WHY DO INDIGENOUS PRACTITIONERS SUCCESSFULLY HEAL?

ARTHUR KLEINMAN University of Washington School of Medicine

and

LILIAS H. SUNG National Taiwan University [l]

Abstract-The authors report findings from a follow-up study of patients treated by a shaman (t&q-ki) in Taiwan. and relate these to early findings from a much larger study of indigenous healing in that Chinese cultural setting. Ninety percent of patients treated by indigenous practitioners suRered from chronic. self-limited. and masked minor psychological disorders. The last group. involving “somatiza- tion” of personal and interpersonal problems. accounted for almost 50”,, of cases. In the follow-up study. IO of 12 consecutive cases treated by this indigenous healer rated themselves as. at least partially. cured. This occurred in spite of any significant symptom change in several cases. and in the face of considerably worsened symptoms in one case. In these cases. behavioral or social gains were respon- sible for the positive evaluation of therapeutic efficacy.

INTRODUCTION Instead, I present the complex issues involved in how The study of indigenous healing may be important we evaluate therapeutic efficacy as the central prob- to the general anthropologist for the light it throws lem in the cross-cultural study of healing. The on a particular culture. It may be important to the explanations I propose for understanding how the in- medical anthropologist for the understanding it pro- digenous healing described in this paper works are vides of a given society’s system of health care. But anchored in a theoretical framework, which I outline the cross-cultural investigation of indigenous healing below. whose hypotheses the field research seeks to holds further significance for the medical anthropolo- test. That framework, based on reading of the cross- gist. Here the interest of the medical anthropologist cultural literature concerning illness and clinical care. is virtually the same as the chief concern of those compares explanations provided by patients. families, clinicians who pursue cross-cultural research. They practitioners, and researchers to interpret healing as seek to elucidate universal as well as culturally- part of a general analysis of the health enterprise in particular features of the healing process; and they Chinese and other large-scale developing and devel- wish to compare indigenous healing with professional oped societies. medical and psychiatric care. Before examining the research framework. I wish The chief research questions are straightforward to stress the inadequacy of our present understanding and have been known for quite some time: Is indi- of the healing process. This is in part a function of genous healing effective? And if so, how? What role the early stage we are at in medical anthropological do cultural factors play in bringing about that effi- research and theory. But it also results from an enor- cacy? how does the efficacy of indigenous healing mous distortion in clinical research and theory. For compare with that of professional clinical care? what researchers in clinical medicine, healing is an embar- does that comparison tell us about the nature of the rassing word. It exposes the archaic roots of medicine healing process? and can we learn anything which and psychiatry, roots which are usually buried under might be practically applied either to the solution of the biomedical science facade of modern health care. extraordinary problems besetting contemporary It suggests how little we really know about the most health care or to the treatment of sickness in different central function of clinical care. It resonates too well societies? with the criticisms leveled by patients and consumers Yet. while the questions are clear. the answers are generally at modern health care. It raises questions not. What we now possess are impressions, anecdotes, which deal with human values and meanings that are unsystematic findings. and strong opinidns. The not easily reduced to technical questions’ which can limited material 1 present below. frail thing that it be answered with simple biological explanations. And is. nonetheless represents one of the few attempts I it strips away the illusion that biomedical research am aware of to systematically follow-up patients is the only scientific approach to health care prob- treated by an indigenous healer in order to determine, lems. Instead, the question of healing makes it appar- first. if this particular form of indigenous healing is ent that much of clinical science can only be effective: and. then. how it might work. In attempting approached from the perspective of social science. to answer these and other questions listed above, I There seems to be a radical discontinuity between have tried to avoid using ready-made explanations, contemporary clinical care and traditional forms of such as the timeworn and essentially unproven healing. Cross-cultural and historical studies of medi- psychoanalytic theories which (to my mind) have cine disclose two separate, but interrelated. healing mtroduced so much obscurantism into this subject. functions: control of the sickness and provision of

7. 8 *ARTHUR KLEINIAN and LILIAS H. Sew

meaning for the individual’s experience of it [2]. contain three Interrelated sectors: popular. profes- Modern professional health care attends solely ,to the sional. and folk. The popular sector IS composed 01 former. In fact. the biomedical education of phys- individual. family. and social nexus arenas in which icians and other modern health professionals. while decisions about illness and care are made and treat- providing them with knowledge to control sickness. ment is carried out. The folk sector is the non-profes- systematicullv blinds them to the second of these core sional. usually non-bureaucratic specialist arena of clinical functions. which they learn neither to recog- health care. Together these two sectors comprise indi- nize nor treat. This leads to the well-known panoply genous healing: except. as in the case of Chinese and of problems in clinical management. which arise from Indian societies. where there are indigenous profes- inattention to or poor performance in clinical com- sional systems of care. Seen from this perspective. munication and the supportive aspects of care: family-based care is the most important and exten- patient non-compliance and dissatisfaction. inade- sively used type of care. In most societies. it provides quate and poor care, and medical-legal suits. most of the clinical care and is the locus of decisions For example, we now know that the quality of doc- about, and evaluations of. such care [9]. Yet anthro- tor-patient communication is a major determinant of pological and clinical studies of indigenous healing compliance and satisfaction [3]. We know that atten- frequently fail to focus on it. and public health plan- tion to communication ana the “caring” aspects of ners often do the same. limiting the legitimated clinical practice has led patients to prefer treatment domains to professional health care. Folk healing is by chiropractors over treatment by orthopedic stir- a much smaller and less important domain of indi- geons for low back pain [4]. We know that in the genous care. but because it is easier to study. it has surgical treatment of peptic ulcer disease, surgeons received the lion’s’share of research attention. When and patients maintain two entirely separate lists of studying healing it is essential to describe which of criteria by which they evaluate surgical outcomes as these sectors one means. successful or not, and that inattention to the patient There are five basic clinical functions performed by list caused surgeons to call a success what patients health care systems. which cut across all three sectors call a failure [S]. Non-medical eye specialists are in- and which constitute the healing process [lo]. These creasingly capturing a larger part of the patient popu- core clinical tasks are: lation concerned with routine eye problems because (1) Cultural construction of illness from disease: they appear to patients to give more “satisfactory” (2) Use of systems of belief and values for choosing care [6]. In Taiwan, only modern professional doctors between health care alternatives and evaluating treat- are sued for malpractice (at one of the highest rates ment outcomes: in the world); indigenous practitioners are virtually (3) Cognitive and communicative processes used to never sued. In all, it has been argued that the curves cope with disease/illness, including perception. classi- of increasing biomedical, technological advance in fication. labeling, and explaining; clinical care, and patient dissatisfaction with the qua- (4) Therapeutic activities per se: lity of care, are inversely related [7]. (5) Management of a range of potential health care The dilemma posed by modern clinical care can outcomes: cure, chronic illness. impairment. and even be put quite neatly into the following terms. Let us death. call disruse any primary malfunctioning in biological Obviously. there are wide cross-cultural and cross- and psychological processes. And let us call illness sector variations in these activities. For present pur- the secondary psychosocial and cultural responses to poses, there is no need to be overly formal about disease. e.g. how the patient, his family. and social these core clinical activities. but it is essential to network react to his disease. Ideally. clinical care recognize that through them social and cultural fac- should treat both disease and illness. Up until several tors become major determinants of healing. Paradoxi- decades ago. when their ability to control sickness cally, the cultural patterning of illness is a therapeutic began to increase dramatically, physicians were inter- activity. Healing efficacy is not a straightforward ested in treating both disease and illness. At present. resultant. but rather is determined by evaluations. however, modern professional health care tends to evaluations which are tied to the beliefs and values treat disease but not illness; whereas, in general, indi- of different sectors of health care systems and which genous systems of healing tend to treat illness, not therefore might be (and often are) discrepant. Healing disease. This is a hypothesis to be tested against our is viewed differently across cultures and in different field research findings. Should it prove true. then it. sectors of health care. It is not the same thing for would appear to pose obvious and far-reaching practitioner and patient. This is an argument to the changes for modern health care. effect that a// health care explanatory models, includ- Before turning to the research, let us briefly review ing those of modern professional medicine and psy- the theoretical orientation which stands behind it. As chiatry, are culture-laden and freighted with particu- noted elsewhere [S], healing (or clinical care) cannot lar social interests. And so is our present understand- be talked about in the abstract, but must be anchored ing of healing. in particular social and cultural contexts. In each From the perspective of health care systems and society there are beliefs about illness, choices of treat- their clinical functions. healing is the sum of the ac- ment alternatives. sick roles and practitioner roles, tivities of the entire system of health care. This insight and health care-related institutions organized as a leads to a seeming paradox: though desperately cultural system: the health care system. This is an sought after and uncertain in outcome on the indivi- explanatory model which makes sense of a very dual level, healing as a cultural process must occur. complex and fluid reality, it is not an entity. Health The indigenous healing described below is an illus- care systems can be thought of as local systems which tration of this. From our perspective, it also should Why do indigenous practitioners successfully heal’! 9

become clear that the tensions built into health care middle-class, Of their sickness complamts. psycho- systems can generate important problems in clinical logical symptoms were extremely uncommon. and care. problems which relate to confIict between differ- most complaints appeared to represent minimal or ent views of health care needs and objectives. It is, self-limited (spontaneously remitting) sicknesses, therefore, completely inadequate to talk about chronic disorders, usually not of a life-threatening patients and healers as if they were independent of kind. and somatization of psychological and interper- the context of clinical care. They (and the healing sonal problems. In all, I saw only two cases of major process) must be located in specific cultures and the psychopathology treated by r&q-kis. Neither was sectors of particular health care systems. Nor can we effectively treated. and r&g-kis told me that their bring explanatory models to bear on illness and heal- treatmtnt was not elfectivc for such disorders. es- ing without first recognizing that they, too. are bound pecially chronic schizophrenia. which they did not to these contexts. The goal. then, of cross-cultural like to treat and rcfcrred to psychiatric hospitals. studies is to work out an overarching comparative Although shamans (wu) are described in the science into which health concepts and activities can Chinese classics, and seem to have operated through- be translated and analyzed. This remains a distant. out ancient China, in more recent times they have though necessary. objective. Inattention to this funda- been particularly prevalent in Fukien Province, from mental theoretical problem. however. is a major where most Taiwanese trace their ancestry [12b]. In reason why cross-cultural studies of healing have traditional Chinese society, shamans were one of a failed thus far to advance our general understanding group of Taoist specialists, which also included: of clinical care and to specify how their findings are Taoist priests, magicians. and female spirit-mediums to be translated into practical clinical strategies which who commune with the dead. These same four types can be applied in different cultural settings, including of Taoist practitioners are found in the syncretic our own. (Taoist-Buddhist) Taiwanese folk religion, though their functions overlap [13]. ~~g-ki~ (literally. divin- ing youth) may be male or female. may be recruited via self-selection or selection by older t&g-kis or the GENERAL RESEARCH PROJECT [I I] community, and may or may not undergo formal AND RELEVANT BACKGROUND training. under a Taoist adept or an cxpericnced rirmg4i.s [ 143. The rcing-kis undergoes trance. in which The research described now forms a small part of he acts as if he were possessed by one of the gods a much larger and still ongoing comparative study of the Taiwanese folk religion. His words and behav- of illness beliefs and practitioner-patient reiationships ior when entranced are believed to be the god’s His in indigenous and professional forms of health care therapeutic efficacy is believed to be the god’s own in Boston and Taiwan. More specifically, it is part efficacy. ‘I&g-kis frequently work with assistants, who of a comparison of clinical communication and its interpret their advice (which is sometimes unintellig- inhuences on compliance. patient satisfaction, and ible or clothed in special terms) for the clients. In course of illness amongst patients treated by Western- my experience, there can be marked differences style doctors. Chinese-style doctors. and a variety of between f~ng-~~s: some spend more time expIaining folk healers in Taipei. The last group included sha- to clients; some emphasize rituals; some specialize in mans (f&pki) [ l’a]. fortune-tellers, interpreters of prescribing herbs or Chinese medicines; and some are ch’irn. physiognomists. and temple-based ritual renowned for their skills in treating certain kinds of experts. In all several hundred patients were studied. problems (e.g., sickness, and particular kinds of sick- including approximately 25 who were treated by ness). several r&g-k& in Taipei. The 13 cases described Rural r&g&is often practice in the village they live below are part of this last group. in, where they farm, fish, etc., like other villagers dur- Through other studies, I had the opportunity to ing the day, but function as shamans at night and observe approximately 25 shamans in Taiwan (15 in on special occasions. Urban t&g-kis not infrequently the capital city of Taipei and 10 in market towns are professionals, who do no other work. They can and villages). I was able to interview 10 shamans in make a considerable amount of money, though most detail. none of whom exhibited major psychopatho- seem to remain at lower-class and lower-middle-class logy. which would seem to be incompatible with the levels. I have seen several t&g-kis in Taipei earn the skills which being a shaman requires. In the course equivalent of ~2~.~ U.S. per week. and one who of this research. I observed nearly 500 patients treated earned that in one night. Even after these sums have by shamans. My impression is that roughly half of been shared with assistants and others who help oper- these cases presented with health problems. a quarter ate the small shrines where t&g-kis practice, this is with personal andkfamily problems. and a quarter still a very large income by Taiwan standards. Thus, with business. financial, and assorted other social it is not surprising that these folk healers are popu- problems. Many shamanistic consultations dealt with larly viewed with considerable ambivalence. and are crises. and crisis management seemed to be a major sometimes accused of being charlatans and Fakes. function of the practice of shamans. More than three- That ambivalence is heightened by the fact that quarters of cases were women. some of whom brought r&g-kis are still feared by some as potential sorcerers. sick children or the clothes of sick children for treat- The popular ideology holds that r&g-kis should ment. and some of whom came on behalf of other be poor and illiterate: that they should make no in- family members (usually males suffering sickness or come from their services which should be performed some other misfortune). Most patients were from the because the god wishes to “save the world and serve lower-class and poorly educated. but a few were the people”: and that they should have experienced 10 ARTHURKLEINMAN and LILIAS H. SUNG

a severe illness. untreatable by any other technique The subject of shamanism in Chmese culture goes from which possession by the god cured them. well beyond the limited focus of this paper. I mention Because of this. they must acknowledge the god as some of its characteristics only to help the reader feel their master and serve him as a disciple, or else they more familiar with the t&g-ki whose patients we will fall sick again and die. The tcing-ki is believed followed-up and report on below. Interested readers to possess special powers only when possessed. and are referred to other descriptions of tcing-kis m it is held he remembers nothing of what happens dur- Taiwan [18]. Several other general points about sha- ing his possession activities when he is himself. This manistic healing in Taiwan are worth noting. The ideology is so powerful that it is extremely difficult popular ideology holds that a shaman should be able to obtain an accurate biographical history from prac- to tell the patient his symptoms and should not need ticing r&g&s, who stress these ideological points’in to, enquire about them. This restricts history taking their stories about their lives. . to a minimum. Since urban t&g-kis (unlike their rural Made illegal ‘and actively suppressed under the colleagues) usually do not know their patients. this Japanese, during their occupation of Taiwan from handicaps the r&g-ki. 7&g-kis rarely obtain follow- 1895 to 1945, shamanism seems to be undergoing a up information about their patients. Most assume if remarkable renaissance at present throughout the patient does not return then it is an indication Taiwan; although recently government health author- that he is healed. But patients hold the opposite view: ities there have publicly vowed to end shamanistic if treatment is ineffective they do not return. Although healing along with all the other kinds of folk and shamans tend to spend more time explaining to their unlicensed healing practices which presently flourish patients than do professional practitioners, this is not in Taiwan. Based on sample surveys we conducted always so, and fairly often one finds that patients do along with reports from inform’ants, we estimate there not understand the ‘t&g-ki’s explanations anymore are at least 800 t&g-kis in Taipei alone. Since each than they do Chinese-style or Western-style doctors’ may see from 5 to 50 clients per day, they obviously explanations, albeit this is not usyally so. Although play a major role in general health care, psychiatric tring-kis seem to appreciate the pragmatic orientation care. and crisis intervention. When we add to t&g-kis of most of their patients. who usually employ several all the other types of folk healers (sacred and secular) different kinds of treatments at once and who say practicing in Taipei, it is certain that folk healers treat that healing requires both god (t&g-ki) and man (doc- most cases of sickness that move beyond the family tor), they rarely refer patients to other practitioners. context. In all of Taipei there are a handful of small Not infrequently, they state that they can cure all psychiatric clinics and only two large general psychia- disorders, and tring-kis have repeatedly told me that tric clinics (those of National Taiwan University Hos- their gods can cure cancer and other life-threatening pital and the Taipei City Psychiatric Hospital). These disorders. are oriented to the medical treatment of psychoses. Finally, healing rituals in the r&g-ki’s shrine, inde- There is virtually no psychotherapy available in Tai- pendent of specific content, seem to have three defin- pei, except for a very small number of therapists who able stages. (1) The patient’s problem is named. treat members of the Westernized elite class. It is not Usually, it is labeled as an external entity e.g. a pos- surprising, then, that folk practitioners treat most of sessing ghost. (2) The appropriate ritual is performed the cases of minor psychopathoiogy and life prob- to. treat the problem, and herbs and practical advice lems. Because folk healing when applied to such prob- are given as well. The patient is told that he is passing lems shares basic features with psychotherapy, I think through a crisis (again outside himself). But often the Tseng [15] is correct in referring to this as traditional patient does not understand the symbolic meanings or indigenous psychotherapy. Since mental illness is associated with this r.ituaI movement from a state of still very highly stigmatized in Chinese culture, and sickness to a state of cure. (3) The patient is told since Chinese culture sanctions minor mental prob- that he is healed. That the bad spirit or ghost possess- lems with a medical sick role, most of this indigenous ing him (and thereby causing his sickness) is gone, psychotherapy is directed toward medical (somatic) and with it has gone his disorder. This tripartite divi- problems. That is. it is a culturally disguised form sion of healing rituals is typical of traditional healing of psychological therapy. rituals in many cultures and even shares a general The specific supernatural explanations the t&g-ki structural similarity with modern clinical care and employs: ghosts, gods, or ancestors are the cause of psychotherapy [19]. the individual’s sickness and need to be placated,

exorcised, negotiated with, etc. These are the com- SEITINC ponents of the clinical reality culturally constructed and socially legitimated in the t&g-ki’s shrine. This The t&g-ki [20]. whose patients we studied, prac- clinical reality, including the explanatory models used tices in Taipei not far from the campus of the to interpret sickness and justify treatment, is distinct National Taiwan University. He is a 47-year old from that found in the practice of other folk healers Taiwanese family head who works as a bank teller or professionals. It has much more in common with during the day, and has been working seven nights pcpular cultural beliefs in Taiwan, however, than do per week as a t&g-ki for several decades. He is some- the professional clinical realities constructed in the what atypical for several reasons, but his therapeutic offices of Western-style and Chinese-style doc- results are roughly similar to those of other r&g-kis tors [16]. Nonetheless, all of the clinical realities in whom we have studied. First. he is atypical because Chinese culture have certain important similarities he has a large cult, with perhaps as many as 50 regu- which distinguish them from clinical realities found lar members and another 50 occasional members. in the U.S. [17]. Second, many of the members of his cult actively Why do indigenous practitioners successfully heal” II

trance. and several of them function as healers. Third, moves upward until his “master” is one of the gods he engages in less ritual activity than most other on this highest plane. rcing-ki.s we have observed; and he also has less verbal Healing sessions begin at night. seven days per interaction with his clients while entranced than do week. They last from just after dinner often until the other r&g-kis. but he is the most charismatic of all early hours of the morning. The shrine has one large the healers I have studied in Taiwan. On most nights room which can hold about 30 people comfortably he spends less than five minutes wtth each case. and and a large altar table and altar. It opens to the street on busy nights he spends about two minutes with along one entire side, and cult members and clients each case. Fourth. the r&g-iii has elaborated his own commonly spill over onto the street. Each night there philosophical system and the cult has its own ideo- are usually IO-30 new patients, and 20-30 cult logy. Like other r&y-kis with cults. he actively members. The shrine’s activities can be divided into recruits new cult members from his patients, telling two parts: the hour or so when the rriptg-ki. entranced. them that the most effective therapy is for them to consults with new clients; and the rest of the time. be possessed (demonstrated by trance and jumping during which cult members and patients socialize and or dancing) and that preventing recurrences of their pray and trance. When cult members are actively problems requires attendance at his shrine. which trancing. it is a wild and colorful scene. Informants assures protection from the shrine’s many gods. Again have described it to me as one of the most exciting like other r&y-kis 1 have observed, much of the heal- experiences they have had. This must be especially ing in the shrine goes on outside the r&g-kis interac- true for lower-class mothers and grandmothers, who tion with patients. and. as we shall see. involves the are otherwise trapped within the confines of the therapeutic activities of certain cult members as well family. Cult members do not merely trance: they as the general therapeutic milieu of the shrine. dance, jump around, sing. exhibit glossolalia. and Of special interest is the fact that about half of sometimes engage in activities with strong sexual the r&g-ki’s cult members are middle aged women overtones. For example. men and women touch and with remarkably similar life-histories and problems. massage each other: they jump around together; Most come from poor families in rural areas. They women rub the inside of their thighs and men exhibit migrated to lower-class sections of Taipei after mar- rapid thrusting movements of the pelvis; at times the riage, and have been afflicted with serious financial ecstatic frenzy of the trances resembles orgasmic be- and marital problems. Most also have other serious havior. All of this is very unusual public behavior family problems. Each has suffered for many years in Chinese culture. unsanctioned in any other place. from multiple, non-specific somatic complaints affect- In their trance and interictal behavior, cult members ing many areas of the body. Most have had clear-cut are expected to display behavior characteristic of the conversion reactions. They relate their symptom his- gods who possess them. While entranced it is not un- tories with a flourish. playing up the dramatic and usual to see individuals express strong emotions, es- colorful qualities. Almost all have been diagnosed as pecially sadness and anger. Cult members say they suffering from neurasthenia. They have made use of feel relieved and happy after trancing. At the begin- virtually every kind of clinical care (indigenous and ning of each healing session, and off and on through- professional) without effect. But since joining the cult, out the night. there is a lot of socializing between most have remained symptom free and no longer con- the cult members. And sometimes members of their sult other practitioners or use drugs. Of the six families also are present. women in this group who we interviewed, n/l fit the New clients register with one of the t&g-ki’s assist- Washington University “hard” diagnostic criteria for ants when they first attend the shrine. They give hysreria [21]. The therapeutic benefit they derive from name, address, problem, and the eight characters (pu the cult is so obvious that their family members will- tm) associated with their birthdate. The last is used ingly tolerate the annoyances resulting from their to calculate their fate. Each new patient burns incense nightly participation in the cult. Indeed. some of these and prays, asking the god about his problem. The women sleep in the shrine each night. and at least patient throws divination blocks to learn if the god two of those who do are mothers with young children. will answer his question. After the divination blocks The shrine is called the “Saintly Emperor’s Palace’.. indicate the god’s consent, the patient waits for the The chief god is the “Third Son of the Jade Emperor” t&g-/o to go into trance and for the assistant to call (referred to as San-tien-hsia. or San-t’ai-tsu), but the him/her. The thng-ki may ask a question or two, but shrine is filled with small statuettes of dozens of other usually does not. He (the god speaking through the gods from the pantheon of Taiwanese folk religion. t&g-ki) informs the patient what is causing his prob- The r&g-ki can be possessed by any oi these gods. lem. He then prescribes various therapies: he gives and each cult member has at least one “master”. the the patient ashes to drink, charms to eat or wear, god who possesses him/her. The t&g-ki is called the sometimes he prescribes herbs. Chinese medicines, or “master” of the shrine. and cult members refer to food therapy. At the end he pronounces the patient themselves in Confucian terms as his “sons”. The cured or orders him to return regularly to the shrine positive virtues of the shrine are contrasted with the and become possessed (indicating that a god who outside world. the “sea of bitterness” (k’u-hi). which wishes to possess him is causing his problems). His is said to be: filled with personal and family prob- explanations frequently mix supernatural. classical lems: inharmonious: threatening: and constantly pro- Chinese medical, popular medical. and even Western ducing sickness and other misfortunes. The shrine’s medical ideas. His therapeutic advice may contain a syncretic. and somewahat idiosyncratic. cosmology similar mix. The two commonest rituals he performs holds that there are three levels of gods with the each take less than one minute. In one he writes a shrine’s gods at the highest level. The cult member charm in the air over the patient which is believed 12 ARTHURKLEINMAN and LILIASH. SUNG to transfer power to the patient and drive away bad FINDIlVGS FROM THE FOLLOW-UP STUDY spirits or ghosts. In the other, he rapidly moves his We attempted to follow-up 19 consecutive clients hands in front of the patient from head downward treated for complaints of sickness over a three-night to mid-body and from feet upward to mid-body. He period in this shrine. Several patients were inter- then grasps at the space over the mid-body and viewed before their interaction with the t&g&. most makes a throwing motion as if he were throwing were not. All patients were visited at their homes two something to the ground. The meaning here is that months after their initial visit to the shrine. Follow-up he is cleansing the patient of bad spirits and ghosts. interviews could not be completed with seven cases: Sometimes, he will massage middle aged and elderly two gave wrong addresses; three refused to be inter- patients. viewed; and two had moved to addresses too far away After spending five minutes with the t&g-ki, the to be followed. Of the 12 patients who were inter- patient returns to his seat in the shrine. There he viewed at home. one (No. 3) gave very brief answers will sit quietly: meditating, praying, or resting. The to most of our questions and refused to answer some patient will remain in the shrine for several hours. of them; and another (No. 4) had been treated at During that time he will be treated by several cult the shrine many times before and was the only return members. who, during their trances, will massage him, patient in our sample. All the others were new give him further divine advice, and attempt to get patients. Each patient was interviewed with the same him to trance and/or jump. Other cult members, who format and questions. Each interview took at least are not entranced, will give the patient, and the family 30 minutes. We asked patients to evaluate their treat- members who most likely have accompanied him, ment in the shrine: was it effective or not? To what friendly and reassuring advice, or will ask them to did they attribute its efficacy (or lack of it)? Had they tell their stories. Clients will disclose full accounts of experienced symptom or behavioral change? Why did their problems to sympathetic listeners several times they evaluate their treatment as effective (or not)? We at least. They and their family members may be given asked if their improvement could have been the result certain things to do, such as burning large amounts of the natural course of the sickne&. We asked them of spirit money to propitiate a god or an angry ances- about intercurrent treatment from other health care tral spirit, or buying special foods to offer to the gods agents for the same problems. We obtained brief his- which they will later take home and eat. Sometimes, tories of the onset and course of their disorders, and the t&g-k and his cult members will direct their attempted to work out our own quick assessment of treatment activities more to the oldest or most res- patients’ current physical and psychosocial status. ponsible-looking female family member accompany- Our evaluations were limited because we were unable ing the patient than to the patient. to perform physical exams, blood tests, X-ray examin- On seven consecutive nights in this shrine, there ations, or psychological tests, either initially or at were 122 new clients: 54 (45%) came seeking treat- time of follow-up. ment for sickness; 33 (27%) came to have their fate Besides the analysis of the follow-up evaluations determined and bad fate treated; 24 (19%) came of these 12 cases, we add a full description of a 13th because of business or other financial problems: and case. That patient, Mr. Chen, was examined by us 11 (97:) came with questions concerning personal and at some length before he was treated by the tcing-ki. family problems. Some of the clients with questions We also observed some of the treatment he received about their fate also were concerned about personal at the shrine, which lasted over many sessions: and and family problems. Most clients were lower-class, we were able to follow Mr. Chen’s course at home two-thirds were female, and all were Taiwanese. At and at the shrine over a period of 7 months. We least 25% of the cases were young children or infants. present his case in order to fill out the necessarily Of the sicknesses complained of, by far the most com- superficial presentation of the other cases. We feel mon problems were acute, but not severe, upper res- justified in focusing special attention on this particu- piratory or gastrointestinal disorders, probably viral. lar case, because it is typical of many other cases Chronic disorders, such as low back pain. arthritis. we studied in both indigenous practice and modern and chronic obstructive pulmonary disease were clinical care. It also provides us with an opportunity present; but more prevalent were chronic, non-speci- to discuss several salient issues in clinical practice in fic complaints, labeled “functional” or neurasthenia Taiwan, issues which hold considerable cross-cultural by Western-style doctors, but which seemed to me significance. to represent somatization with depression, anxiety Several notes of caution. Our sample size is neurosis, hysteria, or other psychological problems. obviously very small. It would be inadequate to base Most infants came with a history of irritability, poor generalizations upon this data were it not for the vir- sleep pattern, and prolonged unexplained crying. tual absence of other follow-up studies of indigenous Such cases were diagnosed to be suffering from practice, and that these findings are in line with our .‘fright”, and were treated with a ritual which calls findings from studies of other indigenous healers as back the soul that is believed to have been frightened well as impressions gained from observation of large away. A client might spend anywhere from the equiv- numbers of patients treated by t&g-&is. Nonetheless, alent of fifty cents to $5.00 U.S., depending on the it is likely our results are skewed toward more posi- treatment he/she received and the amount of incense tive evaluations of healing, since it is reasonable to and paper money he/she had to burn. These charges assume that the clients who refused to be interviewed are comparable to, but usually somewhat less than, were more likely to harbour negative evaluations of charges in Western-style doctors’ and Chinese-style their treatment. However, even with these cautions doctors’ offices. Nonetheless, they are considerable in mind the results are striking and provocative. expenditures for many lower class families. As we see in Table 1, 10 of 12 patients (83%) Why do indigenous practitioners successfully heal’? 13 reported (or their family members reported) at least them), even though several admitted that this was a partially effective treatment. Six patients (SO”,;,) possibility. As we shall see in the Comments. these regarded themselves, or were regarded by family results also point to the strong influence of culture members. completely cured. Only two patients (17?;) on evaluations of therapeutic efficacy. are listed as treatment failures. One evaluated her The t&g-ki essentially regarded all of these cases treatment a failure. but her mother felt the treatment as cured (at least in part). since those who returned would be effective if tried for a longer period of time. to the shrine told him that they were. while those The father of one child evaluated his daughter’s treat- who were not helped did not return. which he took ment at the t&g-ki’s shrine completely ineffective, and to mean they had been cured. Furthermore. cure also implied that it had allowed her sickness to worsen. meant to him that the supernatural agencies causing Nonetheless, an 83?,, rate of cure (even partial cure) these problems were appropriately treated. and this is impressive and would seem to be evidence in favour he felt had happened in each case. In the cases of of the efficacy of this indigenous practitioner’s treat- “fright”, (c/ring. La”: or shou thing “catch fright”). he ment. Or is it? evaluated cure not so much by the condition of the It is fascinating that of the 10 patients whose treat- infants as by the responses of their mothers. Here ment was evaluated by themselves or family members alleviation of the distress of a key family member was to be effective: one reported no symptom change at a criterion of cure. all: one infant and one adult experienced only mini- Our evaluations suggest that .the question of effi- mal symptomatic improvement: while a fourth cacy in this case sample is problematic. To begin with. patient actually experienced worsening of her symp- what was effectively treated? In one case we have a toms. Two of these patients experienced some beha- naughty child who (to our minds) is not sick at all. vorial change (they felt psychologically better after Effective treatment of a sickness may be a similarly being at the shrine). but the other adult did not and irrelevant concern in the two cases of “fright”. These the infant gave no sign of such change. Furthermore, infants may have had some minimal, se&_;imtted stck- in several cases (e.g. No. 6. No. 10. and No. ll), there ness. but just as likely were cranky or “colicky” for was some discrepancy between different family reasons having nothing at all to do with sickness. members’ evaluations of whether or not the f&g-ki’s Several patients seemed to be suffering from self- treatment had been effective. These cases raise a ser- limited disorders (possibly viral syndromes) which ious question about how evaluations of therapeutic probably improved spontaneously, as part of the efficacy are made. Clearly our patients positively natural course of such disorders. We thought that evsaluated their care for different reasons. In some two, and possibly three. of the patients were suffering cases symptomatic change was the chief determinant. from somatization. Their somatic complaints were While in others behavioral change was most impor- secondary manifestations or symbolic expressions of tant. For example, cases No. 4 and No. 6 experienced underlying psychological disorders. Evaluation of no symptomatic change. but derived psychological therapeutic efficacy in these cases depends on what benefits and probably also social benefits (e.g. they happens to the underlying psychological problems. In got out of the house. away from family problems, the two cases with hysteria, treatment seemed at least socialized with friends. enjoyed the exciting atmos- partially successful. Finally, several patients who phere, etc.) from their treatment. Other patients reported symptom relief were receiving other thera- explained to us that negative evaluations of their pies, including Western drugs known to be effective treatment in the shrine might prejudice the gods, for these specific symptoms. Thus, from our perspec- whose favours they were seeking, against them, and tive, only a few of the cases seem to provide evidence thereby worsen their disorders. Other patients appar- in favour of the efficacy of this indigenous form of ently could not bring themselves to challenge the healing. We do not find conclusive evidence to show t&g-!ii and the cult members, who had repeatedly that a single case of a biological-based disease was and’emphatically told them they were cured. Indeed. effectively treated by the ring-ki’s therapy alone. in this shrine and others, if one asks patients to evalu- It is of particular interest that the only patients ate their treatment while they are still in the shrine, who did not evaluate their treatment to be effective immediately after being treated, one obtains uni- both suffered from severe acute disorders: one soma- formly positive evaluations. That is why home visits tic and one psychological. at a later date are necessary. In case No. 1 certain Findings from our other studies support these problems improved. while others did not, but the results. For example, on two other consecutive even- overall impression was one of effective treatment. We ings in this shrine, there were 16 cases who presented have not exhausted all the issues surrounding these with health problems. Fifteen involved somatic com- evaluations of the efficacy of healing. They illustrate plaints, compared with 11 out of 12 in this study. the special criteria patients use to evaluate their treat- The 16th patient was suffering from catatonia. but ment. These criteria differ amongst patients and even the treatment was organized around a relatively amongst family members. They are quite different minor skin lesion which she had rather than for her from those we employed. as a comparison between major mental disorder. (The t&g-ki told us he could our evaluations and patients evaluations demon- not cure severe or chronic mental illnesses.) Here is strates Such a comparison also reveals differences in further evidence for somatic preponderance amongst the criteria indigenous and Western physicians complaints treated by this indigenous healer. And we employ to evaluate therapeutic success. It is worth have evidence that, in Taiwan. indigenous and profes- noting that no patients were willing to say that sional practitioners principally see patients who com- natural course of the disorder was responsible for plain of somatic symptoms. Even in the Psychiatric their improvement (after we explained the concept to Clinic of the National Taiwan University Hospital. ARTHUR KLEINMAN and LILIAS H. SUYC Why do indigenous practitioners successfully heal? 15

+ + I 4 16 ARTHUR KLEINMAN and LILIASH. SUNG

704; of patients with documented psychiatric dis- genous practitioners whom we encountered were orders present with somatic symptoms [22]. This generally quite sensitive and knowledgeable about points to the fact that most psychological care in those disorders for which indigenous treatment was Taiwan is disguised as the treatment of somatic prob- clearly ineffective but for which modern treatment lems. was effective. Nonetheless. rhis problem remains a dis- Of the 15 cases mentioned above: four had chronic turbing and potentially dangerous issue. cardiac and chest diseases; six had mild or moderate Finally, on several occasions we met patients with viral-like, self-limited disorders; and five were exper- chronic incapacity (e.g. hemiplegia from cerebrovas- iencing somatization. Of the last group, two suffered cular accidents or paralysis secondary to infantile from anxiety neuroses and three had major family polio, as in Case No. 4 above) and even terminal and other interpersonal problems. These findings are diseases (e.g. hepatic carcinoma) who had been dis- supported by analysis of approximately 100 cases we charged from modern health care facilities as untrea- followed who were treated by diffeient kinds of indi- table and who were receiving active treatment from genous practitioners. Almost 90% were: (1) non-life- indigenous practitioners. These patients. and their threatening, chronic diseases in which management families, reported that they felt psychologically better of psychological and social problems related to the and experienced active social lives in place of vegetat- illness were the chief concerns of clinical care: (2) self- ing existences, because of indigenous care. This was limited diseases; and (3) somatization. The last group definitely true of three patients we followed who were accounted for almost 500/, of cases. The overwhelming treated in the therapeutic milieu of the r&g-ki’s majority of these cases were satisfied with the shrine. indigenous care they received and believed it to be at least partially effective. However, many cases with THE CASE OF MR.CHEN severe acute diseases were not satisfied with indi- genous care and did not believe it to be effective. Mr. Chen, our patient, is a 44 year old married Clearly. then, indigenous care is effective for certain Hakka male. He is a lower middle-class master wood- kinds of problems but not for others. Intriguingly, worker with a primary school education who lives in our research in Taiwan about half the case loads with his wife and five children in a poor but newly of private Western-style doctors were made up of the developed urban district on the edge of Taipei. He same kinds of disorders that were preponderant in came to this shrine (his first visit here) to be cured the practices of indigenous practitioners. But here we of a chronic recurrent illness. He was introduced to found patient satisfnction to be considerably less and the shrine and its t&g-ki by several of his neighbors evaluations of efficacy no better. The major difference who belong to the r&g-ki’s cult, who, like Mr. Chen. is in the treatment of severe acute disorders, where belong to Taiwan’s Hakka minority [23]. Mr. Chen’s Western-style practitioners are rated by patients as neighborhood includes more than 100 people who very effective, whereas, we have already noted, indi- have been treated at this shrine. He knows dozens genous practitioners are thought not to be effective. of individuals who claim to have been cured by this These evaluations fit with patient choice of treatment. cling-ki’s chief god. In 115 families in Taipei questioned about specific Mr. Chen complains of a vague sensation of dis- sicknesses they had experienced, more than 90% of comfort in his chest: “a feeling of pressure or tension”. all problems were first treated at home. Thereafter, He feels as if his chest muscles are snapping apart. severe acute disorders were brought to Western-style He also complains of being very troubled or anxious doctors, while chronic disorders were brought to (Jan-tsao). He describes this feeling as both a psycho- either Western-style doctors or indigenous healers. logical and physical one: a disturbing sense of inner Self-limited sicknesses and somatization cases tended tension which he feels is located in his chest, where to end up more frequently in the treatment settings it produces a physically discomforting sensation of the latter than in the clinics of the former, though which he also experiences as a general nervousness many were brought to Western-style doctors as well. and worry. Even so, he makes it clear that his preoc- Two further findings are worth reporting. Of 100 cupation is with the physical components, which he cases treated by indigenous healers, at least three had takes to be primary. These include feelings of general negative effects on the patients’ diseases. In two cases, weakness, malaise, and also tension in the back of patients with marked hypertensive cardiovascular dis- his neck. His is a physical illness, he tells us. But ea:es were ineffectively treated while there was pro- he admits his symptoms either start or worsen when gressive worsening of their congestive heart failure. he is worried about business or family problems. As Both cases were delayed from receiving effective care his symptoms worsen, he worries increasingly about because of indigenous treatment. In another case, an his health problem. indigenous healer ineffectively treated a young girl Mr. Chen’s illness first began 16 years before. He with severe hepatitis, and in so doing delayed her was then living alone in Taipei trying to establish from receiving adequate diagnosis and potentially life- a woodwork business. Business was poor, and he was saving therapy. In our experience, however, such situ- suffering serious financial problems. He felt lonely ations are distinctly unusual: most cases who suffered and unhappy. He worried a great deal about failure. from serious disorders for which there was effective Chinese-style and Western-style medicines were un- modern treatment and no effective indigenous treat- helpful. He eventually left Taipei and returned to his ment, but who were receiving indigenous treatment family’s home in a Hakka region of Taiwan. There anyway, were concurrently receiving the appropriate he consulted four Western-style doctors, none of treatment from Western-style doctors. Families of whom was able to diagnose precisely what ailment patients and most (but, unfortunately, not all) indi- he was suffering from. A Chinese-style doctor told Why do indigenous practitioners successfully heal’? 17 him that his problem was caused by “working too returned. They appeared at a time when Mr. Chen’s hard and worrying too much”. That this in turn business was at a crucial stage, one that he believed caused “fire” from his lungs, liver, and heart to “rise could lead to either failure or success. Western and up” into his chest, where it “inflamed the nerves” in Chinese medicines proved ineffective. Western-style his chest. This diagnosis impressed Mr. Chen because doctors’ diagnosed neurasthenia (&en-thing shuui-jo), it could explain both the chest discomfort and the which he accepted as the name of his problem and tension. From that time on he considered himself suf- believed to be a physical disorder. But they, as well fering from huo-ch’i ta (excessive internal hot energy). as the Chinese-style doctors he consulted, were unable This problem he associated with an excessively hot to relieve his symptoms. All X-rays and blood tests (symbolically hot) physical constitution, a tendency done at this time were normal. He became preoccu- to irritability and anger, and a variety of nonspecific pied with his somatic complaints. Although he talked complaints that he had had. He quite literally could to family members and friends about these symptoms, feel heat or “fire” in him when he was worried, burn- he could not talk about his anxiety and fears with ing beneath his sternum-just as the popular ideology anyone. says it does. He met members of the t&g-ki’s cult and the Although the Chinese-style doctor diagnosed his ill- t&g-ki himself. The t&g-ki told him: “You have no ness, he was unable to cure him with Chinese medi- problem! You should rest quietly at my shrine... cine. This led Mr. Chen to seek advice from a fortune- Wait! The god will come to you”. teller who told him (as he already feared) that he He immediately went to the t&g-ki’s shrine. (Note had “bad fate”. The bad fate, said the fortune-teller, that he did this even though it cost him precious time was responsible not only for the illness but also for from his work, which he usually carries out seven the inability of the doctors and the medicines to cure days per week for at least ten, and often more. hours the illness. When his fate changed. then Mr. Chen per day.) After arriving at the shrine (his first visit), would experience good fortune generally and specifi- Mr. Chen quietly sat off in a corner surrounded by cally his illness would be cured by doctors or medi- his friends and neighbors, including the t&g&i’s chief cine. The fortune-teller .went on to report the “true male assistant. They told him that he would be better cause” of his client’s problem: an ancestor-one from after eating charms and sacred ashes which were the underworld who was not being worshipped by being specially prepared for him by the t&g-ki. His his/her descendants-was “bothering” him. The friends frequently reassured him. They repeated the fortune-teller advised Mr. Chen to find out which thg-ki’s advice, which Mr. Chen already had memor- ancestor it was. so that he could properly propitiate ized, ‘iYou have no problem! You should rest quiet- him/her. ly...Wait! The god will come to you”. Every few min- He immediately realized that the ghost haunting utes, other members of the t&g-ki’s cult, usually him might very likely be his biological mother. She people from Mr. Chen’s neighborhood, came up to and his father had divorced when he was four years him and gave him encouraging advice. They told him old. Even though his biological mother had asked about their own cases: how they were healed here. him to come to see her when she was dying and to They told him that he too would be healed. They worship her as an ancestral spirit after her death, his related to him stories of clients with problems either father had prohibited him from doing so. a prohibi- similar to his own or much worse, who were “miracu- tion which Mr. Chen implied had been a chronic lously” cured in the shrine. While he swallowed the source of worry. Mr. Chen confirmed this impression charms the t&g-ki had prepared for him, they smiled by throwing the divination blocks which landed in and said: “Ah! Surely now it will not be long until such a way as to indicate the god’s answer was “yes”. you are better”. During all this time the f&g-ki had Knowing then that it was indeed his mother’s ghost not “officially” consulted with Mr. Chen. But looked which was troubling him, Mr. Chen prayed to her, over at him every few minutes, when he was not offering her meats and wine. He asked her to release entranced, and smiled, shaking his head affirmatively. him from his illness. and in turn prayed that her soul Mr. Chen told me that he expected to be cured and would be released from suffering in the underworld. that he believed one of the t&g-ki’s gods would make Ten days later his symptoms disappeared entirely. his illness go away. For the next 10 years he remained essentially free of this problem, although he recognized a tendency Initial mental status examination to worry about his affairs much more than others did. The full-blown disorder recurred again when his When I first met Mr. Chen at the time of his initial wife developed a strange, incapacitating neurological visit to the shrine, before he had been treated by the disease and at a time when he was once more in t&g-ki, I carried out a full mental status examination. a bad financial situation. His wife’s malady slowly That examination revealed marked anxiety, but no departed over the course of a year. and after she other significant abnormalities. Motor behavior, regained her health and their financial situation im- orientation, speech, and thought structure and con- proved. his symptoms also disappeared. He and his tent were not remarkable. He did not appear wife attributed both cures to the help of gods whose depressed and gave no history of experiencing the temples they had prayed at. even though his wife had somatic concomitants of depression. He was preoccu- also been taking various medicines. Mr. Chen came pied with his chest discomfort and frequently rubbed to the conclusion: medicines could only cure mild or pointed to his chest. He was circumspect with his or “bogus” illness, while the gods alone could cure answers, and did not give full replies to questions “true” illness. about his family and personal history. His behavior Recently. Mr. Chen’s panoply of symptoms seemed to make his friends also somewhat uneasy. 18 ARTHUR KLEINMAN and LILIASH. SUNG

Mr. Chen showed only quite limited insight into fate. driving away evil forces, or acting directly on (and interest in) the psychological sides of his illness. the sickness, depending on the cause.) The rhpki’s favored a somato-psychic rather than a psychosoma- last words were repeated several times: “You have tic causal sequence. He turned most questions about no problem!‘* This is a special term used in this shrine affect and beliefs into responses about somatic com- to indicate that the client will receive the god’s full plaints. When questioned about his feelings and other therapeutic efficacy and will be healed. Again. Mr. aspects of his personal life, he spoke very generally, Chen did not understand the special meaning of this actively suppressed most private information, and ela- term at the time of this first visit to the shrine. Before borated hardly at all. In all of these regards, he was Mr. Chen returned to his seat, the tcing-ki wafted in- like many other Chinese patients I have interviewed, cense and perfumed resin around his head. something and like non-patient informants as well. These aspects that he does to encourage trance behavior. The chief of behavior are unusual when viewed from an Ameri- male assistant encouraged Mr. Chen to let himself can standpoint, but normal when seen from the per- relax and to allow the god to possess him. spective of Chinese culture. Compared with his treatment of other cases. the In summary, Mr. Chen presented no evidence of r&g-ki’s behavior with Mr. Chen was much less dra- psychosis or other major psychopathology. He did matic. He kept his powerful voice low. He did not present considerable anxiety and marked somatic perform any involved, impressive, or frightening ritual preoccupation. Since I was unable to perform a physi- activities, which he did do in other cases. And he cal examination or laboratory tests, the history and made no attempt to focus the concern of his large mental status exam had to suffice as the basis for audience on Mr. Chen. a strategy he sometimes formulating a diagnosis. My impression was (and still employs in difficult cases. This treatment was much is) that Mr. Chen suffered from an acute exacerbation quieter and more private than most I witnessed in of a chronic anxiety neurosis owing to psychosocial this shrine. stress, principally involving financial and business In fact most of Mr. Chen’s “therapy” during this concerns. That same stress had precipitated several first visit was provided by the milieu not the r&y-ki. earlier acute anxiety attacks. These episodes, includ- He received a great deal of support from friends. ing the present one, involved somatization as a When he returned to his seat in the rear of the shrine. secondary manifestation of his primary psychological his friends and neighbors again formed a small group problem. around him. They told him he would now certainly be cured. They suggested he close his eyes. relax. and Treatment in the tang-ki’s shrine try to trance. They also told him not to feel disap- Although Mr. Chen spent more than four hours pointed if he was unable to trance this night. since in the shrine at the time of his first visit, the t&g-ki for one to trance and jump around is like an infant spent very little time with him, less than ten minutes. “growing up and learning first to sit, then to crawl, He was one of approximately 10 new cases the t&g-ki stand, and finally walk”. Mr. Chen did not in fact treated while in his trance. The tring-ki saw Mr. Chen trance that evening. He remained sitting quietly in after the latter had been at the shrine for more than his chair, his eyes often closed, trying. as he later told two hours. The assistant called out Mr. Chen’s name, me, to “meditate”. Mr. Chen reported feeling slightly date, day, and time of birth; and his problem: health better after this first night’s treatment. He was confi- problem. The entranced r&g-ki spoke authoritatively. dent he would be completely cured. He could relate The god stressed the desirability of Mr. Chen coming no evidence to support his self-assessment, however. to the shrine as often as possible. He then told Mr. His symptoms were still present. “Somehow I feel Chen that his problems were due to the shrine’s chief better.” (Since he told us this shortly before he left god, who was troubling Mr. Chen because he wished the shrine to return home, we should bc cautious to become his master. Once Mr. Chen “allowed” the about interpreting this assessment. None of the god to possess him he would become his disciple, patients treated in shamans’ shrines whom I examined and his complaints would go away entirely. Further- ever told me, while they were srill in rhe shrine, that more, the god would protect him (as long as he served they did not feel better even if only very slightly so. the god as a faithful disciple by attending regularly Many seem to feel really better even if only transiently at the shrine) from further episodes of this illness, so; others fear antagonizing the god by making nega- and would reward him with good health, long life. tive comments, especially since they have come to a large. prosperous family, and success in business. enlist the god’s help; and virtually no one is impolite But Mr. Chen must be patient. or stolid enough to reveal openly how they actually The r&g-ki wrote out sacred charms for Mr. Chen. feel in the presence of the t&g-ki and other members He scooped up some ashes from the large incense of the shrine.) pot on the altar table. Both of these were wrapped Mr. Chen returned to the t&g-ki’s shrine each up by his assistant and handed to Mr. Chen, who night for one week. Thereafter, he returned almost was instructed to eat them. Then the t&g-ki took every night for several months, failing to attend only his writing brush and several burning incense sticks when he was engaged in important business and in his right hand and made passing movements before family obligations. After the second night in the Mr. Chen as if he were writing a charm over his body. t&g-ki’s shrine he reported feeling a great deal better. (The meaning of this ritual, which Mr. Chen later and he claims to have felt completely well after the told us he did not understand, is that the t&g-ki third night there. On neither of these evenings did transfers the god’s power through the illegible charac- the t&g-k’i formally treat him. The second night one ter (the sacred symbol) he draws over the client to of the female cult members. herself in trance. actively the client himself, where it heals by improving his treated him. She forced him (much against his wishes Why do indigenous practitioners successfully heal’! 19 and to his clear embarrassment) to jump around with after he first tranced. We visited him at his home. her: but he did not trance. On the following night, We also spoke briefly with his wife and children. Mr. the cult’s chief female healer placed her hands on him, Chen first reported to us: “I feel better . . .I have been massaging and slapping his arms, legs. and chest. cured”. He said both the feeling of discomfort in his (These movements are believed to help drive out evil chest and his feeling of tension had disappeared. influences from the body. This is one of the very few Whereas before his chest discomfort often was pro- socially legitimated occasions when men and women voked by hard physical work, it had not bothered can touch each other’s bodies in public.) Again, he him for the past several days in spite of the fact that was led away from his chair and forced to jump he had been working very hard. He repeated to us around. This night he tranced. He flung himself that he had felt slightly better after his first night around the shrine violently, and eventually collapsed at the shrine. much improved after the second night, to the floor exhausted after about 15 minutes. He but only after the third night there did he feel com- then lay on the floor, not asleep but apparently un- pletely better. He still remains worried about his busi- able to move, for a similar period of time. When he ness and financial concerns (but no longer about his threw himself on the floor sweat was pouring off his health). But these worries he distinguishes from the face. his shirt was completely wet and sticking to his marked tension he had been feeling. He does not feel skin. and he was momentarily the focus of attention as if his responsibilities have been lessened or trans- of the many people in the shrine. (While he jumped ferred to the shrine’s god, indeed he lists them in full around. he copied the actions of the shrine’s many for us. but he is more confident now that he can trancers. who themselves copy the stylized movements successfully cope with them. He repeats again and of characters in Taiwanese folk opera. But Mr. Chen’s again his cure is “strange”: it cannot be explained behavior was considerably less controlled and more by him or by us. Mr. Chen said we must accept it violent than those of the experienced cult members. as something that passes our understanding. The god The latter told us that he would learn in time how has cured his health problem, now he himself must to control his trance behavior). Recalling his first work out his business problems. trance. Mr. Chen states that he heard people talking Objective evaluation. To us. Mr. Chen looks con- around him. and did not feel as if the god was pos- siderably more relaxed, much less outwardly anxious, sessing him. and less troubled and distressed than at the time of Mr. Chen attributed special healing powers to a our initial evaluation. His voice is stronger, and he handsome, middle-aged Hakka woman. his neighbor is more assertive. Unlike our first meeting, he main- and the shrine’s chief female healer who. along with tains eye contact, does not glance away, smiles fairly the r&g&i. are the two most charismatic figures in frequently, and has generally quite good communica- the shrine. Her master is “Monkey”, a deified folk tive rapport. He carries himself with much more con- hero in Chinese culture, who is reported to possess fidence. These behavioral changes are as striking to many magical powers, regarded as clever and cun- my Taiwanese research assistant as they are to me. ning. and who is called by the t&g-ki “he who finds Mental status examination is remarkable only out all secrets” [24]. Her healing skills are highly because it reveals no significant anxiety. Mr. Chen valued in the shrine and were well known to Mr. also denies any physical complaints. We observe him Chen before he came. She told him he must come hard at work and relaxing with his family. In both back to the shrine each night. Since that time he has situations he acts entirely appropriately, displaying returned to the shrine regularly. but has only tranced almost none of the signs of anxiety which were so and jumped around on several other occasions. Most pronounced five days before. of the time he sits quietly in the shrine and meditates: My overall impression is that he demonstrates no or he speaks with friends. During each of his visits, significant psychopathology, and that his former the t&g-ki‘s chief male assistant speaks with him at anxiety has been largely, and perhaps entirely. length. This assistant is a very large man who usually relieved. while his physical symptoms are no longer acts deliberately and calmly. with a soft smile, radiat- present. ing warmth and confidence. His slow. methodical movements and quiet speech and Buddha-like smile Further follow-up evaluations create a model that is the very opposite of anxiety. Almost three weeks after this first follow-up visit, He is a close neighbor of Mr. Chen’s. and has,known I saw Mr. Chen again at the t&g-ki’s shrine. He him for many years. They may sit together for 45 looked much the same as when we first met: restless, minutes to an hour. or even more. Mr. Chen’s motor quite anxious, and preoccupied with his troubles. behavior and speech become noticeably less quick Although he reported feeling well, he also admitted and intense in the assistant’s presence. he still occasionally suffered from discomforting feel- Since his initial visit to the shrine. Mr. Chen has ings of tension in his chest, along with fatigue and taken no medication. He has not gone to consult malaise. He remained worried about his business. (To other shamans or other kinds of healers. He believes me he seemed a good deal more troubled than at that his illness has been cured. and that the cure is our first follow-up visit.) He told me he comes to the result of the shrine’s chief god. whose faithful dis- the shrine almost every night. As soon as he arrives, ciple he has become. he feels better: calmer and less tense. By 11.00 p.m.. when he returns home. he usually feels entirely relieved. When he arrives at home, he is able to go Mr. Chen’s sub,\ecriw ecaluarion. The first follow-up directly to sleep. and sleeps soundly until his usual interview with Mr. Chen took place five days after time for awaking. Mr. Chen told me that though his his initial visit to the tcjlig-ki’s shrine and two days anxious feelings still occasionally return, they are less 20 ARTHUR KLEINMAN and LILIAS H. Scuc severe than before. Moreover. by concentrating on at the shrine. This uas the evemng of a local festlbal the shrine. and “filling my mind with things concern- celebrating the birthday of one of the shrine‘s gods. ing the shrine”. Mr. Chen claimed to be able to exert About 100 people crowded into the shrine and pres- some self-control over these daytime bouts of anxiety. ented offerings of food to the god. It was noisy. klany He feels especially “good”. and even “happy”. when people. in trance. were jumping about. he is able to trance and jump about at the shrine Mr. Chen was present along with his wife and their in the evenings. His wife encourages him to go to youngest child. He told us emphatically that he no the shrine regularly because he seems to be better longer suffered from an illness. ‘At times he still gets after he returns home. whereas he gets worse if he a sensation in his chest but it onlv lasts a feu does not go. He reported no significant changes in moments. His busmess has been doing very well. his business. During the day he now sees more of Outwardly he showed no anxiety. He smiled easily. those neighbors who also attend the shrine. and talked to me at length with considerable com- Mr. Chen told me the following story: one week petence and ease. He did not point to or rub his before the shrine’s congregation made a pilgrimage chest. He was quite well dressed. and appeared (Just to a shrine in the south of Taiwan. Mr. Chen accom- as he purported to feel) prosperous and happy. HIS panied them. Before they departed he felt a painful wife. who also seemed unconcerned. agreed with her lump in his throat. and had difficulty swallowing. He husband’s statements about himself. Later in the also had a night cough. His feeling of tension returned evening, Mr. Chen went into a trance while slttlng and was quite severe. He was deeply concerned about on a stool: he rapidly turned his head from side to his health again. He bought both Chinese medicine side, with his eyes and mouth closed. and with both at a Chinese pharmacy and Western medicine at a hands slapping his thighs. This lasted for about tive Western pharmacy, which the pharmacists prescribed minutes. He did not get up and jump or sing with for his symptoms. but neither was effective. He some- the many cult members who did so throughout the what reluctantly told the r&y-ki about the recurrence shrine. After commg out of his trance. his face was of his problem. This was the first time he had formally covered with sweat and he smiled broadly at his three consulted the r&g-&i since his first visit. The r&y-ki year old son. According to Mr. Chen. his wife. and replied that the god was testing Mr. Chen’s patience. others at the shrine. he had been free of signs and He told Mr. Chen: “After you are able to trance and symptoms of anxiety for several months. and also had jump about’regularly, which you are not yet able to not complained of physical discomfort. do. you will get better”. During the trip to ihe south, One month later. several days before I left Taiwan. the t&g-/G. his chief male assistant, and some of Mr. I paid a final visit to this shrine. Again. it was the Chen’s neighbors who belong to the cult spent much time of a festival. There was much noise and excite- time with him. The evening they returned (four days ment. Most of the t&g-/G’s cult were present. well before this interview), Mr. Chen’s physical symptoms over 100 people, including Mr. Chen. He was relaxed disappeared. though he remained anxious. and obviously enjoying himself. I did not observe an> Before going on this two day pilgrimage, Mr. signs of anxiety, and he neither reported those nor Chen’s business had become very active. He felt under physical complaints to me. He told me he felt well. much pressure to finish his work; moreover. he He reaffirmed that his old illness, “neurasthenia”. he wanted to finish it before he left on the journey. At called it, was no longer a problem. Indeed, from the the last moment, he almost decided not to go. But time of our last encounter until now. he had experi- his triends and neighbors persuaded him to go. His enced no difficulties at ail. He had become an active wife supported this view. At the shrine they visited, member of the cult. and was assisting with the moving Mr. Chen did not trance, but he felt less tense. Indeed. of furniture and ritual objects. Mr. Chen was now he told us he had “a good time” on the trip. part of the shrine’s “therapeutic milieu”. He even During this interview, I was impressed by the talked with several new clients. offering them support obviously high level of Mr. Chen’s anxiety, this time and, in one instance, telling his own story as an In the absence of physical complaints. Unlike before. example of the chief god’s eficacy. He spoke as if he sat in the shrine without closing his eyes and medi- his problem had long since ceased to trouble him. tating. Nor did he exhibit any signs of trance. Instead, With this new client he talked of his “new life” as he constantly looked around to gaze momentarily at a member. and contrasted it with the sufferings of different people, occasionally took a nervous glance his former existence in the “sea of bitterness”. Every- at his watch, and, on the whole. revealed himself to one around him agreed that Mr. Chen had indeed be quite uneasy and easily distracted. Although he been cured. I wanted to question him at length, but did not formally consult the t&g-&i, he spoke with he told me he was embarrassed to talk about “bad him from time to time when he was not in his healing things” when things were now so “good” with him, trance. The chief male assistant sat by Mr. Chen’s his family, and his business. And he reminded me side for most of the evening, talking slowly, occa- to talk of such things could tempt fate, anger the sionally smiling in a relaxed and easy-going style god, and induce a change in fortune. At that moment which contrasted sharply with Mr. Chen’s behavior. the tciny-ki came by and told us: “1s it not enough Just before he departed. he seemed less anxious than Mr. Chen is well? Must you trouble him more‘! He earlier in the evening, laughed aloud at a funny story is cured! The god cured him. What more do you need the Gny-ki told those around him. and warmly to know’!” exchanged formal words of courtesy as he left. To Miss Sung performed a 7 month follow-up. at my mind, Mr. Chen was suffering a recurrence, and which tinie she found Mr. Chen to be unchanged. being treated for it. He was. and had been throughout this time, free of Three months later, we again interviewed Mr. Chen somatic complaints. He did not appear anxious, and Why do indigenous practitioners successfully heal? 21 denied experiencing any acute anxiety states. Mr. treatment outcomes in modern medical settings both Chen was still an active member of the t&g-ki’s in the U.S. and cross-culturally. Such scientifically cult [25]. rigorous studies can be carried out in Taiwan at the National Taiwan University Hospital’s outpatient COMMEN7S psychiatry clinic. where only a small fraction of cases are treated, but not in shamans’ shrines. fortune- The follow-up cases illustrate the complexities sur- tellers’ offices, and ch’ien interpreters’ temples where rounding cross-cultural evaluations of treatment out- the great majority of cases are treated. When the comes. First, studies of indigenous forms of clinical treatment intervention is psychotherapy (modern or care place certain constraints on the analytic tools traditional) the problem of determining outcomes the researcher can use to evaluate illnesses and treat- even in a modern treatment setting is considerable. ment responses. It would have been helpful in these All of which leads me to argue not against doing cases to have carried out our own physical examin- such studies. but for recognition of their serious limi- ations. given certain psychological tests. and reviewed tations. For example. in the follow-up study of 12 X-rays, EKGs, and blood test results. but none of consecutive cases. our results were almost certainly this was feasible. On the other hand, studies that have skewed toward more positive evaluations of treat- attempted to do this have so drastically altered the ment. as we already noted, because we were unable treatment situation. that what they ended up studying to complete follow-up with seven cases, three of was not actual indigenous practice. Secondly. as we whom refused follow-up; and it is reasonable to have pointed out. almost all anthropological assess- assume. for these three cases. that their evaluations ments of therapeutic elTicacy dispense with follow-ups were not positive. It has been my general experience. entirely, and rely simply on the subjective report of moreover, that patients treated by idigenous practi- the patient. almost immediately after he is treated, tioners tend to resist follow-up interviews much more or on the ethnographer’s independent judgement. than do patients studied in Western medical practice. Both approaches are inadequate, since anthropolo- Research fits better (although not always very well) gists usually do not possess the training to make such with the expectations of patients treated by modern assessments (and when they make them usually fail professional medical practitioners than with those to specify how these assessments were made). and who seek indigenous treatment. especially sacred. treatment outcome simply cannot be evaluated im- temple-based treatment. We have already pointed to mediately after treatment is performed because, for some of the difficulties resulting from subjective reasons already_ mentioned, most patients are con- patient evaluations of the efficacy of healing. They strained to affirm at least some level of treatment suc- use different criteria for evaluating treatment than cess while they are still in the treatment setting, and those used by practitioners and researchers. because such assessments give no sense of the effect These concerns make it essential to confront a fun- over time. Furthermore, in most situations it remains damental question: What is healing? Clearly it is a unclear what illness is being treated. It is abundantly somewhat different thing for the patient (and perhaps clear that a chronic recurrent illness, like Mr. Chen’s family), practitiondr. and researcher. Indigenous prac- disorder. requires study for a considerable period of titioners in Taiwan believe most cases are successfully time so as to be able to examine the effect of therapy treated, since few return for treatment. and they on its chronic course and to rule out spontaneous believe failure to return is an indication of treatment remissions. success. This runs directly counter to the popular To make much of a single case, or a single series patient viewpoint that you don’t return to the same of cases. is particularly dangerous. Although Mr. practitioner if you derive no therapeutic benefit. For Chen’s case is one of many I have followed, generali- the practitioner, treatment may be directed at the zations based on independent cases (even a fairly female family member who usually comes with the large number of them) can be quite misleading since illness problem of someone else in the family, so that strong biases operate in indigenous treatment settings successful treatment in part means treatment of that to select unrepresentative cases-those with more im- other person (rather than the sick person) and of the pressive illness manifestations and treatments, and family disturbance created by an episode of illness. immediate responses. Retrospective studies (which From the sacred folk healer’s explanatory frame. ill- make up much of the literature) are notoriously unre- ness may be due to bad fate or possession either di- liable; but even prospective evaluations, such as Mr. rectly causing illness or interfering with treatment. Chen’s case. can be unreliable because there are so Successful treatment means appropriately treating the many important variables which are difficult or im- fate or expelling the god or ghost possessing the possible to control: type of illness, age. social class, client. which should lead to symptom relief (in his prior treatment, concomitant treatment by other theory), but at times (for various reasons that he can kinds of practitioners. etc. Comparative research list) does not. In such a case, he might claim partial requires marched patient groups, but this is difficult or complete cure even in the absence of symptom to achieve in field studies. And,, of course. there is change: although he will either predict such a change a strong observer bias. Almost everything in the treat- for the future or explain that another problem has ment setting encourages the researcher, like the been encountered which also must be “cured”. Practi- patient. to affirm the success (even if in quite limited tioners of shamanistic and other temple-based healing terms) of treatment. in Taiwan are usually quite clever at explaining thera- To my mind. these problems usually make it im- peutic failure in such a way as not to imply that their possible to carry out rigorous studies of indigenous god’s healing powers have been inadequate. Chinese- healing which are comparable to the best studies of style doctors use the pulse both to diagnose illness 22 ARTHUR KLEINMAN and LIL~AS H. SLYG

and evaluate if the patient has returned to a har- treatment principally at, the tllness. Western-sty It’ monious state of bodily functioning. They sometimes doctors both in Taiwan and Boston seem to hale will tell patients who feel entirely better that they are considerable dithcufty in doing this. Part of the prob- still ill, since the underlying problem has not been lem may be that indigenous practitioners seem to be completely treated. I have seen Chinese-style doctors better at elicitine patient views. the nub of which tell patients that even though their symptoms have often concern thk verv issue. Mhereas U’cstern-style not “yet” improved. their pulse indicates treatment doctors perform this clinical task quite poorly. when has been effective. Of course. this very same process they do it at all. Furthermore. the indigenous practi- occurs all the time in Western medicine. when the tioner’s view of the disease is usually more in line physician attributes cure or improvement to with patient beliefs than is the Western medical con- measured changes in blood electrolytes and other cept of disease. chemical values in the absence of clinical signs of im- For the researcher this is a special problem. Which provement. For patients these discrepant practitioner definition does he use for disease (indigenous or bio- assessments may present significant problems that medical). which for illness. and when he evaluates cause them to leave treatment or fail to comply. but cure is it cure of the disease (and which view of the many seem to accept these views as part of the medi- disease) or the illness. or both. Most anthropological cal mystique, the medical expert’s special understand- writing is unclear on this point: so is most of the ing of the problem and its treatment. medical and psychiatric literature. On the other hand, for the shaman, symptom relief As I have noted elsewhere [Xl. most traditional in the absence of complete ritual treatment to expel forms of healing include two closely interrelated func- an evil spirit, or for the Chinese doctor. symptom tions: providing effective control of the disease and or relief in the absence of a return to harmonious illness manifestations. and personal and social mean- balance of yin/yang, hot/cold. or the five body spheres ing for the experience of being ill in a particular cul- (~~-fsQ~g). is not a cure, no matter what the patient tural setting. Evaluations of healing (by either patient says. But these niceties may be explained only to the or practitioner) may involve both or only one of these researcher, because for most indigenous practitioners functions. For patients both are usually essential. For resolution of the chief psychosocial issues which com- traditional practitioners the available evidence sug- prise the illness experience is more important than gests that both are also usually taken into account. these theoretical fine points. More and more. however. modern medical care seems Treatment, for most practitioners, seems to be di- to view only the former as the proper task of clinical rected at two aspects of a given health problem: the care and disregards the latter. This certainly seems disease and the illness. This distinction is as appro- true of Taiwan. and also reflects research and ciinical priate to make in the case of the shaman who treats experiences in Boston. As Horton [27] shows, scien- both the invading ghost (disease) and the symptoms tific medicine is structured to provide technical mfor- and psychosocial problems (illness) produced by the matton, but not personally and socially meaningful disease, as it is in the case of the Western doctor explanations. Modern clinical practice. however. who treats both the biochemical derangement in dia- which Horton does not consider separately from betes (disease) and the symptoms and psychosocial medicine as a science, involves translations between problems which comprise the clinical picture of dia- scientific and popular common sense rationalities. betes as an illness. Seen from this perspective either There is much to suggest that the professional clini- or both may be successfully treated. Problems in clini- cian still can provide (though he usually fails to do cal care seem to arise when the practitioner is con- so) explanations which are meaningful to patients and cerned only with curing the disease. and the patient their families [283. Or put differently. clinical rationa- is searching for treatment of his illness. Indigenous lity like popular rationality deals in personal and folk practitioners in Taiwan seem to be generahy social meaning as well as technical information. What more sensitive than Western-style doctors about is at issue perhaps is clarifying the role of personally treating iktrss. especially the personal and social and socially meaningful explanations in treatment. so problems it gives rise to. From the perspective of the that modern health professionals recognize it as an modern medical profession in Taiwan. indigenous important index patients and their families use to healers are viewed as dangerous because they cannot evaluate therapeutic efficacy. The alternative. of define the diseusr in scientific terms and fail to treat course. is to remove this from the clinical tasks per- it, which could have potentially disasterous results for. formed by the doctor. and make it a special task for patients. another type of health worker or assistant (nurse. sec- From the patient perspective. however. disease and retary, health auxiliary, etc.). In my view. while this illness are usually not distinguished. Most of the time may be an experiment worth trying. it would radically patients are concerned principally with symptom alter the doctor’s image. turning the healer into an relief and treatment of psychosocial problems pro- engineer or technician in his own eyes and those of duced by the stress of illness. But for many patients his patients, and consequently produce a situation that is not enough; they require explanations of their even worse than the one it seeks to remedy. It would health problems which are personally and socially exonerate a clinician from treatmg the psychosocial meaningful, and that usually requires the practitioner aspects of disease: causal and symptomatic. One of to explain about the disease as well as the illness. the chief contributions of behavioral and social Indigenous practitioners (especially sacred folk practi- science to clinical care should be to better conceptua- tioners) in Taiwan seem to be remarkably skilled at lize this explanatory function of clinical practice so judging when to talk about the disease and emphasize that it may be taught and practiced. Comparative its treatment, and when to talk in terms of. and direct cross-cultural studies provide an exceptionally good Why do indigenous practitioners successfully heal? 23

view of this question, and we anticipate that this is his illness would disappear entirely. Mr Chen’s wife’s one area in which they will continue to make relevant concern on one occasion that he continue taking his contributions to primary care in our own society. medicine and the approach of the t&g-ki’s chief male The complex issues which beset efforts by those assistant (who knew Mr. Chen much better than the trained in Western medical thought to determine efli- t&g-ki did) who gave him a type of supportive cacy of non-Western traditional clinical practice il- psychotherapy, focused on reducing his anxiety, both luminate the difficulties which inhere in an evaluation suggest a realization that Mr. Chen was suffering of the success of Mr. Chen’s treatment. from a chronic illness or constitutional tendency From a psychiatric perspective, Mr. Chen’s dis- which had to be kept in check by continued treat- order-his anxiety neurosis-is chronic. with recur- ment. The t&g-ki’s advice that he must return to the rent acute episodes. Therefore, there are times when shrine regularly is a sign of his recognition of the it is quiescent and times when it is fulminant. At the need for ,chronic care. Mr. Chen himself seems to time of our first formal evaluation, five days after the adopt this view at the time of our second follow-up initial treatment in the shrine and three days after visit, when he explains to us how evening visits to the apparently definitive treatment (as Mr. Chen de- the shrine are able to relieve anxiety building up over scribed it), and while he is still receiving therapy, both the course of the day. Mr. Chen’s subjective evaluation and our objective But a major discrepancy remains. Mr. Chen and one point to a significant therapeutic response. Were the Icing-ki are convinced his disorder has been cured. this our only follow-up. we no doubt would be I am not convinced, and suspect that treatment may tempted to evaluate Mr. Chen’s therapy as entirely not have altered the chronic course of his sickness, effective: Mr. Chen seems to be cured of his somatic as it is defined by my psychiatric explanatory model. and psychological symptoms. But three weeks later, Is Mr. Chen cured? The r&g-ki and Mr. Chen say his status is much as it was at the time of our initial yes. I am tempted to say no. The question again turns evaluation. Was this due to incomplete therapeutic on what is meant by cure. Mr. Chen’s symptoms have effect; the natural course of a chronic sickness with gone away, his chronic anxiety seems to be controlled, periodic remissions and exacerbations; or an acute and he has received and incorporated a personally decompensation owing to specific psychosocial stress, and socially meaningful explanation of his illness. By in which the chronic illness played a minor role and the definition of healing 1 gave above. he is cured. still might be regarded as improved since .he had In this sense, it does not matter if cure has been psychological symptoms without somatization? This brought about by the shrine, or a non-specific placebo is a problem for clinical judgement. But the evidence effect, or the natural course of the illness. Put differ- strongly suggests that. whereas the shaman’s treat- ently, Mr. Chen’s illness seems to have been success- ment may well have played a significant role in Mr. fully treated, .but not his disease. My prediction is Chen’s rapid recovery from his acute anxiety reaction that his symptoms will recur. But I also would predict (though this also may have been part of the waxing that they will go away again, as in the past, but per- and waning course of his illness), the return of acute haps more rapidly than in the past while he is treated anxiety three weeks later is most likely an acute recur- at the t&g-ki’s shrine. The acute illness will continue rence of his disease. That is. seen from the vantage to recur (and remit) as long as the underlying disease of three weeks of therapy. the chronic course of Mr. exists. But to demand evidence in support of the suc- Chen’s disease seems unaffected by treatment. though cessful treatment of the disease may be quite unfair, once again we have some evidence to support the because even with appropriate professional psychia- claim that it has at least partially ameliorated another tric care (tranquilizers and psychotherapy) it is un- acute episode (by affecting somatization). Our evalu- likely the disease would entirely disappear either. ations at three-month, five-month and seven-month This viewpoint leads me into treacherous ground. intervals are consistent with therapeutic success, Anxiety neurosis is not an entity but an explanatory because Mr. Chen is asymptomatic and without sig- model. Within the medical explanatory model 1 nificant signs of anxiety. But can we make such an employ, it makes sense to talk of it in terms of disease, assessment and be sure that what we are seeing is illness, and healing. These terms also seem appro- not simply the course of his disease, which merely priate because they are used by Mr. Chen. his family has not yet produced an acute recurrence? This is and friends, the shaman, and the other indigenous a difficult question that should be answered by sub- and Western practitioners Mr. Chen consulted. That sequent follow-ups. although some patients with this is. they make cultural sense. disorder can go years between acute episodes, but As with disease and illness. so with healing. It only even those usually demonstrate significant levels of makes sense to talk of healing from the perspective anxiety in the interictal period. Thus, the tcing-ki of certain explanatory models. From the theory of seems to have had a therapeutic effect on Mr. Chen. the health care system which I have advanced, healing but we can’t be entirely sure [29]. is not so much a result of the healer’s efforts as a From Mr. Chen’s perspective. and that of his wife, condition of experiencing illness and care within the older children. and friends. there was absolute cer- cultural context of the health care system. The health tainty that he had been cured by the time of our care system provides psychosocial and cultural treat: last three follow-up visits. Mr Chen was convinced ment for the illness by naming and ordering the ex- that he was cured at the time of our first follow-up perience of illness, providing meaning for that experi- visit. In fact. even when his symptoms recurred and ence. and treating the personal, family. and social his treatment became more active, he felt that he was problems which comprise the illness. Thus, it heals, essentially cured but that (as the thg-ki suggested) even if it is unable to effectively treat the disease. the god was testing him as part of a final trial before In Mr. Chen’s case. we see this very thing happening. 24 ARTHUR KLEINMAN and LILIAS H. SVSG

Let us offer a provisional and seemingly paradoxical What we have said is not meant to imply that indi- conclusion: Mr. Chen’s disease is not cured: Mr. genous therapy is entirely ineffective against all Chen’s illness is cured; and Mr. Chen’s health care severe. acute. and life-threatening. chronic diseases. In system, not the shaman and not his shrine, is respon- fact. it may exert placebo effect or directly effect such sible for that cure, i.e. Mr. Chen’s illness is healed diseases. For example. in the case of Mr. Chen. the by the cultural construction of clinical reality. In that therapeutic milieu of the r&g-ki’s shrine may have sense, the shaman and his shrine cannot do anything provided him with effective psychotherapy not only but heal Mr. Chen’s illness and the illnesses of others for the treatment of his illness. but perhaps also for like him, who are willing to participate in the cultural his underlying disease. We now know that all forms reality of the shrine and accept its explanatory of psychotherapy seem to work for a wide range of models, and whose personal and social problems are mental disorders [30]. The universal therapeutic com- effectively dealt with there. The same holds for ponents of psychotherapy [31] seem to be present in patients who actively and fully participate in the cul- both modern and traditional forms [32]. Thus. there tural reality of any form of clinical practice (indi- is much in favor of the argument that indigenous genous or modern) in which their illness is treated forms of psythotherapy may effectively treat certain by: (1) the provision of personal and social meaning psychological (and perhaps also psychophysiological) for the illness experience; and (2) the clinical resolu- diseases. Moreover, recent research on the physiologi- tion of personal and social problems constituting ill- cal effects of meditation, behavior therapies. biofeed- ness as a human experience. It is striking to realize. back. and placebos suggests a number of different however, that this kind of cultural healing is least ways by which indigenous therapies may effect biolo- likely to occur in the health care institutions of profes- gically-based diseases. In that the epidemiological sional medicine, whose clinical reality is so con- web causing and sustaining physiological diseases not structed as to discourage this most traditional type infrequently includes major psychosocial factors. indi- of healing of illness from happening, at the same time genous healing may at times work to effect such dis- as it strives to maximize the effective treatment of eases by altering those factors. Thus. to the extent disease. indigenous practitioners provide culturally legiti- mated treatment of illness, they must heal.

CONCLUSION: WHY INDIGENOUS . The equally startling corollary of this argument is. that in most cases modern professional clinical care PRACTlTlONERS SUCCESSFULLY HEAL must fail to heal. Why? Because most of primary gen- Based upon the material we have presented, we eral medical practice is made up of the same types draw the perhaps startling conclusion that in most of disorders found in indigenous practice [33]. Thus. cases indigenous practitioners must heal. Why? As we the majority of cases require successful treatment of have seen, indigenous practitioners primarily treat illness for there to be therapeutic efficacy. But the three types of disorders: (1) acute, self-limited (natur- physician is trained to systematically ignore illness. ally remitting) diseases; (2) non-life threatening, This represents a profound distortion of clinical work chronic diseases in which management of the illness which is built into the training of physicians. It pays is a larger component of clinical management than off on the appiication of biomedical technology to biomedical treatment of the disease; and (3) second- the control of disease, a less common but crucial ciini- ary somatic manifestation (somatization) of minor cal function, while it founders on the psychosocial psychological disorders and interpersonal problems. and cultural treatment of illness. which is a much The treatment of disease plays a small role in the more common clinical function. Failure to heal illness care of these disorders. The indigenous practitioner is not articulated in the health professional’s system usually (but not always) is exceptionally well poised of evaluating the efficacy of healing, but it is articu- to maximize psychosocial and cultural treatment of lated in patient non-compliance and dissatisfaction. the illness. Contrariwise, he may not be competent use of alternative health care facilities. poor and in- to effectively control severe, acute diseases. In the adequate care. and medical-legal suits. sample of twelve cases, only the two cases of severe, That many primary care physicians do, in fact. heal acute somatic and psychological diseases led to nega- most of the time is a function of their clinical skills tive evaluations of treatment by patients and families. in treating illness as well as disease, by which they From our standpoint, the case of the patient with overcome the profound limitations and distortions of progressively worsening congestive heart failure is modern health care. What is needed in modern health another example of ineffective indigenous treatment, care systems, in both developing and developed socie- despite the patient’s positive evaluation of the treat- ties, is systematic recognition and treatment of psy- ment. The cases of infants with infectious diseases chosocial and cultural features of illness. That calls being treated by both indigenous and modern profes- for a fundamental reconceptualization of clinical care sional practitioners suggest that families in Taiwan and the restructuring of clinical practice. For. If ap- are quite sensitive to this issue. They go to Western- propriately trained, the modern health professional style doctors for the control of potentially life-threa- (not necessarily a physician) can effectively and syste- tening diseases, diseases which Western medicine is matically treat both disease and illness. Whereas, in particularly effective in treating; and to t&g-kis for many instances, indigenous healers can neither syste- personally and culturally meaningful treatment of ill- matically nor effectively diagnose and treat disease nesses. They do not go to Western-style doctors for (biomedicallydefined). For reasons I do not have the the treatment of “fright”, which is a cultural illness, space to elaborate on here. this research suggests that but to practitioners poised to apply the culturally most indigenous practitioners (especially sacred prac- sanctioned treatment for this illness. titioners) cunnot be trained to systematically recog- Why do indigenous practitioners successfully heal’.’ 25

nize. refer. or treat disease. They cannot be incorpor- Warren and Milton Funds, Harvard University. ated into modern health care organizations. (In the Research was conducted from January to September, PRC, t&g-kis have not been made into barefoot doc- 1975. while I was Visiting Lecturer. Department of tors, but have been discouraged or prevented from Neurology and Psychiatry, National Taiwan Univer- sity Hospital. MISS Sung is still carrying out some of practicing.) However, certain kinds of indigenous the research. Preliminary reports of our research find- practitioners, such as Chinese-style doctors in Taiwan ings are found in Kleinman (1975b. 1975~): findings (and the PRC), and chiropractors and lay psychother- from the comparative cross-cultural study of practi- apists in the U.S., may be suited for integration into tioner ~patient relationships arc still being analyzed: modern health care. Kleinman A. Cross-cultural studies of illness and This leads me to argue for the creation of a clinical health care: a preliminary report. Bull. Chin. Sot. social science which would be involved in research, Neural. Psychiar. I, 14, 1975b: Kleinman A. Medical teaching, and the actual practice of clinical care. and psychiatric anthropology and the study of tradi- Clinical social scientists (anthropologists or sociolo- tional medicine in modern Chinese culture. J. Inst. gists) or social science-trained clinicians (psychiatrists Ethnology, Academica Sin. 39, 107. 1975~. 12a De Groot J. The Religious System of China, Volume or physicians) would translate and apply relevant be- VI. Book II. Part V. The Priesthood of Animism, pp. havioral and social science concepts through practical 1187-1340. Reprinted by Ch’eng Wen, Taipei, 1972. clinical strategies to real patient care problems and 12b. Hokkien words are romanized in the system of the training of clinicians. (They would, for example, Douglas [34] and Barclay [35], and are italicized in translate and negotiate between discrepancies in pro- the text. Mandarin (liuo rii. the national language of fessional and popular evaluations of clinical care.) In both Taiwan and the People’s Republic of China) that way, medical education and modern health care words are romanized in the Wade-Giles system, and would reintroduce the treatment of illness as a central are italicized in the text. clinical task, but one which is based upon a social 13. Liu C. Essays on Chinese folk beliefs and folk cults, (In Chinese). Monogr. 22, Inst. Ethnol. Academica Sin. scientific foundation for clinical science just as the Nankang. Taipei. Taiwan, 1974. treatment of disease requires a biomedical foundation 14. Ibid. for clinical science. 15. Tseng W. Traditional and modern psychiatric care in Taiwan. In Kleinman et al.. op. cit. 1976. 16. Kleinman A. The cultural construction of clinical re- ality: comparisons of practitioner-patient interactions in Taiwan. In Kleinman A. rf al. (eds) Culture and REFERENCES Healing in Asian Societies. Schenkman. Cambridge. 1. Miss Sung, who was Kleinman’s research assistant in 329-394. 1978. Taipei, carried out much of the research reported in 17. Kleinman A. Social, cultural, and historical themes .in this paper. However. because of considerations of time the study of medicine and psychiatry in Chinese and distance. it was not possible for her to take part societies. In Kleinman et al. (eds.) Medicine in Chinese in writing the paper. for whose content and conclu- Societies: Comparatice Studies of Health Care in sions the senior author is responsible. When “I” occurs Chinese and Other Societies. Fogarty International in the text. it refers to the chief author. Kleinman. Center. National Institutes of Health. Bethesda. 589- 2. Kieinman A. Some issues for a comparative study of 644, 1976. medical healing. Int. J. sm. Psd~iat. 19. 159, F973a; 18. Ahern E. Cosmological disorder: sacred and secular Cognitive structures of traditional medical systems. medicine in a Taiwan village. In Kleinman, er al.. 1976; Ethnomedicine 3, 27. 1974. Gallin B. Hsin Hsing. Taiwan. University of California 3. Cartwright A. Human Relations and Hospital Care. Press, Berkeley. 1966; Jordan D. Gods, Ghosts and Routledge & Kegan Paul. London. 1964; Davis A. Ancestors. University of California Press. Berkeley. Variations in patients‘ compliance with doctors’ 1972; Li Y. Y. Shamanism in Taiwan: an anthropo- advice: an empirical analysis of patterns of communi- logical inquiry. Lebra, W., (ed.), In Culture and Mental cation. Am. J. pub/. Hlth 58, 274, 1968: Stimson G. Health in Asia and the Pacific (Edited by Lebra W.) Obeying doctor’s orders: a view from the other side. Vol. 4. University of Hawaii Press, Honolulu, 1972; Sot. Sri. Med. 8. 97. 1974. Liu C. op. cit., 1974. Gould-Martin K. Medical sys- 4. Kane R. et a/. Manipulating the patient: a comp,rison tems in a Taiwan village. In Kleinman, et al.. op. cit., of the effectiveness of physicians and chiropractic care. 1976: Tseng W. Psychiatric study of shamanism in Lancer I, 1333. 1974. Taiwan. Arch. gen. Psychiat. 26, 561, 1972; Tseng W. Cay er al. Patient’s assessment of the result of surgery op. cit. 1976. for peptic ulcer. Lancer 1, 29. 1975. 19. I am indebted to Dr. Nancy Waxler for pointing this Shaver D. Opticiancy. optometry. ophthalmology: an out to me, first, in her own work in Sri Lanka (Ceylon), overview. Med. Care 12. 754. 1974. and then as a cross-cultural generalization. White K. Life and death and medicine. Scient. ‘Am. 20. A full description of this t&g-ki and his cult is found 229, 22. 1973. in Wang C. A folk doctor and his cult on Keelung Kleinman A. Toward a comparative study of medical St., in Taipei. Unpublished B.A. thesis. Department of systems. Sci. Med. Man 1. 55. 1973b, op. ca.: Kleinman Anthropology, National Taiwan University, 1971. (In A. Explanatory models rn health care relationships. In Chinese.) National Council of International Health: Health of the 21. Woodruff R. Psychiatric Diagnosis, pp. 58-74. Oxford Farnil),. National Council for International Health. University Press. 1974. Washington. D.C.. 1975a. 22. Tseng W. The nature of somatic complaints among 9. Klemman A. 1973b. 1974. 1975a op. cit. psychiatric patients: the Chinese case. Compreh. Psy- 10. Kleinman A. 1973b. 1974. 1975a op. cit. chiat. 16, 237, 1975. 11. Field research in Taiwan was made possible by grants 23. Approximately 177, of Taiwan’s 16 million population from the following sources: Foundations’ Fund for are Chinese who speak the Hakka dialect and are iden- Research in Psychiatry: Social Science Research Coun- tified as a distinct subgroup: the Hakka (K’e-chia-jen. cil: Harvard Yenching Institute: and the Dupont- “guest people”). The Hakka are ethnic Chinese who 26 ARTHUR KLEINMAN and LILIASH. SUNG

once lived in northern China and who long ago sure that my research assistant and I were aware of migrated from there to the south. primarily Kwang- this epithet.. tung province. From there many migrated to Taiwan. 25. Miss Sung recently made a two year follow-up of Mr. They are considered to be one of the most culturally Chen which found him to be asvmutomatic and doine traditional Chinese groups with a strong ethnic iden- just as well as at 7 months. He has become an impor: tity. They tend to be endogamous and reside in their tant and much respected member of the cult. own communities. Taiwan has several large areas that 26. Kleinman A. op. cir., 1973a. are predominantly Hakka. but in Taipei and other 27. Horton R. African traditional thought and Western large urban communities there now is considerable in- science. Africa 37, 50, 1967. termarriage with Taiwan’s predominantly Hokkien- 28. Kleinman A. op. cir.. 1975a. speaking population. However, in the past these two 29. Op. cit. ref. 25. groups frequently fought each other; and even now 30. Luborsky L. er al. Comparative studies of psycho- bitter feelings remain. Many of my Hokkien-speaking therapy: is it true that “everyone has won and all must informants held the following ethnic stereotype of the have prizes?” Arch gen. Psychiuf. 32, 995. 1975. Hakka: more achievement-oriented, more intellectual, 31. Frank J. Therapeutic components of psychotherapy. more filled with their own sense of importance, more J. new. men. Dis. 159, 325, 1974. close-knit, more concerned with cleanliness, and more 32. Tseng W. op. cit.. 1976. traditional in beliefs and customs than the Hokkien 33. Stoeckle J. et al. The quantity and significance of population. These views are portrayed in negative psychological distress in medical patients. J. chron. Dis. terms with resentment for what are seen as the 17, 959, 1964. “strengths” of Hakka culture. Of interest, many Hok- 34. Douglas C. Dictionary ofthe Vernacular or Spoken Lan- kien people have an impression (one I share) that guage of Amoy. Presbyterian Church of England. Lon- Hakka are overrepresented in the medical profession don, 1873. (Western and Chinese). 35. Barclay T. Supplement to Carsrair Douglas’ Dictionar~~ 24. The shrine’s t&g&i, an extremely shrewd person. 01 the Vernacular or Spoken Language of Amoj,. Com- assigned me this same tutelary god, “Monkey”, making mercial Press. Shanghai. 1923.