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Explanatory Models in Psychiatry Explanatory models in psychiatry The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Weiss, Mitchell G and Daryl Somma. 2007. Explanatory Models in Psychiatry. In Textbook of Cultural Psychiatry, eds. Dinesh Bhugra and Kamaldeep Bhui, pp. Cambridge; Cambridge University Press. Published Version doi:10.1017/cbo9780511543609.012 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:23593201 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA Explanatory models in psychiatry Mitchell G. Weiss and Daryl Somma EDITORS' INTRODUCTION the biopsychosocial model. They are also aware of possible critique of the model. This critique includes the perceived Similar experiences of illness or distress are seen as being fixed and static nature of the model and that clinical inter- caused by different elements across different cultures. ests do not take into account the injuence of social context. Feeling gutted and sinking heart are idioms of distress Perhaps the most significant criterion is based on the ques- which are remarkably different across cultures, but their tion of whether too much emphasis on the model in explan- implications at an individual level are very similar. atory model exists. Models are important for developing Furthermore, the causation of the distress will be seen as theory and for research. The approach remains a useful remarkably different. It is evident that, in traditional cul- one for bridging the interests and experiences of clinicians tures, the locus of control may be seen as external which may and their patients. be coloured by cultural expectations, whereas in others the locus of control may be internal. Within each culture, how- ever, individuals may carry their own explanations which Introduction may or may not be strongly influenced by individualS cul- ture. From a clinical perspective, it is crucial that clinicians Over the past three decades the illness explanatory are aware of explanatory models that patients bring to the model framework has stimulated research in clini- therapeutic encounter so that engagement can begin. cally applied medical anthropology, guided clinical Weiss and Somma examine the concepts of the explan- training, sparked controversy in the health social atory model frameuork, its appeal to health professionals and social scientists as well as its limitations. The illness sciences and guided developments in the field of explanatoryframeworkdeals with notions aboutan episode cultural psychiatry. This formulation of explanatory of illness and its treatment by all who are engaged in the models was conceived both to advance perspecti- clinical process and understanding these models means that vism in clinical medical practice and public health, patients' uiews on their conditions are being acknowledged. and to show how ethnomedical study of sickness Weiss and Somma emphasize that the model must be dis- and medicine should contribute to cultural anthro- tinguishedfrom other ways the term is used which may refer pology and social analysis. The appeal of the explan- to the nature of health and other problems in general. They atory model framework for clinical training is based explain three formulations of illness explanatory models on the premise that it is important to examine rela- and describe conceptual underpinning of the illness explan- tionships and consequences of interactions atoryframework. In the beginning of the illness explanatory between patients' ideas about their health problems model framework provided a means of bring cultural differ- ences between patients and clinician (especially when they and those of clinicians and professionals who are came from different ethnic and cultural backgrounds) in responsible for their care. Although the clinical multicultural settings. However, Weiss and Somma illus- interests and applications of illness explanatory trate that this approach should also be seen as managing models extend to all aspects of medicine, it was concerns about an imbalance over-emphasizing biology in mainly experience and interest in psychiatry and Textbook of Cultural Psychiatry, Dinesh Rhugra and Kamaldeep Bhui (eds.). Published by Cambridge University Press ,I. Cambridge University Press 2007. 128 M. G. Weiss and D. Somma culture, and their effects on medical practice clinical interest, explanatory models were particu- through consultation liaison, that spurred initial larly notable because they acknowledged the signif- interest and development of the illness explanatory icance of patients' points of view as complementary model framework. In bridging the interests of psy- to health professionals' assessments. In that sense, chiatry, medicine and medical anthropology its they referred not so much to formal structural or influence has been unrivalled. predictive models, but rather to the way people This chapter examines the concept and underpin- think and speak, as a way of explaining illness nings of the explanatory model framework, its (Helman, 2004). appeal to health professionals and social scientists This formulation must be distinguished from and its limitations. Because it was defined in very other ways the term explanatory model is used, simple terms and applied to so many clinical and which may refer to the nature of health (and other) social science questions, the idea of illness explan- problems in general, rather than anchored to spe- atory models means different things to different cific illness episodes and experiences. Social scien- people, and various ambiguities and misinterpreta- tists and empirical researchers in many fields tions have resulted. Consequently, some psychiatrists, commonly apply the term explanatory model to other health professionals and social scientists have statistical models, analysis of epidemiological pat- been wary of its influence and the possibility of over- terns and theoretical propositions about a wide selling its significance, and we examine the nature of range of phenomena. If we distinguish studies of their critiques. The chapter concludes with a discus- Kleinman's illness explanatory models from these sion of the current role of explanatory models in generic non-illness explanatory model studies, one cultural psychiatry, approaches to studying explan- finds the latter are far more frequent in the medical atory models and their influence on the develop- literature (e.g. 'Crowding and violence on psychiat- ment of cultural epidemiology. ric wards: explanatory models'; 'A test of two explanatory models of women's responses to batter- ing'; 'Explanatory model to describe school district What are illness explanatory models? prevalence rates for mental retardation and learning disabilities'). When we examined 677 Medline refer- The illness explanatory model framework as it is ences with the term explanatory model or explana- now commonly understood developed in the late tory models in their title or abstracts in March 2006, 1970s, and it is associated most closely with the we found 181 of these citations were for articles influence of Arthur Kleinman and networks in cul- concerned with illness explanatory models, and 62 tural psychiatry, medicine and medical anthropo- were concerned with mental-health problems logy. Among various accounts in the literature, one (Table 10.1). that is frequently cited defines the illness explana- The illness explanatory models of patients, family, tory model as 'notions about an episode of sickness doctors and others concerned with health problems and its treatment that are employed by all those and the clinical process did not refer to a professio- engaged in the clinical process', (Kleinman, 1980, nally elaborated explanatory theory or to research p. 105). Interest in explanatory models was equally findings derived from empirical study of explana- concerned with everyone involved in clinical tory variables and outcome measures, even though encounters. At the outset, inasmuch as explanatory they might be influenced by them. Instead, these models were expected to provide a framework to explanatory models were representations of illness, guide ethnomedical study of societies and health described with reference to a set of cognitive systems, attending to 'the conceptions of sickness explanations; symptomatic, emotional and social held by patients, communities, practitioners, and experiences; and to prototypic personal history researchers' was essential (Kleinman, 1977a). As a and associations that collectively characterized the Explanatory models in psychiatry 129 Table 10.1. Medline illness explanatory model studies less concerned with experience, behaviour or social and their focus on psychiatric problems over successive factors as contexts, unless they are identified as 5-year periods causes. This conceptually scaled-down version of explanatory models may simplify the clinical ethno- Period All illness EMS Mental-health problem EMS graphic enterprise to a degree that seems simplistic N N Percentage from an anthropological perspective. On the other hand, for clinicians with little interest in engaging in 1976-1980 1 0 social science research, or even in any kind of 1981-1985 14 1 7.1 research, working with a clear operational definition 1986-1990 25 7 28.0 enhances the appeal of this formulation.
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