Mental Illness and Culture

Ethan Watters in China, standing in front of a mural of the American flag
Ethan Watters is the author of Urban Tribes and a frequent contributor to The New York Times Magazine, Discover, Men's Journal, Details, Wired, and PRI's This American Life.

Ethan spoke with Intercultures Magazine about his latest book, Crazy Like Us:The Globalization of the American Psyche, from his home in San Francisco.

One of the key messages in Crazy Like Us is that cultures shape both the description and symptoms of mental illness. How hard is it to convince people of this?

I usually start by citing examples from recent history. In my opinion, it's the easiest way. For example, the rise and fall of the diagnosis of hysteria in Victorian Europe. Most people know just a little about that and they know that it had extremely florid symptoms, including hysterical leg paralysis and all sorts of physiological tics and gross motor dysfunctions. This was not a matter of anyone faking those symptoms but rather that this was the unconscious mind striving to speak the language of suffering for its given moment in history. Suffering, when it comes out in a symptom, is a form of communication. The unconscious mind searches out the expression of the symptoms that would be understood as suffering in that moment in history.

One of the main ideas that informs this book is actually Edward Shorter's idea of the symptom pool; this notion that at different moments in time, symptom pools rise and fall and the unconscious mind is very adept at seeking them out. Because this is unconscious endeavour, it is very difficult to see and to study directly but when you look across history, and then across cultures, you can see that different cultures do have different symptom pools that rise and fall over time.

What is also critical to remember about the symptom pool is that the medical professionals in a given time have a great deal to do with giving status to symptoms in the symptom pool or determining which symptoms are going to be declared valid.

You write in your book "When the mind becomes troubled it looks to cultural cues to decide what is going to happen next."

There is an unconscious level at which the mind seeks out the symptoms and then there are other more overt ways. When describing your distress, you become very adept at picking up the cues from other people as to how they see you and what category they are putting you into. All those things very much shape the expression of mental illness.

So the next trick in getting people to see this argument that I'm making is to convince them that this is indeed still happening in our time. This is especially challenging with mental health providers who can look back at history and say, "Of course you are right about hysteria, or about recovered memory therapy, or about multiple personality disorder," anything in the past. The assumption is now that we have seen how culture can affect us we are actually doing something different; we are doing something more scientific, something that is true for all human beings.

The case I try to make in the book is that no matter how you look at the human mind even if you look purely on a biomedical standpoint that is itself a story about the mind. My hope is not to steer people away from the biomedical research but I don't think we are ever going to understand mental illness as well as we might until we understand this interaction.

When reading the chapter The Rise of Anorexia in Hong Kong, I was surprised to learn that until recently, there were very few cases of anorexia, as it described in the Diagnostic and Statistical Manual of Mental Disorders the DSM. We're talking here of a modern, cosmopolitan city with many western influences.

Hong Kong-based Dr. Sing Lee came back from being trained in Britain and USA in the late 1980's and began to look through hospital records for cases of anorexia and did not, for the most part, find any. It was an extremely rare disorder in China. Of course there is always the argument that we just did not see it before and there is oftentimes validity in that discourse. However, with something like anorexia, it is very difficult to not see a woman who starves herself to death when searching through hospital records. This was a moment in history where all of the triggers were in place; quickly changing roles for women, highly pressured educational settings and rapid modernization. Yet Sing Lee found few cases and those that he did find seemed fundamentally different from the western description. These were slightly older, lower income women with no fat phobia and no body dysmorphia. There was a clear sense among these women that they were underweight and they had many somatic complaints; food would not go down as opposed to intentionally not eating. The few cases of anorexia really seemed to be a kind of different disease and then Charlene Hsu Chi-Ying, an emaciated 14-year-old girl, dropped dead on a busy Hong Kong street in November of 1994. It became a much mediatised thing the press love the "new disorder story" and the experts love to talk to the press. It is often done in such a way that I don't think many experts or journalists have taken the time to stop and think about the consequences of writing these stories. The case I make in the book is that after 1994 and after the press that surrounded this one death in Hong Kong, you saw not only a rise of this disorder but you saw of rise of the western version of the disorder it was affecting a different group and it had different symptoms; it had DSM symptoms.

Regardless of how a disorder becomes "popularized", whether through the media, scientific or academic community, how it is defined and described can determine how people who are truly ill or suffering can label their problem.

As Dr. Sing Lee says, a certain portion of the population has a general loading of psychopathology they are indeed distressed but their distress is frustratingly inchoate, it is coming from a lot of sources. Charlene Hsu Chi-Ying died in 1994; just before the British handover of Hong Kong to China and after Tiananmen Square. Lots of families were broken up through immigration. It was a really nervous time in the population and there is no one way for the human mind to express that generally loading of psychopathology. That is when the unconscious mind sort of begins to sift through the cultural messages at that moment in history and discover the language of suffering such that it can send out the distress signals.

The fact that the symptom pool has changed also means that the local pool, in this case the Chinese pool, is changed forever. Almost like a species that dies off. We have no idea what that means in terms of possible lost treatments or improvements in healthcare, do we?

That is exactly right and that is a key point. This is not only a matter of changing the symptom pool in a population. Because indigenous populations have their own symptom pool, they also have their own set of mechanisms to work with that set of symptoms. For instance, in a culture where depression is displayed largely somatically by muscle aches and stomach pains, there are herbs, acupuncture, massage and all sorts of ways to address that somatic experience. When you go in there and you say it is not that, it is this western thing as described in the DSM, then you often have done two things: you have introduced a new symptom into the symptom pool and you are disconnecting the indigenous population from their own healing mechanisms that can ameliorate that symptom.

Another chapter in Crazy Like Us describes the post-tsunami influx of psychological trauma specialists in Sri Lanka. They are trained on Post Traumatic Stress Disorder treatment and all sorts of other counselling methods. But for the most part, they know nothing of the culture of the people they are trying to help.

It is a remarkable expression of hubris and it is done with the best of intentions. Some people have taken exception to how hard I was on these people because often, it is done with their own money, they are taking time out of their life and going to help others. In my mind, if you are going to a disaster zone, you had better know what you are doing. You better have some value to add because good intentions are not good enough.

As a healthcare worker, your first priority is to do no harm, is it not?

We went in there with everything in the kitchen sink. There were scientologists, thought field therapists, trauma counsellors of all different stripes, many employing Critical Incident Debriefing an American notion that if you get to someone fast after a trauma and you get them to work through their emotions often through retelling their stories individually or in group settings that you are like an emergency medical technician applying a clean dressing to a fresh wound so it would be less likely to form an abscess and to cause problems down the road. In this case, this is not simply an issue of a culture clash. There is actually no solid evidence that this technique works even in America.

Then there is just this notion, one that anthropologists would shake their head at, that we are introducing other cultures to PTSD as if it were a newly discovered disease with this bizarre underlying assumption that other cultures would have no idea that there are psychological consequences to going through horrible events.

Particularly someone from the mid-western United States, for example, who comes to Sri Lanka a country that has lived through decades of civil war.

This is the other assumption: because we have been protected from trauma we are going to be better at dealing with trauma. I think there is very good evidence that cultures that deal with poverty, violence and trauma actually have more resilience and more mechanisms and ways of living through those experiences than we do in the West. One of my favourite quotes in the book and I am not going to quite get it right was from Arthur Kleinman and he said most of the trauma that happens in the world happens outside of the West and yet we come in and we pathologize those reactions; we say you do not know how to deal with this. We do that because we think that what we know about trauma is beyond cultural; that it is science therefore it must be applicable to everyone. Even the briefest look at the history of PTSD would suggest that indeed PTSD is true for our place and time, as Allan Young of McGill University likes to say, but not true for all places and times.

In the specific Sri Lankan context you explain how there are practices whereby people do not speak of violent acts. They use euphemisms, they use all sorts of coping strategies to deal with traumatic events and these methods are completely contrary to what is being prescribed by the western experts.

They have a very good reason to do that because those mechanisms for the social "tapping down" of retelling the stories are meant to avoid incurring the cycles of violence that you have seen elsewhere in the world; revenge vendettas that just spur more violence down the line. So people are told not to talk about it or to use this metaphoric language. You often have the murder victim's family living next to the family of the murderer in these Sri Lanka villages and they manage to live next door to each other for years and years. Then you have western trained trauma counsellors dropping into town saying the way to heal from this is to really get this out in the open, to talk about it, to relive it which is an idea that we find very compelling here in the West. But it is an idea that could be ineffective or could actually cause harm in another cultural context.

Also, the idea of removing oneself from all responsibilities in one's social group and isolating oneself in order to heal would not be the typical coping or healing mechanism.

Sri Lankans would largely describe the damage after an event like the Tsunami not in terms of the damage done to their minds or their psychology but as damage done to their social group or their inability to fulfill their role in the social group. So you are exactly right, the idea of taking time away from my social role to heal from this bad event is actually the very symptom that Sri Lankans are describing as distressful. They are describing their distress over their inability to fulfill their social role.

Let's cross the Indian Ocean from Sri Lanka to Zanzibar, where you write about schizophrenia. Tell me what you were looking to discover there.

The puzzle I was trying to figure out in that chapter was this much-debated World Health Organization (WHO) study that appears to show that schizophrenics in developing countries do better over time than people with schizophrenia in the "first world". Not just a little better they seem to do a lot better on a lot of different outcomes, including remission rates. The interesting thing is that as much as people debated the meaning of that study, no one had really done the thing that the anthropologist Juli McGruder did; go there and sit with the family and try to tease apart the behaviour and the stories that they tell about this disease and see how it actually plays out. Her belief is that in Zanzibar, and this is not true of spirit possession stories everywhere, that the spirit possession story allows the family a lower level of what is called "expressed emotions".

Amena is the head of this family that Juli McGruder met. Her husband, Hamed, and her daughter, Kimwana, suffer from schizophrenia. Amena runs this household that includes between 10 to 20 people at any given time while caring for these two mentally ill people who live there. Yet Amena does this in a very quiet, almost resigned manner.

To Juli McGruder, this lower level of expressed emotions often looked like resignation. It is in fact acceptance of this illness as a burden and it is not necessarily to overcome but just to shoulder. There are good studies elsewhere that show that families with lower levels expressed emotion that is low criticism towards the individual, a lack of intrusiveness into their lives and thought processes tend to be the families where the person with schizophrenia does better over time. There is a connection between low levels of expressed emotions and better outcomes. Juli's theory is that the spirit possession story used in Zanzibar allows the family to hit that calm emotion note that acceptance of the illness. They do not fight it and they are not constantly monitoring the ill person. They are not curing it or fixing it, and something about that emotional level in the household actually helps. At the end of the day, it helps the person with schizophrenia. It does not cure them but it may help them do a little better over time. We know that with schizophrenia, psychotic episodes can be kicked off by moments of stress; social or personal stress and those lower levels of expressed emotion may indeed help people maintain periods of remission longer than they might otherwise.

Part of the culture in Zanzibar is Islam and I'm wondering what role religion plays in terms of how Amena deals with her situation.

Muslim beliefs, as expressed in Zanzibar, is very much that burdens are to be carried and accepted as sort of a continuous act of penance and the burden is the blessing. God gives you a burden to carry and your ability just to carry it not to get over it or to fix it is an expression of religious devotion.

Mega-Marketing of Depression in Japan might be the most controversial chapter in your book. It paints an unflattering portrait of GlaxoSmithKline and of the business side of mental illness.

It is far too simple to say that depression did not exist there in Japan before GlaxoSmithKline. It is much more of a subtle case. Japan has had for a long time now a diagnosis of what is translated as endogenous depression but that was considered extremely severe and a rather rare mental illness. They were much more concerned about dealing with the severely mentally ill patients. When I talked to people who have studied Japan they told me that the country actually has a tremendous embrace of the emotion of sadness. You hear it in the songs and read it in the stories. They often look to sadness as a way to find moral guidance and it is sort of a quasi-religious experience. In a lot of settings in Japan it is a highly prized emotion. In a way, it is something that you are expected to be able achieve.

So GlaxoSmithKline actually went to the cross-cultural psychiatrists; the people who studied cultural differences and how cultural meaning impacts notions of illness. They began to take that community's knowledge about this because they indeed were after this prize which was to move the line between where the normal and the pathological is in Japan. Let's move other experiences of sadness, which have for now in Japan been in other cultural boxes, into the pathological category.

Shift that spectrum just a little bit and you sell a lot of product?

Especially in a culture that is so prone to sadness. If you're in a culture where sadness is a common experience and maybe even sought after, and then you move the line and say this type of sadness or x-amount of sadness is now a mental illness, then you do suddenly have this tremendous market that you did not have before. Every psychiatrist and cross-cultural researcher I talked to when trying to understand what happened in Japan from 2000 into the middle of the decade has said that GlaxoSmithKline were successful in moving that line. They even came up with a slogan that seemed to work which was, "Mental illness is like a cold of the soul".

As in the example of anorexia in Hong Kong, the real tipping point in Japan was a much mediatised case of a young man, Oshima Ichiro, who killed himself seemingly because he was overworked.

I have found that often the cultural tides will change on one prominent case. Oshima's was a high profile death and a high profile court case. Oshima began working at the Dentsu advertising agency at the beginning of that horrible decade of economic downturn and he worked extremely hard no days off, clocking over 100 hours a week for two years. At some point, he basically began to lose his mind and he eventually took his own life. His parents believed that there was a connection between him being overworked and his death so they launched a lawsuit. It got a lot of press because there was a predecessor to this in the 80's which was called 'death from overwork,' where people would die at their desk after working long hours. So the press got hold of the Ichiro story and called it 'suicide from overwork.' The court case and the discussion that happened around it began to connect depression and suicide. For Westerners it would seem bizarre that that connection had not yet been made because we think of them as inextricably linked. However, in Japan there is a storied tradition of suicide for honour, suicide for change, or for all sorts of other reasons. It is largely considered an act of personal will and not an expression of a mental illness or depression.

And there is a very high rate of suicide if I am not mistaken?

Absolutely. So the court case and the ensuing public discussion, which GlaxoSmithKline capitalized on, sort of led to a changing cultural understanding that maybe in Japan they were not paying enough attention to depression; maybe other countries like the US had better ways of dealing with this and Japan was behind the times. Suddenly there was much more interest in this connection between depression and suicide. To give GlaxoSmithKline full credit, there was a downturn in the suicide rate after Paxil was introduced. This does suggest that these interventions and these culture clashes are not only bad but the outcomes are multifaceted and we need to understand them all. There is some evidence that changing the notion of connection between suicide and depression is actually in the end helpful to some people. It may have saved some people's lives.

The research and development of new treatments, whether through better drugs or better therapy, has to a certain extent helped to reduce the stigma of mental illness in a Western context. Based on your research, can the same be said for other non-Western contexts?

Westerners believe that if we get people to think of mental illness as biomedical disease, the stigma will go away. The unfortunate thing is when you study the outcomes and the progression of this idea around the world, you will find that we are indeed winning the rhetorical battle but losing the war on stigma. When people began to adopt this idea of the biomedical cause of mental illness, they then also wanted more distance from the mentally ill. To them it was more dangerous, more unpredictable.

There is something about when this is employed as a social narrative it makes people view the mentally ill person as more permanently damaged or as more deeply broken than they might otherwise see them if they believed in the spirit possession narrative, for example. People tend to see the biomedical explanation as more damaged and therefore it often increases the stigma. This is not true in every case; a lot of people affected with a mental illness told me that when they got that diagnosis, and it could be explained through biochemistry to their family, that narrative saved their lives because they had a reason for it. But this is not true in all cases; when you study it on average you find that indeed the stigma tended to rise, especially with things like schizophrenia, in places where that biomedical belief is becoming prominent. So you have this sort of conundrum of what I think is fundamentally a scientific fact; they do have a biomedical basis to them but the narrative of the biomedical basis does not seem to help people. I think those questions need to be answered in the coming years.

Ethan Watters, thank you for being so generous with your time.

My pleasure.

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