STATS ARTICLES 2010
Americanizing the global mind?
Andrew Rasmussen, Ph.D, March 15, 2010
Are we doing more harm than good by exporting our diagnoses and remedies for mental illnesses? A new book – Crazy Like Us: The Globalization of the American Psyche – sets the agenda for a vital public discussion.
The last few years in American mental health have been marked by a brutal public flogging. Revelations in 2008 and 2009 that drug research at Harvard and the University of Texas was tainted by millions of dollars in drug company undisclosed payments to the researchers (which were subsequently condemned on the floor of Congress by Senator Chuck Grassley) was followed by high profile media coverage of problems with the practice of psychotherapy.
In October 2009, findings from an article in the journal Psychological Science in the Public Interest, which chronicled how psychotherapists are notoriously ignorant of clinical advances in their field, were reported by Newsweek’s Sharon Begley in a stinging criticism of the profession. In January of this year, a review in the Journal of the American Medical Association (JAMA) of the research on depression medication argued that studies suggesting that drugs are not effective result from unnecessary prescription. In other words, for the minority who are clinically depressed, medication is a godsend, but for the majority who receive it – people who are just sad – it doesn’t do much.
Citing this and other research, Judith Warner called the entire field into question in the New York Times:
“This is the big picture of mental health care in America: not perfectly healthy people popping pills for no reason, but people with real illnesses lacking access to care; facing barriers like ignorance, stigma and high prices; or findings care that is ineffective.”
Now, this criticism has gone global with Crazy Like Us: The Globalization of the American Psyche, by journalist Ethan Watters, a book that takes aim at “the grand project of Americanizing the world’s understanding of the human mind.”
This is not Watters’ first foray into mental health critique, as he is the co-author of two books with UC Berkeley social psychologist Richard Ofshe, Making Monsters (1996), an indictment of the repressed memory phenomenon of the 1980s and ‘90s, and, perhaps more relevant to his current book, Therapy’s Delusions (1999), a scathing assessment of the psychoanalytic (i.e., Freudian) school of psychotherapy. Both books were somewhat successful, received mixed reviews (the former more praise than the latter), and were largely ignored by the academic world.
But those of us who work in the small corner of mental health research that examines the differences in diagnoses and symptoms between cultures are somewhat surprised by Crazy Like Us; our field, generally, remains well hidden in the crease between psychology and anthropology. That our first popular treatment should be a highly critical survey of this field of mental health is doubly shocking.
Watters’ central thesis goes something like this: by expanding their realm through the forces of globalization, American mental health professionals are harming other societies by introducing Western symptoms into the way people in other cultures express their distress and replacing the local explanations for mental health problems with Western scientific models. He begins by introducing readers to a fact that many of us who study mental health globally know well: the expression of and explanation for mental illness depend in part upon the culture in which the individuals afflicted reside. In the language of the field, they are “culturally-mediated.”
Watters provides several good examples of this in Crazy Like Us , but the clearest articulation comes from McGill Unversity Professor, and Editor of Transcultural Psychiatry, Laurence Kirmayer who is interviewed at length. Kirmayer explains that most cultures have an experience of isolation and decreased motivation that we, in the United States, typically, would call depression. In India this might be characterized by a feeling that the heart is physically descending in the body, in Nigeria by reports of a peppery feeling in the head, and in Korea by “‘fire illness’… a burning in the gut.”
Readers interested in hearing a compendium of foreign mental illnesses will not be disappointed. Most of these have analogs in the West (as with depression), but others do not. The most infamous of these is koro of Southeast Asia, or the sudden feeling that one’s penis is decreasing in size or disappearing altogether. If this sounds amusingly off-beat, an outbreak of a similar condition in the 1990s in a number of West African countries resulted in mobs beating and killing several women suspected of witchcraft. These psychological phenomena are real in that they have real behavioral consequences.
These “indigenous” disorders are being displaced by Western concepts primarily, Watters claims, by unwitting journalists in the developing world who defer to Western experts and by adventurous Western mental health professionals out to do good. Westerners introduce ideas of how mental health problems should be expressed – or, more accurately, how they are expressed in Western culture – and sufferers hear about these and mimic them.
Watters credits his hypothesis to the psychiatric historian Edward Shorter, who argued that how mental disorders are expressed changes throughout history as the theories proposed to explain them are popularized. Hysteria in Freud’s day, for example, involved psychogenic paralysis because some young woman in the late 1800s developed the symptom which was then reported by a doctor as a sign of distress, and pretty soon most of the Viennese female upper crust had an arm or leg vüllig paralysiert. Such paralysis is not much of a problem among Viennese womanhood anymore because it fell out of the “symptom pool” after enough people discovered it wasn’t “real” in an organic sense. Watters takes this historical analysis and applies it cross-culturally.
Each chapter of Crazy Like Us is built around a central researcher in cross-cultural mental health, one of “psychology’s version of botanists in the rainforest, desperate to document the diversity while staying only a few steps ahead of the bulldozers.” These guides are joined in the narrative by mainstream American practitioners trying to justify their actions, and real people suffering from the disorders in question. The stories of the afflicted and their families are often moving, and thankfully devoid of the kind of patronizing “victim narratives” so prevalent in discussion of the communities subject to American cultural hegemony. The disorders afflicted upon non-Western cultures are anorexia in Hong Kong, posttraumatic stress disorder in post-tsunami Sri Lanka, schizophrenia in Zanzibar, and depression in Japan.
Watters is a skilled storyteller: A Zanzibari family’s tender care for two schizophrenic members is used to make a powerful argument that seeing the disorder in spiritual terms and not biomedical terms creates a more humane environment for care. Although this is beautifully told, it is the chronicle of “the largest international psychological intervention of all time” in post-tsunami Sri Lanka that gets my money. I should disclose that I know and like the researcher at the heart of this story, Dr. Gaithri Fernando.
In “The Wave That Brought PTSD to Sri Lanka,” the buffoonish acts of Western psychologists as told by Watters are both hilarious and infuriating: Thousands of volunteer therapists arrive in the immediate aftermath of the disaster to stay for two weeks to provide “psychosocial programming,” which turns out to consist of drawing pictures with children and leading week-long trainings that are supposed to produce a legion of skilled trauma counselors. These Western volunteers have virtually no knowledge whatsoever of the Sri Lankan cultures they encounter, let alone the local concepts of mental health and suffering.
They arrive with the certainty that Sri Lankans will suffer a PTSD epidemic, and they get to work doing, well, something. But something is not always better than nothing, particularly when such health tourists are involved. When asked by Watters about the value of coming for such a short period of time, one of these volunteers responds with, “So much of it is showing up.” Having witnessed psychosocial programming in disaster settings first hand, I can confirm that such efforts are often poorly planned and executed, and that this attitude is common. But surrounded by devastation, one wishes mental health practitioners would “show up” with something more obviously useful—a hammer and some nails, perhaps. In the weeks following the January 12, 2010 earthquake in Haiti, I received multiple emails in my inbox about proposals to provide disaster therapy to survivors. There will undoubtedly be Haitians who will need psychological help in the next year or so, but let’s get them into houses before we put them on the couch.
Watters also recounts a more insidious imposition of American mental health than bumbling Westerners who really just want to help. In 1990’s Japan, GlaxoSmithKline worked to create the idea of a subclinical depression in order to market antidepressants. It is well documented (e.g., in corporate memos from Eli Lilly) that prior to the 1990’s, Western pharmaceutical companies felt that Japanese conceptions of depression were too severe to warrant mass-marketing campaigns. The Japanese concept of depression (utsubyô) did not include normal sadness arising from long hours and abuse by bosses, but was limited to that small proportion of the population that were chemically imbalanced and needed inpatient care. Watters makes a persuasive argument that GlaxoSmithKline used notions from cross-cultural psychology to create a marketing strategy for the idea that being sad was a real mental problem – and thus warranted medication. This in turn expanded Japanese notions of depression.
In making his case Watters interviews Osamu Tajima and Junko Kitanaka, Japanese experts in depression, as well as Kitanaka’s mentor, the aforementioned Laurence Kirmayer. Tajima and Kirmayer were contracted by GlaxoSmithKline to educate them on cross-cultural perspectives. In Crazy Like Us, both are frank that they were duped by their former sponsors in this undertaking. Kirmayer remains a vocal opponent of the practices of international pharmaceutical companies.
While well sourced and engaging, Crazy Like Us, surprisingly, does not always provide a clear social critique. In his acknowledgements, Watters thanks those who helped him with “finding my way out of the conceptual labyrinths that these long chapters sometimes created” but I don’t think Watters ever really finds his way out.
Throughout the book Watters confuses the clash between American and indigenous conceptions of mental health with the importation of bad American mental health practices of the sort exposed in the last couple of years. Although Watters clearly wants to make the case for the first of these two problems, his evidence really points to the second. To argue against the counseling efforts of therapists in the Sri Lanka, he cites the now well-known literature on Critical Incident Stress Debriefing that shows that asking people to “process” a traumatic event shortly after the event may actually increase the likelihood that they develop PTSD. With regards to GlaxoSmithKline’s conquest of the sadness of Japanese salarimen, Watters cites the “junk science” practices of industry-sponsored research and keeping null findings on antidepressants’ effectiveness out of the scientific literature. These are disorders that afflict American mental health on its own terms, and that we are exporting these bad practices is the real story of Crazy Like Us.
Despite Watters’ bleak conclusions, there has been some pushback to these forces. The nascent global mental health movement, led by such luminaries as Dr. Vikram Patel, aims to do for mental health what HIV/AIDS activists did for sufferers of that affliction through advocating for local, low cost solutions to addressing depression and anxiety. Global mental health integrates cross-cultural psychology, public health, and human rights, and is based on the promise that mental disorders have underlying universal neurological structures but their symptoms and explanations vary in important ways across cultures. Patel argues that the way to ensure that symptoms and explanatory models are not bulldozered by globalization – and more importantly that effective indigenous models of treatment are not dismantled – is to relocate mental health research and care to local communities.
The job of Western mental health professionals can thus be seen as a sort of technology transfer of the tools of research and service development to local health systems. Patel has shown that this is feasible using community health workers in Goa, India, and his model has been taken up around the world.
After 250 pages of at times brutal critique, Watters is oddly ambivalent as to whether or not American psychiatry’s conquest of the world will necessarily result in replacing something valuable with something less valuable. In the conclusion, he mentions that his wife, a psychiatrist, is concerned that his book might unfairly disparage mental health workers. He responds (rather tepidly) that his “point is not that [other cultures] necessarily have it right—only that they have it different.”
Perhaps Watters has reasons other than his wife’s career to be ambivalent about his stance. Although the examples he provides us uniformly support the central thesis that useful traditions are being lost, he may well be aware of several places in the world where the traditional treatments for individuals suffering from psychotic episodes include chaining them to poles in the ground and, for some, severe beatings. Leaving these practices untouched avoids a central dilemma in global mental health: How do we integrate a respect for the human rights of the mentally disordered with a respect for indigenous solutions that may conflict with those rights?
So what are we to make of American mental health’s “flattening of the landscape of the human psyche itself?” Crazy Like Us is primarily descriptive, leaving us with little to do with Watters’ thesis but stay home. Perhaps this is the right idea, perhaps not. At the very least we have Watters’ cautionary tales to show what can happen when we take our particular forms of insanity on the road.
Andrew Rasmussen, PhD is an Assistant Professor at New York University’s School of Medicine and the Research Director at the Bellevue/NYU Program for Survivors of Torture. http://andyrasmussen.wordpress.com/