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Abstract In this article I examine the similarities between the experiences of ritual possession and those of what is known as ICU delirium in a medical field, as experienced by the nurses who care for the patients. I apply a phenomenological approach to understanding the experience from the viewpoints of the nurses, as well as a counter to the dominant narrative within the biomedical field. I examine the medical literature of ICU delirium, a phenomena that is poorly understood within the biomedical field, bringing into the discussion the APA’s definition of delirium to link the medical and anthropological fields of inquiry. Following the examination of the literature on possession, I examine the experiences of the nurses with whom I worked, fusing their experiences to those of possession and discussing the similarities.

Keywords: Possession, sickness, phenomenology, nursing, medicine

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The Limitless Body: Embodiment, Disembodiment, and Transcendence

I have grown up around nurses, my stepmother is a nurse and I spent time waiting around her office to go home after school in the small town I grew up in. Nursing conversations often happened around me, though I was most often oblivious to those at the time. My wife is a nurse now, and since she started working, I have been one of her key supports, she would often come home from a hard day at work and tell me of what her experience had been, the patients who hadn’t made it (sadly, working on an intensive care unit this was an all too often experience), and the things the nurses (and to a lesser extent, the doctors occasionally) got up to during a night shift to relieve their stress and boredom.1 It was during these conversations that I first heard about the phenomena variously known as Intensive Care Unit Psychosis, Syndrome, or Delirium (referred to herein as ICU delirium) (Price, 2004:134). These stories involved patients behaving in antisocial ways, yelling abuse at nurses, or muttering random things. At first I was amused at the stories my fiancee would tell me, she was giving me an insight into what she went through at work, and she laughed these things off as being almost unbelievable. Sometimes though, the stories would be of how the patients would physically assault her, often with tremendous strength, threatening to break arms or fingers, and these stories would leave me worried, though she would brush them off as part of the job, saying the patient was 'out of it' or didn't mean it.2 Then reading an article on possession ceremonies in India something struck me, many of the same behaviours that those who were undergoing ritual possession displayed were characteristic of what was occurring at times in the intensive care units. Many of the anthropological articles I had read at the time only gave a brief account of possession, stating that it did occur, but bereft of any description of what happened during the possession. It was not until I came across one that described what was happening leading up to, and during the ritual that things clicked into place. This led me to think, that perhaps, these two phenomena might be somehow related, or at least the experiences of those observing these phenomena, were similar enough to theorise it. What interested me was that there seemed to be an ability to have tremendous strength, yet we weren’t able to access it at any given moment, there was some sort of block on it. Given the time frame restrictions, and the fact that there is a substantial amount of research already in possession rituals, I chose to look at the experiences that the nurses were observing in the intensive care unit and contrast it with the literature available on possession experiences. In particular I was interested in how can this phenomena that is called ICU delirium be understood, is it strictly a medical event, or is there perhaps something else going on? If this isn’t strictly a medical event, then what else is going on, is there an alternate way to understanding human subjectivity than what currently dominates Western thought, especially as offered by the medical sciences?

Anthropology has long had an interest in possession, from its very outset there has been an interest in one form or another. Some of the earliest volumes in anthropology dealt with Siberian shamans, witchcraft in Africa, and possession in Asia. Despite, or perhaps because of, the years of research and attempts at understanding possession, very little is concrete in terms of its definition. Smith, in seeking a definition, notes that it is possible to convey a definition in a few lines, or to extend it to a length of volumes (2011, quoted in Malik, n.d.). Boddy in her review of possession literature offers the following as a definition of possession:

Spirit possession commonly refers to the hold exerted over a human being by external forces or entities more powerful than she. These forces may be ancestors or divinities,

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ghost of foreign origin, or entities both ontologically and ethnically alien...Possession, then, is a broad term referring to an integration of spirit and matter, force or power and corporeal reality, in a cosmos where the boundaries between an individual and her environment are acknowledged to be permeable, flexibly drawn, or at least negotiable (Boddy, 1994:407).

But does possession require an external force, can sickness (which in some cases is believed to be the result of possession) cause symptoms which are markedly similar to those experienced in possession? Malik sees possession as being the bodily practice that involves the invocation of another presence in dealing with concerns of people, such as the diagnosis and healing, of disease (Malik, n.d.:4). Malik offers a contrast between modernity and possession, wherein modernity presents a sense of control, but possession is centred around a loss of self and agency (Malik, n.d.:5). Malik goes on saying it is exactly this loss of control and agency in which 'the vital significance of possession emerges as the creation of a ritual condition in which extraordinary possibilities of healing and diagnostics, and the resolution of disease in the broadest meaning of these terms becomes obtainable' (Malik, n.d.;5.). Possession viewed as such, is a practice that involves the invocation of other agents into the body, which involves the loss of self and self agency, but allows for the extraordinary to occur.

However, possession is not always voluntary, and as such, I propose that sickness can be viewed as a possessing agent, much as spirits, deities, or ancestors can be. Sickness can be an agent of the creation of extraordinary possibilities, possibilities that we may not be aware of. It is not a case of the body limiting the mind, rather a case of the mind limiting the body, when consciousness is lacking, the body is capable of performing extraordinary feats, seen in possession or sickness. Through the study of the experiences of nurses in dealing with the phenomena, I intend to show the similarities between possession and ICU delirium.

Literature Review

'Sara was such a small thing, maybe 30kg, she looked about 90, very frail...but when she woke up, she would punch and swear, it took four of us to hold her down' Danielle

(excerpt from field notes, 2014).

ICU delirium is a phenomena that has been observed since the initial Intensive Care Units were started, and since 1966 both medical and psychological perspectives have been pursued in understanding it (Granberg, Bergbom Engberg, and Lundberg, 1998:294). However, little is still understood about the causes of ICU delirium. Drug toxicity, inflammation, and stress have been theorized to lead to a disruption in neurotransmission which may play a role (Kalabalik, Brunetti, and El­Srougy, 2014:196, and Choi, 2013:196), yet nothing has been confirmed. ICU delirium is described as an acute condition causing a change in the normal mental state of a patient, resulting in confusion, paranoia, memory and language difficulty, and hallucinations (Svenningsen and Tønnesen, 2011:186). The medical literature often refers to the American Psychiatric Association's Diagnostic and Statistics Manual (DSM) in order to define delirium which it does as a condition with acute onset and fluctuating course of disturbances in attention and awareness; change in cognition (memory, disorientation, language deficit) which can be distinguished into three categories: 1) hyperactive, characterised by restlessness, hyperactivity, and aggression; 2) hypoactive, characterised by lethargy, apathy, and slowed motor response; and 3) mixed, where

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elements of both hyper and hypo are combined (Svenningsen and Tønnesen, 2011:186).3 The DSM notes that delirium must have 'evidence of a direct cause of physiologic consequence of medical cause' (American Psychiatric Association, 2013).

Without evidence of a medical cause, the same symptoms are referred to as dissociation, under which category possession falls for a medical or psychological definition. Dissociation is defined by the DSM as a disruption in identity, usually marked by two or more distinct personality states with recurrent gaps in memory of everyday events, personal information, or traumatic events that are inconsistent with everyday forgetting and the symptoms are not attributable to the physiological effects of substance or medical condition (American Psychiatric Association, 2013). The distinct personality states can be identified or observed by other individuals, so a family member or nurse observing a patient can say they are not behaving as they would normally. There is a sub­category the DSM has listed which is acute dissociative reactions to stressful events. This is defined as being short term (typically less than a month, sometimes only a few hours), characterized by: constriction of consciousness, depersonalization, derealization, perceptual disturbances (time slowing), micro­amnesia, transient stupor, and/or alterations in sensory­motor function (paralysis, analgesia) (American Psychiatric Association, 2013).

Within anthropology, changes in consciousness such as those described above are often termed under ‘Altered States of Consciousness’, which Bourguignon notes the literature often relates with possession, trance, dissociation, fugue states, hallucinations, and others (Bourguignon, 1973:4­6). Bourguignon goes on to define trance as an altered state of consciousness that modifies any of the following: memory, sensory modalities, sense of identity, or perception (Bourguignon, 1978:495). While Bourguignon has separate definitions for trance and spirit possession, with trance referring to interactions with another being (spirit, deity, etc.), and possession referring to becoming another (person, spirit, deity, etc.), Smith views both as being the same, possession, as within South Asia there was no differentiation between the interacting with, or becoming (Smith, 2006:62).

In order to investigate the experiences of the nurses in this phenomena, I applied a

phenomenological approach. Husserl sees phenomenology as an approach advocates to bracket off the assumption that a world exists independent of our experiences (Desjarlais and Throop, 2013:88). This is useful for anthropology, as anthropology often attempts to describe the way people live, the way in which they experience the world (Jackson, 1996:10). Phenomenological anthropology has been used to show the differences in world views that oppose a Cartesian duality. Jackson provides ethnographic examples from various diverse cultures that counter the Cartesian authority (Desjarlais and Throop, 2013:31­33). As Cartesian duality to mind and body is central to the biomedical model of subjectivity, it is through this that I am using this approach to examine the experiences of nurses in dealing with ICU delirium, and perhaps offer an alternative to the duality expressed in biomedicine. As phenomenology is based on experience, narrative is a critical tool for the analysis. Habermas viewed the everyday as an important site for communicative activity and discourse, and as such, narrative provides a tool to describe the experience without a shift from the experience (Jackson, 1996:38,40).

One of the critiques of a phenomenological approach is that, while it is descriptive it often lacks in the analysis of the subject matter. Desjarlais and Throop dispute this, saying that in order to fully describe, one often has to analyse and explain, or at the very least theorise

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(2011:95). Another critique of the phenomenological approach is the epistemological concern, can we know what another is truly thinking? This question of course concerns all of anthropology, but for Desjarlais and Throop the answer is clear, within anthropology and ethnography, it is best practice to make every effort to confirm views with the participants (Desjarlais and Throop, 2011:95­96).4 The individual experience is important for study as the individual is the medium in which the world is experienced, yet Zigon notes that while phenomenology studies individual experience, it is not concerned solely with the individual. Rather it is concerned with the interrelationships that constitute society, and those relationships are best understood through experience (Zigon, 2009:288).

It is also through experience that anthropology can adhere to the call made by Desjarlais and Throop in examining the interrelated dimensions of lived experiences in our world, and through the intersections of cultures perhaps understand our own experiences better (2011:96­97).

Methods For the research into nurses perspectives I conducted a series of informal interviews with

a group of nurses from an Intensive Care Unit within a New Zealand based hospital. The nurses were known to me through previous research experience, and I inquired about their willingness to participate in research before conducting the interviews. Ethical approval was granted by the University of Canterbury Human Ethics Committee. The ethical approval process was not an easy task, as the Committee seemed concerned that I had not properly thought out the ethical implications of my research. Following multiple emails between myself and a member of the Committee, a decision was made for a full ethics approval application. Though I was not informed of what the specific ethical considerations the Committee was concerned about were, the full ethics approval passed without modification, which led me to wonder whether the Committee were concerned about the ethics of the research or were more worried about the legalities of the research.5

The nurses were gathered together for an informal discussion as a group in order to foster discussion between them, so that they would share stories with each other as well as with myself. This process worked previously in my undergraduate research with nurses, as it allowed them to unwind among a group of peers, something they do not always get a chance to do while working twelve hour shifts. The discussions were always lively, and I attempted to steer the conversations as much as possible along the topic of discussion, which at times was difficult. Each group interview lasted several hours as the nurses were always excited about discussing work and events at work. I conducted a pair of meetings with the larger group, and several smaller meetings with a group of three nurses who were my key informants. In these smaller interviews, I asked specific questions regarding the stories that were told in the larger meetings in order to clarify any details or medical terminology that was used. This process worked well, as it allowed the larger interviews to proceed without my needing to slow down the discussion to ask clarifying questions as these could be discussed in the smaller groups. This allowed the flow of conversation to continue uninterrupted by me, which I felt allowed the nurses to build their stories off of each other, events experienced by other nurses triggering memories. This was evidenced by the nurses saying 'oh that reminds me of...', or 'that was like when...'.

Following the interviews, I recorded my field notes into a journal, adding my own observations of the interviews, such as tone, body posture, and general atmosphere. After all the

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notes were recorded in the journal I proceeded to code the journal, dividing up the interviews under headings. These were the general themes of the stories, I divided these under ‘unreal experiences’, ‘agitation’, and ‘injury resistance’.

Background As stated above, ICU delirium is well studied within the medical literature, but not well

understood. It has been reported in anywhere from 11% to 80% of ICU admissions (Ouimet, et al., 2007:66, for varying rates see also: McNicoll, etc., 2003; Svenningsen and Tønnsen, 2011; Roberts, 2001; Guenther, et al., 2012; Dyson,1999; Randen, Lerdal, and Bjørk, 2013; and Arend and Christensen, 2009). The inconsistency is attributed to several reasons, one being a lack of a common definition of delirium (or the other two names associated with the symptoms; ICU psychosis, or ICU syndrome), another being a lack of tools to identify the symptoms, relying more on nurses own perceptions of behaviour than a clinical tool (Arend and Christensen, 2009:146). Several tools have been developed within the medical field to allow medical professionals to detect ICU delirium, both of which depend on observation. Devlin, et al. reported that delirium was largely underdiagnosed, and that most ICU nurses at the time used their observations for assessing delirium (2008:563). In their study, they found that over 90% of nurses surveyed believed it was underdiagnosed, and almost all (>95%) believed delirium to be a common response to the environment of ICU (Devlin, et al.:563). However, in a more recent study, Guenther, et al. came to the conclusion, that with the introduction of screening tools, (such as CAM­ICU, and RASS)6, the detection of delirium has improved markedly, however, they also note that overestimation of delirium may occur, when the screening tools are not used (Guenther, et al. 2012:e17­e19). Devlin, et al,. and Guenther, et al., differed in their approaches to their research, where Delvin, et al., used nurses to look at delirium reporting, Guenther, et al., utilised medical students. This is a small, but important difference, as within the ICU setting, it is the nurses that are present with the patient for the majority of the time, the nurses in my study were present with their patient for the duration of their shift, minus a lunch break and two to three smaller breaks. Whereas the doctors were present on the unit, and available if needed, they were not always in sight of the nurses, or watching any particular patient. This gave the nurses a more intimate insight into possible personality changes or small changes that the doctors may not be aware of.

One of the themes present in Devlin, et al., was the perception of nurses that patients with delirium were agitated, roughly 70% of nurses believed that their patients with delirium were agitated (2008:563). This was a common theme throughout the literature, especially the literature dealing with nurses experience in dealing with delirium, Marshall and Soucy defined agitation of patients as 'increased violent movement and strong emotion' (2003, 174). Everingham, Fawcett, and Walsh (2013) in their article on the lived experience of nurses in dealing with sedation holds, that is while patients are taken off sedation for the purpose of determining their mental state, spoke about how the nurses often felt unsafe when the patients were agitated, and 'worried about how they were going to wake up' (Everingham, Fawcett, and Walsh, 2013:699­700). Granberg­Axéll, Bergbom, and Lundberg in their study on patient behaviour noted that some patients 'showed violent uncoordinated movements during the weaning process' (2001:79), that is, as the patients dose of sedation drugs is slowly lowered. As Bélanger and Ducharme note, little is known about the experiences of nurses who deal with patients suffering from delirium (2011:313).

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Literature of the patients experience in ICU is more prevalent, with many looking at the experiences of those in ICU, some focussing on memories of the experience. While it is often thought that patients do not remember their stay in ICU or the experiences surrounding it, Granberg, Bergbom Engberg, and Lundberg found that some were able to recall their confused state (1999).They found that among the most common memories from experiences in ICU were confusion around the perception of time, fear of sleep, difficulty in communication, and unreal experiences (Granberg, Bergbom Engberg, and Lundberg, 1999:22­23). These descriptions would classify the patients as suffering from delirium. As far as the unreal experiences were concerned, Granberg, Bergbom Engberg, and Lundberg termed them ‘unreal experiences’ as that is what the patients often thought of them as, they were aware during the interview (remembering the experience in the past) that the experiences were unreal, though at the time they were perceived as real, and as such would be hallucinations (Granberg, Bergbom Engberg, and Lundberg, 1999:23). In previous work, the authors discussed that the most common feeling upon ‘waking up’ was a feeling of complete emptiness and chaos (Granberg, Bergbom Engberg, and Lundberg, 1998:300).7 The authors also reported that some patients felt their body as two opposites, either very weak or very strong, many had feelings of emptiness in the body, as well as feelings of their mind being open and that 'anything could happen to them, both negative or positive' (Granberg, Bergbom Engberg, and Lundberg, 1998:304­305).

Anthropology has long studied possession as noted above, in the 1970s Bourguignon

looked at what she called altered states of consciousness (ASC), which included possession and trance, in her review of as many of the studied cultures at the time, she found that 90% of the world’s societies had some form of possession belief (1973:9­11). Boddy in her review of anthropological literature of possession notes how possession intersects with multiple domains, including medicine, but itself is reducible to none (1994). Interestingly Boddy also comments on the inclusion of possession into the DSM IV, that possession in a culturally sanctioned form, would still be considered aberrant and require treatment (Boddy, 1994:411). While the DSM V, has changed, allowing for culturally sanctioned possession as not falling under a disorder, noting that 'all forms of distress are culturally shaped, including the DSM disorders' (American Psychiatric Association, 2013:758). This had ramifications around the world, as one article noted, referring to the day the new DSM was released,

on the night of the 19th of May 2013, many thousands of people who engage in possession as part of a broadly accepted cultural or religious practice across Latin America, Africa, and Asia, in fact across most of the planet, will go to bed with a hypothetical diagnosis, will go to bed as mad people, according to DSM IV, but will wake up sane (Saville Smith, 2013). As Zane notes, much of the medical anthropological literature on possession signals

possession as an illness, that the possession has caused the illness, while some argue that this is not always the case (1995:22­23). Though in recent times, much of medical anthropology has moved beyond a singular explanation for possession, and indeed for a world view (see Mol 2002, in which she describes how different views enact different experiences for the same medical condition). Csordas sees a link between healing and religion, in that both 'address themselves in one sense or another to suffering and salvation' (2002:12). In a more recent article, he advocates for a discussion between anthropology and psychoanalysis, arguing that anthropology (and

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specifically, phenomenological anthropology), can bring a distinct analysis for experience (Csordas, 2012:69­70).

Boddy notes that one of the prevailing themes throughout the literature on possession is how possession 'resituates individuals in a profoundly alienating or confusing world' (1994:422). That is, the literature shows that possession helps people accept change around them, or within them. Seligman, in her article exploring possession among practitioners of Candomblé, notes that 'Physical or emotional suffering is likely to undermine or disrupt the fundamental coherence of self by creating conditions under which dissonances and contradictions in self experience are not smoothed over by self­regulatory mechanisms' (2010:300). Suffering creates the conditions necessary for some possession experiences.

In his work on hallucinations, Luhrmann notes how Taylor distinguishes between what he terms as ‘porous’ and ‘buffered’ selves. For Taylor, a ‘porous’ self, the mind was easily able to joined with the supernatural, whereas a ‘buffered’ self, the mind is harder to penetrate for the supernatural (Luhrmann, 2011:78). Luhrmann notes that while one may not agree with Taylor’s use of supernatural, or of the existence of spirit, we must accept that 'minds are understood to be open to the world in different ways' (Luhrmann, 2011:78). This of course has salience for possession experiences as well. Hallucinations being a sensory experience without material source, fit many possession experiences. As such it is important to note Taylor’s conclusion that the mind is indeed open to the world in a myriad of ways, some of which are not understood at present.

Some of the most striking ethnographies of possession rituals comes from South Asia. Malik, in his work on dangariya (commensurate with shaman) in North India, describes how the person to be possessed would use red hot spatulas and place them on their tongue, and down their arms in order to prove they have been possessed by the deity (Malik, personal communication). Similarly, Sidky in neighboring Nepal, described how the jhãkri (also similar to the concept of shaman) would prove their possession through the consumption of copious amounts of distilled liquor, eating burning wicks, and licking red hot irons (2009:175). Sidky views the possession states as being what allows the jhãkri to perform their healing rituals, allowing them to access psychological potentials that are otherwise hidden from use (2010: 226­227). In the case of the dangariya, they do not remember the incidents of possession, the entire night while possessed remains a blank to them, while for the jhãkri they are able to remember the events. The literature regarding possession shows that some who are possessed are able to retain memory of the event, while others do not, this corresponds to the literature on delirium, which shows that while some patients do not remember their stay in ICU, there are some that are aware.

'I always try to relate it to their injury...it’s not like they are like this in real life, at

least I hope not' Bernadette (excerpt from field notes, 2014).

As noted above, I had coded my field notes into 3 main topics, those being ‘unreal experiences’, ‘agitation’, and ‘injury resistance’. One of the most prevalent topics that the nurses discussed was the unreal experiences that the patients seemed to experience. This topic seemed to generate a great deal of discussion of the nurses, as often the experiences for them were memorable because they were taken as being humorous. The nurses didn’t take what the patients were saying seriously, most let it brush off of them, knowing that how they were behaving at the

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time, was not how they behaved normally. Some such as Bernadette used the family as a gauge, noting if the family were shocked by the patient’s actions, then it is up to the nurse to calm the family down and explain that the behaviour is due to the injury or drugs the patient is on. Often the nurses were curious as to where the experiences came from 'Cathy had one patient, an older man, who kept asking her to sleep in the bed with him, when she refused, the patient accused all the staff members of walking around with dildoes, and he continually shouted at Cathy to remove her top for him' (excerpt from field notes, 2014). The nurses are aware of the special environment that the intensive care unit makes, with all the machines running constantly, beeping and making noise, people talking around a patient, all these make it easy for a person to perceive ambiguous noise. Lurhmann in discussing hallucinations states that often it is the presence of ambiguity that establishes a precondition for hallucinations. People who hear an ambiguous noise often need to interpret it in some way, and often this can result in a hallucination (Lurhmann, 2011:73).

Sometimes the nurses are able to figure the source for the unreal experiences themselves. Daisy talked about how she had a patient who had overdosed on recreational drugs, the patient woke up and was terrified that the staff members were actually all police here to arrest her. She then later thought all her family had been killed in a car crash. When Daisy thought about it a little more, she remembered that that night she had the radio on, and there was news of a car colliding with a train, killing the passengers in the car. The crash had happened in the same area as the patient was from (excerpt from field notes, 2014).

The nurses were aware that sometimes, even though the patient was ‘out of it’, they could still perceive what was going on around them. Nigella talked about how she would always try to talk in a calm voice even if the patient was ‘out of it’, 'I think they can hear, even though they shouldn’t be able to, what we say does make a difference, at times they wake up and will know exactly what was going on' (excerpt from field notes, 2014). Danielle spoke about how she often used family members to help patients, in getting the family member to reassure the patient that they are in a safe place 'having a familiar voice, I think it helps, it’s something they know' (excerpt from field notes, 2014). Similarly in some possession rituals, an assistant is on hand to keep the one being possessed within the world as well, so they do not stray too far in the spiritual realm, Porath describes the kemantat (roughly similar to shaman)of Sumatra, who have their assistants throw puffed rice and shout at them in order to control their state of awareness (Porath, 2013:24­25). In many ways, this is much like Luhrnmann’s note on how minds are open to the world in many ways, even though a patient may be unconscious, and unresponsive, they are still able to perceive what is going on around them at times (Luhrmann, 2011:78).

Much like the literature on patient experiences stated, some of the nurses experienced patients behaving without awareness of the time, Pauline spoke about a patient she had, who overdosed on alcohol, and when he woke up several days after the incident 'kept asking about his booze, this was days after he was admitted, he got angry when we wouldn’t give him his booze, and kept trying to look around for it, he even tried to self­extubate when we told him it was gone' (excerpt from field notes, 2014).

The second category of experience that I grouped was under ‘agitation’, this

encompassed a large array of behaviours, from aggressiveness to antisocial behaviour, several of the experiences could have been grouped in two categories, but I tried to keep them in one if I

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could. Agitation could be frightening for the nurses, as noted in the literature, nurses worry about their own safety as well as the patients (Everingham, Fawcett, and Walsh, 2013:699­700). Often the patients become physically abusive, punching and kicking at the nurses. The nurses take it in stride as part of their job, Bernadette saying 'we see it so often, it just becomes part of the routine, it happens time and time again' (excerpt from field notes, 2014). Bernadette continued saying 'you know, if this was in any other job, or in regular life, I’d smack them back, but we just have to take it' (excerpt from field notes, 2014). At times, the patients who are the most violent towards the nurses are the ones least likely to be thought of, Danielle related her experience of looking after an older lady (in her 90s) 'when she woke up, she grabbed my finger and pulled it back...she tried to break my finger off...I couldn’t pry her hands off it myself, it took a couple of other nurses to help pry her fingers off...and she was such a small thing, under 40 kilograms' (excerpt from field notes, 2014). Possession according to Smith, tends to be a violent experience, 'possession is always to some extent disruptive and almost always in some sense violent. The disruptiveness occurs in every form of possession, from ecstatic initiatory possession to oracular possession to disease­producing possession. The violence is often expressed in rage (raudra)' (Smith, 2006:598).

Other patients seemed to be unaware of the extent of their own injuries, Pauline described her experience 'he was old, and quite tiny, he’d been a paraplegic for quite a few years, and when he woke up he kept trying to throw himself out of bed...and his strength, it was crazy!' (excerpt from field notes, 2014). Several of the nurses had experiences where the patients were behaving in quite antisocial ways as well, such as Cathy who was asked to take her top off several times by a patient, or Nigella who had an old lady who 'woke up swearing like a sailor at us...the family were shocked, saying ‘Grandma doesn’t usually swear', and when she came round, she was the sweetest little thing' (excerpt from field notes, 2014). Eric talked about a patient he had, who was both unaware of the extent of his injuries and behaving in an odd manner, 'the patient would constantly try to reach up and bite his own toenails, we had him restrained cause he was a spinal patient, but he would still just keep reaching out trying to bite them' (excerpt from field notes, 2014).

The last category was the area that initially attracted me the research, but sadly, was the

area that was lacking the most in terms of description from the nurses. Few could remember experiences they had where the patients seemed to be resistant to injuries, Nigella noted that they often don’t take notice of when injuries don’t occur because 'it’s not the sort of thing we need to look out for, when it doesn’t happen, we’re more aware of when it does'(excerpt from field notes, 2014). That being said there were a few experiences that the nurses had. Danielle related her experience with a patient waking up who constantly flailed their arms about, hitting the rails, the monitors, everything in reach was a target, 'we had to restrain him in the end, he just kept flailing about, but he never bruised or injured his arms'. It was from these experiences that I drew the initial parallels to possession rituals, in which the one being possessed would perform extraordinary feats in order to prove they were possessed. Danielle also talked about her experience in caring for a patient who had suffered extensive head injuries,

the MRI found massive levels of ‘shrapnel’, the patient would not obey their commands, or respond to movements, from a medical sense, the patient was unconscious and unresponsive, the doctors thought the patient would be brain dead and would never

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recover, but after several days the patient ‘woke up’, and was talking and seemed normal (excerpt from field notes. 2014).8

The last two categories, ‘agitation’ and ‘injury resistance’, could be seen as being quite similar to what occurs in possession rituals, at times the patients are not conscious in the medical sense, in that they are unable to obey commands or respond positively to stimuli. They may be awake in the sense their eyes are open and they are moving, but they seem to have altered levels of consciousness from the experience of the nurses. From the available medical literature on patient experiences, the ones who do remember fragments of their stay in the intensive care unit, remember their unreal experiences, so they too are aware that they are not in the normal state of consciousness.

The nurses were all aware that what often happened in these experiences was not normal,

but they took it in their daily stride as part of their job. As Bernadette stated above, it became routine for them in the performance of their job. Nigella said she always tried to remember that it wasn’t a personal attack on her, and that she tried to laugh it off if she could. Danielle said she found it normal now to be punched at, slapped, groped, kicked, and sworn at while at work.

I asked the nurses why they thought there was little research into these areas from their experience. Danielle said she thought it was because nurses don’t do research into things like this 'if it was to do with drugs or effects, then there would be' (excerpt from field notes, 2014). Nigella added that often the doctors don’t see what is happening, so they aren’t aware all the time of the extent of what goes on.

Finally I asked the nurses to offer some explanations for what happens. While the

literature is unsure of the reasons for ICU delirium, the nurses often had their own opinions on what was happening. Danielle offered the blame on ‘sickness’, 'sickness is a crazy thing' (excerpt from field notes, 2014). Nigella believed that it was just something that happened, 'people do weird things, it’s like ‘mother’s strength’, or sort of like fight or flight' adding at the end of our last meeting, that she saw it as a protective measure, 'it’s the patients protecting themselves, the body reacting to being sick' (excerpt from field notes, 2014). In this, I offer the view that sickness can be seen as a possessing agent, or rather, the body’s response to the sickness, much like a deity or spirit, in that in entering the body, it allows for ‘extraordinary possibilities’ in Malik’s words (Malik, n.d.).

Conclusion

'Even when they don’t get drugs, they can still act strange' Bernadette, excerpt from field notes, 2014.

Patients enter an intensive care unit because they have been subjected to an extreme event

of some variety, it is not a unit that a patient comes to for simple things. No matter the reason for admission to the unit, the patient will have experienced a tremendous amount of suffering to the body of some variety. As Seligman noted above, suffering has implications for the experience of possession. The nurses experience in dealing with the suffering of the patients and the patient’s reactions to that suffering shows parallels to possession experiences in many cultural settings. It is not known what causes ICU delirium, various theories have been advanced in order to offer an explanation, but they often only cover some of the experiences, or explain

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some of the characteristics. In the body reacting to the trauma it has experienced it enacts conditions similar to that of possession, a way to preserve itself, allowing the body to perform the extraordinary. I offer that possession experiences offer a partial explanation into what happens during ICU delirium, in that the patient is in an altered state of consciousness. Perhaps in viewing patients as being similar to those in possession alternative treatments can be envisioned, such as rhythmic drumming, which has been shown to lessen the disruption by those experiencing possession. The nurses are aware that while medically speaking the patients are not conscious, the patients still retain enough capacity to be aware at times of their surrounding. Does ICU delirium qualify as possession, in a way, I argue it does. If we return to Boddy’s definition of possession as being an entity or force that is more powerful than the body exerting influence on the body, then I would argue that it does. The suffering that the body has endured is a force that overpowers the body. In addition, looking at Malik’s distinction between modernity and possession, the loss of self and agency that the patient is faced with in intensive care is similar to that of possession experiences.

Reflexive Coda For myself, this was an amazing experience in anthropology on many levels. It allowed

me to experience a more in­depth ethnography than what we encountered in our undergraduate, allowing us to explore areas in which we were interested, while at the same time keeping us grounded as to what we were capable of doing. At times I did feel as though the task I have approached was too much, and my supervisor did a good job attempting to keep me grounded and focussed on what I was researching. All members of the anthropology faculty offered wonderful support during the hard times that I (and several others) went through in the ethics committee process. It was good to see the department supporting us as students, as well as facilitating a process that will hopefully see change happen in the way the ethics committee functions with regards to ethnography and participant observation studies.

In regards to what I would do differently in my research, I think one of the problems I initially had, was where to begin with the anthropological literature. The medical side of the literature was easy enough to find and read through (though not easy enough to understand at times). At times it was a little more trying to attempt to find the material I thought I wanted from the anthropological side. I was interested in researching more from a medical anthropology side, but the research was hard to come to terms with, what I found was on the ethnocentric side, attempting to categorise possession states as forms of mental illness rather than a true anthropological view and attempting to describe it emically. It was almost with a little luck that I found a few very good articles which led to several more being uncovered, but sometimes it seems that is what research is about.

From the participant observation, I felt as though the process I used, larger informal interviews, worked quite well. The nurses were happy to come to them, and afterwards they expressed their gratitude to being involved (though I was more grateful that they would help me out), it allowed them a chance to unwind with work stories among colleagues. I would have liked to have more time to do more interviews, but with the nurses working shifts, it was a problem trying to get a large number of them together on the same day, getting two seemed like a miracle at the time. The smaller interviews worked great for clearing up the questions that I had, and there were a few times that I used even more informal conversations with two of the nurses as a

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chance to discuss things during our regular chats. In that sense, the research ended up being a part of my daily life at times, I was talking to several of them about it even when we didn’t have scheduled interviews.

I think the one thing that stood out for me about the research in general, was about how involved it became. I knew at the start that the research would be time consuming and deep, but I didn’t expect it to become almost all­consuming. It seemed that it was all I talked about every day, if I wasn’t working on it, I was thinking it through in my mind. It came out in conversations, not only at university around others doing research as well, but in my social life as well, I became my research in a way.

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Notes: 1: I am not implying that nurses believe that caring for someone is boring, rather that during the course of a 12 hour night shift when at times there is nothing to do aside from monitor a patient the nurses do need some activity to stay awake, as there is limited activity they can perform at a bedside in order to allow the patient the needed rest and recovery. 2: Nurses often refer to patients as being ‘out of it’, when they aren’t acting appropriately or are behaving in ways typical of ICU delirium. 3: The DSM is the guide for psychiatrists in defining and distinguishing mental states and conditions, it is currently in its 5th edition. 4: With perhaps the exclusion of auto­ethnography, and anthropology of the self. 5: In my full application, I included the specific legislation from New Zealand law which allowed discussion of medical information provided it was anonymous and for the purpose of legitimate research. 6: Confusion Assessment Method for the Intensive Care Unit, and the Richmond Agitation Sedation Score, see attached worksheets. 7: ‘Waking up’ is the term used most often when referring to patients regaining consciousness following sedation or unconsciousness. 8: The brain scan had shown large areas of damage, from what the nurses told, these sorts of injuries are non­recoverable, often the patient is left brain­dead and in a coma.

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