EDITORIAL

"Sociosomatics": The Contributions of Anthropology to Psychosomatic Medicine

The relationship between anthropology and medicine, particularly psychiatry, started off as close and mutually engendering. Nowhere is this better visualized than in the research and clinical work of W. H. R. Rivers (1-3). Rivers, along with several other physicians, took part in the justly famous Torres Straits expedition, an ethnological excursion to the South Pacific at the close of the 19th centurv that kicked off British social anthropology. He went on to conduct path-breaking ethnographies in that region and in South Asia. Ideas that he worked out in this setting, and in experiments with Henry Head on the regeneration of nerves, informed his practice as a psychiatrist during World War I. Rivers' medical training brought both greater rigor and inventiveness to his ethnographic research on kinship (he originated the "genealogical method") and religious healing. Conversely, the interviewing skills and alertness to the consequential force of cultural categories that he developed as an ethnographer prepared him for the contradictions-pathetic and tragic-that he would later experience as a clinician when he treated the anti-Great War poets Siegfried Sassoon and Wilfred Owen for neurasthenia-a piece of medicalization that protected these protesting British officers from being court-martialed and shot for treason (4). This clinical orientation fed back to inform Rivers' cross-cultural accounts of religious healing. Rivers' ideas about protopathic (ie, mediating cutaneous pain and extreme temperature) and epicritic (ie, comprising fine sensory discrimination) sensation were based on his work not only in experimental neuropathology but also in anthropology. Young (5) suggests that these were integrated into a conceptual framework that spanned what then seemed his distinctive fields of inquiry. So, three quarters of a century ago, there was a perfect example of what the future of the relationship between anthropology and psychiatry might have been. The "Culture and Personality" school in American anthropology, with Margaret Mead and Ruth Benedict among others, brought anthropology and psychiatry into an especially close encounter based upon the psychoanalytic framework. From this transdisciplinary engagement, there developed the crosscutting fields of cultural psychology and transcultural psychiatry, as well as an empirical tradition of ethnographic studies of mental hospitals, therapeutic rituals, child rearing, and the emotions in comparative perspective. Eventually, the fields drifted apart. Psychiatry moved in the direction of increased biological interest that, at times, seemed to trivialize the social context; anthropology moved in the direction of cultural, political, and social institutional analyses that, at times, denied the importance of psychological processes and biological contributions to human experience. In recent decades, there has been a revival of the field of medical anthropology as an intermediary between anthropology and medicine. Although medical anthropologists have been active in studying several substantive areas-eg, infectious diseases, disability, substance abuse, health care systems, bioethics, ethnic aspects of epidemiology, the doctor-patient relationship-the interest in psychiatry and psychosomatics has been notable for a relatively large number of studies and the salience of the contributions. Medical anthropologists have demonstrated the powerful effects of cultural categories, collective experiences, and social institutions on the onset and consequences of disease pathology and on the experience of suffering. In particular, anthropological studies have documented the social construction of disease categories, the social course of illness experiences, the social organization of health services and practices, and, to a lesser but growing extent, they have helped identify the sociosomatic processes that connect the physical body and the social body. Of course the interests of anthropologists are not the same as physicians. Anthropologists may seek to improve health and health care, may struggle to better understand biographies and cognitivelaffective aspects of consciousness, but their primary concern is to improve understanding of the social world: politics, economics, organizational structures, the large-scale symbolic systems (linguistic, aesthetic, ethical) of culture. And yet, the abiding concern of ethnographers with everyday life experiences of people living in families and communities assures that there will be overlap with the problem framework of clinicians and clinical researchers. Conversely, the inescapable engagement of clinicians with the patient's family, work, and broader social context (including the now tumultuous changes in the context of the clinician's own practice) draws clinical readers to ethnographies. In this issue of Psychosomatic Medicine, it has been our charge from Joel Dimsdale, the Editor, to show some of the ideas, methods, and findings from anthropology that may hold relevance for psychosomatic research. Selecting contributors was not an easy task. We decided not to include the work of those few anthropologists who have regularly published in the psychosomatic literature, because we thought this work would already be better known, if not entirely familiar, to readers of this Journal. Moreover, that work usually involves quantitative methods that overlap so much with clinical epidemiology and health services methodologies that we thought it may not be challenging or disruptive enough of established psychosomatic approaches to enable readers to see what anthropologists do that is different, although potentially useful. However, we also decided not to include anthropological contributions that are so remote from the objects of clinical inquiry that readers might find them interesting but irrelevant to psychosomatic questions. several of the contributors, including Sing Lee and Laurence Kirrnayer, are psychiatrists. But they are cultural psychiatrists who work with anthropological concepts and methods. Two contributors are members of a new cohort of MDPhDs: Elizabeth Miller and Anne Becker combine anthropology and medicine in their training and research careers. Another, Janis Jenkins, is a member of both Departments of Anthropology and Psychiatry, and another, Margaret Lock, is a member of the Departments of Humanities and Social Studies in Medicine and Anthropology; Allan Young works in the same two departments with Dr. Lock, and also contributes

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EDITORIAL
to a Division of Social and Transcultural Psychiatry; whereas Norma Ware, Elizabeth Miller, and Anne Becker have their professional home in the Department of Social Medicine at Harvard Medical School, an interdisciplinary department that includes both anthropologists and physicians. We selected for health research among ethnically and geographically diverse populations, including East Asians, Melanesians, and Latinos, with a range of different research foci: normative psychobiological conditions in the life cycle (menopause); orphan conditions (chronic fatigue syndrome); culture-specific syndromes (AIDS neurosis in Japan and na tadoka ni vasucu in Fiji); and core psychiatric disease (depression, posttraumatic stress disorder, and neurasthenia). Our guide was representativeness not comprehensivenessrepresentativeness that illustrates different problem areas and approaches that we expect might matter to readers. All of the contributions share certain anthropological orientations that define medical anthropology today. They take a broad view of social health in which political, economic, moral, and medical issues are seen to meld. In this view, health problems have social consequences and often social roots; social problems have health consequences and sometimes health origins. In this perspective it is unavailing to debate whether a given problem, ie, substance abuse or the trauma of atrocity, is either a medical or a social condition. The issue is, rather, when is it more availing for the health of populations to apply one framework or the other, or both, for comparative advantage. The contributions also distinguish disease as a pathological process from the experience of illness; but both sides of sickness are understood to be organized by cultural categories, of which both common sense metaphors and professional models are examples. Culturally shaped perceptions, communications, and coping actions are examined in the experience of illness of the patient and family, but are understood to affect the experience of practice of the clinician and the work of the researcher as well. One of the studies emphasizes the social course of sickness (6). This is in explicit counterpoint to the biomedical idea that diseases are preprogrammed diatheses that develop into a course with a "natural history" that can be prognosticated independently of the biography of the sick person and his or her social context. The social course of sickness involves distinctive conditions such as: gender; finances; the morally salient issues at stake for sufferers in a particular historical epoch; the cultural shaping of diet, exercise, habitus, and available and authorized types of coping; construction of particular social roles; and institutional and relational aspects of local environments. The premise that living with a disorder grows out of both individual and collective experiences is a challenge to the American commonsense understanding of experience. In the former, experience is interpersonal (public as well as private); by the revelations of the latter, it is purely subjective. Several of the studies demonstrate that illness experiences and disease diagnoses are socially constructed (7, 8). The authors treat medical practice and research as social occupations that are facilitated and constrained by social institutions. Those bureaucratic structures do not so much "carve nature at its joints" as much as they organize health problems and practices with respect to technical rationalities with a history, an aesthetic style, and utilitarian uses that are not unrelated to the dynamics of power in social life. That is to say, in these studies, medical knowledge has politics, economics, and is as "cultural" as commonsense knowledge, whether in faraway societies or in everyday life in our own society. In the same way that biology is uncommonsense about the life world, so too does anthropology offer uncommonsense about social life. Doubtless, the most provocative ideas contained in this issue are notions of "local biologies" and "sociosomatics" that destabilize taken-for-granted psychosomatic verities. In departments of psychiatry, biological processes are usually seen as the source of universals; yet in departments of biology, such processes are documented as the great source of differences. The idea of local biologies is rooted in organismic biology and ecology as much as it is in biological and social anthropology. As biological anthropologist Peter Ellison expresses it: "What we have in common as members of a single species is not so much a set of specific, fixed biological characteristics as much as a set of flexible biological responses. Culture and society play a formative role in shaping the context in which these responses occur, as they also do in shaping the meanings we apply to our experiences of these responses" (9). We could add that cultural and social pressures also shape those responses themselves. The studies in this collection, then, locate illness at the interface of the social and the physiological and illustrate the multifaceted nature of the dialectic between somatic and social processes. In the first study of this collection, Ware (6) explores the social forces shaping the course and chronicity of chronic fatigue syndrome. Through a detailed analysis of the process of "role constriction" among individuals with symptoms of chronic fatigue, she demonstrates how sufferers resist their social marginalization through a variety of strategies. Both the marginalization and resistance against it create the context for illness experience. Moreover, both develop and constrain a particular social course by shaping psychophysiological processes contrapuntally and by being shaped by them. The subsequent two studies in this issue offer perspective on the social construction of illness categories and the social constitution of illness experience. In the first of these, Miller (7) details the identification and formulation of a Japanese phenomenon known locally as AIDS Neurosis, a syndrome characterized by nonspecific somatic symptoms coupled with the anxiety that one has contracted the human immunodeficiency virus. AIDS Neurosis has been understood by many in Japan as distinctively Japanese, a concern with HIV infection that many believe draws its unique intensity from core cultural concerns around pollution or contagion with foreign elements. Miller demonstrates that the attribution of cultural meanings and putative cultural uniqueness to this syndrome reflects the various agendas of health bureaucrats, AIDS activists, cultural critics, and mental health professionals that contest the significance of the disorder. It also reflects a Japanese national agenda in international relations of presenting themselves as a special case compared with the West that requires special treatment. Illness meanings for AIDS Neurosis in Miller's examples are socially organized in myriad local contexts and are far removed from any fixed grounding in physiological or affective symptoms. In the next study, Lock (8) marshals convincing historical and cross-cultural evidence that menopause is a social construct, not an invariant physiological event. Her data, for example, reveal striking variations in symptoms associated with the cessation of menses across three cultural groups,

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EDITORIAL particularly with respect to the relative infrequency of reported vasomotor and affective symptoms among her Japanese respondents. Although the symptoms associated with menopause among North American women are framed locally as a physiological transition that is largely the sequelae of declining estrogen levels, Lock shows that the interplay of both local biological and social contexts patterns this experience quite differently among the Japanese. Menopause, she argues, is a biocultural phenomenon. The remaining studies in this collection illustrate the means by which somatic symptoms often reflect social disharmony and are readily identified as particular expressions of transpersonal distress or metaphors for collective experience. Thereby do bodily complaints allow articulation of moral wrongs and negotiation of care and restitution. Kirmayer and Young (10) critique a narrow, strictly psychodynamic view of somatization in their review of culture and somatization. Although traditional psychiatric formulations of somatization hold that somatic symptoms substitute for underlying affects, the authors point out that many patients who present with somatic symptoms are indeed quite capable of acknowledging a psychosocial etiology. Somatization in these cases, therefore, does not so much reflect an inaccessibility of emotional states, as a resonance with culturally appropriate modes of articulation of distress. They review evidence that beyond the possibilities of indexing psychopathology or conveying intrapsychic conflict, somatization spans a broader range of socially patterned expression, resistance, or positioning. Finally, they conclude by cautioning that a purely psychologized approach to somatization reflects only a particular cultural, yet hardly universal, orientation toward the benefits of addressing interpersonal conflicts through explicit discourse on emotion. As an illustration of the embodiment of social deprivation and conflict through somatic complaint, Becker (11) describes the phenomenology and social context of na tadoka ni vasucu, a postpartum somatic illness among ethnic Fijian women. Ethnographic and survey data demonstrate a strong association between inadequacy of social supports and an episode of this illness, indicating its predominantly social etiology. The culturally elaborated vigilance and rhetoric around this syndrome, despite its relative clinical insignificance, not only provide a template for channeling somatic and affective experience, but also moral prescriptions for appropriate care of postpartum women in traditional Fiji. Social and somatic processes are dialectically bound in this disorder, inasmuch as social disharmony is both constitutive of and embodied in na tadoka ni vasucu. In their cultural analysis of a Puerto Rican woman with a history of sexual trauma and depression, Jenkins and Cofresi (12) illustrate the means by which bodily experience and suffering are linked to the social context through a personal illness narrative. They suggest that this illness experience can be understood as configured by a set of "narrative themes." These strategically shape bodily experience in local contexts and organize the experience of distress in a culturally salient form. Insofar as trauma is metaphorically embodied, the symptoms are "somatic indictments" against social wrongs and vividly illustrate suffering as emanating from social conflict, rather than exclusively intrapsychic conflict. Finally, Lee's (13) historical account of neurasthenia, or shenjing shuairuo (SJSR), in China examines the dynamic interplay between illness experience and the social causation and social patterning of distress in China. He examines the ready incorporation and popularization of SJSR among lay Chinese as contingent on history and culture. SJSR, for example, resonates with traditional Chinese medical notions of weakness and depletion, while it also allows a nonstigmatizing means of expression of distress. The ready acceptance of SJSR also reflects the somatosocial orientation of the Chinese and certain socioeconomic and political constraints that shape clinical encounters. In contradistinction to a single and overly simple understanding of SJSR as somatization of inaccessible affective states, Lee proposes that the illness more generally reflects diverse levels and kinds of symptom formation: "... a cognitive style, a negotiative tactic, a sociosomatic language, and a basic way of being-in-theworld." Indeed, a sociosomatic as opposed to a psychosomatic approach to the illness, Lee claims, affords aricherunderstanding of SJSR, demonstrating how social processes pattern bodily experience just as embodied experience evokes its social and political context. In demonstrating that health and illness experiences are both collective and cultural, the studies in this issue begin to identify and explicate the sociosomatic processes connecting the social world with the body-self (Table 1). Moreover, these studies offer a challenge to clinical scientists to reframe the strictly individual and intrapsychic mediation between psychosocial and physiological processes by suggesting that mind-body interactions can more fruitfully be reformulated as "mind-body-in-context." They

TABLE 1. The Scope of Sociosomatics0 Use of "Sociosomatics" I. Social context integrated into mind/body understandings II. The direct impact of social context upon bodily or illness experience A. Social course of illness B. Social construction of illness experience C. Social causality of physiologic response HI. Somatic metaphor of social disharmony Clarification Mind/body interactions are refrained as mind/body in social context Psychophysiologic processes are shaped by social forces Patterns of symptoms are identified as local idioms of distress and cultural syndromes Certain social stressors precipitate or enhance risk for some illnesses Persons are socialized to experience physiologic or psychologic events in particular ways Symptomatic expression of collective experience or distress

" Examples and clarifications are given of various contexts to which the term sociosomatics applies. Note that, although the overarching definition of "sociosomatics" underscores the fundamental dialectic between the body and the social world, the term comprises several more specific meanings that apply to the multifaceted nature of this relationship. A sociosomatic approach encompasses not only the integration of social context into psychosomatic approachesthat is, enhancing the understanding of mind/body interactions to mind/body interactions in contextbut it also posits a direct impact of social processes on the body that is outside of the mediation of conscious awareness. Conversely, physiologic states become metaphor and commentary for social processes, as well.

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EDITORIAL also underscore the distinctive methodological contributions that ethnography promises this field (14). Of course, the evidence for sociosomatic effects had been established long before the authors of studies in this issue set pen to paper. The abiding relationship of poverty to excess mortality and morbidity, the health gradient in most societies that associates lower social class position with poorer health outcomes, the correlations of post traumatic stress disorder with the stress of both natural and man-made disasters, the global association of higher rates of depression with women in situations of relative powerlessness, the independent relationships between family responses, availability of jobs, or the level of social development of a country and the outcome of schizophrenia, for example, have all pointed toward the connection between social context and psychophysiology (15, 16). So too, social science studies of the influence of economic, ethnic, and class factors on whether chronic pain syndrome leads to disability have suggested the connection between social context and psychophysiology, as also have ethnographic accounts of the linkage between trance and possession states and the resistance of marginalized peoples to domestic and public tyranny (17). That symptoms have social uses that contribute to cascades of exacerbation is scarcely news to psychiatrists or psychologists. But that those uses may be more powerfully consequential for somatic conditions than psychological traits/states may actually destabilize taken-forgranted assumptions. In the research by one of us (A.K.), survivors of the extensive political violence created by China's devastating Cultural Revolution (1966-1976), who were often labeled as sufferers of neurasthenia by their care-givers and who met DSM-in criteria for depression and anxiety disorders, reexperienced collective memory of the traumas of political chaos and social disintegration via somatic symptoms. Culturally salient symptomspain, dizziness, fatiguewhatever their origin, had undergone, over time, metaphoric spread from the physical body to the social body, so that they came to express pain in social relations, dizzying effects of moral breakdown and exhaustion from seemingly endless mobilization in political campaigns (14, 18, 19). These victims/patients also complained of famao ("vexation" or "troubled vexation," Chinese) as their chief affective symptom; this bears astonishing resemblance to Job's biblical complaint of being "vexed" (ka'as, Hebrew). The sensibility in both instances is with the idea of being "shaken" by social and moral events, a recognition of the affective and bodily consequences of external force. This sociosomatic (or socioaffective) sensibility differs from contemporary Euro-American cultural emphases on the autonomy of inner "psychological" states. Rather, in contemporary Chinese and ancient Western views, affects are regarded as directly linked to moral and political conditions. The emphasis is clearly placed on social (ie, political and religious) power directly creating bodily consequences. It is this sociosomatic sensibility, captured by metaphors, such as the Chinese idea of "face" (lianmian, Chinese), which means simultaneously one's public moral standing and one's subjective state, that characterizes the studies in this issue. They explore the anthropological insight that the body mediates between cultural representations and collective experience, on the one side, and subjectivity on the other (20, 21). In other words, from an ethnographic point of view, the moral, the political, and the medical are inseparable. Whereas analysis and comparison of narratives, metaphors, networks of illness meanings, and styles of illness experience suggest how sociosomatic processes may bridge the social and biological worlds, it will take investigation by psychosomatic researchers who use both biological and social measures to establish how sociosomatic processes actually work. For example, as several of the studies in this collection argue, socially mediated perceptual, cognitive, and affective processes frame experience in culturally particular ways; these in turndoubtless in concert with endocrinological, immunological, and neurophysiological processes, among others both constitute somatic experience and infuse it with meaning. Here psychosomatic medicine will have a ready readership in medical anthropologists, as well as potential research collaborators, inasmuch as we might conjecture common pathways mediating between the mind and social context and somatic states. And here is where psychosomatic medicine can and should make a fundamental contribution to social science. Anthropologists can show that societies, not just individuals, remember, and that societies accomplish that crucial historical feat via cultural texts (monuments, sculpture), ritual, and bodily experience (habits, taboos, tattoos, dissociative states, culturally salient emotions, and habitual coping processes). But demonstrating the encoding processes through which societal memory, such as that of civil conflict or state oppression, is expressed in normal experience and through symptoms is a project for interdisciplinary psychosomatic research. The studies in this issue seek to attract the attention of psychosomatic researchers to the processes that establish the intercommunications among mind, body, and society. If nothing else, these studies suggest why society is a crucial aspect of mind-brain-behavior formulations of normal and pathological experience, an elemental component of human conditions that cannot be left out if we seek to understand illness and therapy in the real world. These studies also demonstrate that such an engagement with social processes is not just a matter of adding one more variable to a well established psychosomatic research paradigm. Engagement with the social world challenges models and methods that separate mind from body, but also casts the relation of mind and body in new and different ways. It may well require a new language for research. In this language, moral categories transform into emotions; political and economic experience transduces into mortality and morbidity; and power in interpersonal relations intensifies or depletes vitality in the person. And, mutatis mutandis, attentional, dissociative, linguistic, and sensorimotor processes project psychophysiology into interpersonal relations. Sociosomatics is one term in that new lexicon.

ARTHUR KLEINMAN, MD ANNE E. BECKER, MD, PHD

Department of Social Medicine Harvard Medical School Boston, MA 02115 E:mail:gillespi@wjh.harvard.edu

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REFERENCES
1. Rivers WHR: The Todas. New York, Macmillan, 1906 2. Rivers WHR: Medicine, Magic, and Religion, with a preface by G. Elliott Smith. New York, AMS Press, 1979 3. Slobodin R: WHR Rivers. New York, Columbia University Press, 1978 4. Barker P: Regeneration Trilogy: "Regeneration," "Eye in the Door," "Ghost Road." London, Viking Press, 1996 5. Young A: The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton, Princeton University Press, 1995, 43-50 6. Ware N: Sociosomatics and illness course in chronic fatigue syndrome. Psychosom Med 60:394-401, 1998 7. Miller E: The uses of culture in the making of AIDS neurosis in Japan. Psychosom Med 60:402-409, 1998 8. Lock M: Menopause: Lessons from anthropology. Psychosom Med 60:410-419, 1998 9. Ellison P: Reproductive ecology and "local biologies." Paper presented at the panel, "Bridging the Cultural and Biological Divide," Annual Meeting, American Anthropological Association, San Francisco, CA, November 20, 1996 10. Kirmayer LJ, Young A: Culture and somatization: Clinical, epidemiological, and ethnographic perspectives. Psychosom Med 60:420-430, 1998 11. Becker A: Postpartum illness in Fiji: A sociosomatic perspective. Psychosom Med 60:431-438, 1998 12. Jenkins JH, Cofresi N: The sociosomatic course of depression and trauma: A cultural analysis of suffering and resilience in the 13.

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life of a Puerto Rican woman. Psychosom Med 60:439-447, 1998 Lee S: Estranged bodies, simulated harmony, and misplaced cultures: Neurasthenia in contemporary Chinese society. Psychosom Med 60:448-457, 1998 Kleinman A, Kleinman J: The moral, the political, and the medical: A sociosomatic view of suffering. Paper presented at the Taniguchi Foundation Symposium: Comparative Medicine: East and West, 1996 Desjarlais R, Eisenberg L, Good B, et al (eds): World Mental Health. New York, Oxford University Press, 1995 World Health Organization: World Health Report, 1995. Geneva, WHO, 1995 Kleinman A: Writing at the Margin: Discourse Between Anthropology and Medicine. Berkeley, University of California Press, 1996 Kleinman A: Sociosomatics: How the social world affects bodily processes. Jpn J Psychiatry Neural 98: 523-532, 1996 Kleinman A, Kleinman J: How bodies remember: Social memory and bodily experience of criticism, resistance, and delegitimation following China's Cultural Revolution. New Literary History 25:707-723, 1994 Csordas T (ed): Embodiment and Experience: The Existential Ground of Culture and Self. Cambridge, Cambridge University Press, 1995 Scheper-Hughes N, Lock M: The mindful body: A prolegomenon to future work in medical anthropology. Med Anthropol Q 1:6-41, 1987

NOTICE
We are grateful to the Harvard University Department of Social Medicine for its support of the Cross-Cultural Section in this issue. Joel E. Dimsdale, M.D. Editor-in-Chief

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