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In 2012 I took an Abnormal Psychology class at CCSF. My honors project was a response paper to the book  Crazy Like Us: The Globalization of the American Psyche  by Ethan Watters. I loved the book and highly recommend it. Here’s what I wrote about it.

Introduction

Ethan Watters uses four stories to paint a picture about how American culture has a powerful influence on how the rest of the world understands mental illness. Sometimes intentionally, sometimes not, American culture is shaping how these mental illnesses are perceived and treated.

Americans think about mental illness in a very particular way. This thinking depends heavily on biological, genetic, and environmental factors. But largely missing in this view are the cultural factors that shape the course of mental illness greatly. This isn’t how the ill person sees themselves but how their local culture sees them. For example, the stories told about the origins of mental illness, be it spirit possession or chemical imbalance, have a huge impact on mentally ill persons and can alter the outcome of their disease.

Watters describes how cultural cues have affected the presentation of mental illness throughout history right up to today, describing mental illnesses that work their way through societies more like social memes than the results of environmental and genetic processes. A host of illnesses have come and gone through societies throughout the world without any components that would be recognizable as having universally identifiable causes, conditions like Indonesian Amok, Victorian era hysterical paralysis, World War I shell shock, Japanese neuroasthenia, and modern post traumatic stress disorder.

Chapter 1: The Rise of Anorexia in Hong Kong

The author met Dr Sing Lee, Hong Kong’s preeminent researcher on eating disorders. Over the course of Dr Lee’s career, he has seen the epidemiology of anorexia nervosa in Hong Kong change dramatically. Before about 1990 anorexia was an exceedingly rare disorder and it didn’t manifest anything like what was seen in the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR). Western culture became an important influence on HK society. After the case of a woman who died of the HK version of the disease was widely publicized in the media, and the western version of the disease was widely discussed, an explosion of “western” anorexia came to HK.

 Chapter 2: The Wave That Brought PTSD to Sri Lanka

After a tsunami killed more than 30,000 people in Sri Lanka on December 25, 2004, hundreds of western counselors and psychologists rushed in to try and alleviate the massive amounts of post traumatic stress disorder (PTSD) they believed the people would be suffering from. The response was very problematic though. First, Sri Lankans handle stress differently from westerners; they certainly experience stress, but the experience is so different that neither western diagnosis nor treatment is appropriate. For instance, since Sri Lankans rely heavily on their social network of friends and family to handle stress, the idea of taking sick leave from one’s duties and social roles to pursue something like individual counseling (a very western notion) could be exactly the opposite of what should be done.

The author presented several examples of how western thinking doesn’t offer a good picture of PTSD in Sri Lanka.

• Several counselors said that in retrospect, the best thing they brought to the people wasn’t their counseling ability but there mere presence.
• PTSD manifests differently in different cultures in different times. Each disease had somewhat different symptoms and possible treatment. During the Boer Wars, British soldiers suffered Debility Syndrome. Civil War soldiers suffered Da Costa’s Syndrome. World War I soldiers got Shell Shock.
• The author discussed a recent civil war in Sri Lanka where western counselors changed the dynamic of how people talked about the war. This change made many people uneasy and threatened peace in the region.

The author did a critical analysis of Critical Incident Debriefing (CID). This is the system developed that suggests that the “psychological first aid” that Sri Lankans received is a good idea. This is the practice of pre-emptively sending counselors into a disaster area looking to help victims with the psychological aftermath of a disaster. The trouble is that numerous studies show this emergency counseling doesn’t work. Moreso, those treated can fare worse on average than those that did not receive the emergency treatment.

Chapter 3: The Shifting Mask of Schizophrenia in Zanzibar

The author discusses how people with schizophrenia living in different parts of the world have dramatically different outcomes. It may come as a surprise to Americans that the western world with its meticulous scientific practices does not, on average, have the best outcomes. Some large studies show that over 40% of schizophrenics in industrialized nations were judged to be “severely impaired” over time while only 24% of schizophrenics in poorer countries received the same judgment.

The level of expressed emotion (EE) in households and communities with mental illness may affect the outcomes of schizophrenic people. Expressed emotion is a combined metric of the level of criticism, hostility and emotional involvement in a household. For better or worse, American culture generally has higher EE. Americans are more individualistic, and very goal oriented when it comes to doing things like beating a disease. The author mentioned an example of how a parent tried very hard to read up on schizophrenia and help his son beat it (which unfortunately isn’t really possible). Sri Lankans are more likely to do a variety of things that help keep the ill person in society and supported as well as possible: they may blame the disease on an unhappy spirit that comes and goes as it pleases in the ill person, and they take the disease in stride, caring for the ill person when needed and welcoming them back into their lives whenever possible.

Chapter 4: The Mega-Marketing of Depression in Japan

GlaxoSmithKline (GSK) spent a great deal of time and effort positioning themselves to be able to introduce their anti-depressant drug Paxil to Japan. In the end, they succeeded, helping to infect the Japanese with a meme that allowed Paxil to become a billion dollar a year product. The author has very low regard for this and other big pharma companies.

To break into Japan, GSK had to understand the Japanese concept of depression and how their drug might fit into their culture. Feelings of overwhelming sadness are venerated in Japan. The media and stories throughout their history have held in high regard people that have held onto their sadness. It is seen as a grounding and stabilizing force. Only the most extreme depression was seen as problematic.

GSK spoke to many experts in Japanese cultural anthropology and found a few “ins”. Japanese culture has in the past been subject to the same cultural shifts that others have been, taking on European ideas. In 1990 a man committed suicide and the Supreme Court’s ruling introduced the people to the idea that he died of western style depression. They found several sneaky ways around the isolationist laws protecting Japanese including things like promoting the drug while seeking for volunteers for the drug trials and translating western books on depression and medications into Japanese.

The author has many huge problems with GSK and the other big pharma companies in their launch of drugs in Japan and elsewhere. He cites several very important items:

• The science behind the marketing messages for Paxil and other SSRIs is dubious at best. It speaks to the people more as a marketing message than science.
• “Because GSK and other drug companies have control over the creation of the science, Healy argues, “there is almost no possibility of discrepant data emerging to trigger a thought that might be unwelcome to the marketing department of a pharmaceutical company… Healy estimates over half of the studies in the most prestigious journals were being drafted not by the university researchers supposedly heading the studies but by the medical writing companies paid by the drug companies” (237). This is claiming a conspiracy of grand proportions on the part of researchers, the drug companies and the peer reviewed journals!
• Still on the subject of journal articles being written by medical writing companies,“Nassir Ghaemi, director of the Mood Disorders and Psychopharmacology Programs at Tufts Medical Center [writes], “Ghost authorship is the steroid problem of academia…” (237).
• The author says that studies that don’t support the drug companies’ claims are often buried while studies that do support drug company claims are published. (238)
• The author casts doubt on the effectiveness of SSRIs saying that they might only perform slightly better than placebo. (238)
• A Paxil study was published right around the time that Paxil was launching in Japan. It was produced by the most respected scientists and placed in the most respected journal. The study said that Paxil was “remarkably safe and effective” in the treatment of adolescent depression. The timing of the release of the study was no accident. Unfortunately, court obtained documents received a few years later show that the research was fraudulent; that research showed that the drug wasn’t nearly as safe or as effective as the article claimed! (240)
• Dr Marcia Angell, former Editor-in-Chief at The New England Journal of Medicine wrote in 2009, “It is no simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.” Wow. That is a huge statement coming from a person in her position

All of these nefarious strategies have apparently paid off for GSK. They gained their foothold in the Japanese market. Sales climbed from $0 in 2000 to $1 billion/year in 2008!

Reactions

The author’s depiction of big pharma in the last chapter really took me by surprise. His depiction makes them out to be really quite evil. The picture that Watters paints is that Paxil is popular not because it is effective but because GSK has co-opted the entire peer reviewed journal process to promote their product to researchers, doctors and the public. They continue to use immoral and illegal means to promote the use of their products. And in the case of introducing Paxil to Japan, they created a need for their drug where there really was none previously, changing the social landscape of an entire culture. I’d like to look more into this subject to see if his claims are valid.

This book gave me great perspective on the mental health profession in America. We try so hard to codify mental illness, the DSM being the most respected text, as if the mind can only break in particular ways. But the DSM doesn’t give justice to how culture has a strong influence on the core of mental diversity and illness. Each society has strengths and weaknesses built into it. To paint with a broad brush I can say that the differences between America’s individualistic culture and Sri Lanka’s social culture offer the members of each society something different. These societal differences are so profound that they affect how we function at a basic level.

The author’s theme of how western culture continues to leak around the world into all of these cultures bothers me. Part of the reason it bothers me is that he is telling us in almost the same breath how these people have different and good ways of coping with problems, but they look to Americans for help anyway, undercutting their own strengths. But it is hard to deny that our economic power is felt around the world.

Works Cited

Watters, Ethan.  Crazy like Us: The Globalization of the American Psyche. New York: Free, 2010. Print