AMERICANS, particularly if they are of a certain
leftward-leaning, college-educated type, worry about our country’s blunders
into other cultures. In some circles, it is easy to make friends with a rousing
rant about the McDonald’s near Tiananmen Square, the Nike factory in Malaysia
or the latest blowback from our political or military interventions abroad. For
all our self-recrimination, however, we may have yet to face one of the most
remarkable effects of American-led globalization. We have for many years been
busily engaged in a grand project of Americanizing the world’s understanding of
mental health and illness. We may indeed be far along in homogenizing the way
the world goes mad.
This unnerving
possibility springs from recent research by a loose group of anthropologists
and cross-cultural psychiatrists. Swimming against the biomedical currents of
the time, they have argued that mental illnesses are not discrete entities like
the polio virus with their own natural histories. These researchers have amassed
an impressive body of evidence suggesting that mental illnesses have never been
the same the world over (either in prevalence or in form) but are inevitably
sparked and shaped by the ethos of particular times and places. In some
Southeast Asian cultures, men have been known to experience what is called
amok, an episode of murderous rage followed by amnesia; men in the region also
suffer from koro, which is characterized by the debilitating certainty
that their genitals are retracting into their bodies. Across the fertile
crescent of the Middle East there is zar, a condition related to
spirit-possession beliefs that brings forth dissociative episodes of laughing,
shouting and singing.
The diversity
that can be found across cultures can be seen across time as well. In his book
“Mad Travelers,” the philosopher Ian Hacking documents the fleeting appearance
in the 1890s of a fugue state in which European men would walk in a trance for
hundreds of miles with no knowledge of their identities. The hysterical-leg
paralysis that afflicted thousands of middle-class women in the late 19th
century not only gives us a visceral understanding of the restrictions set on
women’s social roles at the time but can also be seen from this distance as a
social role itself — the troubled unconscious minds of a certain class of women
speaking the idiom of distress of their time.
“We might think
of the culture as possessing a ‘symptom repertoire’ — a range of physical
symptoms available to the unconscious mind for the physical expression of
psychological conflict,” Edward Shorter, a medical historian at the University
of Toronto, wrote in his book “Paralysis: The Rise and Fall of a ‘Hysterical’
Symptom.” “In some epochs, convulsions, the sudden inability to speak or
terrible leg pain may loom prominently in the repertoire. In other epochs
patients may draw chiefly upon such symptoms as abdominal pain, false estimates
of body weight and enervating weakness as metaphors for conveying psychic
stress.”
In any given
era, those who minister to the mentally ill — doctors or shamans or priests —
inadvertently help to select which symptoms will be recognized as legitimate.
Because the troubled mind has been influenced by healers of diverse religious
and scientific persuasions, the forms of madness from one place and time often
look remarkably different from the forms of madness in another.
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That is until
recently.
For more than a
generation now, we in the West have aggressively spread our modern knowledge of
mental illness around the world. We have done this in the name of science,
believing that our approaches reveal the biological basis of psychic suffering
and dispel prescientific myths and harmful stigma. There is now good evidence
to suggest that in the process of teaching the rest of the world to think like
us, we’ve been exporting our Western “symptom repertoire” as well. That is,
we’ve been changing not only the treatments but also the expression of mental
illness in other cultures. Indeed, a handful of mental-health disorders —
depression, post-traumatic stress disorder and anorexia among them — now appear
to be spreading across cultures with the speed of contagious diseases. These
symptom clusters are becoming the lingua franca of human suffering, replacing
indigenous forms of mental illness.
DR. SING LEE, a psychiatrist and researcher at the
Chinese University of Hong Kong, watched the Westernization of a mental illness
firsthand. In the late 1980s and early 1990s, he was busy documenting a rare
and culturally specific form of anorexia nervosa in Hong Kong. Unlike American
anorexics, most of his patients did not intentionally diet nor did they express
a fear of becoming fat. The complaints of Lee’s patients were typically somatic
— they complained most frequently of having bloated stomachs. Lee was trying to
understand this indigenous form of anorexia and, at the same time, figure out
why the disease remained so rare.
As he was in
the midst of publishing his finding that food refusal had a particular
expression and meaning in Hong Kong, the public’s understanding of anorexia
suddenly shifted. On Nov. 24, 1994, a teenage anorexic girl named Charlene Hsu
Chi-Ying collapsed and died on a busy downtown street in Hong Kong. The death
caught the attention of the media and was featured prominently in local papers.
“Anorexia Made Her All Skin and Bones: Schoolgirl Falls on Ground Dead,” read
one headline in a Chinese-language newspaper. “Thinner Than a Yellow Flower,
Weight-Loss Book Found in School Bag, Schoolgirl Falls Dead on Street,”
reported another Chinese-language paper.
In trying to
explain what happened to Charlene, local reporters often simply copied out of
American diagnostic manuals. The mental-health experts quoted in the Hong Kong
papers and magazines confidently reported that anorexia in Hong Kong was the
same disorder that appeared in the United States and Europe. In the wake of
Charlene’s death, the transfer of knowledge about the nature of anorexia
(including how and why it was manifested and who was at risk) went only one
way: from West to East.
Western ideas
did not simply obscure the understanding of anorexia in Hong Kong; they also
may have changed the expression of the illness itself. As the general public
and the region’s mental-health professionals came to understand the American
diagnosis of anorexia, the presentation of the illness in Lee’s patient
population appeared to transform into the more virulent American standard. Lee
once saw two or three anorexic patients a year; by the end of the 1990s he was
seeing that many new cases each month. That increase sparked another series of
media reports. “Children as Young as 10 Starving Themselves as Eating Ailments
Rise,” announced a headline in one daily newspaper. By the late 1990s, Lee’s
studies reported that between 3 and 10 percent of young women in Hong Kong
showed disordered eating behavior. In contrast to Lee’s earlier patients, these
women most often cited fat phobia as the single most important reason for their
self-starvation. By 2007 about 90 percent of the anorexics Lee treated reported
fat phobia. New patients appeared to be increasingly conforming their
experience of anorexia to the Western version of the disease.
What is being
missed, Lee and others have suggested, is a deep understanding of how the
expectations and beliefs of the sufferer shape their suffering. “Culture shapes
the way general psychopathology is going to be translated partially or
completely into specific psychopathology,” Lee says. “When there is a cultural
atmosphere in which professionals, the media, schools, doctors, psychologists
all recognize and endorse and talk about and publicize eating disorders, then
people can be triggered to consciously or unconsciously pick eating-disorder
pathology as a way to express that conflict.”
The problem
becomes especially worrisome in a time of globalization, when symptom
repertoires can cross borders with ease. Having been trained in England and the
United States, Lee knows better than most the locomotive force behind Western
ideas about mental health and illness. Mental-health professionals in the West,
and in the United States in particular, create official categories of mental
diseases and promote them in a diagnostic manual that has become the worldwide
standard. American researchers and institutions run most of the premier
scholarly journals and host top conferences in the fields of psychology and
psychiatry. Western drug companies dole out large sums for research and spend
billions marketing medications for mental illnesses. In addition,
Western-trained traumatologists often rush in where war or natural disasters
strike to deliver “psychological first aid,” bringing with them their
assumptions about how the mind becomes broken by horrible events and how it is
best healed. Taken together this is a juggernaut that Lee sees little chance of
stopping.
“As Western
categories for diseases have gained dominance, micro-cultures that shape the
illness experiences of individual patients are being discarded,” Lee says. “The
current has become too strong.”
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Would anorexia
have so quickly become part of Hong Kong’s symptom repertoire without the
importation of the Western template for the disease? It seems unlikely.
Beginning with scattered European cases in the early 19th century, it took more
than 50 years for Western mental-health professionals to name, codify and
popularize anorexia as a manifestation of hysteria. By contrast, after Charlene
fell onto the sidewalk on Wan Chai Road on that late November day in 1994, it
was just a matter of hours before the Hong Kong population learned the name of
the disease, who was at risk and what it meant.
Photo
Credit Alex
Trochut
THE IDEA THAT our Western conception of mental health
and illness might be shaping the expression of illnesses in other cultures is
rarely discussed in the professional literature. Many modern mental-health
practitioners and researchers believe that the scientific standing of our
drugs, our illness categories and our theories of the mind have put the field
beyond the influence of endlessly shifting cultural trends and beliefs. After
all, we now have machines that can literally watch the mind at work. We can
change the chemistry of the brain in a variety of interesting ways and we can
examine DNA sequences for abnormalities. The assumption is that these
remarkable scientific advances have allowed modern-day practitioners to avoid
the blind spots and cultural biases of their predecessors.
Modern-day
mental-health practitioners often look back at previous generations of psychiatrists
and psychologists with a thinly veiled pity, wondering how they could have been
so swept away by the cultural currents of their time. The confident
pronouncements of Victorian-era doctors regarding the epidemic of hysterical
women are now dismissed as cultural artifacts. Similarly, illnesses found only
in other cultures are often treated like carnival sideshows. Koro, amok
and the like can be found far back in the American diagnostic manual (DSM-IV,
Pages 845-849) under the heading “culture-bound syndromes.” Given the attention
they get, they might as well be labeled “Psychiatric Exotica: Two Bits a
Gander.”
Western
mental-health practitioners often prefer to believe that the 844 pages of the
DSM-IV prior to the inclusion of culture-bound syndromes describe real
disorders of the mind, illnesses with symptomatology and outcomes relatively
unaffected by shifting cultural beliefs. And, it logically follows, if these
disorders are unaffected by culture, then they are surely universal to humans
everywhere. In this view, the DSM is a field guide to the world’s psyche, and
applying it around the world represents simply the brave march of scientific
knowledge.
Of course, we
can become psychologically unhinged for many reasons that are common to all,
like personal traumas, social upheavals or biochemical imbalances in our
brains. Modern science has begun to reveal these causes. Whatever the trigger,
however, the ill individual and those around him invariably rely on cultural
beliefs and stories to understand what is happening. Those stories, whether
they tell of spirit possession, semen loss or serotonin depletion, predict and
shape the course of the illness in dramatic and often counterintuitive ways. In
the end, what cross-cultural psychiatrists and anthropologists have to tell us
is that all mental illnesses, including depression, P.T.S.D. and even
schizophrenia, can be every bit as influenced by cultural beliefs and
expectations today as hysterical-leg paralysis or the vapors or zar or
any other mental illness ever experienced in the history of human madness. This
does not mean that these illnesses and the pain associated with them are not
real, or that sufferers deliberately shape their symptoms to fit a certain
cultural niche. It means that a mental illness is an illness of the mind and
cannot be understood without understanding the ideas, habits and
predispositions — the idiosyncratic cultural trappings — of the mind that is
its host.
EVEN WHEN THE underlying science is sound and the
intentions altruistic, the export of Western biomedical ideas can have
frustrating and unexpected consequences. For the last 50-odd years, Western
mental-health professionals have been pushing what they call “mental-health
literacy” on the rest of the world. Cultures became more “literate” as they
adopted Western biomedical conceptions of diseases like depression and
schizophrenia. One study published in The International Journal of Mental
Health, for instance, portrayed those who endorsed the statement that “mental
illness is an illness like any other” as having a “knowledgeable, benevolent,
supportive orientation toward the mentally ill.”
Mental
illnesses, it was suggested, should be treated like “brain diseases” over which
the patient has little choice or responsibility. This was promoted both as a
scientific fact and as a social narrative that would reap great benefits. The
logic seemed unassailable: Once people believed that the onset of mental
illnesses did not spring from supernatural forces, character flaws, semen loss
or some other prescientific notion, the sufferer would be protected from blame
and stigma. This idea has been promoted by mental-health providers, drug companies
and patient-advocacy groups like the National Alliance on Mental Illness in the
United States and SANE in Britain. In a sometimes fractious field, everyone
seemed to agree that this modern way of thinking about mental illness would
reduce the social isolation and stigma often experienced by those with mental
illness. Trampling on indigenous prescientific superstitions about the cause of
mental illness seemed a small price to pay to relieve some of the social
suffering of the mentally ill.
But does the
“brain disease” belief actually reduce stigma?
In 1997, Prof.
Sheila Mehta from Auburn University Montgomery in Alabama decided to find out
if the “brain disease” narrative had the intended effect. She suspected that
the biomedical explanation for mental illness might be influencing our
attitudes toward the mentally ill in ways we weren’t conscious of, so she
thought up a clever experiment.
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In her study,
test subjects were led to believe that they were participating in a simple
learning task with a partner who was, unbeknownst to them, a confederate in the
study. Before the experiment started, the partners exchanged some biographical
data, and the confederate informed the test subject that he suffered from a
mental illness.
The confederate
then stated either that the illness occurred because of “the kind of things
that happened to me when I was a kid” or that he had “a disease just like any
other, which affected my biochemistry.” (These were termed the “psychosocial”
explanation and the “disease” explanation respectively.) The experiment then
called for the test subject to teach the confederate a pattern of button
presses. When the confederate pushed the wrong button, the only feedback the
test subject could give was a “barely discernible” to “somewhat painful”
electrical shock.
Analyzing the
data, Mehta found a difference between the group of subjects given the
psychosocial explanation for their partner’s mental-illness history and those
given the brain-disease explanation. Those who believed that their partner
suffered a biochemical “disease like any other” increased the severity of the
shocks at a faster rate than those who believed they were paired with someone
who had a mental disorder caused by an event in the past.
“The results of
the current study suggest that we may actually treat people more harshly when
their problem is described in disease terms,” Mehta wrote. “We say we are being
kind, but our actions suggest otherwise.” The problem, it appears, is that the
biomedical narrative about an illness like schizophrenia carries with it the
subtle assumption that a brain made ill through biomedical or genetic
abnormalities is more thoroughly broken and permanently abnormal than one made
ill though life events. “Viewing those with mental disorders as diseased sets
them apart and may lead to our perceiving them as physically distinct.
Biochemical aberrations make them almost a different species.”
In other words,
the belief that was assumed to decrease stigma actually increased it. Was the
same true outside the lab in the real world?
The question is
important because the Western push for “mental-health literacy” has gained
ground. Studies show that much of the world has steadily adopted this medical
model of mental illness. Although these changes are most extensive in the
United States and Europe, similar shifts have been documented elsewhere. When
asked to name the sources of mental illness, people from a variety of cultures
are increasingly likely to mention “chemical imbalance” or “brain disease” or
“genetic/inherited” factors.
Unfortunately,
at the same time that Western mental-health professionals have been convincing
the world to think and talk about mental illnesses in biomedical terms, we have
been simultaneously losing the war against stigma at home and abroad. Studies
of attitudes in the United States from 1950 to 1996 have shown that the
perception of dangerousness surrounding people with schizophrenia has steadily
increased over this time. Similarly, a study in Germany found that the public’s
desire to maintain distance from those with a diagnosis of schizophrenia
increased from 1990 to 2001.
Researchers hoping
to learn what was causing this rise in stigma found the same surprising
connection that Mehta discovered in her lab. It turns out that those who
adopted biomedical/genetic beliefs about mental disorders were the same people
who wanted less contact with the mentally ill and thought of them as more
dangerous and unpredictable. This unfortunate relationship has popped up in
numerous studies around the world. In a study conducted in Turkey, for example,
those who labeled schizophrenic behavior as akil hastaligi (illness of
the brain or reasoning abilities) were more inclined to assert that
schizophrenics were aggressive and should not live freely in the community than
those who saw the disorder as ruhsal hastagi (a disorder of the
spiritual or inner self). Another study, which looked at populations in
Germany, Russia and Mongolia, found that “irrespective of place . . . endorsing
biological factors as the cause of schizophrenia was associated with a greater
desire for social distance.”
Photo
Credit Alex
Trochut
Even as we have
congratulated ourselves for becoming more “benevolent and supportive” of the
mentally ill, we have steadily backed away from the sufferers themselves. It
appears, in short, that the impact of our worldwide antistigma campaign may have
been the exact opposite of what we intended.
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NOWHERE ARE THE limitations of Western ideas and
treatments more evident than in the case of schizophrenia. Researchers have
long sought to understand what may be the most perplexing finding in the
cross-cultural study of mental illness: people with schizophrenia in developing
countries appear to fare better over time than those living in industrialized
nations.
This was the
startling result of three large international studies carried out by the World
Health Organization over the course of 30 years, starting in the early 1970s.
The research showed that patients outside the United States and Europe had
significantly lower relapse rates — as much as two-thirds lower in one
follow-up study. These findings have been widely discussed and debated in part
because of their obvious incongruity: the regions of the world with the most
resources to devote to the illness — the best technology, the cutting-edge
medicines and the best-financed academic and private-research institutions —
had the most troubled and socially marginalized patients.
Trying to
unravel this mystery, the anthropologist Juli McGruder from the University of
Puget Sound spent years in Zanzibar studying families of schizophrenics. Though
the population is predominantly Muslim, Swahili spirit-possession beliefs are
still prevalent in the archipelago and commonly evoked to explain the actions
of anyone violating social norms — from a sister lashing out at her brother to
someone beset by psychotic delusions.
McGruder found
that far from being stigmatizing, these beliefs served certain useful
functions. The beliefs prescribed a variety of socially accepted interventions
and ministrations that kept the ill person bound to the family and kinship
group. “Muslim and Swahili spirits are not exorcised in the Christian sense of
casting out demons,” McGruder determined. “Rather they are coaxed with food and
goods, feted with song and dance. They are placated, settled, reduced in
malfeasance.” McGruder saw this approach in many small acts of kindness. She
watched family members use saffron paste to write phrases from the Koran on the
rims of drinking bowls so the ill person could literally imbibe the holy words.
The spirit-possession beliefs had other unexpected benefits. Critically, the
story allowed the person with schizophrenia a cleaner bill of health when the
illness went into remission. An ill individual enjoying a time of relative
mental health could, at least temporarily, retake his or her responsibilities
in the kinship group. Since the illness was seen as the work of outside forces,
it was understood as an affliction for the sufferer but not as an identity.
For McGruder,
the point was not that these practices or beliefs were effective in curing
schizophrenia. Rather, she said she believed that they indirectly helped
control the course of the illness. Besides keeping the sick individual in the
social group, the religious beliefs in Zanzibar also allowed for a type of
calmness and acquiescence in the face of the illness that she had rarely
witnessed in the West.
The course of a
metastasizing cancer is unlikely to be changed by how we talk about it. With
schizophrenia, however, symptoms are inevitably entangled in a person’s complex
interactions with those around him or her. In fact, researchers have long
documented how certain emotional reactions from family members correlate with
higher relapse rates for people who have a diagnosis of schizophrenia.
Collectively referred to as “high expressed emotion,” these reactions include
criticism, hostility and emotional overinvolvement (like overprotectiveness or
constant intrusiveness in the patient’s life). In one study, 67 percent of
white American families with a schizophrenic family member were rated as “high
EE.” (Among British families, 48 percent were high EE; among Mexican families
the figure was 41 percent and for Indian families 23 percent.)
Does this high
level of “expressed emotion” in the United States mean that we lack sympathy or
the desire to care for our mentally ill? Quite the opposite. Relatives who were
“high EE” were simply expressing a particularly American view of the self. They
tended to believe that individuals are the captains of their own destiny and
should be able to overcome their problems by force of personal will. Their
critical comments to the mentally ill person didn’t mean that these family
members were cruel or uncaring; they were simply applying the same assumptions
about human nature that they applied to themselves. They were reflecting an
“approach to the world that is active, resourceful and that emphasizes personal
accountability,” Prof. Jill M. Hooley of Harvard University concluded. “Far
from high criticism reflecting something negative about the family members of
patients with schizophrenia, high criticism (and hence high EE) was associated
with a characteristic that is widely regarded as positive.”
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Widely regarded
as positive, that is, in the United States. Many traditional cultures regard
the self in different terms — as inseparable from your role in your kinship
group, intertwined with the story of your ancestry and permeable to the spirit
world. What McGruder found in Zanzibar was that families often drew strength
from this more connected and less isolating idea of human nature. Their ability
to maintain a low level of expressed emotion relied on these beliefs. And that
level of expressed emotion in turn may be key to improving the fortunes of the
schizophrenia sufferer.
Of course, to
the extent that our modern psychopharmacological drugs can relieve suffering,
they should not be denied to the rest of the world. The problem is that our
biomedical advances are hard to separate from our particular cultural beliefs.
It is difficult to distinguish, for example, the biomedical conception of
schizophrenia — the idea that the disease exists within the biochemistry of the
brain — from the more inchoate Western assumption that the self resides there
as well. “Mental illness is feared and has such a stigma because it represents
a reversal of what Western humans . . . have come to value as the essence of
human nature,” McGruder concludes. “Because our culture so highly values . . .
an illusion of self-control and control of circumstance, we become abject when
contemplating mentation that seems more changeable, less restrained and less
controllable, more open to outside influence, than we imagine our own to be.”
CROSS-CULTURAL psychiatrists have pointed out that the
mental-health ideas we export to the world are rarely unadulterated scientific
facts and never culturally neutral. “Western mental-health discourse introduces
core components of Western culture, including a theory of human nature, a
definition of personhood, a sense of time and memory and a source of moral
authority. None of this is universal,” Derek Summerfield of the Institute of
Psychiatry in London observes. He has also written: “The problem is the overall
thrust that comes from being at the heart of the one globalizing culture. It is
as if one version of human nature is being presented as definitive, and one set
of ideas about pain and suffering. . . . There is no one definitive
psychology.”
Behind the
promotion of Western ideas of mental health and healing lie a variety of
cultural assumptions about human nature. Westerners share, for instance,
evolving beliefs about what type of life event is likely to make one
psychologically traumatized, and we agree that venting emotions by talking is more
healthy than stoic silence. We’ve come to agree that the human mind is rather
fragile and that it is best to consider many emotional experiences and mental
states as illnesses that require professional intervention. (The National
Institute of Mental Health reports that a quarter of Americans have diagnosable
mental illnesses each year.) The ideas we export often have at their heart a
particularly American brand of hyperintrospection — a penchant for
“psychologizing” daily existence. These ideas remain deeply influenced by the
Cartesian split between the mind and the body, the Freudian duality between the
conscious and unconscious, as well as the many self-help philosophies and
schools of therapy that have encouraged Americans to separate the health of the
individual from the health of the group. These Western ideas of the mind are
proving as seductive to the rest of the world as fast food and rap music, and
we are spreading them with speed and vigor.
No one would
suggest that we withhold our medical advances from other countries, but it’s
perhaps past time to admit that even our most remarkable scientific leaps in
understanding the brain haven’t yet created the sorts of cultural stories from
which humans take comfort and meaning. When these scientific advances are
translated into popular belief and cultural stories, they are often stripped of
the complexity of the science and become comically insubstantial narratives.
Take for instance this Web site text advertising the antidepressant Paxil: “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 analyzed by generations of theorists and researchers, has now been
reduced to a batter of chemicals we carry around in the mixing bowl of our
skulls.
All cultures
struggle with intractable mental illnesses with varying degrees of compassion
and cruelty, equanimity and fear. Looking at ourselves through the eyes of
those living in places where madness and psychological trauma are still
embedded in complex religious and cultural narratives, however, we get a
glimpse of ourselves as an increasingly insecure and fearful people. Some
philosophers and psychiatrists have suggested that we are investing our great
wealth in researching and treating mental illness — medicalizing ever larger
swaths of human experience — because we have rather suddenly lost older belief
systems that once gave meaning and context to mental suffering.
If our rising
need for mental-health services does indeed spring from a breakdown of meaning,
our insistence that the rest of the world think like us may be all the more
problematic. Offering the latest Western mental-health theories, treatments and
categories in an attempt to ameliorate the psychological stress sparked by
modernization and globalization is not a solution; it may be part of the
problem. When we undermine local conceptions of the self and modes of healing,
we may be speeding along the disorienting changes that are at the very heart of
much of the world’s mental distress.
Correction:
January 24, 2010
A biographical
note for the author of an article on Jan. 10 about the influence of American
ideas on the treatment of mental illness abroad misidentified the publisher of
his new book. Ethan Watters’s ‘‘Crazy Like Us: The Globalization of the
American Psyche’’ was just published by Free Press, not Basic Books. The
article also gave an outdated name for a patient advocacy organization that has
supported a biomedical view of mental illness. It is the National Alliance on Mental
Illness, no longer the National Alliance for the Mentally Ill.
Ethan Watters
lives in San Francisco. This essay is adapted from his book “Crazy Like Us: The
Globalization of the American Psyche,” which will be published later this month
by Free Press.
A version of
this article appears in print on January 10, 2010, on page MM40 of the Sunday
Magazine with the headline: The Americanization of Mental Illness. Today's Paper|Subscribe
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