Are We Exporting Western Definitions of Mental Illness to the Rest of the World?

A video and an article both look at this issue, but from different perspectives. All of this revolves around an article in the New York Times recently, "The Americanization of Mental Illness,” Ethan Watters, author of Crazy Like Us: The Globalization of the American Psyche.

First up, a video from FORA.tv.

Ethan Watters: The Globalization of the American Psyche

Berkeley Arts and Letters

Summary

American culture is homogenizing the way the world goes mad. Our exportation of everything from movies to junk food is a well-documented phenomenon. But neither our golden arches nor our bomb craters represent our most troubling impact on the world: the bulldozing of the human mind itself.

In Crazy Like Us, leading trend-spotter and science writer Ethan Watters shows that we are not only changing the way the world treats and understands mental illness, we are actually changing the symptoms and prevalence of the diseases themselves.

Watters travels the world to illustrate the ways in which Western influences have changed mental illness.

In Hong Kong, he meets teenagers who have learned from American culture that anorexia is the modern way to express distress, and who began refusing food after a wave of Western celebrities and researchers began raising awareness. In Zanzibar, he witnesses a much milder and more bearable form of schizophrenia than what we have in the States.

In Sri Lanka, he sees western crisis counselors bungle the treatment of tsunami victims and actually cause the community more distress.

And in Japan, he tells the story of the drug companies selling depression itself to create a market for a new drug.

* * * * *

Todd Oppenheimer - Todd Oppenheimer works as a journalist at The Writers' Grotto. During his 25 years as a journalist, Oppenheimer has won a variety of national awards for his writing and investigative reporting and has appeared on numerous radio and television programs, including ABC's "Nightline." His articles have appeared in The New Yorker, Newsweek, The Atlantic Monthly, The Washington Post, Columbia Journalism Review, Mother Jones, and an assortment of daily and weekly newspapers.

He is the author of The Flickering Mind: Saving Education from the False Promise of Technology, a finalist for the Investigative Reporters and Editors Book Award. Ethan Watters - Ethan Watters is the author of Urban Tribes, an examination of the mores of affluent "never marrieds" and the coauthor of Making Monsters, a groundbreaking indictment of the recovered memory movement.

A frequent contributor to The New York Times Magazine, Discover, Men's Journal, Details, Wired, and NPR, he has appeared on such national media as "Good Morning America," "Talk of the Nation," and CNN.

Next, we have an article from Psychiatric Times arguing against a recent Watters' point of view in the article and by extension, the POV in the video clip.

Western Psychiatric Imperialism, or Something Else?

By Ronald Pies, MD | January 12, 2010

Dr. Pies would like to acknowledge both Rakesh Jain MD and Sandy Naiman for inspiring this blog.

In a very long essay in the Sunday (1/10/10) New York Times Magazine, entitled, “The Americanization of Mental Illness,” Ethan Watters suggests that a kind of psychiatric-cultural imperialism has been foisted on other countries and cultures by “the West.”

Specifically, Watters claims that, “For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world…. 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. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures.”

Watters claims, for example, that as the general public and mental health professionals in Hong Kong “…came to understand the American diagnosis of anorexia,, the presentation of the illness in Hong Kong actually became more “virulent.”

Though the Watters thesis has its merits, it is also glib and simplistic in many of its assumptions and conclusions. To be fair: Watters rightly calls attention to the ways that culture and ethnicity can shape both the diagnosis and expression of psychiatric conditions and symptoms. But this is hardly news to psychiatrists: the late Dr Ari Kiev advanced much the same thesis in his 1972 book, Transcultural Psychiatry.

Watters’ more controversial claim is that the exportation of American psychiatric nosology and “biomedical ideas” has changed the way symptoms are diagnosed and expressed in some other cultures. But this claim is very hard to validate. The “American” diagnostic system is, in the first place, not terribly different from the World Health Organization’s International Classification of Disease (ICD), whose descriptions of “mental and behavioral disorders” evolved almost contemporaneously with those of the last two DSMs. It would be very hard to tease out the cross- cultural influence of the DSM classification from that of the ICD, over the past 30 years. More important, Watters fails to consider alternative explanations for his “findings”; for example, rising rates of DSM-type anorexia nervosa in Hong Kong could be due largely to increased recognition of a long-standing, indigenous disorder that heretofore had not been fully appreciated by Chinese clinicians.

An example from American history helps make the point. Many of the basic symptoms of post-traumatic stress disorder (PTSD) have been recognized for centuries—at least since the U.S. Civil War, and probably much earlier—and have gone by various names, such as “soldier’s heart,” “combat fatigue," “shell-shock,” etc. But it took the efforts of troops returning from the Vietnam War to “push” psychiatry toward recognition of PTSD as a bona fide disorder. Understandably, apparent PTSD prevalence rates have soared since the diagnosis entered American nosology in 1980, with the advent of DSM-III. But it is entirely possible that the actual prevalence of PTSD symptoms in the U.S. has not changed markedly over many generations.

So, to return to Mr. Watters’ thesis: it would not be surprising to find that, as clinicians in other cultures began to familiarize themselves with DSM or ICD psychiatric disease criteria, the apparent prevalence rates of certain psychiatric conditions increased in those countries. It is quite another thing to imply that the actual prevalence of these conditions has increased—and that their morphology has changed--as a result of Western influences. Yet Watters seems to imply just this, when he asserts that

“…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. These [Western-based] symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness.”

We would need several generations of very sophisticated epidemiological studies, carried out using identical diagnostic criteria, to substantiate this “contagion-replacement” hypothesis. Anecdotal data, such as those presented in the Watters article, are inadequate. But even if Watters is correct, his claims do not answer the fundamental medical-ethical question: will adopting “Western” diagnostic criteria ultimately lead to a net reduction in suffering, and a net increase in well-being, in other cultures? If, after careful systematic study, the answer to this question turns out to be no, our Western paradigms will have failed. If the answer turns out to be yes, we may conclude that we have been exporting a very valuable commodity.

Dr. Pies would like to acknowledge both Rakesh Jain, MD and Sandy Naiman for inspiring this blog.

Response from Rakesh Jain, MD:

Dr. Pies' comments on this article are entirely in line with my feelings too. I think the Watters article makes the same mistake I see many contemporary Western writers make - this being that if a Western value system has been accepted by the East, it's automatically a bad thing. I, as someone raised in the East (India) and now living and working as psychiatrist in USA for over two decades now, see the real and positive value in 'exporting' our views regarding the diagnoses of mental disorders. Case in point - as a medical student in Calcutta, I would routinely encounter patients with deep burns induced by healers when symptoms of depression and/or psychosis were present. I just came back from India 2 weeks ago, and was thrilled to see many articles on depression in the newspapers (that used Western descriptors). I was told by family and friends who live in India, that such symptoms when present in individuals, are now being seen less as demonic possessions, but as mind-body diseases that require both psychotherapy and/ or medications (along with yoga, diet changes, and physical exercise). This is as a direct result of the mysterious East accepting our cool and cerebral view of what constitutes mental illness. So, as far as I am concerned, the West has gifted the East something wonderful by offering a new view of mental disorders. Such was the case, using India as an example of the West 'imposing' such radical views on India that ultimately turned out to have huge long term positives - widows killing self when the husband died, child marriages, etc. I am not an automatic slave to all things Western - however, it is quite clear to me that the East benefits far more than it harms when the Western definitions of mental disorders are utilized.

This is a tough issue - are the universals in the definitions of mental illness, or do we honor cultural values that differ from our own? This is the emic vs. etic debate that underpins much of multicultural diversity theory:

* Emic models view behavior as culture-specific; behavior must be understood in the context of a particular culture
* Etic models view behavior as universal; behavior must be understood in comparison to behavior in other cultures

I'll be posting more on this in the future.

Tags: Exporting, Western, Definitions, Mental Illness, Rest of the World?, emic, etic, FORA.tv, New York Times, Psychiatric Times, Americanization, Mental Illness, Ethan Watters, Crazy Like Us, The Globalization of the American Psyche, Todd Oppenheimer, Ronald Pies, multiculturalism, psychiatric-cultural imperialism, Psychology, culture, globalization