Explanatory Models

Every person involved in a clinical encounter — patient, family member, nurse, physician — carries a working theory about what the illness is, what caused it, how serious it is, how long it will last, and what should be done. These working theories are what Arthur Kleinman called explanatory models. They are rarely made explicit, they are often emotionally loaded, and they frequently contradict one another. Most clinical failures in chronic illness care, Kleinman argued, can be traced to model conflicts that go unrecognized and therefore unresolved. The patient’s model is not wrong information awaiting correction — it is a coherent, if partial, interpretation of a real situation, and ignoring it produces noncompliance, therapeutic failure, and frustration on both sides. Learning to elicit patient models and negotiate between conflicting ones is, on this account, a core clinical skill rather than a communication add-on.

Origins and Definition

Explanatory models (EMs) are the notions that patients, families, and practitioners have about a specific illness episode. They are responses to urgent life circumstances and justifications for practical action rather than theoretical statements, and they are most often tacit and anchored in strong emotions. (Kleinman, 1988) Kleinman developed the concept within The Illness Narratives (1988), a work grounded in medical anthropology and long-term clinical observation. The framework was designed to make visible the cultural and personal dimensions of illness experience that biomedical categories systematically obscure.

The concept is inseparable from the illness-disease distinction — Kleinman held that illness, disease, and sickness are three distinct categories, and this tripartite separation is the conceptual foundation for the entire EM framework.(Kleinman, 1988) [See Illness-Disease Distinction.] Because illness is the patient’s lived experience of being unwell — not the clinician’s technical category — the patient’s account of their illness is not simply a report of symptoms awaiting translation into a diagnosis. It is itself a structured interpretation: an explanatory model. The clinician’s interpretation is equally a model — constructed through medical training, professional categories, and clinical pattern recognition. When these two models meet in an encounter and their conflicts are not addressed, care becomes less effective and often less humane.

EMs address five main questions, which Kleinman identified as the core dimensions of any clinical illness explanation:

1. What is this illness called?
2. What caused it, and why did it begin when it did?
3. What does it do to the body?
4. How severe is it, and how long will it last?
5. What treatment is appropriate, and what outcomes are expected?

These questions generate systematically different answers from different positions. The patient and family are responding to disruption of a particular life; the clinician is fitting presenting signs into a professional nosology. The structural difference between these positions means divergent models are the norm, not the exception.

The Eight Questions

Kleinman developed a set of clinical interview questions to elicit patient EMs systematically — a kind of bedside ethnography that makes tacit models explicit so they can be worked with. These have come to be called the Kleinman questions or the mini-ethnography questions, and they appear as a clinical method in The Illness Narratives Chapter 7 and are elaborated as a core component of the methodology in Chapter 15. (Kleinman, 1988)

The eight questions are:

1. What do you call your problem? What name does it have?
2. What do you think has caused your problem?
3. Why do you think it started when it did?
4. What does your sickness do to you? How does it work?
5. How severe is your sickness? Will it have a short or long course?
6. What kind of treatment do you think you should receive?
7. What are the most important results you hope to receive from this treatment?
8. What are the chief problems your sickness has caused for you?

These questions are not a diagnostic checklist. They are an invitation for the patient to articulate their model in their own terms. The questions about cause, onset timing, and expected course are especially likely to reveal explanatory content that differs from biomedical assumptions — traditional illness attributions, moral explanations, family histories, lay physiological theories. Eliciting this material does not mean accepting it uncritically; it means making it available for negotiation.

The goal of the mini-ethnography, Kleinman specified, is to systematically map the patient’s lifeworld: daily routines, social supports, economic constraints, family dynamics, and the concrete ways the illness disrupts all of these. (Kleinman, 1988)

Conflicting Models in Practice

The biomedical case record systematically strips away psychosocial context through what Kleinman, following Elliot Mishler, called a ritual transformation: illness narratives become disease records, and the patient’s lifeworld is erased. (Kleinman, 1988) The clinician’s record — dominated by organ systems, laboratory values, and diagnostic categories — is not a neutral documentation of what happened but a translation into a specific model that discards a great deal of the patient’s account.

When patient and practitioner EMs conflict and the conflict is unaddressed, the consequences are clinical. Professional biomedical models often marginalize psychosocial factors and label patients as noncompliant rather than addressing the underlying life stressors that drive treatment resistance. (Kleinman, 1988) Noncompliance, framed this way, is not a patient character defect but an index of unresolved model conflict: the prescribed treatment does not fit the patient’s model of what is wrong, what is needed, or what is possible given the constraints of their life.

Practitioners’ inattention to patient EMs signals disrespect, a form of hubris toward alternative viewpoints, and failure to regard psychosocial dimensions as relevant — all of which impede the therapeutic relationship and undermine the communicative foundations of care. (Kleinman, 1988) The stakes of inattention, Kleinman stated flatly in opening Chapter 7, may be fatal. (Kleinman, 1988)

Conversely, negotiation among patients and practitioners over salient conflicts in explanatory models can remove important barriers to effective care and almost always contributes to more empathic and ethical treatment. (Kleinman, 1988) This negotiation does not require the clinician to endorse the patient’s model; it requires acknowledging it, engaging with the parts of it that reflect real concerns, and working toward a shared understanding that the patient can act on.

Integration of patient narratives and psychosocial interventions with biomedical treatment can lead to substantial improvement even in chronic conditions with clear organic pathology — Kleinman cited asthma and psoriasis as examples from his case experience. (Kleinman, 1988)

Clinical Applications

Kleinman presented the EM negotiation process as a four-step clinical methodology for chronic illness care, elaborated in Chapter 15 of The Illness Narratives. The steps are: mini-ethnography (mapping the patient’s lifeworld), life history (understanding the illness in the context of a biography), explanatory model negotiation, and remoralization. (Kleinman, 1988) Together these constitute what Kleinman called empathic listening, translation, and interpretation — the craft of the clinician who treats illness, not just disease. (Kleinman, 1988)

The negotiation step is not a conversation about which model is correct. It is a practical process of identifying which conflicts between models bear on treatment — not all model conflicts matter equally — and working toward the resolution that will best support the patient’s ability to manage their illness. Negotiating explanatory models between clinician and patient or family reduces conflict and improves therapeutic outcomes while acknowledging the inherent uncertainty of chronic illness. (Kleinman, 1988)

[GAP: Kleinman’s broader critique of the myth of cure within the context of patient-clinician negotiation.] Chronic disease by definition cannot be cured; the quest for cure is a dangerous myth that distracts from step-by-step behaviors that lessen suffering. (Kleinman, 1988) The primary goal must be reduction of disablement in the ongoing experience of illness. (Kleinman, 1988)

Clinical diagnosis is a thoroughly semiotic activity: the practitioner translates patient complaints into disease signs. (Kleinman, 1988) Practitioners, however, are not trained to be self-reflective interpreters of distinctive systems of meaning; they are naive realists. (Kleinman, 1988) [GAP: The original paragraph then introduces unsupported claims about cultural differences, multiple-level translation failures, and the use of explanatory models (EMs) to identify breakdowns.]

Effective clinical care was described in the book’s front matter as requiring a biopsychosocial approach integrating ethnographic listening, explanatory model negotiation, and remoralization therapies alongside biomedical treatment. (Kleinman, 1988) George Engel’s biopsychosocial model provides a parallel framework at the level of disease theory; Kleinman’s EM concept provides the corresponding clinical tool at the level of the encounter.

Criticisms

Several criticisms of the EM framework have emerged in the three decades since its formulation.

EMs are less stable than the framework implies. Kleinman explicitly noted that EMs are working models — provisional, partial, and context-sensitive — rather than fixed beliefs. But critics have argued that even this qualification may overestimate the coherence of lay illness theories. Patients often hold internally contradictory beliefs about their illness simultaneously, and the beliefs they articulate in a clinical interview may differ from those that shape their behavior at home. The mini-ethnography elicits one version of an EM at one moment; it does not necessarily capture what actually governs the patient’s decisions.

The framework was developed in specific cultural contexts. Kleinman worked primarily in Chinese-American and Chinese populations, and the EM concept reflects a specific understanding of how lay illness beliefs are organized. Applied to other cultural contexts — particularly those with highly collective rather than individualistic illness attribution — the five-question structure may not map onto how illness is actually explained.

The negotiation model assumes a particular relationship structure. Explanatory model negotiation presupposes a dyadic relationship between a bounded patient and a bounded clinician. Much chronic illness care, especially in institutional settings, is fragmented across multiple providers, and the patient’s model must be elicited and worked with by many different practitioners who do not share information easily. The institutional critique runs deeper than the dyadic model can address.

Uncertainty must be as central to the practitioner as to the patient. (Kleinman, 1988) Kleinman acknowledged the limits of systematizing clinical work, stating that clinical systems that claim to answer every dilemma in a standardized manner contain a dangerous hubris. (Kleinman, 1988) This hubris falsifies the existential experience of both illness and healing. (Kleinman, 1988)

[HUMAN NOTE]: None yet.

See Also

• Illness-Disease Distinction
• Clinical Judgment
• Mini-Ethnography
• Narrative Medicine
• Biopsychosocial Model
• Remoralization
• Noncompliance
• Patient-Centered Care

Sources