LA CURACIÓ SIMBÒLICA.
Arthur Kleinman, M.D., is a Maude and Lillian Presley Professor of Medical Anthropology and a Professor of Psychiatry at the Harvard Medical School, where he was Chair of the Department of Social Medicine from 1991 to 2000. At the same time, he is Professor of Social Anthropology at Harvard University in Cambridge, Massachusetts. Dr. Kleinman directed the World Mental Health Report and was a member of the Steering Committee of the American Psychiatric Association of the National Institute of Mental Health Taskforce on Culture and Psychiatric diagnosis as well as Co-Chair of the Committee on Culture, Health and Human Development for the Social Science Research Council (www.stigmaconference.nih.gov/bios/Kleinman.htm).
Dr. Kleinman is considered a key Medical Anthropologist for his contributions to several areas of the anthropology discipline. His comprehensive analysis of psychiatry from a cross-cultural perspective, his research on international mental health, his cross-cultural studies of depression, his experience with chronic illness, his study of the anthropological aspects of mental health and his contributions to social health policy are only some examples of a life work dedicated to research in Medical Anthropology in China, Taiwan, and North America. Dr. Kleinman has authored about 200 articles and several books including, Patients and healers in the context of Culture (1980); Social Origins of Distress and Disease; Neurasthenia, Depression and Pain in Modern China (1984); The Illness Narratives: Suffering, Healing and the human Condition (1988); Rethinking Psychiatry: From Cultural Category to Personal Experience (1988); and Writing at the Margin: Discourses between Anthropology and Medicine (1996); he has edited 17 volumes and founded the journal Culture, Medicine and Psychiatry.
Dr. Kleinman builds a bridge between biomedicine and traditional medicine. He believes that studying biology to treat mental illness is not enough and emphasizes that it is absolutely critical to be knowledgeable about the patients’ culture to be able to heal them since ill and health concepts are cultural constructions. Kleinman, as a psychiatrist and an anthropologist, knows that everyone who attempts to guide others into healing pathways needs to start by knowing the particular cultural ways of how to express illness and health as well as, the individual ways to express ill health encompassing sociosomatic experiences that link together moral, political, economic, environmental, social, and every other thinkable condition.
Kleinman Explanatory Model (EM) explains processes by which illness is patterned and interpreted from both patients and health practitioners. He came up with an EM that suggests a diversity of ways of how people express ill health. The EM bestows explanations for aspects of illness such as the aetiology of the illness, the timing and mode of the onset of symptoms, the pathophysiological processes involved, the natural history and severity of the illness, and the appropriate treatments for the condition (Helman 2000:85). Kleinman points out that each medical sector has its own EM. There is the popular or lay, the folk and the professional sector. Kleinman says that the lay EMs tend to be “idiosyncratic and changeable, and heavily influenced by both personality and cultural factors. They are partly conscious and partly outside of awareness, and are characterized by vagueness, multiplicity of meanings, frequent changes, and lack of sharp boundaries between ideas and experience” (Helman, 2000:85). Kleinman sees that the professional sector deals with illness in a non-holistic way and looks for single cause diseases that can be scientifically proven. EM does not exist in isolation but only can be interpreted in its context. The context of an EM may include the political, economic, environmental, social, religious parts of the society and the culture(s) in which a particular individual has been brought up. In this way, people express emotions depending of how family and friends react to it. For example, people with Schizophrenia or Obsessive Compulsive Disorder (OCD) may not complain because they know the stigma associated with the disease; they can not afford health insurance or miss work; they do not want friends and family to react negatively to their condition. The context has an influence on the types of treatment that patients will get and the increase or decrease of social suffering.
In relation with this concept of social suffering, Kleinman explores the influence of somatization, which he defines “as the substitution of somatic preoccupation for dysphoric affect in the form of complaints of physical symptoms and even illness” (Helman 2000:88). It is a way of being-in-the-world that could be unpleasant or stressful and that is expressed as a form of physical symptom(s). Kleinman, in his earlier work, tied somatization strictly with disease and illness, with psychophysiology of depression and with the psychodynamics of displacement; however, now he sees somatization as normative and normal and refers to it as a basic way of being-in-the-world (Kleinman 1995:9). Kleinman sees that everything has an effect on everybody. Life events, social support, family expressions, personal economics, power forces, and personal sense of self affect individuals depending on the culture. In Kleinman’s studies in Taiwan, he reports that many people showed or talked about physical symptoms and signs when they experienced depression. In Taiwanese culture, mental illness is heavily stigmatized; therefore, people hide their mental illness as much as they can and avoid going to psychotherapy. Instead they complain about physical symptoms (such as headache or backache). Thus, sometimes it is not easy for a doctor that is an outsider to the culture of the patient to recognize symptoms and illnesses. Moreover, folk illnesses are learnt, and therefore changeable and patterned within families, so different cultures and social classes manage, deal, articulate, experience, understand, somatize and cure differently.
In order to overcome those difficulties, Dr. Kleinman advocates for better communication between healers and patients. He believes it is critical, for health care professionals, to display rapport among patients and successfully persuade them to come back and/or adhere to the treatment. Thus, Kleinman gives prominence to the importance of the study of language, symbology and interpretations for the contemporary psychiatrist to reach his/her patients. He believes that cross-cultural research is crucial to establish universality of mental illness and an international validity of psychiatric categories to be able to understand patients better and to diagnose and treat them adequately, conforming to their worldviews. For example, he did a case study on a Boston woman, who used to vomit and urinate a lot to get rid of the water that the doctor said she had in her lungs. When the physician learned what the patient was doing to get well, he explained to her that the only way to get rid of that water was taking water pills and then it was shown to her through diagrams the nature of her disease. When she understood, she changed her behavior. This is also an example of how clinical consultations are a transaction between two very different Explanatory Models. As an effective way to help practitioners in interpreting their patients’ illnesses Kleinman has designed a very short cultural assessment questionnaire (http://www.amsa.org/programs/gpit/cultura.cfm) that is presented here for its instructional value:
1.What do you think caused your problem?
2.Why do you think it started when it did?
3.What does your sickness do to you? How does it work?
4.How severe is your sickness? How long do you expect it to last?
5.What problems has your sickness caused you?
6.What do you fear about sickness?
7.What kind of treatment do you think you should receive?
8.What are the most important results you hope to receive from this treatment?
With this proposal, Kleinman builds a stronger and safer bridge between patients and professionals. At the same time, he gives special credit to the traditional healing systems that become professionalized and institutionalized, such as the Ayurvedic and the Unani medical colleges in India. These systems are a form of “cultural healing.” Healing rituals restore social suffering, affirm threatened values and adjust social tensions. Cultural healing is then a form of symbolic healing. Kleinman believes in the idea that there is a symbolic bridge that connects social and personal space (Kleinman 1995:8). Healing rituals are performed not only for the healing of certain individuals, but also for the healing of the whole community. Symbolic healing is a ritual considered a social event where everybody is intimately involved. Then, a symbolic bridge is when individuals with the aid of imagery and symbols become aware of their own situation and have a revelation of what changes they are supposed to do. That bridge connects the patient with the culturally accepted way of healing.
Kleinman believes that ethnography and psychotherapy are similar in the way that both need to gain the trust of the Other to be able to uncover deep and difficult findings that require an intense and long-term relationship between people to be able to reach that level of observation and experience (Kleinman 1988:23). For the health practitioner, interpretation is a core task of healing cross-culturally (Kleinman 1988:119). In the same way, symbolic healing is a healing mode that relies on language, ritual and the manipulation of powerful cultural symbols instead of physical and/or pharmacological treatments (Helman:191). Kleinman explains a model based of four structural processes of how symbolic healing works:
Stage I. Posits the presence of a symbolic bridge between personal experience, social relations, and cultural meanings (Kleinman 1988:131).
Kleinman believes that all people’s experiences are linked up with the group master symbols. Kleinman refers to cultural grammar the symbols that explain how a person orients himself or herself toward the world outside and towards his or her inner world. One can find cultural grammar in the myths of that culture (e.g. the Koran, the Constitution, or even the sacred myth in oral literature). Kleinman calls this the central myths which authorize the values of the group and that serve as a blueprint for the personal myths of the individual. “There is a hierarchy of linked systems running from cultural symbols to social relations and on to self and bodily processes. That hierarchy is the biopsychocultural basis for healing” (Kleinman1988:132). In the symbolic healing, one first needs to heal from the sociosomatic illness and second from the physical illness. With this, Kleinman means that there is an “upward” which is how personal experiences are assimilated into cultural meanings and vice versa a “downward” which is how cultural meanings are expressed into bodily processes.
Stage II. Symbolic connection is activated for a particular person (Kleinman 1988, pp132).
Usually, the popular sector agrees with the core meanings, culture values and world view; otherwise, the professionally licensed biomedical doctor most likely would be unsuccessful in communicating what the illness is and how the treatment mode will function because he/she is redefining a problem and imposing his/her authority by validating his/her beliefs over the illness instead of validating the patient’s beliefs. Most of the time is the answer of what causes the illness that heals the patient. Therefore, interpretation/diagnosis is critical and makes sense to the patient. When the health practitioner interprets he/she is doing more than giving a diagnosis, but it is the activation of some culture myths and symbolic connections. Those connections get displayed and reordered between that person and the culture and the society where the person belongs. The health practitioner puts order where there was chaos by giving a holistic explanation. In their medical setting, does not exist a dualism between mind and body, the individual and the group.
Stage III. The healer skillfully guides therapeutic change in the patient’s emotional reactions (which means bodily processes as well as self-processes) through mediating symbols that are particularized from the general meaning system(Kleinman 1988:133).
The health practitioner uses symbols to activate patients healing responses or reactions such as self-processes or bodily processes. The healing process is supposed to be interactive as opposed to most Western therapy modes where the patient takes on the passive role of the sick person. The healer uses his/her charisma to help the patient understand why the sickness occurred in the first place by showing the patient particular symbols that fit with master symbols or general meaning systems. This is actually the ultimate experience in all patients.
Stage IV. The healer confirms the transformation of the particularized symbolic meaning (Kleinman 1988:133).
The patient takes into account his/her personal history, and after self-reflexion, he/she knows he/she needs to change or do a symbolic transformation that comes with not only the acceptance but also the willingness of the patient to stay in the new stage. This symbolic transformation activates not only the culture code and the social relations, but also the psychobiology, which are the autonomic nervous system and the neuroendocrine system (Kleinman 1988:134) while also fostering hopes and faith on the healing beliefs that affect directly the patient’s emotions. Kleinman explains that there is no need to know the culture symbols to get healed, just a trust in the healer and a belief that the ritual will bring the cure. The transformation comes from seeing things differently and also reacting to problems differently.
Theory and Methods
Kleinman believes that the work of the anthropologist is to interpret cultures and that psychiatrists currently need to have a background in medical anthropology to be able to reach their patients better. Kleinman’s position is that of the social constructionism, meaning that all worlds are culturally constructed, unique, and changeable. Kleinman sees three conceptual problems when doing comparative cross-cultural medical and psychiatric studies:
1. The tendency to describe cross-cultural medical phenomena via overly simplistic, ambiguous, and often misleading dichotomy between traditional and modern forms of medicine (1978:407).
Kleinman explains the dichotomies between traditional and modern medicine, medical anthropology and medical history. This has been an ongoing problem between the historians and the anthropologists because there is a fragmented bridge up until today. Historians deal only with staff that has documentary evidence and events that are unique. Anthropologists deal with cultures, which there are only a few documents, and look for processes since it is almost impossible to know the details of unique historical events. The primitive medicine is believed to deal with magic and religious components. The medical ethnography studies the primitive medicine of the non-Westerners. Medical history studies the Western medicine, which is believed to be more scientific and deal with rational and empirical components. Westerners seem to regard traditional medicine as a lower level than biomedicine and as a separate healing system from the biomedical. Kleinman believes in the need of a unifying framework for comparing medicine that includes the three medical sectors-the folk, the popular and the professional, within a contemporary Western, historical, and non-Western context. Anthropologists break this dualistic model by explaining how the three sectors interrelate and how usually more than one healing system is used at the same time. They explain each sector’s ways of explaining health and illness, define healer and patient, and explain the interaction between them. Kleinman believes the biomedical sector needs to appreciate and learn about the local systems of medical care and its socio-cultural determinants. It is important, therefore, to build a bridge between this fragmented discipline and generate multidisciplinary research for a more holistic way of dealing with ill health. Kleinman suggests the need to reorient biomedical doctors into a more holistic treatment of the person instead of limiting themselves to treat only body parts. Also, this includes the gaining and using of popular and folk knowledge to better understand ill health from the patients’ perspective and further avoid misdiagnosing patients with erroneous levels and inappropriate treatments.
2. The tendency to concentrate almost entirely upon social issues and thus to exclude from cross-cultural analyses individual behavior, especially its biological substrate and subjective dimension, and also the crucial interrelations between social and psychological process (1978:407).
In medicine, in order to understand a person’s illness, one needs to understand his/her culture, personality, lifestyle, environment, background, social relationships, and family’s medical history. Kleinman believes that the goal for the health care practitioner is to be able to see subjectively the patients illness, the suffering that the patients go through and what its means to them. Secondly, most of the time it depends on the quality of the interaction between patient and healer, patient and family and/or support group. This will defined the course of illness: if the patient decides to be compliant or not and the therapeutic outcome. For example, within the popular and the folk sector usually the healers share the same culture values and worldview with the patient facilitating communication and the healing process. Kleinman emphasizes that it is important not to ignore the relation of biological and psychological processes with culture for an improvement in therapeutic efficacy. People view ill health in different ways, even coming from the same social and cultural background. Kleinman believes that health care practitioners need to understand both views of illness and disease to be able to facilitate the healing process. Therefore, anthropologists called disease the doctor’s perspective. The medical professional sector has its own particular worldview. In the process of medical education, students undergo a form of enculturation into the ill health professional perspective. Their perspective on ill health is based on scientific rationality where all assumptions and hypotheses must be capable of being tested and verified and become clinical facts with a logical chain of cause and effect. There is an emphasis on objective and numerical measurement, the emphasis on physicochemical data (rather than less measurable social and emotional factors because Western doctors believe that biological concerns are more “real”), the mind-body dualism (mind is handed to psychiatrists and behavioral scientists while body is handed to medical science and its diagnostic technology), the view of diseases as entities, reductionism (the focus is not on the patient, but on an organ, a group of cells), and the emphasis on the individual patient (rather than on the family or community).
On the other side, illness is the patient’s perspective. Illness is the subjective response of an individual and of those around him/her to his/her being unwell. It is how they interpret the origin and the significance of this event, not only the experience of ill health, but also the meaning that the patient gives to that experience. Some of the symbolic meaning could be moral, social, or psychological. For example, culture-bound disorders are unique disorders and easily recognized by members of a particular culture, and therefore treated in a cultural specific way. Lay theories of the etiologies of illness are within the individual (responsibility, control, vulnerability, resistance, weakness, debilitation, hereditary proneness, degeneration, and invasion); in the natural world (environment irritants, and dirty air); in the social world (witchcraft, sorcery, evil eye, and stress); and in the supernatural world (gods, spirits, and ancestral shades).
Kleinman believes that the distinction between illness and disease is very relevant and very useful today to be able to understand and explain different points of view when dealing with ill health. Also, he believes that cross-cultural medical research is needed to study all the individual particularities and particular illnesses with each psychosocial and psychocultural linkages even though they are not classifiable in the Western diagnosis systems and nosologies.
3.The failure to conceive of the enormous and confusing array of medical phenomena as organized into cultural systems (1978:407).
Kleinman believes that culture and medicine lack of the concept of unification. That is why cross-cultural medical studies have been so difficult to carry out. Kleinman sees that the participant-observer approach of most medical ethnographies and of medical and psychiatric field research produces quality and quantity of knowledge; however, it is not a systematic methodological approach to medical phenomena and therefore can not be compared cross-culturally. Kleinman suggests a model for taking on cross-cultural medical research to point out fundamental structural features that are universal. For example, the medicine used within a culture reflexes its belief and value system about ill health, its social institutions, relationships, roles and behaviors within its people. Therefore, “the medical system is cognitive, affective, and behavioral environment in which illness and health care are culturally organized” (Kleinman 1978:414). Consequently, an outside doctor that comes along and does not know or learn to appreciate how illness and health are viewed and organized by the locals will have difficulties in communicating and functioning in that community, especially when the medical system of that society is an heterogeneous entity. Kleinman suggest a tripartite cultural organizational paradigm to study medicine cross-culturally where the folk, the professional and the popular sector are studied within their beliefs or explanatory models, its roles, its behaviors and its institutions (Kleinman 1978, Figure 1:422). It is important to trace a cultural paradigm because studying the medical system of a society can only be possible within its cultural context. This model makes easy to examine medical systems and its internal and external adaptive responses to ecological, evolutionary, social, technological, economical, political or any other possible changes. For example, a symbolic response to an internal factor would be the nature of the doctor-patient relationship and the healing practices performed.
Taiwan has three separate domains of health care: the professional, the folk, and the popular sector. The professional sector consist both of Western-style and Chinese-style doctors. The folk sector includes shamans (tang-kis), fortune-tellers, temple-based interpreters of ch’ien (fortune) paper, physiognomists, herbalists, and other specialists. The popular sector consists of family, friends, social networks, and community groups (Kleinman 1978:330). Kleinman, in his studies in Taiwan, brought to light how sometimes aspects of the health care sectors can sometimes bring negative effects on acquiring mental and physical health. In Taiwan, he found that when a member of the family is sick, the family’s first reaction is to contain the sick person by hiding his sickness and the social problems that are occurring in the family household due to the illness. In contrast, other cultures sometimes would run to the medical practitioner and/or would tell all the neighbors what is happening. Kleinman says that in Taiwan somatization is a common thing among wives. When a wife needs to gain a higher status in a family could express that by developing depression. The languages spoken in Taiwan are Chinese and Hokkien and in both languages there are words that refer to psychological states such as words meaning “troubled” or “anxious” which are terms for bodily organs. Self-scrutiny is not encouraged. Consequently, Kleinman, found extremely difficult to engage his patients in conversations about personal ideas and feelings. (Helman 2000:183). Kleinman explains how symbolic healing takes place in Taiwan. First, the underlying casual agent is announced and affirmed in the healing system (e.g., the ghost clinging to the backs of dead family members). This is understood as a particular example of the generalized interpretative structure such as the idea that hungry ghosts have to be ritually appeased or placated. Therefore, a depressed Taiwanese wife activates the culture grammar to mobilize her husband, in laws, and rests of the family in seeing the health practitioner. The wife gains status in the family and the community because they give her psychological and physical (helping her with her household chores) support, while at the same time this affects her nervous system, neuroendocrine, and the limbic system, which reverses the physiology of the depression. The family believes that the gods have chosen her as spirit medium and that now she needs to be given special status. Therefore, the ghost, which is the symbolic form that causes the pathology, is manipulated or pushed out via therapeutic rituals. Finally, the ghost is exorcised and the shaman announces its departure and also pronounces the new symbolic status of the patient as free of ghost and healed. Kleinman explains the symbolic healing of Taiwan as an instance of a universal processual structure of the healing pattern as well as techniques that provoke profound psychophysiological changes. Through cross-cultural studies Kleinman connects healing processes that are both in Western and non-Western traditions. Another example of transformation and catharsis in Taiwan is when a shaman has a master myth of a spirit that the patient can connect to via trance state. The spirit is calm, reassuring, and easy to command and the culture myth says that by allowing the spirit in one’s body one can express feelings, get rid of them, get possessed by the spirit on a daily basis and therefore get well and get control of his life again. Then the shaman guides the spirit to express his fears within a ritual setting. The patient relieves his emotions by outpouring all the tensions and negative cognitions, repressions and frustrations. Therefore, the patient was able to change because he acted as a spirit possessed him, and consequently, he changed his personality and started expressing himself and reacting to life events in a different manner. Since this man became a member of a healing cult his status was enhanced, and his daily life was eased with the help of his new social network (Kleinman 1980:333-352).
Current Problems Brought To Light
Kleinman sees that it is important to do cross-cultural studies to find the nature of diseases. However, he has criticized some of the cross-cultural studies because he believes that the research is not well done. For example, he believes the World Health Organization (WHO) International Pilot Study of Schizophrenia, which is a comparison of Schizophrenia types in different countries, enforced a definition of schizophrenia, and therefore a lot of people with schizophrenia were counted out because they did not fit into the Western model of schizophrenia that WHO was looking for. Kleinman calls this a “category fallacy: the reification of a nosological category developed for a particular cultural group that is then applied to members of another culture for whom it lacks coherence and its validity has not been established” (Helman, 2000:175). In other words, WHO failed to see the cultural influences of the particular schizophrenia. The final point is that a solely biological attempt to fit all illnesses into a universal diagnostic framework can lead to a false category. Other needed studies could be: how internal and external factors within the medical system correlate; what is the impact of medical systems on their sociocultural environments; and how to study sociosomatic modes of experience under a sociosomatic language. Kleinman’s stance is that a culture is constructed with its values and symbolic meanings, and therefore, anthropologists or doctors that aspire to be polyculturally trained need to learn how to deconstruct cultures and interpret people to arrive deep into the roots of their beliefs of ill health and recognize correlations and impacts between internal and external factors.
Kleinman hopes that the further study on cross-cultural ill health will help in establishing universality in mental illness and not just trusting the DSM IV as if it is the bible for finding all valid mental illnesses across gender, race, communities and cultures. Therefore, Kleinman wishes to find international validity of psychiatric categories, which will lead to better psychotherapeutic and other treatment techniques.
At this point, I believe we must slightly reconstruct Kleinman’s theory in order to question the validity of a universality of mental illness. From all the readings I have been through, I have perceived a main idea rooted in Kleinman’s ideology that contradicts the possibility of finding a holistic explanation of illness and a holistic treatment. Today’s medical system across-culture is complex, as well as the growing ethnically diverse populations. Globalization is unstoppable; however in medicine we still have many centuries ahead until we reach universal discoveries on how to treat ill health. At the turn of the 21st century, professional medical practitioners cannot be trained to exercise on groundwork of inflexible universal categories. Finding cross-cultural explanations of ill health seems very promising, however finding a treatment that is cross-culturally accepted is a bit idealistic.
Helman, G. Cecil
2000 Culture Health and Illness. Oxford: Butterworth Heinemann.
Kleinman, Arthur and Joan Kleinman
1997 The Appeal of Experience; The dismay of Images: Cultural Appropriations of Suffering in Our Times. In Social Suffering. Arthur Kleinman, Veena Das, and Margaret Lock, eds. Pp.1-24. Berkley: University of California Press.
1995 Writing at the Margin. Berkeley: University of California Press
1992 Pain and Resistance: The Delegitimation and Relegitimation of Local Worlds. In Pain As Human Experience. Arthur Kleinman, Paul E. Brodwin, Byron J. Good, Mary-Jo DelVecchio Good, eds. Pp169-198. Berkley: University of California Press.
1988 Rethinking Psychiatry. New York: The Free Press.
1980 Patients and Healers in the Context of Culture. Berkley: University of California Press.
1978 Comparisons of Patient-Practitioner Transactions in Taiwan: The Cultural Construction of Clinical Reality. In Culture and Healing in Asian Societies. Arthur Kleinman, Peter Kunstadter, E. Russell Alexander, James L. Gate, eds. Pp.329-375 and 407-441. Cambridge, Mass: Schenkman Publishing Company.
1977 Rethinking the Social and Cultural Context of Psychopathology and Psychiatric Care. In Renewal in Psychiatry. Arthur Kleinman and Theo C. Manschreck, eds. Pp 97-139. New York: Halsted Press.