Introduction

To travel internationally is to become increasingly unnerved by the way American culture pervades the world. We cringe at the new indoor Mlimani shopping mall in Dar es Salaam, Tanzania. We shake our heads at the sight of a McDonald’s on Tiananmen Square or a Nike factory in Malaysia. The visual landscape of the world has become depressingly familiar. For Americans the old joke has become bizarrely true: wherever we go, there we are.

We have the uneasy feeling that our influence over the rest of the world is coming at a great cost: loss of the world’s diversity and complexity. For all our self-incrimination, however, we have yet to face our most disturbing effect on the rest of the world. Our golden arches do not represent our most troubling impact on other cultures; rather, it is how we are flattening the landscape of the human psyche itself. We are engaged in the grand project of Americanizing the world’s understanding of the human mind.

This might seem like an impossible claim to back up, as such a change would be happening inside the conscious and unconscious thoughts of more than six billion people. But there are telltale signs that have recently become unmistakable. Particularly telling are the changing manifestations of mental illnesses around the world. In the past two decades, for instance, eating disorders have risen in Hong Kong and are now spreading to inland China. Post-traumatic stress disorder (PTSD) has become the common diagnosis, the lingua franca of human suffering, following wars and natural disasters. In addition, a particularly Americanized version of depression is on the rise in countries across the world.

What is the pathogen that has led to these outbreaks and epidemics? On what currents do these illnesses travel?

The premise of this book is that the virus is us.

Over the past thirty years, we Americans have been industriously exporting our ideas about mental illness. Our definitions and treatments have become the international standards. Although this has often been done with the best of intentions, we’ve failed to foresee the full impact of these efforts. It turns out that how a people in a culture think about mental illnesses—how they categorize and prioritize the symptoms, attempt to heal them, and set expectations for their course and outcome—influences the diseases themselves. In teaching the rest of the world to think like us, we have been, for better and worse, homogenizing the way the world goes mad.

There is now a remarkable body of research that suggests that mental illnesses are not, as sometimes assumed, spread evenly around the globe. They have appeared in different cultures in endlessly complex and unique forms. Indonesian men have been known to experience amok, in which a minor social insult launches an extended period of brooding punctuated by an episode of murderous rage. Southeastern Asian males sometimes suffer fromkoro, the debilitating certainty that their genitals are retracting into their body. Across the Fertile Crescent of the Middle East there iszar, a mental illness related to spirit possession that brings forth dissociative episodes of crying, laughing, shouting, and singing.

The diversity that can be found across cultures can be seen across time as well. Because the troubled mind has been perceived in terms of diverse religious, scientific, and social beliefs of discrete cultures, the forms of madness from one place and time in history often look remarkably different from the forms of madness in another. These differing forms of mental illness can sometimes appear and disappear within a generation. In his bookMad Travelers, Ian Hacking documents the fleeting appearance in Victorian Europe of a fugue state in which young men would walk in a trance for hundreds of miles. Symptoms of mental illnesses are the lightning in the zeitgeist, the product of culture and belief in specific times and specific places. That thousands of upper-class women in the mid-nineteenth century couldn’t get out of bed due to the onset of hysterical leg paralysis gives us a visceral understanding of the restrictions set on women’s social roles at the time.

But with the increasing speed of globalization, something has changed. The remarkable diversity once seen among different cultures’ conceptions of madness is rapidly disappearing. A few mental illnesses identified and popularized in the United States—depression, post-traumatic stress disorder, and anorexia among them—now appear to be spreading across cultural boundaries and around the world with the speed of contagious diseases. Indigenous forms of mental illness and healing are being bulldozed by disease categories and treatments made in the USA.

There is no doubt that the Western mental health profession has had a remarkable global influence over the meaning and treatment of mental illness. Mental health professionals trained in the West, and in the United States in particular, create the official categories of mental diseases. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, theDSM (the “bible” of the profession, as it is sometimes called), has become the worldwide standard. In addition American researchers and organizations run the premier scholarly journals and host top conferences in the fields of psychology and psychiatry. Western universities train the world’s most influential clinicians and academics. Western drug companies dole out the funds for research and spend billions marketing medications for mental illnesses. Western-trained traumatologists rush in wherever war or natural disasters strike to deliver “psychological first aid,” bringing with them their assumptions about how the mind becomes broken and how it is best healed.

These ideas and practices represent much more than the symptom lists that describe these conditions. Behind the promotion of Western ideas of mental health and healing lies a variety of cultural assumptions about human nature itself. Westerners share, for instance, beliefs about what type of life event is likely to make one psychologically traumatized, and we agree that venting emotions by talking is more healthy than stoic silence. We are certain that humans are innately fragile and should consider many emotional experiences as illnesses that require professional intervention. We’re confident that our biomedical approach to mental illness will reduce stigma for the sufferer and that our drugs are the best that science has to offer. We promise people in other cultures that mental health (and a modern style of self-awareness) can be found by throwing off traditional social roles and engaging in individualistic quests of introspection. These Western ideas of the mind are proving as seductive to the rest of the world as fast food and rap music, and we are spreading them with speed and vigor.

What motivates us in this global effort to convince the world to think like us? There are several answers to this question, but one of them is quite simple: drug company profits. These multibillion-dollar conglomerates have an incentive to promote universal disease categories because they can make fortunes selling the drugs that purport to cure those illnesses.

Other reasons are more complex. Many modern mental health practitioners and researchers believe that the science behind our drugs, our illness categories, and our theories of the mind have put the field beyond the influence of constantly shifting cultural trends and beliefs. After all, we now have machines that can literally watch the mind at work. We can change the chemistry of the brain in a variety of ways and examine DNA sequences for abnormalities. For a generation now we have proudly promoted the biomedical notion of mental illness: the idea that these diseases should be understood clinically and scientifically, like physical illnesses. The assumption is that these remarkable scientific advances have allowed modern-day practitioners to avoid the biases and mistakes of their predecessors.

Indeed modern-day mental health practitioners often look back at previous generations of psychiatrists with a mixture of scorn and pity, wondering how they could have been so swept away by the cultural beliefs of their time. Theories surrounding the epidemic of hysterical women in the Victorian era are now dismissed as cultural artifacts. Even recent iatrogenic contagions, such as the sudden rise of multiple personality disorder just fifteen years ago, are considered ancient history, harmful detours but safely in the past. Similarly, illnesses found only in other cultures are often treated like carnival sideshows.Koro and amok and the like can be found far back in the American diagnostic manual (DSM-IV, pages 845—849) under the heading “Culture-Bound Syndromes.” They might as well be labeled “Psychiatric Exotica: Two Bits a Gander.”

Western mental health practitioners are prone to believe that, unlike those culturally contrived manifestations of mental illness, the 844 pages of theDSM-IV prior to the inclusion of culture-bound syndromes describe real disorders of the mind, illnesses with symptomatology and outcomes relatively unaffected by shifting cultural beliefs. And, the logic goes, if they are unaffected by culture, then these disorders are surely universal to humans everywhere. Their application around the world therefore represents simply the brave march of scientific knowledge.

But the cross-cultural researchers and anthropologists profiled in this book have a different story to tell. They have shown that the experience of mental illness cannot be separated from culture. We can become psychologically unhinged for many reasons, such as personal trauma, social upheaval, or a chemical imbalance in our brain. Whatever the cause, we invariably rely on cultural beliefs and stories to understand what is happening. Those stories, whether they tell of spirit possession or serotonin depletion, shape the experience of the illness in surprisingly dramatic and often counterintuitive ways. In the end, all mental illnesses, including such seemingly obvious categories such as depression, PTSD, and even schizophrenia, are every bit as shaped and influenced by cultural beliefs and expectations as hysterical leg paralysis, or the vapors, orzar, or any other mental illness ever experienced in the history of human madness.

The cultural influence on the mind of a mentally ill person is always a local and intimate phenomenon. So although this book describes a global trend, it is not told from a global perspective. In the hopes of keeping the human-scale impact in sight, I have chosen to tell the stories of four diseases in four different countries. I picked these tales because each illustrates how the globalization of Western beliefs about mental health travel on different currents. From the island of Zanzibar, where beliefs in spirit possession are increasingly giving way to biomedical notions of mental illness, I tell the story of two families struggling with schizophrenia. To document the rise of anorexia in Hong Kong, I retrace the last steps of 14-year-old Charlene Hsu Chi-Ying and show how the publicity surrounding her death introduced the province to a particularly Western form of the disease. I deconstruct the mega-marketing of the antidepressant Paxil in Japan to illustrate how drug companies often sell the very disease for which their drug purports to be a cure. The aftermath of the 2004 tsunami in Sri Lanka provides the opportunity to examine the impact of trauma counselors who rush into disaster zones armed with the diagnosis of posttraumatic stress and Western certainties about the impact of trauma on the human psyche.

At the end of each of these chapters I turn the focus back to the West, and to the United States in particular. When viewed from a far shore, the cultural assumptions and certainties that shape our own beliefs about mental illness and the human mind often become breathtakingly clear. From this perspective, it is often our own assumptions about madness and the self that begin to appear truly strange.

The cross-cultural psychiatrists and anthropologists featured in this book have convinced me that we are living at a remarkable moment in human history. At the same time they’ve been working hard to document the different cultural understandings of mental illness and health, those differences have been disappearing before their eyes. I’ve come to think of them as psychology’s version of botanists in the rain forest, desperate to document the diversity while staying only a few steps ahead of the bulldozers.

We should worry about this loss of diversity in the world’s differing conceptions and treatments of mental illness in exactly the same way we worry about the loss of biological diversity in nature. Modes of healing and culturally specific beliefs about how to achieve mental health can be lost to humanity with the grim finality of an animal or plant lapsing into extinction. And like those plants and animals, the diversity in the human understanding of the mind can disappear before we’ve truly comprehended its value. Biologists suggest that within the dense and vital biodiversity of the rain forest are chemical compounds that may someday cure modern plagues. Similarly, within the diversity of different cultural understandings of mental health and illness may exist knowledge that we cannot afford to lose. We erase this diversity at our own peril.

© 2010 Ethan Watters