Thursday, January 14, 2010

The Americanization of Mental Illness

Now this was an interesting synopsis in the New York Times of an upcoming book "Crazy Like Us: The Globalization of the American Psyche,”  by Ethan Watters, and which will be published later this month by Free Press.

In a way it reminds me of two books I treasure, The Tao of Physics by Fritjof CAPRA and Voltaire's Bastards: The Dictatorship of Reason in The West  by Canadian John RALSTON-SAUL.  Both looked the revolution of western scientific discourse and challenged it's massive hubris.  The Tao of Physics addresses the western modus operandi of rational philosophy as mirroring the development of scientific thought, an analytical style that basically treats everything as the sum of its parts and decomposes compound structures into elemental sub-atomic particles.  This is contrasted to Oriental or Chinese philosophy which stresses the integrative completeness of opposites - the Ying+Yang - basically in which the whole is more than merely the sum of it's parts.  The assertion made is that Western approaches deconstruct issues and problems down into their microscopic elements, but end up "missing the forest for the trees".  Similarly, Voltaire's Bastards traces the revolution of The Age of Reason as the Decline of Cohesion. Massive social and economic problems are approached with a ruthless rationality that ends up defining the answer - without solving the problem.  This "intellectual entropy" overwhelms our technocrats every time (witness the recent "Panty bomber" security incident on Xmas Eve).

The basic thesis in "Crazy like Us" is that research has amassed an impressive body of evidence suggesting that mental illnesses may 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.  Americans have for many years been busily engaged in a grand project of Westerning the world’s understanding of mental health and illness.  It may indeed be far along in homogenizing the way the world goes mad.

"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.”

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.
Finally, an explanation for Global Feminism!

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.

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.
So 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.
Mental illnesses, it was suggested, should be treated like “brain diseases” over which the patient has little choice or responsibility. This modern way of thinking about mental illness would reduce the social isolation and stigma often experienced by those with mental illness. But does it?
"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. In other words, the belief that was assumed to decrease stigma actually increased it."
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. 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.”
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 [less developed 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. The spirit-possession beliefs had other unexpected benefits. 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. 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 (EE),” 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.)
What accounts for Americans (or for that matter other Western cultures) high "EE"?

“High EE” reflects a particularly American view of the self. This tends to believe that individuals are the captains of their own destiny and should be able to overcome their problems by force of personal will. "Critical" comments to a mentally ill person doesn'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.”

But 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.
“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.
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 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.
Here is an ad from anti-depressant 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. 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.

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