Reviewed by Patrick J. Salem
As crazy as it sounds, I was afraid that Ethan Watters’ Crazy Like Us was going to be the literary equivalent to Tom Cruise hectoring Matt Lauer about the history of psychiatry, but fortunately, it was an informative, eminently readable, if at times frustrating, argument about the importance of considering local culture in treating mental illness.
Unlike the diminutive actor, Watters main argument against the monolith of psychiatry isn’t the science behind it, rather an attempt by Western practitioners to create normative models for the rest of the globe, dismissing the local mores and customs as unimportant, or worse, as dangerous superstition.
“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 is often 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—influenced the diseases themselves. In teaching the rest of the world to think like us, we have been, for better or worse, homogenizing the way the world goes mad.”
Watters uses four different examples of how the American system of mental health (and its template, the American Psychiatric Association’s book called the Diagnostics and Statistical Manual of Mental Disorders, or DSM-IV) falls short outside the United States. He looks at the rise of anorexia nervosa in Hong Kong, the unheard of incidence of post-traumatic stress disorder (PTSD) in Sri Lanka after the 2004 tsunami, the way an African cultures understanding of schizophrenia went from spirit possession to chemical imbalance, and finally how Japan’s prized cultural personality of austerity and abnegation became the disease of depression.
I have to confess that I’m slightly invested in this topic. For the purposes of full disclosure, I should let you know that I see a psychiatrist on a daily basis. Last night I saw three of them. My wife is a psychiatrist at a state mental hospital in Chicago. Her brother and father are both psychiatrists with the Department of Veteran Affairs. Discussions of efficacy and treatment are ever present at family gatherings, and I was looking to Watters’s examples for foundation and insight.
Watters infuses each of these examples in very real human terms by telling the stories of individuals within these cultures and how the changes wrought by the Americanization of the local view of mental illnesses do more harm than good. He has a storyteller’s feel for the material giving the sights and sounds and qualities of light in exacting detail so that the reader can see the place. Interspersed in these narratives are Watters own feelings and reactions to encountering the mentally ill and the people who treat them. While visiting a state mental hospital on the island of Zanzibar in Tanzania, Watters met a man who spoke excellent English making tea over an open fire in the hospitals courtyard. The man excitedly told Watters of his friends in Arizona where he’d gone to college. Watters assumed the man was a doctor or staff member at the hospital only to learn that he was a patient being treated for “manic depression.”
“Later two guards led me to the entryway of the locked area of the men’s compound. For a few minutes several men on the other side of the barred window talked animatedly to me in Kiswahili. Behind them I could see a half dozen other men in the open area. Some were sleeping, and other rocked restlessly,” Watters writes.
“Given my cultural background, I was incapable of believing that these men were possessed by spirits. Indeed I find it difficult to think of the biological explanation for mental illness as fungible cultural “belief” or “narrative.” I assume, in short, that it is the scientific truth.”
Like Watters, many psychiatrists in the countries he examines are inculcated in the Western approach to treating mental illness because they go to medical school in the United States, are taught by doctors and professors who embrace the model, and perform residencies in hospitals governed by it. It is no wonder, Watters seems to argue, that our attitudes about mental illness are pervasive, and he doesn’t blame the doctors who are trying to balance the local cultures with the model.
Watters is not so forgiving of those who would seek to profit from this globalization. In his examination of depression in Japan, he gives example after example of how pharmaceutical companies pushed the diagnosis and treatment of disorders as a means of creating a new market for their anti-depressants. Watters describes lavish conferences where research studies—funded by the drug companies—proved the efficacy of certain drugs in treating conditions defined by the researchers. It was no surprise to Watters that the treatment of these mental conditions and the research itself led to one conclusion: that these drugs were the solution and that the particular brand of drug that was the best was the one produced by the company that funded the study.
During my reading and subsequently, I’ve had lots of discussions with my wife about Watters’ findings. With me using the book’s examples as indictment, some of these discussions became arguments, some became biology and chemistry lessons, and some became frank dialogues about the subjectivity of all medical science, but in the end, I think my wife’s explanation of the problem would please Watters.
“The DSM isn’t dogma,” she said. “It’s a framework for the language of psychiatry. The problem is that some people cling to the language as immutable. If I encounter a patient from a culture where speaking to and listening to spirits is acceptable behavior, I may think the person is psychotic, but I recognize that in the environment of his culture, he’s not ill.”
At the end of Crazy Like Us, I, like Watters, am left wondering what should be done instead, wondering how we should fix the hodge-podge of treatment techniques. All I know for sure is that a globalized system of treatment is far more dangerous than the fractured approach that mixes potions and poisons with prescriptions and pathologies.
Buy Crazy Like Us: The Globalization of the American Psyche