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- Publié sur Amazon.com
By Brendan Bombaci (anthropology grad student)
Kleinman is a luminary with the capacity to bind two disciplines, much in the same way Lawrence Kirmayer is. For the anthropologist and psychiatrist both, it is immediately obvious that he asks crucial and timely questions in Rethinking Psychiatry, each at the core of every chapter, and from each of which he spawns cogent hypothetical answers. He approaches the psychotherapeutic methods of myriad cultures, including that of the Western world, as though they were fundamentally one-in-the-same, drawing from a long-past unicultural identity, and so deftly compares aspects of their frameworks - such as the use of trance states - but contrasts their culturally specific idiomatic intricacies. In this, as the main theme throughout the book, he weaves in and out of how political, religious, and corporate social structures influence the methodologies and the outcomes of psychiatrical practices from culture to culture, and effortlessly identifies the Western error of total-faith-in-science, and the "category fallacy" (Kleinman 1988:14-15) that is basically the culturally ignorant misdiagnosis of illnesses. My one negative opinion is that the last two chapters of the book are framed as standalone but rather seem to be recapitulation and therefore feel a bit redundant, or at least outstandingly implied, as a result. No matter - I believe that this book is a good introduction to the academic and professional thinking of Arthur Kleinman, with many quality references to show that he is not just postulating from an armchair, and, that his ultimate call-to-action for a culturally educated/mediated Western psychiatry is both heartfelt and ahead of its times.
Starting off with the first three questions (as chapter names), which I will cover through the next two paragraphs, Kleinman asks "what is a psychiatric diagnosis," and "do psychiatric disorders differ in different cultures" (covering both the methodological issues and findings of the latter question). Canonical social scientists will use quantitative demographic information to figure out what racial and/or ethnic background an individual has, based on generalized abstract schemes - usually national origins and incomplete biomedical frames rather than actual cultural difference - that may not "determine how well that abstraction fits with the raw [cultural] data," and without determining "[...] whether anything salient was omitted from the theoretical scheme" (Strauss and Corbin 2007:159). They are thereby at a lack of grounded theory and are working with premodern, preconceived conceptualizations about how people of the world react and act. Using McHugh and Slavney's "two kinds of verification that psychiatric researchers struggle to establish in studies of the prevalence, manifestations, course, and treatment response of particular psychiatric disorders - namely, reliability and validity" (Kleinman 1988:10), an example of the problems this lack can create is given by Kleinman (1988:12) wherein Native Americans who hear voices of the deceased may be regarded in the West as psychotic (but normal amongst themselves) even though the validity verification cannot hold up, and even as American children may experience the same thing in bereavement of a family member and not be considered psychotic at all.
With mentations of the category fallacy and this last rubric, one can more holistically critique Western psychiatry and empathize enough to see how psychiatric disorders differ in different cultures. The most "rigorous" psychiatric studies conducted by the World Health Organization - the 1973-1979 International Pilot Study of Schizophrenia, and the famous follow-up 1986 Determinants of Outcome Study (Kleinman 1988:18-22) - were loaded by the Western diagnostic framework, and thereby with preconceived notions that all cultures experience schizophrenia in the same way. Only similarities between patients (in India, Nigeria, Colombia, Denmark, the United Kingdom, the Soviet Union, and the US) were chosen for inclusion in the outcomes of the first study - excluding important differences in the ways that many surveyed people were reporting mental or somatized illness as well as the finding that most courses of schizophrenia in less developed societies were better than those of industrialized ones. Ironically to this Western viewpoint, Mayr noted in 1981 (Kleinman 1988:19) that such perceptions are "the inverse of the argument evolutionary biologists advance to explain the great diversity of species worldwide [...wherein] biology is viewed as the major source of variation." Kleinman outlines many such variations in how cultures experience and express illness (1988:36-38, 42, 44-45, 47-50, e.g.), even arguing that trance is not a "primitive" pathology or healing method (1988:51) but one that dissolves dualistic thinking - which is perhaps why it works even in hypnosis practice in the West (1988:123), being that many non-dualistic cultures experience better illness outcomes.
Further along in the book we see how (chapter titles given) "social relations and cultural meanings contribute to the onset and course of mental illness" and "professional values influence the work of psychiatrists." It becomes apparent that there are many factors which separate the ways in which cultures do illness, how they treat it, and how they try to embody (and persuade with) symbolism, or not, as a way to take it on successfully (or not). His view is that of the biopsychocultural model of illness and treatment which accounts for, as the name implies, "the development of codes for communicating at cellular, psychological, and behavioral [symbolic] levels" (Kleinman 1988:132, emphasis added) which, in complex ways that deserve careful attention, altogether cause, define, and are affected by illnesses. He outlines the stages through which biopsychocultural healing takes place in much of the non-Western world (1988:131-134), which is a generally less alienating, more socially integrated and supportive, and cultural mythos-coding process that is likely to greatly contribute to the positive courses and outcomes of illness therewith, at the very least by decreasing the worry-inducing, self-deprecation increasing, and socially nerve-wracking effects of psychological illness amplification, or looping (Kirmayer 2007:836). His proposed "program for teaching anthropology at [three] different levels and in different contexts of psychiatry" (1988:153-159, emphasis added) is a well thought-out call-to-action for professionals in these two disciplines to educate and actively work with one another in residency, in academe, and in therapeutic sessions, in order to lessen the dangerous psychological and biomedical impact of Western ethnocentricity and scientific faith on the non-Western world, and, implicitly, to boost the capabilities and social agency of the cognitive anthropology discipline. This book is easy to digest, clear and magnetic in argument, and crucial in medical relevance, and gives you an inkling of how its author came to be such a big name in transcultural psychiatry. Although redundant at times, it is one that every anthropologist and medical student should read.
Corbin, Juliet, and Anselm Strauss
2007 Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory, 3rd ed. New York: Sage Publications.
Kirmayer, Laurence J., MD, and Normal Sartorius, MD, PhD
2007 Cultural Models and Somatic Syndromes. Psychosomatic Medicine 69:832-840.
Kleinman, Arthur, M.D.
1988 Rethinking Psychiatry: From Cultural Category to Personal Experience. New York: The Free Press.