The Americanization of "mental illness"

watters.jpgDuring my guestblogging stint, I have mentioned a couple of American expats who exported their problematic conceptions of "mental illness" all over the world from their base in Toronto. Ken Zucker and Ray Blanchard are egregious examples of this problem, but they are just the tip of the iceberg. It's one of the most important political issues of the 21st century, but it is one of the most difficult for both practitioners and the general public to step back and see in its historical and geopolitical context. It involves challenging some of the most deeply held beliefs about how the world works.

Today, the New York Times has an excellent introduction to the concept, by Ethan Watters, author of Therapy's Delusions. It's a good overview of his upcoming book. Quoth Ethan:

In any given era, 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. That is until recently.
The Americanization of Mental Illness (article)

Crazy Like Us: The Globalization of the American Psyche (book)


  1. It’s a long article, so I’ll print it out and read later. Just wanted to note that the NYT link is worth opening for the lead graphics by Alex Trochut if nothing else — the two depictions of an eagle and Uncle Sam as inkblots really tickled my eye.

    1. @S2, Now you’ve got me straining my eyes. I can see the eagle, but can’t for the life of me spot Uncle Sam. Please help.

      (I don’t want to turn into Mr. Pitt here.)

  2. Your posts about these books and articles are welcome antidotes to psychological and psychiatric delusions, especially as they pertain to the diverse experiences of gender.

    I’ve often wondered this: If there is such a fallacious thing as “gender identity disorder” and those who “suffer” from such an entirely made-up disorder must see doctors before obtaining any official accreditation to “change” genders that they essentially already hold, then why aren’t “masculine” straight males subjected to the same constraints. After all, each day of their lives they are performing and trying to be masculine and many of their mechanitions are hardly “natural” practices, however “normal” they appear.

    If gender is a cultural construction (and it is), then we are all suffering from a gender identity order and disorder because we are all trying to be constructions that are entirely created (whether we are conscious of this or not), constructions borne entirely within the difficult mixture of our feelings, our societal influences, and our physical experience.

    The heterosexual/masculine hierarchy was not always a part of Nigerian cultures, for example. Yoruba ritual valued transgendered persons. (Sex and the Empire That is No More: Gender and the Politics of Metaphor in Oyo Yoruba Religion by J. Lorand Matory is one of my favorite books about this.) But postcolonial Muslim and new forms of colonial Christianized hatred have gradually changed the landscape of gender and sex in Nigerian culture, giving rise to forms of sexism, hetero-sexism, trans-phobia, and homophobia that are actually quite new to the region.

    The link between worldwide notions of mental illness and American delusions is strong. But we mustn’t over-determine America’s influence across the globe and repeat a most basic ethnocentric fallacy. We don’t know how deeply prevalent American notions are until we conduct longterm studies in each country that we include in our comparative analysis. Surface similarities are like chimeras: they announce connections that may not hold under closer scrutiny. Some American notions may touch other continents and countries but become transformed through syncreticism–or the mingling of disparate influences into new forms.

    I hope you stick around Boing Boing longer.

  3. I have read the whole article and it looks like a book example of the concept “meme”. It is scary that the concept of mental illness may be transmitted just by pure communication.
    Q: Is the Internet the biggest mental illness contagious agent in the world??
    A: 4chan anyone?

  4. I’ve read part of the article, and will return to it later. Thanks for posting it.

    On first glance it looks like it is covering at least two different phenomena:
    1. US practitioners, despite their best attempts at cultural sensitivity, end up defining mental illness in terms of what is normal or abnormal for Americans
    2. Because of the spread of US educational material, portrayals in books and movies, etc., people of other cultures are starting to express mental illness according to American patterns.

    In that sense… hey, it’s a self-correcting problem. Maybe the whole world will soon have US mental illnesses, but they’ll have US treatment modalities too. I, for one, am not all that concerned about maintaining the cultural diversity of mental illness.

    In my (undergraduate) abnormal psych class in college, which I guess was 2000? 2001? We talked quite a bit at what defines mental illness. There was never a clear answer, but culture was important. Similar examples to the article: some people practice religious self-flagilation; that would be sick here. And in the US, thinking God is sending you messages through your dreams or through a nature scene is o.k.; thinking God is sending you messages through your television is sick. It seemed there were too conflicting rules of thumb: 1. You’re sick if your thoughts or behavior are preventing you from accomplishing your own goals for work, relationships, etc., even if those goals are different from everyone else’s. 2. You’re sick if you have substantially ‘wrong’ goals and can’t integrate into your host culture, even if you accomplish those goals tolerably well.

    It’s a hard thing, and I don’t envy the social scientists for that. Disorders that have identifiable, organic/chemical causes, or appear substantially similar throughout the world, those would be easy. Match up the physiological symptoms or test results to the book and you’re good. But it seems the vast majority of what people seek help for is in the more difficult world of depressions and anxieties and obsessions and compulsions.

  5. A brain in the developing world in the same state as a severely depressed brain in the US will experience a great deal of pain, just as the US brain does. Now, maybe a different cultural context can help in dealing with that pain, but it’s still there. The sensations that are associated with severe depression aren’t made up when people decide how to carve up mental pathology (though no doubt there are many discrete illnesses that fall under the label “depression” or “major depressive disorder”).

    1. @Marchhare#5: You are making a common assumption that can lead to problems. Sadness exists, but that doesn’t mean it is a disease. For instance, “experts” used to diagnose women who had “too much” sex with a disease called “nymphomania.” Sex exists, and some women all over the world have a lot more sex than other women, but that doesn’t make it a disease. People all over the world get sad, with varying degrees of severity and for varying lengths of time. Making the leap that those with “too much” sadness have a disease called “major depressive disorder” is akin to the leap that women who have “too much” sex are “nymphomaniacs.”

      People who are sad may want that feeling to end, and they may seek out any number of ways to end that sadness, including pharmaceutical options (legal and illegal). Because the legal pharmaceutical industry developed in conjunction with the medical industry, both view sadness through a lens of Western medicine. Pain, especially conceptualizations of “mental pain” are nebulous and subjective and vary by culture and time. We have to be careful about saying a disease exists just because a phenomenon exists. That’s just reification.

      1. Sex and sadness are very different. People routinely actively seek out sex; who in their right mind seeks out sadness? Sex = pleasure(usually). Sadness? Come now.

        1. @VagabondAstronomer#10: Come now, indeed. I am not saying “sex is the same thing as sadness.” I am using an analogy about how concepts that “too much” of something is a disease, addiction, what-not. This medicalized idea of a subjective concept leads to pathologizing metaphors that concretize subjective limits of what is an acceptable level of this or that feeling or behavior.

          Second, that’s a pretty naive view of sadness. You have never deliberately watched a sad movie, listened to sad music, or returned to thoughts of a lost loved one? We actively seek out sadness all the time. To deny the pleasure of sadness and the cathartic feelings when it ebbs seems awfully simplistic.

          1. I certainly wasn’t implying that sex and sadness were being compared. And yes, I understand the concept of sadness/sentimentality in art. However, I take umbrage in the comparison to a lifestyle choice. Depression is not a choice. I am speaking from the position of being someone who has “enjoyed” that little “mind fuck” for 32 some odd years now. My depression has no apparent triggers at times, though certainly it has been conditional. I have been hospitalized twice. I have been off meds for most of this; “diet of the mind”, so to speak. Do you have any experience with this? On a clinical or personal level?
            So yes, to say the least, I’m a tad sensitive when I hear someone say that “sadness” is simply “in my mind”. On a biochemical level, you bet your ass it is.

  6. I’m toying with the idea that mental illness is situational.

    It’s long been true in practice that the majority is sane; perhaps not philosophically or scientifically true, if you like those terms, but for pragmatic purposes you have to recognize that you don’t get pilloried or lynched for being just like everyone else. You get called “insane” for being different.

    Yet, some forms of difference are celebrated, at some times. Heroes aren’t like anyone else (disregarding politically driven falsehoods like “our soldiers/politicians/priests are heroes”) or they would be Everyman rather than Hero. Differences that are useful to society are condoned; the Prophet Ezra and the Fuhrer Hitler weren’t much different in their actions, just in their time periods and circumstances. Ethnic cleansing and genocide go in and out of vogue among humans.

    So, take this thought experiment for an example: If every woman in the world but one is suddenly dead, and artificial insemination no longer works, then virtue and sanity, perhaps even heroism, is polyamory, heterosexuality, and constant pregnancy. Evolution demands species reproduction which demands genetic diversity, after all. Monogamy or male jealousy in such straits would be a sinful insanity, wouldn’t it?

    In an overpopulated ecosystem where unlimited reproduction will provably result in extinction – for example, in a generation ship where resources are limited – then tolerance of homosexuality and gender reassignments or anything else that tends to decrease overall reproduction would be virtuous and eminently sane, right?

    I think people are highly variant in attitudes and behaviour, and society should try to assign judgments like “sin” and “insanity” in ways that benefit society. Plato said something similar in “the Anthill” – no, wait, it was “the Republic”.

    If this is true, then in the current situation where species survival and cultural evolution is better served at the individual level by adopting children rather than birthing them, what can we say about people who insist that homosexuality and gender reassignment are wrong? Seems to me that these people are insane and sinful.

    It’s just a thought.

  7. Marchhare:

    But some disorders, psychiatric policies and medications are entirely dependent on cultural assumptions, and not truly competitive medical research. Some forms of depression are over-prescribed and over-medicated at the sole benefit of Big Pharma.

    “Gender identity disorder” is an entirely made up, fallacious American/Western disease. And the Diagnostic and Statistical Manual of Mental Disorders (especially the anticipated revision due out in 2013) includes and may include even more “pretend” illnesses that benefit Big Pharma and prejudiced doctors more than patients and medical progress.

    Yes, we are all the same human species across the globe with similar physiologies. But our cultural definitions of the body and illness are not all the same.


  8. Kinda funny how people who have surface level interests in these fields end up looking like experts because they write a book. I know I’m no where near an expert but I start to read these things and I get turned off immediately…it is almost like someone is afraid of psychology. Seriously, get over it…if it does nothing for you, don’t go to one…

    As for different cultures, most programs these days teach multiculturalism on day one in regards to mental illness / mental well being and psychology. We know african americans / asians / hispanics / whites all view things from their cultural bias…whites are the generic norm because of the history, but we also know most mental illness is social in nature…as such, one has to look at the illness in context.

    Again, this is taught at any accredited school in the US. We are taught what to look for in different cultures, we are encouraged to talk to clients about their culture if we don’t know…are also know that 99.999% of all culture is equivelent to each other and there is more in-group diversity than out of group diversity, meaning that our stereotypes are meaningless most of the time. Still, we are trained to look for these because regardless of if we like it or not, we know people like to feel comfortable in their own stereotype (even if it isn’t the one others hold of them).

    1. @Clif Marsiglio#8: Your argument sounds like old arguments about phrenology: only phrenologists can be experts on phrenology, and if you don’t like phrenology or are afraid of phrenology, don’t go to a phrenologist. If everyone thought that way, some people would still be getting the bumps on their heads measured.

      It’s important not to dismiss work about “mental hygiene,” or what you call “mental health,” simply because the writer is not as “expert,” by which you seem to mean someone who is a practitioner. People involved in a practice are often the least capable of stepping back and seeing it from a different perspective. Watters raises many important issues, and to dismiss him because you don’t deem him an “expert” is part of the very issue he is raising.

      1. “old arguments about phrenology: only phrenologists can be experts on phrenology,”

        Actually, I would say that if you are not a physician or have no experience at or above this level, you cannot comment on it. In some ways, the phrenologists of the past were right…some of these folks that practiced trepanation in collaboration with this were far beyond that of the doctors of the time. We know with further experience, and with the blessing of those in more advanced fields, this should not be a first line of attack, but we know in some situations it worked. 200 years from now, we are going to look at our practices today as barbaric and realize we got a lot wrong…we also got a lot right.

        Honestly, I’m getting out of this practice myself, even though I respect it…I don’t see it practiced with the scientific merit needed, often with clinicians just going off a hunch regardless of what the empirically based assessments read as the most likely cause / cure. I’m headed towards a much more science based area, but it has been a great detour. Still, I find the general public far more ignorant about the field that I find the clinicianers providing bad practice. Far far far far more ignorant. It is almost as if someone gets bad advice and bases their entire view of the field as wrong…it is as ignorant as the vaccine caruses mah kidses tah be stoopid crowd.

        Humans are far too simplistic overall…maybe the DSM just needs to be broken down to Crazy Within Normal Limits and Crazy Outside Of Normal Limits because this is all it is anyways. Sadly, I know where the anti-psych crowd is going to land even before I split it into a dichotomous grouping :-)

  9. What’s new in this article? On a cultural level, your given culture dictates what is crazy and what is not. But there are also diagnosed patterns of behavior that cause harm to self and others. Not everything is culturally relative, nor should be. Empathy is important.

    To digress a bit, because I have a feeling we’ll see some of this if the response thread gets long enough,funny how the loopiest people I know are the ones who are hostile to psychiatry. I was raised by parents who were such clear examples of personality disorders that they could have been used as textbook illustrations. Whenever the topic of psychiatry came up, however neutrally, their hackles would go up big time.

    Makes me think of Tom Cruise.

  10. There’s a problem I think everyone has been touching on. By saying a mental illness is a cultural construct, or even culturally dependent, one is saying it is ‘not real’. That’s more the connotation than the denotation (why can’t it be real AND cultural?), but I think that is a real perspective. In the end, suggesting one’s frustrations derive from the culture is just a more glamorous way of saying, ‘it’s all in your head’.

    If you’ve lost friends or family members to depression and suicide, or watched love ones fall from ‘productive employee’ to ‘hospital inmate’, you know how hurtful that perspective can seem. Is it really that wild a leap to think that if someone kills themselves because they are sad, they were ‘too sad’ in an objective sense that transcends cultural values?

    1. In the end, suggesting one’s frustrations derive from the culture is just a more glamorous way of saying, ‘it’s all in your head’.

      Not if you consider that culture/society is very real and something that influences and/or controls an individual on a daily basis. I see that culture can very well be like a toxin: Long time exposure to certain rules or influences that don’t suit an individual can cause their physical health to break down.

      I have no trouble believing that for someone who, for whatever reason, feels uncomfortable or vulnerable in a social role that most peers accept or impose as normal, it can be a very real threat to health. Perhaps not the only cause but certainly an important factor.

    2. And you’re criticism seems to be that if someone doesn’t treat mental illness as a brain disease, then any critiques they offer isn’t real. Dude, did you read the article? Watters talks about how people in other cultures react to anorexia & schizophrenia. That isn’t saying ‘mental illness isn’t real.’

  11. I love when people mistake depression for “sadness”…

    When you’re depressed, you’re not just “sad”… you perceive the world in a different way… things are distant, flat, less sharp; colors don’t trigger subtle physiological and emotional reactions…

    People who have had probes in their brain have said the room “suddenly got brighter” and they “felt more of a connection” to people in the operating room. This ain’t just sadness, folks.

    Normal, non-depressed folks judge depressed people by how they appear: “he’s frowning, he’s slumped over, he doesn’t laugh at my jokes, he must be sad.” Instead, they should understand depression is a perceptual disorder, and depressed people are reacting normally to their altered perceptions, just as a schizophrenic is reacting normally to his/her altered perceptions.

  12. As an American, there’s one western mental illness that I don’t understand: the British fascination with “Anti-Social Behaviour Disorder.” The affliction seems to be unique to British culture, and no one has been able to explain to me why the British are so concerned with teenagers being moody.

    1. On the other hand, many people who would be diagnosed with clinical depression in the US might just be regarded as quiet and introverted in the UK. The US has a disturbing bias toward painfully excited extroverts.

  13. Neither Andrea nor the writer of the NYT article are claiming that disorders like depression do not exist. Instead, they are claiming that the old adage “you get what you measure” is as true in the mental health arena as it is anywhere else. If we only learn one standard of measurement, we’ll only find one spectrum of pathologies. If we codify sadness as strictly a problem of seratonin reuptake, we may miss other ways of dealing with it. This does not negate the reality of seratonin reuptake disruption as a contributor to longterm depression, or the validity and usefulness of psychiatry and psychology as disciplines. But the discourse of mental health can and does name and frame problems for which there was once only nebulous description, and the history of that discourse is important to remember when looking at global mental health trends such as the article examines here. If I understand Andrea correctly, she is not saying that these disciplines are totally useless, but rather that they are not useful or flexible or sensitive enough for enough people — namely, the people who do not fit the frame established by the current discourse.

    1. That is exactly how I understood the article.

      Also, just as a lot of textbook’s in the US are adapted to different state standards…it’s seems that the DSM-IV needs to be be adapted to different countries/cultures or, at the very least, be renamed the Western World’s DSM-IV.

      I also think that language and the perception of old and new words add in to the perception of mental illness. Take the Hong Kong anorexia study from the article. Anorexia existed but in a different form. The doctor had cited examples of people who complained of “bloated stomaches.” Media attention on the death of one young woman and the new meanings and reasons attached to it, referenced from Western articles/studies, changed the public’s perception and understanding of anorexia.

  14. @8 I agree with you that many illnesses are made up whole-cloth. This is why I chose a pathology that pretty clearly exists.

    @Andrea #5

    It certainly is a reification. You say that like it’s a bad thing. There is a clearly pathological agony that accompanies at least some cases that are called “major depressive disorder.” And to the extent that we have any handle on the normative at all, that state shouldn’t be and isn’t part of the well-function or flourishing of a human being.

  15. So, when did Kirstie Alley and Tom Cruise take over Boing Boing?

    I value skepticism as much as anyone, but the notion that depression is society’s subjective determination that a person has “too much sadness” is science denialism, plain and simple; it is no different from the anti-climate change, anti-evolution, or anti-vaccination bullshit that would normally warrant dismissal if not mockery.

    Really, the argument that Andrea offers in defense of this view from the defense of those views, either: it’s identical to the anti-climate change view that, well, scientists used to say the climate was cooling, or the anti-evolution view that, well, scientists used to say that evolution was gradual; but now they don’t, so anything that they say now must be wrong. Oh, and you don’t have to be an expert to make the determination – in fact, an expert is the last person you should listen to:

    It’s important not to dismiss work about “mental hygiene,” or what you call “mental health,” simply because the writer is not as “expert,” by which you seem to mean someone who is a practitioner. People involved in a practice are often the least capable of stepping back and seeing it from a different perspective.

    Yeah, no, and as I would rather not have what society has apparently subjectively determined to be “too much measles virus,” I think I’ll take the vaccine.

    1. Andrea is not saying that there is no such thing as clinical depression. She is saying that some forms of it may be sadness and that Big Pharma plays a hand in creating diagnoses for their own huge financial benefit.

      Sometimes it is really just sadness or grief treatable by other means besides meds and not identifiable as a “mental illness.”

    2. @dcamsam#25: Science doesn’t exist in a vacuum, and it rarely exists in its ideal objective form, because human bias and error can plunge science into pseudoscience very quickly. Dismissing critics or skeptics of a purportedly scientific viewpoint as “anti-science” is the oldest move in the playbook.

      Before we knew what caused measles, we treated the symptoms. Once we identified the cause of the symptoms, we treated the virus. That’s how science works. But in the case of what they call “major depressive disorder,” there is not a virus or causative agent that has been identified. It might be genetic, it might be environmental, it might be a combination. It’s likely that a wide variety of variables are the cause, since drugs to date have had far less effectiveness than, say, a measles vaccine. Quoting Szasz:

      “‘Mental illness’ is a metaphor (metaphorical disease). The word ‘disease’ denotes a demonstrable biological process that affects the bodies of living organisms (plants, animals, and humans). The term ‘mental illness’ refers to the undesirable thoughts, feelings, and behaviors of persons. Individuals with brain diseases (bad brains) or kidney diseases (bad kidneys) are literally sick. Individuals with mental diseases (bad behaviors), like societies with economic diseases (bad fiscal policies), are metaphorically sick. The classification of (mis)behavior as illness provides an ideological justification for state-sponsored social control as medical treatment.”

      This line of thought has a rich tradition within philosophy of science (Wittgenstein, Foucault, etc.). A good general market book is ‘Social Order/Mental Disorder.’ And please don’t simply dismiss Szasz because, well, Tom Cruise once agreed with him. That’s identical to your analogies about my argument. Scientific skepticism is at the core of the scientific method, and when people dismiss critics out of hand because they are offended by the criticism (no matter how out there it is), they are not being very scientific.

      1. Dismissing critics or skeptics of a purportedly scientific viewpoint as “anti-science” is the oldest move in the playbook.

        You can label it a “move in the playbook,” but the fact is that the distinction between you and a James Inhofe is the subject of the science with which you disagree, not the strength of its conclusions.

        No, science has not determined the cause of depression. But the fact that the cause has not been determined does not automatically lead to your ridiculous conclusion that this is “the classification of (mis)behavior as illness provides an ideological justification for state-sponsored social control as medical treatment,” nor does the fact that there is a “rich tradition” of sophistry in the face of suffering render it compelling.

        Further, the fact that science has not determined a cause for depression does not mean that such a person is “metaphorically sick”; the cause of high blood pressure is not known, and yet no one with high blood pressure would be labeled “metaphorically sick,” because that would be stupid.

        Really, I know there is a “rich tradition” behind the belief that there is a distinction between the mind and the body, but as far as science is concerned, you are not animated by pixie dust sprinkled by the blue fairy. You, your thoughts, your feelings, and your behaviors are not separable from your body and an illness in one is no more “metaphorical” than an illness in another.

        As for Szasz, maybe I’ll dismiss him because his conclusions are cheap and trite.

        1. Further, the fact that science has not determined a cause for depression does not mean that such a person is “metaphorically sick”; the cause of high blood pressure is not known, and yet no one with high blood pressure would be labeled “metaphorically sick,” because that would be stupid.

          This is a very good point. I like your comments about the false allure of dualism, as well. Illnesses of the mind must ultimately have physical and biological bases because that’s all there is.

          Mental illness is as real as the brain is real.

          In the discussion here I think we’ve really been talking about examples of things that mistakenly are called mental illnesses, but are really judgements of conformity; or we’ve been observing that while anxiety or self-delusion can exist in many cultures the objects of those anxieties or delusions may vary. That’s fine. We should strive to be scientific about such things and challenge questionable classifications. But let’s not throw the baby out with the bathwater. Sometimes psychology and psychiatry will make mistakes, and hurt people in the process — but that’s true of other medical disciplines, too. Would you rather we withhold treatment from the mentally ill for fear of misclassifying them or hurting their cultural sensibilities?

  16. A synthesis of two well-known phenomena, perfect for a pop-sci article.

    BTW the sadness vs. depression issue hinges on your definition of ‘disease’, which is one of those words that everyone _thinks_ they have nailed down. The only thing I’ve ever appreciated about the 12-step philosophy is the related quote “it’s only a problem if it’s a problem.”

    1. The 12-steps and the 12-traditions of AA and related groups are marvelous human plans of intervention. I think we should all try them sometimes to address a host of addictive and social ills.

  17. @dabulamanzikuti 27

    It’s not clear to me that she thinks there really is any mental illness out there independently of the way we talk about the world. Maybe she can clear this up.

  18. I think that the pressure to be relentlessly happy is one of the biggest stressors in modern life. It fits in perfectly with the pressure to look like an airbrushed supermodel. They’re both unrealistic. And they’re both primarily aimed at women.

    1. To both the comments above:

      What do you mean by diagnosed?

      By a professional:
      A quiet introvert could (mistakenly) be diagnosed with dysthymia, I suppose. I would be hard pressed to explore how major depression could be diagnosed just through someone being ‘quiet and introverted’. Misdiagnosed, sure, and, like any profession, misdiagnosis occurs. But, here or there, it would be a misdiagnosis.

      By the lay public or by casual observers:
      Sure, I agree. We do have a serious bias towards extroverts. Possibly because there seems to be a lot of them and they often dominate social gatherings.

  19. Part of this is also what I think of as the Extended Uncertainty Principle, derived from episode 11 of Joan of Arcadia. (If you haven’t seen the series, get thee to Netflix.) The episode had a recurring reference to Heisenberg’s Uncertainty Principle, which was later used as an allegory for human interaction: just by being present and observing, the outcome of a situation can be radically altered.

    The idea here seems to involve something similar: the way you measure doesn’t just change what things look like, it actually changes the things you’re measuring themselves. Propagate the idea of a mental illness, and because ideas affect the mind — sometimes in very subtle ways — the illness itself can become more common.

  20. “I’ve always been mad, I know I’ve been mad, like the
    most of us…very hard to explain why you’re mad, even
    if you’re not mad…”

    ISTM that since Homo Sapiens developed a forebrain we’ve been trying to work out what to do with it and integrate it into the rest of the brain. And we’re still trying to work that out which leads to all sorts of mad behaviour. To some extent we’re all mad because of this. Cultural norms then try to classify various forms of this madness and either promote or denigrate them. They may even try to “cure” them. But this is all a long way away from cases where the brain system is genuinely broken. What’s sad is when the two aspects get confused.

  21. As someone with bipolar disorder, for which there are increasing links to seizure disorders such as epilepsy, it’s interesting to note that seizures are also interpreted differently by other cultures. Of course, one should not lose sight of the fact that both are life-threatening illnesses, with untreated bipolar, for example, having a higher death rate than lung cancer. The question then of not imposing a cultural stereotype upon the mentally ill needs to be informed by the risks of not treating mental illnesses with Western drugs. I know that without lithium and other anti-seizure meds I would not be alive right now and I have trouble with the concept of not offering treatment to another person because of his or her cultural association of mania with religious experience. It is interesting that in the case of providing medicine for physical illness–like polio vaccine–we are less troubled by cultural issues than with mental illnesses.

  22. Lots of folks not reading the FA.

    A main point of which is that the “disease” model of mental illness, which the Western Medical Establishment has been pushing us to accept, is not having the intended effect of lowering the stigma associated with the sufferers. That in other cultures that have a more “spiritual” model of unconventional behavior, sufferers are treated with less stigma and are more able to remain in their place in the community during thier periods of greater health.

    The question of how we extend the real help our science can provide without exporting the social reality that leads to greater stigmatization is a provocative and difficult one. I plan to check out the book.

  23. One thing I think that has been overlooked in this conversation is that psychology is focused on “diagnosis” to the degree that it is required by insurance companies for reimbursement. I think there are many psychologists and psychiatrists in practice today that diagnose people with disorders that they may not actually have in order to get them help. If you are in private practice, having patients pay out of pocket, then you don’t have to diagnose them with anything. However, these are often affluent patients who can afford to pay and make up a small percentage of people who need mental health services. Unfortunately, it is the poorer people who often get the shaft. It is these underserved patients that we often have the least amount of time and availability to help because of lack of funding.

    As a new psychologist, I’ve been watching these discussion with interest over the past few days. I’m surprised that so many people are opposed to mental health – and I suppose it means that my colleagues and I need to do better to make evident the benefits of our profession. Psychology is by no means a perfect science. Despite my training, I make no claim to understand the universality of the human experience. However, real problems do exist and most psychologists and psychiatrists use the latest research to do their best to help.

    1. However, real problems do exist and most psychologists and psychiatrists use the latest research to do their best to help.

      That’s all well and good except that, for instance, homosexuality was a clinically proven pathology for years. Research is predicated on existing bias.

      1. You’re absolutely right. And the great part about science is that we can examine these biases and correct our practice. Alchemy used to be a respectable “science.” Hopefully, the “mental health” of gender and sexuality will go the same way as alchemy.

        Most psychologists, I think, follow the tenet of “It’s not a problem until it’s a problem.” (In fact, this idea is inherent in almost all DSM-IV TR diagnoses. You can be “sad,” but it’s not depression until you miss days of work, sleep all day, gain weight, etc.)

        If someone wants to form a relationship with a cardboard cut-out, that’s fine by me. If it causes them to alienate themselves from others and dismiss other social relationships to the exclusivity of their cardboard lover, then I would hope they would seek some help.

  24. @Antinous

    I think there are some (many) “disorders” in the DSM that are cobbled-together, don’t carve nature at the joints, and may not pick out a set of pathologies. On the other hand, the agony associated with many cases of major depression is clearly pathological, even if “major depression” doesn’t neatly pick out a single disorder. I suspect we’ll have a much finer-grained classification of things like depression once our brain-imagining technology is better.

  25. Wow, more scare quotes in this thread than I’ve seen in a while.

    Maybe the takeaway is that not all so-called “science” is particularly “scientific.” Just because a theory has attained the status of a “consensus” does not make it “true.”

    As an exercise for the reader, which (if any) of the following disciplines are generally scientific and/or authoritative? Which are mere quackery?

    Evolutionary theory
    Particle physics
    Theology (choose your favorite flavor, but compare and contrast with other belief systems)
    Climate change science
    Pure mathematics
    Copernican theory

    1. Hey, I think you were being rhetorical or sarcastic, but let me take a stab at it:

      • Sexology — Didn’t even know it was a field. Sounds goofy, though.
      • Psychology — Behavioralism and experimental psychology seemed reasonable enough when I was studying it, but clinical psychology varies wildly. There’s still Jungian therapists out there who believe in archetypes and collective unconscious. That’s ridiculous. Ok for literary criticism, maybe, but treating actual diseases?
      • Evolutionary theory — not really a discipline in itself. Data-driven biology, archeology, genetics, etc. are all very scientific. Sometimes people say unscientific things, though, especially in public.
      • Particle Physics — Can’t get much more scientific than that. Physics is the ‘gold standard’ for science, as it is universally quantitative, mathematical, and experimentally based. (It benefits some from having few social or political implications, allowing it to skirt some of the emotional conflicts in other fields).
      • Theology, Climate change science, sociology — don’t know enough about the field
      • Pure mathematics — not really a ‘science’ in the same sense ‘logic’ is not a science. But, it is very science like. The gold standard for human thinking. Perfect, in that mathematical proofs are provably and incontestably true and are 100% impersonal (which is to say they are the same regardless what individual does the work, what culture he or she is from, and what his or her beliefs may be)
  26. In my experience, it’s not enough to be delusional, making bad decisions, or annoying others. In order to receive a mental health diagnosis, someone needs to be afraid (of/for) you. If the fear is there, then the other things are optional.

    With that stigma research, it’s not hard to understand the test subject’s hostility. If it’s a purely medical condition, then you’re unpredictable, there’s no telling what you might do. If it’s the result of some trauma, then there’s a narrative with some kind of outcome that you have a voice in.

    When acceptable behavior gets to be decided by specialists, it’s never worked out well. Religious specialists and political specialists have a long history of abusing their power in this regard. Why should we think that pharmaceutical or medical specialists would be immune to such temptation?

    1. When acceptable behavior gets to be decided by specialists, it’s never worked out well.

      But when acceptable behavior is decided by non-specialists, it’s always worked well?

      I wonder how that theory would apply to the maintenance of nuclear reactors.

      1. nuclear reactors are a poor comparison to people: expensive, generating toxic waste, and few in number… sort of the way Americans are encouraged to think of ourselves, come to think of it.

        I think humans are more like kudzu, we need more elbow grease and persistence to manage, less Ph.Ds

  27. For me, the point of Andrea’s post (and links to the article and the book) was to highlight the ways American notions of mental illness have influenced the globe (for the worse, not the better).

    One thing I missed in the linked article was actual firsthand engagement with the medical/anti-medical sensibilities of specific non-Western cultures.

    I can speak to Nigerian attitudes in some detail. It’s worth hearing my examples.

    First, it is worth noting that medicine is often conflated with religion in complex ways. In the roughly two hundred years of informal and formal Nigerian colonialization, th hospitals were often run by Christian missionaries. Thus, the entire late 19th century notion of the modern healthcare was caught up in white, British Religious hsyteria and misunderstanding of traditional black Nigerian spiritual customs. Take in mind that understanding is not the same as being able to list the customs. British colonialists and Christian missionaries became experts in the social anthropological study of Nigerian practices while also systematically trying to wipe them out or minimize these practices influence.

    There are well over 200 ethnicities in Nigeria with distinct cultural ethea (plural for ethos) and practices. (Here “ethnicities” means cultural formations maintained by specific groups of people.)

    Over the years, these ethea and practices have evolved into three main ways of life divided amongst three geographical regions of the country:

    1. Youruba in the Western region;
    2. Hausa in the Northern region; and
    3. Ibo/Igbo in the Southern and Eastern regions.

    After early colonial brutality from the Portuguese and a few other European trade companies, Britain brutally colonized Nigeria in the late 19th century and formalized control through death and apartheid until 1960 when Nigeria gained independence from the UK.

    However, in the interim between 1901 and 1960, new Arab and Christian missionaries also infected Nigerian traditional cultures. The current 50 years of continual inter-ethnic strife in Nigeria comes from two complex horrors:

    1. One cause of the inter-ethnic strife was the 50 years of Nigerian party bosses copying the corrupt practices of the former British colonialists and/or the greedy practices of individual Nigerian warlords and their cults of followers. To break the country, the British selected Nigerians who were willing to drop allegiance to traditional ways and accept money and position to become local emissaries of British rule. Thus, colonialism bred a practice of some Nigerians who are only out for their own influence and that of their cronies and in the early post-colonial days, these greedy men were often still connected to British ruler or they were so called patriots who saw a path to riches through re-colonialization.
    2. Another cause of inter-ethnic strife involves fighting between Muslims and Christians.

      Traditional Ibo, Yoruba, and Hausa cultures were not perfect or pure. But, prior to colonialization and during the time when some regions (like southern Iboland) were not as affected by colonial rule, traditional spiritual practices maintained order and produced a resource rich way of life brimming metal arts, woodworking, rich trade and foodways, complex gendered and sexual experience, and a strong belief in ancestor worship, animal care and welfare, and other forms of “animism.”

      Traditional Nigerian ethnic beliefs in ghost/ancestor possession or worship, witchery or witchcraft, and spirit-theft seem like mental illness to outsiders.

      For some colonialized, Muslimized, and Christianized Nigerians these cultural emblems bring shame. To Muslims and Christians, the Yoruba gods (a still widely maintained polytheistic pantheon including Orisha gods like Ogun, Oya, Oshun, Elegba, and Yemaja) amount to devil worship and craziness.

      But, a closer look shows how distinctly these ancient, thousands-of-years-old spiritual ethea deal with behavioral diversity and basic conflicts.

      For example: By building into the culture the notion that it is a high offense to dishonor a family’s departed ancestry, the culture maintained peace between close knit yet diverse groups while created powerful ethnic dynasties that imposed governmental order locally within far flung regions.

      Witchery allowed what Americans would think of as “off” people to gain communal assistance from other “off” people, to join new groups, and to even contribute to the good of others by supervising herbal health systems and offering counseling regarding the most private of matters.

      But today we in America and the UK are more likely to hear sensationalized reports about “penis theft” ( than non-ethnocentric discussions of traditional Nigerian culture.

      Today, traditional practices are syncretically webbed into Americanized, Europeanized, Muslimized, and Christianized cultures. (Syncreticism is the webbing of disparate influences into new forms.)

      Today, in Nigeria, some may see a psychiatrist and see a tribal counselor too.

      But the intermixing of cultural influences also often breeds tremendous conflict. Basic health problems become battle grounds between traditional and “Western” ways of living.

      Ultimately, Nigeria is a liminal place (an in-between place) caught between many lifeways and struggling in a multi-polar fashion to maintain coherence amongst a sea of vying powers.

      Mental illness is but one of those battlegrounds.

    1. I can speak to Nigerian attitudes in some detail. It’s worth hearing my examples.

      That’s fascinating, dabuamanzikuti. Thank you for sharing. In the American church denomination I grew up in, religious practice and mental health were separate issues. (Which I guess is a fairly liberal position, religiously speaking — but that denomination has been ordaining gay pastors since 1972, so that’s how they roll). I likely unreasonably discount the way mental health and religion are entangled in my own culture, let alone others.

  28. First of all, “mental illness” is a pretty big tent. Probably the authors of the NYT article and many of the commenters here have no real experience with seriously debilitating or potentially life threatening ones.

    The main reason no one has taken Szasz’ arguments for “the myth of mental illness” very seriously for the last 20 years (except Scientologists) is that taking medication and getting talk/behavioral therapy has basically been successful for lots of people with depression, anxiety, ptsd, bipolar, panic disorder, etc.

    The irony of the NYT piece is that, of course, Americans used to view mental illness largely in the context of complex “religious and spiritual narratives”, many of which were basically impediments to people getting better. These narratives generally dictated that if you suffered from one of these diseases, you were weak, inadequate, crazy, looking for attention, or that mental illness was just a failure of will. The idea that stigmatization of people with mental illness has increased with its treatment by the medical community as a “disease” probably isn’t consistent with most patients’ experiences in the U.S. at all.

    But the key question is what Watters and his ilk, as Western cultural critics, would specifically advocate for in terms of changes to the medical care of people in the developing world?

  29. These comments, except for a few, have been decidedly less intelligent than that article. Never did it come even close to saying that mental illnesses aren’t real. Anyone comparing the author to Tom Cruise either has horrible reading comprehension or just didn’t read it (I’m looking at you, dcamsam).

    The point is that mental illnesses result from everything that makes up the mind. That doesn’t just mean biochemical balances (which of course are what it all boils down to, no one is arguing against that you idiots); it means ideas too. Ideas are just the sum of those balances. If you put different stuff into a mind, different stuff will come out. Different cultures lead to different illnesses (not completely different, but noticeably so). That absolutely, 100% does not mean that mental illnesses are fake. It means that they are, in many cases, influenced by external social factors. That is the essence of this article and it’s laughable that people disagree.

    Also laughable is the anecdotal evidence presented against the article’s scientific evidence about stigmatization of sufferers. “The idea that stigmatization of people with mental illness has increased with its treatment by the medical community as a ‘disease’ probably isn’t consistent with most patients’ experiences in the U.S. at all.” Oh, way to go, you sure proved them wrong. Basic scientific understanding versus thousands of years of trial and error isn’t necessarily a one-sided fight. Instead of arbitrarily deciding we’re the best, let’s look at who’s demonstrably better and find out why. Even if they get the cause wrong they can still get the treatment right.

    1. I’m responding as much to Andrea’s argument that mental illness doesn’t exist, that psychology isn’t science, and that the two are a sinister effort to control otherwise healthy people as I am to the article. If drawing attention to that bit of non-clinical denial and paranoia draws a stare, so be it.

      As to the comparison to nuclear reactors: yes, the two are different. One is a very
      complex and if mishandled could result in great suffering, and the other is one that no one would dare suggest be maintained by a non-specialist. Although the notion that humanity is an invasive species that chokes off all life beneath it works, too.

      1. Andrea never said that mental illness doesn’t exist, only that some disorders are cultural constructions borne of racial/sexual/gendered prejudice.

  30. This is a bit silly, but it’s overlooked by the ‘certain leftward-leaning, college educated types’ that are mentioned in the first sentence. So: Americans are incorrectly defining mental illness for other countries? There is an obvious solution: other countries perform their own research. America performs most of the (quality) medical research done across the globe. [aside: That’s a big reason why our healthcare is portrayed as having such a poor bang-for-the-buck (pharmaceuticals are expensive because pharmaceutical research is expensive – did you know it costs $250,000 to apply to the FDA with a New Drug Application?).] So the ‘problem’ is that American researchers research Americans (say that ten times fast) and other countries, rather than performing their own research, use the American research which may or may not apply to them? And this is somehow America’s fault, for not being so considerate as to perform all studies on a global scale?

    There is absolutely nothing stopping these countries from performing their own research and coming to their own medical conclusions. Now you many of you will likely say, “But they can’t afford it!” Well of course! That’s why they’re using our research in the first place! We spend more money annually on pharmaceutical research than some small European countries’ GNP. There’s an old saying: Beggars can’t be choosers. America isn’t changing mental illness for other countries – America is defining mental illness for America. Other countries are /choosing/ to incorrectly define their own mental illnesses by knowingly using American data which doesn’t apply to them. It may be trendy in the ‘certain leftward-leaning, college educated’ crowd to blame America for messing up smaller or poorer countries, but trendy doesn’t equal accurate.

  31. i’m a psychiatrist and neuroscientist. ack, it’s all true and not true at the same time.
    the brain, neural networks, symbols, the halting problem, “selves”. so complex i’d just quit. but warren mcculloch was a psychiatrist, and he lit the cybernetic fire a half century ago. he would only laugh at G.I.D., or cry. why turn back when we are halfway there?
    we are people. we have our own filters. this is an interesting discussion and is always worth thinking about.

  32. It’s a cute trick: re-invent a globalization model that stresses out the rest of the planet…depress the crap out of everybody, then crank up the assembly line with hundreds of anti-depressant drugs, all luvly profits for the drug companies. Are those guys depressed?
    You betcha! They can afford to be. The illusion of happiness has one helluva price tag.

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