EDITORIAL COMMENT
Culture and the Psychosomatic Tradition It is not widely appreciated that culture, viewed simply as a system of meanings that promotes adaptive group living in higher animal forms, has played an integral role in human evolution and also is fundamental to the psychosomatic tradition. Culture operated as an increasingly adaptive feature of group living that was progressively elaborated in the line of evolution leading to man. Put differently, culture constituted a basic characteristic of hominid behavioral ecology in terms of which natural selection operated: Refinements in the genotype and behavior were based on a cultural mode of living and progressively added to it. The concept of culture has played a somewhat ambiguous role in the psychosomatic tradition, however. It has usually been used merely to refer to a person's society, ethnic affiliation, or language. In operating as a possible marker of identity, culture has distinguished between subjects and has functioned as a variable, like age, sex, or social class. Implicit in this usage is the notion that the identified subjects might think or orient differently to the world and that this difference might be associated with distinctive psychosomatic profiles. A problem has been that the concept of culture or ethnicity as a marker of identity has been assumed to refer to nonbiological sorts of things when in fact this particular meaning is hopelessly confounded with what is ordinarily meant by race, which in its correct populational sense, is replete with genetic and physiological implications. Psychosomatic Medicine 54:561-566 (1992) 0033-3174/92/5405-0561 $03.00/0 Copyright © 1992 by the American Psycho
Attempts to limit the concept of culture to purely mental sorts of things (knowledge structures, cognitive tenets, valuational dispositions, or aesthetic preferences) have clarified analytical problems but have created empirical ones (1, 2). Indeed, when a rigorous pursuit is undertaken for indicators of this meaning of culture, the concept seems to dissolve into a plethora of psychological variables and to lose its integrity and seeming analytical power. This sense of culture as measurable psychological variables when applied to the study of psychosomatic phenomena would appear to reduce culture to dry and operational procedures that bear no close relation to what one visualizes by the evocative image of cognitive/emotional/ valuational differences, etc. Anthropologists who take seriously the concept of culture in its purely mental sense have emphasized cognitive/symbolic structures or systems (1); some have used fairly rigorous mathematical procedures (2-4), and others have raised provocative questions about emotional experience (5). These efforts have yielded penetrating insights about human experiential differences. However, so far it has not been possible to link these insights with topics central to the psychosomatic tradition. The mental/conceptual approach to a definition of culture has proven of considerable value to scientists who seek to clarify problems of behavior using principles of evolutionary biology (6). In this instance, culture has served to demarcate a 561
EDITORIAL COMMENT
domain very separable from, but complementary to, that of the biological. Man has been seen as constituted of two types of information, genetic and cultural. The one is inscribed in the material that is physically inherited and the other in the conceptual material that is learned through language and the modeling of behavioral routines that are found in the social environment. Both types of information have an existence "prior to an individual"; both are also "passed on" across generations and both together serve to program behavior and physiology. Both types of information can be reduced to units (genes and cultural traits or "culturgens") that are subjected to the process of natural selection and, hence, both types of information pools evolve (7). The genetically inherited information shapes how and what type of cultural information is incorporated; this has been conceptualized in terms of "epigenetic rules" or "psychological adaptations" (8, 9). Both terms refer to the way genetically based brain processes (designed by natural selection) affect the way culture is learned and implemented. Recently, purely cognitive phenomena (e.g., strategies underlying mate selection, parentoffspring relations) have received the attention of sociobiologists and evolutionary psychologists interested in elucidating the psychological structures designed by natural selection (8, 10-12). Ethological studies have also explored relations between social behavior and physiological regulation (13); this has obvious relevance to how genetic structures are affected by cultural experience. It is clear that psychosomatic issues are embedded in these evolutionarily based substrates of experience and behavior. In such things as pain, autonomic functioning, and endocrine regulation, one en562
counters mental and bodily phenomena whose interrelations and mechanisms are a product of the evolutionary process and which function to program behavior that was naturally selected. Throughout evolution, culture has linked the genome to the learned information about the behavioral environment (14) and in the process, culture regulates physiology. The paper by Ware and Kleinman in this issue of the journal richly illuminates and advocates extending the territory of psychosomatic tradition. It does so by emphasizing the social/interpersonal dimension of culture. In concentrating on two complex sets of body experiences and culturally defined illness profiles and trajectories, the authors manage to show the evocative and analytic power of a widely influential contemporary emphasis of the concept of culture. Ware and Kleinman's paper on Neurasthenia and Chronic Fatigue Syndrome (CFS) constitutes an elaboration of a theoretical and empirical perspective that has been growing steadily in medicine and psychiatry for the last several decades (15-21). The perspective involves using the principles and methods of the social sciences to study medical phenomena not only from a biomedical standpoint but particularly also from the standpoint of culture and alternative meaning systems. As illustrated by Ware and Kleinman, the perspective is comprised of two complementary strands. The first involves creatively using the patient's own understanding and experience of the medical condition that is causing his or her suffering. Because in this perspective individuals are construed as quintessentially social and cultural creatures, its emphasis on personal experience has necessitated a way of codifying the "native" point of view about illness or "the semantics" of Psychosomatic Medicine 54:561-566 (1992)
EDITORIAL COMMENT
illness (19). The perspective differs from the psychoanalytic, which is also highly personalistic, in the requirement that local, situational, meaning-related, and emotionally energizing aspects of illness not be reduced to abstracted psychological constructs and processes. The second strand of the perspective, and the one that Ware and Kleinman concentrate on in their paper, involves the use of contemporary emphases in the social sciences and humanities having to do with the conceptualization of culture. From an emphasis on pure rules, cognition and symbols, conceptualized in local ("emic") terms and operationalized in terms of objective "scientific" criteria, anthropologists have progressively sought to include emotional and aesthetic dimensions of experience, in their conceptualization of culture (22, 23). Finally, and as illustrated in the paper of Ware and Kleinman, anthropologists have sought to include the interpersonal, locally situated, shared, and negotiated world of actors that of necessity also echoes the more distant political and economic structures of the society. This new emphasis on the cultural as "shared scripts," engraved in the larger society, and that when internalized serve to program social relations and contextualize experience, is intrinsic to literary studies as well as the social sciences (many would see no differences between the two). Its power to render the experiences of illness vital and evocative documents of a society cannot be disputed as Ware and Kleinman's paper so beautifully illustrates. One should not lose sight of an important feature of the social science perspective advocated by Ware and Kleinman and that is its applicability not only to the "psychosomatic" problems of preindustrial, smaller scaled societies but also to Psychosomatic Medicine 54:561-566 (1992)
those of cosmopolitan and contemporary ones like our own and China. In their skillful hands, Neurasthenia and CSF is shown to nicely capture the cultural interplay between society, personal striving, and suffering, as embodied in a condition of illness, and to raise basic questions of causation as this has been conceptualized in the psychosomatic tradition. This feature of the study renders it particularly illuminating to readers of Psychosomatic Medicine. It is important to draw attention to the direction of the new "psychosomatic" mode of inquiry that Ware and Kleinman advocate and especially its distinctiveness. Whether looked at historically or analytically, the psychosomatic tradition has always moved out from the local/ interpersonal ("culturally realized") world "into" abstracted psychological and eventually physiological/organic structures (the final substrates of "embodiment"). Ware and Kleinman's paper adds a complementary emphasis, and that is, from the "inside out." They want us to appreciate that in order to be used in a clinical or scientific sense, the somatic base of the embodiment must somehow be made to connect with its meanings in the "outside" social and cultural reality of the person. Stated differently, they are insisting that the symbolization of illness (what it represents) as well as its causation are important cultural dimensions of illness. Through their richly evocative paper, Ware and Kleinman urge that a fully realized cultural side of embodiment needs to be included in the clinical and research equation pertaining to illness as it is studied using the psychosomatic tradition. The engulfing secularization and objectification of the post-modern era has had a negative impact on medicine as a social institution and, thus, Ware and 563
EDITORIAL COMMENT
Kleinman's advocacy is not only humanistically pertinent, but also politically relevant. It needs to be seen as a way of bringing the patient's cultural constituted perspective on suffering into the clinical and research enterprise, attempting to reverse reductionism and "commodification" in medicine. Ware and Kleinman are right to urge researchers and clinicians to try to relate in an empirical sense cultural aspects of illness and personhood (conceived in their social dimension) to physiological or psychophysiological variables as these are studied in the psychosomatic tradition. An empirical psychosomatics that suitably captures the full richness of an individual's cultural embodiment of suffering, such as that described for Neurasthenia and CFS, would constitute a new and exciting chapter in a social science of medicine. It is at present difficult to visualize how this can be accomplished, however. The view of culture as shared, experiential, and negotiated interactions, the meanings of which derive from larger scaled political economic factors, has defied rigorous, operational formulation even in the social sciences. It has also seemed hopelessly descriptive, literary, historical, dialectical, anecdotal, and relativistic to those who argue for scientific integrity in anthropology (24, 25). A clear exception to the criticism that the study of culture is too qualitative and insufficiently rigorous is the work of cognitive anthropologists (2-4). They have managed to derive basic propositions that incorporate the complex ensemble of emotions, beliefs, values, aspirations, etc, that together make up behavior in selected institutional sectors of life. However, this cognitive approach appears to constitute a research strategy that Ware and Kleinman feel is not sufficient, pre564
sumably because it threatens dehumanizing medicine and reducing it to mathematized structures or logical calculi. Even if the cultural dimensions of illness could be incorporated into a suitable propositional framework (formulated as social scripts or operationalized as an inventory about the cultural implications of an illness), it is unclear how the resulting measures can be made to connect with discrete and measurable bodily states or psychological ones, which together constitute the central focus of the psychosomatic tradition. Perhaps Ware and Kleinman's emphasis on the "sociosomatic" should not be expected to connect to the kinds of variables that the psychosomatic tradition has evolved as staple measures. After all, although in their formulation neurasthenia and CFS may function as psychosomatic substrates, they also can be said to operate as illness metaphors, far removed from the "guts and visceral." Ideally, some way of linking bodily states and processes with what a medical condition means to an individual, viewed in his or her full cultural sense, is clearly needed to truly anchor the "sociosomatic" in science, as this has come to be defined in the psychosomatic tradition. But this is to touch on basic ontological and epistemological issues that are highly contestable in anthropology (22-25). One hopes that anthropologists and clinicians will be motivated to develop the appropriate methods and procedures and that the results of their use will be made to connect with the classical roots of the psychosomatic tradition. The consequence of this new line of research will clearly be an enhancement of its cultural relevance and instrumental efficacy. Even if a "sociosomatic" approach cannot be made to connect with the now traditional paradigms and methods of the Psychosomatic Medicine 54:561-566 (1992)
EDITORIAL COMMENT
psychosomatic tradition, its relevance is nevertheless undisputed. Indeed, the Ware and Kleinman study forces one to inquire as to the meaning, purpose, and value of the tradition. Has it evolved only to obtain "scientific" leverage over causation? Is not its overriding purpose that of providing a better means of understanding the complexity of illness/suffering so as to better care for individuals? A culturally invigorated psychosomatic tradition that reminds clinicians and researchers that conditions of illness/suffering embody dilemmas, conflicts, and predica-
ments stemming from society and culture would seem to constitute a sufficient reason for heeding the approach advocated by Ware and Kleinman. Indeed, viewed from this vantage point, the "sociosomatic" approach blends with the evolutionary in underscoring that the psychosomatic tradition provides a way of conceptualizing how the effects of culture, biology, and environment illuminate the conditions of illness and suffering. HORACIO FABREGA, JR. MD
REFERENCES 1. Geertz C: Interpretation of Cultures. New York. Basic Books, 1973 2. D'andrade RG: Cultural meaning systems. In Shweder RA, Levine RA (eds): Culture Theory. Cambridge, Cambridge University Press, 1984 3. Romney AK. Weller SC, and Batchelder WH: Culture as consensus: A theory of culture and informant accuracy. Am Anthropo) 88:313-338, 1986 4 Dougherty JWD: Directions in Cognitive Anthropology. Chicago, University of Illinois Press, 1985 5. Lutz CA: Unnatural Emotions. Chicago, University of Chicago Press, 1988 6. Williams GC: Adaptation and Natural Selection. New Jersey, Princeton University Press, 1966 7. Durham WH: Coevolution: Genes. Culture and Human Diversity. Stanford, CA, Stanford University Press, 1991 8. Tooby ], Cosmides L: On the university of human nature and the uniqueness of the individual: The role of genetics and adaptation. / Person 58:17-67, 1990 9. Lumsden CJ, Wilson EO: Genes, Mind and Culture. Cambridge, MA. Harvard University Press, 1981 10. Daly M, Wilson M: Homicide. New York, Aldine deGruyter, 1988 11. Buss DM: Sex differences in human mate selection: Evolutionary hypothesis tested in 37 cultures. Behav Brain Sci 12:1-49, 1989 12. Thornhill R, Thornhill NW: The Evolution of Psychological Pain in Sociobiology and the Social Sciences, (eds): in Bell RW, Bell NJ, Texas. Texas Technical University Press, 1989 13. McGuire MT, Troisi A: Physiological regulation—Reregulation and psychiatric disorders. Elhol Sociobiol 8:9s-25s, 1987 14. Fabrega H: Language, culture and the neurobiology of pain: A theoretical exploration. Behav Neuro/ 2.235-259, 1989 15. Brody EB: Some conceptual and methodological aspects involved in research on society, culture and mental illness. J Nerv Ment Dis 139:62-74,1964 16. Mechanic D: Medical Sociology. New York, The Free Press, 1968 17. Fabrega H, Jr: Disease and Social Behavior: An Interdisciplinary Perspective. Cambridge, MA Massachusetts Institute and Technology Press, March 1974 18. Kleinman A, Eisenberg L, Good B: Culture, illness and care. Ann Intern Med 12:83-93, 1978 19. Good B: The heart of what's the matter. The semantics of illness in Iran. Culture Med Psychiatr 1:2528, 1977
Psychosomatic Medicine 54:561-566 (1992)
565
EDITORIAL COMMENT 20. Kleinman A: Patients and healers, in The Context of Culture. Berkeley, University of California Press, 1980 21. Eisenberg L, Kleinman A: The Relevance of Social Science for Medicine. Dordrecht, Holland, D. Reidel, 1981 22. Shweder RA: Thinking through cultures: Expeditions in Cultural Psychology, Cambridge, MA, Harvard University Press, 1991 23. Stigler JW, Shweder RA, Herdt G: Cultural Psychology: The Chicago Symposia on Culture and Human Development. New York, Cambridge University Press, 1990 24. Spiro ME: Some reflections on cultural determinism and relativism with special reference to emotion and reason. In Shweder RA, Levine RA (eds): Culture Theory: Essays on Mind, Self and Emotion. Cambridge, Cambridge University Press, 1984 25. Spiro ME. Cultural relativism and the future of anthropology. Cult Anthropol 1:259-286, 1986
566
Psychosomatic Medicine 54:561-566 (1992)
Culture and the Psychosomatic Tradition It is not widely appreciated that culture, viewed simply as a system of meanings that promotes adaptive group living in higher animal forms, has played an integral role in human evolution and also is fundamental to the psychosomatic tradition. Culture operated as an increasingly adaptive feature of group living that was progressively elaborated in the line of evolution leading to man. Put differently, culture constituted a basic characteristic of hominid behavioral ecology in terms of which natural selection operated: Refinements in the genotype and behavior were based on a cultural mode of living and progressively added to it. The concept of culture has played a somewhat ambiguous role in the psychosomatic tradition, however. It has usually been used merely to refer to a person's society, ethnic affiliation, or language. In operating as a possible marker of identity, culture has distinguished between subjects and has functioned as a variable, like age, sex, or social class. Implicit in this usage is the notion that the identified subjects might think or orient differently to the world and that this difference might be associated with distinctive psychosomatic profiles. A problem has been that the concept of culture or ethnicity as a marker of identity has been assumed to refer to nonbiological sorts of things when in fact this particular meaning is hopelessly confounded with what is ordinarily meant by race, which in its correct populational sense, is replete with genetic and physiological implications. Psychosomatic Medicine 54:561-566 (1992) 0033-3174/92/5405-0561 $03.00/0 Copyright © 1992 by the American Psycho
Attempts to limit the concept of culture to purely mental sorts of things (knowledge structures, cognitive tenets, valuational dispositions, or aesthetic preferences) have clarified analytical problems but have created empirical ones (1, 2). Indeed, when a rigorous pursuit is undertaken for indicators of this meaning of culture, the concept seems to dissolve into a plethora of psychological variables and to lose its integrity and seeming analytical power. This sense of culture as measurable psychological variables when applied to the study of psychosomatic phenomena would appear to reduce culture to dry and operational procedures that bear no close relation to what one visualizes by the evocative image of cognitive/emotional/ valuational differences, etc. Anthropologists who take seriously the concept of culture in its purely mental sense have emphasized cognitive/symbolic structures or systems (1); some have used fairly rigorous mathematical procedures (2-4), and others have raised provocative questions about emotional experience (5). These efforts have yielded penetrating insights about human experiential differences. However, so far it has not been possible to link these insights with topics central to the psychosomatic tradition. The mental/conceptual approach to a definition of culture has proven of considerable value to scientists who seek to clarify problems of behavior using principles of evolutionary biology (6). In this instance, culture has served to demarcate a 561
EDITORIAL COMMENT
domain very separable from, but complementary to, that of the biological. Man has been seen as constituted of two types of information, genetic and cultural. The one is inscribed in the material that is physically inherited and the other in the conceptual material that is learned through language and the modeling of behavioral routines that are found in the social environment. Both types of information have an existence "prior to an individual"; both are also "passed on" across generations and both together serve to program behavior and physiology. Both types of information can be reduced to units (genes and cultural traits or "culturgens") that are subjected to the process of natural selection and, hence, both types of information pools evolve (7). The genetically inherited information shapes how and what type of cultural information is incorporated; this has been conceptualized in terms of "epigenetic rules" or "psychological adaptations" (8, 9). Both terms refer to the way genetically based brain processes (designed by natural selection) affect the way culture is learned and implemented. Recently, purely cognitive phenomena (e.g., strategies underlying mate selection, parentoffspring relations) have received the attention of sociobiologists and evolutionary psychologists interested in elucidating the psychological structures designed by natural selection (8, 10-12). Ethological studies have also explored relations between social behavior and physiological regulation (13); this has obvious relevance to how genetic structures are affected by cultural experience. It is clear that psychosomatic issues are embedded in these evolutionarily based substrates of experience and behavior. In such things as pain, autonomic functioning, and endocrine regulation, one en562
counters mental and bodily phenomena whose interrelations and mechanisms are a product of the evolutionary process and which function to program behavior that was naturally selected. Throughout evolution, culture has linked the genome to the learned information about the behavioral environment (14) and in the process, culture regulates physiology. The paper by Ware and Kleinman in this issue of the journal richly illuminates and advocates extending the territory of psychosomatic tradition. It does so by emphasizing the social/interpersonal dimension of culture. In concentrating on two complex sets of body experiences and culturally defined illness profiles and trajectories, the authors manage to show the evocative and analytic power of a widely influential contemporary emphasis of the concept of culture. Ware and Kleinman's paper on Neurasthenia and Chronic Fatigue Syndrome (CFS) constitutes an elaboration of a theoretical and empirical perspective that has been growing steadily in medicine and psychiatry for the last several decades (15-21). The perspective involves using the principles and methods of the social sciences to study medical phenomena not only from a biomedical standpoint but particularly also from the standpoint of culture and alternative meaning systems. As illustrated by Ware and Kleinman, the perspective is comprised of two complementary strands. The first involves creatively using the patient's own understanding and experience of the medical condition that is causing his or her suffering. Because in this perspective individuals are construed as quintessentially social and cultural creatures, its emphasis on personal experience has necessitated a way of codifying the "native" point of view about illness or "the semantics" of Psychosomatic Medicine 54:561-566 (1992)
EDITORIAL COMMENT
illness (19). The perspective differs from the psychoanalytic, which is also highly personalistic, in the requirement that local, situational, meaning-related, and emotionally energizing aspects of illness not be reduced to abstracted psychological constructs and processes. The second strand of the perspective, and the one that Ware and Kleinman concentrate on in their paper, involves the use of contemporary emphases in the social sciences and humanities having to do with the conceptualization of culture. From an emphasis on pure rules, cognition and symbols, conceptualized in local ("emic") terms and operationalized in terms of objective "scientific" criteria, anthropologists have progressively sought to include emotional and aesthetic dimensions of experience, in their conceptualization of culture (22, 23). Finally, and as illustrated in the paper of Ware and Kleinman, anthropologists have sought to include the interpersonal, locally situated, shared, and negotiated world of actors that of necessity also echoes the more distant political and economic structures of the society. This new emphasis on the cultural as "shared scripts," engraved in the larger society, and that when internalized serve to program social relations and contextualize experience, is intrinsic to literary studies as well as the social sciences (many would see no differences between the two). Its power to render the experiences of illness vital and evocative documents of a society cannot be disputed as Ware and Kleinman's paper so beautifully illustrates. One should not lose sight of an important feature of the social science perspective advocated by Ware and Kleinman and that is its applicability not only to the "psychosomatic" problems of preindustrial, smaller scaled societies but also to Psychosomatic Medicine 54:561-566 (1992)
those of cosmopolitan and contemporary ones like our own and China. In their skillful hands, Neurasthenia and CSF is shown to nicely capture the cultural interplay between society, personal striving, and suffering, as embodied in a condition of illness, and to raise basic questions of causation as this has been conceptualized in the psychosomatic tradition. This feature of the study renders it particularly illuminating to readers of Psychosomatic Medicine. It is important to draw attention to the direction of the new "psychosomatic" mode of inquiry that Ware and Kleinman advocate and especially its distinctiveness. Whether looked at historically or analytically, the psychosomatic tradition has always moved out from the local/ interpersonal ("culturally realized") world "into" abstracted psychological and eventually physiological/organic structures (the final substrates of "embodiment"). Ware and Kleinman's paper adds a complementary emphasis, and that is, from the "inside out." They want us to appreciate that in order to be used in a clinical or scientific sense, the somatic base of the embodiment must somehow be made to connect with its meanings in the "outside" social and cultural reality of the person. Stated differently, they are insisting that the symbolization of illness (what it represents) as well as its causation are important cultural dimensions of illness. Through their richly evocative paper, Ware and Kleinman urge that a fully realized cultural side of embodiment needs to be included in the clinical and research equation pertaining to illness as it is studied using the psychosomatic tradition. The engulfing secularization and objectification of the post-modern era has had a negative impact on medicine as a social institution and, thus, Ware and 563
EDITORIAL COMMENT
Kleinman's advocacy is not only humanistically pertinent, but also politically relevant. It needs to be seen as a way of bringing the patient's cultural constituted perspective on suffering into the clinical and research enterprise, attempting to reverse reductionism and "commodification" in medicine. Ware and Kleinman are right to urge researchers and clinicians to try to relate in an empirical sense cultural aspects of illness and personhood (conceived in their social dimension) to physiological or psychophysiological variables as these are studied in the psychosomatic tradition. An empirical psychosomatics that suitably captures the full richness of an individual's cultural embodiment of suffering, such as that described for Neurasthenia and CFS, would constitute a new and exciting chapter in a social science of medicine. It is at present difficult to visualize how this can be accomplished, however. The view of culture as shared, experiential, and negotiated interactions, the meanings of which derive from larger scaled political economic factors, has defied rigorous, operational formulation even in the social sciences. It has also seemed hopelessly descriptive, literary, historical, dialectical, anecdotal, and relativistic to those who argue for scientific integrity in anthropology (24, 25). A clear exception to the criticism that the study of culture is too qualitative and insufficiently rigorous is the work of cognitive anthropologists (2-4). They have managed to derive basic propositions that incorporate the complex ensemble of emotions, beliefs, values, aspirations, etc, that together make up behavior in selected institutional sectors of life. However, this cognitive approach appears to constitute a research strategy that Ware and Kleinman feel is not sufficient, pre564
sumably because it threatens dehumanizing medicine and reducing it to mathematized structures or logical calculi. Even if the cultural dimensions of illness could be incorporated into a suitable propositional framework (formulated as social scripts or operationalized as an inventory about the cultural implications of an illness), it is unclear how the resulting measures can be made to connect with discrete and measurable bodily states or psychological ones, which together constitute the central focus of the psychosomatic tradition. Perhaps Ware and Kleinman's emphasis on the "sociosomatic" should not be expected to connect to the kinds of variables that the psychosomatic tradition has evolved as staple measures. After all, although in their formulation neurasthenia and CFS may function as psychosomatic substrates, they also can be said to operate as illness metaphors, far removed from the "guts and visceral." Ideally, some way of linking bodily states and processes with what a medical condition means to an individual, viewed in his or her full cultural sense, is clearly needed to truly anchor the "sociosomatic" in science, as this has come to be defined in the psychosomatic tradition. But this is to touch on basic ontological and epistemological issues that are highly contestable in anthropology (22-25). One hopes that anthropologists and clinicians will be motivated to develop the appropriate methods and procedures and that the results of their use will be made to connect with the classical roots of the psychosomatic tradition. The consequence of this new line of research will clearly be an enhancement of its cultural relevance and instrumental efficacy. Even if a "sociosomatic" approach cannot be made to connect with the now traditional paradigms and methods of the Psychosomatic Medicine 54:561-566 (1992)
EDITORIAL COMMENT
psychosomatic tradition, its relevance is nevertheless undisputed. Indeed, the Ware and Kleinman study forces one to inquire as to the meaning, purpose, and value of the tradition. Has it evolved only to obtain "scientific" leverage over causation? Is not its overriding purpose that of providing a better means of understanding the complexity of illness/suffering so as to better care for individuals? A culturally invigorated psychosomatic tradition that reminds clinicians and researchers that conditions of illness/suffering embody dilemmas, conflicts, and predica-
ments stemming from society and culture would seem to constitute a sufficient reason for heeding the approach advocated by Ware and Kleinman. Indeed, viewed from this vantage point, the "sociosomatic" approach blends with the evolutionary in underscoring that the psychosomatic tradition provides a way of conceptualizing how the effects of culture, biology, and environment illuminate the conditions of illness and suffering. HORACIO FABREGA, JR. MD
REFERENCES 1. Geertz C: Interpretation of Cultures. New York. Basic Books, 1973 2. D'andrade RG: Cultural meaning systems. In Shweder RA, Levine RA (eds): Culture Theory. Cambridge, Cambridge University Press, 1984 3. Romney AK. Weller SC, and Batchelder WH: Culture as consensus: A theory of culture and informant accuracy. Am Anthropo) 88:313-338, 1986 4 Dougherty JWD: Directions in Cognitive Anthropology. Chicago, University of Illinois Press, 1985 5. Lutz CA: Unnatural Emotions. Chicago, University of Chicago Press, 1988 6. Williams GC: Adaptation and Natural Selection. New Jersey, Princeton University Press, 1966 7. Durham WH: Coevolution: Genes. Culture and Human Diversity. Stanford, CA, Stanford University Press, 1991 8. Tooby ], Cosmides L: On the university of human nature and the uniqueness of the individual: The role of genetics and adaptation. / Person 58:17-67, 1990 9. Lumsden CJ, Wilson EO: Genes, Mind and Culture. Cambridge, MA. Harvard University Press, 1981 10. Daly M, Wilson M: Homicide. New York, Aldine deGruyter, 1988 11. Buss DM: Sex differences in human mate selection: Evolutionary hypothesis tested in 37 cultures. Behav Brain Sci 12:1-49, 1989 12. Thornhill R, Thornhill NW: The Evolution of Psychological Pain in Sociobiology and the Social Sciences, (eds): in Bell RW, Bell NJ, Texas. Texas Technical University Press, 1989 13. McGuire MT, Troisi A: Physiological regulation—Reregulation and psychiatric disorders. Elhol Sociobiol 8:9s-25s, 1987 14. Fabrega H: Language, culture and the neurobiology of pain: A theoretical exploration. Behav Neuro/ 2.235-259, 1989 15. Brody EB: Some conceptual and methodological aspects involved in research on society, culture and mental illness. J Nerv Ment Dis 139:62-74,1964 16. Mechanic D: Medical Sociology. New York, The Free Press, 1968 17. Fabrega H, Jr: Disease and Social Behavior: An Interdisciplinary Perspective. Cambridge, MA Massachusetts Institute and Technology Press, March 1974 18. Kleinman A, Eisenberg L, Good B: Culture, illness and care. Ann Intern Med 12:83-93, 1978 19. Good B: The heart of what's the matter. The semantics of illness in Iran. Culture Med Psychiatr 1:2528, 1977
Psychosomatic Medicine 54:561-566 (1992)
565
EDITORIAL COMMENT 20. Kleinman A: Patients and healers, in The Context of Culture. Berkeley, University of California Press, 1980 21. Eisenberg L, Kleinman A: The Relevance of Social Science for Medicine. Dordrecht, Holland, D. Reidel, 1981 22. Shweder RA: Thinking through cultures: Expeditions in Cultural Psychology, Cambridge, MA, Harvard University Press, 1991 23. Stigler JW, Shweder RA, Herdt G: Cultural Psychology: The Chicago Symposia on Culture and Human Development. New York, Cambridge University Press, 1990 24. Spiro ME: Some reflections on cultural determinism and relativism with special reference to emotion and reason. In Shweder RA, Levine RA (eds): Culture Theory: Essays on Mind, Self and Emotion. Cambridge, Cambridge University Press, 1984 25. Spiro ME. Cultural relativism and the future of anthropology. Cult Anthropol 1:259-286, 1986
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