Arthur Kleinman

Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research

Major health care problems such as patient dissatisfaction, inequity of access to care, and spiraling costs no longer seem amenable to traditional biomedical solutions. Concepts derived from anthropologic and cross-cultural research may provide an alternative framework for identifying issues that require resolution. A limited set of such con- cepts is described and illustrated, including a fundamental distinction between disease and illness, and the notion of the cultural construction of clinical reality. These social science concepts can be developed into clinical strategies with direct application in practice and teaching. One such strategy is outlined as an example of a clinical social science capa- ble of translating concepts from cultural anthropology into clinical language for practical application. The implemen- tation of this approach in medical teaching and practice requires more support, both curricular and financial.

Patients and healers in the context of culture : an exploration of the borderland between anthropology, medicine, and psychiatry

List of Figures Preface 1. Orientations 1: The Problem, the Setting, and the Approach 2. Orientations 2: Culture, Health Care Systems, and Clinical Reality 3. Orientations 3: Core Clinical Functions and Explanatory Models 4. The Cultural Construction of Illness Experience and Behavior, 1: Affects and Symptoms in Chinese Culture 5. The Cultural Construction of Illness Experience and Behavior, 2: A Model of Somatization of Dysphoric Affects and Affective Disorders 6. Family-Based Popular Health Care 7. Patients and Healers: Transactions Between Explanatory Models and Clinical Realities. Part 1. Sacred Folk Healer-Client Relationships 8. Patients and Healers: Transactions Between Explanatory Models and Clinical Realities. Part 2: Professional Practitioner-Patient and Family-Patient Relationships 9. The Healing Process 10. Epilogue: Implications Glossary Bibliography Index

Grand challenges in global mental health

A consortium of researchers, advocates and clinicians announces here research priorities for improving the lives of people with mental illness around the world, and calls for urgent action and investment.

Depression, somatization and the “new cross-cultural psychiatry”

Abstract Contrary to Singers contention that the features of depressive disorders do not exhibit significant cross-cultural differences, the author uses material from field research in Taiwan and data from recent anthropological and clinical investigations to support the opposite view that such differences exist and are a function of the cultural shaping of normative and deviant behavior. Somatization amongst Chinese depressives is used as an illustration. This discrepancy reflects substantial changes in the nature of more recent cross-cultural studies by anthropologists and psychiatrists, changes which are giving rise to a new cross-cultural approach to psychiatric issues. Some features and implications of that approach are described.

Poverty and common mental disorders in developing countries

A review of English-language journals published since 1990 and three global mental health reports identified 11 community studies on the association between poverty and common mental disorders in six low- and middle-income countries. Most studies showed an association between indicators of poverty and the risk of mental disorders, the most consistent association being with low levels of education. A review of articles exploring the mechanism of the relationship suggested weak evidence to support a specific association with income levels. Factors such as the experience of insecurity and hopelessness, rapid social change and the risks of violence and physical ill-health may explain the greater vulnerability of the poor to common mental disorders. The direct and indirect costs of mental ill-health worsen the economic condition, setting up a vicious cycle of poverty and mental disorder. Common mental disorders need to be placed alongside other diseases associated with poverty by policy-makers and donors. Programmes such as investment in education and provision of microcredit may have unanticipated benefits in reducing the risk of mental disorders. Secondary prevention must focus on strengthening the ability of primary care services to provide effective treatment.

Concepts and a model for the comparison of medical systems as cultural systems.

Abstract A model and related concepts are present for ethnographic and comparative research on medical systems as cultural systems. The major structural and functional aspects of the health care system model are briefly sketched. Clinical realities, explanatory model (EM) transactions in health care relationships, a distinction between disease/illness, cultural healing and cultural iatrogenesis, and the core adaptive taks of health care systems are concepts based on this model which have practical clinical and public health, as well as research, implications. A number of hypotheses are outlined which can be used to focus medical ethnographies and to construct comparative cross-cultural studies of health care systems. The model, concepts, and hypotheses attempt to exploit medical anthropologys fundamental tension between medical and anthropological interests; and thereby to contribute to the development of theory that is original to this discipline.

Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It

Cultural competency has become a fashionable term for clinicians and researchers. Yet no one can defi ne this term precisely enough to operationalize it in clinical training and best practices. It is clear that culture does matter in the clinic. Cultural factors are crucial to diagnosis, treatment, and care. They shape health-related beliefs, behaviours, and values. But the large claims about the value of cultural competence for the art of professional care-giving around the world are simply not supported by robust evaluation research showing that systematic attention to culture really improves clinical services. This lack of evidence is a failure of outcome research to take culture seriously enough to routinely assess the cost-effectiveness of culturally informed therapeutic practices, not a lack of effort to introduce ulturally informed strategies into clinical settings. [PLoS Medicine, October 2006]

CULTURE AND DEPRESSION Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder

Some of the most innovative and provocative work on the emotions and illness is occurring in cross-cultural research on depression. Culture and Depression presents the work of anthropologists, psychiatrists, and psychologists who examine the controversies, agreements, and conceptual and methodological problems that arise in the course of such research. A book of enormous depth and breadth of discussion, Culture and Depression enriches the cross-cultural study of emotions and mental illness and leads it in new directions. It commences with a historical study followed by a series of anthropological accounts that examine the problems that arise when depression is assessed in other cultures. This is a work of impressive scholarship which demonstrates that anthropological approaches to affect and illness raise central questions for psychiatry and psychology, and that cross-cultural studies of depression raise equally provocative questions for anthropology.

Depression and somatization: a review: Part I

Abstract The authors describe the relationship between the major depressive disorder and somatization. A literature review documenting the incidence and prevalence of depression in primary care and the rate of misdiagnosis is presented. Evidence is collated that points to several factors in misdiagnosis. The patient often selectively complains about the somatic manifestations of depression, minimizes the affective and cognitive components and is treated symptomatically. This is due to the physicians lack of recognition that the patient may have major depressive disorder and yet not recognize and report the mood component. The authors develop a conceptual model that elucidates the mechanism behind the selective perception and focus by the patient on the somatic manifestations of depression. In this first part, the influence of sociocultural and childhood experience on the ability of the patient to recognize and report mood changes is delineated. Understanding this model is crucial in preventing misdiagnosis and potential iatrogenic harm to the patient.

Suffering and its professional transformation toward an ethnography of interpersonal experience

The authors define experience as an intersubjective medium of microcultural and infrapolitical processes in which something is at stake for participants in local worlds. Experience so defined mediates (and transforms) the relationship between context and person, meaning and psychobiology in health and illness and in healing. Building on this theoretical background, an approach to ethnography is illustrated through an analysis of suffering in Chinese society. The embodied memory of a survivor of serious trauma during the Cultural Revolution provides an example. From there, the authors go on to describe a framework of indigenous Chinese categories for the analysis of experience — mianzi (face), quanxi (connections), renqing (situated emotion), bao (reciprocity). The paper concludes with a discussion of the existential limits of this and other anthropological approaches to the study of experience as moral process.