Is The Rest Of The World 'Crazy Like Us'? Author Ethan Watters thinks that America is "homogenizing the way the world goes mad." In Crazy Like Us, he describes how America's approach to mental illness has spread to other cultures around the world, in a "globalization of the American psyche."
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Is The Rest Of The World 'Crazy Like Us'?

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Is The Rest Of The World 'Crazy Like Us'?

Is The Rest Of The World 'Crazy Like Us'?

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REBECCA ROBERTS, host:

This is TALK OF THE NATION. I'm Rebecca Roberts, in Washington. Neal Conan is away.

Coca-Cola, McDonald's, Nike - to the rest of the world, these are the symbols of the globalization of American culture. Author Ethan Watters says we're responsible for another powerful export: the American approach to mental illness. He says we're teaching the world how we define and treat mental illnesses like depression, anorexia, schizophrenia and post-traumatic stress disorder. And the process is not only disrupting how other cultures heal themselves, it might actually be spreading mental illness.

Today, Ethan Watters and his book "Crazy Like Us: The Globalization of the American Psyche." Later in the hour, Mark McGwire admits to using steroids. But first, "Crazy Like Us." Is there a uniquely American version of mental illness? If so, what is it?

We especially want to hear from people who have experience with mental health, as professionals or patients. Our number here in Washington is 800-989-8255. Our email address is talk@npr.org. And you can join the conversation at our Web site. Go to npr.org and click on TALK OF THE NATION.

And Ethan Watters joins us from member station KQED in San Francisco, California. Welcome to the program.

Mr. ETHAN WATTERS (Author): Thank you so much for having me on.

ROBERTS: From a sort of, you know, 10,000-foot view, as we introduce American versions of mental illness to the world, what are the consequences?

Mr. WATTERS: Well, I think, you know, we shape - we're very powerful in this regard. We shape the way people diagnose the illnesses, categorize the illnesses. And what's gone unappreciated is that culture plays into mental illness. When the mind becomes unstuck for whatever reason, it looks to culture for the language of how to express that distress. And if you look across time -say, for instance, to Victorian England, where you had a wave of hysteria - you know, hysteria was the form of illness of the time. You had thousands of women with leg paralysis and hysterical blindness and convulsions. You could see very clearly that there's something about culture that's shaping the expression. So it appears that the unconscious mind looks to the language of its time to express its internal distress.

And in this era of globalization, the thesis of the book is that we're exporting our notions, our what they call "symptom pools" to distress - to express these internal anxieties to the rest of the world, and they're being adopted in replacing other cultural notions of madness, and, in the process, disconnecting other cultures from local notions of how to heal from those particular forms of madness in other places.

ROBERTS: So, is this more a case of America bigfooting the rest of the world and thinking that American knows best, or is this specific divorce of mental illness from its cultural context and trying to treat it as a disease like any other part of the American version of mental illness?

Mr. WATTERS: I think both those things are true. This is clearly a case of America knows best. There's a tremendous amount of hubris involved in this. There's also, I have to say, a tremendous amount of money to be made. One of the key forces behind this homogenization of the way the world goes mad is the major pharmaceuticals who are promoting certain drugs, but in the process, they're actually promoting the diseases for which the drugs are, you know, claimed to be the fix.

And if they can do that - and the book documents one, you know, a particular case of Paxil in Japan. When they're able to do this - shift a cultural notion in another land to an American version and then connect it up to the drug -there's a tremendous amount of money to be made. So, in other cases, it is, I mean, in other cases that our motivations are better, to be perfectly honest, we're trying to help the world. We do this out of the best of intentions, oftentimes. I think we just often haven't fully understood the full consequences of our interventions.

ROBERTS: I want to go a little more deeply into that example of Paxil in Japan, because you say that in an effort to sell Paxil, the company also ended up selling depression.

Mr. WATTERS: I believe so. And the really remarkable part of this story is that they co-opted many of the people in the field of cross-cultural psychiatry. So the people that knew the most about how culture shaped mental illness, the company actually brought them in on the process. And they did this very studiously. This wasn't an ancillary thing. They thought - they looked at Japan, no one had introduced an antidepressant in Japan because all the drug companies thought that there was no culturally significant idea of depression in Japan, that they thought they could not sell the drug.

And then they finally decided, well, if we could change this cultural notion, if we can move the line in Japan between what is considered to be normal forms of sadness and melancholy to what is considered a pathological form of sadness, we have a lot of money to make. And they very clearly went after this goal. They looked to move that line in Japan, and it appears they've done that. There were no SSRIs selling in the 1990s, and now it's a billion-dollar-a-year business.

ROBERTS: So, this is a sort of combination of moving a cultural definition of what is normal and what needs treatment, and also introducing the notion that the best treatment is a pharmaceutical intervention.

Mr. WATTERS: That's exactly right. Those two things go hand in hand in terms of how the drug companies look to the rest of the world. And interestingly enough, they talk about the evolution of these countries. So they talk about Japan as being five years behind America and China being 10 years behind Japan, but at the head of the evolutionary scale is always America. They're trying to move America - you know, other countries along to become like America, how we think about depression, how we treat it, how we prescribe for it. And, you know, the head of the evolutionary tree is always us.

ROBERTS: But doesn't the removal of mental illness from its cultural context and trying to see it as, as you call it in the book, brain disease, doesn't that stem from an effort to take away the stigma of mental illness...

Mr. WATTERS: That's right.

ROBERTS: ...as not being as something to be treated and helped?

Mr. WATTERS: Absolutely. I mean, we have this assumption that if we can get the world to think like us in terms of the biomedical conception of mental illness, that it's like a disease like another, that it will reduce stigma. And unfortunately what the studies have found is as this idea gets adopted around the world - and it has been gotten adopted around the world - that oftentimes the very reverse occurs, that people want more distance from the mentally ill. They assume that they're more dangerous. They want less to do with them.

So this idea that it makes perfect sense that the mental - that the biomedical notion of mental illness would reduce stigma, but it turns out when these stories get out into cultures, they don't always do the things that we think they're going to do. And in the case of the biomedical notion of mental illness, it appears that it actually does the exact opposite. And there's a good case...

ROBERTS: Why would that be true?

Mr. WATTERS: Well, because people that believe that someone has a brain disease might believe that the mental illness is more intractable, that they are more like a different person, that they can be treated more like a different species, almost, as one researcher put it, that the illness goes much deeper than a person that believes that it's caused by childhood experiences, for instance, or even some notion of spirit possession. Those ideas might allow the person to - the individual looking at the mentally ill person to think that they have more ability to change over time.

ROBERTS: We touched briefly on the notion of diagnosing mental illness from an American perspective, for purposes of selling Paxil in the case we talked about, but also for less nefarious or monetary purposes. And the - you know, the diagnostic tool, the standard in America is the DSM, the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. Is that book spreading around the world, and how?

Mr. WATTERS: Well, it is - you know, people around the world call it the bible of, you know, of the mental illness. People look at it as sort of a field guide to the human psyche. We get tremendous respect from the rest of the world in terms of our medicine and in terms of our mental health apparatus. And so, you know, people in every culture, when they enter into the mental health field, they're, by in large, being - reading books that were made in America, using the DSM diagnostic manual. And the question is how much, you know, how much do these ideas carry cultural assumptions about the human self and the human psyche, and how much can we use those ideas in other cultures?

ROBERTS: Let's take a call from Peggy in Wilmington, North Carolina. Peggy, welcome to TALK OF THE NATION.

PEGGY (Caller): Thank you. I have a question about - even in other cultures, if mental illness is not necessarily recognized, then I'm wondering if the suffering of people who are in pain with mental illness goes untreated.

Mr. WATTERS: Well, I think that's a very good question. And I think the idea is not, I think, that it goes unrecognized in other cultures, but there are other cultural stories that surround it and other ideas and other ways of treating it. But I think...

ROBERTS: Give us an example.

Mr. WATTERS: So say, for instance, schizophrenia in Zanzibar. They're still shrouded with the notions of spirit possession. and I'm not a believer in spirit possession, but I do believe that there are aspects of this cultural belief that can be helpful for the schizophrenic. That is, this spirit possession notion actually very often ties the person very closely to the group.

It is a narrative that's told about the illness that keeps the ill individual within the confines of the social group and the family. And that in itself is a narrative that is ultimately potentially very helpful to the ill person.

So I don't believe it as a scientific truth. I do believe that mental illness exists as a biomedical fact in the human brain, but I can also recognize that cultural stories make a difference, and the cultural story we tell ourselves about the scientific truth of mental illness might not always be the one that is the most helpful.

ROBERTS: Peggy, does that answer your question?

PEGGY: It sure does. Thank you.

ROBERTS: Thanks for calling in. We have an email from Cheryl(ph) in Burnsville, Minnesota, who says: I absolutely believe that one of the major reasons depression is so common in this country is because as children, we're taught that each of us is special and unique. As I have grown up, my depression has been acutely influenced by realizing I'm not that special.

Children must be taught to maintain realistic expectations of themselves rather than continually falling short of expectations imposed by being convinced that they are entirely unique. People I have met from other countries and cultures have not shared this distinctly American view of their own superiority.

Mr. WATTERS: I think that's very true. When you do cross-cultural studies about, you know, the ego, where the ego lies and egocentric versus sociocentric versions of the self, it turns out to be true that Americans are much ego - more egocentric. They believe that the self exists within the human mind. And that just might sound commonsensical to an American, but there are other notions of the self, which - where the self exists as part of a social group more than an individual self.

And I think, you know, I think we have as much to learn from other cultures as to whether that's a healthier way to think about the human mind and the human creature.

ROBERTS: We are talking with Ethan Watters this hour. His book is called "Crazy Like Us: The Globalization of the American Psyche." We're taking your calls at 800-989-8255, and you can send us email. The address is talk@npr.org.

I'm Rebecca Roberts. It's TALK OF THE NATION from NPR News.

(Soundbite of music)

ROBERTS: This is TALK OF THE NATION. I'm Rebecca Roberts, in Washington. We're talking about mental illness this hour, specifically the way that the United States defines and treats such illnesses as depression and PTSD. Ethan Watters is with us today. In his new book, he says that the United States is homogenizing the way the world goes mad. His book is called "Crazy Like Us."

And we want to hear from you, especially if you have experience with mental health as professionals or patients. Is there a uniquely American version of mental illness? If so, what is it? Give us a call at 800-989-8255. Our email address is talk@npr.org. And you can join the conversation at our Web site. Go to npr.org, and click on TALK OF THE NATION.

Let's hear from Chuck in Sacramento. Chuck, welcome to TALK OF THE NATION.

CHUCK (Caller): Hi, thank you very much. Hi, everybody. I - it's a very interesting conversation, and I just wanted to say that I think we as Americans could benefit by realizing to what extent our understanding of mental illness and human nature itself is a product of our beliefs about science and technology.

And I'm a big believer in both, but I think we often go beyond what is strictly true scientifically and have a kind of a mechanistic view of human nature, where we see the brain and personality and consciousness as kind of a machine, where we can take pictures of it and we can tweak it chemically or even surgically. And I think we'd be well to realize that a lot of our ideas are not strictly scientific, and maybe they get into the area of science fiction, almost.

ROBERTS: Chuck, thank you so much for your call. Ethan Watters?

Mr. WATTERS: I think that was said extremely well. I think we do have to understand how these scientific notions cross over into cultural notions of the mind. And I think the only way we can really do that is by looking cross-culturally and understanding that there are other ways to think about the human self. There are other ways to think about the human psyche. And before we tromp into other cultures and try to change them and try to get them to think like us, we should appreciate those differences because they're really the only mirror we have - I mean, I suppose except for history, looking across cultures are the only mirrors we have in terms of understanding our own self and understanding how these stories shape our sense of self and how other stories might or might not be more or less healthy.

ROBERTS: Well, you know, it's interesting, because you mentioned the case of schizophrenia in Zanzibar and how a mentally ill person staying as part of his or her community ends up being a beneficial treatment. But is that culturally specific to Zanzibar? I mean, is that just as hard to export as what you're criticizing the U.S. for?

Mr. WATTERS: I think that's a very good question as to whether we can import or export. I do think the crossing of these things and the mixing of these things is inevitable. Like, globalization is not going to allow us to redraw cultural boundaries. It is inevitably going to be mixed. And our only hope, really, is that the mixture goes two ways, that we can respect other cultures enough to look to their narratives and understand their psychologies, perhaps so that we tread a little lighter in those other cultures, and perhaps that we can adopt some ideas about the psyche, that the ideas can flow across borders, but flowing our way instead of the other way.

ROBERTS: Let's hear from Mary in Vacaville, California. Mary, welcome to TALK OF THE NATION.

MARY (Caller): Yes, hello. I don't know where to begin except that I really value this discussion and especially your author's respect for what you call, I guess, the narration story and explanations that other cultures give. I think it is important to their healing and to try to take that away and give them our Western model could be just a big loss for them.

My husband is American-trained psychiatrist, and I went with him to Saudi Arabia for what we thought would be a short time. We stayed nine years. And during that time, he helped set up training of young psychiatrists in the kingdom of Saudi Arabia. And he did a survey, too, on why they don't choose psychiatry as a specialty among their physicians there.

And so it's - during that period, it's had some change in how their own medical school approached teaching it. And then I lived among the people, and I got to know how they just deal with everyday life. And I came to respect and see as somewhat liberating their narrative style, I guess, of explaining things, and their incorporating of the ups and downs of life as just something of value and not something to be afraid of but, oh, you know, if you're down, then oh, there could be some value in that. There's something good can come from that.

And I think that's liberating in a way. So it just came - it's not - and they - but they respected the Western models that had come in a little bit too unquestioningly, and some maybe don't respect their own models, think maybe anything coming from the West has to be better.

So I think that it's good that this discussion comes to remind people, no, what you have has value. What's coming in could have some value. Let's see how we can incorporate these and make them a very good, healthy blend. And one more thing I probably should mention, because your screener seemed really fascinated by this, there was an American female psychologist working there who did a survey across the country there in Saudi Arabia and found, to her surprise, that the men reported depression twice as often than women, which is kind of like the opposite, I think, of what's reported here. And so, obviously, there's a lot of complexity.

ROBERTS: Mary, thank you so much for your call. Ethan Watters, she brings an interesting - well, several interesting points, but in particular, this notion that it's not just the U.S. imposing its view elsewhere. Sometimes that view is invited and required and that there's not a respect for the indigenous treatment.

Mr. WATTERS: Right. Now, I've heard this story over and over again, told by psychiatrists that have gone across cultures with the intent of being culturally sensitive. They did not want to trample on local notions of illness. They did not want to impose their own beliefs, and they found it actually very difficult to abdicate the role of Western, American expert with the most advanced knowledge.

Even if they didn't want the role, if they pushed it away, they found time and again they were pushed into the role, often by the people that were hosting them. So there's very much a desire for these ideas across the culture, across the world, and oftentimes it's - yeah, it's hard to get around it.

ROBERTS: We have an email from Keho(ph) in Australia, who says: Regarding the Americanization of mental illness, consider also how mental disturbances are treated in different cultures. In Western culture, treatment is a very private matter, usually done one on one in a closed room. However, in some cultures, treatment for what we would consider acute depression entails a fresh-air, day-long ceremony in which one's friends and relatives are present in support.

Mr. WATTERS: That's right. I mean, and you can imagine those two different cultural conceptions actually match up very well with that idea we had before about egocentric versus sociocentric versions of the self.

If your illness is just within you, it makes perfect sense to walk away from your social responsibilities and take the time with a counselor to heal. That is culturally appropriate. In another culture, where your sense of self actually exists as mixed with the people around you - with your role, with the social group, then having a curing ceremony that involves that group, again, makes perfect sense.

So these things, these different cultural notions of the illness and the self are actually connected to different cultural notions for how to heal. And in those cases, it's not necessarily that one is better or worse, but they're matched up. They make sense.

ROBERTS: Let's hear from Pat in Fort Wayne, Indiana. Pat, welcome to TALK OF THE NATION.

PAT (Caller): How you doing? Thank you for taking my call. Can you hear me all right?

ROBERTS: We can, thanks.

PAT: Yeah, I had a question. I'm a recovering alcoholic of 10 years. I'm also bipolar and being medicated for it, and I've always been really curious to exactly what causes my bipolar and depression. You know, right now it's kind of a moot point. I am bipolar and I have depression, and how I got it isn't a factor, you know, whether it's a result of my alcoholism or whatnot.

I've only been medicated for about a year, but I do think back to when I was younger, to what kind of diet I had growing up. I was wondering what studies have been done on how much the American culture, as far as our diet is concerned - it seems like the American culture has seen an explosion of diabetes and heart disease. I was wondering if mental illness is something that is also a result of this change in diet in the American culture along with the rest of the world.

ROBERTS: Ethan Watters?

Mr. WATTERS: I think that's a fascinating book idea. Unfortunately, it's not the one I focused on. But I think looking into mental illness in a broader context, looking at things like diet and cultural narratives and rituals and so forth, there are a lot of people on this trail, and I'm sure there is someone on the trail of diet and mental illness, and perhaps, you know, that could be the next book.

ROBERTS: Well, I think we're also sort of dancing around this notion of the suggestibility of mental illness. You talked about hysteria in Victorian time, that these things clearly crop up in groups. There are - you know, there will be a whole epidemic of anorexia or something, and it certainly seems from the evidence in your book that there are times when talking about mental illness encourages mental illness.

Mr. WATTERS: Or it encourages a particular expression of that mental illness, yeah. And we go back to that idea of the symptom pools, that in any given generation there is a way to express internal distress. And indeed, that does change over time; and indeed the reason it changes is oftentimes because healers change their beliefs about the human mind. And so they think of the mind as working this way, they predict certain notions, and the population responds to that.

And this is not a matter of faking a symptom. This is the unconscious mind trying to figure out how to express itself, and it looks for oftentimes very subtle cultural cues, out there, as to how to do that. So, in, you know, the 1960s and '70s, we had anxiety was the primary way that you would, sort of, express an internal distress and you'd probably take something, you know, a downer to fix that.

Come the 1980s and '90s, depression became the key narrative for how we talked about our general distress and the SSRIs came along with it. So these things actually change, actually fairly quickly. However, within one moment in time, it's often very difficult to see what those cues are and where they exist. When we exist within one culture, it's like being a swimmer outside of sight of land - you can't really tell the currents you're in.

If, however, you look across cultures and see how other cultures actually express these things differently or have different narratives, suddenly you're looking back at your own American self with a greater knowledge and a greater understanding of what's going on.

ROBERTS: Well, the instance of anorexia in China was a helpful explanation to me, reading your book. Maybe you can tell us a little more about that.

Mr. WATTERS: Certainly. Yeah, there was a version of anorexia in China in the early '90s and there was a researcher that was following it, a very rare, very culturally specific form of anorexia. Women were starving themselves. But it didn't have anything to do with fat phobia. It didn't look like the diagnosis in any other way.

Then in 1994, a young woman died on the streets of Hong Kong and the press suddenly got interested in what this woman had died on - died of. And she was a young anorexic. And basically at that point, they imported Western notions of the disease, they imported the DSM diagnosis, they imported Western ideas about what it meant, who was likely to be affected.

And interestingly enough, after that period of time, Hong Kong saw a rise of the diagnosis of anorexia, but not only a rise of the diagnosis, a more American form of the illness. It had - suddenly it had do with fat phobia, and it had to do with body dysmorphia. So although it's, of course, very hard to tell, it appears that the influx of the knowledge about the disease itself actually shaped this expression or put this symptom into the symptom pool of Hong Kong in this very nervous time in the province's history.

ROBERTS: You're listening to TALK OF THE NATION from NPR News. My guest is Ethan Watters. The book is "Crazy Like Us: The Globalization of the American Psyche." And we have an email from Adam(ph) in Chicago who says, I'd be interested to know how talk therapy and other nondrug therapies, self-help books, et cetera, have increased in other countries.

Mental illness, contrary to popular thinking, does not always require drugs to alleviate or cure the symptoms. Also, has diagnosis of ADHD reached greater numbers in other countries?

Mr. WATTERS: That was the one - the chapter I didn't do was on ADHD because I do think that is one of our exports. In terms of the promotion of talk therapy, we are certainly taking that with us, particularly on the back of the PTSD diagnosis. So when disasters happen in other cultures, wars or disasters, we often rush in there with this American notion that the best way to heal from that is immediately to begin to retell the story of the trauma, to talk it through with a professional therapist, to - and that is a particular American notion that does not jive with other cultures' ideas of how to react to trauma.

And when you're reacting to trauma, cultural meaning does actually matter. It helps shape your reactions, predict what your reactions are going to be and...

ROBERTS: Well, you give the example of Sri Lanka after the tsunami.

Mr. WATTERS: That's right. So, you know, thousands of trauma therapists rushed in there to help in all forms. They had - there was, you know, talk field therapists and Scientologists and EMDR therapists, all with their different American notions about to heal from it, and anthropologists that look at this effort, you know, sort of shake their heads because if you go into a country on a week or 10 days' notice, it's very hard to understand the culture.

You don't understand the language. You don't understand the Sri Lankan 30-year history of the civil war, you don't understand the religions or the notions of rituals for the dead. And to assume that our idea of talking about trauma, shortly after the event, can be applied in that place without any problem basically goes to that the American idea that our ideas are certainly the best and the most advanced in the world.

And when you take a step back from that, perhaps when you reverse the scenario - what if Sri Lankan shamen came over to New York after 9/11 and began knocking on doors of the people who had family members die in 9/11 to tell them the appropriate ways to heal? That would seem bizarre to us and utterly culturally insensitive. But as Americans with this idea that we have the most advanced knowledge, it makes perfect sense for us to go and do that in another culture.

ROBERTS: Where are examples of places where Americanized treatment has helped?

Mr. WATTERS: Well, I think - you know, there are valuable drugs to be had. And I think to the extent that we manufacture drugs that help the mentally ill, they should certainly not be denied to the rest of the world. We should make sure when we promote them as scientific that the science behind them is solid and that they are helpful, and they won't trample on cultural beliefs that might even be more helpful.

But certainly, you could look ahead into the future and say, the progress we've made in treating mental illnesses with drugs will certainly advance, and I'm not at all suggesting that we should withhold that from the rest of the world. However, I think that we could have a good discussion about the ways in which we can offer our scientific knowledge to the rest of the world without perhaps trampling on beliefs that might themselves be very valuable in helping someone maintain their life as a mentally ill person.

ROBERTS: And when you have talked to mental health care workers here in this country about the idea of it being a two-way street, are they receptive?

Mr. WATTERS: You know, remarkably receptive. I have a Times - article in the Times magazine this last Sunday, so I've been involved in the discussion over the last week. And to a person, the mental, you know, the mental health professionals, from psychoanalysts on down or on up, have been remarkably receptive to this idea. I think this idea is one that's sort of on the tip of the American mind, and people are ready to hear it and ready to take notice.

ROBERTS: Ethan Watters is the author of "Crazy Like Us: The Globalization of the American Psyche." He joined us from member station KQED in San Francisco. Thank you so much.

Mr. WATTERS: Thank you so much for having me.

ROBERTS: Coming up, baseball slugger Mark McGwire returned to the headlines in a big way yesterday, finally admitting he used steroids when he broke baseball's homerun record in 1998.

We'll have more from NPR's Tom Goldman next. I'm Rebecca Roberts. It's TALK OF THE NATION from NPR News.

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