Mad in America

Relativity of mental illness has enjoyed the favours of philosophers for decades (Michel Foucault, Ian Hacking and, more recently Geoffrey Llyod in his Cognitive Variations). It has lead to the development of the « new cross-cultural psychiatry », heralded by Kleinman in 1977. It  may become the best pop version of culture and cognition – as shown by the recent piece in the New York Times « The Americanization of mental illness », published on the 10th of january. The essay is adapted from Ethan Watters’ forthcoming book, Crazy Like Us: The Globalization of the American Psyche.

As with many fashionable ideas,  it is a bit difficult to isolate the arguments from the seductive examples. The thesis itself, as it appears in the paper, leaves room to different interpretations: « Mental illnesses are not discrete entities like the polio virus with their own natural histories….and have never been the same the world over (either in prevalence or in form) but are inevitably sparked and shaped by the ethos of particular times and places. » What is sparked and shaped by culture? The boundary between mental illness and mental health, the distinction between mental and physical illness, or the division between kinds of mental illnesses? Some examples in the article even suggest that cultural classifications of mental illnesses converge, but give different explanations of their origins, significance or treatments. Others stress the fact that what is spreading is basically a « symptom repertoire », i.e. knowledge of how to diagnose illnesses, rather than definitions of what is diagnosed.

Moreover, as nobody challenges the idea that different cultures have different views on health and medicine, which in their turn influence the treatments people are – or are not – offered, the revolutionary potential of the thesis can be a bit hard to see.  

But the paper highlights two more interesting, or disturbing points: first, that western categories of mental illnesses spread and contaminates the other cultures, and second, that this contagion is not for the best.


In this sense, as I understand it, “mind medicine” would stand in contrast with “body medicine”, either because the contagion isn’t so unilateral (see the rise of Chinese medicine or acupuncture in Europe) or because nobody thinks that the spread of western ideas about cancer or AIDS isn’t a good thing. Anyway, the paper presents a good case of contagion of ideas – and even puts it on trial. The two aspects are of interest, although a bit confused.

The ways the world goes mad

The paper relies heavily on a recent and documented example, showing how « anorexia » spread in Hong Kong after a tragic case where the press reported that a young, very thin girl had died of “anorexia”.  “Food refusal had a particular expression and meaning in Hong Kong” and  “unlike American anorexics, most of (the) patients did not intentionally diet nor did they express a fear of becoming fat”. It would almost be a case of contagion from a single case: after the event caught the press attention, doctors saw more patients reporting or showing « western » symptoms of anorexia. « By 2007 about 90 percent of the anorexics …treated reported fat phobia. New patients appeared to be increasingly conforming their experience of anorexia to the Western version of the disease. ».

Ironically, all the mental illnesses categories of anorexia, hysteria, schizophrenia are said to be « American » – perhaps the author signs a bit too quickly of the fact that ideas are shaped by one own’s culture.

The case is certainly very interesting, and well chosen. « Eating disorders » are multi-faceted, and their varieties, the real nature of the pathology, their mix with normative aspects of bodily appearance, their significance are still objects of inquiry. Still, the shift between the level of symptoms (food starvation), the mental attitudes of patients (fat phobia) doesn’t help seeing whether :

any person who starves herself (or himself) is an anorexic,
any person who starves herself (or himself) has a form of anorexia (there is no anorexia, but just family resemblances between cultural expressions of anorexia)
only persons who starve themselves because of fat phobia are anorexic
persons who starve themselves and are ready to believe that this is because of fat phobia become real anorexic
persons who starve themselves and are ready to believe that this is because of fat phobia are « fake » anorexic. 
There is a « loop » : people who starve themselves come to believe they are anorexic and they become « real » anorexic. 

I guess one needs to be clear on what is at stake, before putting forward a thesis on the “westernization of mental illnesses”.

The spirits do better

The paper goes on showing why this spreading of ideas is not for the best.  A bit of « colonial bad conscience » pervades the whole paper, but doesn’t go without arguments.

Here, the case study is schizophernic (or schizophrenic-like) people –a case which is quite different from anorexia, at least because its neurological aspects are now well established. Anyway, the focus here is on treatment.  The trouble comes here from the fact that the World Health Organization established, after a research over the course of 30 years, that « patients outside the United States and Europe had significantly lower relapse rates — as much as two-thirds lower in one follow-up study. These findings have been widely discussed and debated in part because of their obvious incongruity: the regions of the world with the most resources to devote to the illness — the best technology, the cutting-edge medicines and the best-financed academic and private-research institutions — had the most troubled and socially marginalized patients.”

Two explanations are offered:

First, spirit possession is more « democratic »: anybody « violating social norms — from a sister lashing out at her brother to someone beset by psychotic delusions » is possessed, and thus possession doesn’t result in stigmatisation and exclusion. (The Freudian idea that we are all perverse must thus be a effective one !). But here, the boundary between health and illness is cancelled, and it’s not clear that it supports the idea that different conceptions of illness have different effects.

Second, people would universally have tendency to « essentialize » the biological and thus, western biological theories of mental illness (reducing them to brain chemistry disorders) tends to make the « mad » essentially (and permanently) mad, while traditional conceptions of spirit possession makes him or her only contingently (and temporarily) mad. The latter encourage a better integration of possessed people, finally helping them to be better, and reducing the frequency or intensity of their crises.

The paper reports experiments by Prof. Sheila Mehta, from Auburn University Montgomery in Alabama,  that I hadn’t heard of – and are fairly disturbing. The hypothesis was that « biomedical explanations for mental illness might be influencing our attitudes toward the mentally ill in ways we weren’t conscious of. »

« Test subjects were led to believe that they were participating in a simple learning task with a partner who was, unbeknownst to them, a confederate in the study. Before the experiment started, the partners exchanged some biographical data, and the confederate informed the test subject that he suffered from a mental illness. The confederate then stated either that the illness occurred because of “the kind of things that happened to me when I was a kid” or that he had “a disease just like any other, which affected my biochemistry.” ….The experiment then called for the test subject to teach the confederate a pattern of button presses. When the confederate pushed the wrong button, the only feedback the test subject could give was a “barely discernible” to “somewhat painful” electrical shock”. At the end “Those who believed that their partner suffered a biochemical “disease like any other” increased the severity of the shocks at a faster rate than those who believed they were paired with someone who had a mental disorder caused by an event in the past.”

Does this effect still applies to people coming from non-western cultures ? And don’t these two explanations show that  actually, some explanations (ie the spirit possession) are absolutely better than others, and not – as I believe the paper wants to show – locally and relatively better (spirit possession is good-in-Zanzibar, and brain-explanations are good-in-America) ? Any thought ?


  • comment-avatar
    Dan Sperber 25 January 2010 (12:49)

    I enjoyed Ophelia’s post, but have anthropological reservations about the ideas she reports and seems to agree with about spirit possession. I did my fieldwork in Southern Ethiopia, where spirit possession is quite common, I have had briefer encounters with spirit possession in Mexico, and, although it has not been the topic of my work, I do have a classical anthropological interest in it. Actually, there is a great variety of forms of spirit possession. Sometimes possession is considered an evil from which the possessed must be cured. Commonly, it is considered a personal resource, a kind of gift. Most of the time, I suppose, it is viewed ambiguously as something like both a gift and a weight. Spirit possession cults are quite commonly in the business of helping people in a variety of ways. Curing people with psychiatric illnesses is certainly not a common, let alone a typical way in which they help people. If a comparison is to be made with Western practices, it should be with psychoanalysis rather than with psychiatry. Just as you can keep a shrink forever and not aim at being cured, members of possession cult are not trying to shorten their membership. Both a shrink and a possession cult allow you to pay attention to yourself with serious encouragements that, in most cases, your family, your friends, or your neighbours wouldn’t provide. Maybe Emma Cohen, who has written an excellent book, [i]The Mind possessed[/i], on spirit possession in Brazil, might join the discussion.

  • comment-avatar
    Emma Cohen 27 January 2010 (08:01)

    The explanations for the WHO finding are interesting though apparently poorly informed by any ethnographic observation of spirit possession, much less decades of debate within anthropology about what the mental and biological bases and medical implications of possession-trance are (- this was back in the day when such things were important because researchers were actually interested in offering explanatory accounts for what they observed). Indeed, knowing a little of the ethnography and debate causes me to pause over the premise of the finding, not to mention the explanations. Are they comparing like with like in the first place? And how would they know? If they exclusively take account of behaviours, and not of the interpretations or conceptions, they’ll quickly run into difficulties. The overt behaviours of a person possessed by a spirit and the overt behaviours of a method actor, for example, can look surprisingly similar. Interpretations have got to count for something, not only for reasons of typology and appropriate comparison, but also because these interpretations have important consequences for mental health. Many ethnographers have pointed out (and this was certainly the case in the field setting where I worked also) that two possession behaviours that may appear identical to the untrained observer may actually straddle the divide (as construed by their participants) between acceptable/appropriate/healthy and unacceptable/inappropriate/’mad’. An important criterion, and a cross-culturally common one, concerns whether the identity of the possessing spirit is in some way ‘institutionalized’ within the social context in question. In the majority of religions involving possession-trance, there are conventions, rules, narratives, theologies, and so on concerning the spirits. Someone apparently possessed by a highly idiosyncratic alter-identity that doesn’t know the conventions, acts in unrecognized ways, is ‘untrainable’, unfamiliar, etc. is generally not welcome at a regular possession ceremony. Where I worked, there were at least two such people. They were called ‘crazy’. And so, possessed people can be stigmatized and ostracized too. As Dan pointed out, possession is not always a bad thing, and not always something that people seek to cure. Frequently, people seek quite the opposite – to cultivate relationships with possessing spirits. Possession and healing often go together, but the healing tends to be fairly ‘holistic’, dealing with physical, psychological, financial, marital, employment-related and other maladies and concerns. Indeed, it’s fairly common for the spirit to be conceived of as a kind of curer, physician or counsellor, not the source of problem. So, to say that possession is 1) equivalent to ‘non-Western schizophrenia’; 2) is a single thing – behaviourally and conceptually – within and between these non-Western cultural contexts; 3) is ‘democratic’/neutral/never stigmatized; 4) a form of temporary madness, or a crisis; 5) is invariably warmly received by an understanding society; 6) is something to be cured from, just seems… well, a little bit mad. (To be clear: I refer to the writers of the NYT piece, insofar as they have actually claimed this, NOT the author of this blog post!)