Models, Incongruity, Consonance, and Stress: Implications for Managing Illness

I had a eureka moment when I learned that Toni Copeland had conducted research showing that knowledge of (competence) and behavior which approximates aspects of (consonance) a model of managing HIV among women in Nairobi, Kenya has been shown to be correlated to positive health outcomes, even going so far as affecting T-counts (Copeland 2012). I had obtained similar results in my Master’s research among a group of individuals diagnosed with bipolar disorder and who were attending a peer support group. Among this group there was a shared model of what a person could do to manage their disorder. I found that people whose behavior more closely approximated the model also reported less depressive episodes, mania, anxiety, and stress. In my opinion, this has enormous implications for treatment, especially in the area of my focus – psychological distress. This blog will focus on how the distribution and relationship to individual cultural models relates to health outcomes, the role of stress, and the implications for treatment of psychological distress.

Reflecting what I believe to be a general dissatisfaction with psychotropic medications, the people I worked with in the peer support group often complained of the efficacy and side effects of the drug cocktails they were taking to treat the issues which came with their diagnosis of bipolar disorder. If it can be shown repeatedly that knowledge of a model of managing psychological distress and behavior approximating that model correlate to better health outcomes, a more holistic approach to treatment can be employed.

The concept of cultural models has proven extremely useful to research in the social sciences (Strauss and Quinn 1994; D’Andrade 1984, 1995). If we start with a theory of culture derived from cognitive anthropology which states, culture is that which one needs to know in order to function adequately in any given social system, then the next task of the researcher studying culture would be to determine what exactly is it that the person needs to know. This knowledge is organized in models, consisting of interrelated elements which together represent something (D’Andrade 1984, 1995). Cultural models are not formulated as explicit declarative knowledge (as in theory), but as implicit knowledge, based on schemas embedded in words but not formulated as explicit propositions. Models are actively used, interpreted, and are socially transmitted. It has been shown that people cognitively model their illness experiences in culturally salient ways.

Incongruence, or status inconsistency, to dominant models has been shown to adversely affect health (Janes 1990; Dressler 1992, 2004; McDade 2001, 2002). One example of this is when an individual’s material lifestyle exceeds their social and economic status. This is the classic example of “keeping up with the Joneses”, where there exists a dominant cultural model of what a successful lifestyle consists of, and an individual is stretched beyond his means trying to achieve it. Incongruence or status inconsistency can also happen as a result of rapid cultural and economic change. This happens as a result of emerging markers of social status conflicting with traditional markers, creating discord or stress.

To examine the strength and distribution of a cultural model, or the level to which it is shared among individuals which make up the culture, cultural consensus analysis can be employed. This method was developed by Romney, Weller, and Batchelder (1986) and measures the degree of sharing of knowledge and individuals’ relative degree of shared knowledge. A measure of consensus is then found, weighted by the competence of the respondents. The idea of competence (which was originally raised by Keesing in 1972) is important in that an individual’s ability to meet the expectations of and function within a cultural model affects his or her psychological and physical well-being.

Cultural consonance, or the degree to which an individual approximates, in his or her own beliefs and behaviors, the prototypical cultural model, can also be calculated (Dressler 2000; Dressler et al. 2004, 2007, 2009). In theory, cultural consonance illustrates the relationship of individual experience and culture. Individuals may know a model in a cultural context, but for a variety of reasons they may not be able to act on or achieve accordance with it. If we assume, that for most people, there exists a desire and drive to achieve that which is seen as good or desirable in the model, then the relative ability to meet those ends will have an effect on the individual. Following methods illustrated by Dressler and colleagues (2000, 2007, 2011), individual levels of consonance are shown to be correlated with health outcomes, including levels of psychological distress. These researchers have also found that low levels of cultural consonance to be correlated with high blood pressure.

Stress levels in individuals have long been associated with health outcomes (Cassel and Jenkins 1960; Cassel 1976; Mason 1975). This fact combined with the relationship of incongruity, status inconsistency, cultural competence, and finally cultural consonance to a shared model and stress, illustrates the interrelatedness and importance of the stress process. To create a working definition of the stress process, it is helpful to consider four contributing aspects (Dressler 2004). First of all there are inputs; these can be acute or chronic stressors which an individual perceives as threatening or challenging. Secondly, there are mediating factors which can be psychological or emotional, physiological, metabolic, or morphological. Thirdly, it is helpful to consider resistance resources; these include social support, psychological resources of the individual, and biological resistance factors. Finally, there are outcomes including disease or other chronic conditions. I am suggesting here that by mediating this stress process through either re-evaluating unreachable models of lifestyle or increasing competence and consonance to a model of managing illness, the psychological and biological health of individuals may be improved. In the end, culture matters in both the conception of the meaning of illness and ideas concerning how to manage the illness experience.

Cassel, J.C., Patrick R., and Jenkins C.D. (1960).  Epidemiological analysis of the health implications of culture change.  Annals of the New York Academy of Sciences 84:938-949.

Cassel, J.C. (1976) The Contribution of the Social Environment to Host Resistance. American Journal of Epidemiology 104:107-123.

Copeland, T. J. (2011). Poverty, nutrition, and a cultural model of managing HIV/AIDS among women in Nairobi, Kenya. Annals of Anthropological Practice, 35: 81-97.

Dressler, William W. (1992). Culture, stress, and depressive symptoms: building and testing a model        in a specific setting, pp. 19-33 in Anthropological Research: Process and Application.  John J. Poggie, Billie R. DeWalt, and William W. Dressler Eds. Albany, NY: State University of New York Press.

Dressler, W.W. and Bindon, J.R. (2000). The health consequences of cultural consonance. American Anthropologist 102:244-260.

Dressler, William W. (2004). Social or status incongruence, pp. 764-767 in The Encyclopedia of Health and Behavior. Norman B. Anderson, Ed. Thousand Oaks, CA: Sage Publications.

Dressler, William W. (2004). Culture, stress and cardiovascular disease, pp. 328-334 in The Encyclopedia of Medical Anthropology. Carol R. Ember and Melvin Ember, Eds. New York: Kluwer Academic/Plenum Publishers.

Dressler, William W., Rosane P. Ribeiro, Mauro C. Balieiro, Kathryn S. Oths, and José Ernesto Dos Santos. (2004). Eating, drinking and being depressed: The social, cultural and psychological context of alcohol consumption and nutrition in a Brazilian community. Social Science and Medicine 59:709-720.

Dressler, William W., Mauro C. Balieiro, Rosane P. Ribeiro, and José Ernesto Dos Santos. (2007). Cultural consonance and psychological distress: Examining the associations in multiple cultural domains. Culture, Medicine and Psychiatry 31:195-224.

Dressler, William W., Mauro C. Balieiro, Rosane P. Ribeiro and José Ernesto dos Santos. (2009). Cultural consonance, a 5HT2A receptor polymorphism, and depressive symptoms: A longitudinal study of gene x culture interaction in urban Brazil. American Journal of Human Biology 21:91-97.

Janes, Craig. (1990). Migration, changing gender roles, and stress: The Samoan case. Medical Anthropology 12: 217-248.

Mason, John. (1975). A historical view of the stress field. Journal of Human Stress 1:6-12; 22-36.

McDade, Thomas W. (2001). Lifestyle incongruity, social integration, and immune function among Samoan adolescents. Social Science and Medicine 53:1351-1362.

McDade, Thomas W. (2002). Status incongruity in Samoan youth: A biocultural analysis of culture change, stress and immune function. Medical Anthropology Quarterly 16:123-150.

Romney, A.K., S.A. Weller, and W.H. Batchelder. (1986). Culture as Consensus: A Theory of Culture and Informant Accuracy. American Anthropologist 88:313-338.


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