural background as a healing strategy can go hand in hand with the strategy of distancing from a world that is poisonous and a tradition that has become perverse (Fanon 1965 ). What ethno-psychiatrists view as healing is the patient's ability to hold together different worlds, the one she left behind and the present one in which she is living. In fact, the past should merge into the present and find a place there, not the same one it occupied in the past but resembling it. Ethno-psychiatrists explain listening as being attentive to the different temporalities of the patient's experience, something that the hegemonic tone of today's psychiatric discourse erases and makes invisible. Therapy is thus the reverse of assimilation; it is a political statement and a way to create experiences of "integration" (through interruptions). It is a concept that a politics of migration and psychological theories of the subject share in principle while meaning different things in practice.
Gananath Obeyesekere (1985) has reflected on the work of culture as the process whereby painful experiences are transformed, or translated, into sets of meanings and symbols that are publicly accepted in the world of the patient. This kind of work, though, risks failure, just as walking on a tightrope may result in falling, and translating risks betrayal. In other words, culture can fail to provide the materials that are necessary to bring meaning to experience. Obeyesekere argues that success and failure in turn can provide a critique of culture that can connect anthropology and critical theory. I would add that success and failure can also lead to a critique of the play of cultural representations that brings together anthropology and clinical work and that makes them-at moments-untranslatable and incommensurable. This is the conundrum that the ethno-psychiatrists and I shared; from within our own disciplinary perspectives, all of us struggle with concepts and their use.
To conclude, after spending a lot of time thinking about the questions raised by my ethnography, I am left wondering whether something about the ethno-psychiatric use of cultural material presents the possibility that there is a kind of difference that we cannot fully understand. In this specific context, culture works as a site of translation and mediation that has the potential to produce categories of recognition-just as psychiatry does with diagnoses-but it can also create a space for the acknowledgment of difference and provide a language that welcomes the incommensurability of worlds.
I lost track of Mary's stories after her first six months of therapy at the Centro. I returned to the United States and heard that she continued to see Dr. L and the team at the clinic. Grace, on the other hand, remained part of my life even after leaving Italy. We kept in touch through Charity, the cultural mediator who translated for her at the Centro. After several months, she received a residency permit, but it was the wrong one. Instead of the permit for "victims of human trafficking," she received one based on health care. Apparently, her hospitalization history and her crisis at the shelter made her eligible for this kind of permit also. In the bureaucratic labyrinth, her "psychiatric problems" elicited a response faster than her condition as a "victim." This was the reason they gave Grace at the police station, when she asked for an explanation. She was furious. This kind of permit would not allow her to work, and she felt completely disabled. Ultimately, though, she was able to get a new permit, the one granted to "victims of human trafficking." Charity thought that getting a residency permit that enabled her to find a job was somehow "therapeutic" for her. The lack of recognition on the part of the institutions, especially after having signed a sort of pact with them, can be annihilating for those who experience it as a form of social death. Grace was expelled from the shelter. She was still having crises, but the nuns and the other Nigerian women there believed that she was making them up in order to attract attention and speed up the process of getting the residency permit and finding her a job and a house Her crises were interpreted as manipulative acts rather than a cry that exceeded comprehension. She lived at friends' places for a while, went back to the Pentecostal church that she attended when she worked as a prostitute, and reconnected with people she knew before entering the program. I do not know whether she ever went back to work on the street. With time, she found temporary jobs looking after the elderly. She stopped going to the ethno-psychiatric clinic, and although her crises were not as frequent, they persisted. The rest of her story is still unfolding.