My life in books

In Crazy Like Us: The Globalization of the American Psyche, journalist Ethan Watters investigates the cultural meanings of mental illness from an anthropological perspective and traces the ongoing superimposition of American theories of psychology on other systems of understanding the mind.

Over the past thirty years, we Americans have been industriously exporting our ideas about mental illness. Our definitions and treatments have become the international standards. Although this has often been done with the best of intentions, we’ve failed to foresee the full impact of these efforts. It turns out that how a people in a culture think about mental illnesses—how they categorize and prioritize the symptoms, attempt to heal them, and set expectations for their course and outcome—influences the diseases themselves. In teaching the rest of the world to think like us, we have been, for better and worse, homogenizing the way the world goes mad.

Watters explores this thesis by looking at specific mental disorders in four different areas of the world - Hong Kong, Sri Lanka, Zanzibar and Japan - and how the cultural meanings of these disorders have changed following the introduction of Western paradigms of mental illness

First, Watters looks at the work of Dr. Sing Lee, who was the first scholar to document anorexia in Chinese women. When Lee began his work, anorexia was a rare condition and many of its symptoms did not match those of anorexia in the West. The few anorexic women he encountered did not display two of the key diagnostic symptoms - a fear of being or becoming overweight, and a false perception of their own body shape. All they had in common with Western anorexics was excessive weight loss leading to dangerous emaciation. Seeking to understand why this was the case, Lee looked at the history of anorexia and found that reports of extreme weight loss from 19th century Europe and America, linked to what was then known as hysteria, were similar to what he was seeing in his own practice.

When Lee began his investigation of anorexia, the condition was not only rare, but virtually unknown to the general public. However, the condition became well-known after the public collapse and death from self-starvation of schoolgirl Charlene Hsu Chi-Ying in November 1994. Media reports described the disease as it was known in the West and defined in the DSM.

Over a short period of time the presentation of anorexia in Hong Kong changed. The symptom cluster that was unique to his Hong Kong patients began to disappear. What was once a rare disorder was replaced by an American version of the disease that became much more widespread.

Lee's research and practice led him to see the American definition of anorexia as limiting and in itself culturally influenced. Fat phobia and conflicts about body shape and beauty are Western issues; anorexia in other cultures might be the result of different cultural issues.

The DSM version of the disorder was obscuring the indigenous distresses and patterns of behavior that led young women to adopt self-starvation. If clinicians around the world could avoid the quick and easy adoption of Western assumptions about anorexia, they might be able to hear the complex truths individual women were trying to communicate. Anorexia and eating disorders could tell us much about the pressures on women in different cultures if only their voices weren’t being drowned out by Western narratives about the power of fashion, dieting, and pop culture.

Watters also examines culture-based differences in responses to trauma, using experiences in post-tsunami Sri Lanka, and in other situations such as post-war Rwanda. The Western assessment of medical needs in Sri Lanka, as had been the case in other situations, assumed that there would be an epidemic of PTSD following the tsunami, and many western-trained therapists with no idea of Sri Lankan cultural or religious supports and no facility in the language were dispatched - or volunteered - to "help" deal with the expected need. Sri Lankans were inundated with information about PTSD as understood in the West, and with therapists engaging them in techniques based on the responses of Westerners, primarily Americans, to traumatic experience

Often these campaigns seemed to imply that the psychological consequences of trauma were similar to a newly discovered disease, and that local populations were utterly unaware of what happens to the human mind after terrible events. That implicit assumption often left anthropologists shaking their heads in disbelief. It takes a willful blindness to believe that other cultures lack a meaningful framework for understanding the human response to trauma. “Most of the disasters in the world happen outside of the West,” says Arthur Kleinman, a medical anthropologist from Harvard University. “Yet we come in and we pathologize their reactions. We say: ‘You don’t know how to live with this situation.’ We take their cultural narratives away from them and impose ours. It’s a terrible example of dehumanizing people.”

What workers in the field found was that the experience of response to trauma among Sri Lanka was connected to the individual's social networks, and that contrary to Wesyern experience, talking about the trauma heightened dysfunctional responses rather than reducing them. Sri Lankans had developed ways of defusing and dispersing trauma response through social roles and functions, and talking about the trauma disrupted these mechanisms.

A further example of the cultural differences in presentation and meaning of mental illness looks at the cultural understanding and response to schizophrenia in Zanzibar.Cross-cultural studies of schizophrenia show that there is a better long-term prognosis in many less developed countries than in industrialised nations, and that the delusional content is heavily influenced by culture and can change over time within a culture. The prognosis is particularly affected by how the social network around the schizophrenic responds to them:

Three emotional reactions from family members showed a relationship with the patients with higher relapse rates. Collectively referred to as “high expressed emotion” they were criticism, hostility, and emotional overinvolvement. In particular, high-relapse patients tended to live in an environment where at least one relative routinely criticized and attempted to control the patient’s behavior.

European and North American cultures are strongly individualistic and place the locus of control within the self; family members are more likely to try to "fix" illness and criticise the patient for not taking control and getting better. Researchers in Zanzibar found that family members of schizophrenic individuals tended to be far more accepting of their behaviour - and that schizophrenic individuals tended to be higher-functioning with fewer serious relapses.

Finally, Watters examined recent changes in the meaning and treatment of depression in Japan. Interviews with specialists in the anthropological study of illness and with individuals in the pharmaceutical industry revealed that Japanese cultural understandings of depression as a rare and severe condition, sadness as a respected philosophical state and suicide as an act with multiple meanings, few of them related to depression, were altered by a deliberately crafted public relations campaign crafted by International pharmaceutical companies in order to create a market for SSRIs.

In summing up his research into the cultural component of mental illness, Watters notes that:

The ideas we export to other cultures often have at their heart a particularly American brand of hyperintrospection and hyperindividualism. These beliefs remain deeply influenced by the Cartesian split between the mind and the body, the Freudian duality between the conscious and unconscious, as well as teeming numbers of self-help philosophies and schools of therapy that have encouraged us to separate the health of the individual from the health of the group. Even the fascinating biomedical scientific research into the workings of the brain has, on a cultural level, further removed our understanding of the mind from the social and natural world it navigates. On its website advertising its antidepressant, one drug company illustrates how far this reductive thinking has gone: “Just as a cake recipe requires you to use flour, sugar, and baking powder in the right amounts, your brain needs a fine chemical balance in order to perform at its best.” The Western mind, endlessly parsed by generations of philosophers, theorists, and researchers, has now been reduced to a batter of chemicals we carry around in the mixing bowl of our skulls.

This conflation of the ideas of mind and consciousness with the physical organ of brain has many potential consequences, some of them problematic in the extreme. As Watters suggests,

We should worry about this loss of diversity in the world’s differing conceptions and treatments of mental illness in exactly the same way we worry about the loss of biological diversity in nature. Modes of healing and culturally specific beliefs about how to achieve mental health can be lost to humanity with the grim finality of an animal or plant lapsing into extinction. And like those plants and animals, the diversity in the human understanding of the mind can disappear before we’ve truly comprehended its value. Biologists suggest that within the dense and vital biodiversity of the rain forest are chemical compounds that may someday cure modern plagues. Similarly, within the diversity of different cultural understandings of mental health and illness may exist knowledge that we cannot afford to lose. We erase this diversity at our own peril.