Explanatory Models

Pre Course Reading for CALD 9

eCALD Supplementary Resources

Different cultures have different ways of understanding illness and will attribute different causes for the origin and symptoms of their illness. The way explanations of illness are explained is strongly influenced by cultural values. To a large degree, these values also define the acceptable symptoms of the illness as well as the behaviour, expression and role of the sick person. Explanatory models also contain elements of prognosis, the general course the illness is likely to take and some ideas about treatment.

Why we need to understand the client’s explanatory model

  • Beliefs about the illness might determine whether or not a client seeks help at all
  • Clients from ethnic communities often only present once the illness has progressed to an acute stage
  • Culturally appropriate beliefs can be misunderstood as psychopathology
  • The severity of a disorder can be misjudged
  • Cultural explanations will often reveal culture-bound syndromes
  • Appropriate treatment depends on accurate diagnosis 

It is critical that a clinician takes time to understand the client’s explanation for their illness as well as to share some of their own perspectives with the client. The chances of misdiagnosis are higher if the clinician is unclear about the client’s understanding of their illness. The success of intervention and adherence will depend to a significant degree on the formation of a collaborative model that is acceptable to both client and clinician.

Explanatory models of mental illness outlined by Ton and Lim (2006) and Kirmayer et al. (2003) include:

Biomedical (scientific) model

Biological causes are seen to be the basis for illness. This model is characteristically used in Western allopathic medicine.

Humoral/balance model

Based on the theory that the human body is filled with four basic substances called humors and that all diseases, illness and disabilities result from an excess or deficit of one of these humors. Treatments could include Traditional Chinese Medicine (TCM), Ayurvedic medicine and various herbal medicine traditions.

Moral model

This model involves the belief that the condition is caused by a moral defect such as laziness, weak will or selfishness. Families sometimes use this model as well as the client.

Spiritual/religious model

This holds that illness results from spiritual or religious transgressions or from unmet religious obligations. Offended spirits, gods or God bring punishment. Religious leaders may be involved in treatment.

Supernatural model

Sorcery, witchcraft or other supernatural elements are seen to cause illness. Treatments vary across cultures and may involve either finding the person who placed the curse or a shaman to lift or counteract the spell.

Psychosocial stress model

This model attributes illness to overwhelming psychosocial stressors. Treatment would include addressing the stressors.

Combined models

Individuals often have explanatory models based on one or more of the above, and many combine traditional and biomedical models.

Some people’s models are fixed, while others’ models might be ill-defined and not necessarily easily articulated to a practitioner. Kirmayer et al. (2003) note in a report on a cultural consultation service that explanatory models were not central to case formulations because most clients used pluralistic explanations. What created difficulties were the conflicts that arose between clinicians’ and clients’ explanations when clinicians were too attached to their own perspectives. They point out the possibility that clients who used traditional explanations exclusively may be less likely to consult mainstream health care services. Therefore it is essential  that clinicians remain open to other explanations of illness and are able to integrate these with their own explanations in order to maintain adequate trust and rapport for assessment and treatment to continue.

Kleinman (1980)  identifies three overlapping cultural sectors that influence people’s explanations of health and illness:

  • The most influential originates in the ‘popular sector’ and consists of information from friends, family and community, and common wisdom and knowledge.
  • The second is from the professional sector and is based on Western biomedical knowledge and technology.

The third originates in the folk sector, consisting of spiritual and secular healing systems.