The Americanization of Mental Health

Mental health issues are complex and should be evaluated on many levels, with cultural context near the top of the list. Ethan Watters in his 2010 NYT essay “The Americanization of Mental Illness” discusses how other cultures have been inundated with Western ideas of mental health and consequently expressions of mental illness worldwide have started to “look” American. The author posits that while some Western developments around mental health are positive – pharmacological drugs, for example – most of the Western world’s ideas and beliefs around mental illness are only appropriate within the West. When thrust upon other cultural groups, these ideas and beliefs are almost always detrimental. Watters also implies that the West doesn’t have mental illness all “figured out” and cites the fact that individuals with schizophrenia tend to have lower rates of relapse in developing countries as evidence for the West’s deficiencies in treating some illnesses. Finally, the author suggests that it is the West’s “hyperintrospection” and “penchant for ‘psychologizing’ daily existence” that is ultimately responsible for its increasing rates of mental illness.

The author begins his argument by citing the findings of a prominent Chinese psychiatrist and researcher who witnessed a shift in the presentation of anorexia nervosa in Hong Kong. Prior to the sensationalized death of a teenage girl suffering from anorexia, Dr. Lee said his patients did not express a fear of gaining weight and instead frequently complained of bloating in their stomachs. However, after local papers reported that the young girl died from anorexia, the understanding of the disease and even its expression began to change: Dr. Lee’s former two to three cases of anorexia per year rose to two to three each month. (Note: The reporters copied the description of anorexia from an American diagnostic manual.) Dr. Lee also reported that in the late 90s – after the story broke – 3-10% of young women in Hong Kong had disordered eating patterns and cited their fear of gaining weight as the reason they starved themselves. The author says it is unlikely that anorexia would have “so quickly become part of Hong Kong’s symptom repertoire without the importation of the Western template” for the disease.

Similarly, other Western ideas around mental health and illness are accepted as gospel due to their omnipresence:

• American researchers and institutions run most of the psychology and psychiatry journals and host top conferences in the field;
• Western drug companies spend billions on the research, development, and marketing of medications for mental illnesses;
• Western-trained traumatologists deliver first aid – for both physical and mental trauma – and effectively influence the way victims view mental illness;
• Western mental-health professionals push “mental-health literacy” around the world.

If the world accepts the Western view of mental health as true, that means it’s correct, right? According to the author, therein lies the issue. That is, the Western understanding of mental illness is rarely appropriate for the rest of the world given that a mental illness cannot be understood in a vacuum; the ideas, habits, and cultural trappings of its “host” must be considered for the most accurate diagnosis and provide the best care. Further, the author suggests that the West’s ideas about mental illness are not always appropriate, even for those in the West. Citing a study that showed participants were less sympathetic to controls who described the origin of their mental illness as biological (versus due to psychosocial factors), he attempts to discredit the American and British viewpoint that mental illness framed as brain disease protects sufferers from social stigma and blame.

Finally, Watters “seals the deal” with his revelation that individuals with schizophrenia fare better in developing nations than in the West. As schizophrenia is considered one of the most challenging and complex mental illnesses, one would assume that the West – if it is indeed the authority on mental illness – would provide the best treatment for those afflicted with the disorder. That the prognosis for individuals with schizophrenia is better in developing nations says a lot about the West’s understanding of the disorder, and ultimately about mental health in general. The author makes a strong argument for both the ubiquity of the West’s views on mental health and the danger of such influence.

The author accomplishes his goal of convincing the reader that mental illnesses should be evaluated and treated in their respective cultural contexts and that application of the Western view of mental health in non-Western cultures is not the correct way to address such issues. I believe the strongest evidence for his argument – which he tactfully saved for last – was the discussion of the prognosis of people with schizophrenia. This was one of the author’s most effective techniques. A person reading this in the New York Times on a Sunday morning would easily be persuaded of the author’s – and his many contributors’ – opinion. If I were evaluating the piece solely on how effectively it proved its thesis to its target audience, I’d absolutely say the author achieved this. However, in evaluating the piece more critically, I found that it employs some common journalistic tactics that I find a bit unsavory. Because of these tactics, I have to take this piece with a grain of salt.

While I hold some biases because I was educated in the West and no doubt possess nationalistic pride, I'm not too proud to admit that the West has made (and continues to make) grievous errors in its dealings with people of other nations. In evaluating the human rights issues plastered on the front pages of news publications in the United States, I try to view the issue in the context of that culture. Similarly, I believe mental illness should be treated holistically; that is, treating the person as well as his or her illness, which includes the consideration of his or her cultural group. I agree with the author’s contention and think he makes a great case for this in the piece. However, as I stated previously, I found it difficult to ignore some of the cheap tricks he used to argue his point.

One of the tactics he employed was the use of words like “most,” “many,” and “often” without providing any evidence to support the use of such definitive language. In support of his assertion that the West’s influence on the mental health industry is far-reaching and unavoidable, he states “American researchers and institutions run most (emphasis added) of the premier scholarly journals and host top conferences in the fields of psychology and psychiatry…In addition, Western-trained traumatologists often (emphasis added) rush in where war or natural disasters strike to deliver “psychological first aid,” bringing with them their assumptions about how the mind becomes broken by horrible events and how it is best healed." How many scholarly journals are there and how many of those are actually run by American institutions? Similarly, what are the statistics on Western-trained traumatologists and disaster aftercare? It would be easy to simply go along with the author’s assertions here, but in looking critically, I believe it would be far more effective to include actual figures instead of vague qualifiers like these.

When the author does attempt to include empirical evidence, it is weak and again lacks specificity. For instance, the author glosses over the discussion of how the West’s push for “’mental-health literacy’ has gained ground” by neatly stating that “studies” – without describing any of these alleged studies – have shown that the world has adopted the West’s model of mental illness. A statement of that magnitude would require some evidence, but the author doesn’t think so, and hopes the reader doesn’t notice. He continues, stating how the changes are “most (emphasis added) extensive in the United States,” but “similar shifts” have been reported around the world and “people from a variety (emphasis added) of cultures are increasingly likely (emphasis added) to mention ‘chemical imbalance’…or ‘genetic/inherited’ factors." Again, where is the supporting evidence for these statements? The author hops to the next paragraph – conveniently referencing his previous, unsupported paragraph – describing how the West is “losing the war against stigma." Here he posits that the West’s marketing of mental illness as brain disease is the reason the American public’s perception of the dangerousness of people with schizophrenia increased from 1950 to 1996. Again, he cites “studies (emphasis added)” of these attitudes and fails to describe said studies with any specificity. I don’t disagree that there’s a correlation between these ideas and the public’s ideas about mental health, but Watters does not convince me that there is causation. There are undoubtedly many other factors that have influenced this shift – increasing access to media and growing population density, for example – that the author omits to strengthen his argument.

Finally, the author consistently implies that the West is foisting its ideas of mental health upon the rest of the world, which simply accepts these ideas as fact because it has no other choice. The author could have gained ground on this front when he mentioned the scholarly journals, conferences, and medication marketing primarily controlled by the West. Instead, because he did not expound on this – providing actual data to support these strong statements – I remain unconvinced that this is the case. His introduction to this concept came in the discussion of the tragic death of young Charlene in Hong Kong. In stating how “local reporters often simply copied out of American diagnostic manuals,” we are led to believe that the resulting increase in anorexia cases in Hong Kong that “looked” like American anorexia were due to the West’s conscious influence over Chinese citizens via the media. Why is the blame placed on the West when it was the reporters who chose to reference American material for their articles? If Dr. Lee was documenting anorexia nervosa at the time, why didn’t reporters contact him or other Chinese experts in the field? Again, why should the West be held accountable for journalistic laziness, shortsightedness, and inaccuracy?

In summary, I thought the piece was well written and supported its thesis. If I weren’t tasked with analyzing it, I probably wouldn’t have found any issues with it. However, as I viewed it through discerning eyes, I took issue with some of the author’s supporting evidence. I would be interested to read the entire book, Crazy Like Us, to determine if the author omitted evidence in an attempt to keep the piece somewhat brief, or if this is representative of how the book is written. It is probably obvious that the essay annoyed me. While I agree with the author’s thesis, I think he did what many of us do when arguing our point: he highlighted evidence that supported his view while glossing over and/or omitting evidence to the contrary. The article is effective in convincing the reader that mental illness is a complex issue and there are no one-size fits all remedies for the myriad disorders that exist. While I think the author is a little too quick to criticize the West’s efforts at trying to understand these illnesses and to reduce some of the stigma faced by those afflicted with them, I do appreciate that there is such extensive dialogue about mental health and hope the trend continues.