Professional Documents
Culture Documents
Laurence J Kirmayer
Division of Social & Transcultural Psychiatry, McGill University and Department of Psychiatry,
Sir Mortimer B. Davis—Jewish General Hospital, Montréal, Québec, Canada
This chapter reviews the great diversity of healing practices found around
the world and represented in most urban centres. A general model of healing is
presented that includes both the physiological processes central to biomedical
theory and practice and the symbolic aspects of healing that have physiological,
psychological and social effects. Work on the theory of metaphor in cognitive
science provides a way to understand the transformation of experience across
levels of sensory, affective and conceptual meaning. Healing rituals and other
symbolic action can thus have effects on physiology, experience, interpersonal
interaction and social positioning. Complementary medicine and traditional
forms of healing are attractive to many individuals both because of the
limitations of biomedicine and their metaphoric logic of transformation, which
promises wholeness, balance and well-being. Participation in specific healing
traditions may also contribute to individual and collective identity.
Introduction
Notions of healing are central to any system of medicine. Anthropologists
have documented a rich array of healing practices employed in different
parts of the world. The comparative study of healing systems has shed
light on the universal elements of healing as well as culture-specific fea-
tures. In the classic account of Jerome Frank, all systems of healing share
some theory of affliction, defined roles for patient and healer, a circum-
scribed place and time for healing rituals, specific symbolic actions with
Correspondence to: healing efficacy and consequent expectations for recovery1. Ethnographic
Laurence J. Kirmayer, MD, studies reveal cultural variations in every aspect of this general frame-
Culture & Mental Health
Research Unit, Institute
work. In the contemporary world, migration, telecommunications and
of Community & Family mass media have made such cultural variations not simply a matter of
Psychiatry, Sir Mortimer intellectual curiosity, or a source of scientific hypotheses about the nature
B. Davis—Jewish General
of healing, but a practical concern for clinicians seeking to provide effect-
Hospital, 4333 Cote Ste
Catherine Rd., Montréal, ive care to an increasingly diverse population. Indeed, this is not only an
Québec H3T 1E4, Canada issue for newcomers but a feature of the general population. In Canada,
British Medical Bulletin 2004; 69: 33–48 British Medical Bulletin, Vol. 69 © The British Council 2004; all rights reserved
DOI: 10.1093/bmb/ldh006
Cultures of health, cultures of illness
Christian healing54 Americas Moral error, sin; demonic Prayer, restitution; demonic
possession exorcism
Naturopathy53 Europe and Weakened state of body Strengthen body through diet,
North America cleansing, ‘natural’ remedies
‘New Age’ (e.g. aromatherapy, Europe and Energy imbalance Use of materials and
crystal healing, light therapy, North America manipulations to ‘rebalance’
polarity therapy, Reiki) energy
Possession Cults (e.g. Candomblé, Widespread (Africa, Offending spirits or ancestors Possession by spirit allows
Zar)7 Asia, South America) propitiation
Shamanism6 Hunter-gatherer Offending spirits, magical attack, Shamanic healer travels to spirit
peoples accident world and with aid of spirit
helper (usually an animal),
redresses wrong
Traditional Chinese Medicine9,57 East Asia Imbalance in energy (chi’i, Herbal and other medicines,
yin/yang) or in five phases (air, diet, moxibusion, acupuncture
earth, wind, fire, water)
Unani medicine58 Indian subcontinent; Imbalance in humours or life force Herbal or mineral medicines
Middle East
meaning are text and subtext, literal and metaphorical strands of meaning
in communication and action. Importantly, these multiple levels of inter-
pretation go on in parallel and may reinforce each other, giving experience
profound depth and resonance, or contradict each other creating complex
experiences of irony, ambivalence and ambiguity.
We can apply this notion of a hierarchy of metaphoric spaces, through
which multiple levels of meaning are generated, to the range of symbolic
healing practices. Figure 1 depicts some of the many processes involved
in symbolic healing29. In the central column of the figure, these are
arranged as a hierarchy of levels of organization, first within the central
nervous system (CNS), then on to family and to the larger levels of com-
munity, the physical and social environment, and the spiritual world.
Each of these levels has its own metaphorical logic and dynamics corres-
ponding to specific neuropsychological, interpersonal, social, political or
ecological processes.
These levels of organization within a biopsychosocial hierarchy
require different languages of description. The description of the activity
of the brain, structured by salient environmental and social events,
requires the language of physiological psychology. The lowest level
depicted here is the brainstem which includes reticular formation, usu-
ally held to be the locus of ‘nonspecific’ responses to the arousing or
activating effects of stimuli. Healing actions and agents working at this
level serve to change the overall level of arousal, making the individual
more or less sensitive and active in response to many stimuli. Healing
practices that employ touch, massage, some aspects of placebo response,
and other phenomena of classical conditioning may work in part by
manipulating endogenous control systems for arousal, autonomic func-
tion, and pain control30,31. For example, the expectation that one is
receiving an effective analgesic activates endogenous pain control systems
using endorphins32,33. This phenomenon of placebo analgesia operates
equally when one receives a pharmacologically active medication and can
account for some of the individual variability in response to analgesics34.
A second level of the brain depicted is the limbic system, those phylo-
genetically older structures of the forebrain and limbic system, charac-
teristic of mammals, that have been implicated in emotion35. These
regions of the brain are involved in the encoding and decoding of emo-
tional meaning, empathy and in the regulation of attachment—the
making and breaking of affectional bonds36. Healing interventions aimed
at this level work through the evocation of emotion and the dynamics of
interpersonal attachment.
Higher cortical functioning adds two further levels in this hierarchy of
representations: language and imagery. Therapeutic action at this level aims
to elicit and transform conceptual models of experience. Most cognitive
and psychodynamic therapy is concerned with this level. Ultimately,
Family ritual or
therapy Change in
Family structure or rules
Insight-oriented of interaction
(psychodynamic
or existential)
psychotherapy
Insight,
Cognitive-behavior cognitive
Left
Left Right
therapy Hemisphere Hemisphere restructuring,
Hemisphere metaphoric
Shamanic Language Imagery
incantations, transformation,
hypnotherapy dissociation
Catharsis
Relationship
("supportive") Limbic System Attachment,
psychotherapy Motivation & emotion bonding,
soothing &
social support
Touch, massage,
Endogenous
sensory
pain control
reduction,
Brainstem mechanisms;
environmental Regulation of autonomic function, habituation;
manipulation arousal & pain systems conditioning
Conclusion
Migration, mass media and telecommunication have exposed everyone
to diverse healing traditions that promise effective or integrated treatment
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