Document Actions

This interview by the Boston Globe of professor Arthur Kleinman — author, psychiatrist, anthropologist, and Director of Harvard’s Asia Center — touches on the medicalization of psychiatry, and cross-cultural mental health issues.

Q&A with Arthur Kleinman

Date Published:

Jul 22, 2006 08:00 PM

Author: Harvey Blume

Source: Boston Globe

Arthur Kleinman“AFTER ALL THESE YEARS of being a psychiatrist, and anthropologist,what have you learned that’s useful for living?’’ That’s the questionArthur Kleinman, a professor of anthropology at Harvard and a formerchair of the department, challenged himself to address in his new,plainspoken, and engaging book, ‘‘What Really Matters: Living a MoralLife Amidst Uncertainty and Danger’’ (Oxford).

Kleinman, now 65 years old and still, despite the often somber toneof the book, hale and hearty, has had an influential career as apsychiatrist, teacher, researcher, and writer. His book ‘‘The IllnessNarratives: Suffering, Healing and the Human Condition’’ (1988), nowstandard fare in medical curriculums, is a defining text of medicalanthropology, a field that uses anthropological methods to study thesocial and cultural elements of disease.

In ‘‘The Illness Narratives’’ Kleinman insists that it isn’t enoughfor physicians to master the relevant biology, especially when treatingchronic illness. Chronic diseases, he wrote, ‘‘by definition cannot becured,’’ and to effect even ‘‘modest improvement,’’ a doctor mustappreciate the psychological and social components of the ailment. Itis in part due to Kleinman’s efforts that the idea of healing-alongsidethe more traditional notion of curing-has gained a foothold in themedical establishment.

The new book broadens the scope of Kleinman’s earlier work by askingthe same kinds of questions about human life as a whole that he hadpreviously asked about illness per se. Given that most of us are boundto experience,‘‘some kind of health catastrophe near the close of ourlives, if not sooner,’’ what, he asks, makes for a good life, ameaningful life? To find answers, Kleinman mines his own experience andthat of eight other people-a disparate group that includes a New YorkCity sanitation worker, an Israeli kibbutznik, and an Englishpsychologist who treated soldiers shell-shocked during World War I.What he values in these cases is people’s efforts to act ethically inthe midst of suffering and adversity.

When I met with Kleinman in his office at Harvard’s William JamesHall, opined that ‘‘What Really Matters’’ was obviously not writtenwith the youth market in mind.

KLEINMAN: You have to be of a certain age, to travel throughdark periods. I’ve spent my whole career working on suffering, so it’snot that I’m unfamiliar with it. And I’ve had some diseases-asthma, forexample, hypertension-but they never affected me the way my wife’sneuro-degenerative disease, which has ruined her vision, affected me.The book was written during a stage of my life that was-thatis-difficult.

IDEAS: The book is in some ways a critique of language, isn’tit? You make a point of trying to clear the air of the medical languagethat obscures what you see as the basic realities of human life.

KLEINMAN: There are key psychiatric disorders likeschizophrenia and depression, but I’m very concerned about people whohave ordinary unhappiness, or have experienced a catastrophe, or justbad luck, and are renamed depressed or having an anxiety disorder.That’s happening in a big way right now. I’m concerned about takingordinary life, stripping it of its moral content, and making it overinto a disease.

IDEAS: Are you still a practicing psychiatrist?

KLEINMAN: I stopped practicing about six years ago. But I had25 years of practice and saw thousands of cases. I saw many people inpsychotherapy and also used psychopharmacology. It’s precisely becauseI believe in the seriousness of mental illness that I’ve been concernedabout medicalization, remaking the normal into the abnormal.

IDEAS: Why is this happening?

KLEINMAN: There’s a hyping not just of psychiatry, but all ofmedicine. This has come out of the medical-industrial complex, and theneed to get medicine the resources and support it needs, for research,among other things. I’m all for medical research-but not the hyping.The other day I received a solicitation from a medical foundation, andwas surprised by the first sentence, which said: ‘‘Imagine a world freeof disease.’’ That’s inhuman! There can’t be a world free of disease.Disease is part of what life is about.

By the time you get to be my age, in the middle of your seventhdecade, you’re going to realize that just about every family is goingto deal with a social or health catastrophe. That’s not somethingpeople have been prepared for. It’s grim. But the grimness is made overby religion, aesthetics, ethics, into something that makes lifemeaningful.

IDEAS: One of the key figures in the book is Winthrop Cohen,a hero of World War II in the Pacific, who came to you in his 60s, someyears ago, and was depressed. But didn’t you, when you looked over yournotes more recently, conclude that by calling him depressed you weremissing something essential?

KLEINMAN: I missed the moral statement. Here was a decoratedsolder, who had, in his own words, been turned into a killer,committing several atrocities. The worst was that he’d killed anunarmed Japanese doctor who had been treating Japanese wounded. Thinkof how hard it is for a guy who’s been treated as a hero to say, ‘‘Ikilled a doctor up close, who looked in my eyes, and made me feel I wasa real killer.’’ There are some things you can’t say.

The rest of his life was an encounter with that atrocity, a constantattempt to deal with it, and finally, a kind of giving up. Thatproduced a very severe clinical depression. But the clinical depressionwas in the context of the tragedy. And maybe the illness, the fact thathe really did become depressed, allowed him to speak.

IDEAS: You stress the importance of ethics to meaningfullife-the need to resist local norms, go against the flow. But whetheryou’re writing about Winthrop Cohen, or a survivor of the ChineseCultural Revolution, or a humanitarian worker in Africa, or tellingyour own story, what comes out is how hard it is be ethical, how manygray areas there are.

KLEINMAN: The best most of us, me included, can do, is lessthan heroic. Most of us are caught in situations in our work, in ourinstitutions, maybe even in our families, where part of us is acollaborator. Periodically, we make a decision to stand up forsomething. How do we do that? I don’t have the answers. I’m just sayingthat in looking at people over the course of my life I’m astonished tosee that most of us try to build this ethical part of our lives.

DEAS: How important is guilt to ethical behavior?

KLEINMAN: It is important to the moral imagination. It makesus unpack ourselves, be critical of ourselves, and begin to step out ofourselves. It helps us imagine what it would be like to be in the otherperson’s shoes.

IDEAS: Can you give me an example of ethical behavior from your own life?

KLEINMAN: I’ll never forget this. I was sent by the NIH to amedical research unit in Taiwan during the Vietnam War. I was odd manout because I was from the NIH. The worst the captain who ran the placecould do to me was send me back to Bethesda, Maryland. Navy doctorscould be sent to the boonies in Vietnam with a Marine battalion. So noone ever spoke up, except for me.

We had a neurosurgeon who was comparing the Korean War to Vietnam,and said: ‘‘We’ve made incredible gains in neurosurgery. Today we cankeep a soldier alive who’s got half a brain.’’ I remember him sayingthat, exactly. So I raised my hand and said, ‘‘Well, maybe preventivemedicine would be better.’’ Everyone looked at me. If I was a Navyphysician, I wouldn’t have said that.

Harvey Blume is a writer based in Cambridge. His interviews appear regularly in Ideas. E-mail

(Correction: An interview with Harvard professor Arthur Kleinman inlast Sunday’s Ideas section wrongly stated that he is a former chairmanof Harvard’s anthropology department. He is the current chairman of thedepartment of anthropology, and a former chairman of the department ofsocial m edicine at Harvard Medical School.)