Ethan WattersDuring my first placement at a mental health facility, I remember all too vividly the clinical director informing the staff that we must never make the mistake of mis-diagnosing immigrants. The specific example that was cited was that of an Asian woman who had been improperly diagnosed and treated for schizophrenia based on two factors: (1) her English was poor, so, in not fully understanding any of the questions asked, her responses were disjointed, her affect was that of someone staring into space – perhaps hearing voices – but definitely not being in the moment and totally unable to advocate for herself, except to make it clear that she was experiencing emotional distress and (2) because she never made eye contact with the treating therapist -and it was not understood that in her culture it was considered disrespectful to look into the eyes of a stranger – she was mis-diagnosed and treated for schizophrenic, when what she was suffering from was post partum depression.

Everyone in our class sat there in disbelief. And, that was only one story. Apparently, such diagnoses were occurring all too frequently to various people from different ethnic and religious backgrounds.

On a personal level, I remember feeling outraged upon hearing that trained clinicians were mis-diagnosing and therefore mis-treating persons from different countries and/or cultures, treating the wrong condition and/or disease with the wrong medication and or therapy. For me, this hit too close to home, since my mother had been one such immigrant years earlier, and I knew how victimized she had felt by a system that objectified her (and thereby dehumanized her), often –or so she felt – using her as a guinea pig.

So, in my own small corner of the world, I attempted to educate myself further so that I would never be guilty of such errors. But, the longer I remained in the field, the more I became aware of just how ignorant and, yes, arrogant we in the West truly are when it concerns the psychology of other cultures.

In fact, on the same subject, I have been thinking about an article I read some months ago in the New York Times and feel remiss in not having addressed it sooner.

The article, “The Americanization of Mental Illness,” appeared as an essay from Ethan Watters’ then soon to be published book, Crazy Like Us: The Globalization of the American Psyche.
When I started to read the essay, I remembered my days as a graduate student and a book edited by Gloria McGoldrick and Joseph Giordano that addressed the need to treat differently those whose cultural heritage is not that of our own. That was nearly thirty years ago, and yet we still suffer – perhaps even more so – from the ignorance that propelled the authors to contribute to our field of knowledge by writing ETHNICITY AND FAMILY THERAPY (now in its 3rd edition).

To begin, I fully agreed with one of Watters opening remarks: “We have for many years been busily engaged in a project of Americanizing the world’s understanding of mental health and illness. We may indeed be far along in homogenizing the way the world goes mad.”
Because I feel so passionately about this problem, I am going to offer a synopsis of what Watters claims and ask that you take it to heart and do whatever you are able to do to make sure that no one you love who is suffering from a mental disorder has to suffer unnecessarily!

“In any given era,” Watters writes, “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 … 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.”

He goes on to conclude that “we’ve been changing not only the treatments but also the expression of mental illness in other countries, referring to depression, anorexia and post-traumatic stress disorder among others. Also, he concludes that “it now appears to be spreading across cultures with the speed of contagious diseases. ”

He cites Dr. Sin Lee, a psychiatrist and researcher at the Chinese University of Hong Kong, who documented a rare and culturally specific form of anorexia nervosa in Hong Kong. Unlike American anorexics, Dr. Lee’s patients did not intentionally diet nor did they express a fears of becoming fat. Their description of their problem was specifically somatic, complaining mainly of feeling bloated, which made it painful for them to eat, and the cases he saw were rare, even at that. The public’s understanding only shifted when a teen-aged girl collapsed and died. Then, when the Chinese reporters “copied, the causes and meaning of what was referred to as her “disorder” directly from American diagnostic manuals” everything changed. Western ideas did not simply obscure the understanding of anorexia in Hong Kong; they absolutely changed the expression of the illness itself. For while Dr. Lee had at the time been seeing two to three anorexic patients per year, by the late 1990’s he was seeing that many cases and more each month. “New patients appeared to be conforming their experience of anorexia to the Western version of the disease.”

I don’t think that Watters or any of us would deny the value of many of the scientific advances that have been made in the past fifty years. Yet, I agree that our diagnostic manual cannot and must not be a guide for the world’s psyche.

“The assumption,” he continues, “is that remarkable scientific advances have allowed modern-day practitioners to avoid the blind spots and cultural biases …..”What is being missed – and what Lee cites very clearly – is a deeper understanding of “how the expectations and beliefs of the sufferer shape their suffering.”  He states that professsionals and the media are all guilty of publicizing – and often glamorizing – not only eating disorders, but all disorders.  In doing so, a variety of pathologies are triggered (consciously or unconsciously) by volunerable people who then identify with those whom they read about.

In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that “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 any other mental illness ever experienced in the history of human madness.  This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche. It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions – the idiosyncratic cultural trappings – of the mind that is its host.”

In short:  What we export to the world about our ideas of mental health ideas “are rarely unadulterated scientific facts and never culturally neutral. … Some philosophers and psychiatrists have suggested that we are investing our great wealth in researching and treating mental illness – medicalizing ever larger swaths of human experience – because we have lost older belief systems that once gave meaning and context to mental suffering.”

He is adamant about saying that : “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. When we undermine local conceptions of the self and modes of healing, we may be speeding along the disorienting changes that are at the very heart of much of the world’s mental distress.”

Given the extreme stress created by the failing economy, the world’s ever increasing natural disasters and wars on every continent, we, in the West and others throughout the world must become sensitive and knowledgeable about how our traditions influence us in every aspect of our lives. Yes, we are all human, but our different beliefs, rituals and understanding of the human condition must be addressed, if we are not to rob one another of what makes us unique and if we are to promote better health for one and all.

The greatest good will come from our working together to create less chaos and to develop more resources for treating and, ultimately, eradicating debilitating/chronic physical and mental diseases.

Do let me know if you agree!


1 Comment

  • Levonne says:

    I wonder how much our health care system and insurance has to do with this homogenization? You know, so that payments may or may not be made to health care institutions to treat certain behaviors, or not. Or for that fact to pay once but never again because it becomes a pre-existing condition. I guess I am a bit focused on the health care problems in our country right now. Good writing and research you've done. Thanks.