Wednesday, October 6, 2010

Rerun- Is Mental Illness an American Disease?

This from late January ...

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 ...


Robin said...

I missed this the first time around - glad I caught it this time. I've often wondered how the rest of the world views (and deals with) mental illness. We seem to be at the top of the pack for obesity, heart disease, diabetes, etc. What it is about our culture that leads to all these illnesses? Complacency perhaps?

Gina Pera said...

interesting column, John.

Ethan makes some good points, but like anyone with a "message," he often carries it too far.

Robin asks...what is it about our culture? One possibility: It has always attracted people who are unhappy where they are. ;-)

John McManamy said...

Hey, Robin. Stress is the big common denominator in all the ills you mentioned. In some cases, it may be the cause, but in all cases it makes it worse. There are way too many pressures in modern life, and the things we do to relieve the stress (such as eating junk food) tend to make things worse. The complacency you mentioned fits right in. We try not to think about the consequences.

John McManamy said...

Hey, Gina. Yep, he does carry it too far. I was looking for more nuances to his article, but there were very few. But at least his views weren't in flagrant violation of the facts. You and I have come across way too much of that. :)

Ethan said...

So pleased to see this column on my NYT piece and the responses. As to the criticism I carried it to far all I can say is that it was very difficult to fit the ideas in the book into that shorter form. Some hairs that needed slitting went unsplit so to speak. I don't mean to make this a blatant sales pitch for the book but I would hope you'd find it appropriate nuanced to the subject matter. Thanks again for your thoughts.

Tony said...

Robin Says: "What is it about our culture that leads to all these illnesses?"

As John points out modern life brings about all kinds of stress, and that most certainly has a lot to with cause.

But what perpetuates it? What stands in the way of real recovery?

In my experience of being exposed to lots of different cultures, one thing that stands out to me as something "American" is the issue of accountability.

We've seemingly lost that somewhere. Nothing is anybodies fault. Why does fault even enter the equation?

As a society we seem to spend more time finding fault than we do solving problems.

It's everywhere in our culture. How many times in the workplace have you run across a situation that needs to be fixed, but instead end up spending all the time assigning blame, and subsequently never actually fix the problem?

I see that same pattern in our mental health. How many times do you see someone get all wrapped up in finding fault for their condition... their parents, upbringing, trauma.... it goes on and on. Sure it's helpful to a degree, but at the end of the day real recovery happens when all things being equal we realize that we are the way we are... it just IS.

Once that realization is reached we begin to see that the "problem" is more a reflection of other people's idea of what is wrong with us because we are different than them.

So just whose problem is it then?

Well it can't anybody else's problem... because it's not their fault, so it must be yours...

The never ending thought loop continues.

In computer programming it's the equivalent of division by zero, the creation of an infinite loop that will consume all a machines hardware until it locks up and can't function.

Sounds eerily familiar doesn't it!

John McManamy said...

Hey, Ethan. So glad you enjoyed my piece. I'm serve on the board of NAMI San Diego, so the idea that our our attempts to bust stigma may in fact be increasing stigma sent a jolt through me.

Coincidentally, tomorrow NAMI SD will be honoring Katie Cadigan - producer and director of "When Medicine Got It Wrong" at our annual dinner. The film documents the gross stupidity of psychiatry in the old days, when doctors attributed schizophrenia to bad parenting.

The new biological psychiatry model was supposed to put serious mental illness on the same footing as diabetes and other ills, but - as you note - may have made things worse.

I did a recent piece on why the biological psychiatry paradigm has gone past its shelf life, which begged a re-run of this piece.

I definitely need to read your book. Let's keep in touch.

John McManamy said...

Hey, Tony. This is very perceptive. One thing I have noticed over the years - the people who actually get better are the ones who don't point fingers or cast blame. Yes, they want insight into cause and effect so they won't get themselves into similar situations in the future, such as an abusive relationship or toxic working situation. But the bottom line is they want practical tools to work with, here, right now. These people know that meds can only take them so far, so instead of wasting time blaming doctors and Pharma they work to get the most out of their meds, then figure out what else they need to do. As you said, it's all about getting things done than assigning blame.

herb said...

“As a society we seem to spend more time finding fault than we do solving problems.” --- Tony

Right on Tony! Just read through some of these Internet blogs relating to mental disorders and you’ll find individuals blaming their doctors, medications, therapies, hospitals, institutions, the government etc., etc. to which you ought to throw in the more prevalent litigious society we’ve also become. Given their lack of accountability and responsibility many of these same individuals go on to advocate for banning each and every treatment option. It won’t be long before we’ll be back in the dark ages praying to deities for answers.

Add to which there simply aren’t many blogs, in my opinion, taking a positive lead to encourage consideration of alternative and/or adjunctive treatment options without laying blame for lack of efficacy or potential side-effects.

Let me recall…the case was won become the vendor’s cup of coffee between the thighs of the customer while driving was too hot, spilled and burnt the customer. Not because the customer was simply stupid or irresponsible. Give me a break.

Will taking responsibility for one’s own decision(s) ever show its face in our society again? I doubt it as the new national motto evolving is…”It’s not my fault…blame…” In the mean time I’ve found a number of those willing to educate themselves while remaining hopeful and persistent and open to consider new treatment options have in many instances achieved reasonable goals.