Crazy Like Us

This book aims to demonstrate how, regrettably, Western conceptions of mental illness have been exported successfully across the globe.

Watters, Ethan. Crazy Like Us: The Globalization of the American Psyche. New York: Free Press, 2010.

“Cultures become vulnerable to new beliefs about the mind and madness during times of social anxiety and discord,” (p. 249) writes Ethan Watters in his book Crazy Like Us: The Globalization of the American Psyche. Watters sees social anxiety and discord as making cultures “vulnerable” to new beliefs about mental illness rather than simply receptive to them. Specifically, he looks at the ways the West, and particularly the United States, have been exporting their understandings of the diagnosis, symptoms, and meanings of mental illness around the world. In doing so, we have failed to see that individual cultures have ways of dealing with mental illness that are local and specific and in some cases, more effective than ours. At the same time, in promoting our ideas of mental illness, we may even be causing harm.

Crazy Like Us is a thought-provoking, well-written, and challenging non-academic book that attempts to draw more attention towards global mental health concerns and the impact that our own cultural understanding of the mind and the self is having around the world. The book is personal and human and each chapter provides a look into the lives of individuals and their families who suffer from mental illness as well as those who are tasked to treat them. The patients and professionals portrayed in the book are poignantly described and the material presented is informative and detailed. The book is divided into four main chapters. Each of these focuses on a country and a particular mental illness and describes how local understandings of the mental illness have been modified as a direct result of the exportation and adoption of our predominantly biomedical paradigm of mental health. Watters defines this paradigm in the concluding chapter:

The ideas that 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 the 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 investigates. (p. 254)

In Chapter One, “The Rise of Anorexia in Hong Kong,” Watters explores the history of anorexia in China and finds that, prior to the 1990s, the disease was relatively rare, with just 10 reported cases in psychiatric journals between 1983 and 1988. Those who did have anorexia prior to the 1990s had a different symptomology than those in the West. Notably missing in Chinese accounts were the fear of gaining weight and the body dysmorphia which characterize the disorder in the DSM. In fact, on the contrary, Chinese girls had an accurate body image of themselves and they often attributed their lack of eating to somatic symptoms such as abdominal pain. Watters describes the research of Dr. Sing Lee, the leading expert on eating disorders in China. In the rare cases he studied, it appeared as though he had found a rare form of mental illness that was unique to China, which resembled anorexia, but was itself a distinct disease entity. Similar to R. D. Laing, Dr. Lee believed that the only hope of finding a cure for this mental disorder was in developing a deep understanding of each patient’s subjective experience. In the 1990s, however, things began to change and the incidence of eating disorders in Hong Kong began to rise. What has often been attributed to this increase has been the belief that Western body ideals were influencing adolescent girls through popular culture. But this was not the case. Instead the rising rates of anorexia in Hong Kong were due to the imported Western template for the disease. As Western views of anorexia took hold in Hong Kong, the disease presentation among women began to change. Watters writes: “Amid all the finger-pointing at fad diets and the influence of Western fashion and pop culture, few considered the possibility that the idea of anorexia nervosa itself—prepackaged in its DSM diagnosis and explained by readily available Western experts—might have been part of the reason the disorder caught on so quickly in Hong Kong” (pp. 48-49). In other words, the incidence of anorexia increased in Hong Kong when the media and the psychiatric community adopted the American conception of the disease. Watters believes that the new public discourse on anorexia contributed to its incidence as Chinese girls unconsciously mimicked the behavior of the disorder in order to call attention to their private distresses.

In Chapter Two, “The Wave That Brought PTSD to Sri Lanka,” the export of Western conceptions of mental illness occurred on a much wider and more dramatic scale. In December 2004, a tsunami struck Sri Lanka and caused the death of over a quarter of a million people. As a result, Western therapists and traumatologists flocked to the country, convinced that PTSD cases were about to rise exponentially. Watters describes scores of mental health workers arriving in Sri Lanka to conduct “Critical Incident Debriefing,” to train local people in identifying PTSD, and to encourage those who had survived the horrors of the tsunami to “open up” about their experience in order to properly heal. Once in Sri Lanka, Western counselors and traumatologists used PTSD checklists that were developed from the DSM and neglected to take into account culturally distinct reactions to traumatic events and culturally specific modes of healing. Through his research, Dr. Gaithri Fernando, an assistant professor at UCLA, found that Sri Lankans’ experience of trauma differed from that of Americans in two important ways. First, Sri Lankans felt more physical pain after experiencing a trauma and reacted to disaster “as if they had experienced a physical blow to their body” (p. 91). Second, Sri Lankans did not report pathological internal states of suffering such as anxiety, fear, numbing, and the like. Instead, they reacted to trauma in terms of the damage it did to their social relationships. Thus, they conceived of the damage done by the tsunami as occurring not inside their mind but outside their self. This led Watters to conclude that there is not a human universal when it comes to reactions to trauma and the process through which damage to the psyche becomes an outward symptom is a reflection of cultural beliefs in a particular time and place. Therefore, the only way for Western mental health professionals to be effective in their aid is for them to recognize the local idioms of distress—the particular ways psychological trauma is understood, experienced, and expressed in specific cultural contexts.

In Chapter Three, “The Shifting Mask of Schizophrenia in Zanzibar,” Watters focuses on anthropologist Juli McGruder and her ethnographic study of schizophrenia in Zanzibar. Her interest originated from two World Health Organization studies that showed that individuals diagnosed with schizophrenia in developing countries fared better in their long-term prognosis than those in the industrialized developed world. However, recent research indicates that this generalization may be too simplistic. McGruder thought that what was missing on studies of schizophrenia was an on-the-ground examination of the ways that patients in the developing world were treated by their family members. Again, like R. D. Laing, McGruder wanted to get at what the experience of madness felt like for those suffering from it or around it. In Zanzibar, she found that family members of an afflicted person took a relaxed and non-judgmental view towards schizophrenia. In her research, she found that family members rarely pressured sufferers to engage in “normal” behaviors. Importantly and in contrast to the American view, family members did not assume a cause and effect relationship between productivity and wellness. Although the family saw the sufferer’s productivity as a sign of health, they did not pressure her to continue to be productive with the assumption that it would be curative. Watters demonstrates the direct connection between what is called high expressed emotion and poorer outcomes for schizophrenia. Expressed emotion (EE) is a measure of the family environment that is based on how relatives of a psychiatric patient spontaneously talk about that patient. Family members with high expressed emotion are thought to be hostile, critical, and judgmental of the patient and this experience tends to parallel the experience of schizophrenia itself. In other words, it is not merely coincidence “that one of the central symptoms of schizophrenia is hearing demanding, critical, or disparaging voices” (p. 153). Patients who live in high-emotion households experience higher relapse rates across cultures. McGruder found that religion is one factor that is responsible in keeping a low-emotion household. The belief in spirit possessions is another factor. According to local culture, spirit possession is not seen as something uncommon or even an extreme experience. The application of this belief to schizophrenia actually has the effect of lessening the stigma attached to the disease because “it [makes] bizarre or disruptive behavior more understandable and forgivable” (p. 157). The point that McGruder and Watters are both trying to make in this chapter is that a culture provides its members with a variety of affective and behavioral responses to mental illness. Watters writes, “Because different cultures around the world view mental illness in different cultural contexts, the intensity of emotions attached to these experiences often varies” (p. 160). However, Western psychiatrists and mental health professionals have promoted the biomedical model of schizophrenia around the world. “Mental health literacy” was coined by the West to describe the set of ideas that Western mental health professionals have promoted around the world. Populations that adopt Western ideas are considered more “literate” than those that do not.

In Chapter Four, “The Mega-Marketing of Depression in Japan,” a more sobering and disturbing picture is presented. This chapter catalogues the rise in depression in Japan in the 1990s. Watters argues that this increase resulted from the intentional and deliberate actions of GlaxoSmithKline, the producers of Paxil, seeking to introduce the billion dollar industry of SSRIs to Japan by importing new conceptions of sadness and depression from the West. Previously, the incidence of depression in Japan was low and some of the symptoms of depression—sadness, grief, and melancholy—were seen as a natural part of human life and even a source of strong moral character. Japanese psychiatry did acknowledge a rare and severe form of depression which often required long-term institutionalization, but the everyday variety of depression that was standard in the United States was not present in Japan. However, social upheaval and anxiety made individuals “vulnerable” to new beliefs about depression. At the end of the twentieth century, the country was in economic crisis. Bankruptcies were common as were divorce and unemployment. Then came the devastating earthquake in the city of Kobe in January 1995. With this disaster came an influx of Western mental health “experts” who claimed that the population needed not only basic food and shelter but also psychological intervention. A critical turning point came when Peter Kramer’s bestselling book, Listening to Prozac, was produced as a special on the nation’s largest television network. Millions watched and praised the program. Japanese psychiatrists were taken by surprise at the interest in depression due to the fact that up until that point the public had pretty much eschewed the intrusion of psychiatry into their daily lives and like many people in the country, these psychiatrists did not consider unhappiness to be a mental illness. This is where multinational pharmaceutical companies came in to lend a helping hand in creating depression in Japan. The major problem GlaxoSmithKline faced was that Japanese psychiatrists and mental health professionals still translated the diagnosis of “depression” as utsubyô, which retained its association with an incurable and psychotic form of depression. In the hopes of softening the connotations of the word, marketers used the metaphor of kokoro no kaze, a “cold of the soul.” The image of depression that was marketed to Japan was left deliberately vague so as to encompass the widest possible population and the widest possible range of discomforts. The metaphor of a cold suggested that taking medication for depression was as simple as buying a cough syrup. It also suggested that, like common colds, depression was ubiquitous. What followed was an advertising campaign that featured “ask-your-doctor” commercials about new medications and symptom checklists for depression. To garner even more media attention for depression, the drug companies leveraged the population’s growing concern over high suicide rates. The advertising and public service announcements were a success. There was also the belief that the United States represented the pinnacle of scientific research and moral authority on mental illness. However, there was widespread corruption in scientific studies that were purported to have been conducted by independent academic scholars but were actually being ghostwritten by the drug companies. There was also the problem of drug companies touting depression as an imbalance of serotonin in the brain, a claim that has no current scientific consensus. Additionally, scientific research was finding evidence that Paxil’s effectiveness in treating depression was flimsy, incomplete, and inconclusive. These findings were not publicized and the side effects, ranging from nervous system problems to increased rates of suicide in adolescents, were downplayed and underreported.

The Western biomedical model of mental illness is important and a familiar one. Watters cites key research from the field of cross-cultural psychiatry to suggest that the biomedical paradigm of mental illness only compromises a narrow view of the psychological life of individuals. Our conceptions of mental illness are reflective of our values and these vary from culture to culture. Watters presents good evidence for why we should question the biomedical view and its supposed universalism. At the same time, it’s worth considering that as we have exported the American psyche to the world, it is possible that in some instances we have also managed to export treatments that have drastically improved the lives of people. On the one hand, if a person does not feel as though she is suffering from a mental illness, then chances are she is probably not and there seems to be something inherently wrong about persuading a person otherwise. In this book, Watters argues that many people of Hong Kong, Sri Lanka, Zanzibar, and Japan are better off without us and he very well may be right. However, we cannot rule out the possibility that the biomedical model of mental illness could be beneficial to people in these and other countries.