ILLNESS MEANINGS AND ILLNESS BEHAVIOUR

Arthur Kleinman

Department of Anthropology
Harvard University

Introduction

Most research writings on sickness have proceeded at a pace without much

attention to the categorization, valuation, personal and cultural
significance of illness experience. This failure must seem bizarre to any
laymen with personal experience of serious and chronic illness, and to
clinicians who treat such problems, since it is a routine experience of the
sick and those who care for them (be they family or professionals) that
illness both brings particular meanings to a sick person's life world (e.g.,
the threat of death, the loss of valued body image, a new way of seeing and
living in one's world heretofore taken-for-granted) and also crystallizes
those special meanings in his/her world that constitute and express a
particular form of life (e.g., cancer in the context of a desperately unhappy
middle-age marriage, heart disease in the throes of a mid-life crisis that
has left a businessman demoralized in his failed quest for lost youth, severe
disability in an economically marginal retired couple that threatens bitter
catastrophe in what cultural rhetoric has promised should be the "golden
years").

Social and biomedical scientists have disregarded this obdurately human

aspect of sickness - namely, that we experience symptoms not just with
sensations of pain and deliberate choices in help seeking, but with
unsettling questions of bafflement and suffering that are freighted with
feelings, beliefs and relationships that cannot be divorced from sickness
because they are integral to psychophysiological processes constraining both
the course of disorder and the response to treatment. Researchers have taken
the classical Cartesian tact of reducing sickness to something divorced from
meaning in order to avoid the hard and still unanswered technical questions
concerning how to actually go about measuring meaning and objectivizing and
quantitating its effect on health status and illness behaviour. While such
scientific fastidiousness and strict disavowal have their place in the
development of a professional field, they must also be viewed as detrimental
to the understanding of illness as human experience, since they redefine the
problem to subtract that which is most innately human - beliefs, feelings,
symbolic communication - and replace it with a fabricated strawman, more
straw than man or woman. In contrast, as Plessner (1970) brilliantly shows,
the essential feature of being human is the mediated nature of physical
experience in which bodily processes are mediated by our understanding of
them as meaningful relations in our lives, and that understanding (in a non-
Cartesian, recursive, interactionist manner) becomes part of the bodily
process itself.

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S. McHugh et al. (eds.), Illness Behavior
© Plenum Press, New York 1986
 The meaning and experience of illness must be part of any investigation
of illness behaviour that conceives of that subject in any way commensurate
with real life. Rather than surreptitiously slip meaning back into clinical
and social science studies through such slight of hand euphemisms as symptom
definition, the cognitive dimension of illness behaviour, algorithms of help
seeking and clinical judgement, the appraisal process in stress, the
perception of support, the transmission of information between patient and
health professional - all interesting lines of research, to be sure, we must
study illness meanings per se (head on, so to speak). What are the meanings
of an illness episode? How do we construe them in order to measure them?
How do we assess their sources and consequences? Given the "interpretive
turn" in the social sciences (Geertz, 1983) this may be an especially
appropriate time to address these questions.

A clinical vignette may help project the points raised and illumine the
major issues in the study of illness meanings:

Consider a middle-aged American, white Protestant minister's wife with

chronic neck pain of five years duration. She attributes her pain to an auto
accident five years before. Her orthopedic surgeon, who has operated on her
cervical spine four times in pursuit of pain control, holds the same view.
But whereas he sees the problem wholly and solely as local pathology to the
posterior cervical spine, which after the four surgeries is only now becoming
detectable on X-ray, the patient sees her problem as a punishment from a
severe, uncompromising God for her adultery and separation from her husband
to follow a life-long aspiration to be a creative writer.

Examination of the medical records in different physician's offices

show, surprisingly, that the patient began to complain of pain in her neck
almost a full year before the accident. Her retrospective narratization of
her disorder is no more a purposeful lie than is that of her surgeon, but
rather represents a common problem in illness interpretations. We build
stories to make sense of our lives that are selective fictions, taking up
what we regard as the most important landmarks and most distressing
circumstances in our life experience as we see it at particular moments in
the continuing trajectory of our life course. But not just patients do this.
This is the very stuff of clinical work and even of research. Nelson
Goodman, (1984), the American philosopher, referring to physical science
writes, " ••• but where truth is too finicky, too uneven, or does not fit
comfortably with other principles, we may choose the nearest amenable and
illuminating lie. Most scientific laws are of this sort: not assiduous
reports of detailed data but sweeping Procrustean simplifications."

The orthopedist's account began when there was no demonstrable pathology

in the cervical spine, again not as a lie, but as a particular kind of
clinical construction of reality that will lead inexorably toward the
solution - a framework within which orthopedists have been socialized and by
which they make a living, and therfore, the one holding most relevance for
them: whether or not to operate.

The psychoanalytic psychotherapist whom the patient had been seeing

twice weekly for several years built her analysis around a history of cold
and aloof parents, a lonely childhood, repressive character and unfulfilled
dependency needs. Since the patient had been part of a psychological
research study of the life course, however, we were able to read the very
thorough research records, which disclosed little evidence of unfeeling and
unresponsive parents, loneliness or unfulfilled dependency needs in
childhood. Quite the opposite, these descriptions from the patient's
childhood show her to have had an engaging and supportive family and to have
been an indulged and much loved child with little evidence at the time of
loneliness or unhappiness. But how do we treat this conflict between later
interpretation and a contemporary research record from childhood? Where is
the distortion: in the analyst's account or in the records? [Raffel (1979)

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writes, "It is not that records record things but that the very idea of
recording determines in advance how things will have to appear."]

The pain clinic's behavioural scientists had related the patient's

persistent pain, against which all treatment proved unavailing, to current
life stress, especially an active disability suit. But, opposite to what
they predicted, after resolving her marital conflict to her satisfaction and
winning the disability suit the pain persisted.

This case makes a shambles of easy and superficial assessments of

meaning. It throws in the face of its interpreters grave questions of what
meaning is and how it can be established. But most problematic of all it
makes unavoidable confrontation with a conclusion that Goodman (1984) again
has aptly put:

"For there is, I maintain, no such thing as the real world, no unique,
ready-made, absolute reality apart from and independent of all versions
and visions. Rather there are many right world-versions, some of them
irreconcilable with others; and thus there are many worlds if any. A
version is not so much made right by a world as a world is made by a
right version. Obviously rightness has therefore to be determined
otherwise than by matching a version with a world."

Goodman's argument would not deny the psychobiological processes

constraining illness experience, but it would declare that our knowledge of
those processses as well as of the illness experience is constructed in
keeping with culturally and historically derived lay and professional
understandings.

In response to the vexing problems that emerge from the clinical

vignette and from Goodman's statement, an outline of how the study of illness
meanings might be fostered as part of clinical and social studies of the
phenomenology and epidemiology of illness behaviour (normal and anomalous)
will be outlined in this chapter. First, some technical definitions of
illness and disease will be introduced, and then an analysis will be
presented, relying on materials obtained largely in empirical research on
chronic somatization in Chinese and American societies.

Illness and Disease

By illness, one means the human experience of suffering: the way the
sick person and the members of her or his social network come to perceive,
live with and respond to symptoms (Kleinman, 1982). Illness is first engaged
in lay society, where the sick person and family draw from paradigms of every
day practical knowledge and culturally approved management strategies that
they learned locally as part of being socialized into shared competencies as
members of a local cultural system. These particular paradigms and
strategies have been deployed in others' illnesses and in earlier illness
experiences of their own. Such practical activities are always a remaking or
reworking of existing local beliefs and values as a response to the concrete
contexts of personal experiences and actual social situations within which
illness is embedded. These paradigms and strategies orient the sick person
to his/her bodily complaints, as well as to therapeutic options, including
various institutional settings of care. In this perspective, illness
behaviour is merely the way social scientists have operationalized illness in
the analytic terms of a relatively recently legitimized language of social
behaviour.

By disease, in technical contrast to illness, one refers to the process

of interpretation which occurs where patients suffering illness visit
practitioners of one kind of another. Practitioners, as it were, reconstruct
illness by refracting it through the theoretical lenses of their therapeutic

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professions. Hence, biomedical practitioners construct disease by
reinterpreting the patient's meaningful phenomenological experience of
illness in the sanctioned biomedical meaning system of dysfunction or
structural abnormality in biological processe~. This is the orthodox
biomedical vision (cf. Foucault, 1973). Within biomedicine itself,
physicians who apply the narrow medical model and those who apply the wider
biopsychosocial model construct distinctive diseases. Most importantly,
biomedical definitions of disease are the basis for the bureaucratic
definitions of disability in society (Starr, 1984).

In this perspective then, both illness and disease embody meanings: the
former from person (the patient) and local culture; the latter from person
(the practitioner) and professional culture. While disease meanings are of
increasing interest to medical social scientists who study the culture and
institutions of biomedicine, and who have demonstrated that local cultural
norms significantly influence professional culture (Townsend, 1978; Gaines,
1979, 1982), this paper focuses on the particular significance that illness
experiences hold for patients.

Types of Illness Meanings

Illness meanings are perceived from a variety of distinctive frameworks:

First, there is the ostensible, overt meaning of the symptom (e.g.,

rash, chest pain, headache, shortness of breath) as pain, deformity,
disfigurement, disability. These shared meanings, which are open to group
communication and commentary, are more or less standardized in a local
culture. As a result, when we speak of pain and disability we are
understood. Those understandings may be fairly subtle - in each social group
there are a number of different ways to talk about, for example, headaches
and these differences may make a difference in the way the sick person's
circle responds to her or him.

A second sense of illness meanings, one developed by phenomenologists

(Buytendijk, 1974; Plessner, 1970), has to do with the deeper, usually hidden
personal and cultural significances of particular symptoms as suffering.
Here religious and moral idioms of distress available in local cultural
settings colour the experience. Suffering in Buddhism and in more
traditional Christian theology is not a wholly disvalued experience, but the
basis for transcendence. These meanings are quite at odds with those held by
professionals attending illness in modern secular, medical, bureaucratic
settings.

Much of the work of psychiatrists and psychologists studying medical

disorders throughout this century has centered on the peculiar personal
meanings of illness. Freud's writings are filled with examples of this
genre, which still preoccupies many consultation psychiatrists. Here
amplification of symptoms is interpreted in the terms of the patient's
character structure; the special meanings of illness as threat, loss, gain,
punishment, etc., are drawn on to explain how personality and its
psychodynamic consequences lead to the damping of symptoms. The search for
personal illness metaphors in the biography of a life has become commonplace
in our time (Balint, 1958), but its provenience is ancient in the West, and
there are cross-cultural counterparts in not a few non-Western societies
(Kleinman, 1980; Crapanzano, 1981; Reid, 1983).

Third, illness meanings refer to the culturally marked salience of

particular symptoms in particular societies. Symptoms of cancer in
contemporary Western society are especially fearful and threatening (Sontag,
1976). In the technological society where rationalization and control
diffuse to affect all aspects of life, and where the lowest level of risk is
seemingly unacceptable, the pressure of a poorly explained, often

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uncontrollable, highly malignant disease is a societal-wide threat. Consider
the specially stigmatized signs and symptoms of smallpox and leprosy in late
medieval Europe (Gottfried, 1983), venereal disease in the Victorian age in
Euro-American society and AIDS in the United States today (Brandt, 1984),
mental illness in China over the millenia and neurasthenia in China today
(Kleinman and Lin, 1982), the "vapors" and neurasthenic sensibility in the
Guilded Age in America (Feinstein, 1983). Each of these disorders holds
unique significance and salience in the particular societies mentioned.
These disorders bring particular meaning to involved persons which
constitutes the illness experience.

A fourth meaning of illness is almost the opposite of the cultural

meaning that illnesses confer. Each illness, especially chronic illness, as
it becomes embodied in a particular life trajectory, absorbs personal and
social significances from the sick person's local context in Western society.
For example, heart disease for a failed businessman can become embedded in:
a disintegrating marriage; alcohol abuse; a demoralizing relationship with a
boss; a mid-life crisis in which change in body image and coming to terms
with one's mortality assault a fragily constructed ego. Or in Chinese
society, think of a 30-year-old, deeply disaffiliated worker, a former Red
Guard and rusticated youth, whose bitterness, cynicism and mourning over the
multiple losses in the Cultural Revolution are absorbed into the symptoms of
a chronic illness. Therefore, the assessment and treatment of physical
complaints must take into consideration the psychological and social distress
that are likely sources of symptom amplification.

Fifth, another meaning of illness is how the clinician and researcher

interpret the illness behaviour of a particular person in a particular
situation at a particular time. Here the emphasis is on how clinicians and
researchers come to see the social uses and functions of illness (owing to
their own subtle and not so subtle emphases on the particular person,
setting, or the particular aspect of illness behaviour - coping processes,
support system, help-seeking choices and resources). As every clinician
knows, chronic illness is overdetermined and conveys several and often many
meanings: not just this or that, but this and that •.• and that. For
example, a chronic illness like asthma may serve to authorize and sanction
failure (in work, school, marriage), may mobilize social support otherwise
unavailable (e.g., love and aid from an estranged spouse), may sanction the
expression of anger, may provide time out and away from difficult
circumstances that one feels she or he can no longer tolerate (Kleinman,
1982; Kleinman and Kleinman, 1985). Illness may empower the relatively
powerless, such as the wife of a physical abusive husband whose symptoms
authorize her otherwise unattended demands that her husband share in the
burdensome round of daily household labour. A number of studies have
documented the use of symptoms in the workplace to express worker alienation
and, through the disability process, provide workers with some, otherwise
unavailable, leverage over the work setting. But how do clinician and
researcher decide in any given case which meanings are primary and which
secondary? That process of selective interpretation reflects the interests
of the observer-professional. Here the interests of the interpreter
constrain the interpretation as much as do the interests of the actors.

A sixth meaning of illness might be called retrospective narrative:

that is, the creating of stories whose function is to make sense of sickness
bafflement (Amarisingham, 1982). Here the narrative may function as much to
relate illness to life history as to relate life history to illness. One
sees retrospective narratization particularly after the trajectory of an
illness has been completed or when a chronic illness has settled down into an
established pattern. It is especially common among the elderly, who
frequently weave illness episodes into the fabric of the plot of their life
stories whose denouement they are constantly revising. Retrospective
narratization is also common in situations where an illness has ended in a
catastrophic outcome, or when such an outcome has been barely avoided. Here

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the narrative at times holds a moral purpose, acting something like a secular
ritual. It may reaffirm threatened core cultural values, point up and bring
to conclusion structural tensions, and give shape to a loss (Turner, 1967)
and may even function as a political commentary (Taussig, 1980). For these
reasons, retrospective narratization can be easily shown to distort the
actual happenings of the illness experience, since its raison d'etre is not
fidelity to the historical reality of the illness and its treatment, but
rather validity for a life history and life circumstances. Retrospective
narratives of a more ominous kind occur in the recasting of illness and
treatment experience to suit the purposes of disability suits, medical-legal
suits and other legal actions. There is a reciprocal process in physiCian
explanation and recording, where cases are at certain times reconstructed
with an eye to offical examination of a record so as to protect the
practitioner from bureaucratic criticism. In an era of medical-legal and
peer review pressures, we can expect this aspect of illness meanings to take
on increasing significance.

Finally, illness holds particular meanings for clinicians and

researchers based on their special interests (therapeutic, scientific,
professional, financial). Therefore, the very ways illness accounts are
audited influence the account themselves. This influence affects the telling
as much as the hearing. Patients are quite aware of the "demand
characteristics" of different settings - their homes, a neighbour's room,
public clinic, private office, hospital room, factory clinic, courtroom - and
these help cast the story in a certain form. Similarly, health professionals
also respond to the "demand characteristics" of different settings (e.g., a
busy urban emergency ward, a surgeon1s office, an industrial hygiene clinic,
or a psychiatrist's consulting room). These demands lead to selective
attention to the patient's account such that some aspects are carefully
listened for and heard (sometimes when they are not even spoken), whereas
other things said are literally not heard. One way of understanding this
phenomenon is to view clinical reality - the definition of the problem at
hand and the response to it - as constructed differently by different health
professionals interacting with different patients (Kleinman, Eisenberg, and
Good, 1978; Kleinman, 1980). A saddening dimension of care in America is
that increasingly financial issues loom much larger than they should. These
issues have become influential in clinical encounters and distort clinical
communication and therefore practice. Clinicians and researchers need to
unpack their own interpretive schemas, the versions of the clinical world
they create, to be certain where therapeutic int~rests are being altered by
concerns of theory validation, research publication, making a living, or
professional advancement. These human interests, like the more widely talked
about counter-transference responses of clinicians as individuals to patients
as individuals, need to be the subject of on-going self-reflexive scrutiny by
the interpreters of patient accounts to ensure that the interpretations of
those accounts are not biased. This is a large problem in clinical research
and practice that has never been adequately addressed.

RESEARCH ON ILLNESS MEANINGS

Most of the above will seem old hat to seasoned clinicians, albeit
illness meanings per se have not been written about much. After all, this is
the very stuff of clinical practice which a competent physician develops an
intuitive skill in handling. But to the researcher this must appear like a
nightmare, something that needs to be eliminated if measures of validity and
reliability are to provide some control over clinical data. This soft, messy
"subjective" aspect of illness needs to be transformed into a "harder",
neater set of behavioural variables before it can undergo statistical
manipulation and take on at least the superficial appearance of respectable
data. What is routinely done is simply to discount meanings, to define them
outside the problem framework and, therefore, to keep them from contaminating
the solution framework. For some highly technical purposes, concerned with

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disease determination, this research strategy may be quite acceptable, but if
the purpose is the study of illness, then, to leave the meanings out of the
paradigm greatly impoverishes the subject and the findings.

To illustrate how clinical research can take illness meanings into

account several studies will be reviewed. In his authoritative and subtle
evocation of Tahitian personality and culture, Robert Levy (1973), a
physician-anthropologist, draws from psychoanalytic interviews with a small
number of informants over a decade to write a description of certain illness
meanings and their role in shaping illness experience that reads much like
the best qualitative ethnographic and clinical accounts. As noted elsewhere
(Kleinman, 1983), this format for the presentation of research data is
acceptable in certain quarters (anthropology and psychoanalysis) but not in
others (most biomedical research settings and certain social science ones).
The increasing number of medical ethnographies (Fabrega and Silver, 1973;
Lewis, 1975; Janzen, 1976; Kleinman, 1980: Lindenbaum, 1980; Estroff, 1981;
Reid, 1983: among many others) indicates the usefulness of such a format for
reporting research findings, but clearly this is still a minor stream even in
the study of illness experience. Moreover, ethnographic descriptions of
illness frequently employ quantitiative as well as qualitative measures in
order to enhance their reliability and replicability. Nonetheless, like
detailed single case descriptions and historical accounts, there is a role
for qualitative description and hermeneutic interpretation per se in medicine,
even though this role heretofore has been only marginal (Kleinman, 1980; Good
and Good, 1981; Fabrega, 1974). Quantitative and statistical techniques per
se do not a science make.

If the ethnography of meaning is not legitimated in medicine, then

meaning will not receive a scientifically appropriate assessment in medicine.
Ethnography, the core methodology of anthropology and widely used in other
social sciences, is the systematic description of both qualitative and
quantitative types. Quantitative ethnography includes mathematical scaling
techniques, ethnoscientific eliciting frames and their statistical analysis,
sociolinguistic assessment techniques, and formal measurement procedures of
time, space, change and other co-ordinates of behavoiur and communications.
Qualitative description, taken together with various quantitative measures,
can be a standardized research method for evaluating validity. It is
especially valuable in studying social and cultural significance of medically
relevant events, e.g., illness beliefs, interaction norms, social gain,
ethnic help-seeking, and treatment responses. It is the appropriate method
to describe the work of doctoring. Attribution research in psychology,
survey research in sociology, and ethnoscientific studies in anthropology are
quantitative approaches to meaning to which statistical evaluation can be
applied. But these techniques are less appropriate to the study of the
symbolic meaning of chronic illness experience and its treatment consequences
than ethnography and psychodynamic exploration, or interpretive sociological
and historical inquiry. Moreover, there are established ways of assuring
competent qualitative ethnographic accounts. These include: linguistic
facility; accurate and detailed field notes available for scholarly review;
the response of research subjects to research reports; follow-up studies by
other ethnographers; audio and video taping; utilization of structured
interview; and so forth.

To illustrate the use of qualitative means to study meaning, consider

studies of somatization (Kleinman and Kleinman, 1985). Somatization is the
presentation in a somatic idiom of bodily complaints and medical help seeking
by the patient and the family of personal and social distress (e.g., serious
problems in family, social network, school, work, or medical relationships).
Chronic somatization is chronic illness behaviour that either occurs in
absence of demonstrable disease or more commonly as amplification either of
the pathophysiology of chronic disease or the psychopathology of chronic
stress. Here somatization has become a sickness career. Even though it may
be possible to diagnose a psychiatric disease (depression, anxiety,

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personality disorder) as a contributing problem, the treatment for this
disease component frequently will not end the chronic illness behaviour.

In chronic somatization - chronic pain syndrome in the United States,

neurasthenia in China, or "functional complaints", worldwide - interpersonal
and institutional uses of the sick role, along wih its personal and cultural
significance, create persistent disability. In China (Kleinman and Kleinman,
1985), through clinical interviews and ethnography in clinic and workplace,
it has been learned that chronic somatization in three-fourths of patients
studied, functioned to give workers some limited leverage over an extremely
tightly contolled work-disability system (insofar as chronic illness
behaviour enables workers to take sick leave with pay, change difficult and
demoralizing jobs, or retire early). It also functions to change untenable
family situations, to express political disaffiliation covertly in a society
where it cannot be expressed overtly, to emblematize suffering and remorse
over the tragedies of the Cultural Revolution, and it has other culture wide
significances as well. These meanings are known to astute clinicians
intuitively. They are not described by questionnaires. Patients often
remain unaware of these covert social dimensions of sickness. Financial
gain, for example, (even if it is in the awareness of the patient) cannot be
openly announced because it directly contravenes the requirements of the sick
role that the sick person must want to get better. For the same reason,
structured interviews with patients may be unavailing. The uncovering of
psychodynamic significance may require the building of trust over a long
period. The ethnographic uncovering of social significance may mean
interviewing family, friends, co-workers, observing the patient in his/her
daily life, and studying patients in community as well as clinic and in
relation to broader social themes in the society. Using each of these
techniques (Kleinman and Kleinman, 1985), were able to determine the
characteristic significances of illness behaviour among neurasthenic patients
in Hunan (People's Republic of China). A similar combined approach in
research with chronic pain patients in Boston included: quantitative
measurements of psychological, psychiatric and physical status; survey
measures of stress, social support, work and family functioning; and
qualitative in-depth interview assessment and observation in the clinic,
family and even in the work setting. Here ethnography provides crucial
information on the institutionalization of somatization and on the immense
social significance of somatization as chronic illness behaviour that alters
our research understanding of the problem under study. Ethnography is also
the heuristic basis for hypothesis generation and changes the analytic
framework and even the instruments used to conduct a study.

Applying ethnography has had the additional advantage of broadening the

analytic framework beyond a narrow biomedical understanding of neurasthenia
with its inherant distortions. It forces one to grapple with basic questions
ranging from what constitutes validity and reliability of psychiatric
assessment to the critical examination of social and psychological hypotheses
concerning social behaviour and its determinants. These concerns have
fostered a more rigorous, systematic, psychosocially sophisticated analysis
of clinical issues and, therefore, a more "scientific" understanding of a
clinical problem. Medical anthropology and sociology have already developed
critical discourses on stress, behavioural deviance, social supports, family
structure and function, help-seeking, illness behaviour, and on many other
social dimensions of health and sickness that offer medicine more than just
additional researchable variables. These social science discourses are also
frameworks for interpreting research data, integrating them with major bodies
of findings and analytic concepts for making sense of findings, generalizing
data-based ideas within wider academic contexts, and providing established
standards of academic criticism. That is to say, learning social science
approaches to the study of illness meanings is much more than learning how to
use certain research instruments. It is learning a way of handling concepts
about illness experience, systematically thinking about illness problems, and

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creating a context of criticism that links illness to core concerns in social
theory regarding the meaning of social behaviour.

In a recent study by Manson and colleagues (1985) anthropologists and

psychiatrists investigated the significance of depression among several
American Indian groups by first translating standard psychiatric inventories
into Hopi and other tribes' conceptual and value frameworks. The purpose was
to create a culturally valid psychiatric epidemiologic assessment instrument.
Then they conducted ethnopsychological and ethnomedical studies of how these
local cultures labeled and coped with problems like depression. From this
they derived a culture specific survey instrument to assess prevalence and
types of culture specific categories. Finally they conducted an
anthropological epidemiology using both sets of instruments in order to
compare the findings from indigenous and professional psychiatric assessments
of depression. The result is a much more refined, valid and reliable
assessment of depression in these societies. Good and Good (1985) have used
ethnography, clinical assessments and survey instruments to triangulate
affective disorder among Iranian immigrants to the U.S. They detected both
core universal types and significances of depression, along with culture-
specific patterns of behaviour and meaning. Both of these studies as well as
that by Kleinman and Kleinman (1985) gather information on the relationship
of illness to disease, on the one side, and illness to society, on the other.

ILLNESS MEANINGS: CLINICAL ISSUES

In comparative cross-cultural and historical perspective, it can be seen

that somatization is organized into distinctive styles (Barsky and Klerman,
1983; Kleinman, 1984). These styles seem to result from the intersection of
psychobiological processes with personal and cultural illness meaning. The
neurasthenic pattern still popular in China is a weakness-exhaustion style
that was popular in the West earlier this century, but that has slowly given
way to other styles: chronic pain, bowel preoccupation, and cosmetic
preoccupation styles, among many others. Historians have shown how the
weakness-exhaustion style fit in well with the cultural orientations of the
Victorian period (Sicherman, 1977; Feinstein, 1983). Anthropologists have
described culturally dependent forms of somatization such as heart distress
in Iran (Good, 1977) and shinkeishitsu in Japan (Reynolds, 1976); while
cross-cultural psychiatrists have described somatization as the commonest
presentation of mental illness (especially depressive and anxiety disorders)
in the non-Western world (Kleinman, 1982). Numerous studies have documented
the high prevalence of somatization in primary care settings in the West
(Katon et aI, 1982,1984; Kirmayer, 1984).

Hence, it is essential that clinicians be able to diagnose somatization

and to interpret its sources (psychopathology, coping style, cultural values
and beliefs, social gain, etc.). Heretofore, it has been assumed that
physicians intuitively learned how to interpret chronic illness behaviour.
Recognizing that somatization makes up half of a primary care practitioner's
practice, the following recommendations are advanced to systematize the
clinical assessment of illness meanings in any illness experience.
Clinicians will want to expand or contract this approach based on the chief
issues in the care of particular patients, but the framework has been found
to be a useful one generally in patient care, and especially in the care of
patients with chronic somatization.

The first step is for the physician to elicit the patient's and the
family's explanatory model of the illness. In a supportive and open-ended
manner, the clinician solicits patients' and families' views about the
causes, names, pathology, course and desired treatment of their disorder,
including what they most fear about the illness and its treatment and how the
illness has most seriously affected their family, work, school, recreational,

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and personal life. In turn the clinician will want to examine how local
cultural systems have differentially placed patients at risk or buffered them
against societal wide forces controlling distribution and access to
resources. Where such forces can be altered to the benefit of patients,
physicians will include social intervention in clinical work.

Second, the clinician can then relate this understanding of the illness
to the patient biography and the family history, as well as to the current
situation. This is a somewhat slow process that requires knowledge of
patient and family acquired over time. Past experiences of illness and other
"troubles" that disclose styles of coping, interpreting, and somatizing are
especially valuable sources of information.

Third, the clinician who has assembled this information can then review
it in terms of the seven kinds of meaning outlined earlier. This includes
self-conscious evaluation of what the illness has meant to clinicians:
others and him/herself.

Fourth, in the case of a patient with chronic illness, the practitioner

sorts out over time which meanings are most salient, seem to best account for
exacerbations and remissions, can lend themselves to intervention of
clinical, educational or social kind, and provide a framework with which she
or he can engage the patient and family. The measure of "truth" of illness
meanings should not be thought of simplistically as correspondence between
meaning and "real" word, but in terms of their pragmatic utility, their
coherence, their aesthetic representation. The physician's task is: (1) to
interpret (and help patient and family interpret) illness meanings in such a
way as to assist remoralization and to enhance the healing process; (2) to
provide them with understanding of the sources of symptom amplification and
damping, so that where feasible they can gain mastery over these; and (3) to
control and explain disease and treatment in terms patients and families can
assimilate and act on. The clinician's work also involves the witnessing of
suffering and the sources of distress in those cases where effective
intervention is not available. He or she may be able to assist patients and
families to make sense of the illness experience and even undertake certain
sociopolitical and economic actions as required.

The clinician becomes privileged to understandings of both the

obdurately human sources of misery, and the changing sociopolitical and
economic sources that characterize a local cultural system. At times he or
she may want to engage in social action to address these sources of illness
experience. At other times, a physician may be faced with problems involving
malingering or suicidal threats which need to be addressed in a bureaucratic
framework.

Attention to illness and disease meanings should help assure that the
cultural, professional and institutional values implicit in these activities
are systematically analyzed. There is no "technological fix" solution to
illness meanings as there may be for disease. Rather physicians are forced
to confront the ambiguities, ambivalences, uncertainties, ironies and
paradoxes that are central to sickness and healing as human experiences. The
clinician's mandate to heal must be interpreted in a broader sense here. In
chronic illness, after remedial disease and illness problems are addressed,
the physician's task includes listening intensely, struggling to
empathetically understand, helping to sort out alternatives, sharing the
burden of suffering. The physician will always tinker with an illness
experience in the hope of improving the patient's situation. Validating and
interpreting illness meanings mayor may not lead to practical therapeutic
options. Even where they do not, simply engaging in these ancient and cross-
cultural aspects of healing is an essential part of care and of the work of
doctoring. In that health professionals also have preventive, health
planning, program development and other wider social responsibilities, the
knowledge gained from the confrontation with illness meanings may be applied

158
to social activities within and without medical systems. Finally, through
the knowledge gained about self, social system, and profession, the
physician's engagement in the web of illness meanings holds out the
possibility of self-knowledge and through it liberation from the internal and
external sources of our own oppression.

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