Here are several sources from my book, Unsung Heroes: Living Well and Growing with Type 1 Diabetes, about the four levels of meaning-making in chronic illness Kleinman. This summarizes my view of chronic illness and the role of therapy in supporting you through your illness and healing journey. 

“The visionary Arthur Kleinman (1988) was a U.S. psychiatrist and a professor of medical anthropology and cross-cultural psychiatry at Harvard University. He worked with chronically ill patients for many decades; based on this long career, he found that the heart of chronic illness is the experience of the illness through narratives. Central to his approach in understanding this population’s inner experience is the belief that listening to the experience of someone in pain or struggling with chronic illness lessens their pain and increases their capacity for meaning-making around their disease, which is an inherently helpful process for achieving psychological well-being. Kleinman’s ‘four levels of illness meanings’ (p. 55) informs and guides a deeper empathy for the inner worlds of the individuals around their experiences living with chronic illness” (Cortright, 2023, p. 187). 

“The first level of illness meaning concerns the physical symptoms of the illness itself, the experience of the pains associated with an illness, the processes of monitoring and taking care of the body, and the expression of those experiences to others (Kleinman, 1988, p. 11). For individuals… this first level also includes how an individual manages and takes care of their… lifestyle, and the minute details of one’s day-to-day life. This section also addresses the cultural context within which symptoms are expressed, which in the West is often a mechanical model of the body. In other cultures, the body may be viewed in a more symbolic way and as connected to the world around it. In sum, this level addresses the overall experience and relationship to living with the physical experience of the illness… and its symptoms.” (p. 188).

 “The second level of illness meaning focuses on the cultural aspect of chronic illness (Kleinman, 1988, p. 18). This is the meaning that a particular illness has for the individual living in society, as well as the common views others hold about the illness. How are those who are in institutions (e.g. jails/prisons) treated in a society with a particular illness? What types of celebrations or ceremonies surround particular illnesses?… There can be an element of invisibility and isolation. Many people don’t know much about illnesses or even what they are, including the (at times) severe nature of illnesses” (p. 190).

 “This third level of illness meaning is characterized by the ongoing relationship and inherently integrated nature of an individual’s chronic illness and the experience of one’s daily life with chronic illness (Kleinman, 1988, p. 31). Each person’s inner world includes feelings, imagination, and intellect. An infinite number of situations with their accompanying feelings can arise in an individual’s life. Common among these feelings are rage, sadness, grief, fear, relief, and determination. For example, one may experience overwhelming anger at limitations, envy of others’ health, guilt over failings in life, and fear of death. The description of the intensity of some of the negative feelings is representative of how someone… may be feeling in a moment, or during a period of time when health challenges are more acute. Most often, they are not feelings that are felt all the time, rather they can become this intense for difficult sections of time.

 However, when situations and feelings are processed, for example in psychotherapy, one may learn to eventually accept one’s condition more—even in the face of one’s own mortality. This acceptance can allow the individual to feel more peaceful, less anxious, and be able to experience love and gratitude toward life more fully, as well as develop greater confidence in oneself and one’s body. None of this is to say that the suffering will disappear completely, more that it can become more manageable” (P. 192).

“Kleinman’s (1988) fourth level of illness meanings is related to direct experience (p. 55), which is more difficult to express in words. Kleinman maintained that through the process of contending with a chronic illness, a ‘transcendent’ (p. 55) transformation takes place in one’s personality. This level of illness meaning encompasses the experience of being witnessed while being ill, as well as meaning-making that surrounds difficult feelings and difficult life situations, as discussed in the previous section. However, at this fourth level, illness narratives that are more constructive, hopeful, and connected to reality can be created. Subsumed within the direct experience of the fourth level is the power of the direct human connection to provide comfort, relief, and interconnectedness. 

This level of meaning also encompasses one’s experience of being sick, experiencing great pain and emotional distress, and being faced with the inevitability of death. These experiences may lead the sufferer to envision the chaotic, painful, and unfair aspects of reality, which often shatter any trace of optimism (which can’t also encompass these). In the words of Kleinman (1988), when moving through these experiences, the insight gained by the individual who is ill ‘can be the result of an often grim, though occasionally luminous, lived wisdom of the body in pain and the mind troubled’ (p. 55), which Kleinman goes on to describe as ‘moral insight’” (p. 55)” (p. 198-199). In other words, moral insight is a transformation, which I explore more deeply in my book, but in short can be described as psychological growth where the individual finds sources of optimism and strength that don’t have to do with direct pleasure, but rather with satisfaction that is qualitatively greater because it is available even when the body is in pain, including gratitude, connection through relationships, and other sources of meaning-making.