Hello Mark,

What a nice gift you sent me on a rainy Saturday-morning. This Kleinman’s Category Fallacy is of course a sweet problem in the field of ‘Kennistheorie’ (I have forgotten the English word : Epistemology?).
 
 

“Although depression is present in many different cultures, this does not mean that it may take a complete different form in different cultures.  The, for example, CIDI section of depression represents a fraction of the entire field of depressive phenomena." It is a cultural category constructed by western psychiatrists to yield a homogeneous group of patients. Per definition, it  excludes most depressive phenomena, even in the west, because they fall outside its narrow boundaries.  "Applying such categories in non-western cultures leads to a category fallacy because by definition it will find what is universal and it will systematically miss what does not fit in tight parameters.  But what is missed is more interesting when one does cross-cultural psychiatry because the missed symptoms will be the most striking examples of the influence of culture on depression.

 

We are talking, of course, in terms of Local Idioms of Distress.

In these terms, what Kleinman describes here as ‘Depressive Phenomena’ is not so a certain lady, Phenomena, that is depressed, but a collection of American Local Idioms of distress: Idioms from the life of Clients, idioms from the vocabulary of the local healers.

‘The entire Field of Depressive Phenomena’ Is not Phenomena’s Field, but a myth, created on the spot: Kleinman extrapolates from the experience that every Local Healer in America has its own Field, a Field that partially overlaps the fields of other local healers.

What Kleinman very well knows is that all these healers are very proud of exactly tose parts that do not overlap, and regularly have small wars between each other to get these little parts generally recognized - under teir name, of course.

What Kleinman does describe very accurately, is that these healers have also agreed on the extend of the field that they considder as ‘general overlap’ : “It is a cultural category constructed by western psychiatrists to yield a homogeneous group of patients.”

So, in our terms: The local healers have defined a cluster of local idioms of distress, and given it a name : Depression. Yet, every healer says: “But REAL depression is wider: it is the general cluster + my cluster” And with their own extension of the cluster they advertise to lure their clients away from the next local healer.

Local may be America or it may be Nepal, Ethiopia, the netherlands.

‘Depression’ therefore, in America signifies something else than in Europe. Especially in the field of pathology, a ‘thing’ that IS ‘Depression’ does not really exist, let alone that that ‘thing’ is ‘wider’ than its signifiers.

To me, Kleinman’s Category Fallacy, as you describe it, is a typical case of somebody falling in the trap that he is telling others not to fall in to: He is overestimating the significance of his Western Idiom of Distress by reification.

This means that we work on the base of a cluster of idioms, referring to some Phenomenon that is ‘felt to exist’ in a certain Culture.

Now, when do we have any interest in clustering the idioms, in the case of pathology?

To begin to answer this question we must recognise that ‘Pathology’ in it self is a phenomenon we can only reach through idioms of distress.

What then is the ‘meaning’ of ‘Pathology’ ?

The first meaning may be that of ‘dysfunction’ within some framework of understanding.
In general, medical doctors will tend to explain that this is their way of seeing pathology.
Yet, they overlook the fact that their patients are not mechanical devices without their own frame of understanding and idioms. (And even for a mechanical device, the term ‘dysfunctional’ is not always without ambiguity: A car may be ‘broke’ because it does not function as a means of transport, while to some street-kids it may exactly for that reason be an ideal place to catch some sleep.)

But, another set of idioms to ‘Pathology’ come from the ‘patient’. What we have come to call secondary gain, may well be essential to Pathology. In being ‘sick’ there may be a level of protection: an accepted way of breaking with daily responsibility or pressure.

Therefore we can see that ‘Pathology’ is in a way also an agreement in the daily negotiation between the individual and the society. Once we see this element of negotiation, we can also understand that there are more parties involved in this negotiation: healers have their own interests, because without  consenting patients they cannot exist. Families may well be interested in (temporarily) excluding members from a decision process by defining them as ‘ill’, etc. In this light even the category that originally seemed so ‘humanitarian’: “functionality”, becomes an expression of the interests of the social context.

‘The patient’ therefore becomes a product of re-iteration: there is a socially accepted set of idioms and related signifiers that is known to the patient and to the social context, and therefore sought or avoided, labeled or denied, in a process that we haven’t named yet, as far as I know, but that we could describe as ‘health-negotiation’.

This process in fact results in, or ‘creates’ doctors, patients, idioms of distress, and medicaments or treatments, and this is true for a seemingly objective dysfunction as a broken leg, as well as for falsified memories.

Let’s try to come back to Kleinman’s Category Fallacy.

As regards to the Cross-cultural aspect, what he probably does not see is that the CIDI, and behind it, Western Medical Science, are an expanding industry, looking for new markets. CIDI opens a process of negotiation in a new society, offering the prospective clients, as well as to the indigenous healing-industry (or even in competition with this indigenous industry) new sets of ‘idioms of distress’, in order to provoke the use of it, very similar to the introduction of powdered milk to lactating mothers.

In our case, (IPSER/TPO, as part of the international help-industry), we are offering the new clients a set of complex idioms as there are ‘trauma’ and ‘victim’.

For the last concept, for instance, we have not only the Christian set of signifiers, in which we include ‘misery’, ‘ suffering’ and ‘innocence’ in order to create a helpable subject, but there is also the development of another set of signifiers, which we call ‘Human Rights’. Quite correctly this set is undergone as a western set (pushing the individual out of its context) by societies that give a higher value to the rights of the community.

In Cambodia, or in the Buddhist culture at large, there was no such role as ‘a victim’, since there is no virtue in suffering, and the political definition of ‘just’ or ‘unjust’ is related to the ‘Majjhima Patipada’ or ‘Middle Path’, rather than to some form of idealistic concept(s), and therefore ‘innocence’ was a meaningless concept.

Here in Africa, the help-industry has not only introduced professional victimship (that is to say, a means of livelihood based on being miserable and innocent), but also ‘relief-dependency’ which is the term that the help-industry has coined for the problem they leave behind when they want to move on as soon as there is a new fashion in ‘victim-ship’ (of course, as long as the current misery is fashionable and therefore able to raise funding in the west, this dependence on relief is the very argument that the relief-industry uses for its presence).

This victimship, as we can clearly show from the narratives that we got from you, has its own particular idioms, in which the defining part always stresses ‘innocence’ (peaceful demonstrations, democratic processions, ‘just’ peace marchers’ ) unfounded charges and unjust actions of police etc. (‘suddenly arrested’, ‘not found illegal documents’), a police that is inhuman in general: (torture seventy- and eighty- year old people, raping women and children of different ages, and torturing innocent people). After that we have the tale of suffering, the actual torture, and after that the suffering in the sense of socially being outcasted as a reason for fleeing.

What you do not get, but what might be the story, had the same person been taken under the wing of a radical political group, is the story of active participation in political subversion (ref. The stories of the Dutch ‘underground’ in the 2nd world war, to which virtually every Dutch person belonged), the story of heroically surviving torture, and the story of moving across borders in order to pursue a new economic future.

In order to obtain this kind of narratives you would at least have to change the name of your organisation in “Centre for Torture Survivors” and change the (self) perception of your clients from victims to heroes. Dr. Lewis Aptekar, who works with us here in Addis, describes in a literature review how strong belief systems can be part of a positive coping system wit stress.

In this vision, the solution to Kleinman’s Category Fallacy would seem to be that any cluster of ‘idioms of distress’ having a function in the social negotiation on health creates its own Category. New partners in the negotiations may change the cluster and therefore the Category. The Category is therefore a by definition movable and ‘alive’ phenomenon.

(Within the general category of ‘Colds’, we sub-define the pneumonia as the group that we can cure with ‘this medicament’ and bronchitis as the group that is curable with ‘that medicament’, leaving a part that is not curable with any of them. Therefore the medicament -which is found sometimes quite accidentally, defines the pathology, or the phenomenon.)

There is, however, another possibility to discuss Kleinman’s Category Fallacy, and that is, to no longer recognise that we are crossing cultural borders:
In this new world of fast exchange of information, the client is more and more able to choose idioms of distress within the language-system of the global village. How, and Why, should we stop this? In this view, the client does not negotiate within a restricted cultural identity, and therefore the paternalizing care of the concerned western researcher who is trying not to be ethnocentric, is in fact hopelessly behind the facts.

In this vision the outdated western medical doctor is fighting a desperate struggle against the ‘new-age’ mixture in which within in the health-negotiation the chemical industries is more or less marginalised according to the current fashion.

Of course, this new-age mixture is the counterpart of the CIDI in the global village, representing the idioms that are originally rooted in non-western cultures. Now, why should the CIDI be concerned with the place of ‘chi’ within the body? Will DSM V-R be able to relocate it with a little help from Dupont?

Again, there is no real fallacy, because in either way of seeing the problem, ‘the category’ is an end-result of negotiation. Whether this is the result of a negative, imperialistic process, or of a natural process within a global village, makes no difference: there are no ‘real, objective ilnesses’ in the sense of “an objective reality that is only partially described by a culturally defined set of idioms” - the cluster IS the category.

What rests is our own decision, as researchers or as interventionalists, to take part in the process of health-negotiation. Do we see ourselves as belonging to an outside culture, than: what interests do we have in ‘researching the local idioms of distress’, other than to cluster them into our own ‘categories’ for the sake of our healers?

Or do we see ourselves as neighbours in the global village, introducing our own idioms of distress in the negotiations, like: “Why the fuck do you lunatics don’t stop killing and torturing each other, I can’t sleep, dammit!”, and “If you bastards don’t stop fighting right now, I’ll tear you apart!”.

Mark, this was the result of a rainy week-end in Addis, maybe it needs some clarification at some points, but I hope it will amuse you a bit…
(And maybe put The Kleinman’s Fallacy in a lower priority when evaluating your work?).

Greetings,

Marc-Jan