Varieties of mental illness

There was an interesting article by Ethan Watters in last week’s New York Times Magazine claiming that we are exporting not just movies, fashion, and fast food to the rest of the world, but treatments for mental illness and, in fact, mental illnesses themselves.

The idea of culture-bound syndromes, though controversial, has been around for a while. The DSM-IV lists two dozen of them, from genital retraction syndrome in East Asia to brain fag in the West Indies. But this phenomenon suggests a much bigger thesis: that all mental illness is culture-bound to some degree, and hence that the Americanization of culture means, among other things, the exchanging of indigenous mental illnesses for Americanized ones:

In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations today as hysterical-leg paralysis or the vapors or zar or any other mental illness ever experienced in the history of human madness.

That’s an interesting, not-implausible thesis that raises all sorts of questions about where mental illness comes from and, more generally, about how culture exerts its influence on the individual. Unfortunately, over half the article is devoted to a rather different topic: the relative inadequacy of certain American treatments for mental illness. Watters argues that schizophrenics often fare better under indigenous treatments than they do under American ones. The latter, with their emphasis on the underlying biology, can leave patients feeling depersonalized and socially isolated. Another interesting, not-implausible thesis that raises important questions about how aggressively American psychiatry should be spread.

But though they’re related, these two issues–the identity of mental illnesses, and their treatment–are quite separate, and Watters’s article does a poor job of distinguishing them. For Watters, the thread connecting them seems to be that illnesses themselves change with the culture because ideas about how to treat them do. Any course of treatment presupposes certain ideas about the nature and meaning of the illness. These ideas, which structure how doctors approach treatment, inevitably get taken up by the patients themselves as a way to understand their conditions. But this happens in such a deep way that the patient’s new understanding of the illness changes the nature of the illness itself. This passage sums up Watters’s position as well as any:

Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening. Those stories, whether they tell of spirit possession, semen loss or serotonin depletion, predict and shape the course of the illness in dramatic and often counterintuitive ways. … This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche.It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

This looks to be Watters’s explanation for why mental illness is culture-bound: culture shapes the patient’s understanding of illness which in turn shapes the illness itself. But this obscures the line between the understanding of illness and the illness itself. Treatment for mental illness should take into account the patient’s understanding of her condition, but this is probably less because it changes the underlying illness and more that it simply makes the burdens of illness easier to bear. To the extent that culture-bound syndromes are really different illnesses and not just different understandings of the same illness, Watters’s explanation is almost certainly inadequate. It overestimates the role of doctors’ ideas about illness. If an individual’s mental illness is malleable enough to be shaped by a culture’s ideas about mental illnesses it is almost certainly malleable enough to be shaped by the culture’s ideas on morality, sex, money, death, love, God, and a host of other important matters.