Session 4b: Explanatory Models
Chair: Gretchen Dobrott

Sense and Sensibility’ - Medical Pluralism in Postsocialist Croatia
Tanja Bukovcan
Department of Ethnology and Cultural Anthropology, Faculty of Humanities and Social Sciences, University of Zagreb, Croatia

In the presentation I will outline my PhD research, the main topic of which was medical pluralism in postsocialist Croatia. The research deals with interrelatedness and co-existence of biomedical and non-biomedical systems in the city of Zagreb, the capital of Croatia. The staring point of my research were the patients, their attitudes towards illness and health and their reasons for the selection of specific therapies, healers and/or medical systems, as well as the factors (cultural, social, generational, educational, religious, political-ideological, financial) which determined their choice.
The postsocialist period in Croatia started in the 1990ies and, among other changes, brought about significant changes to the biomedical health care system, which became less state funded and much more market oriented and, as the consequence, more expensive to the end-users, the patients. Simultaneously, and maybe partly because of this, the non-biomedical systems were more ‘loud’ and more visible, ranging from folk healers, herbalists, through exorcists, bioenergy practitioners to ayurveda or acupuncture.
My research findings were the following: for the majority of the people I interviewed biomedicine came first, but in case of chronic, terminal or psychosomatic illnesses, they sought alternative therapies ranging from folk healers to established non-Western medical systems.
As an ethnographer, I was faced with moving stories of loss and trauma (stories of war refugees, patients with PTSS, disabled people), as well as stories of miraculous healings and becoming well again (‘feeling like being born again’) which made me re-examine my position of observer, interpreter and analyst. Anthropology’s unique possibility of understanding and interpreting other cultural norms and relams and its application to this very sensitive field full of emotional attitudes, opinions, beliefs, metaphors and meanings may, in the case of applied medical anthropology, suggest a possible shift towards acitivism.

Indignation in a Cross-cultural Clinical Context
Nathalie Dinh
Université de Montréal, Département de Psychologie and Culture & Mental Health Research Unit, Sir Mortimer B. Davis - Jewish General Hospital, Montreal, Quebec, Canada

Culture is an essential variable of diagnosis and treatment. A cultural perspective draws attention to the social context within which symptoms arise, are given meaning, and are managed. Ethno-cultural work on illness narratives suggests that most people can provide culturally-based explanations for their symptoms. While these explanations are inconsistent with biomedical theory, they relieve patient distress by allowing the patient to create meaning for symptoms. Exploring the characteristics, context, and antecedents of the symptoms enables the patient to convey them to the clinician who may have a divergent explanation of sickness. This case study uses the Cultural Formulation Guidelines of the DSM-IV created for clinicians to elicit a narrative account of the illness experience from the patient. It examines how the patient, a Laotian, diagnosed with post-traumatic stress disorder, used social indignation (“kwam khem keuang”) as an explanatory model after he underwent a traumatic amputation. In explaining his illness through a cultural idiom, the patient was able to reveal both personal meaning of repressed anger and frustration, expressing them in a cultural context that was acceptable to him. This cultural idiom, allowed the patient to reflect upon the structure of the health care system and the specific context in which symptoms and their possible origins are recounted and explored. It also clarified to the treating clinicians some categories of experience and causal explanations that did not fit easily with western biomedical and psychiatric understanding. The case study illustrates how a cultural approach to illness from the patient’s perspective offers a reflexive stance on the clinician-patient interaction that allows for better patient care.

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Explanatory Models of Mental Illness in Urban Tanzania
Samrad Ghane
Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands

“Explanatory models of illness” are perceived as core components of illness experience. These models offer explanations of illness and suffering, and hence construct personal and social meaning for the experience of illness.
The interaction between the illness beliefs of patients and practitioners is thought to be a fundamental factor in (mental) health care. Changes in popular views on illness and healing, following contact with biomedical knowledge and practices, do not necessarily involve the accommodation of professional beliefs. On the contrary, patients may transform, reinterpret and subsequently integrate elements of professional models in previously held systems of thoughts. So far, only a few studies have incorporated a prospective method, allowing a direct observation of belief changes, and none has carried out an in-depth analysis of these changes among patients, diagnosed with a mental disorder.
This paper draws upon an ethnographic fieldwork in a psychiatric hospital in Tanzania, aimed at understanding changes in explanatory models of mental illness among individuals who sought (western-oriented) psychiatric treatment.
In taking a critical approach towards the original concept of “explanatory models”, the paper will, firstly, discuss methods, through which patients constructed and altered their models and narratives. Secondly, attention will be given to the professional views on illness causation, and the way they affected the diagnostic and treatment decisions. Finally, the interaction between the professional and lay explanations of illness will be described within the context of a Dr/patient relationship, marked by hierarchy and power inequality.

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