The globalization of biopsychiatry

This Sunday’s New York Times Magazine includes an excellent article about the globalization of American ways of conceptualizing, treating, and indeed, experiencing mental illness. In “The Americanization of Mental Illness” science journalist Ethan Watters tells a story which, in these neuro-obsessed times, we rarely encounter in popular publications: a narrative about how many experiences of suffering and distress are profoundly shaped by perceptions, expectations, beliefs — what typically gets glossed as “culture” (we’ll return to this point) — and how these perceptions, expectations, etc. are rapidly changing.  Cultural psychiatrists and medical anthropologists will be familiar with most of Watters’ examples, and many will, no doubt, find much to argue with.  However, I think that many specialists will agree that Watters has done a wonderful job of bringing this set of issues a level of public attention which it rarely receives.  The Times Magazine article is based on Watters’ book which is about to be released–Crazy Like Us: The Globalization of the American Psyche–so happily there’s more on the way.

The globalization of North American psychiatry’s diagnostic categories, explanatory models, idioms of distress and modes of treatment has received significant attention from medical anthropologists of late.  On this blog Stephanie Lloyd has written about her work on the adoption of DSM-based models of social phobia in France — a country where, until recently, psychoanalytic interpretations retained their dominance, and Kalman Applbaum recounted a panel at last year’s Society for Medical Anthropology conference on “Mind Games: The Intersections of Globalizing Biopsychiatry, Politics and Social Movements,” which dealt with similar issues. At the end of this post I’ve included a short list of articles and books about the globalization of biopsychiatry.

Indeed Watters’ draws heavily on the work of cultural psychiatrists and medical anthropologists.  He speaks to Sing Lee about the rapid transformation of ideas and symptom presentations of anorexia in Hong Kong which followed the heavily publicized death of a schoolgirl in 1994.  He follows anthropologist Juli McGruder to Zanzibar to examine how local spirit-possession beliefs affect the treatment and lives of people suffering from psychotic symptoms.

In explaining how it is that patients come to present with new clusters of symptoms Watters focuses largely on the ways that medical specialists shape the expectations of their patients:

“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,” (Watters 2010).

Greg Downey has written a post on the article at Neuroanthropology where he argues that Watters’ article perhaps uses an overly cognitive and conscious understanding of “culture” – as something more or less like “belief.”  Downey shows that the actual examples Watters uses shows that “Western ‘culture’ is not just a set of ideas but a whole constellation of ideas, concepts, images, practices, customs, material culture, technology, and other everyday factors that feed into these disorders.”

I agree with Downey, with one significant caveat: I think that the shaping of expectations is an idea which actually encompasses much more than just conscious “beliefs.”  Just think of the enormous literature on the placebo and nocebo effects and suggestion.  These arguments have been developed to explain how the expectancies of patients and healers might shape clinical outcomes, but they also give us a way to begin thinking about how mental illness varies between different historical periods and cultural settings.

However, I think that Downey’s argument—that psychiatric knowledge or technologies don’t get exported in isolation, but are part of a deluge of cultural artifacts, scripts, commodities, institutions—leads us to another very important set of issues, which might be summarized as “How should anthropologists and cultural psychiatrists deal with this kind of complexity?”  Is it enough to gesture toward complexity, calling it a “flow” or an “assemblage” and listing its various elements (as I’ve done above), or should we try to understand the various specific mechanisms through which what we often call macro-processes (like “globalization” or “industrialization”) shape the ways individuals experience and articulate their distress?

While there have been numerous attempts to make such specific links, I’m particularly interested in a few of the recent ones which have gained some traction in medical anthropology.  Here’s one example which Watters mentions in his article. In his discussion of the fugue state in 19th century France, Ian Hacking proposes the metaphor of the ecological niche to speak about a mental illnesses which “appears at a time, in a place, and later fades away,” (1998, p.1).  Hacking suggests this metaphor both as a way out of polemics over whether such illnesses are “real” or “socially constructed,” and as an alternative to the linguistic metaphors (most notably, “discourse,”) which predominate in constructionist arguments.  Like the complex of elements which shape an ecosystem, a number of medical, institutional, demographic, cultural and phenomenological vectors serve to facilitate a particular “way of going mad.”  In order for mental illnesses, such as fugue or multiple personality disorder to come into being as medically recognized entities more is required than the production of a category by experts, Hacking argues.  In addition to fitting into a medical taxonomy, Hacking argues that the illness must be observable or legible as disorder of some kind, it must exist on an axis of cultural valuation running from the romantic to the pathological, and it must provide “some release [for its sufferers] that is not available elsewhere in the culture in which it thrives,” (p. 2).  Finally, while the “discovery” of certain psychiatric entities is facilitated by this set of vectors, the existence of new classifications is knowledge which (albeit indirectly) affects the behavior and actions of patients.
Hacking refers to this process elsewhere as “classificatory looping” and “making up people.

In a 2007 article Laurence Kirmayer and Norman Sartorius expand on this notion of looping to suggest how cultural models, “symptom attributions and explanations can participate in vicious circles of symptom amplification that give rise to culture-specific varieties of panic disorder, hypochondriacal worry, and medically unexplained symptoms,” (2007).  An important background point to their argument is that:

“The body produces a constant “white noise” of somatic sensations that are potential symptoms, and this background noise increases as we age… Physiological perturbations, emotional arousal, and social conflict can all intensify these sensations so that they cross a perceptual threshold and are perceived as disturbing. Symptom schemas assign meaning to sensations, and illness schemas organize patterns of symptoms into coherent entities according to folk knowledge… Such schemas may be anchored in causal explanations but they also reflect the sociomoral and cultural meanings of distress,” (Kirmayer and Sartorius 2007).

Kirmayer and Sartorius suggest that at least seven distinct types of feedback loops are involved in these processes:

“a) physiological perturbation (as a result of functional disturbances of autonomic and other regulatory systems, affecting visceromotor, pain, and other sensorimotor systems); b) emotional distress (in the form of an affective or anxiety disorder or other forms of emotional arousal and distress that do not reach the threshold for clinical diagnosis in their own right); c) disturbances of attention (leading to increased bodily focused attention or, in contrast, ignoring sensations or dissociation); d) misattribution (linking sensations to pathological causes); e) catastrophizing or other types of pathologizing cognitions that undermine coping and elaborate negative expectations associated with symptoms; f) interpersonal responses that may reinforce specific verbal and behavioral expressions of bodily distress; g) health care, disability, and other systemic responses that investigate, diagnose, legitimate, and ratify symptoms and syndromes of bodily distress; and h) larger social and cultural models and institutions that sanction specific modes of talking about and responding to bodily illness. These processes all participate in the ordinary regulation of symptom experience; when they exceed normal parameters, all can be etiological factors in giving rise to persistent bodily preoccupation or somatic distress syndromes,” (Kirmayer and Sartorius 2007).

The point is that this is just one way to think through the specific mechanisms linking macro-processes to expressions of distress.  Another interesting model has been recently suggested by Tanya Luhrmann in her work on “social defeat.”  Luhrmann proposes the term as a way of linking robust ethnography on the subjectivities of homeless mentally ill women living in Chicago with the literature on stress and the incidence of severe mental illness (2007).

But to return to the article, Watters makes two overarching arguments the “Americanization of mental illness” around the world should worry us. Watters’ first argument is quite specific: he gives an excellent overview of the literature questioning whether or not the “disease model” of mental illness actually reduces stigma in the ways it is meant to:

Unfortunately, at the same time that Western mental-health professionals have been convincing the world to think and talk about mental illnesses in biomedical terms, we have been simultaneously losing the war against stigma at home and abroad. Studies of attitudes in the United States from 1950 to 1996 have shown that the perception of dangerousness surrounding people with schizophrenia has steadily increased over this time….

Researchers hoping to learn what was causing this rise in stigma found …that those who adopted biomedical/genetic beliefs about mental disorders were the same people who wanted less contact with the mentally ill and thought of them as more dangerous and unpredictable. This unfortunate relationship has popped up in numerous studies around the world,” (Watters 2010).

Thus in exporting the “disease model”, we are not just dampening cultural diversity, but doing a palpable disservice to people by undermining less stigmatizing ways of interpreting highly distressing behavior or experiences.

Watters ends the article with his second critique—one which builds upon the first—but is also much more general:

“All cultures struggle with intractable mental illnesses with varying degrees of compassion and cruelty, equanimity and fear. Looking at ourselves through the eyes of those living in places where madness and psychological trauma are still embedded in complex religious and cultural narratives, however, we get a glimpse of ourselves as an increasingly insecure and fearful people. Some philosophers and psychiatrists have suggested that we are investing our great wealth in researching and treating mental illness — medicalizing ever larger swaths of human experience — because we have rather suddenly lost older belief systems that once gave meaning and context to mental suffering.

If our rising need for mental-health services does indeed spring from a breakdown of meaning, our insistence that the rest of the world think like us may be all the more problematic. Offering the latest Western mental-health theories, treatments and categories in an attempt to ameliorate the psychological stress sparked by modernization and globalization is not a solution; it may be part of the problem. When we undermine local conceptions of the self and modes of healing, we may be speeding along the disorienting changes that are at the very heart of much of the world’s mental distress,” (Watters 2010).

While I agree with the sentiment, I think that this conclusion makes a couple of assumptions which should actually remain questions open for research.  First of all, there is the notion that “modernization and globalization” are causing or facilitating “psychological stress.”  Again, this is an assumption which needs to be examined at a much more specific level.  The second is the notion that when biopsychiatry arrives, “local conceptions of self and modes of healing” are necessarily erased or destroyed.  I think that this also should be an empirical question—and one which requires close attention to the ways that biopsychiatric ways of thinking about and managing mental illness get taken up in complicated ways and may themselves be shaped by locally dominant cultures of distress.

It is probably a little unfair to complain about some of these details of Watters’ article.  His audience is not one of social scientists, but the educated public. Moreover, during a time when reductive biological arguments rule the roost in most popular discussions of mental illness, Watters has done a great service in bringing attention to an anthropological perspective — and he’s done so in a remarkably clear and nuanced way.  I can also see this article being used in introductory courses on cultural or medical anthropology.  We need more texts like this, so let’s hope that the book lives up to these expectations too.

Additional resources on globalizing biopsychiatry:

Lee, Sing. 1999. Diagnosis postponed: shenjing shuairuo and the transformation of psychiatry in post-Mao China. Cult Med Psychiatry. Sep;23(3), pp. 349-80; discussion 381-99.

Lakoff, A., 2006, Pharmaceutical Reason: Knowledge and Value in Global Psychiatry. Cambridge University Press.

Kitanaka, J., 2008, Diagnosing Suicides of Resolve: Psychiatric Practice in Contemporary Japan, Culture, medicine and psychiatry, 32(2), pp. 152-76.

Lloyd, S., 2006, The Clinical Clash over Social Phobia: The Americanization of French Experiences? BioSocieties (2006), 1, pp. 229-249.

Wilce, J.M., 2008, Scientizing Bangladeshi psychiatry: Parallelism, enregisterment, and the cure for a magic complex, Language in Society, 37(01), pp. 91-114.

Halliburton, M., 2005, “Just Some Spirits”: The Erosion of Spirit Possession and the Rise of “Tension” in South India, Medical Anthropology, 24(2), pp. 111-44.

Conceptualizing social and cultural shaping of mental distress:

Hacking, I. (1998). Mad Travelers: Reflections on the Reality of Transient Mental Illnesses. Charlottesville, VA: University Press of Virginia.

Kirmayer, L.J. & Sartorius, N., 2007, Cultural Models and Somatic Syndromes, Psychosomatic medicine, 69, pp. 832-40.

Luhrmann, T.M., 2007, Social defeat and the culture of chronicity: or, why schizophrenia does so well over there and so badly here, Culture, medicine and psychiatry, 31(2), pp. 135-72.

6 Responses to The globalization of biopsychiatry

  1. The influence of the psychotropics industry in shaping mental illnesses seems a bit overlooked here. DSM-5 is in bad shape, some are calling for it to be simply abandoned due to a lack of transparency, conflict of interest in experts.
    More at english.prescrire.org/spip.php?page=position&id_article=336&theme=322
    Christophe Kopp
    Editor with Prescrire
    Paris (France)

  2. To linger anxiously, even bitterly, over job loss is all too human. To sigh with despair over precipitous declines in one's retirement account is also perfectly understandable. But if the APA includes post-traumatic embitterment disorder in the next edition of its diagnostic bible, it will be because a small group of mental-health professionals believes the public shouldn't dwell on such matters for too long.

    I second Christophe's comment. DSM 1 was the product of the analysis of military personnel, their behavior obviously being affected by the unique stress of a strictly regimented routine. Both in the case of the original and its most recent incarnation, the DSM appears to be a management rather than diagnostic tool. Taylorism for the mind, so to speak.

    marc b.

  3. I agree that the influence of pharmaceutical companies in promoting new disease categories is very important. However, I don't think that this is really "overlooked" in Watters' article. It's more that he is focusing on something slightly different–although closely related. Watters' article is original for its focus on the way that experiences of distress, or at the very least symptom presentations, are changing — not just biomedical classifications. Also, I think that the role of big pharma, conflicts of interest among psychiatrists, disease mongering and so on, has been covered quite thoroughly in the popular media over the past few years.

  4. As a humble member of the educated public I would like to remark that yes: “modernization and globalization” are causing or facilitating “psychological stress.” Sadly, there is no need for a scientific study – and more and more people will be negatively influenced by these unstoppable forces. Modernization is a good thing if you are able to ‘fit in’ – but what if you cannot cope at this new and specific level. And when psychiatry arrives at your doorstep to treat your kin and/or kind, then “local conceptions of self and modes of healing” are absolutely not welcome. Believe me. Or ask anyone who has tried …

  5. A good post: one quibble though, the title – I think "The globalization of biopsychiatry" misses the point slightly because the issue, as Watters identifies is, is diagnostic categories, not biological treatments. Exporting Western-style psychotherapeutic treatments for Western diagnoses is as much a case of globalization as is exporting Western pills, but it's not "bio".

    I think the best summary of the issue is "the globalization of the American psyche", the subtitle of Watters book 🙂

  6. Pingback: Don't see the point in 'help' - Page 2

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