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
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JOHNM. JANZEN Department of Anthropology, University of Kansas

Therapy Management: Concept, Reality, Process

"Therapy management" (diagnosis, selection, and evaluation of treatment, 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 reviewers, and use by later researchers in the analysis of a range of subjects in medical anthropology. "Therapy management' holds promisefor contextually sensitive analyses of the relationships among cultural assumptions and values, behavioral processes, and social and economic structures that influence the therapeutic process.

Thhen an illness occurs, the person who is jurally responsible for the sufferer quickly consults a doctor. If and when the consultV v ing doctor has made his diagnosis, it is again this jurally responsible person who sends for the appropriate treating doctor" (Babutidi in Janzen 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 African society. In the monograph The Quest for Therapy in Lower Zaire (1978) William Arkinstall and I featured this process as "therapy management"; the constellation of individuals who emerge to take charge of the sufferer during incapacitation we called the "therapy management group." In Quest we noted that the therapy management group coalesces W ^^T ~ wheneveran individualor set of individualsbecomes ill or is confrontedwith overwhelmingproblems.Variousmaternalandpaternalkinsmen, andoccasionally their friends and associates, rally for the purpose of sifting information, lending moral support, making decisions, and arrangingdetails of therapeutic consultation.The therapymanaginggroup thus exercises a brokeragefunction betweenthe suffererand the specialist. [1978:4] Genest (1985:348) in a review of the book identified two main features of therapy management: (1) the set of actionswhose aim is to formulatea diagnosis, to select andevaluate the treatments the time of a sickness; (2) the set of individualsinvolved at the at momentin which these actions are at hand, the membersof the family acting as 68

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between sufferer thespecialists the and and as intermediaries involved advocates of themedical concerned. systems As has happenedso often in the history of anthropology,a notion from a social and culturalsetting is lifted out for emphasisand given a name, particular made a "thing." That name and that process are henceforthreified in the literature. Thus, in anthropology,we have totem, shamanism,mana, Cargo cult, and the like, in which the indigenousterm has become the analyticalterm. We were well aware of the hazardsof inventing a technical term like "therapymanageFor ment," but it seemed appropriate. althoughthe Kongo do not have a termfor 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 articleI offer a background the emergenceof the therapymanageon mentfocus and attemptboth to answerquestionsthathave arisensince Quest was publishedand offer suggestions for furtherresearch. Intellectual History of Therapy Management Background In CentralAfricanresearch,numerousauthorshave describedparticular instancesof "therapymanagement." Boswell's (1969) notice of "escorts" in illness episodes in urbanZambiacomes closest to depicting the therapymanagementgroupphenomenon.However, his interpretation the escort's role emphaof sizes social supportand does not go far enough in accountingfor the evaluation of informationand the natureof decision making in the therapeuticprocess. In the non-Africanistliterature,the sociological use of "lay referral" (e.g., since Parsons 1958) covers a dimensionof therapymanagement.But the focus on the "laity" suggeststhatthereis anotherpole, thatof the "professional," which carries 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 relinquishdecision-makingrights to a "professional," and it is not the lay statusof the decision makersthat defines them, but their relationshipto the sufferer. In fact, they may be professionals. Another much-used notion in recent medical anthropology,the "hierarchyof resort," introducedby Romanucci-Ross (1969), has something in common with therapymanagement.However, the notion of a "hierarchy" suggests a tree and brancheswhose logic is followed in sequentialsteps of the therapeutic process. In therapymanagementin successive episodes of a therapeutic Kongo, process are not as crisplydetermined by prior logics as "hierarchyof resort" would suggest but are open to ad hoc questionsand issues that may arise in the midst of a case. The Kongo data and the problematicnatureof the available analyticalconcepts in 1971 led us to look for other ways of formulatingissues concerningthe therapeutic process. Approachesthat emphasizedcompletely disembodiedmedical knowledgeseemed unsuitable.At the time the so-called "new ethnography" and ethnosciencewere the rage, but they offered no way to accountfor the entry of social and environmental determinants eitherthe ways alternativecourses into of healing were combined or the mechanismsby which decisions were reached. Gametheory, in the form of minimaxcalculi of alternative choices andtrade-offs

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(as in economic strategies,war games, and chess), were also currentbut seemed too rationalisticto accountfor the existential setting of sufferingand healing we saw in CentralAfrica. To speak of alternativesin a pluralisticmedical setting as "traditional"and "modem" was totally unacceptable,since modernization theory, althoughstill a viable theoreticalparadigmat the time, seemed extremely rigid and simplistic when we attemptedto fit it to the intricatenegotiationsbetween individualsand the therapeutic alternativeswe saw before us. Its concepts were simply not applicableto the Kongo, who made no particular discrimination between "traditional"and "moder" medical resources.

TheMcGillSeminar:Kongo and QuebecCases Compared In a most directsense the concept of the therapymanagement groupand the title of ourbook go back to a graduateseminarheld at McGill Universityin 1971. Jointlyconductedby Don Bates (Professorof the Historyof Medicine and DirecWilliamArkinstall(a physician), torof the OslerLibrary),my fellow fieldworker and myself, it was attendedby a dozen students. The seminarwas to consider case materialfrom both Africa and North America, specifically from the Kongo of WesternZaire and Quebec. As the seminarprogressed,Arkinstalland I wrote up our Kongo case mateset rialforpresentation discussionby the seminar.A comparable of case studand ies had been collected in connection with the work of an advisorycommitteefor medical educationof the McGill UniversityMedical School. Proundergraduate fessor Bates had chairedthe subcommitteeon "Objectivesof Medical Education in Society," which generateda dozen extensively documentedcases of illness episodes fromgreaterMontreal(Bates 1970). The cases, which covered a variety of issues, were introducedby membersof the committee-physicians, psychiatrists,pastoralcounsellors,and social workers-to probethe adequacyof medical educationboth in dealing with health issues and in educatingmedical studentsto in resolvechronicproblemsin "the system." Protagonists the cases had appeared the beforethe subcommitteeto clarify and furtherinterpret descriptiveaccounts. As in the Kongo datathat appearedin Quest, these were complex situationsthat solutions. The cases also broughtto light chardid not often respondto short-term institutionsand their personnel. It should be acteristicfeaturesof care-providing noted that the illness episodes all occurredbefore the advent of universalhealth insurancein Quebec, althoughthey were studiedwith a view towardunderstanding how such insurancemight deal with cross-service referralsand chronicity. suited for comparisonwith the Coincidentally,the Quebec data were remarkably Kongo material. In the seminar Kongo and Quebec cases with similar profiles were introduced alternately students.Discussion produceda comparativeperby tradition. spective trueto anthropological As the semesterprogressed,I wrotea paperentitled"Decision and Structure in the TherapeuticProcess" (Janzen 1971) that summarizedthe issues that had emergedfrom considerationof the cases and proposedan analyticalframework with which to considerthem. Althoughthe paperwas absorbedinto the book, the basis of the ideas was abandonedfor a Kongo-specificperspective. comparative In the process, some of the reasoningwas truncated.It thereforeseems appropri-

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ate here to review the Quebec materialin the context of summarizingthe "Decision and Structure"paper. Questionsthat the seminarraised of both the African and North American cases had to do with the definitionof the therapeuticprocess, the sick role, deviance, labeling, decision making, choice of therapeuticresource, allocation of both within medical services and within the management authority group, as well as the coordination resources. of Alternatediscussionof the Kongo and Quebecdataprovideda formatfor the discoveryof many ways in which common featuresappearedin the two settings, as well as some markeddifferences.In almostall instancesthe seminarwas struck by how common it was for the physical sign-whether definedby the suffereror the healer-to serve as an expressionof, or a pointerto, wider social, psychological, or life-transitioncrises. This observationmay have been biased by the type of cases at hand-i.e., chronic conditions ratherthan short-term,catastrophic ones. It may also have been due, in the Quebec cases, to the presenceof psychiatristson the commission who routinelyoffered psychosocial assessmentsof the cases along with the biophysical work-upsof the other physicians. Still, it was that between vague and intermittent apparent therewas a markedcorrespondence diffiphysical signs (soreness, headache, menstrualpain, dizziness, respiratory in the absence of clear clinical pathology and what we would today speak culty) of as "stress." A second set of questions the seminarraised about the Kongo and Quebec cases hadto do with the imputation deviance:who controlledit, whetherit was of and what its consequenceswere. Early in the seminarwe had read stigmatizing, Eliot Freidson'srecentlypublishedbook, Profession of Medicine (1971), which dealt at length with these issues. The cases in both Kongo and Quebec that drew the strongestimputationsof stigma concerned young women who had become out pregnant of wedlock- medical" historieswith seemingly little medicalcontent at all. Yet these women often experiencedmultiplephysical signs and symptoms, apparentlyas much to do with their own discomfort and anxiety as with their pregnancy.The North Americanexamples of this type, to a lesser extent thanthe Kongo ones, also reflectedrebellion by the young women against their parents'values and control. (It was, after all, the 1960s.) The only other imputationof deviance among the cases occurredwith an obese Quebec woman. She was the motherof six by an abusive alcoholic husbandand was advised to have her cancerousleg amputated.Her obesity was an annoyanceto the physicians, and stigma was imposed on her for an inabilityto control her eating. Little considerationwas given to the possible psychological causes of her obesity; she was simply orderedto diet more stringently. In discussing these cases in light of Freidson's work, the seminarcame to the conclusion that deviance imputationshould not be considereda majorcomponentof the diagnostic and therapeuticprocess. It was not as significantto the illness episodes as such mattersas who took charge, who controlledor negotiated the key decisions, and within what social and culturalsetting the overall issues were worked out. In other words, the therapymanagementprocess seemed to need a broaderconceptualframeworkthanthe existing concepts of deviance and labelling could provide. It was importantto understandthe immediate social

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nexus that managedlabeling, ratherthan to see it as an asocial cognitive operation. The questionof who took chargein acutehealthcrises came to the fore most disease: the clearly in two cases of motherswho were struckby life-threatening case concerneda young motherwith cardiacfailure(Luzayadio,in Janzen Kongo 1978: Ch. 3), and the Quebec case centered aroundthe aforementionedyoung motherof six with a malignanttumorin her upperleg. Relatedto the questionof who took chargewas the extent to which the authorityto make crucial decisions in the care process was vested in the group. In Kongo the matrilineageand the fathertook over the therapymanagementprocess. In Quebec the patientand her husbandinitially sharedthese responsibilities.Dissatisfiedwith a gynecologist's opinionthatthe swelling in the woman's leg was due to varicose veins, complicated by pregnancy, the couple consulted anotherphysician from whom they learnedthat the problemwas a malignanttumor. When immediatesurgerywas recommended,the woman, with the tacit consent of her husband, again took for amputation severaldays in the hope that chargeanddelayedthe recommended she could somehow save her leg. After surgery, however, a wider constellation of medical and support structuresemerged, and the couple apparentlyrelinquishedtherapymanagement.Indeed,the nuclearfamily seemed unableto handle its affairs duringthis time. With the woman convalescing in the hospital while herhusbandworkedfor an hourlywage as a trucker,they were unableto care for their childrenat home. The patient's mothertook the two youngest for several weeks, and the oldest remainedat home caring for themselves while their father was often gone overnight. At first the woman's physician seemed only vaguely awareof her family responsibilities.Only afterthe patient'srelease from hospital did he initiatecontactswith the Family Service Association in orderto provide a part-timetemporaryhousekeeper. Though neighbors helped, too, coordinated and management supportwere erratic.Neitherextendedfamily norpublic therapy institutionsprovidedthese services to the extent observed in the corresponding Kongocase. The isolatednuclearfamily was cast into crisis when one adultmember became hospitalizedand the other adult had to continue working to earn an income. Similarproblemsin coordinatingmedical care and supportcame up repeatedlyin otherQuebec cases. of The vulnerability the autonomousnuclearfamily in the West and the fluctuationsin household membershipover its life cycle were illustratedin several other Kongo and Quebec cases. A Quebec example revealed the fate of a "terminal family"-that is, a family of grown unmarried siblings at the point when the sole productiveperson among them (a 68-year-old sister who was caretaker, became ill. The others had no resourcesto fall housekeeper,and breadwinner) back upon. The case illustratesnot only this woman's own sickness but also her guilt over the failureto care for her siblings, coupled with a simultaneousdesire to extricateherself from their demands. An identical situationwould be rare in Kongo society, where these siblings would representthe senior core of a matrilineage and, even if unmarried,could claim the supportof junior lineage members. However, even in Kongo, related situationsconcerningvarious structural of transformations domestic life engulfed individualsin cross-currents contraof dictorydemandsand expectationsthatsurfacedfor public scrutinywhen they became sick. In Quest, for example, cases reportedin Chapter8 deal with the grow-

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ing polarizationbetweenjunior and senior houses of a lineage and the relatedafflictionsof individualscaughtin crises of leadershipand succession. Thus in both settingsillness episodes became linked to lifecourse transitions. Both the Kongo and Quebec cases also concernedindividualswho had become alienatedfromtheirkin and soughtsolace and supportfrom another,nonkin Two Kongo cases aredescribedin Quest, Chapters6 and communityor structure. 7. The firstdeals with a man whose professionaland family roles did not fit well together,whose family continuedto expect him to supportthem 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.Througha series of divinationsand diagnoses he came to believe that his chronic asthmawas caused by his own lineage and that he could only become healthy in the supportivesetting of the prophet's village. The move to join the prophetwas comparableto initiatorymembership in a CentralAfricancult of affliction. In Quebec we find a comparablestory of a middle-agedman, following a life of alcoholism and broken ties, finally committinghimself to Alcoholics Anonymous where he received the supportto remainfree of alcohol.
Emergence of the Concept of "Therapy Management Group"

An important insightthatdeveloped from comparingthe Kongo and Quebec cases was that diagnosis and therapymust be seen as a process. In both Kongo and Quebec the issues and problemswere more gradualin their emergence and ultimatelymorechronicthanthe typically episodic encounterswith eitherhealthcare personnelor institutionalsources of supportwould suggest. In both settings a rangeof persons, classes, issues, and perspectiveshad a bearingon the case and neededto be consideredsimultaneously.A theoreticalmodel that was applicable to what we were studyingneeded to take this complexity into account. We found, however, that several of the foremost social-science analysts of the health-caresetting in the late 1960s and early 1970s approachedthe matter from a static perspective. Frake, as a leading proponentof the "new ethnography," relied on interviews to establish hierarchicaltaxonomies of diseases and relatedtherapies(1969) and paid little attentionto the decision-makingprocessor to the social context of decisions. Freidson (1971) offered taxonomic schemes of concerningdisease types and the parameters stigmatizationand deviancy but was concerned with the "career" of these states-how they emerged and by whom they were promulgated.His work reflectedthe then-current influential and work of Talcott Parsonson 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 the sufferer. It was far easier to of this type of model to the hierarchicsystem of professionaldecision making apply in a NorthAmericanmedico-centricsettingthanin an Africancommunity,where criticaldecisions were made mainly by the kin of the sufferer,with professionals and healersserving largely as informational resourcesfor them. To resolve the problems of the foregoing overly static and professionally biasedtypes of analysis, the seminarwas attracted theoreticalwritingsby such to authorsas Nadel (1957) and Barth(1966), who emphasizeddistinctionsbetween culturalvalues, social roles, and the context of decision, and who, like Edgerton

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(1969), were concerned with individual processes of negotiation among thoughtout constructs, lived-in constructs, and actual behavior. Discussion was also influenced by the work of Lewin (1951), more specifically his concept of the "social field." Nadel (1957) seemed to offer an important beginning. All societies . . . providefor the 'systematicorderingof social relationsby 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 futurestructural alignment'. [1957:134-135] For Nadel, choice and decision offered access to structure, and structure was constantly amended by choice in the "never quite identical circumstances" of daily life. 'Decisions and choices' .. are more diffuse than any massive social transforand mations;they effect not any total shift, but move-by-move rearrangements, to they happenall the time, in the mannerof readjustments never-quite-identical circumstances.It is possible, further,thatover a period of time the sequence of individualoptionsmay be such thattheirrelativefrequencyundergoesa definite, perhapsprogressive,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 values of an ideational system, on the other. This perspective laid the groundwork for an analysis of the therapy management process in very different social settings. 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. Transactionshave a structurewhich permits analysis by means of a strategic model, as a game of strategy. They consist of a sequence of reciprocalprestations, which representsuccessive 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 process 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, patients, family, or kin. To see therapeutic choices in this manner yields understanding 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 "cognitive" ideas and stances, but also relationships between individuals. It is the essence 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 transactionand negotiationof therapymanagement effected changes in roles and statuses among individualswas also dealt with in the seminar.In a numberof the Kongo andQuebeccases it was clearthatsickness was morethanjust a "time out" from normallife. Often it was a role-transforming experience-the leg cancer followed by amputation,or the asthmarequiring a change of residence-as well as a collective experience that altered the way individualsrelatedto one another.Factionsmight coalesce thatin turnalteredthe of perception the sickness and its causes. Clearlya broaderandmoreflexible conthan "sick role" was needed to understand these cases. cept A process model that includedchoice and decision needed to consider, additionally, the consequencesof consensus and dissent among partiesinvolved in a given therapeuticprocess. From reviewing the cases at hand, it became clear the thatconsensus within the group surrounding patientwas requiredfor a decision to be reached and action to occur. For example, medical authoritieswere unableto act until there was consensus among the Quebec woman with the leg tumor,her husband,andthe medicalteam. In Kongo actionoften occurredon the basis of partialconsensus within the therapymanagementgroup. Dissension predictablyled to proposalsfor alternativecourses of action. In the Kongo cases one segment of the managementgroup typically prevailed, and their plan of action would be implementedfirst; then anotherfaction's recommendations would be acted on. In other words, two or more sets of diagnoses and therapyproposals seemed to generatemultiple treatmentepisodes, 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-caredecisions in both Kongo and Quebec. In Kongo, for example, some action emanatedfrom lineage heads and influentialand proposalsfor therapeutic wealthykin, whereasothers derivedfrom paltryutterancesof junior membersof the lineage. In the case of the young unwedmother(Chapter in Quest), episodes 7 2, 4, and5 were diagnosedas a "psychologicalproblem"by heryoungerbrother, who had done some reading in Westernpsychology. This diagnosis was never actedupon, however, since seniorbrothersand lineage headswere convincedthat the cause lay in an uncompletedmarriagetransaction.Consequently,insteadof going off to one of the few psychiatristsor psychologistsLowerZairemight have offered at the time, the case centeredon divinationsand family reconciliationsin orderto persuadethe girl's father to offer his blessing without his bridewealth portion.Few comparableinstancesof diagnosticdualismwere in evidence in the Quebeccases, althoughtherewere instancesof similarillnesses thatreceived differentsequentialtreatments. A rathermore difficult question arises when one looks at the status differences between healer and patient, professionaland layperson, within the framework of the therapymanagementprocess. Is "consensus" the appropriate label for a harmoniousinteraction between doctorand patient?Should we speakof the between the two concerningdifferenttypes of diagnosis and therapeutic interplay as recommendation "therapymanagement"?In both the Quebec and Kongo settings disagreementbetween the healer and patient(and patient's advocates)was markedby interrupted treatment,noncompliance, or the search for alternative therapy. Such changes were based on the perceptionof the earlier treatment's

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inefficacy, either by the individualsuffereror by the recognizedadvocateof the moment.These healer-related shifts in therapeutic choice, viewed in light of Lewin's idea of the total social field, suggestedthatthe dynamicsof the healer-patient interactionshould indeed be included within the overall model of therapymanagement. Ourseminardiscussions led finally to a definitionof the therapeutic process as a series of actionsoccurringin a social context in which individuals(usuallyin or groupsor sets), living in orderedrelationships roles, makedecisions abouttheir own welfare, often in closely relatedsequences, on the basis of partiallyshared acts thus mediatedifferclassifications,values, andknowledge. Such therapeutic ing classificationsand values (culture), social structuresor roles (society), and protagonists'assessmentsof the effectiveness of the therapy. The concept of therapymanagement,as definedhere, is thus both cognitive andsocial. Knowledgeof the clinic and of the experienceof sickness and healing is shapedand affectedby social dynamicsamong all individualsinvolved. Therethe fore, to understand therapymanagementprocess, one must examine the cumulative, microhistoricalcharacterof social relations and personal exchanges. Each decision or action affects and shapes successive stages of knowledge-the perceptionof the events, the diagnosis of the disease, and the social field around Thus, unlike some strictlycognitive or rationsufferer,family, and practitioners. alisttheories,the social relationsof the therapymanagement groupareconsidered an active dimension in the strategyof therapyseeking. By contrast,the "social supportnetwork" perspective often excludes emphasis on the cumulative microhistorical process throughwhich knowledge is appliedby individuals;it often fails to appreciatethe implicationsof consensus and disagreementfor decision makingin the search for therapy;and, despite its importancein medical anthropology, its users often ignore the presence of alternativeor contrastingmedical or therapeutic ideologies that are held by segments of the networkor group. Reception of the Therapy Management Concept Numerousreviews and discussions of therapymanagementhave been published (Pfleiderer-Becker 1978; Beidelman 1979; Fabrega1979; MacClean1979; Messing 1979; Edgerton1980; Bibeau 1985; Genest 1985). Reactionsto the conrange by cept may be summarized referenceto three issues: (1) the ethnographic and ethnologicalstatusof the therapymanagementphenomenonboth elsewhere in Africa and in other settings worldwide;(2) therapymanagementand therapy management group as theoreticalconcepts; and (3) methodologicaland clinical issues in applyingthe concept.
Therapy Management as Control over Therapeutic Resources

have affirmedthat in their experiencetherMany reviewersand researchers apy management groupsoccur widely. Lambek(personalcommunication,1986), in his just-completedcomparativestudy of Mayotte and Botswana, for example, confirmsthe presence of the therapymanagementprocess in both societies but identifiesdifferencesin the social compositionof therapymanagementgroups. In

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Botswana,deep agnaticlineages form the basis of domestic society and exercise responsibilityfor both the diagnosis of afflictionandthe care of the sick. In Mayotte, thereis less emphasison lineage, and bilateralfamily networksplay a comparablerole in coming to the aid of sufferersand tendingthem in the hospital. In addition,spiritmediumsand otherhealersplay a centralrole in guiding the therapeuticquest. Feierman(1985), a fellow Africanist, has endorsedthe general idea of the therapymanagement group and has refinedthe concept in a numberof ways. On the basis of his work in Tanzania, he suggests that therapymanagementfundaof of mentallyconcernsdetermination diagnosisandprocurement care for the suffererby anotherindividual. In Kongo someone (the juridical "owner" of an individual,eitherthe lineage heador, 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 independent women do sufferers make these determinationsthemselves. Thus, what I call a "group" in my analyses is a set of individuals, one of whom has rightsof decision makingin Kongo customarylaw, and othersof whom (perhaps kin) assist in lendingsupport,solace, or aid in treatment.The distinctionbetween the legal controlof diagnosis and choice of therapy,on the one hand, and solace and support,on the other, is important. Feierman'sreview also calls into question my use of the term "group" to refer to the constellationof individualswho manage therapyfor the sick. This termcan only be objectedto, however, if it is takento imply "corporategroup" in a technicalsense. It still seems an appropriate term in the less legal sense of a set of individualsinvolved with a suffererto lend "special-purposegroup"-a assistanceor assume authorityin diagnosis and therapy. Feiermanendorses the focus on therapymanagersover healers in the study of Africanmedicine, because it emphasizes the oft-forgottenpoint that therapy, like otheractivitiesin society, is shapedby those who controlit. Thatis, the same that powerstructures shapedomestic institutions,professions, andentiresocieties also shapetherapeutic actions. The issue thatthe study of throughstate structures and that Feiermanexamines at length in the essay therapymanagementopens, citedhere, is the institutional controlof therapeutic choice, whetherin the lineage, household,profession, or state (Feierman1985:80-83). Seen, then, as one level of the control of all therapeuticresources, the phenomenonof therapymanagement may be said to exist worldwide. This formulationovercomes the simplistic dichotomylay/professionalthatdominatessome discussions.
Middle-Range Theory between Individual and Collectivity

Otherwritersbelieve thata focus on therapymanagement medical anthroin can be used to illuminatethe logic of patientbehaviormore clearly than pology approaches that emphasize only the individual. Pfleiderer and Bichman (1985:129-130) suggest that the concepts of the lay referralsystem and the sick role usually see the patient as an individual actor and decision maker. Greater emphasison therapymanagementas a negotiatedprocess providesa way of perceiving the sicknessphenomenonin its social context. Thus, Harwood(1978:132) has proposedthat therapymanagementconstitutesa "middle range" theoretical formulation between the micro-level of the individualsick role, the clinical and

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ritualprocess of healing, and the macro-level of political systems, institutions, and societies. For this reason, he suggests, it would be a fruitfulfocus for comparingmedical systems across societies or cultures. Bibeau(1985:119) has suggestedthatthe concept of therapymanagementis in also useful in the cognitive study of illness, particularly elucidatingrelationships among therapeuticcodes. By studying successive treatmentsemployed in or single cases, Bibeau suggests, one can uncovercomplementary even mutually exclusive featuresin the culturallogic of these codes. Fabrega'sreview of Quest (1979:369) includesnotice of the possibilities for mathematical analysis of "shifts in direction" of illness and care duringsuccessive episodes. With a largernumberof cases, it would be possible, he points out, to develop a "geometryof the pathwaysof illness." The basis for this possibility is spelled out in our work in a lengthy footnote (Janzen 1978:138) thathas so far received little attention.Predictionof the choice of therapeuticresource in succourse lies somewherebetweenstrictdeterminacy, cessive stages of a therapeutic of modeledby a Markovchain, andthe indeterminacy a stochasticprocess. In the former,predictionwould be based on knowledge of the presentand past; in the latter,randomchoice andcombinationwould prevail. We suggest in this note that to successive choices in the cases we studiedwere determined a greaterdegree by the dynamicsof relationshipsbetween individualsand social segments involved in therapymanagementthanby a "pure" cognitive logic. This was the basis of to our rejectionof many of the disembodied,decontextualizedapproaches reconstructingmedicalknowledge. The implicationsof this conclusiongo beyondmathematics.The directstudy to of the therapy managingconstellationlends affirmation the theoreticalview that epistemolknowledgeis always socially embeddedand implies a corresponding ogy of fieldwork. The particularmannerin which ideas are generatedand expressedboth in patients, their therapymanagers, supportgroups, and healers is constellationof individualspresent. Consequently, contingenton the particular just as we took issue with certaintrendsin ethnosciencein the 1970s, so we would that take issue today with some of the "cultureas text" approaches seek probably to generatethe contoursand structures knowledgewithoutlooking at eitherthe of social contextwithinwhich such knowledgeis used or the mannerin which social the it. and relationships powerinterestsmanipulate In medicalanthropology questions of why people utilize differing types of care are still of acute interest. One reason these questions have not been more authoritativelyaddressedin recent years may lie in the methodologicaldifficulty of elucidatingsocially embedded knowledgein the momentof decision. Methodologicaland ClinicalImplications and fieldworker the clichallengesface boththe anthropological Comparable nicianwho wishes to identifyassumptionsandideas thatlead to the choices made by patientor patientmanaginggroups. Both must identifyhow options being entertainedin the communityaroundthe suffererinfluence the sufferer's choices. For the fieldworkerthe problemis not so much identifyingthese options, but of enough of them to determinewhat they mean in the wider society accumulating and cultureand whetherthey are representative.For the clinician the important

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issue is how to relateto these options-whether to give them free reign, to resist them, or to work with them. With regard to the fieldworker'sconcern, Edgerton in his review of The Questfor Therapy(1980:171-172) observed that the data base was not entirely for satisfactory,even thoughthe analysis of the cases was appropriate sketching relationshipsbetween segments of therapymanagementgroups that represented differenttherapeuticideas 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 methodologicalquestionsareraisedby this critique:(1) Canresearch utilizing the extended case method provide a sufficient numberof examples to claim culturalrepresentativeness? (2) Are the resultsreplicable? and Several studies have demonstrated that these questionscan be answeredaffirmatively.In theirwork among the Shambaaof Tanzania,Feiermanand Karlin combinedperiodicsurveys of 160 householdsin a single communitywith intensive study of therapymanagementin cases that emerged from this sample (personal communication).They also studied extended cases from a variety of historical sources. This strategyallowed them to identify not only change through time but also synchronicvariationamong contemporary households. In addition, Sussman(personalcommunication,1985), in anthropological researchcurrently under way in Madagascar,has proposed to study intensively 150 individuals, drawnfrom a largersample by stratifiedor randommeans, in order to identify (among other aspects of health care) therapymanagementproceduresand patterns. These studies illustrateefforts to expand the data base in orderto satisfy sampling criteriaof size and representativeness.In doing so, researchershave adoptedsamplingmethodsthatwere utilized a decade ago in communityresearch by Colson (1971) and Manningand Fabrega(1976). The reactionto the therapymanagementgroupphenomenonhas includeda numberof commentsabout its utility for health-carepersonnel. Mcllvray (1978) and MacClean(1979) have exhortedclinicians working in hospitalsand medical centersin Africa to be sensitive to their patients' therapymanagersand to share informationwith them. Pfleidererand Bichman (1985) advise therapistsnot to "bracketout" the social dimension in the treatmentof sickness. As long as the patientis handledonly as an individual,the therapycan be but partiallysuccessful. Healingin the Africancontext entails not only the ameliorationof symptoms but also the clarification diagnosticissues and the creationof social consensus. of Further Research on the Therapy Management Group Reviews of The Questfor Therapyand reportsof new researchindicatethat several issues in medical anthropologymay be seen in a new light throughthe study of the process of therapymanagementand the compositionof the therapy managementgroup. Six issues, and related examples, will be outlined briefly here. First, the studyof therapymanagementbringsinto focus issues aroundtherof apeuticdecision making. Debate continuesregardingthe determination theraadvocates, idealists, culpeutic decisions, with materialists,hierarchy-of-resort ture-as-text and analysts,transactionalists, otherspromotingtheirviews. Therapy as a perspectivedoes not sweep away and replace these other permanagement

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spectives; rather,it offers a more disciplined and contextually sensitive framework within which to test hypotheses concerningmedical decision making that derive from any of these theoreticalframeworks. A second, and related, emphasis that has been broughtto the fore by the therapymanagement perspectiveis the natureof differentialoptions and choices in pluralisticmedical settings. Cross-referrals consultationsacross medical and traditions within single cases, as illustratedin The Questfor Therapy,have been of confirmed exist widely. As a result,ourunderstanding medicalpluralismhas to evolved frommerereflectionson how medicalsystems may differ in theirgeneral of characteristics a betterunderstanding how they mesh and articulatein parto ticularsocieties and settings. A focus on the decision-makingprocess in therapy is management able to show how differingparadigmsare handledin real life by living actors. For example, Staiano (1986) has applied the "close-in" case-bycase approach examine multiplemedical resourceuse in Belize, a remarkably to pluralisticsociety in this regard.Identifyingher workas a "case study in medical semiotics," she has analyzedthe shiftingrelationshipbetween labeling of sympof toms, on the one hand, and the imputation 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 communication, 1986), she assesses the self-conscious process of "juggling" resources, types of medical knowledge, and institutionalutilization. Not only the considerationof multiple alternativemodels of therapeutic knowledge is at issue here, but also the salience or control of these models in the successive stagesof therapy.A thirdtype of contribution therapymanagement perspectivemay thereforeyield is to introduceinto the evaluationof the clinical or therapeutic settingjural and political-economicfactors. One way this has been is formulated in termsof the patternof care received by needy or neglected individuals. In this regardtherapymanagementmay identify patternsof increasing health risk. Feierman's household survey among the Shambaa of Tanzania the (1981:359, 1985:83-84) demonstrated extent and type of disadvantageexperiencedby those who did not sharein the benefitof collective kin funds and other aid in the event of disease or misfortune.Over a period of 80 years of colonial andpostcolonialhistory, widows and divorcees were shown to have few therapy managementresources. The consequences of their disadvantagewere demonstrated the fact thattheirchildrenshowed up with the most seriousandfrequent by healthproblems.This researchsuggeststhatthe therapymanagement perspective, focusing at close rangeand over time, can provideevidence of growingclass disin enfranchisement society. A fourthissue that may be elucidatedby researchon therapymanagement, one relatedto the controlof health and health-careresources, has to do with the "shapeof knowledge" as a resultof social control. Thereare severaldimensions to this problemthatcan only be suggestedhere. One has to do with the disjuncture between expectationsand outcomes in therapy, and anotherhas to do with the social segments that lay claim to the control of knowledge and resources in the setting. therapeutic Unexpectedoutcomes or "failures" in therapy, sometimes also referredto as lack of complianceon the partof the patient,are not merely to be explainedby

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as the differingsets of ideas held by healersandpractitioners, suggestedin Kleinman's Explanatory Model (1980). Who controlsthe models andthe way thatcontrolis managedmustalso be includedin the analysis. This is effectively illustrated in Redford's(1977) study of decision makingand the managementof knowledge amongteenagepregnantgirls in an urbanNorthAmericansetting. The aim of the aboutthe relationshipbetween studywas to determineteenagers'understandings sex andconception,andonce pregnant,how the girls perceivedandmanagedtheir obstetricand gynecological care. After interviewinghealthofficials and studying the regimensthey hadprescribed,it becameclearthatthe girls did not follow their instructions very closely. Redforddiscoveredthatgirlfriendsand the girls' mothers were the principalsources of informationand figures of supportin decision making. Only rarely did the girls establish meaningfulcontacts with gynecologists andprenatal-care specialists, althoughthey went to themregularlyfor checkups and deliveredtheir babies in maternityclinics. Clinical authoritieswere consistently surprisedat the decisions and moves taken by the girls. However, had health-carepersonnelidentifiedthe girls' assumptionsmore thoroughly,as well as the people with whom the young women conferredabouttheirdecisions, they wouldhave perceivedconsistencyrather thandisjuncture betweenknowledgeand action. The controlof therapeutic knowledgeandresources,as seen in this example, is often assessed in termsof "lay" versus "professional" realmsof discourseand or understanding, in terms of the "doctor-patient"relationship.However, there are many examples of medical decision making, even in highly technical care, where informationand crucial symbols are embedded in a total constellationof social relationshipsthat is dominatedneitherby professionalsnor by laity. A focus on therapymanagementyields understanding the dynamicqualitiesof this of thantype-castingknowledgeand information controlas "lay" negotiation,rather or "professional." A study of the decision-makingprocess, the control of knowledge, and the conveyance of rights in a large urban American leukemia treatment center (Longhofer 1980) illustrates these points. In bone-marrowtransplantsdonors must be blood-group compatible with recipients, and are thus almost always membersof the same family as the recipient. Given the highly suspenseful "all or none" outcome of transplants,which result in either temporaryremission or deathwithin 36 hours, the marrowdonor becomes either the perceived cause of the patient's survival or the implicit reason for his imminentdeath. A diffuse, multiplexrelationshipbinds donor and recipientand comes to dominatethe therapy management process. The chargedatmosphereof the leukemiaclinic brings family memberstogetherto supportthe patientandone anotherin the face of "the double bind," as Longhofercalls it, broughton by the prospectof either instant cure or catastrophy. The study revealed that American families act very much like Kongo kin inversion. Whereasin Kongo rightsof groupsin this situation,with an important decision makingwere conveyed to a "jurallyresponsible" individualwithin the family, in the Americanleukemiacases the patientand donor frequentlytook de facto chargeof therapymanagement.The medical staff, faced temporarilywith uncertainoutcome or hesitancy by the marrowdonor, lost control of the therapeuticprocess, andengaged in a "juggling" of alternative strategiesthatcan only

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be termeda sortof professional"therapymanagement."' This case studysuggests the utility of includinghealerswithin the therapymanagement group, even in societies with a highly professionalizedand technologically sophisticatedmedical institution. A sixth, and final areaof furtherresearchon therapymanagement that flows out of the close-rangestudy of therapeutic choices within a social context is that of the emergenceof specializedcommunitiesof caringand curing, whetherthese be Centraland SouthernAfrican "cults of affliction" (Turner1968; Schuessler 1986), Western self-help groups, or other variants. Many studies delineate the rituals, cosmologies, and organizationalstructuresof African cults, therapeutic but we lack so much as a single reporton the individual-by-individual actions accompanyingthe emergence of such groups. It is likely that these cult groups emergefromsets of individualsbeing diagnosedwith similarproblems,andbeing steeredby theirtherapymanagersto commonsolutions. Corin(1979), in herwork on the Zebolacult thatarose in UpperZaireand spreadto urbancentersof Mbandaka and Kinshasa, noted, as one would expect, that fewer of the sufferers'kin wereinvolvedin decisions andritualsin the city thanin the home setting. Lambek (personalcommunication, 1986) observed on Mayotte that groups of spirit suffererstendedto congregatewith healershaving knowledge of these same spirits. Althoughcomparativeresearchon this subject is scarce, it may be that there are widespreadtherapeutic supportgrouppatternsthatreplacekinsmen in giving diagnosis, interpretive judgment and supportto specialized categories of afflicted or disadvantaged who have lost close proximityand rightsto family resources.A therapymanagement perspectivewould elucidatethe processof the emergenceof such groups. Conclusion What, then, is the verdict on "therapymanagement"as a process, and the "therapymanagementgroup" as a social context for the process? Is the notion, used in a single monographstudy almost a decade ago, worthwhile?It appearsto have had some success in applicationto a varietyof settings, althoughit has not exactly unleasheda revolution in medical anthropology.No doubt many of the ideas and approachesthat have here been subsumed under "therapy management" or the "therapymanagementgroup" could have been formulatedwithout would do well to avoid the pursuit using these exact terms. Medical anthropology of specializedjargon. Nevertheless, the focus that has been emphasizedin this articlecontributes to a sounderunderstanding the mannerin which medicalknowledge is embedof ded in social categoriesand relationships,and how it is articulated,controlled,or continuesto be concernedwith in manipulated thatsetting. Medicalanthropology of the determinants choice in the therapeuticprocess, with the relationshipbetween alternative medical traditionsandpathwaysavailable, and with the control and applicationof medical knowledge. Therapy managementas a perspective of bringsthese issues into focus in a unique way that provides an understanding the relationshipof knowledge to society in health seeking, for the analyst and clinicianalike.

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