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O R I G I N A L P A P E R

Trauma and Humanitarian Translation in Liberia:

The Tale of Open Mole

Sharon Alane Abramowitz

Published online: 17 April 2010Ó Springer Science+Business Media, LLC 2010

Abstract The focus of this paper is the intercultural process through which Open

Mole and trauma-related mental illnesses are brought together in the postconflict

mental health encounter. In this paper, I explore the historical dimension of this

process by reviewing the history of Open Mole, and the ways in which it has been

interpreted, acted on, and objectified by external observers over the last half-

century. Moving into Liberia’s recent war and postconflict period, I examine the

process by which Open Mole is transformed from a culture-bound disorder into alocal idiom of trauma, and how it has become a gateway diagnosis of PTSD-related

mental illnesses, and consider how it is produced as an objectified experience of

psychiatric disorder in clinical humanitarian contexts. By studying how Open Mole

is transformed in the humanitarian encounter, I address the structure and teleology

of the humanitarian encounter and challenge some of the foundational assumptions

about cultural sensitivity and community-based mental health care in postconflict

settings that are prevalent in scholarship and practice today.

Keywords LiberiaÁ

TraumaÁ

Open MoleÁ

Transcultural psychiatryÁ

Culture-bound syndromes Á Idiom of distress Á Community-based mental health Á

Humanitarian intervention

Introduction

The Tale of Open Mole is a story of Liberian suffering in dialogue with

humanitarian agencies’ understandings of local experience around a single local

S. A. Abramowitz (&)

Department of Anthropology, Harvard University, William James Hall No. 302, 33 Kirkland Street,

Cambridge, MA 02138, USA

e-mail: [email protected]

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Cult Med Psychiatry (2010) 34:353–379

DOI 10.1007/s11013-010-9172-0



idiom of distress—an Open Mole, or ‘‘hole in the head’’ (sunken fontanelle),

occurring in adults, along with symptoms of pain, dizziness, headache, confusion,

social withdrawal and occasional fugue states—that is prevalent in rural commu-

nities and across ethnic groups in contemporary Liberia. In this paper, I study how

nongovernmental organizations (NGOs) integrate local categories of somatizeddistress into their operational diagnoses of trauma-related mental illness and

transform social reality through interventions. I present the historical dimension of

this process by reviewing Open Mole’s history, etiology and interventions. I

demonstrate the process by which Open Mole is transformed from a culture-bound

disorder into a local idiom of trauma, and from a local idiom of trauma into an

object of clinical psychiatry. I go on to examine how this process of transformation

occurs by studying the ‘‘dialogic’’ encounter between international NGO ‘‘local

practitioners’’ and ‘clients,’ and use Open Mole to examine how ‘‘culturally

sensitive’’ mental health programs and ‘‘community-based’’ trauma-healing initia-tives yield unintended outcomes.

Culturally sensitive, community-based mental health care is now a widely

idealized model for postconflict mental health and psychosocial intervention [Inter-

Agency Standing Committee (IASC) 2007; Weiss et al. 2003]. Through ‘‘The Tale

of Open Mole,’’ a local idiom of distress with a long social history in Liberia, I track

the trajectory of semiotic movement around a cultural idiom—specifically, the

movement around Open Mole—as it is transformed from a culture-bound form of

somatic illness, to an ‘idiom of distress’ with transcultural psychiatric interpreta-

tions, to a gateway diagnosis for PTSD and a host of other trauma-related mentalhealth and psychiatric disorders at Healthworkers International (HI), an interna-

tional medical humanitarian NGO. I demonstrate how cultural meanings

surrounding mental illness and trauma are strategically integrated into global

programs, thereby transforming the meanings of local idioms into a ‘‘pidgin

psychiatry’’ that transforms original ontologies into different, but legible and

perceptible phenomena that fit within humanitarian epistemologies. The goal of this

paper is to show how meanings of mental illness, trauma and local idioms of distress

are ‘‘appropriated and translated’’ (Merry 2006) in clinical encounters and come to

take on an ‘emanating’ transformation of social definitions and conventions.

Research Setting

The civil war in Liberia (1990–2003) earned an international reputation for the

chaos it inspired in every part of social, moral, religious, political and economic life,

and earned Liberia a dubious reputation as an exemplary model of a ‘‘failed state.’’

The conflict itself lacked an ideological foundation and was known internationally

for its endless splintering factions, the ruthless greed and murderousness of Charles

Taylor and other faction leaders, ‘‘blood diamonds’’ and ‘‘blood timber,’’

widespread rape, displacement, child soldiering and dismemberment and cannibal-

ism (Ellis 1999; International Crisis Group 2004; Moran and Anne Pitcher 2004;

Renner et al. 2002; Sawyer 2005). Between 1990 and 2003, nearly 200,000 people

were killed in warfare—approximately 10 percent of the country’s total population.

354 Cult Med Psychiatry (2010) 34:353–379

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Population displacement occurred on a massive scale within and outside Liberia’s

borders, leading to the flight and repatriation of more than 1 million Liberian

citizens several times and contributing to the spillover of violence into neighboring

states (Sierra Leone, Guinea and Cote d’Ivoire). At the local level in Liberia, the

extent to which violence reached into the lives of every village, hamlet andtownship is palpable.

By the conclusion of the conflict, few standing structures remained in most

communities. Villages virtually inaccessible to major markets were reached by rebels

and burned to the ground. Tens of thousands of Liberians spent years foraging in the

rainforest and avoiding settled areas, which were usually controlled by one faction or

another. Rape occurred so widely that it became a taken-for-granted part of everyday

life. However, since Charles Taylor’s resignation and departure in 2003, the end of the

Liberian civil war, and the intervention of the United Nations Mission in Liberia

(UNMIL), a massive international effort has been under way to reconstruct the countryof Liberia. New institutions, buildings, roads and bridges are slowly being rebuilt.

Children and adults are returning to school, there has been a successful Presidential

election, and the country is starting to report positive economic growth. Liberians are

seeking jobs, night school education, university enrollment, computer training and job

training programs amid an economic environment of nearly 80 percent formal

unemployment. As one Liberian student said, ‘‘During the war, we all had to sleep on

the floor. Now, we are just trying to get our mattresses, and then get our mattresses off

of the floor. Small small, we are trying to rebuild.’’

Tens of thousands of Liberians are attempting to manage the emotional,psychological and somatic consequences of past violence and present vulnerability

while struggling to take back their lives and country from the enduring violence of

the Liberian civil war. Some are doing so through art, theater, socializing and telling

stories to friends and family. Thousands are simply trying to forget, to ‘‘put the past

behind us. Now is a time of forgiveness.’’ Thousands of youth and adults cannot let

go, and cling to the lifestyles, social arrangements, drugs and crime they became

habituated to during the war. This article focuses on a small subset of the population

using psychiatric interventions as a way to find peace and resolve the trauma of war,

which has been re-interpreted by the HI Psych Team through the local idiom of

distress called ‘‘Open Mole.’’ HI is the sole provider of outpatient psychiatric care

outside of Monrovia, Liberia’s capitol city.

Methods

This investigation took place during dissertation research investigating psychosocial

interventions, mental health and psychiatric care, and individual and collective

trauma in the context of Liberia’s postconflict transition (Abramowitz 2009). I

conducted this investigation at a major medical NGO, given the pseudonym

‘‘Healthworkers International,’’1 which is working in several counties in Liberia.

Data collection included an array of ethnographic methods, including participant

1 This study’s findings were provided to HI in an internal report at the conclusion of field research.

Cult Med Psychiatry (2010) 34:353–379 355

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observation of HI-patient clinical consultations, formal and informal interviews with

Open Mole sufferers, traditional healers, and health-care providers. I also analyzed

medical records during two field visits in December 2006 and February 2007 and

participated in community outreach activities, ‘traditional women’s’ groups, and

ex-combatant psychosocial follow-up in seven of HI’s beneficiary communities. Bythe conclusion of my research, I collected 40 clinical case narratives from HI Psych

Team patient visits and considerable qualitative data on the Psych Team’s activities,

operations, and clinical procedures.

What is Open Mole?

Across Liberia, a single unified characteristic defines Open Mole. Open Mole is

understood to be a soft spot in the center of the skull similar to the soft areas in aninfant’s unformed skull, or the sunken fontanel associated with infant dehydration

(Kezala et al. 1989). However, in contrast to the infant skeletal development

processes and the dehydration-induced softening with which the Western medical

literature is familiar, Open Mole is understood to be an acquired disease state that

can occur to adults who experience a sudden fright or shock or who endure chronic

adversity and stress. While its defining symptom is the soft spot on top of the skull,

Open Mole is commonly associated with many symptoms, including: severe

headache, neck pain, back pain, fatigue, weakness, nightmares, troubled sleep,

loss of appetite and social withdrawal (see Table 1 for a comprehensive list of Open Mole symptoms). Many additional symptoms are believed to accompany

Open Mole, but there is little consensus among Liberians about Open Mole’s

ethnophysiology.

The etiology of Open Mole is heterogeneous. Although a belief in the existence

of Open Mole exists across geographical boundaries2 (Bender and Ewbank 2004)

and ethnic groupings,3 it is contested among Liberians on a number of indicators.

Some understand Open Mole to be contagious, while others believe that it is not.

Some believe that Open Mole is caused by tampering with dangerous spiritual

forces, practicing witchcraft or having a dangerous nightmare, while others believe

that it can be caused by sharing a hairbrush or a headscarf, getting caught in the rain

or sitting in the sun too long. Some believed that Open Mole is caused by

committing an act of wrongdoing (like violence, theft or sorcery), while others

believed that Open Mole is a victim’s affliction, carried by those who have had

wrong done to them.

Traditional healers’ medical examination for Open Mole consists of a perfunc-

tory study of the sufferer’s head and a brief recounting of symptoms. The healer

then prepares a paste of herbs and leaves, shaves a small space on the top of the

sufferer’s head, applies the paste and bandages the head tightly. This remedy is

2 Sources cited in this paper document reports of Open Mole across diverse population centers, including

Zorzor, Gbarnga, Beh Town, Gbama Town, Gohgan Town and Bopalu.3 Reports in this paper include Open Mole complaints coming from women from Bassa, Gola, Loma,

Kpelle and Kissi ethnic groups.


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applied once every day, every 2 days or every 3 days, for 2 weeks to 1 month.

There are no herbs consistently used by all healers, and treatment frequency varies.4

This fact implies that the traditional Open Mole treatment may have curative

properties that are cultural and psychosomatic, but perhaps not physiological.

The traditional treatment for Open Mole is a specialized, but not exclusive form

of knowledge, and people capable of preparing the remedy can be found in or near

most communities. In contrast to some historical documents discussing ritual

specialists’ centrality to healing Open Mole, many interviewees for this study

indicated that they were diagnosed and treated by local female friends or relatives,

by women or men they had encountered in towns, refugee camps, or IDP camps, or

by traveling ‘‘country medicine’’ practitioners who had experienced and recovered

from Open Mole in the past and gained special knowledge about its treatment

[reminscent of Muchona the Hornet Interpreter, discussed by Turner (1967)]. The

diversity of traditional Open Mole treatments available undermines popular belief in

their efficacy; some people, having taken treatment, find that they experience only aminor improvement in subsequent days and months, while some swear that their

traditional Open Mole treatment poisoned them.

Table 1 Open Mole symptoms

A Soft Spot in the Center of the Head, Sunken Fontanel

Severe headache Fast heartbeat

Neck pain General body pain

Back pain Heat throughout the body

Tiredness Trembling

Weakness Hearing voices and sounds

Sleeping problems Crying

Decline in appetite Self-isolation

Bad dreams, nightmares Confusion

Worriness Wanting life to end

Forgetfulness Fear of death

Loss of interest in usual activities Numb legs

Poor vision Feeling like there is a worm in one’s head

Eyes swinging, swimming Seeing shadows

4 One Open Mole specialist I worked with, Abraham, was employed on an as-needed basis as a chauffeur

for a car-rental company in Monrovia, Liberia. His range of Open Mole medications included three

remedies, learned from a healer who drew from Gio and Dan healing traditions. The first, ‘‘Everlasting

Leaf,’’ or jagli, also called Gio, was taken from a tree, beaten into a paste, inserted into a leaf and squirted

into the nose three times a day for 6 days. The second remedy, called ‘‘Leh,’’ involved charring the leaves

of a different tree, turning the charred remnants into a paste, shaving the top of the head and adhering the

paste to the scalp. The powerful remedy could not be applied with bare hands and burned terribly whenapplied ‘‘because the place on your head is soft.’’ It needed to be left on for 3 days and then reapplied for

3 days, for a total period of six to 9 days of treatment. It was purported to put the skull back together;

make everything hard and put everything in place. If it was applied for more than the recommended

9 days, or if the patient had a weak resistance, it was so strong that it could kill the patient. The third

remedy was called ‘‘the root of the pepper tree,’’ or Gio ma jalagru, a topical solution squeezed directly

into the eyes. Abraham applied this remedy only when the Open Mole was creating vision problems.


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To understand the disparate interpretations and treatments of Open Mole in

traditional medicine, it is important to understand that the course of the Liberian

Civil War has led to a radical disruption in traditional medical systems’ ability to

reproduce itself. Whereas, in the past, there may have been coherence among

etiology, symptoms and treatments, in the present, traditional medical knowledge isfractured, incomplete and ad hoc. Open Mole treatments, however, extend beyond

the domain of ‘‘traditional medicine.’’ Most sufferers of Open Mole use an array of

strategies to manage Open Mole. Liberians self-medicate widely for Open-Mole-

like symptoms of ‘‘worriness’’—or constant preoccupation with one’s past, present

and future troubles, ‘‘headache,’’ ‘‘blood pressure’’ and ‘‘can’t sleep,’’ using widely

available drugs like diazepam (Valium), sleeping pills, ‘ayurvedic’ sedatives and

‘Chinese medicines’ from Indian and Chinese pharmaceutical companies that have

been smuggled into urban and rural markets.5 They also turn to alcohol and

marijuana to manage Open Mole’s effects. Additionally, Liberians depend on anarray of social strategies to escape Open Mole. They attend church to try to pray the

Open Mole away, they pray privately, they visit with friends and relatives in search

of advice and support and, occasionally, they withdraw from society altogether.

Social interventions are rarely reported to be effective.

The History of Open Mole

There are few previous mentions of Open Mole in the scholarly literature onLiberia, although the references available demonstrate Open Mole’s continued

undulation between psychiatric and somatic interpretations. Bearing remarkable

similarity to the symptom presentations of Open Mole today, Poindexter’s (1953a,

b) epidemiological study of the Gola more than a half-century ago found many

reports of Open Mole and recorded its somatic manifestations:

There is a combination of symptoms among certain native African tribes

referred to as the ‘‘Open Mole’’ of the adult. Medical schools, medical journals

and standard medical texts either do not mention the condition or do not

recognize it as an entity. The ‘Open Mole,’ ‘Craw Craw’ and a few otherconditions referred to by the natives as definite diseases do not have known

specific etiologies… The cases of ‘Open Mole’ in this study present a certain

similarity of symptoms and physical findings. These were all adults with

widened sagittal sutures and easily felt pulsations in the anterior fontanelle

regions. All of them showed elevated blood pressures. Some showed signs of

increased intra-cranial pressure such as pupil changes, hyperactivity of the

peripheral reflexes, rigidity of the neck, etc. There were areas of tenderness

over the head or face. Headache was a common symptom to all. The Hahn

tests and malaria smears were negative except in one case. This appears to be asyndrome worthy of further study (Poindexter 1953b).

5 I was able to purchase off-license remedies for ‘worriness,’ ‘can’t sleep’ and ‘thinking too much’ from

markets at most of the communities I visited with the HI Psych Team.


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By 1968, however, Open Mole had come to be interpreted as a mental illness by

foreign observers, although the presentation of symptoms remained essentially the

same. Dr. Ronald Wintrob of McGill University, who had served for two years as

the only psychiatrist in Liberia and as the director of its sole psychiatric unit, the

Catherine Mills Rehabilitation Center, described Open Mole in an article entitled‘‘Sexual Guilt and Culturally Sanctioned Delusions in Liberia, West Africa.’’ His

goal was to demonstrate in two case studies the clinical presentation of symptoms of

depression, which ‘‘become rapidly obscured by the development of agitation and

paranoid thinking … with the elaboration of a delusional system focused on

fantasies [culturally sanctioned delusions; sic] of snakes and genii.’’ (Wintrob

1968).

Wintrob’s interpretation of Open Mole is offered through a classical transcultural

psychological perspective that provides a fascinating contrast to the current state of

the field. He describes the story of a woman in her mid-20’s who is admitted to the(now destroyed) psychiatric hospital in Monrovia in a state of agitation, with

severely disorganized thinking and overactive behavior. He describes her biography

of social marginality, conflict-ridden relationships and an absence of familial

support, and describes her ‘‘descent’’ into a life of bar-cruising and prostitution. Her

symptoms began during her failure to conceive a child with a new husband. Wintrob

(1968) narrates the beginning of her Open Mole with the following story:

About 4 weeks prior to admission, she began to experience fugue-like

confusional states and episodes of irritability in which she would ‘‘just cuss

the people out’’ who lived in the surrounding houses. She suspected thatsomeone had witched her by putting ‘‘medicine’’ in her food ‘‘to spoil my

belly…’’ Three days prior to admission she had suddenly wakened following a

dream in which a huge black snake wound around her body and was

suffocating her. The next morning, she thought she saw the same snake in the

river, with its tail sticking up out of the water. The snake wound around her

and ordered her to bring a human sacrifice. She replied that she had nobody

she could offer and ran home in a panic. Thereafter she was confused and

restless, complained of her eyes turning, of headache, and of ‘‘Open Mole’’

(fontanelle.) Agitation increased rapidly. She would shout, ‘‘My heart want to jump out. Everything be turning before my eyes. Snake be coming all around

me. The people make me plenty crazy—oh!’’ She slept poorly, overturned

furniture, dumped food on the floor, tore her clothes, and fought with anyone

who tried to restrain her (Wintrob 1968).

Wintrob interpreted her spiritual interpretation of a snake as symptoms of

psychosis while continuing an ongoing regime of medications. He attributed her

Open Mole to denied and repressed guilt feelings about sexual behavior, fear of

imminent rejection by her husband, aggressive impulses and ‘‘fantasies of reparation

such as sacrifice .…

Massive ego regression followed. The culturally sanctioned

delusions in this case appeared to be primarily superego delusions.’’ The Bassa

woman, however, understood Open Mole to be caused by her neighbors through

sorcery, or ‘‘African sign.’’ Following local Bassa interpretations of Open Mole, the

Bassa woman’s visions resonated with a regional belief in the power of ‘‘Mami


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Wata’’ (Drewal 1988, 2008; Frank 1995). We see here how Open Mole’s etiology,

symptoms and moral terms are very much mediated by the professional framework

of the clinical beholder.

In 1975, M. Wheeler observes that Open Mole, identified in treatment at a

hospital in Zorzor, indicated dehydration in children and mental illness in adults. Henoted that in children, Open Mole occurred as a result of dehydration and required

the application of local or commercial topical medicines. For adults, however, Open

Mole assumed a different profile. Wheeler (1975) wrote:

Basically any adult who is ill-at-ease with his environment, anxious,

depressed, or even frankly psychotic is examined by a country doctor, who

often finds a soft spot somewhere on the head of the patient. This is

pathognomonic of open mole. Treatment consists of various salves, plus what

is apparently some form of counseling by the country doctor, and seems to be

surprisingly successful.

By the late 1980s, Kezala and his colleagues (1989) were again studying Open

Mole solely as a physiological problem of sunken fontanel in children, but Open

Mole was alive in Liberia’s psychiatric legacy and remerged just a few years later.

Hales (1996) study of Liberian beliefs about mental illness reported that her study

population—Liberian nursing students and their elder relatives—believed that Open

Mole was an inherited mental illness that was passed ‘‘down the line’’ through the

mother’s side, either from the mother herself or from an ancestor who had been ‘‘so

offensive to the spirits that the whole lineage was punished with mental illness.’’Hales wrote:

The generally accepted belief is that people with excessive symptoms of

anxiety have a congenital opening at the junction of their fontanels, which

provides an entry for evil spirits.… A person with ‘‘open mole’’ is generally

treated for his or her anxiety by talking to a zoe, who then determines the

source of the anxiety. The nursing goal of helping clients to examine sources

of their own anxiety was compared to this kind of ‘talk therapy.’

The ethnophysiology of Open Mole among Liberian populations is clearly

diverse and, therefore, difficult to generalize. Open Mole has resonance with

previously studied somatized mental illnesses widely known among West African

populations (Kirmayer 1984; Makanjuola 1987), including Brain Fag (Prince 1960)

and other illnesses like Nigerian ode ori, innu, and were ironu (Patel 1995). Open

Mole resembles Brain Fag in that pain and burning in the neck and at the crown of

the head is the somatic complaint:

This may be described as pain the back of the neck and over the occiput,

frontal headache, burning sensations over the scalp (‘‘as if pepper had been

rubbed into it’’), a burning sensation in the centre of the head, ‘‘like a piece of red hot iron’’, a feeling of waves passing over the scalp, a feeling of vacancy in

the head, etc. (Prince 1960).

There are accompanied symptoms, including headache, alteration in vision and

onset of weakness and fatigue, associated with mental exertion (for Liberians,


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‘‘stress and worriness’’ constitutes the mental exertion, while for Prince’s students, it

was exams and coursework). Compellingly, Patel (1995) wrote ‘‘…The soul and

spirit is concerned with mental life and emotions, and some authors suggest that

illnesses of the ‘spirit’ and of the ‘soul’ are probably analogous to mental illness.

The somatic localization of the soul and mind is in the head, chest, and/orabdominal regions.’’ Although there is no direct correlation between Open Mole and

other African mental illnesses, the parallel is suggestive. Significantly, however,

Kirmayer and Young (1998) remarked that the classification of Brain Fag and other

somatized illnesses are in fact Western constructions, rather than local idioms of

distress. As we shall see, this problem of classification has important relevance for

the interpretation of Open Mole by humanitarian agencies.

Healthworkers International

Open Mole was first brought to my attention in October 2006 by the general

coordinator of HI–Liberia while I conducted an institutional inventory of mental

health and psychosocial services across Liberia. HI is a fairly typical medical

humanitarian NGO that provides emergency and preventive health services to rural

and urban populations through mobile outreach teams, community-based clinical

work and inpatient hospital care (e.g., Medecins Sans Frontiers, MERLIN, and

IMC). HI provides approximately 30–60 percent of the medical care in the counties

they serve, and has been doing so since 2003. Similarly to most other medical NGOsoperating in Liberia today, the HI mobile medical unit travels into surrounding

counties providing primary health care, health care referrals, free medication and

public education about health issues ranging from infant and maternal health to

HIV/AIDS. They also operate hospitals in regional centers and are relevant on the

national health scene—they participate actively in policy discussions, coordination

efforts and international conferences about the future of medicine and health care in

Liberia.

HI is unusual, however, in that, in the absence of donor support for mental health

care in Liberia, it has taken the initiative to muster funding and resources from their

own coffers to provide psychiatric care, psychological counseling and psychiatric

medications to rural populations. They provide salary, training, supervision,

transport and resources (medical, logistical, pharmaceutical) to a ‘‘Psych Team’’

consisting of two psychiatric nurses and five psychological assistants/counselors. An

on-the-ground expatriate hired for a 6-month period of volunteer service supervises

the Psych Team, but due to recruitment issues, HI has had some difficulty ensuring

continuity of supervision. At times, the Psych Team has been managed by a

psychiatric nurse, while at other times the Psych Team has been run by a

psychologist with a psychoanalytic orientation, leading to a lack of consistency in

processes of prioritization in training and service delivery. The expatriate’s skill set

has been dictated by the availability of European volunteers, more than the needs of

the Psych Team, and during my period of research, the Psych Team had been

without direct extended supervision for a 6- to 9-month period. During these

extended gaps of supervision, the Psych Team receives long-distance supervision


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and technical oversight (several short-term visits each year to provide training,

supported by phone supervision on an approximately weekly or biweekly basis) by a

European psychiatrist.

HI’s investment in mental health is truly remarkable in that key decision makers

at HI headquarters in Europe materially support their conviction that psychologicaland psychiatric care constitute fundamental human rights and are of central

importance in Liberia’s postconflict reconstruction. By the onset of their work in

Liberia, mental health care had fallen into disfavor in humanitarian donor networks,

and it was nearly impossible to attain any funding for clinically based psychiatric

care in Liberia6 from traditional donor groups like ECHO, USAID, UNDP, or the

myriad bilateral and multilateral agencies funding Liberia’s postconflict recon-

struction.7 Even more remarkably, in the continued absence of funding lines, HI’s

European leadership has sustained the political will to continue to advocate for

mental health care in the absence of new funding opportunities.Although HI’s initial foray into mental health in Liberia began with some ex-

combatant rehabilitation projects during 2003–2005, the Psych Team’s responsi-

bilities have expanded dramatically. The Psych Team’s principal responsibilities

include clinical psychiatric consultations in an outpatient setting, diagnosing

psychiatric disorders, and prescribing psychiatric medication to people suffering

from PTSD, depression, anxiety, episodes of psychosis, and schizophrenia. To build

a mental health education and outreach capacity, the Psych Team organizes

‘traditional women’s groups’ in the communities they serve, where they bring

together ‘traditional’ women—local female residents in rural communities—andconduct group therapy in a quasi-educational format. They then turn these groups

into local outlets for outreach and clinical referral.

Postconflict Mental Health: Intervention Debates

For the last 20 years, scholars and practitioners have debated the diagnosis and

treatment of posttraumatic stress disorder (PTSD), and the appropriateness of PTSD

counseling and psychosocial intervention in postconflict settings. Within this

debate, considerable psychiatric, psychological, medical and anthropological

discourse has been dedicated to debating problems of validity, utility, cross-cultural

sensitivity, the rights of the mentally ill and the practical conditions of normal

suffering and response in postconflict contexts. The locus of disagreement around

mental health care in postconflict settings revolves around rapid mental health and

psychosocial interventions for PTSD (Van Ommeren et al. 2005). Psychiatrists and

medical anthropologists tend to agree with the following assertions: severe cases of

acute and chronic PTSD exist; PTSD can destroy health, lives and social worlds;

and PTSD and other trauma-related mental illnesses require medical and counseling

interventions (Baingana et al. 2005; de Jong et al. 2003; International Federation of

Red Cross, Red Crescent Societies 2009; Salama et al. 2004). Advocates for

6 The only other organization in Liberia providing psychiatric care is also self-funding its own efforts.7 I discuss this phenomenon in a publication in progress.


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psychosocial intervention argue that experiences and memories of violence have

important implications for the possibility of reconstruction in postconflict settings;

impeding civil society reconstruction efforts, preventing the reintegration of

ex-combatants in community life and damaging family, societal and political

dynamics for years and decades to follow (Reno 2004; Sawyer 2005; UNMIL 2005).However, scholars and practitioners disagree over attempts to address these

issues in postconflict settings. Important critiques assert that the Western-based

PTSD diagnosis may be an inappropriate framework with which to understand non-

Western, conflict-related experience, and individual resiliency, and community

resources. It is argued, moreover, that the PTSD framework may be incapable of

engaging local biomedical experience, integrating local explanatory models, and

working with locally understood illness trajectories to create appropriate treatment

options (Bracken et al. 1995; Summerfield 1995). In contrast, advocates for the

provision of mental health care, including treatment for PTSD, argue that thosesuffering from established severe mental illness are vulnerable to harm, violence,

abandonment, stigma, sickness and neglect (Desjarlais et al. 1995; Silove et al.

2000). Via de facto inclusion, this debate has also come to encompass the treatment

of disorders frequently associated with PTSD comorbidity, including depression,

anxiety, and drug and alcohol abuse that often implicitly fall into this category of

debate.

Academics and practitioners are making efforts to move beyond the debate by

tackling these issues through interdisciplinary study (Kirmayer et al. 2008), policy

recommendations for a diversity of minimum standards [Inter-Agency StandingCommittee (IASC) 2007; Psychosocial Working Group 2003] and the adoption of a

holistic approach to humanitarian practice, exemplified by the ‘‘black box’’ term

psychosocial. In comparison to underfunded psychiatric interventions and now-

controversial trauma healing activities, psychosocial interventions that place a

premium on ‘‘community-based interventions’’ have become the norm in postcon-

flict settings. Under the label psychosocial, a consensus has emerged around the

goal of providing population-based mental health services that are based on a public

health framework, with the key characteristics of being ‘‘affordable, effective,

acceptable, and culturally valid interventions at the community level (Banatvala and

Zwi 2000).’’

A central tenet of the public health approach to postconflict mental health is that

the structure of intervention is crucially important for ensuring that short-term

mental health interventions are transformed into positive long-term outcomes for

efficacy and institutional development (Baingana and Bannon 2004; Baingana et al.

2005; Inter-Agency Standing Committee (IASC) 2007; Mollica et al. 2004). de Jong

and Komproe explain it best when they state that public, community-based mental

health programs fulfill six crucial functions: (1) they use contextual approaches that

integrate the social worlds of the patients into a locally relevant framework for

managing trauma, (2) they integrate competing academic perspectives on mental

health and social welfare through service delivery structures, (3) they facilitate

interventions that encompass all of the complex determinants of mental illness, (4)

they empower ‘‘natural’’ social support systems already in place at the local level,

(5) they strengthen social cohesion and social capital and (6) they create ‘‘a cascade


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of training and supervision on different levels.’’ In doing so, de Jong and Komproe

(2002) argue that community-based mental health programs

can train hundreds of professionals and paraprofessionals and thousands of

community leaders in tailored training programmes. Such large-scale buildingof a human-resource capacity allows the community to restore the social fabric

that is disrupted or destroyed by the ongoing cycles of violence in many parts

of the world.

The community-based mental health care model is hypothesized to have greater

sensitivity to local culture, to be more able to demonstrate cultural competency, to

use local outreach more effectively and to emphasize community participation in

the development of healing networks of care. Mollica et al. (2004) argue for the

immediate provision of support for ‘‘de-facto mental health system[-]primary health

care practitioners, traditional healers, and local and international relief workers[who] use culturally validated and scientifically established mental health

interventions throughout the system.’’ This follows a recent move in the global

health literature to regard violence as a public health (vs. a political or sociological)

problem, which might be addressed through public health frameworks of

intervention and treatment (Krug et al. 2002; Pedersen 2002).

Open Mole at Healthworkers International

HI learned about Open Mole during their work on ex-combatant rehabilitation from

2004 to 2005, when local patients began to report the problem in early clinic

encounters. At this time, HI’s expatriate psychologist, the key figure responsible for

training the Psych Team, decided on a dualistic approach to the problem of Open

Mole. Like Wintrob and Hales decades before, she determined that Open Mole was

a psychosomatic displacement onto the body of anxiety, depression and psycho-

logical trauma. The psychologist numerated and catalogued the causes for this

psychosomatic displacement in an internal report to HI officials—sufferers of

mental illness who displaced anxiety, depression and trauma onto their bodies were

somatizing pain as a result of their difficulty mourning the loss of husbands or

children, maltreatment, neglect, domestic violence and economic difficulties, as

well as changes in status. (The case of Garmah (below), a woman who mourned the

death of her husband and bemoaned her economic vulnerability and self-reliance,

poses an excellent model for this narrative interpretation.) According to the

psychologist, Liberians may have believed that they suffered from Open Mole, but

in fact, they were suffering from psychological distress.

The first move in translating the idiom of Open Mole into humanitarian practice

was to isolate Open Mole as a culturally specific idiom of distress that was also an

empty signifier; Open Mole needed to become a disease stripped of ontological

meaning. Toward this end, the psychologist worked actively to train Psych Team

members and local outreach workers in rural communities that Open Mole was a

displacement of something else; that it was a misapprehension of the true cause of

suffering. Open Mole was reduced to an idiom of complaint, rather than an actual


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complaint with an ontologically valid status that was recognized in the clinical

encounter as a generalized phenomenology of psychosomatic (and possibly

biomedical) experience (in contradiction to the biomedical findings of Poindexter

and the biomedical implications of Wheeler and Kezala).

The second move was to create the lexical pairing of Open Mole with locallyuntranslatable Western psychiatric disorders like depression, anxiety and PTSD—

Open Mole’s comorbid disorders—in HI’s framework. This was accomplished in a

most accidental and well-intentioned way. To integrate cultural awareness and

sensitivity into the mental health framework of the HI Psych Team, an early

decision was made to adopt the Open Mole illness classification into its working

operations. In HI medical records, complaints of Open Mole and diagnoses of

psychiatric distress are reported as follows: Open Mole—with anxiety, Open

Mole—with depression, Open Mole—with schizophrenia and Open Mole—with

psychosis. The diagnosis of Open Mole is made on the basis of the patient’snarrative and is reviewed and reconsidered occasionally in subsequent patient

counseling sessions. Treatment programs involve long-term prescriptions of

antidepressants, antianxiety agents, and antipsychotics including fluoxetine,

amitriptyline, alprazolam and haloperidol. As resources and supply paths are

limited, the Psych Team has few other psychoactive medications available for their

clinical work. This repertoire of medications is called on to satisfy most treatment

needs.

This process of humanitarian translation seems to have emerged as a result of an

epidemiological fallacy of generalization. Because HI’s Psych Team’s patientpopulation worked in overwhelmingly Kpelle and Loma areas, the majority of Open

Mole complaints came from Kpelle and Loma patients, leading HI’s expatriate

leadership to erroneously conclude that Open Mole is an idiom of suffering with

Kpelle and Loma cultural specificity, rather than a somatic complaint with

countrywide presence and relevance. Issues of marginality may have been at stake

as well—of all Open Mole complaints, internal HI reports found that 80 percent of

complainants were women, and 20 percent were men. According to my informants,

women have been more predisposed to Open Mole than men for as long as Open

Mole has existed. As one informant stated, ‘‘Women are weaker than men. They

can’t understand that everyone must die. But men understand this, and that is why

they will not develop Open Mole.’’

What does this mean for a cultural psychiatry of trauma? Open Mole is a puzzle

that is ‘‘good to think with’’ about the intersections of PTSD, idioms of distress and

transcultural psychiatry in postconflict settings. It poses a clear case of a local idiom

of distress that had been appropriated into a clinical setting, resulting in an increase

in rural patients seeking psychiatric treatment, leading to the translation of an

indigenous illness (or idiom of distress) into a biomedical diagnosis requiring

psychopharmaceutical intervention. However, what the local ontology of trauma is

remains unclear. Here, I think it is important to point out that, for there to be a local

ontology, there needs to be some coherence around what constitutes ‘‘the local.’’

The very recent and radical, long-term disruption of the war has disrupted many of

the ways of ‘‘being’’ local in Liberia—it has very much eroded a sense of shared

identity and experience. Consequently, in Liberia, the local ontology of trauma is


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and a general sense of fear. Symptoms of severe depression such as sadness,

generalized pain, despair and suicidal thoughts ( N = 5–7) seemed to cohere around

the middle of the chart, and patients reported symptoms of psychosis very rarely

( N = 2–3).

However, as HI has engaged with the illness category of Open Mole, the meaning

of open mole has undergone a gradual shift among the populations receiving HI

medical and Psych Team services. Open Mole has lost all practical meaning as an

expression of embodied suffering through its defining symptom, the sunken

fontanelle. Although it was understood elsewhere as a childhood illness, an

Table 2 Frequencies of

symptoms among 40 clinical

cases presenting with the

primary symptom of Open Mole

Symptom No. of cases

Headache 20

Fast heartbeat 20

Insomnia/difficulty sleeping 16

Worriness 15

Loss of appetite/weight loss 13

Nightmares 11

General sense of fear 9

Eyes swinging 8

Weakness 8

Cries a lot 7

Social withdrawal 7

Trembling 7

Neck pain 7

Generalized body pain 7

Confusion/disorientation 6

Sadness 6

Didn’t understand life/what life held

for me/thoughts of ending life

5

Heat in body 5

Flashbacks 4

Fatigue 4Poor memory/forgetfulness 3

Hearing voices 3

Running into the bush 3

Aggressive behavior 2

Chest pain 2

Hallucinations 2

Feeling of insects or worms crawling

in body or head

2

Poor concentration 1Back pain 1


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aggravated response to bereavement or catastrophic life events or a consequence of

African sign (sorcery), Open Mole has come to be understood at HI as a symbol of

long-term suffering that is the consequence of war-related hardships, deaths, losses

and postconflict worries, vulnerabilities and fears. This seems to be a self-fulfilling

process—after all, the long history and the pervasive violence of the Liberian civilwar have translated directly into the nearly universal presence of traumatic war

histories in patients’ lives and autobiographies. In a process of overdetermined

causal associations, HI patients link their complaints of Open Mole to the deaths of

husbands and children, family conflict, stunted life chances and deaths and illnesses

of sisters and wives. (Some examples of stories heard in initial clinical encounters of

Open Mole complaints are listed in Table 3.) Therefore, at HI, nearly all narratives

of Open Mole are told as histories of trauma. Again, following Kirmayer and Young

(1998), somatized symptoms are reproduced as a Western construction, rather than a

local construction.Open Mole narratives, in their initial rendering, are diverse, unsystematic and

nonlinear. They emphasize the somatic, de-emphasize the patient’s personal history

and freely combine problems as divergent as headaches, backaches, insomnia and

hearing voices into systematic rubrics for diagnosis. A presentation of Open Mole

suffering is fed through an interpretive process yielding the outcome of an

identifiable psychiatric diagnosis and course of treatment. Patients initiate the

clinical encounter with a complaint, then request medication, and Psych Team

members and the clinical questionnaire coach them through the clinical process.

While patients give an account of their symptoms and their narrative, the PsychTeam members jot down notes about the patient’s physical and behavioral

presentation, speech and complaints. Most of the time, family interviews and

medical histories are unavailable. Medication is not prescribed for a period of

3–6 weeks, while HI counselors attempt to counsel patients on a weekly basis

through relationship issues that may be causing them distress. If, at the conclusion of

three clinical interviews, patients’ symptoms have not abated, HI personnel proffer a

diagnosis and begin to prescribe prescription psychiatric medication. Sometimes, HI

psychology assistants are able to avoid prescribing medication altogether and

manage clients’ symptoms through counseling interventions, including family and

marital counseling, referrals to other social support networks and individual therapy.

Of the 40 patients I studied, 9 were diagnosed with Open Mole, undifferentiated

by further diagnosis. Eleven were diagnosed with Open Mole/Anxiety, five were

diagnosed with Open Mole/Depression and five were diagnosed with Open Mole/

PTSD. Five patients were diagnosed simply as ‘‘Severe Depression,’’ one patient

was diagnosed as psychotic and no diagnosis was administered for seven patients.9

In an ideal environment, psychiatric diagnostic procedures would include the

production of an extended psychiatric narrative that included multiple modes of

assessment, an extended case history, family interviews and ongoing observation.

But in practice at HI, the reality of assessment practice involved a relatively brief

9 Figures include four cases of comorbid diagnoses, including two cases of Open Mole with PTSD/Open

Mole with depression, one case of Open Mole with PTSD/Open Mole with anxiety, and one case of Open

Mole with anxiety/Open Mole with depression.


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interview, a single standardized questionnaire and a framework for ‘‘checking in’’

that was monotonously repeated week after week for drug distributions. In this

grossly simplified process, Open Mole serves an indexical function for the PsychTeam, who must curate from the Open Mole narrative a clinically acceptable

outcome. Open Mole narratives signify variants of psychosis, schizophrenia,

depression, anxiety and PTSD, but the Psych Team must listen to the patient’s

experience narrative to isolate the specific diagnosis of Open Mole that the

interview will generate.

As Table 3 suggests, in diagnoses, process of interpretation and translation can

be ad hoc. From the data collected, there appears to be no direct association between

diagnosis and treatment. A narrative reference to hearing voices or seeing visions

may yield a diagnosis of depression and a treatment protocol of fluoxetine, while awoman who experiences flashbacks of her husband’s murder during the war may be

advised to return for counseling if she is diagnosed with Open Mole/PTSD, or she

may be prescribed a low dosage of haloperidol for her flashbacks, with may be

diagnosed as Open Mole/anxiety. Fluoxetine or alprazolam is routinely prescribed

Table 3 Open Mole narratives and diagnoses

Narrative Diagnosis and treatment

‘‘A’’ heard the story about the brutal butchery of her son

on the Guinean border. She immediately ‘‘went off inher head’’ and ran into the bush, and ever since then

has never been quite right.

Dx: Open Mole/psychosis

Rx: Haloperidol

‘‘B’s’’ Open Mole developed when the war came to her

village in 1991. She heard gunshots. From that point,

she developed Open Mole, manifested by a headache,

she developed many different kinds of forms of

suffering and she’s never been quite right since.

Dx: Open Mole/PTSD

Rx: Counseling

‘‘C’s’’ Open Mole is resulting from a conflict with her

husband in the present. He wants her to leave her

church and join the Seventh Day Adventist Church,

but she prayed and gave devotion at her own churchthroughout the war, and she doesn’t want to leave. He

is making palaver (conflict). She is suffering from a

headache, worriness, fast heartbeat and bad dreams.

Dx: Open Mole/depression

Rx: Fluoxetine

‘‘D’s’’ Open Mole began in 1993, when ULIMO killed

her boyfriend during a raid, while D was pregnant.

Her worriness caused her to have an abortion, and she

treated her Open Mole with traditional remedies.

Dx: Open Mole/anxiety

Rx: Haloperidol

‘‘E’s’’ Open Mole began in 1991, when she saw her

nephew murdered at the crossroads in Salala. Her

sister has died, and her son has lost his mind. She

feels sad, cries and gets confused. She has terriblenightmares of the war.

Dx: Open Mole/anxiety, Open

Mole/depression

Rx: Paroxetine

‘‘F’’ developed Open Mole in 1987 after having a dream

with a series of foreboding portents and symbols.

After that, she began to experience terrible

headaches.

Dx: Open Mole with depression

Rx: Fluoxetine


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for symptoms associated with depression, and amitriptyline is also used for

depression when alprazolam seems to have little effect. Haloperidol is prescribed

quite often when there are symptoms of possible psychosis, including ‘going off

one’s mind’ or running into the bush, but it also may be prescribed for other

symptoms, including flashbacks, hearing voices, being confused or disoriented,

socially isolating oneself and demonstrating uncontrollable anger. See Table 4 for a

listing of frequencies of medications diagnosed at HI.

Although HI mandates a three-visit waiting period for counseling before the

distribution of medication, most patients are given medication if they return after

three counseling sessions. Once they are put on a medication regimen, counseling

largely disappears from their clinical consultation encounters, and courses of

medication continue indefinitely. As an exponentially increasing number of OpenMole cases create greater time constraints on the already overburdened Psych Team

staff, clinical interview days in some communities have come to resemble refugee

camp ‘‘distributions’’ (of medication, rather than food and goods), rather than

extended opportunities for counseling and ‘talking.’ Under the pressure of time and

patient load, the Psych Team changes diagnoses and issues psychiatric treatments on

an ad hoc basis, in an effort to ‘do something’ to help the sufferer. With persistence,

a patient can wear the Psych Team down into changing a diagnosis of ‘‘Open Mole

with PTSD’’ to a diagnosis of ‘‘Open Mole with anxiety,’’ earning them the

privilege of being medicated.The Psych Team constantly reiterated that the medications HI offers are expected

to ameliorate symptoms, not to act as remedies. Despite this, it was often unclear

(possibly due to a reporting bias created by the clinical context) whether or not

patients understood or believed that their treatment plans are palliatives, not cures.

Nearly 100 percent of the patients who were asked reported to HI Psych Team

members that their symptoms had improved. This was clearly true for psychotic

patients, for some of the patients being treated for severe depression and for some of

the patients being treated for PTSD, but few patients receiving care for Open Mole/

anxiety seemed meaningfully relieved by their courses of medication. Sometimes, Ihad a sense during clinical interviews that minor improvements in appetite or

insomnia were offered as evidence of the patient’s belief in the drug’s efficacy, and

as part of an entreaty for continued treatment. Many patients, however, seemed to be

biding their time for the drugs to ‘‘kick in’’ or ‘‘take effect.’’

Table 4 Frequencies of

medications diagnosed among

40 HI patients

a Due to periodic supply issues,

paroxetine and fluoxetine were

used interchangeably

Medication No. of cases

Haloperidol 9

Counseling 9

Paroxetinea

7

Fluoxetinea 5

None 5

Amitriptyline 3

Cyamezine or diazepam 2


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The Dialogic of Intervention: Three Case Studies

The locus of interaction between humanitarian organizations and local clients was

the clinical interview, and it was in the context of the ‘‘dialogic’’ (Bakhtin and

Holquist 1981) of the interview that meanings, values and medicines weretransacted. Despite the cultural sensitivity and localization of Open Mole Treatment,

at HI, the meaning, diagnosis, narratives, interpretations and treatments of Open

Mole were all unclear, situationally negotiated and imprecise to local Liberian

patients and to the mental health workers. In the dialogic of the intervention, the

Psych Team was the partner in communication most invested in the shifting of

categories—in managing the switch of Open Mole from culture-bound syndrome to

idiom of trauma. The patients were the partners most invested in obtaining the end

goal of medication, to permanently resolve their symptoms of sufering. In the

context of this dialogic, the relationship between ‘‘talk’’ and ‘‘medicine’’ was oftenconfusing to mental health workers and patients, with the ‘‘talk’’ component of care

leading to contention between patients and workers and the ‘‘medicine’’ component

of care yielding questionable medical outcomes.

But first, let us observe a few typical Open Mole cases. Case 1, Garmah’s case,

illustrates the typical client profile, mode of interventions and trajectory of treatment

frequently found among complainants of Open Mole.

Case 1: Garmah

On a hot day in Liberia’s dry season of 2006–2007, I sat at a round, roughhewn

wooden table in a small, blue-painted clinic room in a northern Liberian county with

three members of HI’s Psych Team. Two female mental health workers were

headed to the market to track down ex-combatants who had participated in the

postconflict rehabilitation program facilitated by the NGO several years earlier. One

male mental health worker headed over to the palaver hut to work on mother and

child attachment issues with women in the local community. I remained in the

breezeless clinic room with the last two mental health workers—a social worker and

a psychiatric nurse—to observe weekly psychiatric clinic consultations. The videoclub shack in the yard outside blasted out the clattering sounds of filmic gunfire

from a Chuck Norris movie.

HI mental health workers received Garmah into their examination room. Garmah

is a sad, quiet, 40-year old widow and mother of nine children (two deceased) who

lived off of a subsistence farm near a local industrial settlement. She is a long-term

patient of HI with a standing diagnosis of Open Mole with PTSD and depression,

and her treatment course had alternated between paroxetine and fluoxetine,

depending on supply availability. Garmah reported her psychiatric narrative thus: In

1990, a traumatic event took place in her presence. Her records reported a traumaticevent: President Samuel Doe killed her husband just before the onset of the conflict.

At this time, she began to experience the symptoms noted in HI’s diagnostic

interview documents: ‘‘worriness,’’ poor vision, severe headaches and weakness in

her neck—all of which culminated in the development of Open Mole. Initially, an


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herbalist named Kebbe, on Kerry Street in Monrovia, where she had sought refuge

during the war, treated her. Kebbe’s treatment provided some salve, but ultimately

the Open Mole returned, along with Garmah’s constant ‘‘worriness’’ over the death

of her husband, and the persistent realization that, in his absence, no one would help

her support her children in the present or in years to come. She was solely reliant onthe small business that she made from her garden. Garmah had been receiving

psychiatric treatment with HI for over a year, and on the day I met her, she

complained of a severe headache, pain in her neck and a poor appetite. Of particular

relevance to the HI mental health team was Garmah’s reports of severe headaches,

bad dreams, nightmares and ‘‘worriness.’’ Since the beginning of Garmah’s

treatment with fluoxetine, she reported that her nightmares had ceased. Many of her

other symptoms continued to persist. The Psych Team issued her a new supply of

fluoxetine and reminded her of her next scheduled appointment.

Case Study 2: Margaret

Margaret is a tiny, thin, elderly widow with a broad smile and thick, gnarled fingers.

She has three living children, and several children who have died. Margaret started

having signs of open mole during the war, at the time that she lost her oldest son, in

1991. In her own words, ‘‘Open Mole fell on her at the time of the war,’’ and she

‘‘went off and ran into the bush.’’ She was treated with country medicine and

recovered. In 1993, she lost her husband to illness, and her Open Mole returned.

Since then, she has suffered from headaches, heat in the body, fast heartbeat,flashbacks of her son’s death and an ongoing fear of death. She worries a great deal

about her Open Mole, and she is also quite worried about the deaths of her husband

and son. HI diagnosed Margaret with Open Mole, PTSD variety. She has

consistently sought country medicine treatment since 1993, sometimes going to

great lengths to find country medicine specialists, but nothing has worked.

When I met Margaret, she complained of weariness, insomnia, her eyes

swimming, headache, flashbacks and dreams of her late son and husband. After 1

month of observation, her diagnosis was changed to Open Mole with anxiety

features and depression, which made it possible for HI’s psychiatric nurse to start

prescribing medication: She is now on a regimen of 1.25 mg of haloperidol/day—a

standard prescription for Open Mole sufferers with anxiety features.10 Since

treatment, there has been some change, but not much. She continues to have

flashbacks and dreams.

At the time of her clinical interview, John, the psychiatric nurse, was eager to

demonstrate the HI Psych Team’s counseling skills, and illustrate their prioritization

of ‘‘talk therapy’’ over pharmaceutical intervention. For my benefit, he started trying

to counsel her about her psychological symptoms, which surprised Margaret. First,

he asked her, ‘‘Do you have the feeling that you are going to die?’’ ‘‘Yes,’’ she said.

He replied, ‘‘Everyone is going to die.’’ In an aside to me, John interpreted her silent

10 By comparison, in the United States, haloperidol is used to manage symptoms of psychosis,

schizophrenia, hyperactivity, aggression and delirium, but not PTSD, depression or anxiety. In clinical

care in the United States, the typical dosage of haloperidol is 1–5 mg (up to 10 mg) every four to 8 h,

about five to eight times the incredibly low dosage that Margaret is receiving.


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suffering to mean that this woman, a Methodist, fears that, because her son died an

unnatural death, she will not see him when she dies. She did not seem much

comforted by his counsel, though it was done in exemplary therapeutic tone.

John’s harsh message of, ‘‘Get over it. You need to let it go, forget about it. Stop

crying. Everyone dies. Death is natural’’ was paradoxical: It was delivered in theempathic, low-voiced tone of the Western-trained therapeutic intervention but had a

distinctly nonempathic message. John’s message reveals intense, culturally

embedded expectations surrounding the emotional management of grief and

bereavement. Death in Liberia is—and perhaps always has been—intensely public.

It occupies a large space in the public sphere in funerals, in radio and newspaper

obituaries, with town criers and in mourning activities. Mourning and bereavement,

however, are not allowed to occupy a limitless space in the public domain. Grief,

fear, worry and despair are expected to be carefully managed—and many people,

particularly women, cannot meet these expectations. And it appears as though OpenMole is the consequence. In Margaret’s case, her inability to meet social

expectations of emotional management is now being medicated with a very low

dosage of antipsychotic medication, and she is feeling slightly better. But she is still

afraid of the consequences, for her and for her son, of her son’s unnatural death.

Case Study 3: Nowa

The first client this day sat down quietly at the wooden table, and Florence and Sita

began the paperwork while Nowa presented her case for the second week in a row.She reported that she could not sleep because her heart was racing and reminded the

mental health team that they had prescribed some small green and yellow tablets—

fluoxetine—the week before. She said that she believed that she had Open Mole—

she felt like she was carrying a heavy load all the time, she felt pain throughout her

body and, with her fast heartbeat, she could not sleep at night. Nowa’s friend, who

had accompanied her to the clinic and was seated on a bench outside, had told her

about Open Mole. Since taking the medication, the pain in her body had been

somewhat relieved, but she continued to suffer. The Psych Team told her that they

would review her case after three consultations and suggested that perhaps she did

not need medication. ‘‘Maybe we can just sit and discuss. Maybe you know how it

started. Most people believe in the tablet, but we don’t do that with Open Mole.

Maybe we will just sit and talk.’’ She left the clinic room with a new week’s supply

of fluoxetine, and little talking had transpired. Nowa had failed to activate the

lexical trigger for obtaining Open Mole treatment and was directed to an alternative

course of conflict resolution.

The HI Psych Team had noticed an ever-expanding number of patients

demanding rural-based psychiatric care, and they were having a difficult time

meeting the demand. It seemed that Open Mole was on the move, that it had

acquired a life of its own through its appropriation into HI’s clinical context. To

understand this fact, it is of crucial importance to recognize that HI’s Open Mole

patients believed that the medication being dispensed at HI was for the treatment

and resolution of Open Mole. At HI, Open Mole treatment has been coupled with

other services, including general psychiatric treatment, medical care, ex-combatant


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outreach, traditional women’s groups and mother–child groups. Through this

extension of services, a kind of social marketing effort, or ‘‘snowball’’ recruitment,

has been under way to bring local communities into the scope of Open Mole

treatment. Unfortunately, the operative marketing message in these recruitment

processes is that HI is giving out medication to heal Open Mole, rather than theintended message: HI can help resolve your suffering through therapy, and we will

use medicine as a temporary measure. This is perilous, because it has created a

situation in which Liberian sufferers of widely prevalent form of psychosomatic

distress are learning help-seeking behaviors that will gain them access to potent

psychiatric medications, in the belief that they will be ‘cured.’ Moreover, some of

these medications have serious side effects, such as haldol’s extrapyramidal side

effects, and there are physical consequences of intermingling different forms of

antidepressant medications.

Garmah, Nowa and Margaret’s case studies point us toward the other half of theintervention dyad: the knowledge, interpretive frameworks and subjectivities of

HI’s Liberian Psych Team members. The Psych Team members are the crucial

lynchpin in the constitution of HI’s Open Mole interventions as community-based,

local and ‘‘culturally relevant.’’ Nearly all HI’s Psych Team members remembered

childhoods filled with Open Mole as a widespread event in their families and

communities. However, in their dual adult statuses as educated Liberians and NGO

workers, they often personally doubted and publicly renounced the legitimacy of

these Open Mole experiences. They overlay their early accounts of Open Mole with

critical commentaries about tradition, superstition and ignorance among Liberians,and their narratives often concluded with a testament to their greater insight and

knowledge as a result of their NGO training and education.

Psych Team ambivalence about Open Mole was bound up with their ambivalent

status as local employees and cultural interlocutors of an international humanitarian

medical organization. Psych Team members were deeply involved with their

postconflict statuses as professional health workers for a prominent international

medical NGO. As health workers, they held salaried positions that gave them

precious middle-class status, stability and respectability in a fraught and unstable

postconflict environment. But their ambivalence toward their work was more than

just the product of social status concerns. The Psych Team members’ postconflict

identities were deeply enmeshed in their own self-perceptions as healers and helpers

(Abramowitz 2010). Their confidence in their work, their skills and their knowledge

sets were bound in complex ways with their individual relationships with past and

present expatriate supervisors. From the expatriate psychologist who founded the

Psych Team, they were intensely trained to ‘see’ the psychological consequences of

war exposure and experiences and have been taught to counsel victims and

perpetrators of violence with sensitivity and care. From their distant supervision by

a European psychiatrist, they have been trained to adhere strictly to the clinical

questionnaire, to interpret physical symptoms through a psychiatric lens and to

situate their observations in a framework of diagnosis and treatment.

However, Psych Team members too believed in the ontological validity of Open

Mole. All of the Psych Team members recounted pre-HI memories, experiences and

knowledge of Open Mole—stories that they narrated timidly in clinical settings but


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told more vociferously in informal environments. Psych Team members explained

the illness course of Open Mole as follows: ‘‘If they [Open Mole sufferers] run away

from their troubles, the problem will be left behind; but in reality, the problem

would stay. They would just go crazy. Most Open Mole leads to a mental disorder.’’

For the mental health workers, Open Mole is real and makes a causal contribution tomental illness, and patients are being treated with psychiatric medications to avert

full-blown mental illness. This interpretation contrasts strikingly with the intent of

expatriates, who had intended that Open Mole would function as a culturally

sensitive symbolic code for mental illness, which the Psych Team decodes to

provide trauma-related mental health treatment.

Conclusion: Toward a Pidgin Psychiatry?

Psych Team members continue to diagnose, counsel and medicate for Open Mole in

hundreds of clinical encounters, but despite their role in structuring these

encounters, they are unable to significantly alter the course of the intervention by

inserting their community-based , local knowledge into the power-laden process of

the clinical encounter. This fact must force us to fundamentally reconsider what we

mean by ‘‘community-based,’’ ‘‘cultural sensitivity’’ and ‘‘local healing systems.’’

Are healing systems locally relevant simply by virute of inserting local idiomatic

language and employing local staff fluent in local languages? Or does local

relevance require more than the criteria set forth by de Jong and Komproe, relatedearlier in this paper?

Local relevance, to my mind, requires some degree of epidemiological validity

grounded in an ethnographically informed psychiatric epidemiology that is carefully

linked up with an ontology of suffering. But from the humanitarian perspective, the

central office of HI International regarded the Psych Team project as a paragon of

success for its demonstration of cultural relevance and community-based human-

itarian mental health care. It boasted a rural mobile outreach team that brought

clinical psychiatric care into inaccessible communities. Liberian nationals—middle-

class Liberians who spoke local dialects, were trained in psychiatric diagnosis and

treatment, and had social origins in the service area—staffed the program. It was

culturally sensitive—it had integrated a local idiom of distress, ‘‘Open Mole,’’ into

the HI diagnostic framework, and clinical interviews routinely used Open Mole as a

framework for taking case histories and prescribing remedies. Clinical supervision

was available, and the Psych Team was trained to emphasize that ‘‘talk’’ was

preferred to ‘‘medicine’’ in each of their consultations. In addition, the HI Psych

Team conducted outreach services, community education initiatives and client

follow-up to ensure that their services were understood, locally relevant and

effective. On nearly every count, it was a model of postconflict mental health care in

humanitarian intervention.

And so we must ask, Why Open Mole? What work did Open Mole do for HI’s

practice of humanitarian intervention? For HI, Open Mole worked as more than an

idiom of distress. The classification of Open Mole itself has created a space for the

application of modern psychiatric classification systems in rural schema of language


123



and meaning. It functions as a lexical switching point, a sign at the intersection of

systems of meaning in which communications around pain and suffering take on

meaning that is decipherable to the other in the moment of communicative

encounter. What emerges from the clinical encounter around Open Mole is a kind of

‘‘pidgin psychiatry.’’ By pidgin psychiatry, I reference a process of communicationtaking place in the context of an intercultural encounter that is replete with the

fractures and harsh edges of communication. Open Mole is the center of a linguistic

compromise around an encounter meant to manage suffering and healing, across

which multiple forms of social goods, meanings and medicines are transacted.

Open Mole is intrinsically situated in a humanitarian cultural logic in which

‘‘cultural relevance’’ operates more as an ideology than as an outcomes-oriented

approach to clinical intervention. The HI Psych Team members are the unwitting

gatekeepers of this communication and act as cultural mediators between the NGO

and the patients. The next step forward for the medical anthropology of conflictsettings is to examine the linguistic and clinical interactions of internationally

employed ‘‘local healers,’’ to complicate our all-too-routine differentiation of

medical healing systems into ‘‘the global’’ and ‘‘the local.’’ Local employees

constitute the crucial gatekeepers to paradigms of care. An ethnographic study of

their roles, and their subjective interpretations of their labor, can have a great deal of

value for the future of mental health research in postconflict and development

settings.

Myriad forces outside the dialogic of the clinical interview—local medical

histories, NGO mandates and bureaucratic problems with training and supervi-sion—shaped, constrained and limited the clinical encounter around Open Mole

between HI patient and HI staff. In this way, Open Mole had a local history and a

clinical structure that continued to have a life of its own outside the medical

encounter, even as HI attempted to appropriate the local idiom into its system of

medical translation. In this way, Open Mole challenged the best intentions of

policymakers’ and program designers’ efforts to keep mental health local, culturally

sensitive and relevant. On a policy level, transnational comparative survey work can

and should be conducted to assess the efficacy of appropriating local idioms into

systems of medical translation and the feedback impact it has on the quality of

clinical care provided.

Despite the great efforts made toward cultural sensitivity, HI has remained

culturally insensitive to the powerful symbolic meanings and interpretations of ‘‘the

tablet’’ and Western medicine in local populations. In Liberia, there is a widespread

but indiscriminate belief in rural populations that ‘‘the tablet’’ is a cure-all for most

forms of illness. The problem of overmedication, inappropriate medication practices

and abuse of pharmaceuticals is widely known among public health practitioners.

However, HI should be commended for its commitment to providing high-quality

community-based psychiatric and psychological care to needy populations. They are

presently the only NGO in Liberia providing this service and are providing real and

much needed relief to sufferers of debilitating illnesses and diseases. But HI’s

efforts to integrate local idioms of distress into their diagnostic practice, though

noteworthy, have a confusing logic and uncertain consequences for patients and for


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staff, posing potent questions for the practice of cultural sensitivity and community-

based mental health in postconflict settings.

Research Limitations

During my research at HI, I was strictly limited to a participant-observer role at the

clinic. Because I lacked permission to interrupt the clinical encounter (except on an

ad hoc basis) to collect additional information about the patients’ experiences, or to

administer a standardized questionnaire to investigate patient symptoms, I was

unable to collect standardized data on Open Mole symptoms and illness trajectories.

It has therefore been impossible to apply statistical analysis to my Open Mole

findings. The data presented are therefore to be understood as opportunistic,

nonrandom, and specific to the fieldwork situation. Additionally, due to concernsabout confidentiality, I could not gain permission to conduct external interviews

with HI patients, to obtain interview material regarding their understandings and

interpretations of Open Mole. However, I conducted external interviews with Open

Mole sufferers and Open Mole traditional healers outside of the HI clinical

framework to fill in gaps in qualitative data.

Unlike other papers in this issue, my methods of data collection prohibited an

exhaustive examination of each individual case, and I could not administer

formalized surveys or intervene in clinical interviews. Consequently, I was unable

to assess whether or not cases met DSM-V criteria for PTSD, schizophrenia,depression and anxiety diagnoses. As a result, the public health implications of these

findings remain uncertain.

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