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 What's Behind the Symptom?

Uni'JCI'silY of Micbi~. DC::Dlbom

R. Brooke Thomas
U.iv .... iry of M..SlICbn ...... Ambo.." On Psychiatric Observation
IntematiolUll Aclvillory Board and Anthropological Understanding
Gt!org< Annt'i4KQs. Ham Bot:r. r~r~ Brown. Xocitill (AJltPt<da. D~h(JrDh
Go"'on. ,'(o<hillllcTT<I"a. Jurillh Jr.lJlla. Mo~rfJ1J'" 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 Angel Martinez-Hernaez

Hippoeratoo' Latin American logacy;
Humoral Medicine in the New World
George M. Foster

Volume 2
Forbidden Narratives: Translated by
Critical Autobiography as Sodal Science Susan M. DiGiacomo and John Bates
K8thryn Church

Volume 3
AnQhropology and Intemational Health: Foreword by Arthur M. Kleinman
AaLan Ca&e Studlcl$
Mark Nichter and Mimi Nichter

Volume 4
The Anthropology of Infectious DiseaGo:
International Hoallh PerupoctiveG
Edited by Mama C. Inhom and Pater J. Brown

el Routledge
Scc the b:llc!< of lhi.s book roC' Qiher hd~ in ThC()ty IlntJ Pr;:u:lict' in Medic:.1 Anthropology .md Intern;,· ! \. Tay!o< 6. F..<IIIdI (; ro"P
Ii"",,! Health. LONDON AND NEW YORK
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in memoriam
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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
 CONTENTS

Introduction to the Series .............................. .. ....... ............... .. ........ ......... . ix

Preface .... ... .... ..... ........ ....... .. ..... ....... ..... ...... ........ .......... ....... ....... ........ ..... .. xi
Foreword ....... .... ........ ......... .. ... .......... ....... ........ .. .... .......... ....... ..... ...... .... .. xv

1 What is behind the symptom'? ....... .... ..... ........ ... ........................ ........ . 1
PART ONE: ON PSYCHIATRIC OBSERVATION ...

2 The dream of a biomedical psychiatry .. ...... ............. .... ... ....... .. ........ 21
3 Kraepelin versus Freud: A retrospective .. ...... ........... ....... .. .............. 39
4 Neo-Kraepelinism: Nosologies .. .. ...................... .. ........ .. .. ... .... ... ...... 65
5 Neo-Kraepelinism: Epidemiologies ....... .......................... ............ .... 89
6 The limits of psychiatric observation ........ ... ........ ....... ................... 113

PART TWO: . . . AND ANTHROPOLOGICAL UNDERSTANDING

7 Toward an anthropology of symptoms:

Four pre-interpretive approaches ......... ................. ........ .... ............. 127
8 Toward an anthropology of symptoms:
Henneneutics and politics .. ............... .. ....... .. ....................... ........... 147
9 Semiotic incursions .. ...... .. ........ ... ................... ... ............ .. ... ............ 177
10 Ethnographic interpretations: Symptoms,
symbols and small worlds ...... ..... ........ ....... ................ .................... 203
11 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 interna-
tional 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 ap-
plications informed by current anthropological theory. The distin-
guishing characteristic of this new series is its emphasis on cultural
aspects of medicine and their links to larger social contexts and con-
crete 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:
EncyclopicJj~ 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
 1
.xii PTr!face
trend and one particular conceptualization. This does nol prevent me. however.
I Taylor (UNAM-Mexico), Joan Prac, Juanjo Pujadasand Oriol Romanf(Rovira
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
Preface xiii
i Virgili University) and Thllio Seppilli (Univer~ity of Perugia)-read and
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 Martfnez-Hern~ez's 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 conn~lS
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 Martfncz-Hcm~('.z 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 CHAPTER 1
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 What Is Behind The Symptom?
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 Car l'clUlctitude sc distingue de III verite, et III conjccture n'exclut pas In "gueur. [For
knowledge they represent. The question of the ontology of symptoms as CXlld= is distinct froro truth, I1Ild conjecture does not exclude rigor.]
forms of living in the world-even with all the interest in phenomenology -JllCqucs UlClll1, Ecrir.s
-is a decidedly secondary interest in psychiatric anthropology, and in
psychiatry. The ethical question of what good this knowledge is for~eems
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 In The Vital Balance, the American psychiatrist Karl Menninger posed a
the pain and tribulation . In that sense, symptoms and signs lose a crucial question that, despite its apparent simplicity, has been of great importance
signi ficance. Whether deconS!ructed by clinicians or ethnographers the action in the history of psychiatry: "What is behind the symptom?" (1963, p. 325).
seems to be a search for something else (the disease state, the political He was seeking what was, in his opinion, the ultimate meaning of symp-
economy, the embodied symbol). Something else-usually said to be deeper,
toms for, in his words. "no man steals a watch for the sole purpose of ob-
hidden, more significant-replaces the human voice and sentiment.
taining a timepiece. No man cuts his throat merely in order to die." "Human
Interpretation can annul the human project itself when it avoids the prima
motivation is not that simple," but the result of a multitude of pressures and
facie expression of suffering. Medicine misconceives what is al stake when
events that the therapist must discover and describe (p. 326).
it emphasizes "First, do no harm." Anthropology does the same when
From the end of the 18th century, when psychiatry was taking its first
in terpretation precedes acknowledgment. Symptoms and signs. to paraphrase
steps as "special Medicine" (Castel, 1980, p. 109), to the period in which
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, Menninger formulated his theory on the importance of environmental pres-
heard, engaged, and helped. Where is this utterly human ethical project amidst sures on mental imbaJacce (1963), the problem of the nature of the symp-
the icons, indexes and other vehicles of meaning that preoccupy the scholars tom has been at the center of a series of psychological and psychiatric
in today's psychiatric anthropology? What about the symptoms of social debates. Even in the biologicist period in which we are immersed at present,
injustice and health inequalities as a raison d'etre for moving psychiatric the question of the nature and conlent of the symptom has become com-
anthropology toward policies and prograrns?This has become a major feature mon ground for psychiatric reflection (Jackson, 1992; Wilson, 1993). In
of the anthropology of infectious disease. Shouldn't il be a serious focus in fact, we are faced with one of those fundamental scientific questions that
psychiatric anthropology as well? transcends fashions and trends, since it addresses the very purpose of the
discipline: the study acd alleviation of mental dysfunction.
-Arthur Kleinman
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·
course can be u~ in everyday circumst:mcc:s. Once 1M a.~ked me about an
expression which his f:llher often used and whicb he found completely incom-
prehensible: "Women are ~ 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 argu-
ments 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 exer-
cise 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 na-
tive 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 tex-
ture and pigmentation of Las Meninas in order to prevent it from deleriorat-
245
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 etiolo-
gies remain hypothetical. Given this situation, what the palient says is of
primary imporlance for defining such diagnosLic criteria as "auditory hallu-
cinations" or "feelings of hopelessness"-a whole range of phenomena ac-
cessible only through the patient's speech. In contrast to the observational
capacity of biomedicine, with its technological ability to penetrate the uni-
verse 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, be-
cause 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 pa-
tient 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, be-
cause 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 in-
volves a political commitment having to do with the corporate and socioeco-
nomic interests of the profession, at the cost of treating winks as twilChes.
The clinical relation required by neo-Kraepelinism (and also by biomedi-
cine in general) bctween professional and patient is rather odd from an eth-
nographic 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
Epilog~: Open Worlc 247
anguish that it causcs. Patients describe what they feel, relate their symp-
toms and tell the story of their affliction. From all this information the pro-
fessional 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 inven-
tory 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 pro-
cesses of the receiver of the message. In this way the autochthonous mean-
ing 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 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 appar-
enl, and in fact inverse: the clinician naturalizes the semiosic. while the de-
tective reads hwnan will into footprints and physical evidence.
The problem of disguising symptoms as physical signs is no trivial mat-
ter, but one of fundamental practical importance. If an Iranian woman's com-
plaint of heart distress is understood by the clinician to mean only physical
sensations, it is a clear misreading. If this same hypothetical clinician con-
tinually modifies the treatment because his schizophrenic patients complain
unceasingl y about their nerves, there is a fai lure of interpretati on and a com-
munication 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 inter-
pretation 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 de-
pression?
Nonetheless, symptoms can be understood in another way, as they were
in psychoanalysis and in the phenomenological-existential school 0[ psy-
chiatry. An interpretive ethnography of symptoms and affiiction also plays
an important and distinctive role here. Because it has no interest in establish-
ing pathological meanings, it bypasses the debate about whether the causes
of mental illness are moral, social, psychological or biological. This is sim-
ply 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 at-
tention 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
Epi1ogu~: Open Won: 249
the art critic or literary critic, although a symptom is not Las MenifUls, nor a
s
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 We-
ber 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, develop-
ing 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 symp-
toms.
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, par-
ticularly 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 ethnogra-
pher 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, how-
ever, 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-
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 understand-
ing 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 con-
dition thaI produces distress. the approach of the clinician who reities symp-
toms 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 ethnogra-
pher robs language of meaning by reducing everything to a linguistic phe-
nomenon .
The image of the ethnographer seeking SOme hypothetical original mean-
ing 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 mis-
take 10 see symptoms as a mere natural facts, not because clinical psychiatry
Should abandon its therapeutic intent. but because, in the absence of well-
founded etiological knowledge, we run a greater risk of confusing the cul-
turally specific with the universally pathological . The headache and brainache
ofa Puerto Rican; the heart di stress of an [rani an woman; the auditory hallu-
cinations of a NaLlve American in mourning; the nervios of chronic psychi-
atric 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 pathogenic-
ity/pathoplasticity model-all these arc facts thaI speak for themselves. The
dual taSk of anthropology here is 10 provide a critical perspective on con-
temporary psychiatry, and to open up symptoms to the work of understand-
ing. None of which should prevent us from finding in symptoms not only
culture and language, but also pain. oppression and suffering.
NOTES
I. In Ihe McdilClTlIncan contexl, to compl:tin of .. the kidneys" is a common refer-
ence to lower-bock pain.
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 . INDEX

A Culture and personality 130-131. 145

American Psycruatric Association
(APA) 32. 37 (n. 14).67-68,71-79.
114.124
Amok 14,57,64(n.23),116.134.135.
136. 159
Anthropology of biomedicine 23-29
Ataque de Dervios 14. I I 1.210
Ayurvedic IJledicine 27. I 14. 117. \18.
119,192
B 248.250
Bartbes. Roland xii. 17 (11-10).178-
185,188.190.191.194.197
Bilis 14
Biomedical psycruatry 11.24-25. 66.
119
Biomedicine
and psycbiatry xii . 3. 5.22-36. 2 I O.
246
as acullurai system 29.159.197-
197
c DSM-n 34. 35. 37-38 (n. 14), 68. 70
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
(n.4)
Culture-bound syndromes 14. 17
(n. 17),24.57. 64 (n.23). 77.91 .
106. III. 116. 117.118,121. 124.
128.250
o
Depression 32. 38 (n.14). 57. 66.75.
76-77, 89.90.93,103.133 . 159.
193,210,219-220. 225.247.
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,
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

273
 lntkx
274
Dreams 40. 41. 44-47. 49-50, 51. 59.
86, 138, 151. 234. 243
E Golden era of social epidemiology 90
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 153.154.155-156.163.174.199
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 N
Gadamcr. Hans-Georg 3. 164
Galician culture 12- I 4
a sombra 14
millora 12. 14
o enganido 14
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
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, 152-
Intcrn.ttionaJ Classificalion of
Disc3Scs OCD) 32. 37 (n . J 4). 68.
90.94.109.121.123 . 124
K 243. 244 (n. 3)
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, 63-
64 (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
/ntkx
L New Haven Study 89-90
Latah 14.57.64 (0. 23).116.121.123.
134. 159
l.bi-Strauss. Claude J 55-156. 175-
176 (n. 2. 3 and 4). 206
M 225
Mal d'oUo 12-15.231
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. 147-
149,150-164,203.204.207,209,
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
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
275
New mcdieo! semiotics 178.187.191-
199.203
o
Oedipus complex 3-4.4.7.48,91.224.
p
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. 61-
63 (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 /mkz lmio: 277 iI
and Int.:rno.tional Study of
II
Schi7..ophrenia 14. 17 (n.3). 28. 32.36 and sign xi. ~v. 4·5,23, 32.35 , 36
(n. I). 50, 52·54. 55 . 56, 57 , 59. (n.2). 61. 65. 84, 108·1<19. 112 Scbizopbrenia (lSOS) 109
63 (n, 17), 74,75.76.82, 108. (n.3). 114-115, 118. 121. 125. and Present Stale Examination !
114, 149. 154, 208·232, 235 130,137.139· 141,142·145.152. (PSE) 92. 93, 103·104, 109. 110
and epidemiology 89. 90,92·)05. 154·156.160·161. 168·170, 170. :1
108·109 173.181. 182·185.186·187.188, y
and narralives 215·226 189.190, 191. 193, 194. 197.
I
and prognosis 52, 53. 93·95. 95· 198·199.200 (n .2), 204. 205. Young, Allan 18 (n.15). 60. 66. 67, 69.
103 209,210,235·236, 237. 244, 141,165·166,169
and symptomatology Il. 52·54, 55, 245.246. 247.248. 250
56. 66, 82. 103·105 and text xv, 7. 44-47. 132. 150.
Social suppor·slress·discase par~digm 155, 189,193, 194,195.197.
26.37 (n.6) 203.204.205.207,208.210. I'
Somalaalio('l 105·107
Structuralism 8. 17 (n. 9), 156. 175·
213.215.217.229·230. 235,
238 . 240,241 . 242, 243
iI
176 (note 3).177.185.188
Suslo 14. 115, 116. 159 T
Symptom II
and aesthetics 156, 203.240.241.
249
Taussig, Miehacl2. 157. 168·171 , 172, !I
1·74.204 :!
and biograpby 7, 39-40. 42. 43, 44. Topopbobia 43
47. 54·56,183,203,215·226. Trait.:mcnt moral 30, 37 (n.9)
247 Thrner. Victor 3. 150·152. 153. 159 :i
and economic·politics xv. 2.3. 168· and dominant ritual symboL~ 150.
175.203 152. 153.208.230
:I I
and c;.;perience xii. xv, xvi . 42. 43. and psycboanalysis 151·152 II
94.107.108.115. 121. 122. 123. I!
132. 148, 152, 154. 155, 156.
157.160·164.174·175.190, 194.
v .i
1

198.204.215.223,224,227. Versteben 7,40. 56. 85. 65. 155 I

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
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