By Diane Cole
Crazy Like Us: The Globalization of the American Psyche
In a strongly argued new book, Crazy Like Us: The Globalization of the American Psyche, journalist Ethan Watters presents a disconcerting portrait of the latest incarnation of the Ugly American: as global shrink. Read it at the risk of hating yourself (or your colleagues, or Watters, or American culture and capitalism) in the morning. But don't read it and risk missing what our global cultural blinders may be preventing us from seeing.
Crazy Like Us is a withering indictment of America's role in spreading our own concepts of mental illness around the world—a form of American psychiatric imperialism, you might say. "The virus is us," he contends, and we keep on spreading it. (Whoa! See what I mean about hating yourself?!)
Okay, so does Watters have anything new to tell us beyond leftie America-bashing, which is tedious even for a bleeding-heart liberal like me? The answer is yes, but you have to sift through his political assumptions to find it.
To give Watters his due, he's clearly done his homework, researching the cross-cultural psychology literature and interviewing internationally recognized experts. He's traveled to Hong Kong, Japan, Sri Lanka, and Zanzibar, and uses case histories from each locale to illustrate the ways in which he believes we're "homogenizing the way the world goes mad" by exporting our own culture-bound (and DSM-defined) understanding of mental disorders to non-Western cultures.
The prime culprits are pharmaceutical companies and Western-style marketing campaigns, combined with a worldwide overreliance on and overestimation of American psychiatric know-how. Watters finds that when a country's medical establishment assumes that Western treatments are always superior, traditional healing techniques from those cultures become undervalued and are frequently dismissed.
He begins his whirlwind, state-of-the-world's-mental-health tour in Hong Kong, where in recent years, a steep rise in cases of anorexia and bulimia has seemed to mirror the rapid increase in advertising dollars spent on marketing beauty and diet products with the message that thinner is better. At the same time, ever-higher levels of political uncertainty and economic anxiety began bubbling up as the populace began preparing for the territory's transfer from British control to mainland China's. However, Watters hypothesizes there was another dynamic at work in the proliferation of these cases.
Fifteen years ago, according to Sing Lee, whom Watters identifies as China's leading expert on eating disorders, Hong Kong had far fewer instances of eating disorders, and patients rarely or never voiced conflicts or worries about their body-image. Then, in 1994, a Hong Kong schoolgirl's death from anorexia sparked widespread media reports and warnings about harmful eating disorders. While the media's descriptions of a "fat phobia" fixation on thinness would have sounded familiar to Americans, Watters contends that framing the symptoms in this way was new to Hong Kong. He believes that constant media attention helped create a Western-style eating-disorder epidemic.
In the wake of the schoolgirl's death and the massive attention given to it, the number of Lee's patients began to grow exponentially—all of them reporting obsessive thoughts about body-image. Soon, it was his original patients—those who hadn't expressed anxiety about how their bodies looked—who began to seem "atypical," precisely because they didn't conform to American concepts of the disease. Thus, according to Watters, "Western assumptions about eating disorders were not only steamrolling local variations but also potentially acting as a vector, both spreading these illnesses and shaping their expression."
The suggestion is provocative, yet it seems impossible to tease out the number of cases "spread" by Western assumptions from those originating from the rise of political and economic anxiety that suffused Hong Kong at the time that eating disorders burgeoned. It appears that Lee hasn't yet come up with an alternative, "non-Western" method to aid his eating-obsessive patients—a point that leads me to wonder if a more productive focus for this chapter would have been to answer the question of how methods derived from a specific culture can lead to better outcomes. Also, if a blame-game is to be played, why point the finger at America, when it was the Hong Kong media and local medical professionals who turned to Western psychiatric explanations?
The next stop is Sri Lanka, site of the devastating tsunami of December 2004, and a case history that the recent earthquakes in Haiti and Chile make especially timely. It's the book's most successful chapter, presenting a cautionary tale about the ways in which good deeds, however well intentioned, can backfire. Watters describes the extraordinary international relief response, which brought food, shelter, medical supplies, and other provisions to the people of the ravaged area—along with numerous American mental health professionals, who found their way there to help treat a predicted "second tsunami" of post-traumatic stress disorder and other mental ills. As well-intentioned as these professionals were, however, Watters believes too many failed to comprehend or respect the differences between Sri Lankan and American concepts of emotional trauma and distress. In addition, he contends, many of those who came to help were more interested in advancing their careers by conducting trauma research than in actually helping. In addition, the help that was offered, says Watters, usually consisted of by-the-book therapeutic protocols for treating an assumed condition of PTSD. Perhaps worst of all, he finds that Western-style "healing" had the potential to divide communities into rival groups: those who accepted the "new" way of retelling stories of trauma in order to master them, and those who maintained their traditional method of using silence to keep the past at bay.
Thus, he writes, rather than helping rebuild torn communities, "trauma counseling services had the potential to have the exact opposite effect." Instead of turning this into a political statement, however, the moral could be expressed more simply, as "stranger, do no harm." Ask people what they think they need before you give what you assume they need.
Up next: Zanzibar, where Watters observed how families care for relatives suffering from schizophrenia, and tried to answer the question, "Why did people diagnosed with schizophrenia in developing nations have a better prognosis over time than those living in the most industrialized countries in the world?" He admits there are no conclusive answers, but quotes research suggesting that Zanzibari traditional beliefs about schizophrenia as originating in spirit possession allow patients and caregivers a structure for hope of recovery, or at least periods of remission. The reason for hope is that such "spirits" are understood to come and go at their whim, staying and leaving for different lengths of time—perhaps, one day, disappearing altogether. In addition, Zanzibar's traditional belief systems encourage acceptance of the condition as part of life, and support the view of maintaining respect for the possessed individual as a member of the family and of the larger community. Also, traditional community and family structures encourage care by household members. By contrast, the Western medical paradigm defines schizophrenia as a disease caused by "brain chemistry"—a narrative that, Watters feels, dehumanizes and stigmatizes patients, and gives caregivers a rationale for being overly controlling.
Watters demonstrates the link between a culture's understanding of mental illness and how communities care for their own. But he also delineates how some families in Zanzibar have successfully combined the use of Western antipsychotic medications with their traditional caring routines. That makes his dismissal of "brain chemistry" all the more baffling. The important point, it seems to me, is to respect and treat patients as individuals, regardless of the paradigm one uses to define the disease.
Finally, Watters chronicles the megamarketing of antidepressants in Japan by GlaxoSmithKline and other pharmaceutical companies. It's the story of capitalism in search of new markets at any cost, and he tells it with gusto. He recounts, step by step, the path by which GlaxoSmithKline introduced a seductive advertising campaign that redefined the ways the Japanese had traditionally thought of depression and suicide. Campaign slogans that equated depression with "a cold of the soul" helped transform public perceptions of melancholy from a culturally respected personality trait into a symptom that could be treated by a magic pill. A concerted advertising and media blitz led to ever-increasing requests by consumers for prescriptions, and sales were soon booming—much as they are in the United States. Indeed, only now are we in America becoming aware of the degree to which antidepressants have been oversold and overmarketed here. If anyone needs more details about the big bucks Big Pharma is willing to pay to seduce academics, researchers, and physicians at all levels, not to mention the public at large, this is where Watters shines. Indeed, he presents a case history not only about Japan, but about how we Americans have allowed (and enabled) many of the same forces to seduce us. I only wish he'd been less interested in figuring out how to blame America for the success of morally sleazy marketing practices than in helping us figure out how to guard against, or prevent, future Big Pharma marketing-based seductions.
Watters is at his best reminding us that, just as no two patients are alike, no two cultures are either. Despite his often overblown language, his critique of "psychiatric imperialism" is eye-opening and provocative. Still, it's hard to miss the irony that he's fallen prey to his own simplistic cultural assumptions: to him, exported American therapeutic insights always seem to have dubious value, while non-Western traditions are invariably preferable. In some ways, the cautionary message of his book can be boiled down to a simple warning: instead of transporting intellectual baggage from one culture to another, "check your assumptions at the border."
Diane Cole, a contributing editor for U.S. News and World Report, is the author of the memoir After Great Pain: A New Life Emerges. Contact: email@example.com. Tell us what you think about this article by e-mail at firstname.lastname@example.org, or at www.psychotherapynetworker.org. Log in and you'll find the comment section on every page of the online Magazine section.