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Chapter 1

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 transl