Rethinking Psychiatry by Arthur Kleinman

Author:Arthur Kleinman
Language: eng
Format: epub
Published: 2018-10-02T16:00:00+00:00

One of the more interesting controversies in the psychotherapy field is the question of whether the effects of psychotherapy are due to specific or nonspecific agents of change (Strupp and Hadley 1979; Karasu 1986). Each school of psychotherapy claims that unique elements in its technique of practice are responsible for specific therapeutic effects (see, for example, Wolpe 1958; Beck, Rush, et al. 1979; Klerman et al. 1984). Outcome research conducted by adherents to a particular school tends to support these claims (e.g., Rush et al. 1977). But overall the empirical evidence fails to demonstrate specific effects of specific techniques. Rather it points to nonspecific, shared aspects of psychotherapy as the most likely chief determinants of efficacy (Frank 1974; Karasu 1986; Torrey 1986). Later in this chapter, I will return to this research for assistance in building a model of the therapeutic process cross-culturally.

In part because of these findings, a common criticism applied to psychotherapy by its medical critics is that it is merely a dressed-up placebo. Placebo responses are the improvement in symptoms produced by supposedly nonactive substances (e.g., sterile water or a sugar pill). They are believed to work through the activation of physiological processes owing to the patient’s faith in the treatment or the healer (Shapiro 1959). Placebos occupy a strange position in medicine (Brody 1977). Though they average a 35 percent improvement rate for medical conditions across the board, they are viewed by clinical researchers as a source of confounding effects in clinical trials of the efficacy of new treatment agents. In fact, placebo responses vary between 10 and 90 percent in such trials, and seem to be strongly influenced by the quality of the doctor-patient relationship (Moerman 1979). Rather than laud a powerful nonspecific treatment effect that all physicians should be trained to maximize, placebos are disdained by medical researchers and teachers.

Psychotherapy may very well be a way of maximizing placebo responses, a nonspecific treatment effect, but if so, it should be applauded, rather than condemned, for exploiting a useful therapeutic process which is underutilized in general health care. The placebo effect can be reconfigured as the activation through the process of interpersonal communication of a powerful endogenous therapeutic system that is part of the psychophysiology of all individuals and the sociophysiology of relationships (Hahn and Kleinman 1983)—what Lionel Tiger (1979) has called the biology of optimism. The comparison of psychotherapy to placebos also indicates the ambivalence with which medical science looks upon this archaic remnant of medicine’s past. Psychotherapy is threatening to academics attempting to forge a psychiatric science because of its ties with folk and popular therapies and its “soft,” psychosocial image. It is of great interest to the anthropologist, however, since it enables her to detect the fault lines that split the psychiatric profession into different camps.

Cross-cultural studies bring a broader perspective to the study of how the psychiatrist heals. Whereas the systems of psychotherapy constitute culturally salient psychiatric treatment in the West, they are not what the vast majority of non-Western psychiatrists do.

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