Ecological Understandings and Cultural Context

I enjoyed this paper but I’m doubtful whether it can be considered at all as a signal advance on existing procedures. The contribution to psychiatry of “illness narratives” (Kleinman 1988)—the stories and explanations which people volunteer about their episodes of illness—is now well recognized, as is the idea that to understand the illness we must situate it in the patient’s culture in the fullest sense—within knowledge about the body and its ills, ideas of causality and individuation, as well as the more observable restraints of social position, the demands of others, and any intention or goal on the part of the patient. Psychiatric modes of understanding and treatment are now well recognized, both in small-scale societies and in the urbanized industrial West; nor is blaming the healer for actually carrying the disease particularly unusual.

I’m doubtful whether any greater understanding of biosocial facts is achieved through the multimodal framework (MMF). Samuel (1990) doesn’t offer any convincing demonstration that his typology offers a more plausible or useful approach than any other to, say, Ndembu possession. The “ecological” way of putting it was outlined earlier this century for clinical psychiatry by Adolf Meyer in his “psychobiological” model; surely it is now evident that a full account of any human pattern entails looking at the biological, the psychological, and the social (e.g. Littlewood 1997), but we cannot assume a priori that all these would (or should) fit neatly together as the terminology “of a single environment” proposes. Obvious biological understandings rely on naturalistic thinking—on cause and effect relationships independent of human awareness, while with the social we have by contrast to take human agency into account, along with representation, memory, planning, and deceit. And discrepancies between different ways of understanding may themselves be fundamental to the social articulation of certain illnesses like myalgic encephalomyelitis (disease? malingering?) or psychopathy (mad? bad?). Our professional uncertainty guarantees its practical utility.

To presume to fit these neatly together as “ecology” seems to involve a certain sleight of hand. The claim that “many cases of illness should be viewed as manifestations of distress in the ecologically embedded individual,” or that such cases must be understood “in relation to the dynamic network of reciprocally constraining relationships and contexts in which they are embedded,” is little more than bland holism. Deeley illustrates the resources of the ecological perspective with the story of an eighteen-year-old Indian lady with aphonia. But to refer her failure to get better back to “aspect 7” of the MSi hardly amounts to an adequate understanding of her case; it is merely an unconvincing citation of an abstract typology on which the possibility of change or no change is already written. It doesn’t advance our understanding at all, but it does at least make it seem more scientific. And at which particular ecological level can we then argue certain patterns as “maladaptive” (Littlewood 1991)?

I would suggest that the young woman’s experience can be understood adequately if we know much more about her culture and her situation within that culture: the significance of exams for her, her personality and past experiences, the significance of spirit possession for her family (how much do they live generally in an ultrahuman world?), the meaning of Islam for a Hindu family, expectations of the efficacy of puja or medical treatment, etc. In other words, a “thick” description of her life world (as the phenomenologists put it) is currently lacking.

My emphasis on cultural meanings and intentions is not to say that a full social specification of the observed pattern is plausible, that our ability to dissociate is somehow to be taken for granted. On the contrary. But we can do so without the MMF. Trimble’s speculative hypothesis about left-sided symptoms being more common in hysteria is obviously relevant, but we need to bring in the context of the exceptional cases, and the field of data on hypnosis and spirit possession, and of course the local significance of bilaterality (Needham 1977).

An unrelated point: I’m not sure that the whole idea of psychoanalysis’ hidden...