Sunday, January 31, 2010

Is Mental Illness an American Disease?

An article by author Ethan Watters in the Jan 8 NY Times Magazine throws down the gauntlet:

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. ...

The article, "The Americanization of Mental Illness," is an adaptation from the just-released book, ‘‘Crazy Like Us: The Globalization of the American Psyche.” In the article, Mr Watters uses the example of a “culturally specific” form of anorexia documented by one researcher in Hong Kong during the 80s and 90s. Unlike Americans with anorexia, those in Hong Kong simply complained of bloated stomachs without dieting or expressing fear of becoming fat. The illness was rare.

Then, in 1994, in the wake of the death of a school girl, the local press attempted to explain the phenomenon using American diagnostic language. According to Watters, “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.” Not surprisingly, there was an outbreak of “fat phobia.”

Says Watters:

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 the illness or the pain is not real, Watters is quick to add. But an illness of the mind needs to be understood in its cultural context. Ironically, says Watters, the western notion (promoted by advocacy groups such as NAMI) that mental illness is a no-fault “brain disease” may have the opposite effect of increasing rather than reducing stigma. According to Watters, citing the research of Sheila Mehta of Auburn University:

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.

The author cites a four-decades study that found a steady rise in the American public in their perceptions of schizophrenia as dangerous. Meanwhile, in Turkey, according to a study, “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).”

Most of us are aware of three WHO studies over the course of 30 years (starting in the 70s) that found that patients outside the US and Europe had significantly lower relapse rates (as much as two-thirds lower in one follow-up). Watters reports on anthropologist Juli McGruder from the University of Puget Sound who spent years in Zanzibar studying families of those with schizophrenia. There Muslim and spirit possession beliefs are incorporated into healing practices. Rather than spirits being “cast out,” they are “coaxed out” with acts of kindness.

Says Watters: “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.”

The author adds:

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.

This negativity is referred to by experts as “high expressed emotion (high EE),” which include criticism, hostility and emotional overinvolvement (such as overprotectiveness). White American families caring for a family member with schizophrenia have notoriously high EE rates, with much lower EE rates among Mexican and other families.

It’s not that American families are unenlightened, says Watters. Rather, they “were simply expressing a particularly American view of the self,” and “applying the same assumptions about human nature that they applied to themselves.”

No one is seriously talking about withholding meds and other western treatments and therapies from individuals in need. But we do need to be mindful, says Watters, that even our best science is far from culturally neutral. Thus:

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.

Something to think about ...


wildflowersandweeds said...

Something to think about indeed. Isn't this a case of nature and nurture. Environment as well as genetics. Awareness does bring about dialouge, thus least I thought that's how it was supposed to work?!

I don't really get it. So America is penalized, if not having fingers pointed at for having heightened or excacerbated mental illnesses. We have freedom of speech and albeit Hollywood that creates drama, but I don't buy that we make up mental illness.

John McManamy said...

Hi, Wildflowersandweeds. You have to forgive me for my "straight" reporting here. I was trying to be faithful to Watters' account without my own views getting in the way. I was strongly tempted to provide some context, but then it would have been a piece about how I saw the dots connected rather than how Watters saw them.

So thanks for giving me the opportunity to put this in some kind of context. Here goes:

You are right on the money when you say it isn't a case of nature and nurture. All the brain scientists are saying it's both. That it's genes AND environment. It's not either-or.

So, if we are ill because of past trauma or present stress it is all being mediated through the brain. Some brains are better equipped to react to whatever life happens to throw their way than others. There are a lot of convincing studies on that show that people with certain gene variations, for instance, are more vulnerable to stress-induced depression.

Perhaps Watters goes into this in his book.

Certainly Watters makes a convincing argument when he focuses on the cultural context of mental illness. And he has a wealth of expert opinion to back him up. As I see it, this breaks down into at least five talking points:

1. Our western society with its high expectations and demands is a virtual breeding ground for mental illness. Stress is going to trigger all manner of ills.

2. In western society, behavior that doesn't conform to the norm is going to be noticed. A severely depressed individual, for instance, is not going to last long in a job that requires interacting with the public or performing complicated tasks. This same depressed individual, by contrast, may have gone unnoticed tending cows in a pastoral society.

3. We all have different ways of looking at the same phenomenon. We see schizophrenia as a "brain disease," which indeed it is - no question about it. But a more naive view that doesn't see the individual as broken may better enlist family and community support.

4. Supportive families are definitely associated with better outcomes, and there is good evidence that other cultures bring their strengths to the table in this regard.

5. Mental illness is indeed a disease of the brain, with environment as a component. This has major implications for treatment. Do you fix the brain with medications? Or do you fix the environment by changing the environment (such as finding new friends who don't do drugs) or helping the individual cope with his environment (such as through cognitive behavioral therapy)? Often, it's doing both. But in our society, the emphasis is on medications to fix the brain, while often forgetting what needs to be done to improve that person's environment.

We certainly don't make up mental illness. I don't think Watters was saying that. But I do think we are living in a society that often sets our brains up to fail, then assigns fault when our brains do fail.

I don't claim to have the answers here, which is why we need to be asking questions. Which is why I'm extremely grateful for your questions, which you can be sure are on the minds of everyone who read this piece.

We're never going to hit upon "the truth," but we can certainly acquire more insights, and the way to do this is keep asking questions. So please keep asking. :)

Elizabeth said...

Watters’ article in The NYTimes had me rushing out to buy his book. It’s a welcome sign that the pendulum may be shifting a bit away from what I see as an overemphasis on psychotropics, and came at a serendipitous time in my life. This last year I’ve been trying to create a better culture for myself—a healthier, more accepting way of thinking about my disorder. And I had just gotten a good dose of high EE from my mother that I was trying to digest.

Earlier last year I’d decided that I was going to celebrate Christmas day with my friends and daughter and skip going to my mother’s, where I have to face sisters with whom I’ve faced considerable tension with over the years—particularly the one who feels free to scream that I’m crazy and insane whenever I say something she disagrees with. (I can deal with the one who tried to give me an exorcism in the garage one Christmas when she was drunk, but not her pederast-turned-evangelical—I won’t go on, but let’s suffice it to say that I’m not the only one in the family with a screw or two loose.) Christmas, all too often, is a breakdown time for me, so I decided to adjust my life accordingly. I told my mother that my daughter and I would celebrate Christmas with her on Christmas Eve, and had assumed that would be fine with everybody. I mean, I’m not exactly on my sisters’ speed dials. I explained to my mother that stress can trigger an episode, that I had tried and failed to bridge differences with my sisters over the years, and that this would be the best for all. What followed was not at all what I expected.

My mother was extremely hurt and angry. She told me to grow up, that everyone experiences stress and I just have to learn to deal with it. And while we’re at it, what am I doing only making $25,000 a year when I could get a better job? Plenty of people have jobs that are stressful, jobs they hate, but that’s just life. And I’ve been using my disorder as an excuse. There it was, the old “suck it up and pull yourself up by your bootstraps” advice.

Watters helped me see why my mother thinks such things. The old protestant work ethic that is so much a part of American life tells her that I just don’t exercise my will enough. And her religion tells her that people get what they deserve. After all, she endorses Pat Robertson’s view that Haiti suffers disasters because they made a deal with the devil. Along those lines, the family agrees that if I’d just “get saved” and accept that Robertson and his ilk have it right, these ups and downs would vanish.

High EE can easily turn into high EEK for someone suffering from mental illness. This puts many of us in a tight spot, because when we are cast into unemployment due to our disorders, turning to family for help can turn out to be the worst solution. Yet for many in America, family is the only safety net around. It’s a catch-22, but one made more bearable if we can reach some understanding and peace with the fact that under some systems of thought, mental illness is an incomprehensible evil or just an excuse for laziness and a weak will. Or, as in the case with my family, both. I can’t change my family’s thinking, but recognizing it for what it is takes some of the sting out.

John McManamy said...

High, Elizabeth. I hear you loud and clear, and I'm so glad that reading Watters has helped you understand what's going on family-wise and that this understanding is helping you cope.

Good family support equates with better outcomes, and the reverse is also true, so don't be afraid to stick to your guns and keep your family a long distance away.

Realizing the truth can be a profoundly healing experience, and it sounds like this is happening for you. Thank you very much for sharing this with us.