[xmca] NY Times: The Americanization of Mental Illness

["Peter Smagorinsky" <smago@uga.edu>]

The Americanization of Mental Illness 

http://www.nytimes.com/2010/01/10/magazine/10psyche-t.html?em

o 

By ETHAN WATTERS

Published: January 8, 2010 

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. 

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. 

 
<http://www.nytimes.com/2010/01/10/magazine/10psyche-t.html?pagewanted=2&em#
secondParagraph> Skip to next paragraphIn 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." 

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. 

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 for the Mentally Ill 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
<http://topics.nytimes.com/top/reference/timestopics/organizations/a/auburn_
university/index.html?inline=nyt-org> 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. 

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."

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. 

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
<http://topics.nytimes.com/top/reference/timestopics/organizations/w/world_h
ealth_organization/index.html?inline=nyt-org> 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
<http://topics.nytimes.com/top/reference/timestopics/organizations/h/harvard
_university/index.html?inline=nyt-org> 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." 

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
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics
/paxil_drug/index.html?inline=nyt-classifier> 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. 

 

 

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