One very useful way to begin to understand how culture influences individuals' beliefs concerning the preservation of health, the causes of illness, and appropriate courses of action to take in the event of illness is the concept of cognitive schemas (Angel & Thoits, 1987; D'Andrade, 1992, 1995; Langacker, 1987; Singer & Salovey, 1991). Schemas refer to culturally based embedded and hierarchical abstractions concerning both categories and processes (D'Andrade, 1995). Several schemas are involved in recognizing, labeling, and acting on any aspect of reality, in our case, symptoms and illnesses. Schemas can perhaps be best conceived of as stored bodies of lore, knowledge, and experience that we use to make sense out of raw input. Obviously, the concept of schema is only a useful way of characterizing the complexity of human cognitive processing. Schemas do not exist in some specific area of the brain, and they are constantly being revised and altered as we experience new things and learn about the particular aspect of reality to which they refer (Angel & Thoits, 1987).
Schemas concerning health and illness are particularly salient to the study of health and illness because they influence what we label and react to as pathological and how we respond to symptoms and deviations from what we consider normal. They also help influence our perceptions of good health and what we need to do to maintain it (Angel & Thoits, 1987). D'Andrade (1995), a leading cognitive anthropologist, provides a useful example of the importance of understanding illness-based schemas in determining how people make sense of illnesses. D'Andrade has carefully studied American's beliefs about illness. His work began with the traditional anthropological categorization of symptoms and illness in terms of their characteristics. For example, people find it simple to categorize specific illness in terms of such statements as "you can catch_from other people," or "_is the result of old age," or "-
runs in families." In one study, D'Andrade had his college student respondents categorize 30 illnesses in terms of 30 such statements for a total of 900 judgments. By examining the logical connections between these, he was able to reduce the number of meaningful clusters to three: (a) those consisting of illnesses that are serious, fatal, crippling, affect the heart, and are not experienced by everyone, (b) those illnesses that are caused by germs or a lack of resistance, contracted in cold weather, accompanied by a fever, sore throat, or runny nose, and are not crippling or incurable, and (c) diseases that have no cure, run in the family, indicate old age, and are caused by emotions (D'Andrade, 1995, pp. 127-128).
Although these clusters make sense to participants in the culture that produced them, D'Andrade was dissatisfied by the fact that the categorizations themselves provide no information on how they are generated. As a sensitive observer, he came to realize that in order for one to understand how people make judgments about illnesses, one must understand the schemas that give rise to the categorizations. D'Andrade's focus on schemas provides a potentially fruitful way of examining the social and cultural aspects of health and illness. Culture, as it is reflected in our internal schemas, influences how we interpret symptoms, feelings, and behaviors, both our own and those of others. Through its influence on interpretive schemas, it defines what is healthy, acceptable, and normal, and what is ill, deviant, and abnormal. The task for researchers is to discover new and imaginative ways of studying individuals' schemas as they relate to health and illness, and to determine exactly how those schemas are influenced by culture and social class.
Unfortunately, the concept of schema introduces a serious complexity into the study of the cognitive aspects of illness. There is no reason, in fact, to treat schemas as if they are entirely cognitive (D'Andrade, 1995). Cognitions, after all, are closely tied to basic emotions and physiological processes. The complexity introduced into the study of culture and human cognition by the concept of schema makes our task of understanding illness behavior more difficult, but it clearly reflects the real complexity that exists in this world of mingling cultures. The concept of culturally influenced schema is a clear theoretical advancement because it goes beyond the notion of culture as a set of rules or norms that inevitably structure behavior or understanding. Schemas are highly malleable, and individuals can use them or aspects of them as their personal agendas require. It is important, after all, to view the human actor as a culturally embedded, yet autonomous actor who need not be led blindly by aggregate beliefs and practices. Rather, he or she should be understood as someone who can pick and choose from the cultural repertoires with which he or she is presented.
VI. PSYCHE AND SOMA: THE MIND-BODY DISTINCTION IN WESTERN MEDICINE
To be human is to inhabit a body. Yet the notion of inhabiting a body implies that there is some nonmaterial essence that coexists with the body, but that is in some way separate from it. Such an entity can be seen as a soul or a vital force, or perhaps even the "mind." Cultures differ in the extent to which they differentiate between the physical and the nonphysical aspects of the self. In the West, both medical and popular discourse differentiate between the mind and the body, or the psyche and the soma, to use the Greek roots that refer to these aspects of the self (Lock, 1993; Lock & Scheper-Hughes, 1996; Pollock, 1996). The psychological and psychiatric specialties deal with disorders of the mind and emotions, and somatic medicine treats the body and its disorders. What mind actually consist of is a matter of continuing debate, and we will leave the resolution of that debate to philosophers and cognitive scientists. What is of great importance for our purpose, though, is the fact that in the West people differentiate between the mind and the body in how they talk about symptoms. In the United States we feel "stressed" or "depressed" or "anxious," and we attribute nonphysical causes to these feelings. Other cultures do not differentiate between the psychological and the somatic in quite so clear a manner (Angel & Guarnaccia, 1989; Kleinman, 1988b; M. Rosaldo, 1984).
VII. CULTURE, EMOTION, AND HEALTH
The intensely personal and subjective nature of illness leads us to the realization that emotion and illness are closely intertwined. When one is ill, one feels discouraged, anxious, tired, and so on. As critics of extreme mind-body dualism point out, physical illness has immediate emotional correlates, and emotional distress can manifest itself somatically. Those cultural factors, therefore, that influence emotion and self-perception are highly salient in the study of cultural influences on health.
A growing body of anthropological literature is providing convincing evidence that although basic emotions may be the same in different cultures, the events and contexts that elicit them and provide labels for emotions such as anger, shame, and despair can be rather different. Behaviors by others that threaten one's sense of self in a culture like that of the United States in which individuality and personal autonomy are valued may cause anger, whereas similar behavior in a less individualistic Asian culture may not elicit that particular emotion. It would be possible, but also a mistake, to conceive of the schema governing illness perception and behaviors as purely cognitive. The culturally based cognitive aspects of schemas clearly give meaning to symptoms and behaviors, but they also directly elicit such emotions as fear, anxiety, or anger. The emotional aspect of illness, therefore, must be understood in conjunction with its cognitive aspect.
In recent years the study of cultural influences on emotions and self-concept has blossomed (Cousins, 1989; Heine & Lehman, 1995; Holland & Quinn, 1987; Kitayama & Markus, 1994; Markus & Kitayama, 1991; Marsella, DeVos, & Hsu, 1985; Pollock, 1996; Shweder & LeVine, 1984; Shweder & Sullivan, 1993). The core question motivating these investigations is whether or not emotions are culturally universal (Wierzbicka, 1986). The growing consensus, and our own view, is that cognition and emotion are intimately intertwined in specifically contexualized ways. In Michelle Rosaldo's words, "feeling is forever given shape through thought and thought is laden with emotional meaning" (M. Rosaldo, 1984, p. 143.). What elicits anger or fear or insecurity or any other emotion or feeling depends upon what we, as cultural actors, find enraging, frightful, or threatening.
Together the mind and the body make up the "person" whose personal experiences are interpreted and influenced by the social context that defines the local moral order (Fabrega, 1974; Kleinman 1988a, 1986; Kleinman & Good, 1985; Lock, 1993; Pollock, 1996). In Asian societies, in which interdependence is valued over independence, the self is construed much more collectively than in the West, and emotional responses to what are viewed as threats to the self are commensurately different (Heine & Lehman, 1995; Kitayama & Markus, 1994; Kitayama, Markus, Matsumoto, & Norasakkunkit, 1997; Markus & Kitayama, 1991; Scherer, 1997; Suh, Diener, Oishi, & Triandis, 1998). Such culturally based aspects of the self-concept are affected by acculturation and one's degree of identity with a traditional or host culture (Rhee, Uleman, Lee, & Roman, 1995), and, given the changing nature of culture, they are clearly historically and politically situated as well (Schooler, 1996).
In order to help make sense of the complexity involved in the association between culture and health, we posit a basic model with two axes around which the literature indicates that individuals and cultures construe illness. In the figure below, an illness definition model, the horizontal axis differentiates between what is publicly observable (objective) and what is entirely private (subjective). This axis allows us to differentiate between those aspects of disease and sickness that are publicly visible or that can be objectively diagnosed and verified, and those that cannot be verified by an external observer. A florid psychotic episode, for example, provides public verification of psychiatric disease, especially when it is combined with a physician's diagnosis. Cancer or heart disease, as clinical entities, can be diagnosed through clinical tests.
Subjective experience, on the other hand, cannot be objectively verified and remains the privileged domain of the individual. It is, in principle, private, and information that an individual provides concerning his or her internal state must be taken at face value because it cannot be objectively verified. Much mental illness and personal suffering is of this nature; when there are no objective tests that can be employed to verify the existence of pathology, self-reports of subjective states serve as the only markers of illness. When no objective indicators of disease are present, an individual is at risk of being considered a malingerer or hypochondriac.
On the vertical axis of the model we differentiate between the mind (psyche) and the body (soma). As noted, in the West we differentiate between somatic illness and psychiatric illness in medical specializations, as well as in public discourse. As the work we cited earlier makes clear, though, not all cultures differentiate between the mind and the body to this extent. Nor, we would add, does our subjective experience. More traditional cultures typically view the self as holistic and illness as consisting simultaneously of physical, mental, and even social components.
Although there are clearly other dimensions that we could introduce, this model emphasizes two important dimensions that are directly affected by culture. Western biomedicine focuses most heavily in the somatic/objective quadrant and deals with physical diseases with clear biological markers. The softer sciences, including social psychiatry, focus more on the psychic half of the model, especially on the social and cultural influences on disease.
B. Somatization: An Example
The fact that subjective experience does not differentiate between physical and mental states has important implications for research on culture and health, as well as for clinical practice (Angel & Thoits, 1987; Lock, 1993; Lock & Scheper-Hughes, 1996). Angel and Guarnaccia (1989) illustrate how emotional status and perceptions of physical health are intertwined in a study that used survey responses from a large sample of Mexican Americans and Puerto Ricans in the United States. This study illustrated the fact that standard survey methodologies, which are frequently used to assess physical and emotional status, may confound the two, because individuals do not distinguish between the physical and the emotional in their lived experience.
This work is part of a tradition dating from Zborowski's (1952) classic study in which he found that individuals from different ethnic groups respond to pain differently, and subsequent research that documented a tendency among members of traditional cultures to "somatize," a term used to characterize the tendency to express affective distress or social discord as physical (somatic) illness
(Grau & Padgett, 1988; Katon, Kleinman, & Rosen, 1982a, 1982b). Somatization refers to the presence of physical symptoms for which there is no diagnos-able physical pathology (Kirmayer, 1984a, 1984b). In somatization disorder the body serves as a medium for expressing social and emotional distress. The expression of affective distress somatically is common among the old and the poor, who must deal with physical decline, isolation, and poverty (Grau and Padgett, 1988; Kleinman, Good, & Guarnaccia, 1986; Krause & Carr, 1978).
One of the major motivations for the study of the role of affective distress on physical illness is the consistent finding that a large proportion of those seeking general medical services have little organic basis for their symptoms (Grau & Padgett, 1988; Katon et al, 1982a, 1982b). In their study, Angel and Guarnaccia (1989) used the Hispanic Health and Nutrition Examination Survey (H-HANES), a large-scale epidemiological and health survey in which respondents received a physical examination, to compare a physician's overall assessment of an individual's health to the respondent's own assessment. The physician and the respondent independently rated the respondents health as excellent, very good, good, fair, or poor. Angel and Guarnaccia found that respondents who had high scores on a standard depressive affect scale, the Center for Epidemiologic Studies Depression scale (CES-D), rated their health as significantly worse than did the physicians. This association was significantly affected by the language in which the survey was conducted. It appears, then, that rates of physical illness and psychological distress that are found using standard survey instruments are potentially influenced by factors related to culture, language, and level of acculturation (Angel & Thoits, 1987).
Angel and Guarnaccia (1989) also reported large differences between Mexican Americans and Puerto Ricans in levels of affective distress. Although the association between depressive affect and negative assessments of physical health held for both groups, Puerto Ricans reported much higher levels of affective distress and poorer physical health than Mexican Americans. Researchers, in fact, consistently find that Puerto Ricans score higher on standard symptom checklists than any other ethnic group (Dohrenwend, 1966; Haberman, 1976, 1970; Srole et al., 1978). This may, of course, reflect differences in the social desirability of the symptoms in the scales (Dohrenwend, 1966), or it may be a reflection of cultural patterned ways of expressing distress (Haberman, 1976).
With the data available it is not possible to definitively determine why Puerto Ricans score so much higher on scales of affective distress than other groups. Angel and Guarnaccia (1989) speculate, however, that the symptoms included in the scales used in these studies are similar to those that are typical of a condition called nervios (nerves) in traditional Puerto Rican and other Hispanic cultures. Nervios is a culturally meaningful idiom of distress among Puerto Ricans. Those who have recently arrived from the island, and who are experiencing hardship may well express their distress using this idiom (Angel &
Guarnaccia, 1989; Kleinman et al., 1986; Krause & Carr; 1978). Symptoms of nervios include, headaches, trembling, heart palpitations, stomach and appetite disturbances, trouble with concentration, sleep problems, and worrying (Guarnaccia & Farias, 1988). Sufferers are more frequently women than men, and they are disportionately from rural and lower class backgrounds.
Certain evidence suggests that Mexican Americans may also express distress in terms of a similar idiom. A study of schizophrenics by Jenkins (1988) found that Mexican-American families characterized their family member's schizophrenic symptoms as symptoms of nervios and that they focused on a series of somatic complaints that tended to destigmatize the illness. Unfortunately, the literature on psychopathology for Mexican Americans provides quite inconsistent findings (Angel & Thoits, 1987). Again, though, the data reveal that the social desirability of symptoms, levels of acculturation, and culturally specific response styles influence responses to survey probes in, as yet, poorly understood ways.
Much research will be necessary to better understand what cultural factors affect the subjective experience of mental and physical illness and its expression. Numerous anthropologists have worked on this problem (Frake, 1961; Gaines, 1992b; Good, 1977; Kleinman, 1986; Kleinman & Kleinman, 1985; Manson, Shore, & Bloom, 1985). The importance of a better understanding has been made clearer by the very cosmopolitan nature of the modern world. In recent years the number of large multinational projects has increased, and it has simply become impossible to ignore local cultural and social class influences on health. Increasingly, even quantitatively oriented researchers are beginning to appreciate the importance of ethnography in epidemiological and health studies (Pelto & Pelto, 1997; Trostle & Sommerfeld, 1996).
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