Crazy Like Us: The Globalization of the American Psyche [Hardcover]

Four thoroughly reported chapters make a devastating case. Many well-meaning people (who for instance flew to Sri Lanka right after the tsunami to help) and some straight-up money-driven forces (big pharma) have really failed to try to understand non-western ways that cultures deal with serious mental illness. It's a hubris very much in line with our other exports -- "democracy" to the Middle East, say -- but one that you'd think would be a little less egregious because of all the scientists involved. Hopefully this book, which was a smooth yet very detailed read, will spark a long-overdue debate. As a psychologist in training, I'm glad I read this book.

A successful virus is adaptive. It evolves as needed to survive and colonize new hosts. By this definition, contemporary American psychiatry is a very successful virus. Exploiting cracks that emerge in times of cultural transition, it exports DSM depression to Japan and posttraumatic stress disorder to Sri Lanka.

Journalist Ethan Watters masterfully evokes the heady admixture of moral certainty and profit motive that drives U.S. clinicians and pharmaceutical companies as they evangelically push Western psychiatry around the globe. On the ground in Sri Lanka following the tsunami, for example, hordes of Western counselors hit the ground running, aggressively competing for access to a native population "clearly in denial" about the extent of their trauma. Backing up the foot soldiers are corporations like Pfizer, eager to market the antidepressant Zoloft to a virgin population.

Watters has done his homework. Each of his four examples of DSM-style disorders being introduced around the world is rich in historical and cultural context. Despite their divergences, each successful expansion hinges on the mutual faith of both the colonizers and the colonized that Western approaches represent the pillar of scientific progress.

It is ironic that Americans are so smugly assured of the superiority of our cultural beliefs and practices, in the face of mounting evidence to the contrary. Do we really want others to emulate a country with skyrocketing levels of emotional distress, where jails and prisons are the primary sites of mental health care? Does our simplistic cultural metaphor of mental illness as a "chemical imbalance, " with human minds reduced to "a batter of chemicals we carry around in the mixing bowls of our skulls," represent true enlightenment?

Our implicit condescension is made explicit if we imagine the converse, one of Watters' interview subjects points out: "Imagine our reaction if Mozambicans flew over after 9/11 and began telling survivors that they needed to engage in a certain set of rituals in order to sever their relationships with their deceased family members. How would that sit with us?"

Not only is our missionary zeal condescending, it may be harmful. Watters provides evidence to suggest that the "hyperintrospective" and "hyperindividualist" model of Western psychiatry can be destabilizing to time-worn, tried-and-true indigenous healing practices, in some cases even producing the problems we naively believe we are combating.

"What is certain," Watters cautions in his conclusion, "is that in other places in the world, cultural conceptions of the mind remain more intertwined with a variety of religious and cultural beliefs as well as the ecological and social world. They have not yet separated the mind from the body, nor have they disconnected individual mental health from that of the group. With little appreciation of these differences, we continue our efforts to convince the rest of the world to think like us. Given the level of contentment and psychological health our cultural beliefs about the mind have brought us, perhaps it's time that we rethink our generosity."

Perhaps it is already too late to turn back the tide. Thanks to the exportation of Western diet and lifestyle, 19 out of 20 inhabitants of the tiny island of Nauru in the Pacific Islands are now obese. Previously hardy islanders are stroking out in their 20s and 30s. The globalization of the American psyche is more insidious, but perhaps in the end it will prove equally catastrophic.

Reading Crazy Like Us left me with a nightmare image of a homogeneous future world with McDonald's and Starbucks (see my review of Starbucked: A Double Tall Tale of Caffeine, Commerce, and Culture) on every corner, obesity gone wild, and Western psychiatry reigning supreme.

This book brings up many thought-provoking points about the arrogance and in some cases, damage of the Western exportation of ideas about the orgins and treatment of mental illness. But one of the author's main premises is that mental illnesses are different in different cultures and in different times. That's not the case. Some of how they are expressed may be different, and there may be some different variants, but accounts from the classical age of the Greeks and Romans on down the line all report clearly identifiable symptoms that could be clustered into affective disorders (depression, bipolar, etc.), thought disorders (schizophrenia and subtypes), and stress reactions (from withdrawal to eating disorders to PTSD). Symptoms of depression, mania, paranoia, and mental confusion have been documented for centuries. There may be many different human cultures on the earth, but we all have human brains.

Another of the author's premises is that the Western medicine for mental illness doesn't work well in other cultures. That may well be true, but the author doesn't show examples of where it has worked or given us any kind of qualified evidence-based, broad-based comparative study; he has only selected anecdotes that support his thesis. I think any attempt to use Western medicine of any kind in a community that is not receptive to it, or for which the doctors ignore or dismiss cultural healing traditions, has potential for unforeseen and even disastrous consequences. But if done with cultural sensitivity and offering options rather than dictating treatment, it could be very helpful to people who are suffering greatly.

Another bias seems to be against medication and "big Pharma," a call to arms that is very trendy right now, whereas in his previous book, "Therapy's Delusions," he lambasted talk therapy in favor of brain science and medication. Most people who are living successfully with mental illness in this culture will say that is a combination of medication and some supportive mode of therapy that helps them stay in remission and live normal lives--something that was rarely possible for those with severe mental illnesses before therapy and medications were invented.

The Western cultural emphasis on the individual and the "pull yourself up by your bootstraps" mentality is much more damaging to people who are vulnerable to mental illnesses than the Western psychiatry/psychology. If we could keep the Western insight into brain science and the Western meds AND therapies that actually work, AND add in or keep the tight-nit, ultra supportive families and communities of the old or developing world, those with real mental illnesses would be much better off. Whatever the type of care is, it's the quality of the human relationships that count.