Exorcists, psychiatrists, and the problems of possession in northwest Madagascar

For the Sakalava of northwest Madagascar, spirit possession and madness occupy opposing poles on a spectrum of experiences which, in indigenous terms, range from a good, powerful, and inescapable state to a destructive, dangerous, and frightening illness. While possession by the most powerful spirits is honorable and permanent, the excessive suffering that some mediums experience leads them to seek a way out; in other cases, chronic madness frustrates the afflicted and their kin who search for, but rarely find, a cure. Psychiatrists and protestant exorcists offer last resort options to these individuals, but the efficacy of their treatments varies greatly. While patients and healers are all Malagasy, sub-ethnic divisions are, nevertheless, crucial to defining the tensions that arise within these two alternative therapeutic contexts. The relevance of each approach and efficacy of its associated treatments hinge on the success of the psychiatrist and exorcist to mediate between these ethnic divisions. In turn, each practitioner is faced with the task of integrating conflicting epistemological realities surrounding illness. While exorcisms may be painful and frustrating to patients, the exorcists are more successful as healers, since they first accept and then transform the patients' explanations for and experiences of possession and madness. During protestant healing rituals, possession is viewed as an appropriate idiom for describing illness, and madness is redefined as normative, not deviant, behavior. Failure among psychiatrists can be traced to their inability to comprehend or accept their patients' experiences, a disjunction exacerbated by their acceptance of a cognitive model based on western sensibilities. The psychiatrist must grapple with the frustrations and misunderstandings that arise when these Malagasy and western models collide. Ultimately this carries implications for empowerment vs disempowerment of patient and healer in the therapeutic context. The problems revealed in this study of therapeutic process in Madagascar may bear on similar situations cross-culturally.