It's a sad, sad world

Wesley Yang follows the western psychiatric establishment around the world, watching its representatives sometimes hurt the very people they try to help. Crazy Like Us: The Globalization of the American Psyche Ethan Watters Free Press Dh95 The history of western intervention abroad - well-meaning, overconfident, oblivious to cultural context, and therefore doomed to magnify and multiply the problems it has come to solve - gets a powerful new chapter in Ethan Watters's Crazy Like Us: The Globalization of the American Psyche. The book is a critical account of four western psychiatric interventions around the globe, and its heroes are a loose collection of researchers and anthropologists who dissent from the mental health orthodoxy that has spread from the United States to the rest of the planet.

The other doctors, aid workers, experts and executives Watters meets, by contrast, do not understand the cultures they have decided to educate and to heal - and they do not think they have to. As a result, they do not help the people they have come to help. Sometimes they hurt them. The westerners parachuting into foreign lands to promote various forms of "mental health literacy", as they call it, believe machines that can watch blood flow through the brain and drugs that can change the brain's chemistry have elevated modern psychiatry above the primitive diagnoses of the discipline's long infancy, when "culturally contrived manifestations of mental illness" ran riot.

During this age of blind empirical groping, doctors first identified symptoms like convulsive fits, paralysis and linguistic impediments as indicators of mental illness. But each time new diagnoses emerged in the medical literature, and in public discourse, doctors found that the incidence of these same symptoms skyrocketed. This shifting of the "symptom pool", as the medical historian Edward Shorter calls it, was a constant embarrassment to psychiatry's claim to provide timeless and objective descriptions of a hard reality.

But today, the new orthodoxy insists, western psychiatry is at last rooted in an objectively "biomedical" account of how the brain works and fails. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Illness is, on this view, a universally valid guidebook that describes "illnesses with a symptomatology and outcomes relatively unaffected by shifting cultural beliefs."

Not so, insists Watters. "All mental illnesses," he writes, " including such seemingly obvious categories such as depression, post-traumatic stress disorder, and even schizophrenia, are every bit as shaped and influenced by cultural beliefs and expectations as hysterical leg paralysis, or the vapours, or zar, or any other mental illness ever experienced in the history of human madness." All mental illnesses are cultural for the simple reason that all forms of expression are irreducibly cultural. The modern western individual for whom American psychiatric diagnoses were conceived is itself a cultural artefact - a radical break from conceptions of the self obtaining in the many non-western cultures where the individual is regarded "as inseparable from your role in your kinship group, intertwined the story of your ancestry and permeable to the spirit world". Thus any account of mental illness that uses a uniquely western template for all minds everywhere will inevitably "blind local clinicians to the unique realities of patients in different cultures".

Each of the four case studies that Watters examines poke holes in a different aspect of the western mental health orthodoxy. In Hong Kong, China's leading researcher of eating disorders finds that shifting cultural beliefs can radically alter the nature and distribution of a mental illness. In 1994, the highly publicised starvation death of a 14-year old schoolgirl - and the subsequent profileration of news reports containing the western definitions of an anorexia nervosa - led to a dramatic rise in the awareness, and the incidence, of the disease.

In Sri Lanka, thousands of Western-trained "trauma counsellors" marvelled at the obstinate cheerfulness and resilience of the natives in the wake of the 2004 tsunami that ravaged the island. They concluded that the Sri Lankans were "in denial" and needed to be forced to confront the trauma they have just experienced - lest the unprocessed terror seep into their unconscious to fester and manifest itself as post-traumatic stress disorder. Toward that end they employed a "debriefing" technique that, in 1996, the British Medical Journal had concluded was "ineffective and has adverse long term effects" - namely the instigation of the very symptoms it is intended to avert.

The first western psychiatrist in Tanzania was keen on weaning the natives away from superstitious beliefs in spirit possession that stigmatise the mentally ill. Here, as elsewhere, western psychiatry acted as a tireless promoter of the view that mentally ill people are afflicted by an illness like any other. The view is meant to reduce the stigma experienced by the mentally ill. But everywhere the idea has been accepted, the effect has been to increase public aversion to the sick, further isolating them from their communities.

By contrast, Tanzanian beliefs in spirit possession have the effect of keeping the schizophrenic within the social group. A western anthropologist marvels at the "amazing tolerance" and "passive acceptance of abnormal behaviour" that one Tanzanian family shows toward the mentally ill in their midst. In the West, where the allegedly enlightened and humane biomedical view dominates, schizophrenics experience fewer periods of remission and lower levels of functioning than they do in cultures that believe in ghosts.

Not even a disease as seemingly straightforward as depression is exempt from a remarkable degree of cultural determination. Japanese people have traditionally considered profound sadness to be a poetic ennobling emotion, not a disease to be banished with the aid of doctors and pills. For this reason Eli Lilly, the makers of Prozac, declined to enter the Japanese market. "Executives in the company believed that the Japanese people wouldn't want to accept the drug," observes Watters, "More precisely, they wouldn't want to accept the disease." Glaxo SmithKline, the makers of Paxil, did not give up so easily. A "mega-marketing campaign" successfully altered the traditional Japanese view of sadness and depression. By 2009, sales of Paxil in the country had reached $1 billion.

The researchers that Watters lionises correctly note that the importation of western psychiatric process smuggles in cultural assumptions that threaten to upset social balance. For example, therapists working in Sri Lanka after the tsunami urged reflection and "individual quests of introspection" onto Sri Lankans - who conceived of themselves as tightly woven into kinship networks in which the well-being of the individual is contingent on the well-being of the group, and the well-being of the group as contingent on collective avoidance of unconstrained speech.

In doing so, they "largely discredited the power of local healing practices, as well as resiliency, coping and survival strategies" in a way that "had the potential to continue, in a new form, the very cultural demolition that had caused the population its greatest distress." In the end, Watters concludes, "offering the latest western mental health theories in an attempt to ameliorate the psychological stress caused by globalization is not a solution; it is part of the problem."

Wesley Yang writes for Tablet Magazine and n+1.

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