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Rethinking Psychiatry: From Cultural Category to Personal Experience
Arthur Kleinman, M.D., examines how the prevalence and nature of disorders vary in different cultures, how clinicians make their diagnoses, and how they heal, and the educational and practical implications of a true understanding of the interplay between biology and culture.
237 pages, Paperback
First published June 27, 1988
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Displaying 1 - 5 of 5 reviews
December 30, 2024
A thoughtful read and very ahead of its time. Kleinman explores the expression of different mental illnesses through a cross-cultural anthropological lens. He urges us against Western-centred arrogance when it comes to understanding psychiatric illness. He doesn't in the slightest argue against psychiatry as a discipline, but instead draws upon a wealth of perspectives to argue the importance of really listening to the experience of the patient at hand rather than jumping very quickly to standard medication and diagnosis based on apparent presentation.
January 20, 2008
Kleinman argues for a more inclusive clinical methodology – one that gives equal weight to personal, social, and cultural factors, alongside the biological criteria that dominate our medical system. However, issues of time, training, bureaucracy, economics, and politics build seemingly insurmountable barriers against such a utopian vision of full-blown anthropologically based psychiatric processes.
“Healing systems – professional as well as folk – can, though often they do not, offer interpretations that challenge orthodox political definitions of reality (e.g., Taiwanese shamanistic religious cults, in the past, offered one of the only permitted visible symbols of Taiwanese nationalism). They can contest the routinization of suffering and societal ideologies that seek to justify it. Folk healers as much as psychotherapists can revivify or instill personal and family hope through moral metaphors that contradict the corrosive self-images of an age that, like our own, seems obsessed with economic and biological determinist rhetorics of personal gain and narcissistic desire, and in their place reaffirm transcendence. And psychotherapists and other healers can reject clichéd soap-opera solutions to personal crises, which reinforce the politically expedient and commercially profitable illusion that we live in a domesticated “natural” world of expectable order in which disorder is atypical and need not be endured. In the place of this illusion, psychotherapists and other healers can offer the hard-won critical – and therefore moral as well as political – awareness that our experiences are difficult, uncertain struggles with menace and loss in local life worlds over which we exert imperfect control, sometimes hardly any, and in which the transformation of impending chaos into transient order is, for most of us, a precarious victory to be won (or lost) every day with usually inadequate resources and within an intimate circle of interdependence on others.” [p. 129]
I found the book fascinating, and have highlighted dozens of long passages throughout. Some of the evidence is so clear as to seem almost self-evident, and yet these are things I have never given much thought to before. Cultural differences in psychological illness and treatment are much more complex than we, in the Western world, could imagine. For instance, in excerpts from Kleinman’s work in China, we learn that three psychiatrists have desks in a large open room, and three patients are treated concurrently, while others wait. Our North American ideas of a single patient in a quiet room with the full attention of a physician are unknown in this environment. Instead, the psychiatrist and the patient are trying to communicate in the midst of noise and commotion. Family members break in to tell the story from their perspective, which is invariably quite different from the patient’s version. And each patient is allowed an average of only six minutes to explain their problem, receive a diagnosis, and a suggestion for treatment. Cultural, economic, state, and employment issues all intervene in the process.
“Of all the medical specialties, I contend, psychiatry has the most pervasive relationship to culture. Psychiatry is…a window on a culture’s source of distress and on the human consequences of such distress.” [p. 182]
This book is a bit dated (published in 1988), and yet I had no sense that things have changed much in the past 20 years. I fear that Kleinman’s vision of a more culturally inclusive psychiatry has not made much progress. I look forward to reading a more current appraisal.
“Healing systems – professional as well as folk – can, though often they do not, offer interpretations that challenge orthodox political definitions of reality (e.g., Taiwanese shamanistic religious cults, in the past, offered one of the only permitted visible symbols of Taiwanese nationalism). They can contest the routinization of suffering and societal ideologies that seek to justify it. Folk healers as much as psychotherapists can revivify or instill personal and family hope through moral metaphors that contradict the corrosive self-images of an age that, like our own, seems obsessed with economic and biological determinist rhetorics of personal gain and narcissistic desire, and in their place reaffirm transcendence. And psychotherapists and other healers can reject clichéd soap-opera solutions to personal crises, which reinforce the politically expedient and commercially profitable illusion that we live in a domesticated “natural” world of expectable order in which disorder is atypical and need not be endured. In the place of this illusion, psychotherapists and other healers can offer the hard-won critical – and therefore moral as well as political – awareness that our experiences are difficult, uncertain struggles with menace and loss in local life worlds over which we exert imperfect control, sometimes hardly any, and in which the transformation of impending chaos into transient order is, for most of us, a precarious victory to be won (or lost) every day with usually inadequate resources and within an intimate circle of interdependence on others.” [p. 129]
I found the book fascinating, and have highlighted dozens of long passages throughout. Some of the evidence is so clear as to seem almost self-evident, and yet these are things I have never given much thought to before. Cultural differences in psychological illness and treatment are much more complex than we, in the Western world, could imagine. For instance, in excerpts from Kleinman’s work in China, we learn that three psychiatrists have desks in a large open room, and three patients are treated concurrently, while others wait. Our North American ideas of a single patient in a quiet room with the full attention of a physician are unknown in this environment. Instead, the psychiatrist and the patient are trying to communicate in the midst of noise and commotion. Family members break in to tell the story from their perspective, which is invariably quite different from the patient’s version. And each patient is allowed an average of only six minutes to explain their problem, receive a diagnosis, and a suggestion for treatment. Cultural, economic, state, and employment issues all intervene in the process.
“Of all the medical specialties, I contend, psychiatry has the most pervasive relationship to culture. Psychiatry is…a window on a culture’s source of distress and on the human consequences of such distress.” [p. 182]
This book is a bit dated (published in 1988), and yet I had no sense that things have changed much in the past 20 years. I fear that Kleinman’s vision of a more culturally inclusive psychiatry has not made much progress. I look forward to reading a more current appraisal.
November 18, 2009
If you are interested in mental health across cultures, this is the bible.
April 17, 2023
Ugh what you said in a whole book could have been said in a few pages…in fact it was said in a few pages and the rest was just a frustratingly repetitive rewording. I’ve never met an anthropologist professor who wasn’t full of themselves, this one was no exception.
July 5, 2008
Arthur Kleinman, a psychiatrist and medical anthropologist, approaches psychiatric diagnosis and the concepts of disease and illness from cross-cultural and anthropological perspectives.
Though the idea that psychiatric diagnoses are culturally informed constructs may seem like a no-brainer to those who recognize that more than just biological processes play a role in mental disorders/distress, the professional application of this idea -- which should include recognizing our assumptions, large and small, questioning our assumptions, allowing ourselves to let go, at least in part, of our deeply ingrained perspective (based on life experiences, education, and field training) in order to understand and appreciate the perspective of another -- can be an overwhelming, daunting, and fundamentally disorienting task.
As is often the case, I think, with many issues related to cultural awareness and sensitivity, the awareness of the need for sensitivity can be mistaken for the actual ability to work in ways that are truly culturally sensitive. The ability to approach a cross-cultural clinical relationship with a cross-cultural perspective, however, is an essential component of responsible clinical work.
To quote Kleinman:
"Cross-cultural comparison, appropriately applied, can challenge the hubris in bureaucratically motivated attempts to medicalize the human condition. It can make us sensitive to the potential abuses of psychiatric labels. It encourages humility in the face of alternative cultural formulations of the same problems, which are viewed not as evidence of the ignorance of laymen, but as distinctive modes of thinking about life's troubles...There is, thank goodness, an obdurate grain of humanness in all patients that resists diagnostic pigeonholing. Most experienced psychiatrists learn to struggle to translate diagnostic categories into human terms so that they do not dehumanize their patients or themselves. Yet, the potential for failure in this core clinical skill is built into the very structure of diagnostic systems. An anthropological sensibility regarding the cultural assumptions and social uses of the diagnostic process can be an effective check on its potential misuses and abuses. Irony, paradox, ambiguity, drama, tragedy, humor -- these are the elemental conditions of humanity that should humble even master diagnosticians" (Kleinman, 1988, p. 17).
Though the idea that psychiatric diagnoses are culturally informed constructs may seem like a no-brainer to those who recognize that more than just biological processes play a role in mental disorders/distress, the professional application of this idea -- which should include recognizing our assumptions, large and small, questioning our assumptions, allowing ourselves to let go, at least in part, of our deeply ingrained perspective (based on life experiences, education, and field training) in order to understand and appreciate the perspective of another -- can be an overwhelming, daunting, and fundamentally disorienting task.
As is often the case, I think, with many issues related to cultural awareness and sensitivity, the awareness of the need for sensitivity can be mistaken for the actual ability to work in ways that are truly culturally sensitive. The ability to approach a cross-cultural clinical relationship with a cross-cultural perspective, however, is an essential component of responsible clinical work.
To quote Kleinman:
"Cross-cultural comparison, appropriately applied, can challenge the hubris in bureaucratically motivated attempts to medicalize the human condition. It can make us sensitive to the potential abuses of psychiatric labels. It encourages humility in the face of alternative cultural formulations of the same problems, which are viewed not as evidence of the ignorance of laymen, but as distinctive modes of thinking about life's troubles...There is, thank goodness, an obdurate grain of humanness in all patients that resists diagnostic pigeonholing. Most experienced psychiatrists learn to struggle to translate diagnostic categories into human terms so that they do not dehumanize their patients or themselves. Yet, the potential for failure in this core clinical skill is built into the very structure of diagnostic systems. An anthropological sensibility regarding the cultural assumptions and social uses of the diagnostic process can be an effective check on its potential misuses and abuses. Irony, paradox, ambiguity, drama, tragedy, humor -- these are the elemental conditions of humanity that should humble even master diagnosticians" (Kleinman, 1988, p. 17).
Displaying 1 - 5 of 5 reviews