• •

~ Pergamon Soc. Sci. Met!' Vol. 45. No.6, pp. HII-R25. 1997
C 1997 Elsevier Science Ltd. All rights reserved
PH: S0277-953li(96)00422-4 Printed in Great Brilain
0277-9536(97 SI7.00 + 0.00

THE BLACK BOX IN SOMATIZATION: UNEXPLAINED

PHYSICAL SYMPTOMS, CULTURE, AND NARRATIVES OF
TRAUMA
HOWARD WAITZKIN' and HOLLY MAGANA
Division of Community Medicine. University of New Mexico, 2400 Tucker Avenue N.E .. Albuquerque.
NM 87131-5326, U.S.A. and Cenler for Health PoliC)' Research University of California, Irvine. Irvine.
CA. U.S.A.

Abstract-Stimulated by OUf clinical work with patients who manifest unexplained "somatoform"
symptoms in the primary care setting. Ihis article addresses a theoretical black box in our understand-
ing of somatization: how cs culture mediate severe stress to lli~.~tug.-Syrop' oms that cannol be
expl~.i!le~tJn: the presence of hysical iIInes..s1 Despite vanous problems in his explanation of hysteria,
Freud broke new ground by emphasizing narratives of traumatic experiences in the development and
treatment of unexplained physical symptoms. Except in anthropologically oriented cultural psychiatry.
contemporary psychiatry has traveled away from a focus on narrative in the study of somatization. On
the other hand, recent interest in narrntive has spread across many intellectual disciplines, including the
humanities and literary criticism, psychology. history, anthropology. and sociology. We op¢rationally
define narratives as attempts at storytelling that ponray the interrelationships among physical symp·
IOms and the psychologic, social, or cultural context of these symptoms. Regarding somatization and
trauma, we focus on the ways that narrative integrates the cultural context wilh traumatic life events.
In explaining the bl~tck box. we postulate that extreme stress (torture. rape, witnessing deaths of rda·
tives. forced migration, etc.) is processed psychologically as a terriblc, lar~y- incoherent narrative of
events too awfuLt~Lh.olA in consciousness~ltur.e_pa.ltems_the-ps.ychQIQgi and somatIc expression oT
the tcrriblc narrative. Methodologically, we have dcvelo~ some techniques for eliciting narratlves of
severe stress and somatic symptoms. which we illustrate with observations from an ongoing research
project In designing interventions to improve the care of somalizing patients, we are focusing on the
creation of social situations where patients may feel empowered to express more coherent narratives of
their prior traumalic experiences. © 1997 Elsc\'icr Science Ltd

Key It"ords-somati:wtiol1, trauma. narrative, patiem-·doclor communication

As the novel Ceremony proceeds. Tayo returns to

J will lell you something about stories {he said}. They
aren't just entertainment. Don't be fooled. They are all we
have, you see. all we have to fight off illness and death.
You don't have anything if you don'! have the stories
(S;lko. 1977. p. 2).
Tayo, the Native American protagonist of Leslie
Marmon Silko's novel, experiences an incapacitat-
ing sickness: overwhelming fatigue, nausea, vomit-
ing. and an indifference to the people and places
fonnerly closcst to him. His symptoms begin in a
moment of crisis. On an island in the South Pacific
during World War II, he glances at the race or a
Japanese soldier whom he has been ordered to kill.
In that Asian face, he sees the image of his own
grandfather and senses the seeds of his own culture.
At the same moment, he breaks down, no longer
can shoot or fight, later passes through various
military hospitals, and winds up on the streets of
Los Angeles, his clothes stained from his own
vom\\.
-Author for correspondence.
811
his homeland in New Mexico and. with the support
of loving family members, friends. and lovers,
begins a personal quest for healing. This quest
slrangeJy leads to the home of a shaman. a spiritual
healer named Betonie, who works his healing ceT-
emony in the shack where he lives. overlooking the
garbagc dump in Gallup, New Mexico. The cer-
emony, which culminates the novel and explains its
litle, involves a spiritual ex.orcism of Tayo's painful
experiences during war and during the so-called
peacc that the repression of Nativc Americans has
achieved in the United Slates. In the ceremony,
Tayo's telling the story of his Japanese "unclc",
and of the inability to kill a forefather, leads to a
cure of his physical symptoms and spiritual desola·
lion.
THE CLINICAL PROBLEM
Reminiscent of Tayo's narrative about (fauma
and healing. we began more than 10 years ago to
see patients at our community clinic in southern
California with similar clinical histories. During the
<
812 Howard Wailzkin and Holly Magana
height of internal conflicts and a markedly
increased presence or
Unilcd States military forces
\\-'ithin several Central American countries. patients
like the following began to seek primary care ser·
vices.
X.O.. a 19-year-old woman from a rum] area in
Guatcmnla, migrated to the United Stales after witnes-
sing the deaths of s~veral family members and friends
during militilry combat in her native country.
Subsequently. she had been afnicted by an",iely, tremors.
restlessness. palpitations. excess sweating, and hypervcnli-
kllian. Arter she arrived in the United States, her symp-
toms worsened when her mOl her's new husband. an
alcoholic. initialed domestic violence and baltered the
palient herself scveral limes. X.O.·s native language was
Quiche. and even though she was omlly proficient in
Spanish. she was illiterate. Her Iimiled language skills
and education. as well as her non·tr:lnsferable working
skills in the North American economy. created additional
stress.
x.o. presented lO a primary care resident physician at a
community clinic with multiple somatic complaints
including chest pain, abdominal discomfort. pelvic press·
ure, headaches. numbness of her hands. nightmares,
insomnia. and agitation. A thorough medical history,
physical exam, and laboralory evalualion excluded or·
ganic causes. In addition, the resident obtained a psycho·
social history that revealed her stressful pre-migration
experiences. Post· traumatic stress disorder (PTSD) and
somatization were diagnosed as coexisting problems.
Psychiatric treatment was obtained. The primary care
physician and the patient's family cooperated in Iherapy
and as a support syslem. A Iricyclic antidepressant was
used on a shorHenn basis. Her emotional and physical
symploms gradually declined.
R.L was a 27-year-old male from EI Salvador. He fled his
nativt: country after finding OUI [hal his name had
appeared on a death squad list for immediate execution. A
white hund prinl with the initials E.M. (EscuatJrolles de 10
."[lIertt'. Dealh Squads) also had appeared on the front
door of his house. Nine monlhs after his luri\'al in lhe
United Slates. he learned that his wife had been assaulled
ilnd abducled by paramilitary forces. His two children wit-
nessed Iheir mother being raped and killed by a group of
unidentified men during an allcmpt to extract inrornHltion
aboul R.L.·s whereabouls.
Shortly thereaf1er. R.L. presenll:d LO a primary care
physician at a community clinic. During previous weeks
he had experienced multiple symptoms. including wl:ak-
ness (which caused him to be lerminated from his tern-
ponley job). changes in sensation. abdominal pain. chest
pain. insomnia. and weighl loss. R.l.'s primary care
physician pursued several possible organic diagnoses by
ordering diagnoslic studies. He also prescribed analgesics
>Ind other medications. Afler e:<tcnsive evaluation. no
physical cause was found for Ihe patient's somatic symp-
corns.
Psychialric consultation was Ihen sought Somatizalion
was diagnosed. Low-dose antidepressant medicalion was
insliluled ,IS individual therapy continued. The psychia-
trist coordinated follow-up wjlh the primary care inll:r-
nisI. R.L. grew more aware or emotional faclors
exacerbilling his symptoms and developed new coping
slratcgies. He joined a group or local Cenlral
American refugees. where he was encouraged to write
lind 10 recite poetry as a [herapeulic tool. During the
following months. his somalic symptoms gradually
decreased.
Confronting patients like these, we and our
colleagues searched for prior studies that could
shed light on a central question: how does culwre
mediate> severe stress to produce symptoms that
canno' be explained by the presence of physical
illness? Such "somatoform" 5 m [oms (defined as
sym toms for which no h sical cause can be
found seemed quite common, especially among
refugees who had experienced psychosocial trau-
.1lli\S before leaving their countries of origin.
during relocation 10 other countries, during lhe
process of migration to the United States. and
after their arrival in this country. In our review
of the literature on somatization, presented else·
where (Castillo et aI., 1994, 1995), we localed
ample evidence of the impact of culture on the
experience and presentation of bodily symptoms.
In particular. we recognized the major conceptual
advances that have occurred in the field of cui·
tural psychiatry during the last 20 years (we
refer later to some of this important literature).
On the other hand, despile literary examples like
Tayo's, we found very imprecise reports of the
relationships among severe stress. the experience
of PTSD, and cultural differences in the pallern-
ing of somatic complaints.
At the outset, we acknowledged that severely
traumaLized_palienLs-compO$.e.-<mlY. a subset"Of
patients \....ho somatize. \Ve believed that fewer
patients who sought primary care services for
somatororm symptoms had experienced severe
trauma than those who had not, although to our
knowledge the distribution of traumatized versus
non-traumatized paricnts among those who soma-
tize had nol been clarified through prior
research. Further, we recognized that interest in
trauma has expanded rapidly during receol years
in both clinical and non-clinical circles. perhaps
in part due to intellectual fashion. In fact. a cri-
tique has emcrged concerning interpretations of
trauma. including the syndrome of "post-trau-
matic stress disorder"; this critjque treats such
interpretations as themselves cultural construc-
tions with questionable precision in explaining
psychologic distress (Hacking, 1995; Young.
1995). On the other hand. the very striking co-
occurrence of severe trauma and somatization
among our primary care patients led us to
believe that these relationships warranted closer
examination than had taken place so far. In par·
licular, we hoped to clarify what proportion of
somatizing patiems in the primary care selling
had experienced severe trauma, and through
what mechanisms culture mediates trauma in the
production of somatoform symptoms.
 The black box: in somati7.ation
A RESEARCH PROJECT ON CULTURE, TRAUMATIC
STRFSS, AND SOMATIZATION
Subsequently, we initiated a research project 10
help clarify the relationships among culture, tmu-
matic stress, and somatization; the study has
focused on immigrants and refugees from Central
America. especially the subset of somatizing
patients who have experienced extreme stress. We
have used a structured diagnostic instrument (the
Composite International Diagnostic Interview,
CIDI, an instrument developed by the World
Health Organization to be used across cultures and
languages), a clinjc-at assessment. and several
measures of utilization and costs in comparing
three Latino ethnic groups-Central Americans.
Mexicans, and Chicanos (persons of Latino descent
born in the United States)-as well as a non· Latino
comparison group, For this project we have
adapted several research techniques to the primary
care setting, since we have found clinically that
patients with soml..l1oform symptoms-as well as
patients with psychiatric symptoms-usu;:llIy present
first to primary care practitioners, ralher than to
mental health professionals.
Based on previous research and clinical expcri~
ence. we hypothesized that war-related experiences.
migration stress, refugee status, and Jack of accul-
turation would be associated with somatol"orm
symptoms among patients who seck primary care:
and that, because of their increased exposure to
war-related experiences and migration stress,
Central American refugees would show higher levels
of somatoform symptoms than other Latino and
non-Latino subjects. Our data analysis also aimed
to reveal the varying nuances of somatoform symp·
toms and their relation to PTSD in the four cultural
subgroups. In our initial quantitative report. we
have presented data that, for the most pan, confirm
our hypotheses (Holman et (II., SUbmitted).
Subsequent articles will examine PTSD among the
patients. physicians' difficulties in caring for soma-
tizing patients, and barriers to health care and men-
tal health services.
A black bax
Meanwhile. although this research project has
revealed some important associations among cui-
lUre, traumatic stress, and somatization, the causal
linkages remain uncertain. Specifically. in our work
so far. it has become clear that a theoretical black
box exists in our understanding of the psychology
of somatization. This blaek box can be depicted as
in Fig. I. Referring back to the key question raised
earlier, ).h.e_mechanisms-by-whieh culture mediates
traumatic stress to roduce somatoform symE!Q.!TIs,
a~osed to more overt sychoIQg~_dislutbance.
remain poorly understood. What are the precise
ways that_W!umatic stress is proccssed-at~(he indi-
viduaf revel. and is influenced b ~uJlu.r.al_pattern-
.-- -
81,
Cullure
_
§--C
Black Somatic Symploms
bo); Psychologic symploms
Fig. I. Schematic view of the black box in somatization.
ing, to yield somatic versus emotional symptoms?
DcspJ e 'loel}-'--CYb"s-ctved-cu(turar--uitferences In
somatization. this particular issue involving the
mechanisms lhat link trauma, culture. and somati-
zation has received surprisingly little attention.
except to a limited extent in recent cultural psychia-
try.
In the rest of this article, wc pursue what is in
the black box and assert that the conceptual and
methodologic approaches of narrative analysis Can
help us clarify the black box's contents. First, 10
link narrative and somatization. we return to the
early years of Freud's work on hysteria and Haee
historically how Frcud·s position has evolvcd in lat-
ter day psychoanalysis. literary criticism. and non~
psychoanalytic psychiatry. Recognizing thc limi-
tations of thesc efforts, we then examine more
recent studies. spanning several intellectual disci·
plines. that focus on narrative in psychologic pro-
cesses. As the beginnings of a theory. we postulate
that the black box contains a narrative of trauma.
processed psychologically in waY5 that depend on
the specific sociocultural context. We then i1lu~tratc
methods of eliciting narralives about extreme stress
and somatic symptoms. which draw on some non·
quantitative data from in·depth interviews con-
ducted as part of our study. In conclusion. we com-
ment on lhe clinical care 01" somatizing patients and
the creation of empowering situations (hat encou-
rage the expression of mOre coherent narratives
about prior traumatic experiences.
By examining the gaps in understanding about
the relationships among trauma. culture. and soma·
tization. we realize that we arc tackling part of the
mind-body problem that has puzzled clinicians and
researchers for generations. That is. many before us
have speculated on the mechanisms by which symp-
toms arc produced and experienced under varying
cultural. social, and psychologic conditions. We do
not claim in any way to have resolved the problem
of how such conditions mediatc somatization.
Instead. as in prior research on depression (e.g.
Brown and Harris. 1978). we arc trying to c.:larify
how problems in the social world are interconnected
with psychobiological phenomena such as the ex-
perience of somatic symptoms without physical dis-
ease. Our central claim will be that such
interconnections occur at least in part through the
construction of narratives that manifest greater or
lesser degrees ouoherenee. In this paper. our
explo~~eory-driven.as we use limited case
materials to shed light on the conceptual scheme
lhat we arc proposing. For later work in this series.
we will present additional data that illustrate the
consistencies and complexities of these processes.
8/4 Howard Wailzkin and Holly Mag<liia
PHYSICAL SYMPTOMS ANO INCOHERENT NARRATIVES
Of TRAUMA IN PSYCHOANAL\'515 AND LITERARY
CRITIClS:\'f
In seeking the contents of the black box-and
more especially the connections between somatic
symptoms and coherent versus incoherent narratives
of traumatic events-we return to psychiatry at the
turn of the 20th Century. when somatization gener-
ally bore the name ·'hysteria". This term derived
from the Greek rool, hystera. meaning "uterus", As
implied by this etymology, hysteria generally was
seen as an emotional disorder affecting women.
Regarding hysteria, Freud argued for the impact of
repression and dissociation as psychologic defenses
in the processing of stressful experiences in child·
hood (Freud and Breuer. 1895; Freud, 1905, 1953).
In one of his most famous case studies, and one
that has received wide polemical anack especially
from feminist critics, Freud analyzed "Dora", a
young "voman who suffered from several somatic
symploms for which no physical cause could be
found: shortness of breath. severe coughing attacks,
and intermittent loss of voice ("aphonia"), Despite
the dated and controversial arguments that Freud
offered in analyzing this case, his focus on the
meaning of somatic symptoms within an incoherent
narrative of trauma will inform our later consider-
ation of more contemporary materials.
As Freud depicted Dora's experience, a reader
sensitized to the gender politics and clinical view-
points of the 1990s would see the case 35 a rather
straightforward example or sexual abuse. In brief,
Dora's father. who previously had undergone sue·
cessful anti·syphilitic and psychotherapeutic Ireat·
ment with Freud, also initiated his daughter's
analytic treatment. As Dora's therapy evolved,
Freud focused on a serie5 of unwanted sexual
advances toward Dora during her adolescence by
Herr K .. a friend of Dora's family. Herr K.'s wife,
it turns out, also had entered into a sexual relation-
ship. or at least a very intimate friendship, with
Dora's father. who.n she had nursed during his ill-
nesses. From Freud's standpoint. one motivation
for Dora's father in seeking treatment for his
daughter involved an exchange, in which his re·
lationship with Frau K, could be stabilized by offer-
ing a healthier and more acquiescent Dora to Herr
K. Further complications revealed in Dora's analy·
sis included, in Freud's view, her own heterosexual
erotic fantasies about Herr K., homosexual attrac-
tion to Frau K., and repressed sexual altraction
(Qward her father.
Early in his presentation of Dora's case, Freud
l.Icknowledgcd the association between hysteria and
severe psychic trauma [with Breuer, and following
Charcot. he earlier had emphasized this connection
(Freud and Breuer, 1895»). Freud then explored the
meaning of the specific symptoms involved.
Beginning with a passionale kiss that Herr K.
forced upon Dora al the age of 14, Freud inferred
Dora's genital excitement, her "disgust" at these
pleasurable feelings, and her repression and dispJa·
cement of these feelings to symptoms of respiratory
distres5 and inability to vocalize.
Despite the obviolls problems of this interpret·
£Ilion seen from the present epoch (including but
not limited to: discounting [he trauma of the actual
seduction and sexual abuse by a shift in emphasis
10 Dora's sexual fantasies; an overly sexualized
view of female psychologic processes; and an uncri-
tical stance on the sexual power of the male figures
in such experiences; Gearhart, [985; Miller, 1984;
Malcolm, 1984; Masson, /992), Freud clearly called
attention to the connection between psychic trauma
and otherwise unexplained physical symptoms,
\Vhile he recognized that the mechanisms remained
not fully clear, he believed that this connection
!l1USt depend on the "meaning" of the symptoms
within ~ partly or fully repressed story of a patient's
lived experience-what we no\1,I might call an inco~
herent narrative of that experience:
As far as I can sec, every hyslcrical symptom.. cannot I
occur more than once,. unless it has a psychical signifi- i
c<lnce, a meaning. The hysterical symptom does not carry l
this meaning with it. but the meaning is len I to it, soldered (
to it, as it were: and in every instance the meaning can be I
a different one, according to the nature of the suppressed /
-
(0 t:.. ./
thoughts which me struggling for expression (Freud, 1905.
pp.40-4/).
For Freud, one goal of psychotherapy with patients
suffering from hysteria, as well as a spectrum of
other psychologic difficulties, involved a gradual
bringing to consciousness of these unconscious
meanings. As Marcus has pointed out, Freud's
vision implied that mental illness resulted from
shortcomings in patients' narrative accounts of their
experiences, and that mental health derived from
possession of a more complete and better organized
narrative (Marcus, 1985).
The incoherence of narrative accounts became a
crucial component of Freud's interpretation of hys·
teria; this kernel became an important reason that a
focus on narratives could elucidate the connections
between severe trauma and somatic symptoms.
From this viewpoint, the therapeutic process
required the telling of a coherent story, shared by
therapist and client, of traumatic events experienced
earlier and defended against through repression,
displacement. and dissociation. For patients with
hysteria, this challenging process often proved im-
possible because of patients' resistance to full
exploration of the psychic conflicts that lay beneath
somatic symptoms. Such frustrations in the treat-
ment of somatization arose clearly in dealing with
patients like Dora, who herself abruptly terminated
her therapy as, Freud claimed, her insights were
becoming more profound.
Freud's emphasis on narrative in hysteria has
continued to attract admiration and criricism.
mainly in European psychoanalytic circles but also
 The: black box in somatization
in North American literary criticism. In Europe,
Lacan in particular explored the structure of
language and related language to psychiatric symp-
toms. Regarding hysteria, Lacan traced somatic
symptoms to gaps in a patient's narrative of desire:
The symptom is first of all the silence in the supposed
speaking subject.. it is in the very movement of speaking
that the hysteric constitutes her desire. So it is hardly sur·
prising that Freud entered what was, in reality, the re·
lations of desire to language and discovered the
mechanisms of the unconscious (Lacan, 1981. pp. 11-12).
Lacan emphasized the dialectic reversals in the psy·
choanalytic process, particularly the relations of
desire between Dora and Freud himself: that i!;,
Dora's transference toward Freud and Freud's
countertransference toward Dora (Lacan, J 985).
Feminist critics influenced by Lacan have treated
Freud's writings on hysteria as a form of literary
production. containing inrernal contradictions and
ideologic assumptions about women's biologic
nature and social roles (Cixous, 1979: Cixous and
Clement, 1986; lrigaray, 1985, 1991: Moi, 1985;
Ramas. 1985; Rose, 1985; Spreng nether. 1985). On
the other hand, the specific links between traumatic
experiences and somatic symptoms have received
surprisingly little attention in this more recent psy·
choanalytic and literary exploration of hysteria. In
general, these works do not explore the precise
mechanisms by which trauma enters into narrative,
the impact of sociocultural conditions on the cogni-
tive processing of traumatic narratives, the relation
between narrative and somatic symptoms, and the
healing effects of bringing the traumatic narrative
to consciousness.
Contemporary, non-psychoanalytic psychiatry,
especially in North America, has traveled further
away from a focus on narrative in the study of
unexplained somatic symptoms. With the exception
of an important corner of psychiatry influenced by
cultural anthropology, to be discussed further
below, psychiatric research has moved morc in a
direction of classifying psychosomatic disorders
according to various taxonomies, with less attention
given to the nature of traumatic experiences con-
nected to somatic symptoms, or to the processing
of narratives concerning those experiences. From
the coining of the term "somatization'" by StekeJ in
1924, psychiatric studies in the field have tended to
distinguish among various categories and syn·
dromes of psychosomatic disorders (Shorter, 1992).
For instance, a group led by Guze described several
versions of "somatization disorder", operationally
defined as multiple symptoms (numbering between
10 and 20 depending on the version), beginning
before age 30, and unexplained after medical evalu·
ation (Perley and Guze. 1962; Guze, 1967). The
American Psychiatric Association's taxonomies.
influenced by Guze's approach, have proposed
varying numbers and groupings of symptom counls
in defining somatization disorder; these c1assifi-
SSM.ls.6 B
81 S
cations have changed over time and have acquired
distinctions from related disorders such as "body
dysmorphic disorder", "somatoform pain disorder",
"hypochondriasis", and so forth (Smith, 1990;
Kirmayer and Robbins. 1991; American Psychiatric
Association, 1987. 1994). Such classifications also
have provided a basis for cpidemiologic research on
the statistical distributions of these disorders in the
general population and in populations of patients
seeking primary care services, inclUding refugees
who have experienced severe trauma in their
countries of origin or during the process of mi-
gration (Castillo el al.. 1995; Escobar, 1993;
Kellner. 1994; Smith. 1994). As shown now by sev-
eral studies of patients who present with unex·
rlained pelvic pain and gastrointestinal symptoms,
somatization can present itself as one delayed mani-
festation of sexual abuse in childhood (Morrison,
1989; Morrison. 1989; Harrop-Griffiths ef al., 1988;
Kimerling and Callioun. 1994; Lechner eJ 01.. 1993;
Pribor et 01.. 1993; Walker eJ 01., 1992a.b. 1993;
Walling eJ al.• 1994).
Classificatory and empirical studies in non-psY4
choanalytic psychiatry have led to several obser-
vations that contribute to a fuller understanding of
the linkages among culture, trauma, and somatiza·
tion. For instance, it is now clear that somatization
occurs with a hi h prevalence in all culJ.uraLgmups
(Klrma~cr, 1984)~ln addition, the memory for trau-
matic events is related more closely to the persist-
ence of symptoms than to the occurrence of the
traumatic events per se (McFarlane. 1993; Wystak,
1994), and premorbid psychologic adjustment
appears to be an important predictor of the re·
sponse to severe trauma (Young, 1995). Recent
research also has revealed that psychologic drstfess
and- somatOforrnsymptOiUscom-monly. coexist in
the same p.cr..s..QDs_and_thcEfo[t _Qften are comQ-
Icmentar)' rather than alternative modes of Rsycho·
Iog;cru;;ctioning (Simon and Von Korff, 199\).--
On the other han , thiS wor has tended to
downplay the specific traumatic experiences that
generate unexplained somatic symptoms, as well as
the narrative linkages between trauma and symp-
toms. The emphasis on taxonomy and epidemiol·
ogy. despite such observations as those above,
generally has not enhanced an understanding of the
precise interconnections among trauma, sociocul·
tural conditions, symptoms, and healing at the indi-
vidual leveL These foci also have shed little light on
how to help patients who suffer from somatoform
symptoms.
NARRATIVE IN PSYCHOLOGIC PROCESSES
To understand the links between narrative and
somatization, it may help to look more closely at
what constitules narrative and how narrative oper·
ates within psychologic processes. In particular,
narrative analysis helps clarify how narratives differ
 816 Howard Waitzkin and Holly Magana
in their coherence; we are postulating that the
coherence versus incoherence of narratives regard~
iog prior severe trauma has much to do with soma·
tization and its treatment. Interest in narrative, of
course, has spread across many intellectual disci-
plines. To mention only a few examples: in psychol-
ogy. a major line of critical study during the past
decade has called imo question the pCrlinencc of
prior concepts and methods to problems of cogni-
tion. meaning, and self-understanding (Bruner,
1987, 1990; I'olkinghorne, 1988: Rosenwald and
Ochberg, 1992). These efforts in psychology have
emphasized personal narratives in learning and
human development. as well as in applications to
psychotherapy. In studies rocusing on the impact of
inhibition in symptom production at the cognilive
and physiologic levels, the therapeutic effects of voi-
cing coherent narratives that depict prior traumatic
events have become clearer (Pennebaker, 1989,
1993: Griffith and Griffith, 1994). Analogous efforts
10 use narralives as a focus for research have
occurred in history, anthropology, sociology, and
such professions as law, education, and social work.
(Mishler, 1986; Riessman, 1993).
Narratives in cultural psychiatry (lmJ the medical
humanities
Several major works in ~ltural psycl~Jave
broken new ground by examining the impact of cul-
ture on personal narratives of physical and mental
illness. Kleinman, for instance, has analyzed the
divergent belief systems that patients from different
cultural backgrounds can convey in narratives of
their physical symptoms and how these symptoms
llre related to their social experiences. Kleinman
represents patients' "narratives of illness" through
highly edited or summarized representations of talk.
rather than through detailed transcriptions
(Kleinman, 1986, 1988, 1995). These studies of nar-
riHives in medicine apply interpretive perspectives
that do not depend on the in-depth analysis of tran-
scribed speech and that do not focus specifically on
the narmtive processing of traumatic experiences.
Related research in cultural psychiatry has
emphasized cultural differences in somatization as
varying "idioms of distress", the unique com lexcs
of symptoms that a 'ear prominentl' in various
cultures, the social construction of il ness_behavior,
and the culturally based cognitive structures by
w.hiche ,penence 0 il ness ....is QIganized
r (Kirmayer. 1984, 1986; Angel and Thoi", 1987;
Jenkins and Karno. 1992; Guarnaccia, 1993)
-Regarding trauma more specifically. recent work
concerning the history and ethnography of PTSD
has reviewed critically the notion of traumatic mem-
ory and the impact of culture. as they relate not
only to post-traumatic stress but also to such psy-
chiatric syndromes as hysteria Hnd somatization
(Young, 199;). These efforts in cultural psychiatry
have focused especially on the cultural context of
psychiatric disorders and the differential patterning
of somatic symptoms based on cultural variation.
In the "medical humanities", several investigators
have treated medical narratives as forms of storv-
tclling that resemble literature. These writers ha~e
used a literary approach (0 edited and summarized
aCCOunts of medical encounters (as opposed to the
in-depth interpretation of transcribed speech) in
calling attention to patients' stories of illness
(Brody. 1987, 1991; Charon, 1989; Coles, 1989:
Hunter. 1991). Such studies have taken their bear-
ings in part from morc general work in the huma~
nities and especially literary criticism. which has
dealt with the characteristics of narratives in litera-
ture and has inquired into the relalionships between
literary narratives and the social context in which
genres such as fiction and poetry are produced
(Mitchell. 1981, 1990).
Operational definitions of narratives
{n such studies, the precise definition of narrative
varies, depending partly on the theoretical orien-
tation of the investigators. In medicine and psychol-
ogy some definitions remain quile broad, including
references in the clinical literature to narratives of
illness or psychotherapeutic narratives aboul past
life events. On the other hand, some studies use
more restrictive definitions, treating narratives as
discrete units with clear beginnings. endings, und
characteristic chronologie or thematic sequencing of
events (Riessman, 1993). In our own prior work on
communication in medical encounters. we have
found that patients' narratives tend to be inter-
ruptcd or referred to in passing; as a resull, we
have preferred a definition of narrative that does
not require completion as iI coherent whole.
From this viewpoint. we operationally define nar-
ratives as attempts at storytelling that portrdY the
interrelationships among physical symptoms and
the psychologic, ·social. or cultural context of these
symptoms (Waitzkin and Britt, 1993; Wailzkin eJ
al., 1994). Such narratives may include stretches of
talk lhat present rather complete stories but '1lso
briefer fragments, sometimes interrupled or incom-
pletely expressed, that appear in patient-doctor
encounters or in research interviews as question-
~lIls\....er exchanges or introjections. This broad den-
nition of narrative takes its bearings in part from
recent literary criticism; the approach differs some~
what from the detailed ';unpacking" of transcribed
narratives thal has become customary in sociolin-
guistics (Riessman. 1993) and from approaches in
cootent analysis or grounded theory thal depend on
the coding and categorization of verbal behavior
(Strauss and Corbin. 1990). Our notion of the con-
text portrayed in medical narratives is inclusive
enough to encompass cultural practices and ex-pec-
uttions, economic or political problems. and psy-
chosocial issues thut arise in everyday lived
c:<pericnce. Regarding somatization and trauma, we
 The black box in somatization
focus on the ways that narrative integrates the cul~
tural context with traumatic life events.
Narrarive. trauma, culture, symptoms
How specifically does narrative link trauma and
culture? The work of Bakhtin and more recent the-
orists influenced by him emphasizes the socia! and
cultural context of narrative. In brief, Ihis critical
perspective focuses on the sociocultural embedded-
ness of written or oral discourse (Bakhtin. 1973,
1981, 1986), For instance, Bakhtin identifies
"speech genres". which are defined as typical forms
of utterances that occur within specific sociocultural
circumstances. Thus. in dialogue between pro~
fessionals and laypeople, a "scientific" or "techno-
cratic" speech genre may clash with a genre of
everyday speech. As Wertsch has pointed out in
adapting Bakhtin's concepts. the use of discrepant
speech genres can create a "multivoicedness of
meaning", which can be found not only in lilerature
but also in the non~literary discourse observed in
specific institutional sellings such as cduCalioll(11
and professional encounters (\Vertsch, 1991).
This work leads to an expectation lhat the cul-
tural and social context patterns personal narrative
at the psychologic level, and Ihat the subtleties of
meaning in narrative may become misleading as
lay people interact with professionals. Bakhtin and
Wertsch do not attend in depth to the narrative
processing of trauma. Yet their work indicates that
various cultures may pattern narratives of trauma
differently. and thal meanings conveyed in such
narratives may appear through expressive forms
that vary widely across cultures.
Drawing further links among trauma, narrati\'c,
and somatization. several recent studies have dealt
with sexual or other physical abuse as a severe form
of traumatic experience. but generally have not
attended to the impact of culture. For .stance. in
her psychoanalytically oriented study of the
emotional impact of abuse. Herman catls atlention
to the "unspeakable" story of such experiences that
generally is repressed bUl then manifesls itself in
psychologic and behavioral disorders (Hcmwn,
1992). While not focusing only on somatization.
Herman offers several case histories in which
patients manifest unexplained somatic symptoms. in
association with other psychiatric disturbances.
Hennan argues thal severe trauma often leads 10
one or more of three typical syndromes: borderline
personality, multiple r'~rsonality disorder, and
somatizatiuli. ,::rom her own and others' experience.
~he emphasizes the value of bringing to conscious-
ness and pUlling into words the story of traumatic
experience as a step toward healing and recovery.
This "testimony" converts a "pre-narralivc", unfor-
mulated memory of traumatic experience. to i:I fuller
narrative which includes not only the cve-nt itself
but also the responses of tbe victim and other per~
sons touched by the event; Herman and others
817
argue that lhis process of narrati\'c building
becomes the cornerstone of treatment for the vary-
ing manifestations of trauma-induced suffering
(Herman, 1992; Mollica, 1988).
In explaining the impact of traumatic abuse on
symptoms, other recent studies have begun to
examine the psychologic processing of narratives
concerning abusive experiences, Again from a psy·
chiatric perspective, Warshaw describes the narra-
tives that batlered women mention in their
presentation of somalic symptoms to non~psychia~
tric health care professionals but notes that the lat~
ler often overlook or downplay such narratives in
their accounts of women's medical problems.
Although Warshaw incorporates theorctical per-
spectives from feminist literary criticism. she does
not deal with cultural variability in the processing
of trauma (Warshaw, 1989: Conway el al., 1995).
In a study of the narratives of somatizing patients
who suffered childhood abuse, Morse et al. (sub~
milled) have tried to find more specific linkages
between the traumatic experiences and the presen-
tation of unexplained physical symptoms. From
transcribed interviews. these researchers tracc soma-
tization largely to experiences when children's
attempts to tell adults about abuse were met with
threats of punishmenl. Again the impact of culture
in the patterning of somalic symptoms docs nol
receive specific attention (Morse et al.. submitted).
A pathbreaking, and tragically ironic, analysis
pertains to Inc Central American experience, like
that affecling the patients we have observed clini-
cally, In an article published shortly before his
death, the Salvadoran psychologist Martin~Bar6.
who laler was assassinated by paramilitary forces.
discusses the extreme stress of war, torture. and pol-
itical persecution within El Salvador and describes
somatization as one frequent response to this stress.
The article presents :1 thorough account of the trau-
matic life experienc~s that lead to development of
unexplained physical symptoms. On the other hand,
Martin-Bare does not delve into the concrete narra-
tives of patients who underwent traumatic experi-
ences resembling his own, nor does he try to
explicate the culturally mediated psychic mechan-
isms by which extreme stress translates into somatic
symptoms (Martin-Bare, 1989).
Such discussions of somatization in lhe literature
of psychology and cultural psychialry recognize Ihe
importance of culture. which they show to pattern
somatization in characteristically different ways; yel
these studies generally do n01 examine narratives of
trauma in the interplay of culture and psyche to
yield somatization as a characteristic response, as
opposed to other foons of psychopathology
(Kleinman, 1986, 1988, 1995; Fabrega, J991;
Shorter, 1994). To point out cultural variability in
somatization docs not explain how the development
of unexplained somatic symploms occurs in some
individuals and not in others, or why trauma pre~
 818 Howard W<lillkin and Holly Magana
disposes to somatization dift'erently across cultures.
Likewise. these works tend not to foclls-..2!l......!.he
coherence versus incoherence of specific narratives
of trauma as a possible ~lUfi1[tRj"nror some ofWe
obsec..v.ed.....Yaria.Qjlity among cultures an among in-
dividuals In the appearance 0 somatization.
Despite major advances in narrative analysis and in
cultural psychiatry, the concrete processes by which
trauma connects to 'somatization. mediated by cul-
[ural difference. remain puzzling.
THE BECI:'\NINGS Of A THEORV
How is extreme stress processed psychologically.
and how is this process mediated by culture?
Narrative is a useful conceptual focus in trying to
answer this question. As a Slart. one might postu-
late that extreme stress (tonure. r<lpe, witnessing
deaths of relatives. forced migration, dC .. i.e. the
frequently described antecedents of PTSD) is pro-
cessed psychologically as a terrible narrative. a nar-
rative of events too awful to hold in conscious
memory. a narrative that cannot be wid coherently
in the internal storytelling of everyday conscious-
ness. a narrative so terrifying lhat il must somehow
be transformed. Within the nomenclature of tra-
ditional psychoanalysis. "repression" or "displace-
mcnl" or "dissociation" arc psychologic defenses
against the terrible ",Irralive, and "hysteria" the
predictable result. Yet such terms scarcely appear
adequate to describe the psychic processing of over-
whelming stress and the appearance of somatoform
symptoms in persons who otherwise show little or
no evidence of the usual "neurotic" fealures evoked
by these terms.
r
Culture paltcrns the characteristic psychologic
and somatic processing of the lerrible narrarive. In
I some cultures, overt psychologic breakdown ilnd
the stopping of participation in customary social
roles may be a preferred "wHy of knowing" a nar·
I rative too terrible to tell. In other cultures. such
'I psychologic symptoms may be disprcferred. and
maintenance of customary social roles may be
encouraged normatively even in the face of over·
whelming stress. In the laller cultural contexl. the
lcrrible n<lrrativc then may be transformed into
~ somatic symptoms.
We would argue thal the mech<lnism by which
,,; .~ \,1,
i.)'1 ,, trauma is transformed into somatic symptoms often
,)'1. J
;N
'rr: involves an incoherence in narrative structure.
because of which the traumatic experience cannot
be told as a coherent whole. This argumenl recog·
nizes the substantial variability that manifests itself
in the connections among trauma. culture. and
somatiz<ltion. As noted earlier. patients who have
experienced trauma comprise only a subset of
som.nizing palients. Further. sOlllutization oflen
may occur as a comorbid condilion along with such
disorders as depression or anxiety, even though cul-
tural norms may predispose to the appearance of
somatic as opposed to psychologic symptoms for
most members of lhe culture who experience severe
trauma (Castillo e( al.. 1994, 1995), Yet the narra-
live structure and ilS coherence versus incoherence
may provide a link among trauma. culture. and
somatization in many patients whose physical
symptoms cannot be explained by physical diseasc.
How specific symptoms present themselves also
depends parlly on how culture patterns their ex-
pression. For instance, in Southeast Asian cullures.
which place high esteem and positive cvaluation on
the head. traumatic experiences associated with war
and imprisonment predictably would manifest
themselves as symptoms of headache. especially
when the (muma has involved blows to the head
(Hoang and Erickson. 1982; Lin e( al.. 1985;
Mollica et aI., 1990). On the other hand. in Latino
cullure.s, where conceptions of "nerves" and the
impact of nervous conditions on physical symptoms
are commonplace. complaints referable to the ner-
vous system (such "pseudoneurologic" problems as
di7..ziness. numbness. weakness of extremities, and
so forth) predictably would appear more frequently
(Angel and Guamaccia. 1987; Escobar e( al.. 1992).
Cultural patterning of somatic symptoms also has
become clear in ethnic groups such as Italians,
Jews. Irish Catholics. and upper-middle·c1ass white
Europeans (Shorter. 1994). In these groups, culture
ilppears to mediate severe trauma in producing
somatic complaints of characteristic forms. rather
Ihan rem-lining it more frank breakdown in day-to-
day psychosocial functioning.
In short, !hc "black box" in somatization--our
own mctaphor for our ignorance concerning the
mechanisms by which trauma. culture. and soma to-
form symptoms arc conm:cted·-appears to include
several key clements. First. a narrative of terrible
lrauma is processed psychologically in different
ways. depending on the sociocultural context
(Fig. 2). The coherence versus incoherence of this
narrative becomes a crucial feature in the trans-
formation of lraumatic events into somatofonu
symptoms. From the perspectiw of Bakhtin and
Wcrtsch. the sociocultural context patterns personal
narrative at the psychologic level. as well as the ex~
pression of narrativ~ in social interactions. including
those between patients and health care pro-
fessionals. While the experience of overt psychologic
disturbance and breaking with customary roles
("psychotic" ideas of rt:ferencc. terrors of "the
dreaming", ritualistic rage, and so forth) may
emerge as the patterned reaction to extreme stress
in some cultures. elsewhere the transformation of
terrible narmlivc into somatic symptoms may
become the culturallv sanctioned "way of knowing"
and of rocessin such stress. Predictably. dilfcrent
cultures will vary not only in determining whether
narratives of extreme stress express themselves by
overt psychologic disturbance as opposed to
 The black box in somatization 819

Cuhurc 1- - - - - - - - - - - - - ~
, I Terrible Namlli\le: I t - - - somatic symptoms
I : Cullural pillemiog I I (culturally palleroed)
I I I I
Se,'ere ~tres5 - - - -- - - __ t Overl I- - - - t
psychologic I t or
: disturbance I - - - .. psychologic symploms
I prderrt:d I (culturally pallcrncdl
I I
I I
I Somalic I
t S)'mplOms I
t preferred I
I I
I I
t Coherence of narr:ui"e I
I Biologic diHercnces I
I I
I Childhood experiences t
I Ps)'chologic defenses t
I Repres~ion I
I Displacement I
I Dissociation I
I I
I Dlher I
I_____________ .JI

Fig. 2. Schematic view of Ihe conlents of Ihe black bO,l in somaJ:zation: cultural. psychologic, and bio-
logic processing of the terrible narrative.

somatic symptoms, but also in the patterning of
somatic symptoms when they occur,
At the individual level, one also expects variabil-
ity in the reaction to extreme stress. Because of bio-
logic differences that are genetically determined, or
because of varying childhood experiences that crc-
ate greater or lesser vulnerability to trauma. some
individuals may react to severe stress with less psy-
chologic disturbance, or less somatic symptomatol-
ogy. That is, within cultures. different biologic or
experiential predispositions may lead (0 individual
variation in the psychologic processing of the terri-
ble narrative, Therefore, not all individuals within a
given culture react to traumatic stress in the same
way. and culture influences the pattern by which in-
dividuals process their narratives of severe trauma.
This variability, we believe, may depend on the
coherence versus incoherence of narrative structure.
which links trauma. culture, and somatization at
the individual leveL·

'"In our ongoing research. we have developed II conceptual
model based on this preliminary theory that we are try-
ing to operationalize and assess through a continuing
study of trauma. culture. and somatization. In brief.
we conceptualize trauma as an antecedent condition.
We propose that certain characteristics of trauma may
be related to the presentation of somatofonn symp-
toms. Specifically, we expeci that the number. types.
andlor severity of trauma may be uniquely associated
with somatization. PTSD. andior other comorbid psy-
chiatric disorders. From this viewpoint trauma is not
the only predisposing characteristic in somatization.
and a proportion of patients present with somatic and!
or psychologic symptoms without antecedent trauma.
We also propose that the relationship between trauma
and somatization is associated with a number of con-
textual variables, including cultural traditions. social
class. age. gender. personality traits. and barriers 10
care. At the psychologic level, we postulate that narra-
live coherence becomes a crucial mediating variable
that links trauma. culture, and somatization; other per-
linent mediating variables include cognitive processing
(such as the search for meaning. counterfactual think·
ing, and attributional search); social responses (es-
pecially the supporti\:c versus constraining features of
social relations): and alexithymia (the relative inability
to express emotions verbally). In our research. we are
assessing the relative importance of these variables as
predictors of somatization. with and without anu~ce­
denl trauma. and in varying cuhural contexts, This
research should clarify the impact of narrative coher-
ence versus other factors in the developmenl of somali-
zation,
METHODOLOGIC ISSUES: ELICITING NARRATIVES Of
TRAUMA AND SOMATIC SYMPTOMS
During the past decade. a sophisticated critique
of traditional methods in psychology. sociology,
anthropology. and the humanities has emphasized
the inadequacy of these methods in fully capturing
the meaning of a variety of human experiences.
Only a few examples of this emerging critique and
emphasis on analysis of narratives will give a sense
of the recent ferment concerning what methods may
be appropriate to study experiential meaning. As a
leader in the development of categorical coding
schemes and structured interviews, for instance,
Mishler has argued persuasively for the importance
of analyzing narrative in its sociocultural context.
From this perspective, he has elucidated the place
of narratives within routine medical encounters.
particularly the contrasting "voices" of medicine
and of the lifeworld (Mishler, 1984). He also has
argued fOT the importance of in-depth interpretive
analysis in research interviewing and self-crilically
has documented the limitations of quantitative
schemes of categorization and diagnostic assessment
(Mishler. 1986).
Several more recent efforts have pursued the
development of suitable methods to study narratives
in medical settings. For example, Riessman has
820 Howard \Vaitzkin and Holly Magana
extended Mishler's approach by calling attention to
the "strategic uses" of narrative for the presentation
of self and illness during research interviews
(Riessman, J 990, J 993). Viney and Bousfield have
focused on psychosocial processes in a narrative
analysis of transcribed interviews with persons
affected by AIDS (Viney and Bousfield, 1991). The
latter researchers also have developed some prelimi-
nary methods of assessing the validity and re-
liability of interpreting narratives through the
participation of multiple interpreters whose analyses
then can be compared. This approach resembles
our own prior attempts to improve the analysis of
medical narratives through a group process of in-
l'I al..
terpretation (Waitzkin, 1990, 1991; Waitzkin
1994).
Finally, in efforts 10 clarify reproducible patterns
in speech, linguists have develored methods for
analyzing transcribed narratives of traumatic experi-
ences. For instance. Gce (199J) has presented a sys·
tcmatic approach toward interpreting the structure
of narratives in speech. Gee accomplishes this step
through intensive analysis of transcripts from spo·
ken narratives provided by patients, including those
who carry a diagnosis of schizophrenia. His inter-
pretive framework of "poetic structures·' in speech
helps elucidate otherwise incomprehensible features
of what has been considered "psychotic" language
(Gee, 1991). Similarly, in her linguistic analysis of
cross-gender communication, Tannen has called
attention to differences in the linguistic structures of
speech typically used by women and men. In par·
ticular, this approach has called attention to narra-
tives of traumatic experiences which can create
gender-based tensions and miscommunication
within social interaction (Tannen. 1994).
Such explorations of methods more pertinent to
the eliciting and interpretation of narrative suggest
some new directions to enrich research like that our
group is doing, as described earlier. In addition to
structured diagnostic instruments and clinical inter
views. it is helpful to work out a supplemental
method that allows patients to express their own
fuller narratives about experiences of severe stress
and somatic symptoms. Predictably, these narratives
may emerge in several situations: (I) to some extent
in encounters with health care professionals (but
predictably a limited extent that may be inter-
rupted. downplayed, or marginalized by the medical
practitioners. as found in our previous research on
the marginalization of contextual problems in medi~
cal encounters) (Waitzkin, 1991); (2) as relatively
limited comments within the structured diagnostic
inter....iew using the CIDl and related instruments;
or (3) as more extensive comments during the in
depth clinical interview by a psychologist.
In our work, we have recorded all the aboye
encounters; have transcribed a portion of them as
time and resources have permitted; and have
worked on a supplemental, interpretive, non-quanti
tative analysis of the narratives thus revealed. In
particular, we are trying 10 compare narratives of
the same patient in the medical encounters and
those in the clinical interview. Again, the purpose
here is to elicit narratives of extreme stress and to
Iry to clarify how the experience of stress is
mediated by culture to produce somatization as the
sanctioned response.
To illustrate this line of work, let us consider
"data" from one among the 1456 patients recruited
for the somatization project described above. As
noted previously, this patienf provided responses in
the CIDI, the structured diagnostic interview, which
permitted quantitative analyses of the relationships
among 50matiza[ion and a number of independent.
predictive variables. Yet how can these statistical
analyses possibly capture the richness, so to speak,
of her lraumatic experiences, the impact of Native
American and Latino cultural backgrounds. and
lheir connection with her tendency to sornatize?
The patienl is a 34-yc<lr-old Chicana woman, born in the
United States of Latino and Native American descent,
who came to the clinic for treatment of vaginal itching
and discharge and pelvic pain. During the encounter with
her physician, she makes no reference to symptoms OU[4
side the pelvis. Although the physician docs not elicit
further somatic symptoms during the first encounter. the
crDI. given by a research assistant. identifies five symp-
toms in four organ systems which remained unexplained.
In the structured instrument, however. little infomlation
emerges about the details of the traumatic experiem:es in
her life or about how these experiences might be related to
her unexplained somatic complaints.
Not until the in-depth, clinical interview. given
by a trained psychologist. does the patient's narra~
tive of trauma and somalic symptoms emerge in a
clear way. although even here the narrative remains
fragmented and at times "incoherent" (in the psy-
choanalytic sense of Freud, Marcus, and others, as
discussed above). The notable incoherence of the
narrative combines with explicit references to cul-
4
tural beliefs, including an "Indian voice" that pro-
tects her from emotional and physical harm. This
voice emerges as one of several clements of incoher 4
ent narrative structure that provide evidence of dis-
sociation, in which major gaps become apparent in
thc integration of traumatic memories and physical
symptoms (Kirmayer, 1994. 1996; Lcwis-Fernandez.
1994). The following notes summarize pertinent
parts of the clinical interview.
In brief. this patien[ has experienced a long series of psy-
chosocial traumas. which include sexual and physiC<l.1
abuse during childhood and two marriages, When she was
six years old. the paticnt's mothcr went to prison. During
the mOl her's absence. she li ....ed with various relatives and
4
was physically abused in one home and sexually molested
in another. She was in a serious car accident at age 16, the
same year that she married and had a child. Her husband
was physically abusive. and she left him, only to marry
another abusive man. She left the second husband when
he pulled a gun on her and threatened to kill her. At the
4
time of the interview. she was keeping her whereabouts a
 The black box in somatization
secret, as his threats to kill her had continued after the
separation.
This patient has suffered from multiple illnesses and
somatic complaints since early childhood and has under-
gone 10 surgeries. Currently she complains of eight symp-
toms and suffers from si" physical illnesses. In particular,
she describes having had severe headaches since childhood.
When she was young they were so bad that they caused
her 10 loose memory and to remain fatigued for severnl
days. She vehemently denies. however. that there is any
connection between her health problems and the stresses
that she has experienced.
Since childhood, the patient has heard voices. When the
voices t:llk to her. sometimes it feels as if she is in a
trance. If too many of them arc talking. they make her
head hurt. She often writes down what the voices say and
she has noticed that the handwriting she uses has several
distinct styles. Some of the voices are able to spell per-
fectly, although ordinarily she is a poor speller. She
describes <in "Indian" voice that protects her and l:xpl<lins
this in the context of information that her grandmother
has shared with her aboul good spirits thaI "don't Iry to
get in your body. bUl only talk to your mind". The Indian
voice has protected her through am her life.
Although the patient draws a link between headaches and
the voices (she states that her head hUrlS when too many
of the voices are talking to her), she docs not draw a cau-
sal link between the headaches and any of the abuses that
she has experienced. She describes her symptoms and ex-
periences in a disjointed and dreamlike fashion.
Later during the interview. the psychologist elicils
eight symptoms that remained unexplained. includ-
ing severe headaches, At this point. the patient
describes the onset of Ihe headaches during child-
hood, as well as the technical diagnostic measures
that were initiated, that have led to the diagnosis of
migraine. Although the headaches do manifest
some characteristics of classic migraine. which
include vomiting, they also are associated with evi-
dence of dissociation, such as memory loss and ex-
haustion. For this patient, the presence of voices,
and especially a culturally patterned Indian voice.
shapes the interrelationships among trauma, cul-
lure, dissociation, and somatoform symptoms. AI a
conscious level, the patient does not connect the
headaches, voices, and sexual abuse that shc was
experiencing at that time:
Interviewer: How was your health in childhood'! Did you
have any ..
Patient: Yeah.
I: You were ~ick a lot. what kinds of problems?
P: I had hepatitis and (words) in '68, 1 was in the hospital
for a month, I had epilepsy attacks, they were giving me
medication three times a day but then they stop because
(words)
I: (words)
P: J was feeling migraines or pressure, 'cause you know I
was little. I rell off the sec~saw and I had like a little peb-
ble. a little piece of rock or a little pebble there, you
know, (words) so I had those (words) where Ihey put the
needles, not needles uh .. CAT scan, (words) all different
stuff. because they though! it was a tumor.
R21
L Ok"y.
P: And I'd get real bad headaches. I mean super. And
then I'd jusl vomit.
I: ls this when you were little?
P: Uh-huh. I'd vomit and r don't remember anything and
uh ... it was like an epilepsy attack.
I: So your headaches caused you to . . omit and lose mem·
ory?
P: Yes. like tired for three days. now I can control it
'cause I'm older but ror three days I'm like: exhausted.
pressure under the eyes. the check boncs and Ihcn I havc a
real bad sinus.
1: And how about as a teenager, did yOIl have ;,my of
these problems in your tccn years?
The coherence of this patient's narrative is frag.
mentcd and incomplete. She has experienced numer-
ous stressful and traumatic events throughout her
life. These events come to light during different
phases of the in-depth interview with a psychologist
and receive no mention at all during the encounter
'''''ith her primary care physician. The traumatic
events and the physical symptoms remain uncon-
nected in the patient's and in the physician's con-
sciousness.
Culture does, ho'....ever. influence the coping
mechanisms that this patient uses in the form of the
"Indian voice" that the patient feels protects her. a
voice originating for the patient in Native American
beliefs about good and bad spirits. Here, the meta-
phorical black box thaI processes trauma and cul-
tUTe contains an incomplete or incoherent narrative
of childhood experiences and traditional teachings.
The culturally influenced narrative is not sufficiently
comprehensive to incorporate the extent of this
patient's lraumatic experiences. Yet the protective
voice can be thought of as a culturally influenced
narrative that has helped this patient to function on
t.I daily basis. even though it may not have been
capable of helping her process the trauma suffi-
ciently to alleviate the mUltiple physical and psycho-
logic symptoms that she experiences. This narrative
remains an unspoken link to physical symptoms
that continue to trouble the patient in ways inac-
cessible 10 medical intervention, despite her many
altcmpts to seck solutions in the medical sphere.
Eliciting the narrative requires a method that per-
mits in-depth probing, well beyond that of the stan-
dard medical or research interview.
IMPLICATIONS FOR FUTURE INTERVENTIONS
Let us conclude by speculating how best to help
clients like those we are studying. Unfortunately,
the most effective approach to treat somatizing
patients remains unclear. Such patients, who usually
present to primary care practitioners, often receive
extended and cxpensive diagnostic evaluations,
either because the physician does not recognize
somatization or because he or she feels the need to
822 Howard \Vailzkin and Holly Magai'la
exclude organic causes as well. Even when a prac-
titioner diagnoses somatization accurately, treat-
ment options remain limited. parlly because
patients often resist psychiatric evaluation and
therapy.
Yet, at least among the high proportion of soma·
tizing patients who have experienced severe trauma,
there is little question that bringing to consciousness
(J narrative of trauma. its relation to somatic symp-
toms, and the impact of culture at least offers
promise as a treatment option to be evaluated.
Although this promise is tempered by the consistent
observation that ongoing economic. political. and
familial issues play an important role in somatiza-
tion and its treatment, we believe that structured
therapeutic approaches that emphasize thc construc-
tion of coherent narralives of trauma deserve
;:\ssessmcnt for many patients who s.uffer from
somatol"orm symptoms. In addition to the psycho-
analytic justifications discusst:d earlier. recent work
in several fields suggests the possible valuc of thera-
peutic strategies that emphasize the formulation of
coherent narratives in dealing with severe trauma
(Herman. 1992). For instnnce. psychothcrnpeutic
explorations with survivors of childhood abuse or
political trauma such as torture during ildulthood
suggest the importance of a patient's enunciating a
,I
coherent narrativc. sometimes referred to as "tcs-
timony", as a critical component of the healing pro-
cess. Case reports of such tcstimonics, either in
individu:.l1 therapy or in non~profcssional support
groups. indicale the usefulness or narratives that
link trauma. culture, and physical symptoms in the
treatmem of patients who suffer from somatization.
Such efforts cohcre with morc systematic findings in
psychologic research lhat "putting stress into
words" nol only alleviates emotional distress but
also appears to exert positive effects on physiologic
measures of arousal (Pennebaker. 1989, 199J).
In our rescarch. we are exploring the efficacy of
Paulo Freire's model of consciousness-raising
groups. which previously have been used as a tech-
nique of empowerment for educational interven-
tions in Latin America (Freire. 1970, 1983, 1994).
Such techniques previously have achieved success in
such areas as public health education and the modi-
fication of high risk sexual behavior in AIDS con-
trol programs (W<.lllerstein and Bernstein, 1988:
W<.llierstcin. 1992: Magana ef 01.. [992) and re-
semble the group processes that h,lve provided for~
urns for the "testimonies" of trauma victims
(Mollica, 1988: Herman, 1992). Allhough empow-
ered speech clearly is not equivalent to empowered
action. several of (hese programs that have applied
Freire's educational approaches \0 health care have
found that many participants in empowerment
groups even(ually take greater initi<llive in dealing
v.:ith adverse conditions in other arena5 such as
housing and employment (Minkler and Wallerstein.
in press; Wallerstein t!I a/.. in press; Pierce et al.,
J 996). We are trying to study how the processing of
narratives occurs in such groups and how the thera-
peutic (or, as Freire would say, '·liberating") pro·
cess might take place.
Specifically, can such groups provide a culturally
sanctioned space in which the terrible narrative
finally could be returned 10 consciousness. expressed
explicitly and coherently, and worked through in a
supportive social context? While this question has
not yet been answered, intervention studies which
cvaluate and compare empowerment groups versus
olher therapeutic options for somatizing patients
will clarify thc efficacy of approaches encouraging
the expression of coherent narratives that link
traumn, culture. and somatoform symptoms. If
such studies yield positive results. this conceptual
approach to narratives of trauma may yield a thera-
peutically useful way of opening up the black box
that currently deals with extreme stress in a manner
that. though culturally sanctioned. becomes expens·
ive. misleading, and perhaps more painful somati-
cally [han need be the case.
Such a way of looking at the black box in soma-
tization becomes l:onsistenl with Tayo's realization,
during the healing ··ceremony" with Betooie. of
how his own cure will unfold:
"We all have been waiting for help a long time. But it
never has been casy. The people must do It. You must do
it". Bctonic sounded as if he were explaining something
simple but importanl to a small child. But Tayo's stomach
clenched around the words like knives stuck into his guts.
There was something large and terrifying in Ihe old man's
words. He wanted to yell at the medicine man, to yell the
things the white doctors had yelled at him-that he had to
think only of himself. lind not about the 01 hers, that he
would never gel well <IS long ::IS he used words like ··we"
and ·'us". BUI he had known thc answer all along, even
when the white doclors were telling him he could gel well
anJ he was trying to believe them: medicine didn't work
Ihat way. because the world didn't work that way. His
sickness was only parI of something larger. and his cure
woultl be found only in something great and inclusive of
everything (Silko. 1977. pp. 125-126).
,..kkflllll·/edgen!e}1fS--This work was supported in part by
granls from the National Institute of Mental Health (I
ROI MI-I47536 and MH5J808). the Health Resources and
Serviccs Administralion (5 D28 PE 19154). and the
Fogarty Internationi:ll Center of the National Institutc5 of
Health (TW 01982). We are grateful lo colleagues in the
NIMH Somatizalion Project and tht:. Health Policy and
Research Seminar at the University of California, Irvine,
for critical feedback un an earlier draft, to Stephany
Oorgcs for underslanding Ihe importance of narratjve in
healing and how this process is depicted in fiction, and es·
pecially to the patients who. having lived Ihrough very
traumatic experiences. agreed to participate in our
research.
REfERENCf:S
American Psychiatric Association (APA) (1987) Diagnostic
(llld SW(i.Hicaf Manllaf of Melltal Disorders. 3rd edn
(DSM·[II-R). APA. Washington. DC.
 The black bo.\ in somatization
American Psychiatric Association (APA) {I 994) Di(lgllOSlic
and Stati.nical Manual of Me/llal Di.~order.\". 4th edn
(DSM·IV). APA, Washington, DC.
Angel, R. and Guarnaccia, P. (l987) Mind, body. and cul-
ture: som:Hizalion among Hispanics. Social Sciem'/' &
Medicine 28. 1229-1238.
Angel, R. and Thoits. P. (1987) The impact of culture on
the cognitive slructure of illness. Clliture, Medkiltl' and
P.\·.l'chialry t I, 465-494.
Bakhtin. M. (1973) Mllrxism (Jnd the Philosophy (!f
Umguagl'. Harvard University Press. Cambridge. MA.
Bakhtin. M. (1981) The Dialngic Imagillat;on. University
of Texas Press, Austin. TX.
Bakhtin. M. (1986) Speech Genres ami Olltt'r LiJlt, E.u'l.lS.
University of Texas Press. Austin. TX.
Brody. H. (1987) Swriej' of Sickness. Yale University
Press. New Hen'cn. CT.
Brody. H. (1991) The lh'ala'.l" POltw. Yale Uni\'ersiLy
Press, New Haven. CT.
Brown. G. W. and Harris. 1". (1978) T11e Social Origi/l,\' I~r
DI'pressioll. Tavistock. London.
Bruner. J. (1987) Life as narrative. Sacral Re.H'{(rch 54(1),
11-32.
Bruner. J. (1990) ACTs of Meoning. Harvard University
Press. Cambridge. MA.
Castillo. R .. WaiL,~kin. H. and Escobar, 1. I. (1994)
Somatic symptoms and mental health disorders in immi-
grant and refugee populalions. In Met/1lI1 Healfh
Disorders in Primary Care. cds J. Miranda. A.
Hohmann. C. Attkisson and D. LIfSOIl. pp. 163-IH5.
Jossey-Bass. San Francisco.
Castillo. R. Waitzkin, H" Escobar. J. I. and Villasc-rior.
t mary ('arc.
Y. (1995) Mental health disordcrs and sOlllatoform
symptoms among immigrants and refugees who seek
primary care services. Archil'e.\" f?f F(Jmily Medicill(' 4.
637-646.
Charon. R. (1989) DoclOr-paticlH,;rcadcr-writer.
Soundings 72. 1101-1116.
0;(OU5. H. (1979) Befllllu.ua Di,.ecrs: Portrair of Dora.
Calder. London.
Ci;\Clu$. H. and Clemcnt. c. (1986) Tire Nt'I1'Iy Horn
Woman. University of Minnesota Press. Minneapolis.
Coles. R. (1989) The Call vI Stories. Houghton. Milnin.
Boston.
Conway. T.. Hu. T. C. Warshaw. c.. Kim. P. and Bullon.
A. (1995) Violence victims' perception of fl\nctioning
and well-being: u survey from an urhan public hospilal
walk-in clinic. Journal (?I" fhe NaliO/wl Medi("al
As.wcimiofl87,407-412.
Escobar. J. I. t 19(3) Psychiatric epidemiology. In Clflfllre.
Eflmit'it\-" and Ivil/llfal II/m'ss. cd. A. Ga\\'. pp. 43-·73.
Americ;\Il Psychiatric Press, Washington. DC.
Escobar. J. I., Canino. G .. Rubio-Stipec. M. and Bra . . o.
M. (1992) Somalic symptoms after a natural Jisaster: a
prospective slUdy. Aml'rin/ll Jmmwll!f PsychiC/fry 148,
965-967.
Fabrega. H. (1991) Somatization in cultural and historical
perspectivc. In Curre1lf Concept.l· f~f Somali:alilm. cds L.
J. Kirmayer and J. M. Robbins. pp. 181-199. American
Psychiatric Press. Washington. DC.
Freire. P. (1970) Pedagogy I?( lin' Oppre.ued. Herder and
Herder. New York.
Freire. P. (198J) £dUl:atiOIl fa,. Crith',,1 COII.\"C;ou.\·I/(',H.
Seabury. New York.
Freire. P. (1994) Pedo!-:oKI' of lIopf'. Continuum, New
York.
Freud. S. (l905) Fragment of an analysis of a case of hys-
teria. In The Completl! P.\)·('/lOlogical Work.c .)·({f}ulard
Edifioll. cd. J. Stradley. Hogarth. London.
Freud. S. (1953) A Generallntrodllction /() Psy("lwallalyJi.\".
Pcrmabooks. New York.
823
Freud. S. and Breuer. J. (1895). Studies in hysteria. In Thl!
Compleft' P~'Y('/lOlogi(,fJI Works: S((lndard Edition. ed. J.
Strachey. Hogarth. london.
Gearhart. S. (1985) The scene of psychoanalysis: the unan-
swered questions of Dora. In In Dora's Case: Freud-
Hysruia-·Feminism. cds C. Bernheimer and C. Knhane.
pp. 105-127. Columbia University Press. New York.
('ce. J. P. (1991) A linguistic approach 10 narrative.
.JOUr/wi of ,"'Iarrath'e and L!fe His/ory I. 15-39.
Griffith, J. L. and Griflith, M. E. (1994) The 80(ly Speuk.l""
Tllt'Ni/"'lIfi" Dia/ogfWJ fllT :\1i"d~B(}(~1' Prohlems. Basic
Books, New York.
Guarnaccia. P. J. (1993} Auu/ul.".\· de flN\·i(J.~ in Puerto
Rico: culture-bound syndrome or popular illness'!
Medical Aflfl"opolog.r IS. 157-170.
GUle. S. (1967) The diagnosis of hystcria: whal arc we try-
ing to do'! Allleriwn Journal of P.\'YflJiairy 124,491-498.
I·lacking. I. (\995) Rell',ilillg Ille SOli/. Princelon
Uni\'cr~ity Press. Princeton. ;-.JJ.
Harrop-Grilliths. J.. Katon. W .. Walker, E.. Holm. L.,
Russo, J. and Hickok. L. (1988) The associaLion
between chronic pelvic p,till. psychi,ltric diagnosc!:. and
childhood sexunl abuse. OhJ/('(ric.~ (lild Gylll'cology 71,
589-594
1·lerman. J. L. (1992) Trauma (/ml Recover.r. Basic Books.
New York.
Hoang. G. and Erickson. R. (1982) Guidelines for provid·
ing medil..:al C;lrc to Southc<l!<i1 Asian refugees. Journal of
t!lf' AJIINiCftll Medical ...h wciulioll 248, 710-714.
Holman. A.. W<Jitzkin. H.. Silvcr. R.• Castillo. R.,
Villasclior, Y. and Escobar. J. I (submitted)
Somatization and trauma: inter-ethnic differences in pri·
Hunler. K. M. (1991) Doctor.\" SlOries: rile Nt/mail'l!
Slrllcfw'{' f?f Mediml Kllow/edge. Princeton University
Press. Princeton.
1rigar<JY. L. (1985) Sp{'{"///lrm 14' 'he' Ofher ~VOIIU/fl. Cornell
Univer:-;ily Press. Ith'Jea.
Irigaray. l... (1991) The critique of patriarchy; psychoana-
lysis and languagc. In TIl(' Irigaray Reader. cd. M.
Whitford. pp. 21-153. Blackwell. Oxford.
Jenkin:-;. J. and Karon. M. (1992) The meaning or
cxprcssed emotion: thcorNical issues raised by cross·cul-
luml n:scan:h. Anwt'inl/1 JlJurnal r~1' I');ychiarry 149. 9-
2t.
Kellner. R. (\994) Psychosomatic syndromes, somatization
and somaloform disorders. P.I".!'l"hoIJlI'rtJr.r amI
P.\·\Tho.lOnuuic.\· 61, 4- 24.
Kim~r1ing. R. and Calhoun. K. S. (1994) Somalic symp·
toms. social support. and lreatment seeking among sex-
ual assault victim$. Journal of Consulfing CHI/iml
PSl'cholo~1" 62. 333-340.
Kir~aycr. 't.. J. (1984) Culture. affect <lnd somatizalion
(parts I and II). Transcultural P.I·.w·hiarrit· RCJcard,
Re~'h'l\" 21. 1:37-262.
Kirmaycr. L. J. (1986) Somatization and the social con-
struction of illness experience. In lIIne,u Behul'ior: A
Mllliidi.w·iplinal'.l· Perspl.'l'firc. eds S. McHugh and T. M.
Vallis. pp. 111-133. Plenum. New York.
Kirmayer. L. J. (1994) Pacing the void: social and cultural
dimensions of dissoci'ltion. In Di.tsocfalion: (',lllure.
Mimi. (lml Body. cd. D. Spiegel. pp. 91-122. Amcrican
Psychiatric Press. Washington. DC.
Kirmayer. L. J. (1996). Landscapes of memory: trauma.
narrllLive and di~soeiatioll. In Ti.'fUe Pa.\"{: Culfllrul
E.~.wn 011 Alemon' and Trallma. eds P. Anlze and M.
Lam·bck. Routlcdge. London.
Kirmaycr. l. J. and Robbins, J. M. (1991) C,/rrem
Concepts of Somari:afioll. American Psychiatric Press.
Washington. DC.
Kleinman. A. (1986) Social OrigitlS of Distr('s.\" and
DisCiISt': DC'/Hl'.uion. NelJra.Hhenia. ami Pain in Alodern
China. Yale University Press. New Ha\'en. CT.
, .
824 Howard Waitzkin and Holly Magana
Kleinman, A. (1988) The Illness Nwra{h'es. Basic Books.
New York.
Kleinman. A. (1995) Writing at the Margin: Discourse
Between Anthropology and Medicim:. University of
California Press, Berkeley.
Lacan. J. (1981) The FOllr Fwulamelflol Corlceprs of
Psycho-Analysi.c Norron. New York.
laca"n. J. (1985) Intervention on transference. in //1 Dora's
Case: Freud-Hysferia-Feminism, cds C. Bernheimer and
C. Kahane. pp. 92-104. Columbia University Press.
New York.
Lechner. M. E. el al. (1993) Self-reported medical pro-
blems of adult female survivors of childhood sexual
abuse. JourtJal of Famif)' Practice 36, 633-638.
Lewis-Fernandez. R. (1994) Culture:: and dissociation: a
comparison of ataqlll' de nCT\'io.\· among Puerlo Ricans
and possession syndrome in India. In Di.f.HJciatiOJl:
ellllUre. Mind, and Body, ed. D. Spiegel. pp. 123-167.
American Psychiatric Press. Washington, DC.
Lin, E. H. B.. Carter. W. B. and Kleinman, A. M. (1985)
An exploration of somatization among Asian refugees
illld immigrants in primary care. American JOl/rnal oj
Public Health 75, 1080-1084.
Magana. J. R.. Ferreira-Pinto, J. B.. Blair, M. and Mata,
A. (1992) Una pedagogia de concientizacion para la pre-
vencion del VIH/SIDA. Rel'isIa LalilfO Aml'ric(J11(J de
Psicologia 24, 97- 108.
Malcolm. J. (1984) In Ihe Freud Archiw!s. Knopf. New
York.
Marcus, S. (\985) Freud and Dora: story, history, case
history. In III Dora's Ca.rl': Frelld~JI)'Steria-Femi/li~'}}J,
cds C. Bernheimer and C. Kahane. pp. 56-91.
Columbia UniwrsilY Press. New York.
Marlln·BariL I. (1989) Political violcnce and war as causes
of psychosocial trauma in EI Salvador. International
Journal of I\.f('ll/(JI Heallh 18, 3~20.
Masson. J. M. (1992) The A.~.wll/t on Truth: Freud's
Suppre.l"si(m of Ihe Sedltctioll Theory. Harp~r, New
York.
McFarlane. A. C. (1993) PTSD: synthesis of research and
clinical studies: thc Australia bushfirc disaster. In
huemalirmal flandhook of Traumaric Stre.~s Syndrolllt's,
cds J. P. Wilson and B. Raphael, pr. 42J-429. Plenum,
New York.
Milkr. P.. (1984) ThOll Shall 1\lol Be Aware: SocieIY:\'
Betrayal oj tht' Child. Farrar. Straus, Giroux. New
York.
Minkler. M. and Wallerstein. N. (1997) Improving health
through community organi7.ing amI conUllUnilY build·
ing. In Community Organi=ing and Community Bllilding
ji)r Ikallh. ed. M. Minkler. Routledge, London.
Mishler, E. G. (1984) TIre Discourse of Medicine:
Diale('ricJ oj Merliwllnlen'iell's. Ablex, Norwood, NJ.
Mishler. E. G. (1986) Rt'search hrrl!fl'il'll'ing: COlllex/ Gnd
Narratil'C'. Harvard University Press. Cambridge, MA.
Mitchell, W. J. T. (cd.) (1981) On ,Varratil'l·. L1niversity of
Chicago Press. Chicago.
Mitchell. W. J. T. (1990) RepreSCJltalion. In Crilical
Tams (or Litl'rl1')' Stud)" eds F. Lenlricchia and T.
McLau'ghlin, pp. '1 J-22. Univ~r:sity of Chicago Press.
Chicilgo.
MoL T. (1985) Represenlation of patriarchy: sexuality and
epistemology in Freud's Dora. In In Dam's 01$(':
Frt:'rjd-Hl'.fleria-FemiJli~'tn, cds C. Bcrnheimcr and C.
Kahane,' pp. 181-199. Columbia University Press, New
York.
Mollica, R. (1988) The trauma story: the psychiatric care
of refugee survivors of violence and torture. In Pos/-
Traumatic Therapy Qnd Victims of Violence, ed. F.
Ocbbcrg, pp. 295-314. Brunner/Maze!, New York.
Mollica. R.. Wyshak, G .• Lavelle, 1.. Truong. T .. Tor. S.
Yang, T. (1990) Assessing symptom change in Southeast
Asian refugee sUf'o'ivors of mass violence and lorture.
Americon Journal oj Psychiatry 147, 83-88.
Morrison, 1. (1989) Childhood sexual histories of women
with somatization disorder. American Journal of
Psychia/ry 146, 239-24 [.
Morse, D. S., Suchman, A. L. and Frankel. R. M. (sub-
mitled) The meaning of symptoms in ten women with
somatization disorder and a history of childhood abuse.
Pennebaker, J. W. (1989) Confession, inhibition, and dis-
ease. Adl'lmces in Experimenta( Social Psychology 22,
211--244.
Pennebaker, J. W. (1993) Putting stress into words: health.
linguistic. and therilpeutic implications. Behaviortl!
Res{'arch (/nd Therapeutics 31, 539-549.
Perley. M. and GU7.C, S. (1962) Hysteria-the stability and
usefulness of clinical crileri.1. New England Journal C!f
Medicine 266, 421-426.
Pierce. J. C .. Miller, A. F. and Westley, J. (1996) A ran·
domized clinical trial of a group empowennenl program
for somaticizing patients: moving away from medicaliza-
lion. Presented al annual meeting of Society of General
Internal Medicine. Washington, DC, May.
Polkinghornt=. D. (1988) Narra/ive Knowing and tlu.'
Human S{·icllces. State University of New York Press.
Albany.
Pribor. E. F.. Yutzy. S. H., Dean, J. T. and Wetzal, R.
D. (I993) Briquet's syndrome, dissociation, and abuse.
American Joumal of Psychiatry ISO, 1507-15 I I.
Ramas. M. (1985) Freud's Dora, Dora's hysteria. In III
Dora's ('(loW!: Frelld-HyMeria-Femim'sm, eds C.
Bcrnheimer and C. Kahane. pp. 149-180. Columbia
University Press, New York.
Riessmun, C. K. (1990) Strategic uses of narrative in the
presentation of self and illness. Social Science &
Medici,,/! 30, 1195-2000.
Riessman. C. K. (1993) Narrarive Ana'ysk Sage. Newbury
Park. CA.
Rose, J. (1985) Dora: fragment of an analysis. In In
Dora's Ca.~{·: Frelld-Hyswria-Femini.ml, cds C.
Bcrnheimer and C. Kahane, pp. 128-148. Columbia
University Press. New York.
Rosenwald, G. C. and Ochberg, R. L. (cds) (1992) Storied
Li~'es: The ell/lllra) PO/itic5 of SeIFUnder.~randing. Yale
University Press, New '·{aven. CT.
Shortcr, E. (1992) From Para~vsis 10 Fatigue: A His/or)' of
Psycho;;onwlic fJlne.fS in lire Alodem Era. Free Press,
New York.
Shoner, E. (1994) From the ,tfilld inlo ,he Body: The
Culfural Origins of p.~)'Cho.\'()malic Symptoms. Free
Press, New York.
Silko, L. M. (1977) Ceremony. Penguin, New York.
Simon, G. E. and VonKorrr, M. (1991) Somatization and
psychiatric disorder in the NIMH Epidemiologic
C<llchmcnf Area study. American Journal of Psychiatry
148, 1494-1500.
Smilh. G. R.. Jr (1990) Somali:a/ion Di.mrder in Ihe
Medical Selting. U.S. Government Printing Office
(DHHS Publication Number (ADM) 90-1631),
Washington. DC.
Smith, G. R. Jr (\994) The course of somatization and its
effects on utilization of health care resources.
Psyc!rosomatics 35, 263-267.
Sprengnether, M. (1985) Enforcing Oedipus: Freud and
Dora. 1n In Dora'~' Case: Frelld-Hysleria-Femini.ml, eds
C. Bcrnheimer and C. Kahane, pp. 254-275. Columbia
University rress, New York.
Strauss, A. and Corbin. J. (1990) Busies of Qualitaril'e
Res{!ardr: Grounded The()ry Procedures and Techniques.
:"age. Newbury Park, CA.
Tannen, D. (1994) Gender and Discourse. Oxford
University Press, New York.
••
The black box. in somatization
Vincy. L. L. and Bousfield, L. (1991) Narrative anulysis: a
method of psychosocial research for AIDS~infectcd
people. Social Science & Medicine 32. 757-765.
Waitzkin. H. (1990) On studying the discourse of medical
encounters: a critique of quantitative and qualitative
methods ilnd a proposal for reasonable compromise.
Mt·dical Cafe 28. 473-488.
Waitzkin. H. (1991) TIle Pa/ilin of Meeliwt Encoll/uen:
NOll' Patients find DnC!ors De(ll with Sociul Prob/ems.
Yale University Press. !'lew Haven. CT.
Waitzkin. H. "nd Britt. T. (1993) Processing narralives of
self-destructive behavior in rouline medical encounters:
health promotion. discasl: prevention. and the discourse
of health care. Soda! 5cie1l("(' & Medicine 36. 1121-
1136.
Waitzkin, H .. Britt. T and Williams, C. (1994) Narratives
01" aging and social problems in medical encounters with
older persons. Journal of Healtlt and Social JJehUl'ior 35.
322-348.
Walker, E. A., Katon, W. J.. Hansom. J .. Harrop-
Griffiths. J.. Holm. L., Jones. M .. Hickok, L. and
Jemelka. R. (1992a) Medical and psychiatric symptoms
in women with childhood sc.'(ual abuse. PJ.l'i:ho.wmafic
Mj~didllf' 54, 658-664.
Walker, E. A.. Katon, W. J., Jcmelka, R. P. and Roy-
Burne, fl. P. (1992bJ Comorbidity or gastrointestinal
complaints, depression, and anxiety In the
Epidemiologic Catchment Area (ECA) Study. American
Jormw/ofMedicille92(IA),IS-265.
Walker, E.. Katon, W.. Roy-Byrne, P. P.. Jemelka. R. P.
Russo. J. (1993) Histories of sexual victimizution in
patients with irritable bowel syndrome or inflammalory
8,5
bowel disease. AmeriCfm JOIHwl of PJyc1l;alry 150. 1502-
1506.
Walling, M., O'Hara, M., Reiter, R .. Milburn. A., Lilly,
G. and Vincent. S. (1994) Abuse history and chronic
pain in women: II. A multivariate analysis of abuse and
psychological morbidity. Oh.uetrics and Gple('()!ogy 84.
2110-206.
Wallerstein. N. (1992) Powerlessness. empowermenl. and
health: implications for health promotion programs.
AmerictJll Journul of Health Promofion 6. t97-205.
Wallerstein. N. and Bernstein, E. (1988) Empowerment
education: Freire's ideas adapted to health education.
Health £dllnuioll Qlwrlerl)' 15.379-394.
Wallerstein. N .. Sanchez-~erki. V. and Dow. L. (1997)
Freirian pr,lxis in health education and communily
organizing: a case study of an lldolescent prevention
program. In Commlmif.l' Organh:ing (Jilt! ConllmmilY
Building for Health, ed. M. Minkler. Routledg.c.
London.
Warshaw. C. t1989) Limitations of the medical model in
Ihe care or battered women. Gender and Socie,y 3. 506--
517.
Werlsch. J. V. (1991J Voices of Ihe Mind: A SocioCllltural
Appro(1ch In .f'flediatnl Aclio/!. Harwtrd University Press.
ClInbridge, MA.
Wystak. G. (1994) The rdation between change in reports
or traumatic events and symptoms of psychiatric dis-
tress. Gcneral Hospital Psychiatry 16, 290-297.
Young, A. (1995) Harmon)' oj !fIusiol1s: lnl'entillg
Pos/lreJumaric Sln's.\· [)isordl'T. Princeton Universily
Press. Princeton, NJ.