therapy managin group

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Therapy Management: Concept, Reality, Process Author(s): John M. Janzen Source: Medical Anthropology Quarterly, New Series, Vol. 1, No. 1 (Mar., 1987), pp. 68-84 Published by: Blackwell Publishing on behalf of the American Anthropological Association Stable URL: http://www.jstor.org/stable/648771 Accessed: 29/04/2009 11:09 Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at http://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unless you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you may use content in the JSTOR archive only for your personal, non-commercial use. Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at http://www.jstor.org/action/showPublisher?publisherCode=black. Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed page of such transmission. JSTOR is a not-for-profit organization founded in 1995 to build trusted digital archives for scholarship. We work with the scholarly community to preserve their work and the materials they rely upon, and to build a common research platform that promotes the discovery and use of these resources. For more information about JSTOR, please contact [email protected]. Blackwell Publishing and American Anthropological Association are collaborating with JSTOR to digitize, preserve and extend access to Medical Anthropology Quarterly. http://www.jstor.org

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Page 1: Therapy Managin Group

Therapy Management: Concept, Reality, ProcessAuthor(s): John M. JanzenSource: Medical Anthropology Quarterly, New Series, Vol. 1, No. 1 (Mar., 1987), pp. 68-84Published by: Blackwell Publishing on behalf of the American Anthropological AssociationStable URL: http://www.jstor.org/stable/648771Accessed: 29/04/2009 11:09

Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available athttp://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unlessyou have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and youmay use content in the JSTOR archive only for your personal, non-commercial use.

Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained athttp://www.jstor.org/action/showPublisher?publisherCode=black.

Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printedpage of such transmission.

JSTOR is a not-for-profit organization founded in 1995 to build trusted digital archives for scholarship. We work with thescholarly community to preserve their work and the materials they rely upon, and to build a common research platform thatpromotes the discovery and use of these resources. For more information about JSTOR, please contact [email protected].

Blackwell Publishing and American Anthropological Association are collaborating with JSTOR to digitize,preserve and extend access to Medical Anthropology Quarterly.

http://www.jstor.org

Page 2: Therapy Managin Group

JOHN M. JANZEN Department of Anthropology, University of Kansas

Therapy Management: Concept, Reality, Process

"Therapy management" (diagnosis, selection, and evaluation of treat- ment, as well as support of the sufferer) and "therapy management group" (the set of individuals who take charge of therapy management with or on behalf of the sufferer) are two concepts developed in medical anthropological research in Central Africa and reported in The Quest for Therapy in Lower Zaire (Janzen 1978). The concepts are described in terms of their historical development, subsequent reception by review- ers, and use by later researchers in the analysis of a range of subjects in medical anthropology. "Therapy management' holds promisefor con- textually sensitive analyses of the relationships among cultural assump- tions and values, behavioral processes, and social and economic struc- tures that influence the therapeutic process.

~ W ̂ ^T Thhen an illness occurs, the person who is jurally responsible for the sufferer quickly consults a doctor. If and when the consult-

V v ing doctor has made his diagnosis, it is again this jurally re- sponsible person who sends for the appropriate treating doctor" (Babutidi in Jan- zen 1978:130). These words of a Kongo writer in 1910 describe the essence of a process of guardianship that comes to the fore during illness in this Central Afri- can society. In the monograph The Quest for Therapy in Lower Zaire (1978) Wil- liam Arkinstall and I featured this process as "therapy management"; the con- stellation of individuals who emerge to take charge of the sufferer during inca- pacitation we called the "therapy management group." In Quest we noted that the therapy management group coalesces

whenever an individual or set of individuals becomes ill or is confronted with overwhelming problems. Various maternal and paternal kinsmen, and occasion- ally their friends and associates, rally for the purpose of sifting information, lending moral support, making decisions, and arranging details of therapeutic consultation. The therapy managing group thus exercises a brokerage function between the sufferer and the specialist. [1978:4]

Genest (1985:348) in a review of the book identified two main features of therapy management:

(1) the set of actions whose aim is to formulate a diagnosis, to select and evaluate the treatments at the time of a sickness; (2) the set of individuals involved at the moment in which these actions are at hand, the members of the family acting as

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intermediaries and involved as advocates between the sufferer and the specialists of the medical systems concerned.

As has happened so often in the history of anthropology, a notion from a particular social and cultural setting is lifted out for emphasis and given a name, made a "thing." That name and that process are henceforth reified in the litera- ture. Thus, in anthropology, we have totem, shamanism, mana, Cargo cult, and the like, in which the indigenous term has become the analytical term. We were well aware of the hazards of inventing a technical term like "therapy manage- ment," but it seemed appropriate. For although the Kongo do not have a term for this process, they very much recognize it as a reality. Also, as we shall see, it is by no means limited to them.

In this article I offer a background on the emergence of the therapy manage- ment focus and attempt both to answer questions that have arisen since Quest was published and offer suggestions for further research.

Intellectual History of Therapy Management

Background

In Central African research, numerous authors have described particular in- stances of "therapy management." Boswell's (1969) notice of "escorts" in ill- ness episodes in urban Zambia comes closest to depicting the therapy manage- ment group phenomenon. However, his interpretation of the escort's role empha- sizes social support and does not go far enough in accounting for the evaluation of information and the nature of decision making in the therapeutic process. In the non-Africanist literature, the sociological use of "lay referral" (e.g., since Parsons 1958) covers a dimension of therapy management. But the focus on the "laity" suggests that there is another pole, that of the "professional," which car- ries as much or greater weight in therapy management (Kleinman 1980). In Kongo this distinction is difficult to use and misleading, because the "laity" never really relinquish decision-making rights to a "professional," and it is not the lay status of the decision makers that defines them, but their relationship to the sufferer. In fact, they may be professionals. Another much-used notion in recent medical anthropology, the "hierarchy of resort," introduced by Roman- ucci-Ross (1969), has something in common with therapy management. How- ever, the notion of a "hierarchy" suggests a tree and branches whose logic is followed in sequential steps of the therapeutic process. In therapy management in Kongo, successive episodes of a therapeutic process are not as crisply determined by prior logics as "hierarchy of resort" would suggest but are open to ad hoc questions and issues that may arise in the midst of a case.

The Kongo data and the problematic nature of the available analytical con- cepts in 1971 led us to look for other ways of formulating issues concerning the therapeutic process. Approaches that emphasized completely disembodied med- ical knowledge seemed unsuitable. At the time the so-called "new ethnography" and ethnoscience were the rage, but they offered no way to account for the entry of social and environmental determinants into either the ways alternative courses of healing were combined or the mechanisms by which decisions were reached. Game theory, in the form of minimax calculi of alternative choices and trade-offs

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(as in economic strategies, war games, and chess), were also current but seemed too rationalistic to account for the existential setting of suffering and healing we saw in Central Africa. To speak of alternatives in a pluralistic medical setting as "traditional" and "modem" was totally unacceptable, since modernization the- ory, although still a viable theoretical paradigm at the time, seemed extremely rigid and simplistic when we attempted to fit it to the intricate negotiations be- tween individuals and the therapeutic alternatives we saw before us. Its concepts were simply not applicable to the Kongo, who made no particular discrimination between "traditional" and "moder" medical resources.

The McGill Seminar: Kongo and Quebec Cases Compared

In a most direct sense the concept of the therapy management group and the title of our book go back to a graduate seminar held at McGill University in 1971. Jointly conducted by Don Bates (Professor of the History of Medicine and Direc- tor of the Osler Library), my fellow fieldworker William Arkinstall (a physician), and myself, it was attended by a dozen students. The seminar was to consider case material from both Africa and North America, specifically from the Kongo of Western Zaire and Quebec.

As the seminar progressed, Arkinstall and I wrote up our Kongo case mate- rial for presentation and discussion by the seminar. A comparable set of case stud- ies had been collected in connection with the work of an advisory committee for undergraduate medical education of the McGill University Medical School. Pro- fessor Bates had chaired the subcommittee on "Objectives of Medical Education in Society," which generated a dozen extensively documented cases of illness episodes from greater Montreal (Bates 1970). The cases, which covered a variety of issues, were introduced by members of the committee-physicians, psychia- trists, pastoral counsellors, and social workers-to probe the adequacy of medical education both in dealing with health issues and in educating medical students to resolve chronic problems in "the system." Protagonists in the cases had appeared before the subcommittee to clarify and further interpret the descriptive accounts. As in the Kongo data that appeared in Quest, these were complex situations that did not often respond to short-term solutions. The cases also brought to light char- acteristic features of care-providing institutions and their personnel. It should be noted that the illness episodes all occurred before the advent of universal health insurance in Quebec, although they were studied with a view toward understand- ing how such insurance might deal with cross-service referrals and chronicity. Coincidentally, the Quebec data were remarkably suited for comparison with the Kongo material. In the seminar Kongo and Quebec cases with similar profiles were introduced alternately by students. Discussion produced a comparative per- spective true to anthropological tradition.

As the semester progressed, I wrote a paper entitled "Decision and Structure in the Therapeutic Process" (Janzen 1971) that summarized the issues that had emerged from consideration of the cases and proposed an analytical framework with which to consider them. Although the paper was absorbed into the book, the comparative basis of the ideas was abandoned for a Kongo-specific perspective. In the process, some of the reasoning was truncated. It therefore seems appropri-

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ate here to review the Quebec material in the context of summarizing the "De- cision and Structure" paper.

Questions that the seminar raised of both the African and North American cases had to do with the definition of the therapeutic process, the sick role, de- viance, labeling, decision making, choice of therapeutic resource, allocation of authority both within medical services and within the management group, as well as the coordination of resources.

Alternate discussion of the Kongo and Quebec data provided a format for the discovery of many ways in which common features appeared in the two settings, as well as some marked differences. In almost all instances the seminar was struck by how common it was for the physical sign-whether defined by the sufferer or the healer-to serve as an expression of, or a pointer to, wider social, psycholog- ical, or life-transition crises. This observation may have been biased by the type of cases at hand-i.e., chronic conditions rather than short-term, catastrophic ones. It may also have been due, in the Quebec cases, to the presence of psychi- atrists on the commission who routinely offered psychosocial assessments of the cases along with the biophysical work-ups of the other physicians. Still, it was apparent that there was a marked correspondence between vague and intermittent physical signs (soreness, headache, menstrual pain, dizziness, respiratory diffi- culty) in the absence of clear clinical pathology and what we would today speak of as "stress."

A second set of questions the seminar raised about the Kongo and Quebec cases had to do with the imputation of deviance: who controlled it, whether it was stigmatizing, and what its consequences were. Early in the seminar we had read Eliot Freidson's recently published book, Profession of Medicine (1971), which dealt at length with these issues. The cases in both Kongo and Quebec that drew the strongest imputations of stigma concerned young women who had become pregnant out of wedlock- medical" histories with seemingly little medical con- tent at all. Yet these women often experienced multiple physical signs and symp- toms, apparently as much to do with their own discomfort and anxiety as with their pregnancy. The North American examples of this type, to a lesser extent than the Kongo ones, also reflected rebellion by the young women against their parents' values and control. (It was, after all, the 1960s.) The only other impu- tation of deviance among the cases occurred with an obese Quebec woman. She was the mother of six by an abusive alcoholic husband and was advised to have her cancerous leg amputated. Her obesity was an annoyance to the physicians, and stigma was imposed on her for an inability to control her eating. Little con- sideration was given to the possible psychological causes of her obesity; she was simply ordered to diet more stringently.

In discussing these cases in light of Freidson's work, the seminar came to the conclusion that deviance imputation should not be considered a major com- ponent of the diagnostic and therapeutic process. It was not as significant to the illness episodes as such matters as who took charge, who controlled or negotiated the key decisions, and within what social and cultural setting the overall issues were worked out. In other words, the therapy management process seemed to need a broader conceptual framework than the existing concepts of deviance and labelling could provide. It was important to understand the immediate social

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nexus that managed labeling, rather than to see it as an asocial cognitive opera- tion.

The question of who took charge in acute health crises came to the fore most clearly in two cases of mothers who were struck by life-threatening disease: the Kongo case concerned a young mother with cardiac failure (Luzayadio, in Janzen 1978: Ch. 3), and the Quebec case centered around the aforementioned young mother of six with a malignant tumor in her upper leg. Related to the question of who took charge was the extent to which the authority to make crucial decisions in the care process was vested in the group. In Kongo the matrilineage and the father took over the therapy management process. In Quebec the patient and her husband initially shared these responsibilities. Dissatisfied with a gynecologist's opinion that the swelling in the woman's leg was due to varicose veins, compli- cated by pregnancy, the couple consulted another physician from whom they learned that the problem was a malignant tumor. When immediate surgery was recommended, the woman, with the tacit consent of her husband, again took charge and delayed the recommended amputation for several days in the hope that she could somehow save her leg. After surgery, however, a wider constellation of medical and support structures emerged, and the couple apparently relin- quished therapy management. Indeed, the nuclear family seemed unable to handle its affairs during this time. With the woman convalescing in the hospital while her husband worked for an hourly wage as a trucker, they were unable to care for their children at home. The patient's mother took the two youngest for several weeks, and the oldest remained at home caring for themselves while their father was often gone overnight. At first the woman's physician seemed only vaguely aware of her family responsibilities. Only after the patient's release from hospital did he initiate contacts with the Family Service Association in order to provide a part-time temporary housekeeper. Though neighbors helped, too, coordinated therapy management and support were erratic. Neither extended family nor public institutions provided these services to the extent observed in the corresponding Kongo case. The isolated nuclear family was cast into crisis when one adult mem- ber became hospitalized and the other adult had to continue working to earn an income. Similar problems in coordinating medical care and support came up re- peatedly in other Quebec cases.

The vulnerability of the autonomous nuclear family in the West and the fluc- tuations in household membership over its life cycle were illustrated in several other Kongo and Quebec cases. A Quebec example revealed the fate of a "ter- minal family"-that is, a family of grown unmarried siblings at the point when the sole productive person among them (a 68-year-old sister who was caretaker, housekeeper, and breadwinner) became ill. The others had no resources to fall back upon. The case illustrates not only this woman's own sickness but also her guilt over the failure to care for her siblings, coupled with a simultaneous desire to extricate herself from their demands. An identical situation would be rare in Kongo society, where these siblings would represent the senior core of a matri- lineage and, even if unmarried, could claim the support of junior lineage mem- bers. However, even in Kongo, related situations concerning various structural transformations of domestic life engulfed individuals in cross-currents of contra- dictory demands and expectations that surfaced for public scrutiny when they be- came sick. In Quest, for example, cases reported in Chapter 8 deal with the grow-

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ing polarization between junior and senior houses of a lineage and the related af- flictions of individuals caught in crises of leadership and succession. Thus in both settings illness episodes became linked to lifecourse transitions.

Both the Kongo and Quebec cases also concerned individuals who had be- come alienated from their kin and sought solace and support from another, nonkin community or structure. Two Kongo cases are described in Quest, Chapters 6 and 7. The first deals with a man whose professional and family roles did not fit well together, whose family continued to expect him to support them with his salary. The second details the story of a man who moved out of his lineage community, with their blessing, to join a prophet. Through a series of divinations and diag- noses he came to believe that his chronic asthma was caused by his own lineage and that he could only become healthy in the supportive setting of the prophet's village. The move to join the prophet was comparable to initiatory membership in a Central African cult of affliction. In Quebec we find a comparable story of a middle-aged man, following a life of alcoholism and broken ties, finally com- mitting himself to Alcoholics Anonymous where he received the support to re- main free of alcohol.

Emergence of the Concept of "Therapy Management Group"

An important insight that developed from comparing the Kongo and Quebec cases was that diagnosis and therapy must be seen as a process. In both Kongo and Quebec the issues and problems were more gradual in their emergence and ultimately more chronic than the typically episodic encounters with either health- care personnel or institutional sources of support would suggest. In both settings a range of persons, classes, issues, and perspectives had a bearing on the case and needed to be considered simultaneously. A theoretical model that was applicable to what we were studying needed to take this complexity into account.

We found, however, that several of the foremost social-science analysts of the health-care setting in the late 1960s and early 1970s approached the matter from a static perspective. Frake, as a leading proponent of the "new ethnogra- phy," relied on interviews to establish hierarchical taxonomies of diseases and related therapies (1969) and paid little attention to the decision-making process or to the social context of decisions. Freidson (1971) offered taxonomic schemes concerning disease types and the parameters of stigmatization and deviancy but was concerned with the "career" of these states-how they emerged and by whom they were promulgated. His work reflected the then-current and influential work of Talcott Parsons on the "sick role." In assessing how the course of the sickness was handled, he tended to be concerned more with the professionals' work than with the total social surroundings of the sufferer. It was far easier to apply this type of model to the hierarchic system of professional decision making in a North American medico-centric setting than in an African community, where critical decisions were made mainly by the kin of the sufferer, with professionals and healers serving largely as informational resources for them.

To resolve the problems of the foregoing overly static and professionally biased types of analysis, the seminar was attracted to theoretical writings by such authors as Nadel (1957) and Barth (1966), who emphasized distinctions between cultural values, social roles, and the context of decision, and who, like Edgerton

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(1969), were concerned with individual processes of negotiation among thought- out constructs, lived-in constructs, and actual behavior. Discussion was also in- fluenced by the work of Lewin (1951), more specifically his concept of the "so- cial field."

Nadel (1957) seemed to offer an important beginning.

All societies . . . provide for the 'systematic ordering of social relations by acts of choice and decision.' Though people would look to 'structure' as a 'reliable guide to actions', they also take decisions which 'may affect the future structural alignment'. [1957:134-135]

For Nadel, choice and decision offered access to structure, and structure was con-

stantly amended by choice in the "never quite identical circumstances" of daily life.

'Decisions and choices' .. are more diffuse than any massive social transfor- mations; they effect not any total shift, but move-by-move rearrangements, and they happen all the time, in the manner of readjustments to never-quite-identical circumstances. It is possible, further, that over a period of time the sequence of individual options may be such that their relative frequency undergoes a definite, perhaps progressive, change. [1957:136]

For Nadel, then, "choice and decision" occur within a range of latitude and at several levels, demonstrating in statistically verifiable interactions the existence of roles and structural arrangements, on the one hand, and the categories and val- ues of an ideational system, on the other. This perspective laid the groundwork for an analysis of the therapy management process in very different social set-

tings. Barth's notion of "transaction" also played an influential role in the work

of the McGill seminar. Although Barth's work had concentrated on economic and

political transactions, his approach lent itself eminently to the therapeutic process.

Transactions have a structure which permits analysis by means of a strategic model, as a game of strategy. They consist of a sequence of reciprocal presta- tions, which represent successive moves in the game. [1966:4]

For Barth, the successive moves of actors in a transaction add a cumulative, "ledger"-like quality to previous undertakings. The underlying logic of the pro- cess may be inferred by examining the sequence of choices and decisions against the background of dominant values.

Transactions, as Barth understands them, can be applied to the therapeutic context by examining how choices are confronted and managed by healers, pa- tients, family, or kin. To see therapeutic choices in this manner yields understand- ing of the cumulative impact of successive choices, and the mutual effect that actors have on one another. The therapeutic process becomes a mini-history, in which each successive decision changes the range of possibilities and makes its contribution to the ultimate outcome. This view incorporates not only "cogni- tive" ideas and stances, but also relationships between individuals. It is the es- sence of the processual or generative model that choice and decision occur not in a vacuum, but in society-that is, to cite Nadel, in "the latitude allowed to actors in interpreting their roles and managing their relations with one another" (1957:136).

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The extent to which the transaction and negotiation of therapy management effected changes in roles and statuses among individuals was also dealt with in the seminar. In a number of the Kongo and Quebec cases it was clear that sickness was more than just a "time out" from normal life. Often it was a role-transform- ing experience-the leg cancer followed by amputation, or the asthma requiring a change of residence-as well as a collective experience that altered the way individuals related to one another. Factions might coalesce that in turn altered the perception of the sickness and its causes. Clearly a broader and more flexible con- cept than "sick role" was needed to understand these cases.

A process model that included choice and decision needed to consider, ad- ditionally, the consequences of consensus and dissent among parties involved in a given therapeutic process. From reviewing the cases at hand, it became clear that consensus within the group surrounding the patient was required for a deci- sion to be reached and action to occur. For example, medical authorities were unable to act until there was consensus among the Quebec woman with the leg tumor, her husband, and the medical team. In Kongo action often occurred on the basis of partial consensus within the therapy management group. Dissension pre- dictably led to proposals for alternative courses of action. In the Kongo cases one segment of the management group typically prevailed, and their plan of action would be implemented first; then another faction's recommendations would be acted on. In other words, two or more sets of diagnoses and therapy proposals seemed to generate multiple treatment episodes, each one based on only partial consensus.

Even this unfolding model of the therapeutic process was, however, far too simplistic to encompass hierarchies of status and authority characteristic of health-care decisions in both Kongo and Quebec. In Kongo, for example, some proposals for therapeutic action emanated from lineage heads and influential and wealthy kin, whereas others derived from paltry utterances of junior members of the lineage. In the case of the young unwed mother (Chapter 7 in Quest), episodes 2, 4, and 5 were diagnosed as a "psychological problem" by her younger brother, who had done some reading in Western psychology. This diagnosis was never acted upon, however, since senior brothers and lineage heads were convinced that the cause lay in an uncompleted marriage transaction. Consequently, instead of going off to one of the few psychiatrists or psychologists Lower Zaire might have offered at the time, the case centered on divinations and family reconciliations in order to persuade the girl's father to offer his blessing without his bridewealth portion. Few comparable instances of diagnostic dualism were in evidence in the Quebec cases, although there were instances of similar illnesses that received dif- ferent sequential treatments.

A rather more difficult question arises when one looks at the status differ- ences between healer and patient, professional and layperson, within the frame- work of the therapy management process. Is "consensus" the appropriate label for a harmonious interaction between doctor and patient? Should we speak of the interplay between the two concerning different types of diagnosis and therapeutic recommendation as "therapy management"? In both the Quebec and Kongo set- tings disagreement between the healer and patient (and patient's advocates) was marked by interrupted treatment, noncompliance, or the search for alternative therapy. Such changes were based on the perception of the earlier treatment's

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inefficacy, either by the individual sufferer or by the recognized advocate of the moment. These healer-related shifts in therapeutic choice, viewed in light of Lew- in's idea of the total social field, suggested that the dynamics of the healer-patient interaction should indeed be included within the overall model of therapy man- agement.

Our seminar discussions led finally to a definition of the therapeutic process as a series of actions occurring in a social context in which individuals (usually in groups or sets), living in ordered relationships or roles, make decisions about their own welfare, often in closely related sequences, on the basis of partially shared classifications, values, and knowledge. Such therapeutic acts thus mediate differ- ing classifications and values (culture), social structures or roles (society), and protagonists' assessments of the effectiveness of the therapy.

The concept of therapy management, as defined here, is thus both cognitive and social. Knowledge of the clinic and of the experience of sickness and healing is shaped and affected by social dynamics among all individuals involved. There- fore, to understand the therapy management process, one must examine the cu- mulative, microhistorical character of social relations and personal exchanges. Each decision or action affects and shapes successive stages of knowledge-the perception of the events, the diagnosis of the disease, and the social field around sufferer, family, and practitioners. Thus, unlike some strictly cognitive or ration- alist theories, the social relations of the therapy management group are considered an active dimension in the strategy of therapy seeking. By contrast, the "social support network" perspective often excludes emphasis on the cumulative mi- crohistorical process through which knowledge is applied by individuals; it often fails to appreciate the implications of consensus and disagreement for decision making in the search for therapy; and, despite its importance in medical anthro- pology, its users often ignore the presence of alternative or contrasting medical or therapeutic ideologies that are held by segments of the network or group.

Reception of the Therapy Management Concept

Numerous reviews and discussions of therapy management have been pub- lished (Pfleiderer-Becker 1978; Beidelman 1979; Fabrega 1979; MacClean 1979; Messing 1979; Edgerton 1980; Bibeau 1985; Genest 1985). Reactions to the con- cept may be summarized by reference to three issues: (1) the ethnographic range and ethnological status of the therapy management phenomenon both elsewhere in Africa and in other settings worldwide; (2) therapy management and therapy management group as theoretical concepts; and (3) methodological and clinical issues in applying the concept.

Therapy Management as Control over Therapeutic Resources

Many reviewers and researchers have affirmed that in their experience ther- apy management groups occur widely. Lambek (personal communication, 1986), in his just-completed comparative study of Mayotte and Botswana, for example, confirms the presence of the therapy management process in both societies but identifies differences in the social composition of therapy management groups. In

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Botswana, deep agnatic lineages form the basis of domestic society and exercise responsibility for both the diagnosis of affliction and the care of the sick. In May- otte, there is less emphasis on lineage, and bilateral family networks play a com- parable role in coming to the aid of sufferers and tending them in the hospital. In addition, spirit mediums and other healers play a central role in guiding the ther- apeutic quest.

Feierman (1985), a fellow Africanist, has endorsed the general idea of the therapy management group and has refined the concept in a number of ways. On the basis of his work in Tanzania, he suggests that therapy management funda- mentally concerns determination of diagnosis and procurement of care for the suf- ferer by another individual. In Kongo someone (the juridical "owner" of an in- dividual, either the lineage head or, in the case of a slave, the master) has the right to make these judgments and decisions. Only in the case of adult males and in- dependent women do sufferers make these determinations themselves. Thus, what I call a "group" in my analyses is a set of individuals, one of whom has rights of decision making in Kongo customary law, and others of whom (perhaps kin) assist in lending support, solace, or aid in treatment. The distinction between the legal control of diagnosis and choice of therapy, on the one hand, and solace and support, on the other, is important.

Feierman's review also calls into question my use of the term "group" to refer to the constellation of individuals who manage therapy for the sick. This term can only be objected to, however, if it is taken to imply "corporate group" in a technical sense. It still seems an appropriate term in the less legal sense of a "special-purpose group"-a set of individuals involved with a sufferer to lend assistance or assume authority in diagnosis and therapy.

Feierman endorses the focus on therapy managers over healers in the study of African medicine, because it emphasizes the oft-forgotten point that therapy, like other activities in society, is shaped by those who control it. That is, the same power structures that shape domestic institutions, professions, and entire societies through state structures also shape therapeutic actions. The issue that the study of therapy management opens, and that Feierman examines at length in the essay cited here, is the institutional control of therapeutic choice, whether in the lineage, household, profession, or state (Feierman 1985:80-83). Seen, then, as one level of the control of all therapeutic resources, the phenomenon of therapy manage- ment may be said to exist worldwide. This formulation overcomes the simplistic dichotomy lay/professional that dominates some discussions.

Middle-Range Theory between Individual and Collectivity

Other writers believe that a focus on therapy management in medical anthro- pology can be used to illuminate the logic of patient behavior more clearly than approaches that emphasize only the individual. Pfleiderer and Bichman (1985:129-130) suggest that the concepts of the lay referral system and the sick role usually see the patient as an individual actor and decision maker. Greater emphasis on therapy management as a negotiated process provides a way of per- ceiving the sickness phenomenon in its social context. Thus, Harwood (1978:132) has proposed that therapy management constitutes a "middle range" theoretical formulation between the micro-level of the individual sick role, the clinical and

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ritual process of healing, and the macro-level of political systems, institutions, and societies. For this reason, he suggests, it would be a fruitful focus for com- paring medical systems across societies or cultures.

Bibeau (1985:119) has suggested that the concept of therapy management is also useful in the cognitive study of illness, particularly in elucidating relation- ships among therapeutic codes. By studying successive treatments employed in single cases, Bibeau suggests, one can uncover complementary or even mutually exclusive features in the cultural logic of these codes.

Fabrega's review of Quest (1979:369) includes notice of the possibilities for mathematical analysis of "shifts in direction" of illness and care during succes- sive episodes. With a larger number of cases, it would be possible, he points out, to develop a "geometry of the pathways of illness." The basis for this possibility is spelled out in our work in a lengthy footnote (Janzen 1978:138) that has so far received little attention. Prediction of the choice of therapeutic resource in suc- cessive stages of a therapeutic course lies somewhere between strict determinacy, modeled by a Markov chain, and the indeterminacy of a stochastic process. In the former, prediction would be based on knowledge of the present and past; in the latter, random choice and combination would prevail. We suggest in this note that successive choices in the cases we studied were determined to a greater degree by the dynamics of relationships between individuals and social segments involved in therapy management than by a "pure" cognitive logic. This was the basis of our rejection of many of the disembodied, decontextualized approaches to recon- structing medical knowledge.

The implications of this conclusion go beyond mathematics. The direct study of the therapy managing constellation lends affirmation to the theoretical view that knowledge is always socially embedded and implies a corresponding epistemol- ogy of fieldwork. The particular manner in which ideas are generated and ex- pressed both in patients, their therapy managers, support groups, and healers is contingent on the particular constellation of individuals present. Consequently, just as we took issue with certain trends in ethnoscience in the 1970s, so we would probably take issue today with some of the "culture as text" approaches that seek to generate the contours and structures of knowledge without looking at either the social context within which such knowledge is used or the manner in which social relationships and power interests manipulate it. In medical anthropology the ques- tions of why people utilize differing types of care are still of acute interest. One reason these questions have not been more authoritatively addressed in recent years may lie in the methodological difficulty of elucidating socially embedded knowledge in the moment of decision.

Methodological and Clinical Implications

Comparable challenges face both the anthropological fieldworker and the cli- nician who wishes to identify assumptions and ideas that lead to the choices made by patient or patient managing groups. Both must identify how options being en- tertained in the community around the sufferer influence the sufferer's choices. For the fieldworker the problem is not so much identifying these options, but of accumulating enough of them to determine what they mean in the wider society and culture and whether they are representative. For the clinician the important

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issue is how to relate to these options-whether to give them free reign, to resist them, or to work with them.

With regard to the fieldworker's concern, Edgerton in his review of The Questfor Therapy (1980:171-172) observed that the data base was not entirely satisfactory, even though the analysis of the cases was appropriate for sketching relationships between segments of therapy management groups that represented different therapeutic ideas and approaches. He observed that some of the cases were cut off arbitrarily because the field study covered only a year's time. Two fundamental methodological questions are raised by this critique: (1) Can research utilizing the extended case method provide a sufficient number of examples to claim cultural representativeness? and (2) Are the results replicable?

Several studies have demonstrated that these questions can be answered af- firmatively. In their work among the Shambaa of Tanzania, Feierman and Karlin combined periodic surveys of 160 households in a single community with inten- sive study of therapy management in cases that emerged from this sample (per- sonal communication). They also studied extended cases from a variety of his- torical sources. This strategy allowed them to identify not only change through time but also synchronic variation among contemporary households. In addition, Sussman (personal communication, 1985), in anthropological research currently under way in Madagascar, has proposed to study intensively 150 individuals, drawn from a larger sample by stratified or random means, in order to identify (among other aspects of health care) therapy management procedures and pat- terns. These studies illustrate efforts to expand the data base in order to satisfy sampling criteria of size and representativeness. In doing so, researchers have adopted sampling methods that were utilized a decade ago in community research by Colson (1971) and Manning and Fabrega (1976).

The reaction to the therapy management group phenomenon has included a number of comments about its utility for health-care personnel. Mcllvray (1978) and MacClean (1979) have exhorted clinicians working in hospitals and medical centers in Africa to be sensitive to their patients' therapy managers and to share information with them. Pfleiderer and Bichman (1985) advise therapists not to "bracket out" the social dimension in the treatment of sickness. As long as the patient is handled only as an individual, the therapy can be but partially success- ful. Healing in the African context entails not only the amelioration of symptoms but also the clarification of diagnostic issues and the creation of social consensus.

Further Research on the Therapy Management Group Reviews of The Quest for Therapy and reports of new research indicate that

several issues in medical anthropology may be seen in a new light through the study of the process of therapy management and the composition of the therapy management group. Six issues, and related examples, will be outlined briefly here.

First, the study of therapy management brings into focus issues around ther- apeutic decision making. Debate continues regarding the determination of thera- peutic decisions, with materialists, hierarchy-of-resort advocates, idealists, cul- ture-as-text analysts, transactionalists, and others promoting their views. Therapy management as a perspective does not sweep away and replace these other per-

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spectives; rather, it offers a more disciplined and contextually sensitive frame- work within which to test hypotheses concerning medical decision making that derive from any of these theoretical frameworks.

A second, and related, emphasis that has been brought to the fore by the therapy management perspective is the nature of differential options and choices in pluralistic medical settings. Cross-referrals and consultations across medical traditions within single cases, as illustrated in The Quest for Therapy, have been confirmed to exist widely. As a result, our understanding of medical pluralism has evolved from mere reflections on how medical systems may differ in their general characteristics to a better understanding of how they mesh and articulate in par- ticular societies and settings. A focus on the decision-making process in therapy management is able to show how differing paradigms are handled in real life by living actors. For example, Staiano (1986) has applied the "close-in" case-by- case approach to examine multiple medical resource use in Belize, a remarkably pluralistic society in this regard. Identifying her work as a "case study in medical semiotics," she has analyzed the shifting relationship between labeling of symp- toms, on the one hand, and the imputation of etiologies on the other, in cases that move across distinct medical systems (1986:175-235). Sargent's work on the choice of obstetric and gynecological care facilities in the Republic of Benin (1982) also adopts this perspective. In a new work in progress (personal com- munication, 1986), she assesses the self-conscious process of "juggling" re- sources, types of medical knowledge, and institutional utilization.

Not only the consideration of multiple alternative models of therapeutic knowledge is at issue here, but also the salience or control of these models in successive stages of therapy. A third type of contribution the therapy management perspective may therefore yield is to introduce into the evaluation of the clinical or therapeutic setting jural and political-economic factors. One way this has been formulated is in terms of the pattern of care received by needy or neglected indi- viduals. In this regard therapy management may identify patterns of increasing health risk. Feierman's household survey among the Shambaa of Tanzania (1981:359, 1985:83-84) demonstrated the extent and type of disadvantage expe- rienced by those who did not share in the benefit of collective kin funds and other aid in the event of disease or misfortune. Over a period of 80 years of colonial and postcolonial history, widows and divorcees were shown to have few therapy management resources. The consequences of their disadvantage were demon- strated by the fact that their children showed up with the most serious and frequent health problems. This research suggests that the therapy management perspective, focusing at close range and over time, can provide evidence of growing class dis- enfranchisement in society.

A fourth issue that may be elucidated by research on therapy management, one related to the control of health and health-care resources, has to do with the "shape of knowledge" as a result of social control. There are several dimensions to this problem that can only be suggested here. One has to do with the disjuncture between expectations and outcomes in therapy, and another has to do with the social segments that lay claim to the control of knowledge and resources in the therapeutic setting.

Unexpected outcomes or "failures" in therapy, sometimes also referred to as lack of compliance on the part of the patient, are not merely to be explained by

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the differing sets of ideas held by healers and practitioners, as suggested in Klein- man's Explanatory Model (1980). Who controls the models and the way that con- trol is managed must also be included in the analysis. This is effectively illustrated in Redford's (1977) study of decision making and the management of knowledge among teenage pregnant girls in an urban North American setting. The aim of the study was to determine teenagers' understandings about the relationship between sex and conception, and once pregnant, how the girls perceived and managed their obstetric and gynecological care. After interviewing health officials and studying the regimens they had prescribed, it became clear that the girls did not follow their instructions very closely. Redford discovered that girlfriends and the girls' moth- ers were the principal sources of information and figures of support in decision making. Only rarely did the girls establish meaningful contacts with gynecolo- gists and prenatal-care specialists, although they went to them regularly for check- ups and delivered their babies in maternity clinics. Clinical authorities were con- sistently surprised at the decisions and moves taken by the girls. However, had health-care personnel identified the girls' assumptions more thoroughly, as well as the people with whom the young women conferred about their decisions, they would have perceived consistency rather than disjuncture between knowledge and action.

The control of therapeutic knowledge and resources, as seen in this example, is often assessed in terms of "lay" versus "professional" realms of discourse and understanding, or in terms of the "doctor-patient" relationship. However, there are many examples of medical decision making, even in highly technical care, where information and crucial symbols are embedded in a total constellation of social relationships that is dominated neither by professionals nor by laity. A fo- cus on therapy management yields understanding of the dynamic qualities of this negotiation, rather than type-casting knowledge and information control as "lay" or "professional."

A study of the decision-making process, the control of knowledge, and the conveyance of rights in a large urban American leukemia treatment center (Longhofer 1980) illustrates these points. In bone-marrow transplants donors must be blood-group compatible with recipients, and are thus almost always members of the same family as the recipient. Given the highly suspenseful "all or none" outcome of transplants, which result in either temporary remission or death within 36 hours, the marrow donor becomes either the perceived cause of the patient's survival or the implicit reason for his imminent death. A diffuse, multiplex relationship binds donor and recipient and comes to dominate the ther- apy management process. The charged atmosphere of the leukemia clinic brings family members together to support the patient and one another in the face of "the double bind," as Longhofer calls it, brought on by the prospect of either instant cure or catastrophy.

The study revealed that American families act very much like Kongo kin groups in this situation, with an important inversion. Whereas in Kongo rights of decision making were conveyed to a "jurally responsible" individual within the family, in the American leukemia cases the patient and donor frequently took de facto charge of therapy management. The medical staff, faced temporarily with uncertain outcome or hesitancy by the marrow donor, lost control of the thera- peutic process, and engaged in a "juggling" of alternative strategies that can only

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be termed a sort of professional "therapy management."' This case study suggests the utility of including healers within the therapy management group, even in so- cieties with a highly professionalized and technologically sophisticated medical institution.

A sixth, and final area of further research on therapy management that flows out of the close-range study of therapeutic choices within a social context is that of the emergence of specialized communities of caring and curing, whether these be Central and Southern African "cults of affliction" (Turner 1968; Schuessler 1986), Western self-help groups, or other variants. Many studies delineate the therapeutic rituals, cosmologies, and organizational structures of African cults, but we lack so much as a single report on the individual-by-individual actions accompanying the emergence of such groups. It is likely that these cult groups emerge from sets of individuals being diagnosed with similar problems, and being steered by their therapy managers to common solutions. Corin (1979), in her work on the Zebola cult that arose in Upper Zaire and spread to urban centers of Mban- daka and Kinshasa, noted, as one would expect, that fewer of the sufferers' kin were involved in decisions and rituals in the city than in the home setting. Lambek (personal communication, 1986) observed on Mayotte that groups of spirit suf- ferers tended to congregate with healers having knowledge of these same spirits. Although comparative research on this subject is scarce, it may be that there are widespread therapeutic support group patterns that replace kinsmen in giving di- agnosis, interpretive judgment and support to specialized categories of afflicted or disadvantaged who have lost close proximity and rights to family resources. A therapy management perspective would elucidate the process of the emergence of such groups.

Conclusion

What, then, is the verdict on "therapy management" as a process, and the "therapy management group" as a social context for the process? Is the notion, used in a single monograph study almost a decade ago, worthwhile? It appears to have had some success in application to a variety of settings, although it has not exactly unleashed a revolution in medical anthropology. No doubt many of the ideas and approaches that have here been subsumed under "therapy manage- ment" or the "therapy management group" could have been formulated without using these exact terms. Medical anthropology would do well to avoid the pursuit of specialized jargon.

Nevertheless, the focus that has been emphasized in this article contributes to a sounder understanding of the manner in which medical knowledge is embed- ded in social categories and relationships, and how it is articulated, controlled, or manipulated in that setting. Medical anthropology continues to be concerned with the determinants of choice in the therapeutic process, with the relationship be- tween alternative medical traditions and pathways available, and with the control and application of medical knowledge. Therapy management as a perspective brings these issues into focus in a unique way that provides an understanding of the relationship of knowledge to society in health seeking, for the analyst and clinician alike.

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