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5 Suffering and Its Professional Transformation Toward an Ethnography of Interpersonal Experience

图书名称:Writing at the Margin: Discourse between Anthropology and Medicine
图书作者:Arthur Kleinman    ISBN:
出版社:Berkeley: University of California Press    出版日期:1995年

Interpretation and Experience

This chapter is a revised and expanded version of an article written with Joan Kleinman which was originally published in Culture, Medicine and Psychiatry (15[3]:275–301) in 1991. The expansion draws upon materials from Arthur Kleinman and Joan Kleinman, "How Bodies Remember" (New Literary History 25 [summer 1994]:707–723).

An effective strategy in medical anthropology is to demonstrate how a patient's illness complaints and convictions reproduce a particular moral domain. Via visible social archetypes and invisible social processes, pain and lay modes of help seeking are shown to replicate a cultural world, one, moreover, that the anthropologist can validly interpret. The theory may come from Durkheim, Weber, Marx, Freud, or Foucault, and the style of ethnographic writing may be no-nonsense naturalism or vexed postmodernism, yet the accomplishment is to show that illness is a socially constructed reality to which the ethnographer has privileged access.

This interpretative strategy is often followed by a second analytic feat in which the anthropologist reveals how the clinician reworks the patient's perspective into disease diagnoses and treatments that reproduce the health profession and its political-economic sources. The semiotic iteration of the suffering of lay men and women into the taxonomies of healing professionals is then shown to distort the moral world of patient and community.

Thus, when a psychiatrist transforms the misery that results from political calamity—say, the horror of the Cambodian genocide or the numbing routinization of poverty in urban ghettos—into major depressive disorder, posttraumatic stress, or sociopathic personality disorder, the anthropologist claims that, notwithstanding technical and ethical intentions to the contrary, psychiatry ends up delegitimating the patient's suffering as moral commentary and political performance. At least by implication, psychiatrists are held to trivialize the experience of their subjects, and even perhaps render them more difficult to work through. The anthropological accounts, then, claim to make a fundamental critique of the psychiatric transformation of that irreducible existential quality of illness. That professional transformation, it is claimed, sometimes with more than a little suggestion of moral superiority, re-creates human suffering as inhuman disease (J. Cassell 1991).

The anthropologists' interpretive dilemma is that they participate in the same process of professional transformation. The interpretation of some person's or group's suffering as the reproduction of oppressive relationships of production, the symbolization of dynamic conflicts in the interior of the self, or as resistance to authority, is a transformation of everyday experience of the same order as those pathologizing reconstructions within biomedicine. Nor is it morally superior to anthropologize distress, rather than to medicalize it. What is lost in biomedical renditions—the complexity, uncertainty, and ordinariness of some man or woman's world of experience—is also missing when illness is reinterpreted as social role, social strategy, or social symbol … as anything but human experience.

Please do not misinterpret our intention. We are not positing an anthropological oxymoron like suffering as experience taken neat, without its cultural meanings and historical changes. There can be no such acultural, ahistorical human phenomenon. But we are suggesting that anthropological analyses (of pain and passion and power), when they are experience-distant, are at risk of delegitimating their subject matter's human conditions. The anthropologist thereby constitutes a false subject; she or he can engage in a professional discourse every bit as dehumanizing as that of colleagues who unreflectively draw upon the tropes of biomedicine or behaviorism to create their subject matter.

Ethnography does participate in this professional transformation of an experience-rich and -near human subject into a dehumanized object, a caricature of experience. That it occasionally resists such transformation seems to have more to do with the constraints imposed by participant observation as an empirical practice—by its very nature a way of knowing difficult to isolate from the messiness and hurly-burly of daily living—than with anthropological theorizing about experience and its modes.

Categories for the Ethnography of Experience

What categories might an ethnography of experience, in particular one concerned with the study of illness and other forms of suffering, draw upon to resist the tendency toward dehumanizing professional deconstruction, or simply to become more self-consciously reflective about the human core of human experience? It is our opinion that a contextual focus on experience-near categories for ethnography should begin with the defining characteristic of overbearing practical relevance in the processes and forms of experience. That is to say, something is at stake for all of us in the daily round of happenings and transactions.[1]

Experience may, on theoretical grounds, be thought of as the intersubjective medium of social transactions in local moral worlds. It is the outcome of cultural categories and social structures interacting with psychophysiological processes such that a mediating world is constituted. Experience is the felt flow of that intersubjective medium. In Pierre Bourdieu's (1989) terms it is the social matrix out of which habitus is structured and where shared mental/bodily states in turn structure social interactions. Yet, in practical terms, that mediating world is defined by what is vitally at stake for groups and individuals. While preservation of life, aspiration, prestige, and the like may be shared structures of relevance for human conditions across societies, that which is at stake in daily situations differs (often dramatically) owing to cultural elaboration, personal idiosyncracy, historical particularities, and the specifics of the situation.[2] What is at stake in life settings, then, is usually contested and indeterminate (Kleinman 1992).

Ethnographers enter the stream of social experience at a particular time and place, so that their description will be both a cross-sectional slice through the complexity of ongoing priorities and a part of the temporal flow of changing structures of relevance. That such structures are contested, indeterminate, novel, and changing means that the ethnographer's descriptions are always about a local moral world that can only be known incompletely, and for which the relative validity of observations must be regularly recalibrated. Moreover, what the ethnographer experiences matches how individuals encounter the flow of experience (Dewey 1957:269). They do not dominate it, or invent it, but rather are born or thrown into the stream of lived interactions. (See Jackson 1989:1–15 for a review of phenomenological sources for this existential appreciation of experience.)

A central concern in ethnography should be the interpretation of what is at stake for particular participants in particular situations.[3] That orientation will lead the ethnographer to collective (both local and societal) and individual (both public and intimate) levels of analysis of experience-near interests that, we hold, offer a more valid initial understanding of what are social-psychological characteristics of forms of life in local worlds than either professional sociological categories (roles, sets, status) or psychological terminology (affect, cognition, defense, behavior).[4]

The focus on what is at stake encourages the ethnographer to build up an ethnopsychological inventory of key indigenous conceptions, but not to stop the analysis at that point. The level of indigenous categories qua categories can quickly become artificial—as the misadventures of ethnoscience clearly disclose—because it leaves out precisely what orients those categories to practical experience. Moreover, a list of ethnopsychological categories in itself can only partially provide the grounds for understanding what is shared in human conditions and what social psychological processes mediate experience. The former, the conditions of being human, refers to the existence of certain defining rhythms and limits to experience: birth, life cycle change, moral development, death, and bereavement. Human conditions—for example, the subject of this chapter, suffering—constrain lived experience. They offer a resistance in the flow of life to the elaboration of life plans.[5] The dialectical dance between these shared resistances and the culturally elaborated yet simultaneously idiosyncratic structures of relevance creates the "bewildering inexpediency" of human experience (Manning 1981). It also shapes the character of danger, the scope and possibilities of transcendence, and the other existential quiddities that taken together represent whatever is meant by the expression human nature . That is to say, the flow of experience is not the product of a human nature (personality, instinct, etc.) but the condition for its emergence as both shared and culturally particular, and therefore far from the determinative agency that has been claimed by psychoanalysts, cognitive behaviorists, or most other psychological theorists.[6]

The upshot of this phenomenological vision is that viewed from close up, the density of personal awareness (the actors' and the observers') of the richness of human experiences is difficult to express and uncertain owing to its repleteness, subtlety, and complexity. Yet when viewed from afar the historical shape of experience is apparent as are cross-culturally shared elements and rhythms. The ethnographer's focus moves back and forth. The task is to interpret patterns of meaning within situations understood in experience-near categories; yet, ethnographers also bring with them a liberating distance that comes from their own experience-near categories and their existential appreciation of shared human conditions. That means that ethnography, like history and biography and psychotherapy, holds the possibility of a way of knowing more valid to the dialectical structure and contingent flow of lived experience than reductionistic forms of knowing that by definition distort the existential conditions of life. This perspective also suggests why understanding ethnopsychological categories, though essential, is insufficient: we know much more than we can say or understand; we are awash in the meanings of experience; the historical flow and cultural elaboration of experience lead us to organize figures out of grounds that are greatly relevant to particular occasions. (Our informants and our audiences are also trained in varying levels of irony, as Geertz [1988] puts it.) Getting at mediating psychological processes requires that eventually we shift to the view from afar—we cannot otherwise abstract universalizing processes from the particularizing content of ethnopsychological meanings—but to understand actual situations we must use both lenses.

In sum, then, what is at stake for particular men and women in their local worlds offers an example of the type of category we regard as crucial for advancing an ethnography of experience.[7] In discussing this category, we have all too quickly touched upon other aspects of experience—for example, the existential pressure for coherence and unity (see Oakeshott 1985), the immediacy of its felt quality (Cassirer 1962:78; Merleau-Ponty 1962), the confusing multiplicity and indeterminancy of its flow (à la Bergson [1889] and William James [1981: 279–379]), the notion that it is emergent, achieved, and contested, not preformed (as in Dewey 1957:269), the character of brute resistance to life plan that must be transcended and that expresses the finitude of experience (Jackson 1989:1–15), the existential responsibility to come to terms with its teleology (Sartre 1956:553–556; Frankl 1967: 84–93), and so on. These recognizable aspects of experience suggest other categories that must inform our ethnographies. For the purposes of this chapter, however, a single category will be all that we can handle, though we shall return to certain others later in the chapter.

Human Suffering

We will examine the suffering that is a concomitant of illness and its social sources as an illustration of the ethnography of experience. Biomedical interpretations of illness have properly been criticized for leaving the experience of suffering out of assessment of the disease. In order to depict suffering, anthropological accounts disclose how the idiosyncracies and divided interests and cross-purposes of personal life lived under the strenuous constraint of disease processes are actually culturally patterned into recognizably shared forms: for example, the desperate withdrawal and isolation of seriously ill Gnau patients near the Sepik River in New Guinea (Lewis 1975), the neurasthenia of Chinese with major depression in Beijing or Taipei (Kleinman 1986), the nervios of Puerto Rican immigrants to inner city ghettos on the East Coast of the United States (Guarnaccia 1989) and so on. To accomplish this analytic feat the illness experience is frozen at a certain moment as if the illness narrative had reached completion or the illness course had terminated at a final stop. Of course, in the actual flow of illness experience, there is no final stop. Even death is followed by bereavement and the further and influential trajectory of the remembered past (for the family and the practitioners). The anthropologist creates the illusion of finality and continuity and coherent meaning, when in fact even the simplest illness episode has more complex resonances than can be accounted for by the analytic models that are available to us. The abstraction of a definitive cultural form out of the inchoate transitoriness and recalcitrant uncertainties of the everyday experience of illness does violence to the personally idiosyncratic and the situationally particular, to the "blooming buzzing" confusion of the stream of living. As shown in The Illness Narratives (Kleinman 1988a), cultural representation is only one of at least several discrete kinds of illness meanings—the others include the personal and interpersonal meanings in a local setting—yet in numerous medical anthropological accounts it is all that readers learn about an illness. The authors hold that the anthropological tendency to create cultural archetypes out of the always messy and uncertain details of a personal account of illness—an approach to which we too have contributed—is as invalid an interpretation of the human core of suffering as is the biomedical tendency to create a purely biological metaphor for pain. Both render the peculiarly human quality of suffering—that which is most at stake for the participants—fungible. By alienating the illness from what is at stake for particular individuals in particular situations, cultural analysis creates an inhuman reality every bit as artifactual as the pathologist's disease entity. If there is no purely "natural" course of disease, there also can be no purely "cultural" symptomatology.

Suffering can be defined from the historical and cross-cultural record as a universal aspect of human experience in which individuals and groups have to undergo or bear certain burdens, troubles, and serious wounds to the body and the spirit that can be grouped into a variety of forms. There are contingent misfortunes such as serious acute illness. There are routinized forms of suffering that are either shared aspects of human conditions—chronic illness or death—or experiences of deprivation and exploitation and degradation and oppression that certain categories of individuals (the poor, the vulnerable, the defeated) are specially exposed to and others relatively protected from. There also is suffering resulting from extreme conditions, such as survivorship of the Holocaust or the atom bomb or the Cambodian genocide or China's Cultural Revolution. The cultural meanings of suffering (e.g., as punishment or salvation) may be elaborated in different ways for current-day Sri Lankan Buddhists or medieval Christians, but the intersubjective experience of suffering, we contend, is itself a defining characteristic of human conditions in all societies.

To illustrate this point in order to draw out its significance for understanding human suffering as the focus of an ethnography of experience, we will turn to a case of the bodily mode of experiencing personal and political distress—that is, somatization—in Chinese culture.

Case Illustration

Huang Zhenyi is a worker from a rural county town in his late twenties with depression.[8] He attributes his chronic headaches and dizziness to a traumatic childhood experience during the Cultural Revolution, about which he can talk only to his wife. During winter vacation from school, when he was twelve, Huang Zhenyi returned to the schoolyard. Someone had tacked up a piece of paper with "Throw down Chairman Mao!" written in bold characters across it. Not knowing what to do about this anti-Mao slogan, he ran to see his close friend, who told him to quickly inform their commune leaders. This he did, and those cadres responded by calling in the public security (police) agents. Three of them interviewed Huang Zhenyi at his school. They asked him who wrote the poster, and when he could not respond they accused him. The policemen threatened that if he didn't confess they would not let him return home. Frightened after being interrogated for several hours in a small room at the school, from which he was not allowed to go to the toilet in spite of a painful urge to urinate, he told the police that he had found the slogan but was not the one who wrote it. He was angry at his friend for not supporting his story by telling what had actually happened. Eventually, late at night, his interrogators allowed Huang to return home. There he found his mother distraught over his absence. He explained the problem to her and assured her he was not at fault.

The next morning the three agents came to Huang Zhenyi's home and took him to the public security building. Brutally, they assured Huang Zhenyi that this time he would never leave the small interrogation room until he confessed. Terrified that he would not be allowed to eat, relieve himself, or see his mother again, Huang Zhenyi signed the confession, accepting sole responsibility for writing the poster.

When he returned home he told his mother that he had written the poster, fearing that if he told her the truth it would only create greater trouble for her and for him. Huang Zhenyi still recalls with obvious pain his mother crying and cursing him, "If I knew before you'd end up like this, I wouldn't have wanted you." He remembers breaking down in tears, but he found himself unable to tell his mother the truth. "I felt like a coward. I couldn't tell her."

This experience recalled for him an earlier one. At age eight he had gone with several classmates to fish in a nearby pond, instead of walking to school. They were very late getting to class. The teacher punished them by locking the boys in a small mud-walled room. They escaped by knocking a hole in the wall and hid in a nearby cotton field. Their teacher, who was known for being a strict disciplinarian, ran after them and caught Huang Zhenyi's two friends but not him. "I was so frightened I froze in my place. I could not move." Later in the evening he returned home, and the next day went back to school. The teacher, greatly angered by Huang's behavior, ordered him to do menial work around the school rather than study. Huang Zhenyi refused to do the hard labor, and this led his teacher to criticize him severely in front of other teachers. After this experience, Huang Zhenyi reported "my liver became small, and I became frightened, cowardly." From this time onward he felt "paralyzed" whenever he had to "stand up" for himself before adults.

Because of his confession, the twelve-year-old Huang Zhenyi—who again felt "paralyzed," unable to break his silence before his adult accusers—was marched through the local county town wearing a dunce cap, carrying a sign around his neck on which he had written a self-criticism for the "terrible act," surrounded by thousands of local peasants and cadres, who cursed him, spat at him, and threw dirt and pebbles at him. The next day he was sent to work as a peasant at a local production team. He was expected to do the work of an adult. No one would talk with him at first. The heavy labor was so exhausting that Huang Zhenyi thought he would not survive. Each day he had to undergo self-criticism, while local groups of children jeered at him. In a mass criticism session he felt himself go numb, as if paralyzed. He wanted to yell out the truth but couldn't get himself to do it, to break his silence. No one would believe him, Huang Zhenyi reasoned. He had been patient so far, he would endure the unendurable, since there was no way out. Finally, after a year of hard labor, a year during which he several times thought he could no longer stand the work and the isolation, his fellow peasants praised him for doing the work of an adult and enduring his punishment in silence. They pleaded on his behalf with the local authorities that he be allowed to return to school, which he did.

Eventually Huang left this commune and moved to a county town in another province, where he finished high school and where his past was unknown. He became a key worker and joined the Communist Party. He was able to do the latter since the local party officials, owing to the chaos of the time, knew nothing about his past and because of his highly regarded poor peasant background. He never told his mother his version of what had happened. When she was dying he thought of confessing to her the full story but decided against it. "I was too frightened to speak out and didn't think it would do any good." Huang's mother died not knowing of her son's innocence, a point he returns to again and again as a palpable reason for his current feelings of desperate shame and self-hatred.

Now, looking back, he feels depressed, hopeless, desperate. He retains great anger at the three policemen and at his classmate, who would not admit to the interrogators that Huang Zhenyi had told him he had found, not written, the anti-Maoist poster. He feels a searing sense of injustice, a feeling that he associates with a burning sensation in the head, dizziness, and exhaustion. He is fearful that someone in the party will learn of his past and expel him on account of it.

Huang believes he will never recover from this event. "It has affected my character. I am withdrawn; I don't like to be too friendly with others. I am a coward. I cannot trust others." He sees his only hope as writing a novel about his experience that would fictionalize it to protect his anonymity and generalize it so that it comes to represent the "losses and defeat" his generation has experienced. "Like me, we are a lost generation that has suffered so much." But Huang Zhenyi doubts he will accomplish this goal. He has no formal training or natural skill to write fiction. He actively fears the consequences of others learning about his past. He feels trapped. Each time he takes up a pen to write the story, he is overcome by a self-defeating lassitude, dizziness, and sense of his inefficacy. Hence Huang's physical complaints are amplified (perhaps created) by the literal embodiment of chronic frustration, inability to act—if we use his word, "paralysis," but of will, not muscle—and the unbearable inner hurt of shameful "injustice" that he can neither publicly articulate (save through the personally unavailing neurasthenic pain) nor privately expiate.

Huang Zhenyi's own statement that his losses during the Cultural Revolution represent those of his generation signifies a collective awareness in China that the Cultural Revolution deeply affected the lives of entire cohorts of Chinese, in this case adolescents. Unlike others I have interviewed to understand the relationship of neurasthenia to political oppression, his losses during these terrible times were not the physical loss of close family members (his mother died after the Cultural Revolution). Instead Huang is talking about the loss of self-esteem, self-confidence, the normal developmental period of becoming an adult, the normal relationships with family members, and also of hope in his future and that of his society.

Doubtless there are parallels in pre-Communist China and in other societies, the United States included. We are not trying to suggest that what happened to Chinese in the Cultural Revolution is without precedent or cannot be compared to social sources of misery in other societies. But it is also the case that we mean to implicate an entire generation in Huang's distress. His demoralization and anguish may be (and probably are) greater than that of others, owing to his personal vulnerability and the magnitude of the crisis he experienced. He developed a disorder, most others did not. Yet it is precisely because Huang's disorder exposes the inner hurt the Cultural Revolution caused that we may suspect this type of psychological wound is fairly widespread among the members of his generation. To our minds, it represents the personal effects of a society-wide delegitimation crisis; a loss of engagement with the dominant moral order (see chapter 6). For most members of that generation the psychological effects of the Cultural Revolution are unlikely to have led to the despair that Huang experiences. We do not know with what intensity and quality of distress it has afflicted them. We can be sure it has left its mark, however, and that that mark is more like a wound than a blemish. China's leadership seems to have written this "lost generation" off, concentrating instead on the new generation of students, who are expected to be better prepared, educationally and psychologically, to take maximum advantage of the new emphasis on technological and economic growth.

The story of Huang Zhenyi, including the interpretive paragraphs, was published in 1986. By September of 1989, it was eerie to read the closing words about hopes for the new generation. In the Tiananmen Massacre and its repressive aftermath, the Chinese government has gone on, it would seem, to create a second "lost generation." There is a popular cultural delegitimation of the party and the state every bit as widespread and deeply felt as at the end of the Cultural Revolution. One can only wonder what has happened to the man to whom I gave the pseudonym Huang Zhenyi, or how many other Huang Zhenyis will arise out of the ashes of the latest democracy movement? In the face of such ongoing oppression is it surprising that bodily idioms of distress are commonplace, that neurasthenia again seems on the rise?

A student of Chinese culture will experience little difficulty interpreting even this brief illness narrative in light of core Chinese cultural configurations. One of Huang Zhenyi's chief complaints, dizziness or imbalance, tou yun, resonates with a central metaphor in traditional Chinese medicine, balance or harmony between macrocosm and microcosm, between the constituents of the body/self and the social world. Huang Zhenyi's disharmony is in the circulation and amount and forms of his qi (vital energy), and in his past experiences; they in turn disharmonize his emotions and create illness. To be dizzy—a common though usually unmarked symptom of neurasthenia in the past and of chronic fatigue syndrome at present in the West—is to be unbalanced, to experience malaise, to be dis-eased. Dizziness was understood by our informants to be the embodiment of alienation. The broken moral order was quite literally dizzying. To experience dizziness was to live and relive the memory of trauma. It was as close as many could come to expressing political opposition and cultural criticism, at a time when overt expression of such hidden viewpoints could lead to dangerous political outcomes: public violence, humiliation, demotion or job loss, forced self-criticism, exile, imprisonment. Dizziness also expressed for some the felt experience of falling (or fear of falling) from a higher to lower social position. The topsy-turvy cycles of the Cultural Revolution spread this experience across all social positions. One group ascended via struggle, was in turn struggled against, and then was passed by, as another group grasped for higher position, only to fall in turn.

Huang Zhenyi's exhaustion and pain can be analyzed in the same way. Exhaustion from sleeplessness, and the paralyzing fatigability and weakness associated with it, recalled shared traumatic events. Months of working frenetically in political campaigns, often at contradictory purposes, convinced sufferers that they and perhaps the nation had reached the end of revolution. Vital resources were exhausted. Personal and collective efficacy had been drained. Fatigue and weakness in traditional Chinese medical theory express loss or blockage in the flow of qi (vital energy). Devitalization is understood to affect the body-self and the network of connections, the microcosmic local context and the macrocosmic society.

Pain—headaches, backaches—also recreated the effects of the Cultural Revolution's turmoil on human lives. This lived metaphor, like the others, was easily extended from personal anatomy to the social body, from the anatomical network of muscles, bones, nerves, and blood to the social network of interpersonal experience in conflicted work and family settings. Pain, inner resentment, collective suffering, and social resentment merged. Each complaint, elaborated in the context of a story that integrated social and bodily suffering, extended the metaphoric reach of the pain, exhaustion, and dizziness as moral commentary, first, about the self and its local life world, ultimately, about the society. That is to say, somatic complaints expressed what was at stake in the flow of experience. There is not one source of symptoms; different social experiences engage the same culturally prepared bodily processes (Kleinman and Kleinman 1994).

A student of Chinese culture could follow this line of emic analysis to interpret Huang Zhenyi's physical complaints as a somatopsychic idiom of distress that expresses the psychosocial effects of political problems in a politically acceptable and culturally sanctioned collective rhetoric of complaint. Indeed, one could write an entire book on the relationship of neurasthenia to depression in China and its mediation through culturally shaped bodily experience among patients whose complaints are similar to Huang Zhenyi's (in fact, Kleinman 1986 is one such book).

Yet Huang Zhenyi's tale has so very much more in it than the cultural semiotics of symptoms and disease that violence would be done to the account—we would suppress its echoing misery—if we stopped at this level of analysis. If we left off at that point, we would turn Huang Zhenyi into a passive object, a caricature unworthy of the tragic tale he had told us and the moral significance it held for him that he wanted us to take away from the encounter to transmit abroad. The same inauthenticity would occur if we interpreted this story solely in psychodynamic terms or even as a political tract. Those implications are also present, but they, like the illness experience, are only facets of a complex narrative of suffering, the human veracity of which is its concentration of multiple divergent meanings. What is most at stake for Huang Zhenyi—the historical injustice, the obdurate sense of shame, the frustrated desire to express his grievance and right a terrible wrong, and the practical need to protect himself from the machinery of oppression—was only in part at stake for the Chinese psychiatrists who listened to his story, and was not at all relevant for us. Yet understanding what was at stake in this encounter, we are now convinced, tells us something more valid about Huang Zhenyi's actual experience of suffering than separate cultural, political, or psychodynamic interpretations.

Suffering in Chinese Culture: The Limitations of Cultural Analysis

Take a recent piece in Ethos, the Journal of the Society for Psychological Anthropology, by Sulamith Heins Potter (1988), a Berkeley anthropologist who has conducted field research in China. In that anthropological article, Potter contributes to a growing literature that seeks to distinguish non-Western cultures from North American and Western European cultures by emphasizing the point that whereas Western societies are individual-centered, non-Western societies are sociocentric. This dichotomy seems to be one of the basic orientations of contemporary psychological anthropology.

Potter's argument asserts, based on her rural field research, that Chinese regard emotions as irrelevant idiosyncrasies lacking in serious implications for social relationships. The Chinese, she tells us, do not locate significance in the connection between the emotions, the self, and the social order. For them, emotions are "a natural phenomenon" without important symbolic meaning for the maintenance and perpetuation of society. Emotional experience and expression of feeling have no formal social consequences. Suffering, she avers, is not understood by the Chinese as inner personal experience. Nor would the personal experience or expression of suffering, by extension of her argument, hold social significance in Chinese society. Rather a Chinese person's anguish, resentment, ominous feeling of menace, bitter demoralization, hopeless despair, or raging alienation are of no intrinsic importance to the social order. Feelings are never the legitimating rationale for any socially significant action undertaken by Chinese, insists Potter. Americans, of course, are described as the absolute obverse of this caricature. For us, emotions are everything. They are the "legitimating basis that establishes a relationship between a person and a social context." Social action for us is spurred by feelings; the form and meaning of our lives derive directly from our emotions.

Thus, we have Edward Said's (1978) Orientalism equation, albeit with a reversal in the values, now favoring the formerly colonized. The cultural other is the alien opposite of what we hold ourselves to be. What is flawed in our world is perfected in theirs. But to accomplish this interpretive feat, what evidence is adduced must (1) portray homogeneous, unidimensional stereotypes, not real people; (2) discount examples of the opposite, which of course abound in Chinese (and also in American) culture; and (3) above all, leave out any shared human qualities that suggest there is an obdurately panhuman grain to human conditions. The upshot of Potter's transformation comes dangerously close to what Said accused the orientalists of accomplishing: narrowing the humanity of the other and thereby of ourselves.

To make such comparisons, one tends not to, one must not , emphasize actual experiences of suffering or narratives of personal misery; they are too powerfully human; their concrete details—always original and affecting and usually plural and ambiguous enough to contest—disintegrate abstract dichotomies; they smudge the cold prose of social analysis with the bitter tears of moral sentiment. It is not that Huang Zhenyi after all is not more sociocentric than his North American counterpart but that that very sociocentric orientation to the world is the medium in which his individuality is expressed. Or rather, as Nan Lin (1988) has pointed out in a powerful recent essay on the Chinese family, Chinese, like Huang Zhenyi, are both sociocentric members of family groups and rugged individualists. Different patterns of transmission from generation to generation of moral authority and material property, argues Lin, foster a divided orientation of the self. (See also Ellen Oxfeld [1992] on divergent constructions of the self among Chinese.)

Any culturally valid theory of psychosocial dynamics for Chinese society would have to transcend the simplistic sociocentric/egocentric dichotomy and also, to our mind, would find inadequate and distorting a number of standard psychoanalytic presumptions. Rather we should begin with a historical reconstruction of Chinese cultural categories of personal experience and interpersonal engagement. Emotion (qing or zhih ) is not presented as an independent phenomenon, separable from the rest of experience. The Su Wen section of the pre-Chin Huang-di nei jing (The Yellow Emperor's Classic of Internal Medicine ) sets out an indigenous theory of the emotions as they relate to health and illness. Suicidal grief, immobilizing sadness, manic passion, and other extreme emotional states are held by the dominant Chinese medical tradition of systematic correspondences up to the present to be etiological factors that cause organic pathology; they are also signs of social pathology. They are pathogens, internal etiologic factors (neiyin ) that create organic dysfunction. In traditional Chinese medicine (TCM) emotion is not a general phenomenological descriptor. Instead, there are seven specifically named entities, the qiqing , seven kinds of situationally embedded emotional reactions, namely joy (xi ), anger (nu ), melancholy (you ; also translated as anxiety/depression), worry (si ), grief (bei ), fear (kong ), and fright (jing ). These, if excessive, may become pathologic factors. These factors are said to influence the normal circulation of qi and the blood in the internal organs, thereby causing morbid conditions. In this view, the human body as well as its pathological changes are in a continuous state of adapting to the variations of the "natural environment." This is the concept of tian ren xiangying —nature and man adapt to each other—and here "nature" includes the four seasons, the physical and social environment, and the physical structure and physiological processes of each person. Thus, emotional pathology may become both sign and cause of social pathology, and balancing the emotions means harmonizing social relations and vice versa. Dizziness or imbalance is a sign of illness. Suffering simultaneously affects and is affected by the relational balance between body-self and the natural world. (In a vast civilizational culture like China's, plural traditions abound, and we could find a few exceptions to support another interpretation of the emotions. But this we take to be the paramount view.)

From at least Zhang Jiebin's (1710) Qing Yue's Medical Text right up to the most recent writings of China's leading theorists of psychopathology, the prototypical Chinese view of emotions and emotional disorders has recognized various sources and consequences of depression and anxiety states, while holding a somatopsychic view within which the causal line from environment to person is held to be mediated by the body. The body is also regarded as the main idiom or medium through which psychological, social, and psychosomatic problems are expressed.

Francis Hsu (1985) points out that affect in Chinese culture is understood as specific feelings: love, hate, loyalty, sympathy, betrayal, aspiration, despair, and so on. It is further understood to be inseparable from the performance of particular tasks in specific situations that are part of one's social role, says Hsu.

In Taiwan today there is a major movement by academic psychologists to sinicize psychological theory and methodology. A leading figure in the sinicization movement is K. K. Hwang, professor of psychology at the National Taiwan University, who offers, to our mind, the most conceptually satisfactory interpretation of emotion among Chinese. Hwang (1987) defines renqing (the emotional response of an individual who confronts various concrete situations in daily life) as the essential meaning of emotion. Renqing is happiness, anger, fear, love, hate, and desire.[9] If a person understands other persons' emotional responses to various circumstances in life and can respond empathetically to their reactions, then that person is said to "know renqing ." Emotions need not be expressed openly. A sensitive person "knows the tone" (zhih yin ). For example, close friends are "those who know me" (zhih jizhe ).

Thus, emotion means a contextualized response, a response one feels or senses in experiencing the concrete particularity of lived situations. The person who knows renqing reads his and others' responses to the situation through all the senses: sight, smell, sound, and other sensations, including an inner resonance. Renqing is also a resource that is part of social exchanges. Affection, like goods or services, is exchanged. But unlike money, it is difficult to calculate. Indeed, it is said that "one is never able to pay off debts of renqing to others." And that is why social relations involving establishment of networks of influence so central to Chinese daily life transactions turn on whether renqing is withheld or given as gift. Thus, "reading," "exchanging," and "repaying" renqing (here understood as favor) constitute what is at stake in relationships. Finally, Hwang argues, renqing is also a set of social norms by which one has to abide in order to get on well with others in Chinese communities. Hwang relates renqing to mianzi (face) and to la guanxi (creating networks of relationships or connections) and bao da (repayment or reciprocity) as the central Chinese models of experience. Renqing is both social and deeply personal; it captures the dialectical quality of experience; it is individual and interpersonal. It represents the moral core of experience. Sociocentricity alone is an inadequate category to interpret what the Chinese mean by emotion; this term points to something that is simultaneously sociocentric and individualistic in experience.

The methodological question is how to elicit both sides of the dialectic. And here there is a major problem. For as the leader in the movement to sinicize psychology, Yang Kuo-shu (1987), also a professor at the National Taiwan University, has shown, research must confront the tripartite division of all social relations among Chinese. The nearest compartment is occupied by family and close friends. Here trust is unconditional, and certain private feelings can be revealed. The second compartment contains distant family and friends. Here trust is conditional, and feelings will only occasionally be expressed, and always with great caution. The most distant compartment contains relations with strangers, including researchers (i.e., professional strangers). Here there is an absolute lack of trust, and inner experience is not to be expressed lest it is used against one's family and social network. Such a worldview is likely to lead the researcher toward certain conclusions (i.e., the Chinese are sociocentric) and away from others (i.e., the Chinese are also strongly individualistic).[10]

Other key indigenous sources that create a more valid understanding of experience, and therefore of the experience of suffering, include the third-century text Renwu zhi (On human personality, chapter 2), by Liu Shao, who presents a political and transactional view of the self. The ideal person is to be bland; one is to blend with others and situations "like salt, that by itself is not salty. One is clear, but not sharp; substantial, but not overbearing; attractive, but not obvious … decisive and cautious, there is no knowing all one is capable of. With this one can regulate and control." Balancing emotion and situation is essential to master social relations with others. Demonstrating strong feelings, including the menaced and aggrieved affects of suffering, is dangerous, because it gives others power over relationships and restricts one's flexibility to respond effectively. Ultimately, uncontrolled emotional displays threaten one's position in a world of power. Balance, blandness, control provide greater access to power and protect one from the feared effects of power: loss of resources or status or life.

As for Potter's deconstruction of emotion among Chinese, one has only to point to a few classical sources to challenge her conclusion that emotions in Chinese society are irrelevant to the legitimation of the social order.[11] Qu Yuan (332-295 B.C. ), hero of the Li Sao (Encountering sorrow) has traditionally exemplified the delegitimation of an unjust social order.[12] His tale of sorrow is that of the wanderings of an upright official outcast from a corrupt court, a lonely individualist. The poem is a deeply moving meditation on his grief. The poetry's haunting sadness becomes the idiom of moral accusation. Qu Yuan's suicide is the ultimate act of delegitimation of the social order; a paradigmatic moral exemplar for Chinese remembered each year at the time of the Dragon Boat Festival (the fifth day of the fifth moon), and embodied in the eating of zonqzi (glutinous rice wrapped in leaves), both by participants in the festival and, after they are thrown in the water, by Qu Yuan's spirit. (Perhaps Huang Zhenyi, who came from Qu Yuan's homeland, even had Qu's lament in mind as a model for his own dirge of personal suffering and political injustice?)

From pre-Chin times the songs or odes of the land, defined as shi yan zhi ("verbalized emotion") were gathered together to record, somewhat like an ancient Gallup poll, how well the realm was governed. These songs were thought of as not just the upwelling and outpouring of personal sentiments but as deriving from the social ethos. Joy, sadness, and disgruntlement, as conveyed in the odes, were believed to express the tangible conditions in the political order and to comment on the moral climate of the times. Confucius indicates this quite clearly in the Great Preface to the Book of Odes, the She King (Shi Jing ).

… in an age of good order [the odes are] quiet, going to be joyful;—the government is then a harmony.

… in an age of disorder [the odes are] resentful, going on to the expression of anger;—the government is then a discord.

… when a State is going to ruin, [the odes are] mournful, with the expression of [retrospective] thought;—the people are then in distress. Legge 1960

Classically, Chinese poetry explored concentrated life experiences, like the endurance of suffering, for their echoing emotional quality and universal significance. Writing such poetry was itself a way of witnessing and also of protesting one's times. Here is Arthur Waley's translation of Zuo Si's (Tso Ssu) third-century classic, The Scholar in the Narrow Street, a scholar-official's criticism, through the portrayal of suffering, of himself and his era. (The moral sentiment is as appropriate for intellectuals in present-day China as for those in past periods.)[13]

Flap, flap, the captive bird in the cage
Beating its wings against the four corners.
Depressed, depressed the scholar in the narrow street:
Clasping a shadow, he dwells in an empty house.
When he goes out, there is nowhere for him to go:
Branches and brambles block up his path.
He composes a memorial, but it is rejected and unread,
He is left stranded, like a fish in a dry pond.
Without—he has not a single farthing of salary:
Within—there is not a peck of grain in his larder.
His relations upbraid him for his lack of success:
His friends and callers daily decrease in number.
Su Ch'in used to go preaching in the North,
And Li Ssu sent a memorandum to the West.
I once hoped to pluck the fruits of life:
But now also, they are all withered and dry.

Though one drinks a river, one cannot drink more than a bellyful;
Enough is good, but there is no use in satiety.
The bird in a forest can perch but on one bough,
And this should be the wise man's pattern.
(1940:75)

The tradition of using the emotional response of readers or an audience to indict the system of political power extends right down to modern times through the writings of Lu Hsun, Lao She, Ba Jin, and many other Chinese authors. Shame, menace, loss, grief, and other emotional expressions of suffering are master symbols of China's revolutionary literature. For Lu Hsun (1963), the most influential of all Chinese writers in this century, the suffering of common people, as depicted in the social roots of their sorrow and desolation, represented the moral delegitimation of cultural as well as political authority. In the revolutionary theater put on for villagers by local representatives of the Chinese Communist Party (CCP) during the years of civil war, their emotional response to memories of suffering under cruel landlords was used to sanction land reform and the destruction of their class enemy. The campaigns of the Great Leap Forward, AntiRightists, and Cultural Revolution reenacted this bitterness of experience as the transformation from "eating bitterness" (i.e., suppressing resentment and grievance) to expressing it publicly, often in the most extreme forms, against those designated at the time as the enemies of the people. The killing of landlords, the ritual degradation of intellectuals, the expulsion of party leaders, the erasure of alternate political memories—all were sanctioned through the conjuring of intense emotional reaction to the experience of suffering. The literature of the wounded following the Cultural Revolution, to which Huang Zhenyi's story belongs, is another example of the political uses of public sentiment; here it is used to delegitimate the Cultural Revolution.

Social Origins of Distress and Disease (Kleinman 1986) describes the case histories of individuals whose distress and disease resulted from the excesses of the Cultural Revolution. The stories of suffering they told were meant in large measure to articulate pain and despair as a moral commentary on the sources of their tragedy. Their idea was the classical one described in this chapter: ruinous social policies ultimately ruin personal lives, the felt experience of whose haunting tragedy becomes the most telling political commentary on the times; precisely because that account is lived and powerfully felt, it has moral authority. Those stories were told as a moral witnessing of the Cultural Revolution: personal bitterness and defeat passed a sentence of condemnation.

To interpret such problems, because of the bodily idioms that frequently accompany them, solely as illness is to medicalize (and thereby trivialize and distort) their significance. The idea of postraumatic stress disorder in North American psychiatry, which is increasingly being applied to victims of political trauma such as Cambodian and Salvadoran refugees, is the latest example of this invalid transformation of moral into medical meanings of suffering (see Young 1990 and chapter 8 below). For here the intimate physiological consequences of political violence are converted into an anonymous medical euphemism. In so doing, their moral significance is weakened or even denied entirely.

Think of what "stress" means for an elderly Chinese as opposed to a similarly aged North American. The former has lived through the breakdown of social order in the 1920s and 1930s, when epidemics and other consequences of a disintegrating social order dominated personal experience. What would be the equivalent in North America of the "stress" of the Anti-Japanese War when 20 million people died and 180 million were uprooted? During the first eight years of the People's Republic, Mao Zedong admitted that eight hundred thousand counterrevolutionaries were killed. The aftermath to the 1989 Democracy Movement has taught us what counterrevolutionary means! From 1959 to 1961, following the disastrous policy of the Great Leap Forward, China experienced perhaps the most deadly man-made famine in history: perhaps as many as 30 million died of starvation. And so on. The very idea of posttraumatic stress as a disorder invalidates the moral and political meaning of suffering. After all, in both traditional Chinese and Western cultures, the idea of suffering turned on the idea of having to endure or bear great hardship. The idea of suffering carried the moral significance of endurance, and in its Buddhist and Christian senses, there is the idea of transcendence. Those teleological connotations are lost when suffering is configured as a stress with which we cope (either adaptively or ineffectively) or a disease that can be "cured." Foucault's analysis of the practice of the professions in modern society emphasized that the responses of experts to stress and disease—experts, that is, who define rationality as a self-designation of what they think and who regard suffering as having no teleological significance but rather as an opportunity for technical intervention—become a very powerful, perhaps the most powerful, source of social control for just this reason.

One need only read Susan Sontag's (1989) recent cultural analysis, AIDS and Its Metaphors , to see that for the other side of our comparison—suffering in the United States—we would need to fashion an equally rich and complex indigenous analytic framework to get at the cultural elaboration of personal experience in North America, a society by the way where to bear or endure hardship for most of its members seems to run counter to the now-dominant secular text of a world without pain or suffering.[14] The ideas of personal responsibility for suffering, hidden contagion silently transforming genetic codes into cancer or AIDS and thereby threatening at the very core our society's myth of technological control and our penchant to view as predictable and therefore insurable risks the quiddity of human tribulations, the banishment of death from our response to AIDS, and even Sontag's utterly American wish to remove the meanings AIDS inflicts on sufferers—all are examples of the significance of suffering among North Americans that we can only mention in passing. They show obvious differences but also a few surprising similarities with our Chinese materials (see Kleinman 1988a:100–120, 146–157).[15]

And then? Having in hand different analytic frameworks and different accounts of suffering, then what do we do? If we stick to the texts, we might be tempted to throw up our hands over radical untranslatability. But we will not do this, we the authors of this chapter believe, if we stay close to the ethnographic context of experience.[16] For there is, we hold, something panhuman in the experience of distress of the person, in the bearing of wounds, in the constraints to the human spirit, in the choke and sting of deep loss, in the embodied endurance of great burdens, in the search for coherence and transcendence. There is something definitively human at the core of the experience, which to be sure is elaborated in greatly different ways in different cultural settings, but something that would emerge as universal from cross-cultural translation in the final stage in cultural analysis, if ethnographers focused their descriptions more self-consciously on experience and its modes. That is, translation must be not the first but the last step in cultural analysis, as Stanley Tambiah (1990) has put it. Not the first, as it all too often is in psychiatry and psychology, because then ethnographers lose the valid cultural grounding of experience. But at the last it must be carried out—because if we fail to compare, we are not merely left with cultural solipsism, but with inhumanity: something less than the moral grounds of human experience.

Conclusion

Thus, just as biomedicine delegitimates the suffering in somatization by entifying it as disease , so too do the other professions and institutions of postmodern society (including all too frequently medical and psychological anthropology) transform somatization into something other than human experience. Michael Taussig's (1987) writings are to our mind among the more troubling examples of doing violence to the authenticity of the flow of lived experience—they undermine the status of suffering as a legitimate moral domain—but he is not alone.[17] We, each of us, injure the humanity of our fellow sufferers each time we fail to privilege their voices, their experiences. Accounts of the responses of poverty stricken mothers in the favelas of Northeastern Brazil to the high rates of death among their children (Nations and Rebhun 1988) and of the experiences of survivors of interethnic violence and of the Bhopal disaster (Das 1994) are exemplary contributions to the anthropology of suffering precisely because they privilege the experience of sufferers to such an extent that it simply is no longer possible to disregard or disguise their grief, or to deny its implications for understanding the experience of the moral orders behind the distancing categories of public health or anthropology.

The professionalization of human problems as psychiatric disorders, undeciphered anthropological codes, or class warfare causes sufferers (and their communities) to lose a world, the local context that organizes experience through the moral reverberation and reinforcement of popular cultural categories about what life means and what is at stake in living. Experts are far along in this process of inauthenticating social worlds, of making illegitimate the defeats and victories, the desperation and aspiration of individuals and groups that could perhaps be more humanly rendered, not as representation of some other reality (one that we as experts possess special power over), but rather as evocation of close experience that stands for itself.[18]

We human beings live in the flow of daily experience: we are intersubjective forms of memory and action. Our experiences are so completely integrated—narratized moments, transforming narratives—that the self is constituted out of visceral processes as much as expressed through them. Because the order of that flow is historical and cultural, what we feel, and see and recall, is a symbolizing physiology. Because of the social construction of the flow of experience, psychosomatic processes are transmitters and receivers of cultural codes. Because of the psychophysiological grounding of experience, cultural codes cannot make of each of us precisely what they will. There is also a panhuman constraint on the continuities and transformations that represent our lives and our networks which derives from the limited number of social ways of being human. Because of the political economy of experience, that panhuman constraint is itself twisted and turned by the local contexts of pressure that encourage or oppress our aspirations, that defeat us, that defend us, that are us.

Can there be a society without sadness? Can there be a culture without menace? Can the flow of experience, no matter how fantastically different is its cultural elaboration of loss or how serene, optimistic, or trivial its historical configuration of that which must be endured, escape suffering?

This essay is not saying that anthropology or psychiatry provides invalid knowledge. Far from it. We believe these two fields have greatly enriched our understanding of the social and psychological origins and consequences of illness, and of the powerful influences of social context and psychological orientation on the forms and processes of care. Even when it comes to the experience of suffering, both fields have opened up important directions for investigation. And yet, the materials required to understand suffering are of such a different order that we believe research approaches to it must deal directly with an experiential domain that heretofore, perhaps with the exception of the work of phenomenologists (which has its own problems), has been the grounds of art.[19] How social and behavioral science is to transform that realm into a suitable subject matter is not entirely clear to us. We feel certain, though, that this must happen if human suffering qua experience is to be part of the problem framework of our disciplines. Inasmuch as outstanding works of ethnography, biography, and history aspire to engage the phenomenon of experience, we feel comforted that the challenge, though a great one, can be met. That challenge, however, is not to create a universal science of human suffering, which would be archly ironic.[20]

We also most definitely are not insisting that the topic covered in this chapter is the most central or important topic for psychological or medical anthropology. The study of experience is simultaneously both another subject and a way of examining several of these fields' concerns. It deserves a place in medical and psychological anthropology.

Finally, we are not saying that suffering defies understanding or that it cannot be defined. We are not implying an irrational or mystical quality to suffering. Human beings find their plans and actions resisted by forms of resistance in the life course, in social relations, in biophysical processes. Out of these forms of resistance emerge what is shared in our human condition: loss, deprivation, oppression, pain. Human conditions are shaped as well by our responses to those forms of resistance: grief, rage, fear, humiliation, but also by what Max Scheler (1971:46) called transcendent responses: endurance, aspiration, humor, irony. Yet these are so greatly elaborated by systems of meaning and individual idiosyncrasy that human conditions must always contain great divergence too. Suffering is constituted out of these shared forms of resistance and by our greatly different ways of reacting to inevitable misfortune. Suffering and transcendence are among the things most at stake in the practical forms of daily experience. For that reason they deserve to be the self-conscious subject matter of ethnography and cross-cultural comparisons.[21]

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