Mark Nichter

Idioms of distress: Alternatives in the expression of psychosocial distress: A case study from South India

This paper focuses attention on alternative modes of expressing distress and the need to analyze particular manifestations of distress in relation to personal and cultural meaning complexes as well as the availability and social implications of coexisting idioms of expression. To illustrate this point the case of South Kanarese Havik Brahmin women is presented. These women are described as having a weak social support network and limited opportunities to ventilate feelings and seek counsel outside the household. Alternative means of expressing psychosocial distress resorted to by Havik women are discussed in relation to associated Brahminic values, norms and stereotypes. Somatization is focused upon as an important idiom through which distress is communicated. Idioms of distress more peripheral to the personal or cultural behavioral repertoire of Havik women are considered as adaptive responses in circumstances where other modes of expression fail to communicate distress adequately or provide appropriate coping strategies. The importance of an ‘idioms of distress’ approach to psychiatric evaluation is noted.

Current models of nicotine dependence: what is known and what is needed to advance understanding of tobacco etiology among youth

Youth smoking has risen dramatically during the last 5 years, leading one to the conclusion that prevention interventions have not been particularly effective. This paper provides an examination of features that define adult nicotine dependence and argues that these features need to be considered in any studied examination of youth etiology and development to nicotine dependence. We review the historical context for the concept of nicotine dependence, features that define the concept and current models of substance dependence more generally. Recommendations for future research are provided.

Idioms of Distress Revisited

I am pleased to have this opportunity to offer some reflections on what I have foreseen as an idioms-of-distress research agendum, and some thoughts on what an idioms-of-distress assessment adds to anthropological research on human suffering and culturally informed therapy facilitation in clinical settings. The term idioms of distress has now been in circulation for 30 years and has clearly taken on a life of its own. It was used in DSM IV and is likely to be considered for use in DSM V. A point of discussion in psychiatry at the moment is whether idioms of distress and ‘‘culture syndromes’’ are redundant terms or whether they refer to different phenomena. I weigh in on this issue as well as address two critiques of the way the term idioms of distress has been conceptualized by some scholars. I suggest that a distinction among idioms of distress, cultural idioms of distress and cultural syndromes is warranted. And I suggest that the two critiques of idioms of distress reviewed are necessary correctives, returning us to the original intent of an idiomsof-distress agenda. Finally, I highlight a few of the unique contributions made by papers in this issue that push an idioms-of-distress assessment in new and productive directions. In 1977, I wrote a pair of papers laying out an idioms-of-distress research agenda and calling attention to the role practitioners (from diagnosticians to diviners) play in framing experiences and expressions of distress in ways that Obeyesekere (1985, 1990) later came to refer to as the work of culture. My papers were published a few

The layperson's perception of medicine as perspective into the utilization of multiple therapy systems in the Indian context.

Lay perceptions of medicine in a village in South India are discussed in terms of their influence on the utilization of the available alternative therapy systems: cosmopolitan, professional ayurvedic, traditional ayurvedic, and folk practitioners. Villagers seeking medical help focus on the types of medicines and paraphernalia exhibited in medical shops and tend to employ a trial and error approach which creates a client-dominant medical market characterized by low compliance. The type of form of therapy is often considered more important than the therapy system. Concepts of habitude, power, diet and physical properties of medicine affect the choice of treatment and the patients compliance with instructions, leading to rejection of medicines that are inconsistent with indigenous notions of etiology and ethnophysiology. The public health implications of medicine-taking behavior should receive scrutiny in situations where medicines targeted for high risk populations are not gaining the desired results.

Reconsidering the Placebo Response from a Broad Anthropological Perspective

This paper considers how the full range of human experience may catalyze a placebo response. The placebo effect has been characterized as something to control in clinical research, something to cultivate in clinical practice and something present in all healing encounters. We examine domains in which the term ‘placebo’ is used in discourse: clinical research, clinical practice, media representations of treatment efficacy and lay interpretations of placebo—an underresearched topic. We briefly review major theoretical frameworks proposed to explain the placebo effect: classical conditioning, expectancy, the therapeutic relationship and sociocultural ‘meaning.’ As a corrective to what we see as an overemphasis on conscious cognitive approaches to understanding placebo, we reorient the discussion to argue that direct embodied experience may take precedence over meaning-making in the healing encounter. As an example, we examine the neurobiology of rehearsing or visualizing wellness as a mode of directly (performatively) producing an outcome often dismissed as a ‘placebo response.’ Given body/mind/emotional resonance, we suggest that the placebo response is an evolutionarily adaptive trait and part of healing mechanisms operating across many levels—from genetic and cellular to social and cultural.

Gendered dimensions of smoking among college students

Ethnographic research, including interviews, focus groups, and observations were conducted to explore gendered dimensions of smoking among low level smokers, including the acceptability of smoking in different contexts; reasons for smoking; the monitoring of self and friends’ smoking; and shared smoking as a means of communicating concern and empathy. Important gendered dimensions of smoking were documented. Although males who smoked were described as looking manly, relaxed, and in control, among females, smoking was considered a behavior that made one look slutty and out of control. Young women were found to monitor their own and their friends’ smoking carefully and tended to smoke in groups to mitigate negative perceptions of smoking. Gender-specific tobacco cessation programs are warranted on college campuses.

Illness semantics and international health: The weak lungs/TB complex in the Philippines

Attention is drawn to illness semantics and the need to move beyond health social science research on discrete diseases to sets of illnesses perceived to be interrelated within popular health culture. Considered is the weak lungs/TB complex as it is conceptualized in relation to other types of lung disease as well as predisposing factors which influence the moral identity of the afflicted and the social relations of illness. The illness category weak lungs is broad and covers a variety of symptom states inclusive of TB. While some people equate weak lungs with TB, many others think of weak lungs as a condition which may develop into TB over time. TB is recognized to be contagious, but many people do not perceive weak lungs to be contagious. Treatment practice is discussed in relation to perceptions of illness severity, economics, expectations from medicines and coexisting health concerns. Faith in biomedicine is strong. Broad usage of the term weak lungs affects self-treatment practices and over-the-counter purchase of TB medications. Several TB medicines are labeled in such a way as to give the impression that they are vitamins for the lungs. This association leads people to think that the medication is useful for all illnesses which weaken the lungs, even if taken for a short duration. Attention is drawn to the manner in which inappropriate use of TB medication increases the chances of drug resistance. Data presented on TB drug resistance in the Philippines suggests why a consideration of illness semantics is important.

Qualitative research: contributions to the study of drug use, drug abuse, and drug use(r)-related interventions.

This article describes how qualitative social science research has and can contribute to the emerging field of drug and alcohol studies. An eight-stage model of formative-reformative research is presented as a heuristic to outline the different ways in which qualitative research may be used to better understand micro and macro dimensions of drug use and distribution; more effectively design, monitor and evaluate drug use(r)-related interventions; and address the politics of drug/drug program representation. Tobacco is used as an exemplar to introduce the reader to the range of research issues that a qualitative researcher may focus upon during the initial stage of formative research. Ethnographic research on alcohol use among Native Americans is highlighted to illustrate the importance of closely examining ethnicity as well as class when investigating patterns of drug use. To familiarize the reader with qualitative research, we describe the range of methods commonly employed and the ways in which qualitative research may complement as well as contribute to quantitative research. In describing the later stages of the formative-reformative process, we consider both the use of qualitative research in the evaluation and critical assessment of drug use(r)-intervention programs, and the role of qualitative research in critically assessing the politics of prevention programs. Finally, we discuss the challenges faced by qualitative researchers when engaging in transdisciplinary research.

Using qualitative research to inform survey development on nicotine dependence among adolescents

Researchers interested in measuring tobacco use and dependence among youth face several formidable challenges. These challenges include: most existing measures have been developed for adult samples and may not be suitable for adolescent respondents; surveys must be relevant to different youth subcultures and to both genders; questions must be developmentally appropriate and not perceived as judgmental or condescending; and the multidimensional nature of nicotine dependence in youth must be recognized and measured. This paper demonstrates how researchers can address these challenges by using qualitative techniques to obtain information on youth tobacco consumption, and then using this information to inform the development of quantitative instruments. A case study is presented where a measure of tobacco dependence originally developed for adults is adapted for use with adolescents. A seven-step formative research process is outlined, consisting of gathering information in open-ended interviews, conducting follow-up research, modification of questionnaire items and addition of new items based on the information gathered, constructing a reliable instrument that is readable and acceptable to youth, reducing the length of this instrument without significantly hurting reliability and validity, conducting additional follow-up research involving case studies, and examining cultural differences. Following a formative research process like this one will help tobacco researchers gain a better understanding of how nicotine dependence develops.

From Aralu to Ors: Sinhalese Perceptions of Digestion, Diarrhea, and Dehydration

This paper explores popular Sinhalese perceptions of diarrheal diseases and related health care behavior. Also addressed are cultural interpretations of dehydration and perceptions of oral rehydration solution (ORS). The social marketing of ORS is considered. It is suggested that the marketing of ORS be more closely linked to education programs which promote appropriate conceptualization of dehydration. The need to more closely integrate nutrition education and diarrheal management programs is discussed.