Rethinking Psychiatry

Rethinking Psychiatry

From Cultural Category to Personal Experience

Arthur Kleinman, M.D.

The Free Press

New York

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To Peter, Anne, Marcia, and Stephen, for whom, after so many years, I have felt the need to explain what my work is about. To Leon, who critiqued what I first wrote, saving me once again from inveterate faults; and who continues to model for me, long after I have formally been his student, the best possibilities for social scholarship in psychiatry. And as always to Joan, for giving me, over almost a quarter of a century, the self-sustaining understanding that what I had to tell was worth saying and therefore worth time and passion.

Realism, like reality, is multiple and evanescent, and no one account of it will do.

Nelson Goodman, Notes on the well-made world

The biological and the social are neither separable, nor antithetical, nor alternatives, but complementary. All causes of the behavior of organisms, in the temporal sense to which we should restrict the term cause, are simultaneously both social and biological, as they are all available to analysis at many levels. All human phenomena are simultaneously social and biological, just as they are simultaneously chemical and physical. Holistic and reductionist accounts of phenomena are not causes of those phenomena but merely descriptions of them at particular levels, in particular scientific languages. The language to be used at any time is contingent on the purposes of the description….

R. C. Lewontin, Steven Rose, and Leon J. Kamin, Not in Our Genes

Preface

For many psychiatrists, including those in positions of authority within the profession, cross-cultural research is merely exotic. The reality of mental illness in different societies, as depicted in the work of anthropologists and psychiatrists who are engaged in cross-cultural studies, is seen, in North American and Western European psychiatry, as marginal to the purposes of the field. The concept of culture is treated in most psychiatric textbooks as unessential to mental illness and psychiatric treatment. Neither fish (biology) nor fowl (psychology), social norms and cultural meanings simply don’t count for much. In the main-line professional ideology, they are soft. That is to say, the entire cultural apparatus of language, symbols, and interpretations is the source of great ambivalence for the contemporary psychiatric researcher. If cited at all, and most frequently they are not, cultural issues are placed at the bottom of a long list of potentially influential forces; the sheer length and atomized nature of the list dilute the significance of each of its constituents, lending a sense of impracticality and irrelevance to the relationship of culture and mental illness. The present period of biological revanchism in psychiatry—when many psychiatrists seem to believe that understanding the biological basis of mental disorders is, if not around the corner, at most two or three streets away, and that such knowledge will be all the clinician needs to know to treat patients with schizophrenia and depression—is particularly deaf to cultural themes.

One must ask, why should a discipline whose roots are so deeply planted in Western culture, whose major figures are almost entirely European and North American, and whose data base is largely limited to the mainstream population in Western societies, why should so strongly Western-oriented a discipline regard cross-cultural research among the more than 80 percent of the world’s people who inhabit non-Western societies as marginal? Is not cross-cultural research essential to establish the universality of mental illness and the international validity of psychiatric categories? Are not comparative studies an antidote to professional ethnocentrism? Can psychiatry be a science if it is limited to middle-class whites in North America, the United Kingdom, and Western Europe? Yet, in spite of these powerful reasons for international research, psychiatry has made only the slightest of contributions in international medicine, and most psychiatric journals and textbooks evidence little if any interest in the psychiatric aspects of international health.

Against this disquieting background, I will highlight a quite different point of view, a vision of psychiatry in the perspectives of other, non-Western cultures—so huge a portion of humanity, yet so silent a presence in psychiatry. What happens when we make the cross-cultural findings of psychiatric research central to our interpretations of mental illness, or when we make psychiatry the subject of anthropological inquiry? Let us then, place psychiatry in the middle of a ring of mirrors held up by Chinese, Japanese, Indian, Nigerian, Iranian, Melanesian, Hispanic American, and still other cultures’ indigenous conceptions, illness perceptions, and therapeutic experiences. The mirrors expose psychiatry’s central assumptions and paradigms of practice to cross-cultural comparison. Anthropological studies further extend this revealing cultural analysis into the house of psychiatry itself—its institutions, roles, system of training, and knowledge. To accomplish this task, I ask seven anthropological questions about psychiatry’s cross-cultural findings and also about psychiatry’s taxonomy and practices. These are not the only questions one might ask, but they are the ones whose discussion I believe is most revealing.

This book was written for the general psychiatrist and for members of that great penumbra of health and mental health professionals that surrounds psychiatry, as well as for the informed layperson who is interested in mental illness and the psychiatric profession. I wrote these chapters not as a scholarly study, but as an account of my thoughts in the course of pursuing cross-cultural and anthropological research for the past two decades. A researcher spends his days in the narrow, twisting streets of a highly technical problem framework; he travels an unmapped, difficult route of minute empirical details that have spun off from the research quest (the broad boulevards) that first motivated his work. Over time that project takes on a life of its own, so that the researcher, in collusion with like-minded colleagues, gets caught up in problems that would seem to anyone but his small research circle remote from the original concerns that prompted the project in the first place. The little roads don’t turn back into the major highways; they get even narrower. We end up writing for each other. Every once in a while it is essential to ask what does it all mean? What relevance does our work have to the diverse interests of a wider audience? The seven questions that I have posed represent an effort to work my way back to the original interests that led me into anthropology and cross-cultural psychiatry. Those early interests arose from a desire to rethink psychiatry. That is what I have tried to do in this book, without too much detail, without jargon, and in a space small enough to be encompassed in an evening or two’s reading.

The title may seem presumptuous. This is after all not a definitive review of psychiatry that marches chapter after chapter through the chief themes, controversies, and empirical findings. Far from it. I have produced a rather personal essay about a small corner of the discipline, cross-cultural research and its anthropological interpretation—a cameo, not a panorama, a small well-tended garden, not a vast, sprawling park. Yet I feel certain my subject is a microcosm of core tensions in psychiatry broadly. Each of the questions initiates a chapter treating a highly specific, technical problem in cross-cultural research. Through an exploration of that problem, however, the subject is enlarged to touch at least one and usually several abiding controversies in psychiatry. At the end I wish to have created a special vision of psychiatry—not a major canvas, not even a representative picture, and certainly not the only anthropological vision, but one that I have worked toward over years of mastering a special subject and traveling a road few mental health professionals travel.

The view of Florence is distinctive if seen after climbing San Miniato or hiking to Fiesole. The experience of getting there shapes the perception of the vista. No less so for a profession, a clinical practice, a science in the making. This is where my work has taken me. This is what I have seen. This is what troubles me. A different window, to be sure. An unusual angle, granted. A special view, all right; yet one that says something different about questions too often taken for granted or even denied. Each practitioner in the course of a career rethinks his discipline. Here is how psychiatry looks when an anthropologist-psychiatrist who has spent much of his research career in East Asia mulls over his work, reconsiders his readings, and tries to make sense of the major cross-cultural issues in psychiatry as they pertain to the discipline as a whole.

The ideas presented in this book were developed in close collaboration with colleagues in the Harvard medical anthropology and cross-cultural psychiatry group. I wish to acknowledge in particular the formative contribution of my colleague Professor Byron Good—I cannot establish where his ideas leave off and my own begin—and that of other present and former members of our group: Drs. Mary Jo DelVecchio Good, Mitchell Weiss, Peter Guarnaccia, Paul Cleary, Pablo Farias, Thomas Csordas, Janis Jenkins, Linda Garro, and especially Joan Kleinman. Graduate students in anthropology have also contributed to the ideas developed below: Paul Brodwin, Terry O’Nell, John Russell, Scott Davis, Anne Becker, Karen Stephenson, Lawrence Cohen, and Paul Farmer. I wish to acknowledge as well the contribution of foreign visitors in the 1985-86 academic year: Drs. Ravi Kapur (India), Liu Shixie (China), Joan Anderson (Canada), and Rob Barrett (Australia). Support from the Rockefeller Foundation, from an NIMH contract to review cross-cultural studies of depression and anxiety, and from an NIMH training grant in clinically applied anthropology were instrumental in facilitating review of the relevant cross-cultural literature. The cases from China that I describe come from research supported by the Committee for Scholarly Communication with the People’s Republic of China of the National Academy of Sciences. A magical month at the Rockefeller Foundation’s Bellagio Study Center gave, along with great quiet and enchantment, time and freedom from other responsibilities to revise the text and reconsider the recommendations of colleagues and friends and a wise senior editor, Laura Wolff. The calm competence and genuine humanness of my assistant, Joan Gillespie, made the labor of writing and rewriting much less trying than it otherwise would have been. Finally, my thanks go to the chairmen of the three departments at Harvard of which I am a member—Professors Stanley Tambiah and Irven DeVore (Anthropology), Myron Belfer (Psychiatry at the Cambridge Hospital), Leon Eisenberg (Social Medicine)—for their continuing support of my effort to build a colloquy between anthropology and psychiatry.

Arthur Kleinman

Cambridge

October 1987

Prologue: Why Anthropology?

No anthropologist, in fact, is to be found willing to surrender the abstract world of history for the abstract world of science, to adopt (that is) a purely quantitative conception of man and of society, of civilization, moral development and religion, and to be content with measurements in place of historical events, statistical inference in place of historical fact, statistical generalization in place of historical enumeration. And the reason for this is, perhaps, that the conclusions of such a science would be relatively unimportant.

Michael Oakeshott, Experience and its Modes

Psychiatry has been overtaken in the 1980s with a fervor for biological explanations. The discovery and development over two decades of psychoactive medications with specific effects on particular disorders spurred research into their physiological effects and in basic neuroscience. The latter is in a golden period, with so many breakthroughs occurring so quickly that the entire shape of the research enterprise has changed several times. The medical model with its emphasis on delineating discrete diseases and their equally specific pathological underpinnings, which had been under serious assault from psychodynamic, behavioral, and community orientations, has come back with a vengeance well expressed by the return to our medical roots motto.

This in turn has transformed psychiatric epidemiology from a marginal discipline concerned with measuring symptoms of general distress and avoiding the taxonomic chaos of an earlier period into a robust program of disease-specific studies closely tied to the impressive development of research diagnostic criteria, standardized clinical assessment instruments that yield high rates of inter-rater reliability, and a new official diagnostic system of the American Psychiatric Association that has had tremendous influence throughout the profession and worldwide. The latter, DSM-III, sets out operationalized inclusion and exclusion criteria for each of the psychiatric disorders. The growth of psychiatric epidemiology has further clarified the distinguishing characteristics of mental illness and opened up opportunities for remarkably innovative research into the genetic and other neurobiological causes of disease. Although research has thus far failed to identify a unique pathophysiology for each of the psychiatric disorders and although biological markers are few and far between, enough progress has been made on the physiological correlates of major depression, panic disorder, and schizophrenia to justify the dominant paradigm of heterogeneous disorders with specific biological sources. Research is now able to establish more reliable rates of psychiatric disease, and to examine vulnerability and provoking factors that place individuals at higher risk.

With all these developments on the biological side of psychiatry, the reader may well ask, why is anthropology at all revelant?

To begin with, the very developments just reviewed also disclose that more is involved in the causal web of psychiatric disorders than changes in neurotransmitters and endocrinological activity. Epidemiological research has begun to parse the social contribution to vulnerability for mental illness through delineation of such factors as life events that are perceived as stressful; social supports that can be assessed as inadequate; and the social origins of helplessness and of a negative sense of self. Family expressions of hostile, negative, and overinvolved emotional response to schizophrenic members have been found to be valid predictors of relapse and worsening course. Cognitive behavioral measures of personal inefficacy and persistent sense of threat and loss have been shown to correlate strongly with depression and anxiety disorders; even more importantly, they have led to the development of psychotherapeutic treatment techniques that are as effective as antidepressants and antianxiety medications. Moreover, unemployment, poverty, and powerlessness continue to show a statistical association with higher rates for most mental disorders. Thus, social psychological aspects of illness and treatment have also been shown to be of considerable significance.

Cross-cultural studies have contributed to this picture. They reveal that the core psychiatric disorders can be diagnosed in a wide range of societies. Certain of these disorders—e.g., depression and anxiety disorders—have particularly high rates in situations of uprooting, refugee status, and forced acculturation. Remarkably, yet still without adequate explanation, the course of schizophrenia has been shown to be better in less technologically developed societies and worse in the most technologically advanced ones. Some disorders appear to be found only in particular culture areas—the so-called culture-bound disorders. These culture-bound syndromes include not just susto, latah, amok, and other folk illnesses in the non-Western world, but quite possibly agoraphobia and perhaps also anorexia nervosa in the West and among the Westernized elite in developing societies. Patterns of seeking help for psychiatric disturbance vary widely across ethnic boundaries. Some cultures appear to innoculate their members against particular disorders, e.g., alcoholism among Chinese, who until very recently have had extremely low rates, while others put their members at especially high risk, e.g., alcoholism among North American Indians. And of course treatments vary greatly across societies. Research on genetic predisposition, on the family’s contribution to the genesis of psychopathology, and on the contribution of environmental factors such as tropical diseases, natural catastrophes, and occupational hazards have all encouraged cross-cultural investigations. Anthropologists have been asked to collaborate in this comparative research enterprise, and a number have done so.

It would be easy to embellish this line of reasoning to establish as practical the use of cultural analysis in psychiatry. But I seek to advance a different justification. Culture holds importance for psychiatry, in my view, principally because it brings a special kind of criticism to bear on research regarding mental illness and its treatment. From the cross-cultural perspective, the fundamental questions in psychiatry—how to distinguish the normal from the abnormal; how disorder is perceived, experienced, and expressed; why treatments succeed or fail; indeed the purposes and scope of psychiatry itself—all are caught up in a reciprocal relationship between the social world of the person and his body/self (psychobiology). For the anthropologist, the forms and functions of mental illness are not givens in the natural world. They emerge from a dialectic connecting—and changing—social structure and personal experience. That dialectic is the golden thread running through ethnographies of life in different cultural systems, and also through the structure of criticism that anthropologists draw upon to understand mental illness and the mental health professions. In the anthropological vision, the two-way interaction between social world and person is the source of thought, emotion, action.¹

This mediating dialectic creates experience. It is as basic to the formation of personality and behavior as it is to the causation of mental disorder. Mental illnesses are real; but like other forms of the real world, they are the outcome of the creation of experience by physical stuff interacting with symbolic meanings.

The tie between social and personal worlds is mediated by language, symbols, value hierarchies, and aesthetic forms that are the pervasive cultural apparatus which orders social life. Nor is psychiatry exempt from this dialectic. Psychiatric concepts, research methodologies, and even data are embedded in social systems. The work of the practitioner and the powers of the profession originate in the same dynamic systems of values and relationships and experiences. Through them, psychiatric diagnostic categories are constrained by history and culture as much as by biology. Indeed, in the concepts of anthropology, biology, history, and culture are deeply interwoven.

In the chapters that follow I will apply this framework of cultural criticism to psychiatric research and practice. The attempt to apply psychiatric categories, so profoundly influenced by Western cultural premises, to non-Western societies is dramatically illustrated in cross-cultural research, the subject of the first three chapters.

Chapter 1

What Is a Psychiatric Diagnosis?

Disease is not a fact, but a relationship and the relationship is the product of classificatory process….

Bryan S. Turner, The Body and Society

What other taxonomies might revolutionize our view—for taxonomies are theories of order?

Stephen Jay Gould, Animals and us

Individuals are types of themselves and enslavement to conventional names and their associations is only too apt to blind the student to the facts before him. The purely symptomatic forms of our classifications are based on the expressive appearances that insanity assumes according to the temper and pattern of the subject whom it affects. In short, individual subjects operate like so many lenses, each of which refracts in a different angular direction one and the same ray of light.

William James, cited in Eugene Taylor: William James on Exceptional Mental States, The 1896 Lowell Lectures

I am sitting in a small interview room at the Hunan Medical College in south central China. It is August 1980 and the temperature is over 100 degrees. I am sweating profusely and so is the patient I am interviewing, a thin, pallid, 28-year-old teacher at a local primary school in Changsha whose name is Lin Xiling.¹

Mrs. Lin, who has suffered from chronic headaches for the past six years, is telling me about her other symptoms: dizziness, tiredness, easy fatigue, weakness, and a ringing sound in her ears. She has been under the treatment of doctors in the internal medicine clinic of the Second Affiliated Hospital of the Hunan Medical College for more than half a year with increasing symptoms. They have referred her to the psychiatric clinic, though against her objections, with the diagnosis of neurasthenia.²

Gently, sensing a deep disquiet behind the tight lips and mask-like squint, I ask Mrs. Lin if she feels depressed. Yes, I am unhappy, she replies. My life has been difficult, she quickly adds as a justification. At this point Mrs. Lin looks away. Her thin lips tremble. The brave mask dissolves into tears. For several minutes she continues sobbing; the deep inhalations reverberate as a low wail.

After regaining her composure (literally reforming her face), Mrs. Lin explains that she is the daughter of intellectuals who died during the Cultural Revolution while being abused by the Red Guards.³

She and her four brothers and sisters were dispersed to different rural areas. Mrs. Lin, then a teenager, was treated harshly by both the cadres and peasants in the impoverished commune in the far north to which she was sent. She could not adapt to the very cold weather and the inadequate diet. After a year she felt that she was starving, and indeed had decreased in weight from 110 to 90 pounds. She felt terribly lonely; in five miserable years her only friend was a fellow middle school student with a similar background from her native city, who shared her complaints. Finally, in the mid-seventies she returned to Changsha. She then learned that one of her sisters had committed suicide while being struggled by the Red Guards, and a brother had become paralyzed in a tractor accident. Three times Mrs. Lin took the highly competitive entrance examinations for university education, and each time, to her great shame, she failed to achieve a mark high enough to gain admission.⁴

Two years before our interview, she married an electrician in her work unit. The marriage was arranged by the unit leaders. Mrs. Lin did not know her husband well before their marriage, and afterward she discovered that both he and his mother had difficult, demanding, irascible personalities. Their marriage has been characterized by frequent arguments which end at times with her husband beating her, and her mother-in-law, with whom they live, attacking her for being an ungrateful daughter-in-law and incompetent wife. Both husband and mother-in-law hold her responsible for the stillbirth of a nearly full-term male fetus one year before.

Over the past two years, Mrs. Lin’s physical symptoms have worsened and she has frequently sought help from physicians of both biomedicine and traditional Chinese medicine. When questioned by me, she admits to more symptoms—difficulty with sleep, appetite, and energy, as well as joylessness, anxiety, and feelings that it would be better to be dead. She has an intense feeling of guilt about the stillbirth and also about not being able to be practically helpful to her paraplegic brother. During the past six months she has developed feelings of hopelessness and helplessness, as well as self-abnegating thoughts. Mrs. Lin regards her life as a failure. She has fleeting feelings that it would be better for all if she took her life, but she has put these suicidal ideas to the side and has made no plans to kill herself.

From Mrs. Lin’s perspective, her chief problem is her neurasthenia. She remarks that if only she could be cured of this physical problem and the constant headache, dizziness, and fatigue it creates, she would feel more hopeful and would be better able to adapt to her family situation.

For a North American psychiatrist, Mrs. Lin meets the official diagnostic criteria for a major depressive disorder. The Chinese psychiatrists who interviewed her with me did not agree with this diagnosis. They did not deny that she was depressed, but they regarded the depression as a manifestation of neurasthenia, and Mrs. Lin shared this viewpoint. Neurasthenia—a syndrome of exhaustion, weakness, and diffuse bodily complaints believed to be caused by inadequate physical energy in the central nervous system—is an official diagnosis in China; but it is not a diagnosis in the American Psychiatric Association’s latest nosology.

For the anthropologist, the problem seems more that of demoralization as a serious life distress due to obvious social sources than depression as a psychiatric disease. From the anthropological vantage point, demoralization might also be conceived as part of the illness experience associated with the disease, neurasthenia or depression. Here illness refers to the patient’s perception, experience, expression, and pattern of coping with symptoms, while disease refers to the way practitioners recast illness in terms of their theoretical models of pathology.

Thus, a psychiatric diagnosis is an interpretation of a person’s experience. That interpretation differs systematically for those professionals whose orientation is different. And other social factors—such as clinical specialty, institutional setting, and, most notably in Mrs. Lin’s case, the distinctive cultural backgrounds of the psychiatrists—powerfully influence the interpretation. The interpretation is also, of course, constrained by Mrs. Lin’s actual experience. Psychiatric diagnosis as interpretation must meet some resistance in lived experience, whose roots are deeply personal and physiological. The diagnosis does not create experience; mental disorder is part of life itself.

But that experience is perceived and expressed by Mrs. Lin through her own interpretation of bodily symptoms and problems of the self, so that the experience itself is always mediated. Because language, illness beliefs, personal significance of pain and suffering, and socially learned ways of behaving when ill are part of that process of mediation, the experience of illness (or distress) is always a culturally shaped phenomenon (like style of dress, table etiquette, idioms for expressing emotion, and aesthetic judgments). The interpretations of patient and family become part of the experience. Furthermore, professional and lay interpretations of experience are communicated and negotiated in particular relationships of power (political, economic, bureaucratic, and so forth). As a result, illness experiences are enmeshed in and inseparable from social relationships.

When a psychiatric diagnosis is made, these aspects of social reality are implied. Diagnosis is a semiotic act in which the patient’s experienced symptoms are reinterpreted as signs of particular disease states.⁵

But those reinterpretations only make sense with respect to specific psychiatric categories and the criteria those categories establish. All diagnoses share this characteristic, whether the disorder is asthma, diabetes, hyperthyroidism, or depression. However, the signs of psychiatric disorders are more difficult to interpret for two reasons. They are only in part, and even then only for certain disorders, a result of biological abnormality; and psychiatric complaints overlap with the complaints of other ordinary kinds of human misery, e.g., injustice, bereavement, failure, unhappiness.

A psychiatric diagnosis implies a tacit categorization of some forms of human misery as medical problems. Earlier in Western society, what is now labeled depression, a psychiatric disease, may have been labeled as medical disorder (an imbalance in the body’s humors), a religious problem (guilt or sinfulness), moral weakness (acedia), or fate (Jackson 1985, 1987). In traditional Chinese medicine, only madness and hysteria were viewed as mental disorders; other problems which we would now call psychiatric were reinterpreted as either manifestations of medical disorder or life troubles owing to the malign influence of gods, ghosts, and ancestors.

In brief, then, though medical diagnosis is taught to medical students and sometimes practiced on patients as a natural activity—meaning that symptoms are said to match underlying physiological processes—it is anything but natural. What we take a symptom to be is a cultural matter, as is the assumption that a symptom mirrors a single defect in physiological processes. That assumption is not only cultural but naive. One of the most dependable occurrences in clinical care is the practitioner’s inability to draw a precise one-to-one correlation between symptom (an experience) and disease diagnosis (an interpretation within a bounded conceptual system). Patients with endoscopic evidence of active ulcer craters in their stomach may have no pain or other symptoms. Conversely, patients with seriously disabling low back pain often have no demonstrable disease. In fact, even when a nerve root is compressed, neurologists cannot say what it is that causes pain (Osterweis et al., eds., 1987, pp. 123-145). There is no direct measurement of pain independent of its subjective experience, and that experience amplifies or dampens or expresses in unpredictable, idiosyncratic ways the symptom pain. The diagnosis of a structural or functional abnormality tells the practitioner little at all about severity of symptoms, functional impairment, or course and treatment response (Feinstein 1987).

Although diagnosis is said to be based on a hypotheticodeductive method, in which practitioners test possible diagnostic categories against the patient’s symptom story to determine which diagnosis best explains the account and which can be rejected, McCormick (1986) shows that formal hypothesis testing among competing diagnoses is a great rarity in medical practice. Demystifying diagnosis, this physician reasons that simple recognition—based on knowledge, the conceptual system we have learned to use to order the world, and on practical experience, what we have actually been trained to see and do—is the essence of diagnosis in all branches of medicine. The diagnostic interpretation is a culturally constrained activity (though it is also constrained by brute materiality in experience) in which the practitioner’s professional training in a particular taxonomic system for ordering experience renders that experience and its interpretation natural. What are we missing, asks the naturalist Stephen Jay Gould (1987, p. 24), because we must place all we see into slots of our usual taxonomy? The neophyte clinician