NYAPRS Note: As several articles we have recently sent articulate, the experience of behavioral health is largely contingent on socio-economic factors that are routinely pathologized by a prescriptive medical approach to diagnosis. NYAPRS’ own Molly Donahue examines this trend from a global perspective through a look at Ethan Watters’ groundbreaking work Crazy Like Us: The Globalization of the American Psyche.
The Social Context of Mental Illness through Global Proliferation
NYAPRS; Molly Donahue, 8/4/2014
The experience of mental illness cannot be separated from cultural, social, or historical context.
So states the compelling and well-documented central argument of Ethan Watters’ Crazy Like Us: The Globalization of the American Psyche (2010). Watters’ startling book explores four case studies (anorexia in Hong Kong, post-traumatic stress disorder (PTSD) in Sri Lanka, schizophrenia in Zanzibar, and the mass marketing of depression in Japan) of how the dominant Western understanding of mental illness has established problematic footholds around the globe. After the publication of the third edition in 1980, the American Diagnostic and Statistical Manual of Mental Disorders (DSM) became the global standard for diagnosis, and since paved the way for glossing over culturally significant presentations of mental illnesses.
Mental illnesses are not spread evenly around the globe, Watters asserts. They arrive as responses to specific social and economic circumstances unique to a region or people. His argument goes against the reigning logic from the biomedical movement, which hunts for the causes of mental illness in bad genes, biochemistry, and the structure of the brain. The biomedical narrative, Watters argues, often has the unintended consequence of worsening stigma, particularly in the Western world where untreated mental illness is incorrectly linked with violent, demonstrative behavior (for more on this, start with Todd Essig’s brilliant editorial, “The Myth of Mental Health and Gun Violence” found here). Instead, Watters and his research supports the psychosocial roots of (and treatments for) mental illness.
Watters’ chapter on trauma is a provocative and heartbreaking depiction of the negative effects of forcing Western framework of PTSD had on the survivors of the 2004 tsunami in Sri Lanka. Thousands of mental health relief workers flocked to the country in the wake of the disaster, and armed with the DSM and a prescribed set of human responses to distress, further exacerbated the trauma experienced by families by ignoring cultural cues. It is a stark revelation of the harm that continued ideological obstinacy can have on vulnerable populations.
Watters warns against diagnostic entrenchment, which has traction for psychiatry abroad and in the United States. The sweeping under the rug of social and cultural forces isn’t a tendency found solely in developing nations. Wayne Munchel called attention to this trend, and other alarming by-products of pathologizing Ameircan poverty, in a recent article for Mad in America. “Schools frequently identify poor children as ‘Severely Emotionally Disturbed, (SED), at-risk and in need of treatment,” Munchel says. “But [the schools] pay scant attention to the social conditions that are causing the disturbances.” The stubborn reliance on the set of Western guidelines to identify and treat mental illness across cultures, including within the Western world, is a costly standard.
Still, as both Watters and Munchel identify, there are many programs and organizations around the globe moving away from diagnosis-based treatment and toward social justice and community support oriented recovery plans. Watters discusses the movement in his chapter on treating schizophrenia in Zanzibar, and demonstrates its success when compared to Western techniques elsewhere in the world. The Mental Health and Poverty Project in South Africa pinpoints the cyclical nature of poverty and mental illness, and recognizes that support for one must include recognition and support for the other.
Ultimately, with the rise of diagnosed mental illness in the States, and the continued application of the DSM around the globe, Watters advocates for a change in how we think about and treat mental illness within the framework of globalization. A complete overhaul of the Western psychiatric treatment infrastructure is not a real solution, nor is ignoring the DSM. A middle-ground is the best option moving forward: using the DSM and common practices as tools, but also incorporating respect for diversity and community support into psychological services – and it’s not a new idea. Anthony Marsella’s 1982 book points back to the early 1960s as the genesis of the discussion, and Watters’ text serves as a cold depiction of how little progress has been made in 50 years.