Emslie Horniman Award – Antonia Knifton

Home Past Awards Emslie Horniman Award – Antonia Knifton

Award Holder: Antonia Knifton
University: University of Kent
Title of Research: Delusion or Devotion? Towards an Anthropological Model for Kanak Psychiatry

Emslie Horniman Final Report

An Emslie Horniman Scholarship enabled me to carry out extended field work in the South Pacific islands of New Caledonia. My proposed field work was a specifically time-sensitive project as New Caledonia was in the process of negotiated devolution from French administration. Consequently an unbroken, extended period of fieldwork both enabled me to meet the residential criteria necessary for some types of accreditation and access, and to experience and record boundary reactions as the mandated referendum date approached.

New Caledonia has a highly emotionally charged history rooted in its establishment as a French penal colony. In keeping with extensive scholarly critiques of the bureaucratic and spatial industrialization of structures of confinement in western Europe; New Caledonia saw its penitentiary infrastructures successively reimagined as prisons, military hospitals and asylums. While these structures of confinement historically operated within the strictures of French law and reserved their punitive and restrictive regimes to regulating French military personnel and transported French convicts, the advent of a settler population extended their function and geographical reach. Modern health infrastructures have built, both figuratively and geographically,  on these historical foundations. In consequence there continues to be a regional disparity in the facilities and services available to Caledonians.

An Anthropological Model of Psychiatry

Contemporary authorities pride themselves on providing equivalent healthcare to that available in large French provincial towns. This model of service provision makes a virtue of undifferentiated care for what is currently a multi-ethnic population demonstrating considerable socio-economic variation. Beyond a pre-conceived and readily popularized social and ethnic division between indigenous Melanesians and established European settlers the New Caledonian population is comprised of indigenous Melanesians, Polynesians, descendants of European settlers, recent and transitory European French expatriates, North Africans, descendants of Vietnamese and Indian indentured labourers, migrant Melanesians from neighbouring states and recent and transitory French expatriates themselves reflecting the ethnic diversity of contemporary, ‘Metropolitan’ French citizenship. The largest growing census group are those French, New Caledonian residents who choose to define themselves as ‘mixed race’ Caledonians.

My research proposal stemmed from the presence in the French-language ethnography of a sketch of an indigenous healing tradition. As described by the earliest resident missionaries, this tradition blurred the distinctions between herbal remedies, spirit practices and environmental causation of what may be termed mental illness. Due to its penitentiary heritage New Caledonia can be distinguished from its near neighbours by an intense and early encounter with the formal structures and strictures of asylum psychiatry. I originally intended to study the ways in which this indigenous tradition was apparent in, or influenced contemporary diagnostic practices and care planning. I had expected that this examination of interactions between a heavily bureaucratic, centralized form of hospital-based psychiatry and residual indigenous practices would allow me to formulate an anthropological model of indigenous Melanesian, or Kanak, psychiatry that would provide a basis for opening a dialogue with Pacific-region health service planning and delivery.

Statistical Significance

All research proposals undergo a degree of transformation in direct contact with the constraints of the field site. It became very rapidly clear to me that as the urban psychiatric services were managed in such a way as to stringently follow standardized French policies and procedures I would observe little professional practice that differed from that which I had previously observed in France. The geographical concentration of psychiatric services and organisational factors contributed to the fact even allowing for an unbroken, extended period of fieldwork the number of consultations and admissions that fulfilled the requirements of my research proposal were unlikely to yield the type of data that I could subsequently analyse statistically, or indeed provide enough individual cases to build up a body of background research and detailed case histories.

A salient feature of New Caledonian psychiatry, as I saw it in the first few weeks in an urban setting, was the proportion of initial contacts with institutional services that are a result of contact with the criminal justice system. Consequently I took on a voluntary role at a family and visitor centre at the main prison. My residential status allowed me to be considered for this type of placement with a national and international non-profit organisation. I found that my willingness to commit myself to the minimum duration of voluntary placement and to participate in a regular weekly rota allowed me privileged access to fellow volunteers’ knowledge and laid the groundwork for later, rural fieldwork. Melanesian Caledonians, noticeably over-represented in this level of the criminal justice system, afforded me a great deal of trust and patient explanation of even the most mundane details of long-distance transport networks and other practicalities. The difficulty in achieving this type of privileged access, which had been put forward as perhaps the most obvious obstacle in my proposed research, seemed to be negligible where I was differentiated from professional  trainees and expatriates alike by my openly voiced enthusiasm to travel outside of  urban areas and to volunteer, rather than earn a salary or visibly spend money on exclusive leisure activities.

Due to the proportion of people likely to receive a psychiatric diagnosis that pass through the criminal justice system in New Caledonia, I was able to interact with not only friends and family of detainees but equally with former detainees and friends and families of people who had passed between criminal justice and psychiatric services over extended periods of time and between regions. In the course of these initial interactions I was able to reach an idea of a pattern of organisational and regional movement and to select a rural field site where I would be certain to have personal introductions and meet individuals who could facilitate the extension of the trust and access that I had built up in my voluntary placement.

As my most productive initial interactions occurred under the auspices of a prison family centre it is perhaps unsurprising that the Melanesian Caledonians whom I met professed a keen awareness of a society facing multiple fractures. These family members expressed a regional identity that took precedence over an emergent national identity. They encouraged me to visit and immerse myself in their region before I began to discuss the societal issues that they themselves discussed at length and in depth.

Youth and Despair

A prevalent theme that emerged from my urban field site was the link that Caledonians, and Melanesian Caledonians especially, perceived between political and financial uncertainties and youth criminality. Offending behaviours and behaviours resulting in intervention by psychiatric services were commonly amalgamated and varyingly described with language that echoes formal psychiatric diagnostic terminology and emotive terms denoting suffering. Patterns of internal migration that became apparent during my fieldwork led me to be predominantly in conversation either with people in rural settings or people who considered their urban residency to be a temporary situation. Thus even for long term urban residents, recourse to psychiatric care and behaviours that prompted concern were associated with negative aspects of urban life. Aspects of urban life that attracted negative associations were disruption of inter-generational households, substance use, idleness and reduced participation in organized worship and faith-related social activities.

It is worth noting that when I reviewed collected materials, if the age of the speaker is masked, sweeping generalizations that associate such negative aspects of urban life with young people are grouped according to socio-economic status, gender and regional origin, cutting across the age range. I also noted that across age groups both genders are more likely to associate negative aspects of urban life with young men. Against this attitudinal back drop young men are predominant in the criminal justice system, overwhelmingly so in the youth justice system, and predominant in in-patient psychiatric care.

Melanesian Caledonians’ descriptions of the factors that generate this feeling of urban unrest, danger and despair were the motors that led me to select a rural field work site to consider what form an anthropological model of psychiatry might take. Urban Melanesian Caledonians with strong, active rural connections told me that they can sympathize with the anxiety and despair that they believe lies behind young men’s problematic behaviours. However, again and again, I was pointed towards anti-social alcohol (often specifically spirits) and cannabis consumption as the causal factors that pushed understandable, somehow ‘normal’ sadness and anger over the limit into what was equally often described as ‘bad’ or ‘mad’ socially unacceptable behaviour.

While a  sense of rural/urban divide with moral overtones grew throughout my field work and was shared by Caledonians from all ethnic groups; an alternative interpretation was only presented by long term French settlers and Melanesians. This interpretation associated the negative aspects of urban life with expatriate French influences and often with recent and transitory expatriates. I was aware that in presenting ideas to an anthropologist, assumed to be interested in traditional dances, healing plants and wood carving; this approach to current social problems gave a short cut to talking about old traditions.
To counterbalance some of the skewing of carrying out much of my urban fieldwork in and around the criminal justice system I chose to relocate to a small provincial town where I assisted at a weekly boarding secondary technical school. This setting brought me into regular contact with groups of young men, a group often absent or reluctantly participant in the more formal pattern of faith-based social activities.

Coping Communities

The anthropological method of encouraging people that I met to tell me their stories and to identify people they thought were possible research participants led to me combining elements of social network or social contact tracing, parallel storytelling and kinship research. From an initial point of contact with friends and family of detainees I renewed contact with a former detainee and his extended kin. Kinship and location are closely entwined in New Caledonia. Meeting my initial contact’s kin in the city led to me travelling to the provincial town that he had come from. Relocating to the provincial town led me to meet kin from the more remote hamlets. Eventually I took up residence in a hamlet in which almost everyone was from the same paternal clan as my initial contact and where he had received care and support when in crisis.

In many ways my deepening contact with rural Melanesian lifestyles and customs reversed the journey that many of the young men in the criminal justice and psychiatric system had taken. Having to a certain degree stepped into each families story at an unhappy ending I had followed them on the journey that was the arduous weekly or monthly reality of supporting a mentally ill family member. In accompanying, mainly women, on these journeys I came to an understanding of the hardships that are frequently phrased in the jargon of ‘futility’ and ‘non-compliance’. In a paradoxical reversal of direction of travel, as services become increasingly specialized, contained and compulsory, families with concerns around their young peoples’ mental health actively propel them further into remote, cohesive hamlets, further away from criminality, conviction and confinement but further from diagnosis and treatment.

The remotest settings, without even the most rudimentary health infrastructures nonetheless provided quality of extended kin care and social inclusion that were admirable. The resilience of individuals and communities in coping with the often violent and disruptive behaviour of people likely to receive psychiatric diagnosis in contact with services appeared to depend on a distinction between ‘bad’ people and ‘mad’ and ‘bad’ behaviour. I came to recognize a loose continuum of behaviours that are believed to be variably acceptable in a highly situational manner and equally influenced by environmental, emotional and personal factors. If there is a basis for an anthropological model of Melanesian psychiatry in New Caledonia it is: people can all do mad things, mostly they aren’t madpeople, they’re just madder at the moment than most other people, people can all do bad things and some people do badder things when they are madder. Sometimes bad things are too bad and sometimes people are mostly madpeople.

European Health Citizenship in a Pacific Island Knowledge Network

In reviewing the literature I had formed an expectation of encountering a general independence movement in New Caledonia. I found that New Caledonians were well-informed and thoughtful consumers of current affairs programing with a strong sense of French-Island identity but a less well-defined sense of Pacific Island identity. Especially during my time assisting in a secondary technical school I found that young Melanesians related their life experiences to those of multi-ethnic urban communities in Metropolitan France and frequently identified as mixed race Caledonians. Young urban professionals drew conversational parallels with residents of France’s Indian Ocean territories and distanced New Caledonian lifestyles and multi-ethnic society from those of neighbouring Melanesian island nations. I found a vocal preference for more autonomy from centralized administration from Metropolitan France, and for electoral reform. The most commonly expressed arguments relevant to health and social care are very little different from similar arguments that I have heard expressed in large provincial French towns, with reference to centralized budgetary controls and more local options.

In the light of evidence-based and equality and diversity led arguments for better health care for indigenous peoples across the Asia-Pacific region I expected that there would be a corresponding debate among health care professionals relating to Melanesian models of care. I found that current debate centres on equivalent care, in the sense that care available in Metropolitan France should be available in New Caledonia and especially that technologically advanced treatments and diagnostic imaging should be available without sending patients to France or Australia. Inequities in service provision between regions in New Caledonia are seen through the filter of a rural/urban divide. It was pointed out to me by several health care professionals that such inequities exist in Australia and that it is considerably easier for a patient in Noumea to access treatment in Brisbane than for many rural Australians to access equivalent treatment.

As in many places were health care resources are stretched and inequities of provision remain, psychiatric care is something of a poor relation. Where many of the basic indicators of public health in areas such as child-maternal health, parasite vector disease and respiratory disease are unmet community-based mental health provision particularly is rarely prioritized. In these circumstances acute outpatient and in-patient and secure services are often the only options other than informal kin care. Current regional best practice models of community-based psychiatry are seen by many health care professionals as too culturally-specific and often dominated by a Polynesian social model that doesn’t fit either New Caledonia’s multi-ethnic urban areas or predominantly Melanesian rural areas.

An Anthropological Model of Engagement

As I came to the end of my fieldwork I could not promise with any kind of reliability that I would return to compare my conclusions with the path taken by New Caledonian psychiatric services. Long term humanitarian projects devote time and energy to preparing sensitive, realistic exit strategies. It was with some trepidation that I came to realize that not only was I in no position to prepare such a sensitive and realistic exit strategy but that even if I did so, the people whose lives I’d shared in some small way knew themselves to be in no position to match my promises with promises of renewed hospitality. I left New Caledonia with the knowledge that the quirks of geo-political convention that had facilitated my field work were remnants of a history that projects like my own expected to see shift towards a Southeast Asian and Pan-Pacific orientated future that could well render future field work more difficult.

The picture of psychiatry in New Caledonia that emerged from my extended fieldwork is by socio-political necessity a freeze-frame view. The challenges and opportunities facing health care professionals and family carers, as and when I came to see them, bear the imprint of New Caledonia’s past. At whatever pace the political processes of negotiated devolution move forwards the pace of change of health service funding, recruitment and training will reveal which of the co-existing models of service provision will prevail and to what extent future psychiatric services will be shaped by discussions around identity, culture and citizenship, or will be largely shaped by financial factors.

I consider myself lucky, along with the negative features of working in a society in rapid transition, to have had the positive experience of being in a particular place where there is such a sense of co-existing potential and of valued heritage on the point of being carried forwards. Anthropology may be said to have given importance to a notion of recording that which might otherwise be lost. Certainly, the time I was able to spend with Melanesian Caledonians gave me a clear impression that however anthropologists and fellow social scientists may choose to position their academic and applied practices in relation to contemporary academic discourse, other disciplines or other professions; for many Melanesians an anthropologist, even a student anthropologist, remains a preferred recipient for tales of what was once uniquely theirs, what is still uniquely theirs and what they hope will come through to the other side of uncertainty.

I must extend my thanks to the Horniman Award for providing me with the scope to share something of the lives of people intensely aware of themselves as having a part to play in shaping their futures and as people having an opportunity to contribute to a global conversation around imagining the health and wellbeing that they want for future generations.

While the development of an anthropological model of Melanesian psychiatry in New Caledonia remains uncertain, I am confident that the insights shared with me and the examples of individual resilience and compassion that I observed  will contribute to the development and implementation of an anthropological model of engagement and meaningful participation in my continuing professional practice.