What's behind the symptom?

THEORY AND PRACTICE IN MEDICAL ANTHROPOLOGY AND INTERNATIONAL HEALTH A aeries edited by Susan M. DIGiacomo UnivcnityofM>S5..,hu,e<u. Amh=. Edltortal Board H. Kris Heggenho(Jgen H......... d UDIWttlil)' <Ambridge, M..S4d>u><IU DanIel E. Moerman Uni'JCI'silY of ｍｩ｣｢ｾＮ＠ What's Behind the Symptom? DC::Dlbom R. Brooke Thomas U.iv .... iry of M..SlICbn ...... Ambo.." IntematiolUll Aclvillory Board On Psychiatric Observation and Anthropological Understanding Gt!org< Annt'i4KQs. Ham Bot:r. ｲｾ＠ Brown. Xocitill (AJltPt<da. ｄｾｨＨｊｲ＠ Go"'on. ,'(o<hillllcTT<I"a. Jurillh Jr.lJlla. ｍｯｾｲｦｊＱＧＢ＠ Kamal o aria L<Jllc, ShIT/<)' U"ricn/xJum . Marg<P'<r Loclt. s<rha Lo.,. Mark Niehrer. DrmCdn Pcricrs,". n,omas Ou. Nancy S<hcpcr.Hughu, Merrill Singer Founding Editor Ubbef Crandon-Malamud' Volume 1 Hippoeratoo' Latin American logacy; Humoral Medicine in the New World George M. Foster Volume 2 Forbidden Narratives: Critical Autobiography as Sodal Science K8thryn Church Volume 3 AnQhropology and Intemational Health: AaLan Ca&e Studlcl$ Mark Nichter and Mimi Nichter Angel Martinez-Hernaez Translated by Susan M. DiGiacomo and John Bates Foreword by Arthur M. Kleinman Volume 4 The Anthropology of Infectious DiseaGo: International Hoallh PerupoctiveG Edited by Mama C. Inhom and Pater J. Brown el Scc the b:llc!< of lhi.s book roC' Qiher ｨ､ｾ＠ Ii"",,! Health. in ThC()ty IlntJ Pr;:u:lict' in Medic:.1 Anthropology .md Intern;,· Routledge ! \. Tay!o< 6. F..<IIIdI (; ro"P LONDON AND NEW YORK Copyright © 2000 OPA (Overseas Publishers Association) N.V. Published by license under the Routledge All rights reserved . No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, inc\ud i ng photocopying and recording, or by any information storage or retrieval system, without permission in writing from the publisher. 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Transferred to Digital Printing 2006 British Library Cataloguing in Publication Data Martinez-Hernaez, Angel What's behind the symptom? ; on psychiatric observation and anthropological understanding. - (Theory and practice in medica! anthropology and international health; v. 6 JSSN 1068-3291) 1.Symptomatology 2.Medical anthropology 3.Psychiatry l.Title 616' .047 ISBN 90-5702-6]2-0 To my parents in memoriam CONTENTS Introduction to the Series .............................. .. ....... ............... .. ........ ......... . ix Preface .... ... .... ..... ........ ....... .. ..... ....... ..... ...... ........ .......... ....... ....... ........ ..... .. xi Foreword ....... .... ........ ......... .. ... .......... ....... ........ .. .... .......... ....... ..... ...... .... .. xv 1 What is behind the symptom'? ....... .... ..... ........ ... ........................ ........ . 1 PART ONE: ON PSYCHIATRIC OBSERVATION ... 2 3 4 5 6 The dream of a biomedical psychiatry .. ...... ............. .... ... ....... .. ........ 21 Kraepelin versus Freud: A retrospective .. ...... ........... ....... .. .............. 39 Neo-Kraepelinism: Nosologies .. .. ...................... .. ........ .. .. ... .... ... ...... 65 Neo-Kraepelinism: Epidemiologies ....... .......................... ............ .... 89 The limits of psychiatric observation ........ ... ........ ....... ................... 113 PART TWO: . . . AND ANTHROPOLOGICAL UNDERSTANDING 7 8 9 10 11 Toward an anthropology of symptoms: Four pre-interpretive approaches ......... ................. ........ .... ............. 127 Toward an anthropology of symptoms: Henneneutics and politics .. ............... .. ....... .. ....................... ........... 147 Semiotic incursions .. ...... .. ........ ... ................... ... ............ .. ... ............ 177 Ethnographic interpretations: Symptoms, symbols and small worlds ...... ..... ........ ....... ................ .................... 203 The limits of ethnographic interpretation .. ..... ............ .. ...... ...... .. .... 233 Epi logue: Open work ... ...... ..... ... .............. ....... ........ .. .... ... ......... .. ... ......... 245 References .......... ... ........ ........................ ... .............. ..... ....... .. ... ..... .......... 251 Index ................... .. ... ....... ....... .... ... ..... ................... ... ..... ... .... ................. . 273 INTRODUCTION TO THE SERIES Theory and Practice in Medical Anthropology and Intmuztional Health seeks to promote works of direct relevance to anthropologically informed international health issues, practice, and policy. It aims to bridge medical anthropology-both biological and cultural-with international public health, social medicine, and sociomedical sciences. The series' theoretica Iscope is in ten tionally flexible, incorporating the most current advances in social science theory, while its topical breadth ranges from specific issues to contemporary debates to practical applications informed by current anthropological theory. The distinguishing characteristic of this new series is its emphasis on cultural aspects of medicine and their links to larger social contexts and concrete applicability of the anthropological endeavor. PREFACE La S3l\tt est la vic dans Ie sile:nce des olEWlcs. [Healtll is life Lived in tile silcnc:.c: of tile: organs} - R. Lcriche De III SMlt lila maladie: ｅｮ｣ｹｬｯｰｩｊｪｾ＠ fra/lfaise If health is silence, then this book is about speech, the meaning of complaint, the voice of illness. It is also about the clinical gaze, that peculiar form of scrutiny which lays down the conditions for medical and psychiatric knowledge. In the context of Western science, the symptom has been an undisputed redoubt of biomedicine. Although medical and psychiatric manuals have differentiated between signs as observed by the professional and symptoms as expressed by the sufferer, symptoms have generally been regarded as physical manifestations, natural realities that acquire meaning only through medical interpretation. The voice of the sufferer is thus silenced. Deprived of legitimacy, the sufferer's words are associated with crror and ignorance. However, in recent years, this traditional perception of symptoms has been challenged. For at least the past two decades, such specialities as medical and psychiatric anthropology have advanced into new ethnographic territories: symptoms, illnCl'S, the body and suffering. Kluckhohn's characterization of anthropology as an intellectual poaching license, taken up by Clifford Geertz in "'Blurred Genres" (1983, p.21), has become unexpectedly relevant in the terrain of illness and its forms of expression. As a result, anthropology has been able to mobilize its well-known sensitivity to lay and local discourses against the naturalism of totalizing biomedical interpretations. 'This book is another move in this game of confrontations and poaching activities. Followiogchapter 1, the book isdivided ioto two parts addressing different ways of viewing symptoms: as organic manifestations and as symbolic constructions. In the fIrSt part, I develop a critique of the perception of symptoms as simple pathophysiological phenomena, focusing in particular on the hegemonic paradigm of contemporary psychiatry: neo-Kraepelinism. The aim of this section is, then, not to review various psychiatric trends and their ways of conceptualizing symptoms, but to examine in depth onc particular .xii PTr!face trend and one particular conceptualization. This does nol prevent me. however. from malcing a brief foray into classical psychoanalysis as a counterpoint to Kraepelinism. Nor does it mean that my critique is limited to psychiatry; much or it is also applicable to biomedicine in general . fn the second pan. I approach symptoms as symbolic and cultural forms of expression. Here also my elTons are reslricted to one parlicular theoretical doma in; !hat of an interpretive or hermeneutic psychiatric anthropology. I support this approach wi!h my own ethnographic data as well as an incursion into the field of semiotics. My purpose here is to envision symptoms as an open process. a communicative act. the result of a creali ve interplay of values and discourses. everyday experience, local knowledge and forms of oppression . It is an attempt LO return to symptoms !heir meaningful dimension, to rescue their oft-denied semiotic and cultural nature. Nevertheless. alongSide this general aim there arc other, more specific ones. [ hope to show that contemporary psychiatry treats winks as twitches; that this approach places serious limitations on both clinical practice and epidemiology: that there is a less positivist and more efficient way of perceiving symptoms: that symptoms can also be ethnographic objectS: and that Bar!hes. Foucault and Peirce are mistaken in their approach to symptoms because they fail to take into account the human sender of the message. r could point out several others, but I leave this task to the readers' critical judgment. Many people have helped to bring this book to completion either directly or indire<:tly, academically and/or personally. First of all, I would like to thank the twO people who were my supervisors when. in November 1994, I publicly presented an earlier version of this book as a doctoral disscrtation in the Department of Anthropology of the University of Barcelona: namely. Professors Claudio Esleva Fabregat and Josep Maria Comelles. In many conversations both formal and inrormal, the first has shared with me the rich harvest of a professional lifetime, a wealth of insight from which I have benefited, I suspect, much more than [ am consciously aware. The second has been a demanding critic. an excellent friend and a generous teacher. I am aJso grateful for critical comments, help and inspiration from Ioan Frigole, Joan Bestard, Jose Lufs Garda, Marcial Gondar, Joan Obiols and Ignasi Terrades. The first was my tutor. while !he rest were members of the examining board of my doctoral dissertation. Other scholars-Carole Browner (UCLA), Marfa J. Bux6 (University of Barcelona), Dolors Comas (Roviri i Virgili University), Jesus Contreras (University of Barcelona), Aurora Gonulez (Universidad Aul6noma de Barcelona), Carl Kendall (Tulane University), Arthur Kleinman (Harvard University), Lluls Mallart (Uni versi ly 0 r Paris X), Eduardo Menendez (CIES AS-Mexico), Rafael Perez 1 I Preface xiii Taylor (UNAM-Mexico), Joan Prac, Juanjo Pujadasand Oriol Romanf(Rovira of Perugia)-read and i Virgili University) and Thllio Seppilli Ｈｕｮｩｶ･ｲｾｴｹ＠ commented on part or the whole of the manuscript. They too deserve my thanks. Susan DiGiacomo's invaluable help is worthy of special mention. She is not only responsible for the English translation of this book, togelher with John Bates, but is also a valiant scholar who knows how to speak the tru!h to academic power and reveal its mystifications. I would also like to thank my colleagues from the Departments of Anthropology of the University of Barcelona and of the Rovira i Virgili University for their support. I am grateful to the Departmenl of Anthropology of the University of California at Berkeley for welcoming me as a visiting scholar in 1996, when I rewrote several chapters of this book. I also acknowledge my gratitude to Nancy Scheper-Hughes for facilitating my stay in the department, and particularly to Stanley Brandes for his salloir jaire as an advisor. I should also mention the Department of Psychiatry of the University of Barcelona and the Clinical Section of Barcelona-Department of Psychoanalysis (Uni1Jersity of Paris VIII), where I learned much of what I know about psychiatry and psychoanalysis. The mental health care facilities in Barcelona where I did the ethnographic fieldwork that is the source of the case examples used in Chapters 1, 10 and 11 should nOl go unmentioned: the Hospital Clinic of Barcelona. the InstaULO Frenopatico, ARI and the Cencer for Psychosocial Rehabil itaLion for chronic psychotics of the ARAPDIS Foundation. Likewise, I am grateful to all my informantS. Although at first it was not easy for me to develop emparhic relations with them, I believe that, with time, I became a familiar character in !heir daily lives. Proof of this came one day when a new patient arrived at the center for psychosocial rehabilitation, the ARl, where I was carrying out my fieldwork . Seeing the familiarity with which the others treated me, he asked, "Have you been here long?" I replied that I was an anthropologist, and explained that I was doing research and was very interested in what they residents did and thought. To my surprise he shot back, "Is that so! And how long have you been feeling like this?" My research was possible thanks to funding provided by lhe Programa Sectorial de Formaci6n de Projesorado Universi.J.ario y Personallnvesligador (Program for the Training of University Teachers and Researchers) of the Spanish Ministry of Education and Science (reference AP92 40978896) and by the Direcci6 General de Recerca de La GeneralicaI de Catalunya (Research Office of the Autonomous Government of Catalonia; reference xiv Prefoct: 1996BEA1300384). The translation of the text into English was financed thanks to the help of two of my colleagues at the Rovira i Virgili University, Dolors Comas and Juanjo Pujadas. Many people have conuibuted 10 the making of this book in alcss academic fashion . MonlSe, my wife, has made valuable suggestions and criticisms. The comments of Pere and Charo have enriched my brief incursion into Freud's work. I am indebted to Isabel and Hugo for the pleasure of long conversations on these topics which sometimes went on for days. The wholehearted support ofMonlse. Tomas, Gabi, Isabel. Pilar, lordi, Felicitas, Carmen. Gabriel, Carmelo, lnes and Mishin as well as Irene, Enzo and Andrea has been of incalculable value. r do nOt want to end this preface without mentioning my parents, who passed away while still young. This book is dedicated to their memory. Had I nOl lost them as I did, I would have wrilten a very different book. They introduced me to suffering and los$, but also 10 the wholeness of life in the face of human limitation . FOREWORD Angel ｍ｡ｲｴｦｮ･ｺＭｈｾＧｳ＠ great contribution in !his intriguing volume is to use !he image of the "what" that stands behind the symptom as a means of canvassing much that really matters in contemporary medical anthropology and psychiatry. Symptoms, as the author invokes them, inform the reader as much about an lhropol ogy and medicine as about patients and illnesses. Whal S Behind the Symptom? is the most thorough elaboration of the semiotics of psychiatry in our era. Commencing with the seemingly secure relation of symptoms and signs and a disarming-if soon 10 be ensnaring-definition of his own making, !he author draws !he reader deeper and deeper into the many confusions, arresting distortions, and creative misunderstandings that confound !he work of meaning in medicine and anthropology. His prose is simple and direct, but his goal is anything but Rather, like a master magician, Martfnez-Hernaez conjures up the very reality he seeks 10 analyze by turning the analysis, as it were, into a simulacrum of the problem itself. This is a major achievement. So, when all is said and done, what does lie behind symptoms? What looms large in the background of words and categories? What small or vast presence lies hidden beneath the sOUllds and complaints? A tangle of symbol systems, biology, and the political and economic processes of everyday social experience form this deeper presence. This sociosomatic gangli.on ｣ｯｮｾｬｓ＠ the subjective with the collective in the context of pathology and an normahty too. Psychiatric disorder makes it unavoidable that psychological processes -memory, affect, self-aIso receive their due in this contextual world of felt signs and storied, signifying lives. A model of the text may advance the henneneulics of signs and symptoms, as the author avers, but !his comfortable (and comforting) image of the book, the page, the sentence now seems to me simply too intellectualist, too redolent oCthe security of the library to bea useful key to overheated or frigid worlds where danger is at the heart of things, uncertainty is everywhere and action, even when it so clearly falls short or worsens things, still must take place. Local worlds are places of overwhelming practicality. They are no more texts than !hey are games. So what are they? One wants to say !hey are the very stuff of lived experience, the moral entanglement of collective and individual experience. But what is e.xpericnce and how does it relate to signs and symptoms? Is experience to psychiatry as symptom is to anthropology? Or is it the other way round? xvi Foreword There are destabBizi ng thoughts galore here that ｍ｡ｲｴｦｮ｣ｺＭｈｭｾＨＧ Ｎ ｺ＠ draws into a scholarly account that unsettles conventional understandings. Medical anthropology seems more the product of !he Hedgehog than the Fox we usually take it to be. Signs and symptoms run like a golden thread as the core knowledge of a discipline that is shown to have accumulaled a trove of concepts and findi ngs that illumine this subjecl With close readings of Freud, Kraepelin, and a generation ofpsychiall'ic anthropologists, Martinez-Hemaez tells, along the way, several di fferen! stories, iDcluding those of anthropology, psychiatry, psychiatric epidemiology, and semiotics. Bu! above all this is the Story of the symptom in medical anthropology. It must be extraordinary that cries of pain and other human complaints arc formulated by psychiatry and anLhtoplogy primarily as epistemological debates over the kind of knowledge we have of them and the kind of knowledge they represent. The question of the ontology of symptoms as forms of living in the world-even with all the interest in phenomenology -is a decidedly secondary interest in psychiatric anthropology, and in psychiatry. The ethical question of what good this knowledge is ｦｯｲｾ･ｭｳ＠ equally secondary. This must be telling us something about the disciplines. Psychiatric anthropology, like psychiatry itself, begins not at all with the ethical act of afflrming the patient's experience of suffering, acknowledging the pain and tribulation . In that sense, symptoms and signs lose a crucial signi ficance. Whether deconS!ructed by clinicians or ethnographers the action seems to be a search for something else (the disease state, the political economy, the embodied symbol). Something else-usually said to be deeper, hidden, more significant-replaces the human voice and sentiment. Interpretation can annul the human project itself when it avoids the prima facie expression of suffering. Medicine misconceives what is al stake when it emphasizes "First, do no harm." Anthropology does the same when in terpretation precedes acknowledgment. Symptoms and signs. to paraphrase Emmanuel Levinas, ¥e useless in themselves. They become humanly useful when they draw attention to the injured, to the disabled, so they can be seen, heard, engaged, and helped. Where is this utterly human ethical project amidst the icons, indexes and other vehicles of meaning that preoccupy the scholars in today's psychiatric anthropology? What about the symptoms of social injustice and health inequalities as a raison d'etre for moving psychiatric anthropology toward policies and prograrns?This has become a major feature of the anthropology of infectious disease. Shouldn't il be a serious focus in psychiatric anthropology as well? -Arthur Kleinman CHAPTER 1 What Is Behind The Symptom? Car l'clUlctitude sc distingue de III verite, et III conjccture n'exclut pas In "gueur. [For is distinct froro truth, I1Ild conjecture does not exclude rigor.] CXlld= -JllCqucs UlClll1, Ecrir.s In The Vital Balance, the American psychiatrist Karl Menninger posed a question that, despite its apparent simplicity, has been of great importance in the history of psychiatry: "What is behind the symptom?" (1963, p. 325). He was seeking what was, in his opinion, the ultimate meaning of symptoms for, in his words. "no man steals a watch for the sole purpose of obtaining a timepiece. No man cuts his throat merely in order to die." "Human motivation is not that simple," but the result of a multitude of pressures and events that the therapist must discover and describe (p. 326). From the end of the 18th century, when psychiatry was taking its first steps as "special Medicine" (Castel, 1980, p. 109), to the period in which Menninger formulated his theory on the importance of environmental pressures on mental imbaJacce (1963), the problem of the nature of the symptom has been at the center of a series of psychological and psychiatric debates. Even in the biologicist period in which we are immersed at present, the question of the nature and conlent of the symptom has become common ground for psychiatric reflection (Jackson, 1992; Wilson, 1993). In fact, we are faced with one of those fundamental scientific questions that transcends fashions and trends, since it addresses the very purpose of the discipline: the study acd alleviation of mental dysfunction. 244 Whar:S Behind lhe Symplom? and tbus to include tbem in Ihe consultable record of whal mnn hali said (1973. p.39). Nevertheless. as in 1M's case, there may be circumstances in which this access 10 the answers given by others is. if not unfeasible. at least uncertain, situations in which it is difficult \0 separate the semiosic from the physical, winks from twitches, signs (natural) from symptoms (symbolic). Here a hermeneutic approach to symptoms reaches limits of a sort opposite (0 those encountered by neo-Kraepelinian attempts to reify and naturalize the sufferer's speech. symptoms and cultural categories. There is now the danger of culturalizing the nalural, of mislaking the physical for the semiosic, signs for symptoms-but there is also the possibility of pausing to linger, although not passively, on this threshold. NOTES J. The informant in question nol only denies eJl.prcssing bi.mself figuratively, but h;u; considel'1lble difficulry understanding Ihat metaphorical or metonymic dis· in everyday circumst:mcc:s. Once 1M ｡Ｎｾｫ･､＠ me about an course can be ｵｾ＠ expression which his f:llher often used and whicb he found completely incomprehensible: "Women are ｾ＠ rc31 headache." When I cXplained to him Ihal some· Ibing was missing from the expression and-quile apart from tbe falsity of the asser1ion--it should be understood 10 meM: "Women crente problell'lS and.there· fore, cause beadaches," he simply was nol able 10 understand the key 10 the hidden meaning. Here il seems tbat his Iwitch or pbysieal sign consists of tJlking Literally Ib:ll which is figuralive. 2. l.n Catalan. !he language of Catalonia (northeastern Spain). 3. Attempts bave also been made to analyze. the process of conscructtng meanings using cognitive anlhropology. See espccially Ihe work of Shore (1991), in which the author attempts to combine bermeneutics and cognltiv;sm. Epilogue: Open Work In this book I have analyzed two approaches: 1) the symptom as organiC manifestation and 2) the symptom as symbolic construction. At this point, it has been established that the nrst approach closes the symptom off from interpretation by denying the semiosic nature of its production, while the second opens it up to interpretation by restoring the existence of the human sender of the message. By way of conclUSion, I want to make these arguments explicitly. My aim in the first part of this book was to show how neo-Kraepelinism stresses the passivity of the sender of the message to such an extent that his or her creative and expository ability is annulled. It is certainly true that psychiatry distinguishes between signs and symptoms in such a way that the former are regarded as signals or observable physical indications, and the latter as statements or subjective evidence. Moreover. the diagnostic exercise remains a semiology for deciphering a code consisting of physical and nonphysical signs, However, neo-Kraepelinian approaches seem to restrict the interpretation of meaning to clinical inference. The symptom has no native meaning. but is rather evidence of pathology. In this reification we can observe the lack of interest in the symptom as a message, or in its sender; the symptom is presented as a natural fact. Central to neo·Kraepelinism is the precedence the reader's intention takes over the meaning of the work and the intention of the author. The symptom and its disease are defined in organic terms, with the aim of prescribing a \reatmenl By way of analogy. it may be said that symptoms are observed rather than interpreted in the same way that an art restorer analyzes the texture and pigmentation of Las Meninas in order to prevent it from deleriorat245 246 What s Behind the Symptom? ing. In the case of symptoms, however, the author is present, and while she speaks, complains or otherwise e:K.presses her suffering, she dynamically conSU1Jcts and reconstructs her statements with a communicative purpose. I have already pointed Out that for most mental disorders, organic etiologies remain hypothetical. Given this situation, what the palient says is of primary imporlance for defining such diagnosLic criteria as "auditory hallucinations" or "feelings of hopelessness"-a whole range of phenomena accessible only through the patient's speech. In contrast to the observational capacity of biomedicine, with its technological ability to penetrate the universe of [he organs, contemporary psychiatry is limited to dealing more with symptoms than with physical signs. On many occasions, for instance in 1M's hermetic narrative, signs become indistinguishable from speech itself, because manifestations of psychosis such as "delusions" or "disorganized speech" present not as biological evidence, but emerge from the speaker's vcry words . But the maller does not end here . If we add to these limitations Canguilhem's observation that symptoms and signs are rarely superimposed (1966, p. 61), the problem gets worse. For example, as Canguilhem himself points oul any good urologist knows that a patient who complains of "my kidneys'" is someone who has nothing in his kidneys, because for the patient kidneys are "a muscular and cutaneous territory." not organs (1966. p. 61) . Of course, if the tcchnological means exist to produce physical signs. whatever patients say about their kidneys will become less important, because the clinician will have something observable and measurable to rely on. Psychiatry, by contrast. is almost completely limited to the domain of the patien/ 's utterances. to "my kidneys hurt" or "1 hear voices" constructed in a narrative of afiliction. At this point the paths diverge: psychiatry can either treat symptoms as physical signs reified to make them manageable within a universalist paradigm; or it can recognize that symptoms are not signs and therefore require interpretation. Neo-Kraepelinism opted for the first of these two possibilities. This involves a political commitment having to do with the corporate and socioeconomic interests of the profession, at the cost of treating winks as twilChes. The clinical relation required by neo-Kraepelinism (and also by biomedicine in general) bctween professional and patient is rather odd from an ethnographic point of view. The clinician takes the position that Lacan neatly captured as the "subject who supposedly knows" (1973, p. 240). In perfect oppOSition to this, patients "do not know," and when they feel unwell, they tUfn to the profeSSional in search of relief, both for their malaise and for the ｅｰｩｬｯｧｾＺ＠ Open Worlc 247 anguish that it causcs. Patients describe what they feel, relate their symptoms and tell the story of their affliction. From all this information the professional salvages only a few facts on which to base a diagnosis. This salvage operation involves convening "Oh. my God! Life has no meaning since my husband died" into "feelings of despair." If in the telling the patient's story seems to wander from the subject-UOf course my daughter's grown up now and wants to live by herself'-tbe professional may listen patiently for a bit. but finally asks, "Do you feel tired in the mornings? Have you lost weight receDtlyT The patient gets the point. and tries to be more focused . Once again the psychiatrist may interrupt with more questions: "Have you ever thought about suicide?" "Have you ever thought that life just wasn't worth living?" "Do you sleep well at night?" The patient responds to these questions. but generally in biographical and moral terms. Again the clinician tries to narrow it down to "How long have you been feeling like this?" or "Are you taking any medication?"-thus converting the story into an inventory of facts reshaped in terms of diagnostic criteria. Situations similar to the ODe outlined above have been defined by Brown (1993) as the opposition between the patient who tells a story (his or her own). and the psychiatrist who follows the story as he would a mystery, in search of clues and evidence (p. 25.5). At frrst this idea seems suggestive. Think of the traces of pipe tobacco smoke still floating in the air, the mud on the shoes of Mr. X, the microscopic piece of Persian carpet which gives Sherlock Holmes a vital piece of infonnation for solving the case. In an apparently similar fashion, the clinician untangles the patient's tale, not to talee pleasure in it but to convert it into a language of facts: "low energy," "insomnia." and "poor appetite," but also "feelings of hopelessness," "low self-esteem," etc. Symptoms are raised to the same level ofreification as the mudstained shoes or the pipe smoke in a process of inference through which what the patient says is transformed into the logic ofreal facts--traces. clues. natural signS-Whose meaning depends on the logical and conceptual processes of the receiver of the message. In this way the autochthonous meaning vanishes because it is inexpert. ignorant of the true code by which facts acquire meaning: loss of weight, feelings of hopelessness, poor appetite, thoughts of suicide and insomnia as manifestations of' depression. However. clinical procedure and criminal investigation are net entirely similar. Like Holmes, the psychiatrist also wants to find out "whodunit," but has the advantage of a ready-made classification. In addition, the signs of interest to a psychiatrist are natural and universaJizable, while the detective has to confront a potentially infinite variety of individual situations because 248 ｅｰｩＱｯｧｵｾＺ＠ Whal:S Behind lhe Symptom? human will has intervened. a "motive" which is clearly the intention of an author. This is why. despite Brown's suggestive "Psychiatric Intake as a Mystery Story", the analogy of the clinician and the detective is only apparenl, and in fact inverse: the clinician naturalizes the semiosic. while the detective reads hwnan will into footprints and physical evidence. The problem of disguising symptoms as physical signs is no trivial matter, but one of fundamental practical importance. If an Iranian woman's complaint of heart distress is understood by the clinician to mean only physical sensations, it is a clear misreading. If this same hypothetical clinician continually modifies the treatment because his schizophrenic patients complain unceasingl y about their nerves, there is a fai lure of interpretati on and a communication problem. The list of examples is as long as that of possible worlds of affliction, and we do not have to deny the existence of literal meanings that allow a degree of understanding in order to see that widely divergent meanings can make the situation untenable. Although in different cases the nuances vary, the processes are always the same: the conversion of symptoms into physical signs; the suppression of authorship; avoidance of the message; and the meaningful incenlion of the complaint. In short, the intention of the reader comes to dominate. limiting the symptom to his own interpretation. The semiosic has become physical, a natural phenomenon thaI acquires meaning only insofar as the receiver of the message constructs it. The resulting model is unidirectional, with interpretation moving from the clinician to the patient or, more accurately, from the professional to the disease itself. The only variability of any significance here is produced by clinical inference: will the diagnosis be anxiety or depression? Nonetheless, symptoms can be understood in another way, as they were in psychoanalysis and in the phenomenological-existential school 0[ psychiatry. An interpretive ethnography of symptoms and affiiction also plays an important and distinctive role here. Because it has no interest in establishing pathological meanings, it bypasses the debate about whether the causes of mental illness are moral, social, psychological or biological. This is simply not its problem, or at least. not its main preoccupation. Its aim is to understand affliction or, in Geertz'S terms, (0 gain access to (and record) the responses given by others. Interpretive ethnography, in contrast to neo-Kraepelinism, focuses its attention on recovering the autochthonous meaning of symptoms, both literal and symbolic. The aim here is not therapy but understanding symptoms through their context. In this there is a certain similarity to the approach of Open Won: 249 the art critic or literary critic, although a symptom is not Las MenifUls, nor a complaint Finnegan Wake. There is no need to seek aesthetic meaning in symptoms, although some anthropologists have tried this approach (Good, 1994; Devisch, 1991). In any case. aesthetics-a dogmatic science, as Weber characterized it-goes in search of meanings that have little to do with our purposes. These digressions aside, however. the response to a work of art is not so very different from the response to a symptom. Interpretive antltropology seeks in the symptom an intention other than its own, developing conjectures that must be validate<! by the message of the work. TIle work and its author therefore take center stage rei alive to a priori elic categories modifiable, as Pike cautions us, by fieldwork. The pigmentation, texture, or other physical aspects of the symptom-as-paintiDg are simply not of interest., and the elhDographer goes straight to the interpret3.1iOD of "the said." Therapy is not a possibility; yet., curiously, this contemplative stance yields a kind of application. not an uncritically pragmatic one. but a resource which emerges from the emnographic process itself: it reveals the native meaning of symptoms. In the clinical interview above, in which the patient spoke of the burden of grief she has carried since the death oCher husband, theciinician read into her story a palhological meaning largely alien to the ethnographer's task. Only some of the messages contained in her words caught his interest, particularly those which furnished the basis for a diagnosis. What is important for the ethnographer is precisely wh3.1 the cliniCian discards as irrelevant.: the meaning of death and loss iD a specific cultural cODtext, the structures of kinship that give rise to certain tensions between mother and daughter, the spiritual entre3.1y implicit in her "'Oh my God!" What interests the ethnographer are the cultural meanings evoked by the narrative, shared meanings of the sort transmitted by a wink, the hierarchies of meaning expressed in a cultural code; the individual psychology oflbe winker (or the sufferer) is not the issue here. At this point, the ethnographer goes beyond the infonnant, as the cJ inician does with the patient, i Dsearch of knowledge thal is Dot limited only to the individual's experience, but with the important difference that in ethnography this does not produce a conflict between naturalist approaches and semiosic realities. It is difficult to imagine an ethnographer trying to discern meaningful intention in red spots on the skin, because physical signs, in and of themselves, do Dot communicate anything. This is not to say, however, that patients, observing their spOts, may not subsequently use them to construct symptoms that are fully semiosic. Here it is possible to carry out the ethnographic task of investigating the meaning of the spots for the sur- s 250 What s Behind the Symptom.' Cerer as a representative of a cultural tradition or social group that shares certain ideas aboUI such occurrences. The aim then becomes an understanding of the terms in which the natural can become the object of a particular cultural construction, without losing sight of the fact that "the said" is said by someone. To the extent that the symptom refers to a physical or psychological condition thaI produces distress. the approach of the clinician who reities symptoms is not the same as that of the hypothetical ethnographer who sernioticizes physical signs. It is the difference between locating the referent of a word. and searching for an intentionally constructed message where there are only natural signs. In both cases. although in opposite ways, what is ultimately neglected is the existence of language: the clinician converts symptoms into a language of facts and natural Signifiers, while our hypothetical ethnographer robs language of meaning by reducing everything to a linguistic phenomenon . The image of the ethnographer seeking SOme hypothetical original meaning for physical signs is. of course, absurd. In our conceptual world there is no confusion between the universe of facts and the symbolic order which would permit unlimited derivations of meaning. However, it is also a mistake 10 see symptoms as a mere natural facts, not because clinical psychiatry Should abandon its therapeutic intent. but because, in the absence of wellfounded etiological knowledge, we run a greater risk of confusing the culturally specific with the universally pathological . The headache and brainache ofa Puerto Rican; the heart di stress of an [rani an woman; the auditory hallucinations of a NaLlve American in mourning; the nervios of chronic psychiatric patients in Barcelona; the nervoso of the Brazilian favelas; the diffuse quality of depression in South Asia; and the culture-bound syndromes which expose the limitations of universal psychiatric criteria and the pathogenicity/pathoplasticity model-all these arc facts thaI speak for themselves. The dual taSk of anthropology here is 10 provide a critical perspective on contemporary psychiatry, and to open up symptoms to the work of understanding. 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I 14. 117. \18. 119,192 o Depression 32. 38 (n.14). 57. 66.75. 76-77, 89.90.93,103.133 . 159. 193,210,219-220. 225.247. 248.250 and cullure 105-109.161. 162-163 versus db at I 13- I 24 Dcvcreux.Goorge 122. 131. 134-138. 139, 144. 146, (n .S and 6). 192, 214.243 Dbat 14. 113-124 DiagDostic Interview Schedule (DIS) 109. 110. III Diasnoslical and Statistical Manual. DSM-I 34, 35. 37·38 (D . 13 and 14). 68 Diagnostical and Statistical Manual, DSM-n 34. 35. 37-38 (n. 14), 68. 70 Diagnostical and Statistical Manual, DSM-m and DSM·nI-R 32. 35-36. 67-87. 90. 110. \I 8. 129. 208 Diagnostical and Statistical Manual. DSM-IV 32.35-36.67-87.90, 110. 114.124. 129. 145 Disea.se versus illness 15.18 (n.19). 159- 160 B Bartbes. Roland xii. 17 (11-10).178185,188.190.191.194.197 Bilis 14 Biomedical psycruatry 11.24-25. 66. 119 Biomedicine and psycbiatry xii . 3. 5.22-36. 2 I O. 246 as acullurai system 29.159.197197 c Camberwell Family Interview (CFT) 101 Canguilbem. George 23. 24-25. 66. 132. 133. 154.246 Cathcsis 41 . 44. 6 I (n.4) Celos 14 Cbinese medicine 27. 158. 192 273 274 Dreams 40. 41. 44-47. 49-50, 51. 59. 86, 138, 151. 234. 243 E Eco, Umberto 17 (n . 5). 177. 179. 185. 188-190.191. 194. 197.205.206. 208. 225. 238 Elecl1oconvulsive therapy (ECTj 21- 22.30,33.209 Embodiment paradigm 3. 132. 157. 163, 164.176 (no Ie 5) Etlmobotany 146 (n.7) Elbnosciencc 134. 142-145 Exogamy 48 Explanatory Models (EMs) 157-158. 162-163.165-166.196.231 (n. I) Experience ncar/experience distant 14- I 5. 18 (n. 18) Exprcssod Emotion (EE) 101 F Fabrega. Horacio 14- 75. 81 . 82. 86 (n .5). 102. 143-145 Fox possesion 18 (n.18), 147- 149 Foucault. Micbcl xii. 22-23. 30.36 (n.2). 59-60.167.178, ISO-182. 185,194 Fralc:e. Charles 142-144 Freud. Sigmund xiv. xvi,S. 34, 40-51 . 54. 59 . 60. 61-63 (notes). 86. 134.135.131.138.151.157. 206.224 . 243 and Kraepelin 39-64 G Gadamcr. Hans-Georg 3. 164 Galician culture 12- I 4 a sombra 14 millora 12. 14 o enganido 14 275 /ntkx lntkx Geerl2.. Clifford lIi. 3. 5-7.9-11.14-15 . 29.159.196.204,229,243.248 Goffman. Ervin 30. 134. 138-141. 158. 211.236 Golden era of social epidemiology 90 Good. B}'I"On 2.3. 5. 17 (n. I). 28.29. 31 (n.8), 67. SO. 89.144,150-157. 159.160. 161,162.163.165.166. 170.174, 199.203.204.207.210. 249 H Heallh-<:are syslem 157. 158. 165 Henle-K1>cb paradigm 23. 25 [dioms of distress 132. 163. 149 Olness Semantic Network 132, 152153.154.155-156.163.174.199 Intcrn.ttionaJ Classificalion of Disc3Scs OCD) 32. 37 (n . J 4). 68. 90.94.109.121.123 . 124 K Kleinman. Arlhur xii. ltV-lIvi, 2. 3 • 6. 11 (n.3) . 18 (n. 19). 27, 29. 35. 37 (n.5). 38 (n.16). 85. 86 (n .5). 89. 95. 97. 101. 110. 112 (n .2). 120. ISQ. 157- 163. 165. 166. 168. 170. 194. 196. 197.203.204.205.206. 210 KOTO 14.57.64 (n. 23). liS, 120,121. 123.159 Kraepclin. Em il II vi. 39-40, 51-61, 6364 (noles) 65-67,69.71-72, 74. 77. 78. 87 (0.6). 89. 91 . lOS. 106, 109.112(n.3). 123. 136.215. 236. 242 and Freud 39-64 L Latah 14.57.64 (0. 23).116.121.123. 134. 159 l.bi-Strauss. Claude J 55-156. 175176 (n. 2. 3 and 4). 206 New Haven Study 89-90 New mcdieo! semiotics 178.187.191199.203 o M Oedipus complex 3-4.4.7.48,91.224. 225 Mal d'oUo 12-15.231 p Mal de pelea 14 Meaning-centered approach 3,132. 159, 161, 163, 166. 167 Medical anthropology and clinically applied anthropology 2-3.17 (n.I). 166 and aitical interpretive perspective 2-3. 174 and aitico! medieai anthropology 3, 166-167. 168-175. lU1d critically applied medical lIDthropology 3 and clinical/critical debate 2-3. 170-171 and Gramsci 29. 167, 171.172.175 (n.1) and bermeDeutics xv. 2-3. 132. 147149,150-164,203.204.207,209, 243. 244 (n. 3) and man;ism 3, 156-157.166-175. and pbenomenology lIvi, 17 (0.3). 149. 157. 163-164 Midtown Manhattan Study 89-90 Modelo M&lico Hegcm6nico (Hegemonic Medical Model) 29 Monomania 31 N Neo-Kraepelinism :0.65-87,89-112. 116,130.136,150.163,204,209, 210,215.237,244.245,246,248 Nervios 14. 171-173, 208-232. 242. 250 Neuroleptics 21. 209 Paresis 23 Patbogenicity/patboplasticity 58·59, 84.106-108,119,120,121,250 Peitce. Cbarles Sanders ltii. 17 (n.5). 125,177.178, ISO. 184, 185-188. 190.191. 193.194.196. 197. 198. 200 (0. 3-1). 203. 205. 206 Placebo effc<:t 37 (n.5) Positivist medicine 23, 30,31. 181 Positron Emission Tomogtllpby (PET) 21 Psychoanalysis xii, xiii. 5, 17 (n.7), 33-34,35,36.37 (n.13). 39-51. 6163 (DOtes), 67. 68, 69. 74, 86 (n.3). 91.131.151-152,184. 189, 190. 200 (n.2). 223. 224. 225. 243. 248 Psychoanalytic anthropology 40, 91. 131. 134-138.145-146 (n_4-6).243 Psychosurgery 33. 31 (n.ll) R Ricoeur, Paul 3. 7-8. 17 (n.II). 40.61 (n.5), 62 (n.9. 10. 14), 125. 164. 195,201 (n.IO). 206-207. 229. 238 s SIlUSsurC, Ferdinand de 177. 178-180. 184, 185.186.188. 203,205. 206 Scheper-Hughes, Nancy mi. 2.3,37 (n.8),164, 167,168.171-174.203, 211 Ii il I: :1 276 lmio: /mkz Schi7..ophrenia 14. 17 (n.3). 28. 32.36 (n. I). 50, 52·54. 55 . 56, 57 , 59. 63 (n, 17), 74,75.76.82, 108. 114, 149. 154, 208·232, 235 and epidemiology 89. 90,92·)05. 108·109 and narralives 215·226 and prognosis 52, 53. 93·95. 95· 103 and symptomatology Il. 52·54, 55, 56. 66, 82. 103·105 Social suppor·slress·discase ｰ｡ｲｾ､ｩｧｭ＠ 26.37 (n.6) Somalaalio('l 105·107 Structuralism 8. 17 (n. 9), 156. 175· 176 (note 3).177.185.188 Suslo 14. 115, 116. 159 Symptom and aesthetics 156, 203.240.241. 249 and biograpby 7, 39-40. 42. 43, 44. 47. 54·56,183,203,215·226. 247 and economic·politics xv. 2.3. 168· 175.203 and c;.;perience xii. xv, xvi . 42. 43. 94.107.108.115. 121. 122. 123. 132. 148, 152, 154. 155, 156. 157.160·164.174·175.190, 194. 198.204.215.223,224,227. 235.240,242. 249 and illness nlllTlllives 109. 132. 149. 150.156.160. 161·162,163. 166. 167. 175. 182, 198, 243 and ifldcx xvi. 4·5, (86. 187, (88. 196,197,198. 204, 235 and mctapbor 2. 149. 156. 173, 203.204,205.206,229.238· 239. 240. 241 . 242. 244 (n. I) and symbol xi, xv. xvi, 2, 7. 43 . 44, 47, 59,103.119.133,149.150. 159.168. 169,173.174 . 187. 189.190.197.198, 199. 200 (n.2). 203·232, 238, 239, 240, 243.244.245 . 24&, 250 and sign xi. ｾｶＮ＠ 4·5,23, 32.35 , 36 (n.2). 61. 65. 84, 108·1<19. 112 (n.3). 114-115, 118. 121. 125. 130,137.139· 141,142·145.152. 154·156.160·161. 168·170, 170. 173.181. 182·185.186·187.188, 189.190, 191. 193, 194. 197. 198·199.200 (n .2), 204. 205. 209,210,235·236, 237. 244, 245.246. 247.248. 250 and text xv, 7. 44-47. 132. 150. 155, 189,193, 194,195.197. 203.204.205.207,208.210. 213.215.217.229·230. 235, 238 . 240,241 . 242, 243 T and Int.:rno.tional Study of Scbizopbrenia (lSOS) 109 and Present Stale Examination (PSE) 92. 93, 103·104, 109. 110 iI 277 II ! :1 y Young, Allan 18 (n.15). 60. 66. 67, 69. 141,165·166,169 I I' iI II !I Taussig, Miehacl2. 157. 168·171 , 172, 1·74.204 Topopbobia 43 Trait.:mcnt moral 30, 37 (n.9) Thrner. Victor 3. 150·152. 153. 159 and dominant ritual ｳｹｭ｢ｯｌｾ＠ 150. 152. 153.208.230 and psycboanalysis 151·152 :i v .i Versteben 7,40. 56. 85. 65. 155 Voodoo dcatb 25 ·26. 37 (n.5), 97 w Wild man behavior 127.131. 134, 147. 213 World HeaJtb OrganiZlltion 32. 86 (n.I).121 · 122 and Decenninant of OuCcome of Severe Menlal Disorders (DOSMD) study 94·96, 98, 101, 103·104. 109 and International Pilot Study of Schizophrenia (lPSS) 92·96. 97. 98, 103·4. 109 :! :I I II I! 1 I \