Purpose
The purpose of this assignment is to reflect on the new information presented in this book. It is meant to increase your awareness and critical thinking about the experience and treatment of common psychological disorders in the US and around the world.
Reading to Critically Evaluate
Please read Chapter 4 in Crazy Like Us: The Globalization of the American Psyche by Ethan Watters.
You are encouraged to ask questions of the reading as you read, make notes of areas of confusion, surprise or disagreement, and mention this in this assignment!
Directions
- Write two paragraphs (minimum of 200 words) in which you identify Watter’s main thesis of the chapter and discuss your overall thoughts and reactions to the main thesis.
- Write a one-paragraph response (minimum of 100 words) to ONE of the following questions listed below.
- Include two quotes from the chapter that stood out to you. Include the page number or time stamp where your quotes can be found.
Questions (choose only one)
1. What questions form in your mind when you learn that most of the influential studies on SSRIs were ghostwritten by private firms hired by drug companies?
2. Did you find it difficult to grasp the idea that the Japanese did not always connect suicide with depression and in fact viewed it as an expression of the purity of the Japanese character (something to be admired, excused or seen as an act of personal resolve)? Why or why not?
Grading
Full points for the assignment will be earned when all 3 portions of the assignment are met. Two-paragraph (minimum of 200 words) general reaction (6pts), one-paragraph (minimum of 100 words) response to question (2pts), two quotes with page numbers/time stamps (2pts). Check out the rubric!
ALSO BY ETHAN WATTERS
Urban Tribes:
A Generation Redefines Friendship,
Family, and Commitment WITH RICHARD OFSHE
Makings Monsters:
False Memories, Psychotherapy, and Sexual Hysteria
C
RAZY
L
IKE
U
S
THE GLOBALIZATION OF
THE AMERICAN PSYCHE
ETHAN WATTERS
FREE PRESS
A Division of Simon & Schuster, Inc.
1230 Avenue of the Americas
New York, NY 10020
www.SimonandSchuster.com
Copyright © 2010 by Ethan Watters
All rights reserved, including the right to reproduce this book or
portions thereof in any form whatsoever. For information address
Free Press Subsidiary Rights Department, 1230 Avenue of the Americas, New
York, NY 10020
First Free Press hardcover edition January 2010
FREE PRESS and colophon are trademarks of Simon & Schuster, Inc.
For information about special discounts for bulk purchases,
please contact Simon & Schuster Special Sales at 1-866-506-1949 or
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Manufactured in the United States of America
1 3 5 7 9 10 8 6 4 2
Library of Congress Cataloging-in-Publication Data
Watters, Ethan.
Crazy like us: the globalization of the American psyche / Ethan Watters.
p. cm.
1. Mental illness—Cross-cultural studies. 2. Psychology, Pathological—
Cross-cultural studies. 3. Irish—Race identity. 4. Mental illness—
United States. 5. Globalization—Psychological aspects. 6. Psychiatric
epidemiology. I. Title.
RC455.4.E8W38 2010
http://www.simonandschuster.com/
616.89—dc22 2009030661
ISBN 978-1-4165-8708-8
ISBN 978-1-4165-8719-4 (ebook) For my mother, Mary Pulliam Watters
Contents
Introduction
Chapter 1
The Rise of Anorexia in Hong Kong
Chapter 2
The Wave That Brought PTSD to Sri Lanka
Chapter 3
The Shifting Mask of Schizophrenia in Zanzibar
Chapter 4
The Mega-Marketing of Depression in Japan
Conclusion
The Global Economic Crisis and the Future of Mental Illness
Sources
Acknowledgments
Index
C
RAZY
L
IKE
U
S
Introduction
To travel internationally is to become increasingly unnerved
by the way American culture pervades the world. We cringe
at the new indoor Mlimani shopping mall in Dar es Salaam,
Tanzania. We shake our heads at the sight of a McDonald’s
on Tiananmen Square or a Nike factory in Malaysia. The
visual landscape of the world has become depressingly
familiar. For Americans the old joke has become bizarrely
true: wherever we go, there we are.
We have the uneasy feeling that our influence over the
rest of the world is coming at a great cost: loss of the
world’s diversity and complexity. For all our self-
incrimination, however, we have yet to face our most
disturbing effect on the rest of the world. Our golden arches
do not represent our most troubling impact on other
cultures; rather, it is how we are flattening the landscape of
the human psyche itself. We are engaged in the grand
project of Americanizing the world’s understanding of the
human mind.
This might seem like an impossible claim to back up, as
such a change would be happening inside the conscious and
unconscious thoughts of more than six billion people. But
there are telltale signs that have recently become
unmistakable. Particularly telling are the changing
manifestations of mental illnesses around the world. In the
past two decades, for instance, eating disorders have risen
in Hong Kong and are now spreading to inland China. Post-
traumatic stress disorder (PTSD) has become the common
diagnosis, the lingua franca of human suffering, following
wars and natural disasters. In addition, a particularly
Americanized version of depression is on the rise in
countries across the world.
What is the pathogen that has led to these outbreaks and
epidemics? On what currents do these illnesses travel?
The premise of this book is that the virus is us.
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 has often been 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—influences the diseases
themselves. In teaching the rest of the world to think like us,
we have been, for better and worse, homogenizing the way
the world goes mad.
There is now a remarkable body of research that suggests
that mental illnesses are not, as sometimes assumed,
spread evenly around the globe. They have appeared in
different cultures in endlessly complex and unique forms.
Indonesian men have been known to experience amok, in
which a minor social insult launches an extended period of
brooding punctuated by an episode of murderous rage.
Southeastern Asian males sometimes suffer from koro, the
debilitating certainty that their genitals are retracting into
their body. Across the Fertile Crescent of the Middle East
there is zar, a mental illness related to spirit possession that
brings forth dissociative episodes of crying, laughing,
shouting, and singing.
The diversity that can be found across cultures can be
seen across time as well. Because the troubled mind has
been perceived in terms of diverse religious, scientific, and
social beliefs of discrete cultures, the forms of madness
from one place and time in history often look remarkably
different from the forms of madness in another. These
differing forms of mental illness can sometimes appear and
disappear within a generation. In his book Mad Travelers, Ian
Hacking documents the fleeting appearance in Victorian
Europe of a fugue state in which young men would walk in a
trance for hundreds of miles. Symptoms of mental illnesses
are the lightning in the zeitgeist, the product of culture and
belief in specific times and specific places. That thousands
of upper-class women in the mid-nineteenth century
couldn’t get out of bed due to the onset of hysterical leg
paralysis gives us a visceral understanding of the
restrictions set on women’s social roles at the time.
But with the increasing speed of globalization, something
has changed. The remarkable diversity once seen among
different cultures’ conceptions of madness is rapidly
disappearing. A few mental illnesses identified and
popularized in the United States—depression, post-
traumatic stress disorder, and anorexia among them—now
appear to be spreading across cultural boundaries and
around the world with the speed of contagious diseases.
Indigenous forms of mental illness and healing are being
bulldozed by disease categories and treatments made in the
USA.
There is no doubt that the Western mental health
profession has had a remarkable global influence over the
meaning and treatment of mental illness. Mental health
professionals trained in the West, and in the United States in
particular, create the official categories of mental diseases.
The American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders, the DSM (the “bible”
of the profession, as it is sometimes called), has become the
worldwide standard. In addition American researchers and
organizations run the premier scholarly journals and host
top conferences in the fields of psychology and psychiatry.
Western universities train the world’s most influential
clinicians and academics. Western drug companies dole out
the funds for research and spend billions marketing
medications for mental illnesses. Western-trained
traumatologists rush in wherever war or natural disasters
strike to deliver “psychological first aid,” bringing with them
their assumptions about how the mind becomes broken and
how it is best healed.
These ideas and practices represent much more than the
symptom lists that describe these conditions. Behind the
promotion of Western ideas of mental health and healing
lies a variety of cultural assumptions about human nature
itself. Westerners share, for instance, beliefs about what
type of life event is likely to make one psychologically
traumatized, and we agree that venting emotions by talking
is more healthy than stoic silence. We are certain that
humans are innately fragile and should consider many
emotional experiences as illnesses that require professional
intervention. We’re confident that our biomedical approach
to mental illness will reduce stigma for the sufferer and that
our drugs are the best that science has to offer. We promise
people in other cultures that mental health (and a modern
style of self-awareness) can be found by throwing off
traditional social roles and engaging in individualistic quests
of introspection. These Western ideas of the mind are
proving as seductive to the rest of the world as fast food
and rap music, and we are spreading them with speed and
vigor.
What motivates us in this global effort to convince the
world to think like us? There are several answers to this
question, but one of them is quite simple: drug company
profits. These multibillion-dollar conglomerates have an
incentive to promote universal disease categories because
they can make fortunes selling the drugs that purport to
cure those illnesses.
Other reasons are more complex. Many modern mental
health practitioners and researchers believe that the
science behind our drugs, our illness categories, and our
theories of the mind have put the field beyond the influence
of constantly shifting cultural trends and beliefs. After all,
we now have machines that can literally watch the mind at
work. We can change the chemistry of the brain in a variety
of ways and examine DNA sequences for abnormalities. For
a generation now we have proudly promoted the biomedical
notion of mental illness: the idea that these diseases should
be understood clinically and scientifically, like physical
illnesses. The assumption is that these remarkable scientific
advances have allowed modern-day practitioners to avoid
the biases and mistakes of their predecessors.
Indeed modern-day mental health practitioners often look
back at previous generations of psychiatrists with a mixture
of scorn and pity, wondering how they could have been so
swept away by the cultural beliefs of their time. Theories
surrounding the epidemic of hysterical women in the
Victorian era are now dismissed as cultural artifacts. Even
recent iatrogenic contagions, such as the sudden rise of
multiple personality disorder just fifteen years ago, are
considered ancient history, harmful detours but safely in the
past. Similarly, illnesses found only in other cultures are
often treated like carnival sideshows. Koro and amok and
the like can be found far back in the American diagnostic
manual (DSM-IV, pages 845–849) under the heading
“Culture-Bound Syndromes.” They might as well be labeled
“Psychiatric Exotica: Two Bits a Gander.”
Western mental health practitioners are prone to believe
that, unlike those culturally contrived manifestations of
mental illness, the 844 pages of the DSM-IV prior to the
inclusion of culture-bound syndromes describe real
disorders of the mind, illnesses with symptomatology and
outcomes relatively unaffected by shifting cultural beliefs.
And, the logic goes, if they are unaffected by culture, then
these disorders are surely universal to humans everywhere.
Their application around the world therefore represents
simply the brave march of scientific knowledge.
But the cross-cultural researchers and anthropologists
profiled in this book have a different story to tell. They have
shown that the experience of mental illness cannot be
separated from culture. We can become psychologically
unhinged for many reasons, such as personal trauma, social
upheaval, or a chemical imbalance in our brain. Whatever
the cause, we invariably rely on cultural beliefs and stories
to understand what is happening. Those stories, whether
they tell of spirit possession or serotonin depletion, shape
the experience of the illness in surprisingly dramatic and
often counterintuitive ways. In the end, all mental illnesses,
including such seemingly obvious categories such as
depression, PTSD, and even schizophrenia, are every bit as
shaped and influenced by cultural beliefs and expectations
as hysterical leg paralysis, or the vapors, or zar, or any
other mental illness ever experienced in the history of
human madness.
The cultural influence on the mind of a mentally ill person
is always a local and intimate phenomenon. So although this
book describes a global trend, it is not told from a global
perspective. In the hopes of keeping the human-scale
impact in sight, I have chosen to tell the stories of four
diseases in four different countries. I picked these tales
because each illustrates how the globalization of Western
beliefs about mental health travel on different currents.
From the island of Zanzibar, where beliefs in spirit
possession are increasingly giving way to biomedical
notions of mental illness, I tell the story of two families
struggling with schizophrenia. To document the rise of
anorexia in Hong Kong, I retrace the last steps of 14-year-old
Charlene Hsu Chi-Ying and show how the publicity
surrounding her death introduced the province to a
particularly Western form of the disease. I deconstruct the
mega-marketing of the antidepressant Paxil in Japan to
illustrate how drug companies often sell the very disease for
which their drug purports to be a cure. The aftermath of the
2004 tsunami in Sri Lanka provides the opportunity to
examine the impact of trauma counselors who rush into
disaster zones armed with the diagnosis of posttraumatic
stress and Western certainties about the impact of trauma
on the human psyche.
At the end of each of these chapters I turn the focus back
to the West, and to the United States in particular. When
viewed from a far shore, the cultural assumptions and
certainties that shape our own beliefs about mental illness
and the human mind often become breathtakingly clear.
From this perspective, it is often our own assumptions about
madness and the self that begin to appear truly strange.
The cross-cultural psychiatrists and anthropologists
featured in this book have convinced me that we are living
at a remarkable moment in human history. At the same time
they’ve been working hard to document the different
cultural understandings of mental illness and health, those
differences have been disappearing before their eyes. I’ve
come to think of them as psychology’s version of botanists
in the rain forest, desperate to document the diversity while
staying only a few steps ahead of the bulldozers.
We should worry about this loss of diversity in the world’s
differing conceptions and treatments of mental illness in
exactly the same way we worry about the loss of biological
diversity in nature. Modes of healing and culturally specific
beliefs about how to achieve mental health can be lost to
humanity with the grim finality of an animal or plant lapsing
into extinction. And like those plants and animals, the
diversity in the human understanding of the mind can
disappear before we’ve truly comprehended its value.
Biologists suggest that within the dense and vital
biodiversity of the rain forest are chemical compounds that
may someday cure modern plagues. Similarly, within the
diversity of different cultural understandings of mental
health and illness may exist knowledge that we cannot
afford to lose. We erase this diversity at our own peril.
1
The Rise of Anorexia in Hong Kong
Psychiatric theory cannot deny its participation in the social
trajectory of the anorectic discourse, which articulates
personal miseries as much as it does public concerns.
SING LEE
On the morning of my visit to Dr. Sing Lee, China’s
preeminent researcher on eating disorders, I took the
subway a few stops north of downtown Hong Kong to the
Prince of Wales Hospital in the suburb of Shatin. In the clean
and well-lit subway corridors, I passed several large posters
featuring outlandishly slender, bikinied young women
promoting a variety of health care regimens, cellulite-
removing creams, and appetite-suppressant supplements.
The advertisements over the handrails in the subway cars
repeated the offers. The magazines and newspapers being
read by the commuters were filled with similar pitches,
often featuring before and after photos, young women
becoming little more than skin and bones after the offered
treatment. Such products are a huge business in Hong Kong
and increasingly in mainland China. Over the past few years
the beauty industry in Hong Kong (including dieting,
cosmetics, skin care, and fitness) has outspent every other
business sector on advertising. In that week’s issue of the
popular weekly magazine Next, a remarkable 110 of the
publication’s 150 ads were for slimming or beauty products
and services.
The reporting and photojournalism that appeared
alongside those ads had a slightly different obsession:
telling tales of young women celebrities. That morning’s
Standard, one of Hong Kong’s English dailies, prominently
reported the recent misadventures of several famous young
women, including Britney Spears, who had that week been
held against her will at the UCLA Medical Center. She had
been “5150ed,” which is the code for a California statute
that allows doctors to hold a patient involuntarily if she is
deemed a danger to herself or others. On the opposing page
was an article about the Japanese pop idol Kumi Koda, who
lost her job as a spokesmodel for Japan’s third largest
cosmetics company, Kose Corp., after making pejorative
comments about the fertility of older women. The cute and
perky 25-year-old had gone on a popular radio show and
given her medical opinion that a “mother’s amniotic fluid
turns rotten once a woman reaches about thirty-five . . . It
gets dirty.”
The biggest story in The Standard, in fact the front-page
story in every paper in Hong Kong that morning, was a sex
scandal involving a handful of the region’s best-known
female pop stars and a young actor. Hundreds of very
explicit nude photos had been posted on the Internet of
singer Gillian Chung and actresses Bobo Chen and Cecilia
Cheung Pak-chi, among a dozen others. That same week a
humanitarian crisis was erupting along the Gaza-Egyptian
border and a severe snowstorm was sweeping across much
of eastern China, threatening to strand millions of holiday
travelers, yet no other story could compete with this sex
scandal. Everyone, from politicians to op-ed writers, felt the
need to criticize the behavior of the young women. Even
Hong Kong’s Catholic bishop John Tong weighed in on the
subject of celebrity sin and cyber etiquette, saying that it
was important to “keep our minds decent” and “not post or
circulate these pictures.”
Of course it’s not possible to say exactly what these
advertisements, images, and stories of celebrity
misadventures might have been adding up to in the minds
of average adolescent girls in Hong Kong. It didn’t take
much reading between the lines, however, to perceive a
high degree of confusion and ambivalence surrounding the
issues of female body image, sexuality, youth, beauty, and
aging. Young women in some contexts were worshipped for
their attractiveness, while in other situations they were
humiliated and publicly vilified with a vitriol that would be
hard to overstate. Whatever understanding Hong Kong
teenage girls were piecing together about the
postadolescent world from these sources, it is safe to say
that it was not unconflicted.
Given this environment, it would make sense to most
Americans and Europeans that occurrences of anorexia and
bulimia have spiked here in the past fifteen years. Nor
would it likely be a surprise that Gillian Chung, one of those
young celebrities in the sex scandal, had herself battled
bulimia. Most well-educated Westerners understand that
anorexia is sparked by cultural cues, but they often have a
fairly narrow conception of what those cues might be. Most
assume that anorexia, with its attendant fear of fatness and
body dysmorphic disorder, is born of a peculiar modern
fixation with a slender, female body type, and that popular
culture transmits this fetish to young women. As we’ve
exported our obsessions with slender models—our Barbie
dolls and our Kate Moss fashions—it makes sense to us that
eating disorders have followed in their wake.
But although this commonsense cause and effect might
be part of the story, Sing Lee’s research shows that there
have been other, more subtle, cross-cultural forces at work
here. The full story of how anorexia spread from the
American suburbs to Hong Kong is more complex and, in
many ways, more troubling. It turns out that the West may
indeed be culpable for the rise in eating disorders in Asia,
but not for the obvious reasons.
After making my way across Shatin, I found Lee’s small
suite of offices among the labyrinth of midrise buildings that
make up the Prince of Wales Hospital. Introduced by his
assistant, Dr. Lee was younger than I expected. At 49 years
old, he’s had a remarkable output as a scholar despite the
fact that he has split his time between seeing patients at
the public hospital, teaching, and running a mood disorders
center. He admits that at times he has been accused of
being a workaholic. “I do work long hours, but I’ve never
experienced much work stress,” he said to me in what I
would come to know as his characteristic humble manner.
“I’ve wanted to be a psychiatrist since high school and I still
love the work of meeting patients and writing about ideas.”
Given the amount of time he spends in his office, he’s
allowed himself to build a comfortable environment. The
place has the feel of a stylish bachelor pad. The bucket seat
and gearshift of a sports car sat on the floor next to the
couch. Directly across from his desk was one of his prized
possessions: an antique vacuum tube stereo connected to
two imposingly large speakers. The tuner was made in the
early 1960s and at the time cost as much as a VW Beetle
and requires vacuum tubes the size of small lightbulbs to
operate. For a true classical music audiophile such as Lee,
however, there is no substitute for the resonant tones it
produces.
Even after two decades of charting the cultural currents
that have brought the American version of anorexia to these
shores, Lee remains passionately interested in talking about
the puzzle. He was the first scholar to document anorexia in
Chinese women. The remarkable thing he found was that
before the illness was well known in the province, Chinese
anorexia was unlike that found in the West. These atypical
anorexics, as he calls them, displayed a different cluster of
symptoms than their Western counterparts. Most, for
instance, did not display the classic fear of fatness common
among Western anorexics, nor did they misperceive the frail
state of their body by believing they were overweight. It was
while he was trying to puzzle out these differences that he
witnessed something remarkable.
Over a short period of time the presentation of anorexia in
Hong Kong changed. The symptom cluster that was unique
to his Hong Kong patients began to disappear. What was
once a rare disorder was replaced by an American version of
the disease that became much more widespread.
Understanding the forces behind that change may not only
explain why anorexia became common in Hong Kong, but it
may also lead us to reconsider the momentum behind the
disease in the West.
The Death of a Patient
When Sing Lee came back to Hong Kong from his training in
England in the mid-1980s, he took a job at the Prince of
Wales Hospital and began looking for Chinese anorexics.
Having been introduced to the disorder while in England he
was, like many young psychiatrists, fascinated by the
fundamental conundrum of the disease: Why would healthy
young women with plenty of resources starve themselves?
At the time Lee began his search, the long-held belief that
eating disorders were confined to American and Western
European populations was just beginning to show cracks.
Even though prominent eating disorder researchers were
making the argument as late as 1985 that anorexia didn’t
exist outside of the United States, cases were beginning to
show up in Russia and Eastern Europe. Although it was still
believed to be rare in Latin American countries, researchers
and clinicians also began discovering young women with
anorexia in Japan and South Korea.
In China and Hong Kong the disorder remained all but
unknown. Searching the two major psychiatric journals
published in China, Lee found not a single paper
documenting a Chinese woman with anorexia. With little to
go on, he got to work searching the databases at the Prince
of Wales Hospital. After an exhaustive search, he managed
to identify just ten possible cases in the five years from
1983 to 1988. Given the thousands of patients seen at the
hospital, he determined that anorexia was an exceedingly
rare disorder in Hong Kong. His first paper on the topic,
published in 1989 in the British Journal of Psychiatry, was
titled “Anorexia Nervosa in Hong Kong: Why Not More in
Chinese?”
The low rate of anorexia was a mystery that Lee wanted
to figure out. Perhaps Chinese cultural beliefs or practices
contained protective mechanisms. He knew, for instance,
that historically there was little Chinese stigma surrounding
larger body shapes. In fact popular Chinese sayings
suggested that “being able to eat is to have luck,” “gaining
weight means good fortune,” and “fat people have more
luck.” He also considered that the later onset of puberty in
Chinese girls compared to girls in the West might be a
preventive factor. The physical changes that come with
puberty might be less psychologically stressful when
experienced with an added year or two of emotional
maturity.
But even taking these differences into account, Lee
couldn’t quite understand why the behavior was so
uncommon among local adolescents. In many ways Hong
Kong seemed primed for the disorder. It was a modern
region that, thanks to years of British rule, had incorporated
many Western values as well as styles of dress and eating.
There were fast-food restaurants and health clubs. Thin
Western and Chinese celebrities were idolized. It was a
patriarchal culture, in which parents and teachers put
intense pressure on students to compete. The Chinese
obsession with food and the layered meanings of sharing
meals within a family should have made food refusal a
dangerously attractive behavior for an adolescent looking to
send a distress signal to those around her.
All the triggers for anorexia that had been identified in
Western literature seemed to be present in full force, and
yet eating disorders remained rare. Lee suspected that
there was something else, some factor that hadn’t been
fully considered in the Western literature, that remained
absent in Hong Kong. What that factor might be he could
only guess.
Treating the few cases he could find, Lee discovered
another puzzle. He noticed that the women who starved
themselves in Hong Kong were different from the anorexics
he had studied while training in England. The variations
were sometimes so pronounced he wondered if he was
seeing the same disease. To illustrate those differences, Lee
recounted to me the story of one of the first patients he
personally treated, a 31-year-old saleswoman I’ll call Jiao.
Lee still clearly remembers the first time he met Jiao in a
hospital examination room in 1988. Although he knew from
his research how thin anorexic patients could become, he
couldn’t help but be taken aback at the sight of her. “She
was shockingly emaciated—virtually a skeleton,” he recalls.
“She had sunken eyes, hollow cheeks and pale, cold skin.”
She was alert but uncommunicative. At 5 feet 3 inches, her
ideal body weight should have been in the neighborhood of
110 pounds. Indeed, she had been that weight four years
earlier, before she began to waste away. By the time she
sought medical treatment she weighed just 48 pounds.
During his physical exam of Jiao, Lee noted that she had
dry skin and a subnormal body temperature. More
concerning, her blood pressure was low and her heartbeat
was a plodding 60 beats per minute. He took X-rays after
giving her a drink laced with barium so he could examine
her esophagus. He also used an endoscope to examine her
upper gastrointestinal system for blockages or lesions.
Convinced the disorder wasn’t organic in origin, he began to
piece together her personal history.
Jiao was the youngest child of three living children (two of
her brothers died soon after birth). She had grown up in a
working-class family in a rural village near Hong Kong,
where she still lived. Like many in the Hong Kong area, her
family was both emotionally enmeshed and yet physically
disjointed. To earn a living, her father had lived apart from
the family for many years at a time, and yet, when he was
present, he demanded the absolute loyalty he felt was his
traditional due as head of the household. During his visits
home he often berated Jiao and her mother for small
infractions, such as interrupting him when he spoke, and he
freely expressed his disappointment that Jiao had not
performed better in school. Her mother was a traditional
housewife who was subservient to her husband and was
socially isolated because she spoke only a Chinese dialect
called Hakka. Although it was not a happy home, there was
no history of mental illness, sexual or physical abuse, or
eating disorders.
Jiao’s struggles with eating had begun in earnest four
years earlier, in 1984, when her boyfriend deserted her by
emigrating to England. She was devastated by his departure
and began to refuse food and skip meals. Explaining her
change in eating patterns to her family, she complained of
pain and discomfort in her abdomen. During this time she
became increasingly socially withdrawn and lost her job.
Over those first years of the illness she saw various doctors.
She was encouraged by health professionals as well as her
family to eat more. Nevertheless she steadily lost weight
year after year.
While relating her personal history to Lee during that first
interview, Jiao cried at times but for the most part just
looked sad and tired.
“What do you think is your main problem?” Lee finally
asked her.
“Abdominal fullness and thinness,” she replied.
“What else?”
“A bad mood, it’s hard to describe. . . . It is no use talking
about it anymore,” she said and began to weep.
“Is there a name for your condition?” Lee asked her.
“I don’t know,” she said. “Can you tell me what kind of
disease it is?”
Lee had her draw a picture of herself. This technique is
often used to assess whether anorexic patients have a
distorted perception of their emaciated condition. The stick
figure sketch she handed back to Lee, however, closely
matched her skeletal condition.
Jiao’s presentation left Lee in a quandary. On the one
hand, she was clearly starving herself to the point of death.
On the other hand, she didn’t fit many of the American
diagnostic criteria for anorexia. The Diagnostic and
Statistical Manual of Mental Disorders, published by the
American Psychiatric Association—the third edition released
in the late 1980s had quickly become the worldwide
standard—stated that someone suffering from anorexia not
only rigidly maintains an abnormally low body weight but
expresses an “intense fear of becoming obese, even when
underweight,” and has a disturbed self-image, such as
claiming to “feel fat when emaciated.”
But Jiao did not express a fear of being overweight. In
addition, she didn’t have any misperception about the
emaciated condition of her body. She described herself
pretty much exactly as Lee saw her: as a very sick and
dangerously thin young woman.
When he gave her the standard eating disorder
questionnaire of the time, it also showed clear differences
from what one would expect of an anorexic in the West. For
instance, Jiao insisted that she never consciously restricted
the amount of food she ate. Western anorexics, he knew,
usually admitted to obsessing over food portions and
quantities. When asked why she often went for whole days
without eating, Jiao would say only that she felt no hunger
and, pointing to the left side of her abdomen, describe how
her stomach often felt distended.
These deviations from the Western diagnosis weren’t
unique to Jiao. Most of the Hong Kong anorexics Lee was
able to interview or treat around this time similarly denied
any fear of being fat or of intending to lose weight to
become more attractive. They often spoke of their desire to
get back to a normal body weight. When explaining their
refusal to eat, they most often ascribed the behavior to
physical causes such as bloating, blockages in their throat
or digestion, or the feeling of fullness in their stomach and
abdomen. Their often repeated claim that they had no
appetite also ran counter to conceptions of the disease put
forward by Western experts. Psychiatrist Hilde Bruch, who
wrote one of the seminal books on anorexia, The Golden
Cage, asserted that “patients with anorexia nervosa do not
suffer from loss of appetite; on the contrary, they are
frantically preoccupied with food and eating. In this sense
they resemble other starving people.”
As a group, these Hong Kong anorexics were different
from their American counterparts in other ways as well.
These were not the “golden girls” described in Western
literature on eating disorders. Anorexia in the West was
known to afflict well-to-do, popular, and promising young
women who were sometimes perfectionists in other parts of
their lives, such as school or sports. But Lee’s patients were
often from poor families and among the lower achievers in
their schools. They also did not give any hint of the moral
superiority sometimes observed in Western anorexics.
Most curiously, they were often from outlying villages, not
a population that Lee suspected would be most influenced
by the globalization of Western pop culture. They had not
begun their self-starvation after reading diet books or
engaging in the exercise fads of the day. His atypical
anorexics were not among the young women in Hong Kong
adopting Flashdance fashions or going to Jazzercise classes.
If Western pop cultural influences were at the heart of this
disorder, there were certainly populations in Hong Kong who
should have been harder hit. Hong Kong was, and remains,
the most international of cities, and there were plenty of
groups of adolescents and young women fully engaging in
Western fashion and pop culture. But Lee’s patients did not
come from these jet-setting subcultures.
While Lee had great respect for the clinical knowledge he
had gained during his training in the West, he knew it posed
a challenge as well. With the DSM becoming the world’s
diagnostic manual for mental illness, it was easy to gloss
over different disease presentations to make them fit the
Western standard. But Lee was convinced that the
distinctions between the American presentation of anorexia
and what he was witnessing in Hong Kong was a meaningful
difference that could lead to new insights into the disorder.
He knew that if he was going to understand what was
happening with his Hong Kong patients, he was going to
have to get to the bottom of those differences.
Yin, Yang, and Qi
Despite Lee’s uncertainty about the diagnosis of anorexia,
Jiao was clearly in need of immediate attention. With Lee’s
encouragement she checked into the hospital, but she
proved to be a difficult patient. She used a shifting series of
excuses to refuse the food offered by the dietitian. Lee
speculated that her resistance to his ministrations might be
bound up in the culture clash between Western and Chinese
medicine. Hoping to hit a resonant cultural note that would
lessen her resistance, he called in a Chinese herbalist and
then a qigong master to participate in her treatment. The
herbalist reported to Lee that Jiao’s condition involved a
variety of imbalances between the liver, the spleen, and the
stomach. Her extreme sadness over her lost love had
caused her liver function to break down, the herbalist
explained, which in turn had thrown off the workings of her
spleen and stomach. This had resulted in poor absorption of
food nutrition, limiting her body’s ability to transform food
into qi, the flow of energy that animates all living things.
These problems had led to a weak heart and ineffective
kidneys. In addition, the herbalist found a general imbalance
in her system that he described as an excess of yin and a
depleted reserve of yang.
Because the liver malfunction was at the beginning of the
cascade of internal distress, the herbalist recommended a
mixture of herbs he said would selectively soothe and repair
that organ. The treatment, Jiao was told, would allow her to
let go of the unhealthy energy that surrounded the memory
of her lost love. Jiao refused to drink the concoction.
The qigong master was even less successful. He also
believed that Jiao’s flow of qi was dangerously low. He
performed rituals to unblock her pent-up qi. By the third
treatment, the qigong master quit the case, telling Lee that
the patient was “not willing to recover.”
With neither Western nor Eastern healing modalities
having much impact, Jiao decided to leave the hospital. She
was discharged just before Christmas of 1988. Although she
had gained weight during her hospital stay, from 48 pounds
to 59 pounds, in a checkup two weeks later she had already
dropped four of those pounds. She refused readmission to
the hospital and began to avoid outpatient visits as well.
Over the next few years Lee twice visited her at home,
hoping to lure her back into treatment. During this time her
weight dropped back down to 50 pounds.
In 1992 Lee once again visited Jiao at home, taking two
female medical students with him. Jiao looked as skeletal as
ever and told of heart palpitations and lower limb weakness.
Two of her front teeth had decayed to the point that they
had been removed. Jiao’s mother gestured to Lee that she
was still not eating much. Because of the mother’s language
barrier, a neighbor was brought in to explain the need for
inpatient treatment to her. The neighbor said that many in
the village had tried unsuccessfully to encourage Jiao to eat
more. The neighbor wanted to know from Lee what this
mysterious disease was called and what caused it.
After the visit Lee and the two medical students took Jiao
for a short walk in the village. She showed the students a
picture of herself before the onset of the illness and seemed
happy when they said she was pretty in the photos. She
asked the students if they would reject her as a friend
because of her current terrible appearance. At the end of
the visit, Jiao agreed to consider returning to the hospital,
but when Lee phoned her a few days later she declined
again.
It was only two weeks later that Jiao showed up in the
emergency room of the Prince of Wales Hospital. She was in
terrible shape. She weighted only 42 pounds, her blood
pressure was low, and sacral bedsores were appearing on
her skin. She gasped for breath at the slightest exertion. To
Lee’s relief, Jiao agreed to hospitalization.
During her first day in the hospital, Lee noticed a positive
turn in her outlook. Jiao asked for a referral to the
occupational therapy department so that she could learn
typing and computer skills. She hoped this would put her in
line for a better job later in life. Some of the medical
students who had been following her case with Dr. Lee gave
her a present of a hat and scarf. The gift pleased Jiao. She
asked to get a haircut and began to talk of “making a new
beginning.” She began to take small amounts of food orally.
Two days later, at four in the morning, Jiao’s heart gave
out. The autopsy showed no specific pathology other than
multiple organ atrophy due to her self-starvation.
His failure to help Jiao recover fueled Lee’s passion to
figure out the meaning of anorexia in Hong Kong. Thinking
back on the case, he became convinced that the Western
understanding of the disease, focusing on body image and
fat phobia, was of little use in cases like Jiao’s. What was
needed was not a global template for anorexia, but a much
more local understanding of the personal and cultural forces
at play. Relying on a global template, he believed, could be
worse than just ineffective. The increasingly wide use of the
Western diagnostic categories and the many assumptions
that lay behind them had the potential of blinding local
clinicians to the unique realities of patients in different
cultures.
A Personal Test and Global Spread
Lee knew that he had to understand anorexia on two
different levels. There was the question of why women
began the behavior of self-starvation, and then there was
the question of what happened to their mind and body as
the regimen of starvation gained momentum in their daily
life. Lee felt it was critically important to understand what
anorexia felt like on a physiological level. “I was curious
about the basic question: How can they eat so little?” Lee
recalls. “Why did lunchtime make no difference to them?
What did it mean to turn off the biological clock that
signaled the body to eat?”
Empathy is prized among all mental health providers, but
it’s an ephemeral and untestable quality. A doctor may think
he or she is sensing the internal world of the patient, but
how can one really know? This is especially problematic
when facing a patient with a severe mental illness. Can a
doctor who treats a schizophrenic empathically connect with
the workings of that patient’s mind? Lee realized that, unlike
in other mental disorders, a doctor treating an anorexic
patient had some opportunity to share in the patient’s
experience. Because the key symptom—restricting one’s
eating—was an external behavior, Lee saw an opening to do
an experiment. He decided to mimic the behavior of an
anorexic in the early stages of the disorder.
“I got it in my head,” says Lee, “that if I wanted to truly be
an expert on this condition, I needed to experience it for
myself.” So he began to severely cut back on his food intake
and skip lunch entirely. He also began an intense exercise
routine. Like all dieters, at first he felt the normal drop in
energy and mood as his body struggled to make it through
the day with a depleted supply of calories. After a few weeks
he had lost five pounds, but he still felt like he was dragging
himself through his daily routine. After a month and a half of
restricting food, he was another five pounds lighter but felt
no better. His stomach ached and growled for food.
It was around the three-month mark that some gear
shifted in his physiology. His energy began to return and his
mood improved—more than improved, actually: he felt
great. He was going to bed later and waking up earlier. He
performed behaviors that he would have identified in a
patient as potentially pathological. As he rode the elevator
up to his office every morning, for instance, he did arm
exercises on the handrails. He began to feel a
hyperalertness and sense of mastery over his body and his
life. For much of the day he was on the sort of pleasant
runner’s high that one feels in the middle of a good workout.
His hunger, which for months had been sounding a
deafening alarm, had become a background whisper that he
could easily ignore.
He found himself feeling somewhat superior to other
people, who seemed to be ruled by their incessant need for
food. He couldn’t understand why so many people who tried
to diet lacked the willpower to do so. He found that he was
inordinately pleased that he had the strength of will to see
his project through. The next ten pounds came off with little
effort and his friends and family began to comment on how
thin he was. He had lost over 12 percent of his body weight.
Although Lee felt the desire to stay on his restrictive diet,
he managed to shake himself out of the behavior. His
excuse to himself at the time was that he needed to go to
London for an intense exam at the Royal College of
Psychiatry, and he worried that his lack of nutrition would
limit his mental abilities. It had been a dangerous
experiment but a successful one; he had heard a bit of the
siren song that patients with anorexia often follow to their
death.
One of his patients once told him that anorexia felt like
getting on a train, only to discover too late that she was
headed in the wrong direction. This patient felt she had little
choice but to stay on that train to the final destination. Lee
now had some idea what she meant when she used that
metaphor to describe the psychological momentum that can
build behind anorexia. He had starved himself to the point
where the behavior can turn from a willful choice into a
dangerous addiction.
As Lee’s first papers on anorexia in Hong Kong moved
toward publication, much was changing in the world of
eating disorder research. Scattered case reports had been
followed by outbreaks of eating disorders reported in Africa,
India, and the Middle East. One study showed that students
in Nigeria were scoring as high as Westerners on disordered
eating scales. In the East, anorexia had become increasingly
common in Taiwan, Malaysia, Singapore, and Japan.
The popular explanation at the time was that Western
media were influencing the way women around the world
viewed their bodies; as Western movie stars and models
became the world standard for glamour and attractiveness,
it appeared that eating disorders followed. Although that
seemed like common sense, researchers who tried to prove
a connection between Western acculturation and eating
disorders were often frustrated. Usually these studies
involved giving a group of immigrant women a test to
measure abnormal eating attitudes, along with a set of
questions intended to gauge their level of acculturation to
their new home. The assumption was that women who had
adopted Western norms would have higher scores on the
disordered eating tests.
For the most part, however, these studies failed to make
this seemingly commonsense cause-and-effect connection.
In a review of eighteen such studies, a team of American
researchers concluded, “Despite the long-standing
hypothesis that a greater exposure to Western values leads
to an increased risk for eating disorders, this review of
acculturation research presents no compelling evidence for
such a relationship.” These researchers noted that the
majority of studies failed to find a connection, and the few
that did were offset by studies showing that immigrant
women who were assimilated into Western culture
sometimes had lower scores on disordered eating scales
than women who held to their traditional beliefs and habits.
These latter studies that showed an inverse relationship
between acculturation and disordered eating were the most
controversial because they directly challenged the accepted
wisdom that the true pathogen for eating disorders hid
within Western attitudes toward the female body.
Regardless, studies of British schoolgirls from South Asia
consistently showed that those with a lower level of Western
acculturation had higher levels of body dissatisfaction and
eating disordered behavior. Strikingly similar results were
found among Hong Kong–born women who moved to
Australia.
It was clear that the pathogens that were spreading eating
disorders around the world were not as simple as exposure
to Western fashion, diets, or popular culture. What exactly
was motivating the spread of the disorder remained a hot
topic of debate. If, as Lee had discovered, local forms of
anorexia were often markedly different from the DSM
version of the disease, perhaps there weren’t any universal
causes for anorexia because it wasn’t a single, unified
disease. Or perhaps there was another spark for the spread
of the disease that hadn’t yet been considered.
The Mirror of History
Lee realized that his handful of Hong Kong patients
represented a unique opportunity to examine an expression
of anorexia divorced from Western cultural beliefs about the
condition. Whereas it was all but impossible for a woman
with an eating disorder in the United States to remain
unaware of the various cultural meanings behind the
behavior, Lee’s Hong Kong atypicals often knew of no other
sufferers and lacked even a name for their condition. They
had come to the disease on their own and were negotiating
a private meaning for their refusal to eat.
Hoping to glimpse the disease from a new perspective,
Lee dove into the early history of the disorder. He became
particularly interested in the work of a Canadian scholar
named Edward Shorter, a medical historian who had
recently written several influential papers on the history of
anorexia. Reading the description of young women who
starved themselves in the early to mid-nineteenth century,
long before there was an official category for the illness, Lee
was taken aback. The descriptions of those early self-
starvers from more than a hundred years ago and half a
world away sounded remarkably similar to the Hong Kong
patients he was seeing in his practice.
Shorter recounts the story of a 16-year-old girl treated in
1823 by a Frankfurt physician named Salomon Stiebel. In
Stiebel’s account, the girl’s troubles started when her
parents insisted she break off a budding romantic
relationship with a suitor they deemed inappropriate. After
the girl was given the bad news “she felt a heavy pressure
on the lower region of her esophagus, became pale and
breathless, was unable to speak, and had to sit down.” This
feeling of pressure on her esophagus returned daily, making
it impossible, she reported, for her to eat solid food.
Although it seems clear that her self-starvation was
psychological in origin—beginning as it did with the
termination of a romance—the girl experienced her refusal
to eat as a physical symptom: a literal blockage in her
throat.
In his research Shorter reported a number of similar
descriptions. Like Lee’s patients in Hong Kong, these early
anorexics reported a range of somatic reasons for refusing
to eat. Echoing the explanations from Lee’s patients, several
nineteenth-century doctors reported that patients ascribed
their food refusal to painful digestion. Many, like the girl in
Frankfurt, told of the sensation of having an impassable
lump in the throat. Food would “not go down,” they would
claim. Others claimed other physiological problems, such as
the inability to chew.
These cases were interesting to Lee for what was absent.
Like his atypical patients in Hong Kong, these early
anorexics did not report a desire to lose weight, nor was
there evidence that they had a fear of becoming fat. In
addition these patients did not have a distorted body image,
such as believing they were fat even though they were
emaciated. Lee began to wonder whether he was seeing in
his Hong Kong patients a rare pre-twentieth-century form of
anorexia.
Shorter argued in his papers that the only way to
understand the Western evolution of anorexia is to see it in
the context of the archetypical psychological diagnosis of
the nineteenth century: hysteria. Along with starving
themselves, early anorexics often presented a number of
classic symptoms of hysteria. This was true of the lovelorn
girl from Frankfurt; her other symptoms of distress included
pain at the slightest pressure on her sternum, numbness in
one hand, and a persistent cough. She developed a facial tic
and skin sensitivity on her face. She also experienced
periods of catalepsy, a zombie-like state in which she heard
what was going on around her but could not move or
respond. Although this cluster of symptoms would look
strange today, it would have been nothing new to the
doctors of her time.
The middle decades of that century were a golden age for
hysteria. At its high-water mark, hysteria could include a
remarkable variety of symptoms: convulsive fits, paralysis,
muscle contractions, linguistic impediments, amnesia,
spinal irritation, day blindness, cold sensitivity,
hallucinations, and astasia-abasia, the inability to stand or
walk. The latest theories about the disease were often
topics of conversations in upper-middle-class drawing
rooms, where the latest editions of the New England Journal
of Medicine and the Lancet could often be found. Like the
Dr. Phils and Dr. Drews of our time, many practitioners in the
Victorian era had a taste for the status and celebrity their
positions offered them. Physicians such as Charles Laségue
and Jean-Martin Charcot made their names by discovering in
their patients novel manifestations of what was then the
quintessential illness of womanhood. These doctors filled
lecture halls to announce their discoveries and were toasted
by royalty.
Documenting the rise of the disorder, historians such as
Janet Oppenheim have given us a glimpse of how deeply
hysteria influenced Victorian culture. Oppenheim found the
disease not only in the mental health and medical literature
of the time, but everywhere she looked. Popular magazines
and newspapers, public hygiene literature, novels, short
stories, personal letters, diaries, and autobiographies—it
was an idea that had a tremendous hold on the population
at the end of the nineteenth century. In the spring of 1881
one popular French journalist wrote, “The illness of our age
is hysteria. One encounters it everywhere. Everywhere one
rubs elbows with it. . . . Studying hysteria, Monsieur
Laségue, the illustrious master, and Monsieur Charcot have
put their finger on the wound of the day. . . . This singular
neurosis with its astonishing effects . . . travels the streets
and the world.”
Although self-starvation resulting from stomach pain, lack
of appetite, vomiting, or the sensation of having a lump in
the throat began as a bit player in the grand drama of
hysteria, it steadily gained prominence in the ranks of
hysterical symptoms in the second half of the century. By
1860 Louis-Victor Marce, the director of a large asylum in
France, reported that it was “very common” to observe
“young women who, just having reached puberty after a
precocious physical development, lose their appetite to an
extreme degree. No matter how long they have abstained
from food, they experience a distaste for it which even the
most insistent urging is unable to reverse.” Between 1860
and 1864 the young women in a Lisbon school alternated in
groups between symptoms of hysteria—leg weakness,
paralysis, and day blindness—and periods of vomiting that
went on for months. At one point 90 out of 114 girls
participated in the epidemic of vomiting.
As eating disordered behavior became increasingly
common among hysterics, doctors began to debate its
meaning and cause. Various labels appeared in the early
literature, all hinting at different root causes: “apepsia
hysterica,” “neuropathic disorders of gastric sensibility,”
“nervous dyspepsia,” “hyperaesthesias of the stomach,”
“gastrodynia,” and “visceral neurosis.” “In the years before
the phenomenon received a formal diagnostic label,”
Shorter writes, “the symptoms tended to be inchoate and
poorly defined because neither doctors nor patients had yet
a clear model of the disease.” This time of uncertainty,
Shorter suggests, made for a kind of incubation period for
the illness of anorexia, a time when the debates among
doctors began to shape the public’s and the patients’
understanding of the behavior.
It wasn’t until 1873 that anorexia nervosa finally received
that formal recognition. That year Laségue, already famous
for his work with hysterical patients, dubbed the disease
“hysterical anorexia.” (A year later the word “hysterical”
would be dropped and the term “anorexia nervosa” would
become standard in the medical literature.) The typical
patient, he reported, was a young woman between 15 and
20 who had recently suffered an emotional trauma and
began a “refusal of food that may be indefinitely
prolonged.” He noted that months might go by without the
patient’s health declining. Indeed she might enjoy a surge of
energy. “Not only does she not sigh for recovery, but she is
not ill pleased with her condition, notwithstanding the
unpleasantness it is attended with.”
For another historical scholar, the moment in time when a
disease became officially recognized and named by the
established medical order might be nothing more than an
interesting historical footnote. Shorter, however, was an
expert in the history of psychosomatic illnesses, and he
knew better than anyone that the pronouncements of
famous doctors could have a powerful, though unconscious,
effect on people. As his body of research shows, history was
full of ever-changing psychosomatic symptoms shaped in
large part by the expectations and beliefs of the current
medical establishment. “As doctors’ own ideas about what
constitutes ‘real’ disease change from time to time due to
theory and practice, the symptoms that patients present will
change as well,” he writes. “These medical changes give the
story of psychosomatic illness its dynamic: the medical
‘shaping’ of symptoms.”
Shorter believes that it was Laségue’s famous paper and
the public interest in the medical debate surrounding the
diagnosis of anorexia that forged a kind of template for self-
starvation. As the medical establishment settled on the
name, the agreed-upon causes, and a specific symptom list
for the disease, they were, Shorter argues, “disseminating a
model of how the patient was to behave and the doctor to
respond.” What was once a mishmash of conflicting medical
theories surrounding self-starvation had now gained the
appearance of a precise disorder with a specific at-risk
population.
That new conception of this illness took hold not only
among women who had already manifested disordered
eating but in the population at large. There are no broad
epidemiologic studies of eating disorders from the time, but
the anecdotal evidence for what happened next is
persuasive: soon after the official designation of anorexia
nervosa, the incidence of the disease began a dramatic
climb. Whereas in the 1850s self-starvation was a rare
symptom associated with hysterics, by the end of the
century the medical literature was littered with references
to full-blown anorexics. As one London doctor reported in
1888, anorexic behavior was “a very common occurrence,”
of which he had “abundant opportunities of seeing and
treating many interesting cases.” In that same year a young
medical student confidently wrote in his doctoral
dissertation, “Among hysterics, nothing is more common
than anorexia.”
A New Behavior Dives into the Symptom Pool
What caused the increase in cases of anorexia in the late
nineteenth century? Does the naming of a disorder allow
doctors to suddenly recognize and report what they had
previously overlooked? Or is there an interplay between the
codification of a new mental illness and the sudden
appearance of those symptoms in the general population?
With the introduction of any new illness category (as we’ll
see in the chapters on depression in Japan and PTSD in Sri
Lanka), there are always those who argue that the apparent
increased incidence of a condition is simply due to the fact
that the disease in question had previously gone unnoticed
or underreported. Although there is often some truth to that
assertion, the other possibility has rarely been squarely
addressed. For his part, Shorter unequivocally argues that
there is a clear connection between the official recognition
of anorexia nervosa and the growing number of women who
began to self-starve in Europe and then the United States.
Shorter believes that psychosomatic illnesses (such as leg
paralysis at the turn of the twentieth century or multiple
personality disorder at the turn of the twenty-first) are
examples of the unconscious mind attempting to speak in a
language of emotional distress that will be understood in its
time. People at a given moment in history in need of
expressing their psychological suffering have a limited
number of symptoms to choose from—a “symptom pool,” as
he calls it. When someone unconsciously latches onto a
behavior in the symptom pool, he or she is doing so for a
very specific reason: the person is taking troubling emotions
and internal conflicts that are often indistinct or frustratingly
beyond expression and distilling them into a symptom or
behavior that is a culturally recognized signal of suffering.
“Patients unconsciously endeavor to produce symptoms that
will correspond to the medical diagnostics of the time,”
Shorter told me when I called him in Montreal to speak with
him about Lee’s work. “This sort of cultural molding of the
unconscious happens imperceptibly and follows a large
number of cultural cues that patients simply are not aware
of.”
Because the patient is unconsciously striving for
recognition and legitimization of internal distress, his or her
subconscious will be drawn toward those symptoms that will
achieve those ends. Such a dynamic makes the official
public naming of a disease such as anorexia nervosa a
perilous event. It is clear to Shorter that psychiatrists and
physicians themselves have long been key players in
validating which new disorders or behaviors appear in the
symptom pool.
In the late nineteenth century the process of adding a new
symptom to the hysteria symptom pool would go like this:
On the basis of a few new and exciting cases, doctors would
publicly describe and debate and then codify the new
pathological behavior. Popular magazines, newspapers, and
journals would write about the new medical findings.
Women in the general population would unconsciously begin
to manifest the behavior and seek help. Patients and
doctors would then engage in what is called “illness
negotiation,” whereby they would together shape each
other’s perceptions of the behavior. In this negotiation the
doctor would provide scientific validation that the symptom
was indeed indicative of a legitimate disease category, and
new patients would increase the attention focused on the
new symptom in the professional and popular press,
creating a feedback loop that further established the
legitimacy of the new symptom.
So although there may have been a small number of
patients who presented novel behaviors without a cultural
template (like Lee’s atypical anorexics in Hong Kong), the
widespread adoption of a new hysterical symptom such as
anorexia or leg paralysis would follow the official
“discovery” of the symptom or disorder and the
establishment of the cultural feedback loop.
Anorexia was rare in the mid-nineteenth century not
because physicians somehow failed to notice their starving
patients, Shorter believes, but because it hadn’t yet been
widely acknowledged as part of the symptom pool of that
time. Only after it became a culturally agreed-upon
expression of internal distress did it become widespread.
Interestingly, pathological behaviors don’t attain a
permanent place in the symptom pool. It takes a certain
amount of public and professional attention to keep
behaviors like those common to hysteria in play in the
minds of a population. And indeed in the middle part of the
twentieth century many of the most dramatic symptoms
connected to hysteria drifted out of the symptom pool.
When the psychiatrist Hilde Bruch began her study of
anorexia in the 1940s, she reported that it was once again
“so rare . . . that it was practically unknown.” Searching the
admissions records at Presbyterian Hospital in New York
during those middle decades of the twentieth century, she
found on average only one case per year. Like Lee’s
anorexics, the patients Bruch saw during those years often
weren’t aware that their condition had a name, nor did they
know others who suffered similarly. Each one, she recalls,
“was an original inventor of this effort at self-assertion.” The
disorder once again became the topic of intense public and
professional interest after February 4, 1983, when the
popular singer Karen Carpenter collapsed from heart failure
brought on by anorexia nervosa. After that jump in interest,
the number of articles on the topic steadily grew throughout
the decade. By the late 1980s you’d have been hard-
pressed to find a Western teenager, especially among those
girls in the high-achieving, upper-middle-class demographic
group, who did not know about anorexia nervosa. It was
back in the symptom pool, luring another generation of
women.
A Clean Slate
Looking at the rise and fall and rise of anorexia over the
century, Lee was convinced, like Shorter, that eating
disorders were not at all like diseases such as the mumps or
polio; they didn’t have a natural history that could be
separated from the specific time and place in which they
existed. “Mental illnesses, specifically anorexia, do not exist
independent of social and historical context,” Lee
concluded. “There may therefore be no true natural history
of [anorexia nervosa], but rather a social history at a given
time and place, a perspective which questions radically the
biomedical assumption that there is a ‘core problem’ with
[anorexia nervosa].”
Lee began to suspect that his handful of atypical cases in
Hong Kong were akin to the rare cases of self-starvation in
the early nineteenth century, before it had been codified by
the prominent psychiatrists and physicians of the day and
publicized around the Western world. “I began to think that
these atypical patients I was seeing might shed some light
on the early appearance of self-starvation before it became
known as anorexia,” he recalls. “You can’t go back a
hundred or two hundred years to re-interview early anorexic
patients.”
He came to believe that the reason his patients didn’t
report their self-starvation as coming from a fear of fatness
was because that explanation would have made no sense in
their cultural surroundings. Fear of fatness wasn’t
recognized in the Hong Kong culture as a legitimate reason
for self-starvation; it was therefore unavailable to the
patient both as a private belief and as an explanation she
might give her doctor.
However, there were other explanations at the time that
did make sense. For instance, the Chinese have historically
looked to bodily sensations to indicate psychological
distress. Because of this long history of somaticizing mental
distress, it made sense to Lee that the atypical anorexics he
was seeing often focused on stomach complaints and the
feeling of bloating as the cause of their behavior. Chinese
philosophical thinking avoided making the Cartesian
distinction between the mind and the body. A Chinese girl’s
complaint of stomach pain might carry as much meaning
and impact as a signal of emotional distress as a Western
teenager’s complaint of anxiety or depression. Lee also saw
in his patients echoes of a certain Confucian asceticism—an
almost monk-like self-denial, asexuality, and lack of worry
about their bodily decline or even death. “Their food denial
communicated powerful cultural symbols, private meanings
and interpersonal messages,” Lee concluded. Decoding
these messages required a deep understanding of the
specific cultural forces influencing the self-conception of
these women.
In trying to parse out these meanings, Lee was racing
against time. Even as he was making progress
understanding the particular cultural meanings behind food
refusal in Hong Kong, the Western diagnosis of anorexia was
becoming accepted across the globe. Lee feared that the
DSM diagnosis of anorexia, with its focus on fat phobia and
body image distortion, would obscure more subtle, culturally
specific forms of self-starvation.
Slowly but steadily, in the early 1990s he noticed mental
health providers around him succumbing to a kind of color-
blindness, an inability to see the cultural and individual
differences in the patients they interviewed. As each year
passed, he could see the influence of the Western diagnostic
manual grow, particularly in younger generations of
clinicians. Reviewing other doctors’ notes on new cases of
anorexia referred to him, he would see such sentences as
“The patient still denied having a fear of fatness or dieting.”
For these younger doctors, it couldn’t be a case of anorexia
unless it conformed to the DSM criteria. Lee worried that
these clinicians were adhering to a foreign diagnostic
manual at the expense of understanding both the patient’s
subjective experience and the cultural meaning specific to
Hong Kong at that time. If they became blind to the local
realities of their patients, he feared, they would have little
hope in treating them.
A Death on Wan Chai Road
Although the psychologists and psychiatrists in Hong Kong
began to adopt the DSM description of anorexia, the general
population of Hong Kong remained largely unaware of the
disease. As of the early 1990s, there had yet to be any
outreach campaigns to local high schools. There had been
no Chinese celebrities afflicted with the disorder and little
reported about the condition in newspaper or magazine
articles.
Lee speculated that this very lack of public awareness
about anorexia might be key to the rarity of the disorder,
reducing the likelihood that distressed individuals would
choose, as he put it, “anorexia as a convenient form of
illness.” Which is another way of saying that anorexia
remained outside the symptom pool for the majority of the
population. Lee had a fear, though. As he wrote
prophetically in 1989, he worried that somewhere there
might be an “epidemiogenic trigger” for anorexia that, once
tripped, would “exert an explosive effect.” Five years later
that fear was realized.
At 1 p.m. on November 24, 1994, the last day of her life,
14-year-old Charlene Hsu Chi-Ying walked past the trophy
case at Saint Paul Secondary School, underneath the banner
of the Virgin Mary, and out into the Happy Valley district of
Hong Kong. Wearing her school uniform and carrying her
school backpack, she was unsteady on her feet. She had
fainted twice in the previous week. Just the day before, she
had blacked out in front of her school and had to be sent to
the nurse’s office with a cut knee.
Heading home from Happy Valley to her family’s
apartment in the Healthy Gardens high-rise complex, she
walked north through a forest of skyscrapers toward the
central business district of Hong Kong. Having grown up in
the city, she found the cultural mélange she passed through
to be quite normal. She passed the Seventh Day Adventist
Pioneer Memorial Church and a Buddhist temple. She
walked by one McDonald’s and another a few blocks later.
She walked past the Hong Kong Cemetery, the Saint Michael
Catholic Cemetery, and then past the Muslim cemetery. She
also passed by the front doors of the hospital where her
lifeless body would soon be delivered.
Charlene was about to become famous in Hong Kong as
the public face of anorexia nervosa. Her death that day
would introduce the disorder into the public consciousness
and be a critical turning point in the evolution and spread of
the illness. It is therefore important to try to understand—
both intellectually and on a gut level—what it meant to be a
14-year-old in Hong Kong at that particular moment in
history.
The mid-1990s were an uncertain and nervous time for
the population of Hong Kong. The transfer of sovereignty
from Britain to China was just three years away. Even before
the 1989 Tiananmen Square protests, many families had
attempted to emigrate. After the massacre the number of
those trying to get out of Hong Kong doubled; before the
handover more than half a million people would leave.
This caused a great deal of stress on family networks.
Most countries allowed families to immigrate only in
Western-style nuclear groups: a set of parents and a set of
children. But traditional Chinese ties to extended families
remained strong. Indeed in the unforgiving and competitive
business environment of Hong Kong, support from extended
families was an important social safety net. The emigration
of each family unit weakened that safety net for the
relatives left behind.
“Through the early 1990s, each time we returned from
summer holidays, a few more children had disappeared to
Canada, Australia, the United States, Britain,” wrote one of
Charlene’s contemporaries. “For us confused adolescents, it
was a blur of hasty farewells to friends pulled out of school
midterm. . . . All around us, people were panicking about the
future of the British colony, stunned by the bloody crushing
of the student-led protests in Beijing.”
One can get a sense of the confluence of these forces in
the Hong Kong of the 1990s by watching movies about teen
life during the period. One in particular, Autumn Moon,
directed by Clara Law in 1992, tells us a great deal. Along
with those of other so-called second-wave directors in Hong
Kong, Law’s films are moody and strive to communicate the
postmodern disconnect of the time. Autumn Moon is about a
15-year-old Hong Kong girl who strikes up an unlikely
friendship with a bored and nihilistic Japanese tourist named
Tokio. The teenage girl, Hui, is caught between two
countries: her parents have already emigrated to Canada,
leaving her in Hong Kong to wait for the death of her
grandmother. Like Tokio, Hui is disconnected from traditional
culture. She can’t cook and believes that McDonald’s
represents traditional Chinese food. The movie also riffs on
the globalization of teen culture; when Hui worries that in
Canada no one will have heard of Madonna, Tokio reassures
her, “Don’t worry. Madonna is everywhere.”
As the movie suggests, no segment of the world’s
population is more vulnerable to being swept away by the
currents of globalization than adolescents. Teenagers are
often the first to adopt Western dress and slang and identify
with movies, music, and television. But Autumn Moon
reveals that teenagers in Hong Kong were not simply
interested in Western pop cultural tastes in music and food.
What was changing was the very nature of adolescence. The
first scene shows Hui standing in front of her bedroom
mirror; in a voiceover she says, “I am fifteen years old. I’ve
only just found out that the cold weather doesn’t start right
after summer. Autumn is in between.”
Social scientists have coined a shorthand for the Western
view of adolescence, calling it “storm and stress.” Research
in the United States and Europe has consistently shown that
the teenage years bring with them the highest prevalence
of risky behavior, including substance abuse, wild driving,
and unprotected sex. Some researchers have assumed that
what we’ve learned about adolescence in the United States
and Europe is true of teenagers around the world.
Cross-cultural research has shown, however, that the
storm and stress assumptions about adolescence are far
from universal. According to Jeffrey Jensen Arnett, a
professor at Clark University and the author of Adolescence
and Emerging Adulthood: A Cultural Approach, at the heart
of the cross-cultural difference is the importance placed on
achieving independence. Our Western conception of
adulthood places a high value on individual identity and self-
sufficiency, and much of the storm and stress of Western
adolescence comes from the push and pull of this
movement toward separation.
However, in many traditional cultures, particularly in Asia,
personal independence has not been the goal of adulthood.
Instead, inter dependence—reliance on and obedience to
one’s family, clan, and village—has been the goal.
Teenagers on their path to adulthood are not expected to
strain the bonds that tie them to their family. Because
traditional cultures have de-emphasized the notion that
adolescence is the road to personal independence, much of
the storm and stress experienced by Western adolescents
has been absent.
But there were signs that this was changing. “If it is true
that cultural values of individualism lie at the heart of
adolescent storm and stress,” Arnett concludes, “it seems
likely that adolescence in traditional cultures will become
more stormy and stressful . . . as the influence of the West
increases.”
So not only were governmental and family structures
undergoing rapid change in the mid-1990s in Hong Kong,
but the very nature of adolescence was in flux. Social stress
on the adolescent population was obvious; what had yet to
be determined was how that inchoate psychological charge
would express itself.
Thinner Than a Yellow Flower
It was during this nervous time in the history of Hong Kong
that Charlene Hsu Chi-Ying began to lose weight. Until late
in the summer of 1994 she had been a parent’s dream. Her
grades and test scores consistently put her in the top
percentile of her school. She had a close group of friends
and was active in sports and afterschool activities. Her
mother was never sure why her daughter started to eat less,
as the incident that seemed to spark her food refusal
seemed trivial: her mother had not let her go on a class trip
to mainland China.
Once her weight loss started in August, her personality
quickly changed as well. By October she had become sullen
and uncommunicative. She never mentioned that she was
trying to diet, nor did she mention believing that she was
overweight. Her classmates noticed the change in her
personality. Once a gregarious girl with a group of friends,
by October of that school year she had taken to sitting in
the corner of the lunch room by herself, reading while the
other students ate.
Although the diagnosis of anorexia never came up, both a
school counselor and an outside social worker met with
Charlene to encourage her to eat more and go to a doctor
for a checkup. The last meeting with school personnel took
place the day she fainted in front of the school. The
schoolmistress, Ting Yi, said that the staff had decided not
to tell Charlene’s parents about the incident but to use the
threat as leverage for change. Charlene had one week, they
told her, to improve herself before they would notify her
parents.
The next day Charlene took her fateful last walk. After
passing by the graveyards and the hospital, she turned onto
the busy Wan Chai Road. This is where she often hopped a
tram to take her home to Healthy Gardens. Before she
reached the tram stop she became unsteady on her feet. A
shopkeeper from across the street named Chan Suk-kuen
spotted Charlene. She would later tell the inquest board that
Charlene caught her attention because she was so
preternaturally thin. The shopkeeper briefly lost sight of her
when a double-decker tram obscured her from view. When
the tram passed, she saw that Charlene had collapsed onto
the sidewalk. Chan Suk-kuen and half a dozen other people
came to her aid. When she didn’t revive, they called the
police and an ambulance.
The policeman who checked her backpack and found her
school identification card at first couldn’t reconcile the
smiling and healthy young woman in the picture with the
emaciated and ghostly figure being loaded onto a gurney.
The coroner who examined Charlene’s body, Dr. Au Kam-
wah, found that she weighed 75 pounds. Her adrenal gland,
thyroid, kidney, and stomach all showed signs of atrophy.
She had virtually no stores of subcutaneous fat. Her heart
was tiny, weighing just three ounces. The policeman’s
confusion was repeated at the hospital, where several of the
nurses, upon seeing the skeletal body on the stretcher,
initially assumed it was the remains of an elderly woman.
Had Charlene made it home and died in her family’s
apartment in Healthy Gardens, her passing might not have
caught the attention of the media. However, because she
collapsed on a busy shopping street in the heart of Hong
Kong, the story was irresistible. All of Hong Kong’s Chinese
and English papers gave prominent placement to the story
of her death. “School Girl Falls on Ground Dead: Anorexia
Made Her Skin and Bones,” read one headline in a Chinese-
language paper. “Girl Who Died in Street Was a Walking
Skeleton,” reported the English-language South China
Morning Post. “Schoolgirl Falls Dead on Street: Thinner Than
a Yellow Flower,” reported another Chinese-language daily.
The Chinese-language papers used the phrase yan shi
zheng for the disorder. Yan means to loathe or to dislike, shi
means eating, and zheng means disease or disorder. The
literal translation of the term for anorexia in both the
Cantonese and Mandarin dialects would be something along
the lines of “the disorder of loathing to eat” or “the disease
of disliking eating.” This was the first time people in Hong
Kong had read about a local case of anorexia in their daily
papers.
Of course all of the articles tried to address the burning
question on everyone’s mind: What was the meaning behind
this strange disease that led a young girl to starve herself to
death?
To answer the question, Chinese reporters looked to
Western sources and experts. One reporter for a Chinese-
language daily was clearly cribbing from the DSM when he
described anorexia this way: “The patients are so afraid of
gaining weight, that even when they are underweight, they
insist that they are fat.” Several papers quoted Western
experts to explain that dieting and the fashion industry were
culpable. “Weight loss became a tragedy!” began one story.
“It was speculated that a 15-year-old girl had been losing
weight with the wrong methods, and her health condition
deteriorated day by day.” Dieting and the beauty industry
were not the only causes cited in the papers. “Besides
weight loss for beauty, other causes of anorexia include
family strife and school pressure,” claimed one article in a
Chinese-language daily. It also noted that the pressure of
being a celebrity sometimes brings on the disorder,
reminding readers that a famous American singer had died
of the disease.
A year later a public inquest was held to determine the
cause of Charlene’s death. Charlene’s mother, schoolmates,
teachers, and counselors all gave testimony. The papers ran
stories emphasizing that anorexia nervosa was a dangerous
disease that threatened young women in Hong Kong.
Headlines read “Call for Vigilance to Prevent Anorexia
Deaths” and “Teen Death Sparks Anorexia Concern.”
There was no evidence at that moment that anorexia was
a widespread disorder among young women in Hong Kong.
Indeed the tone of alarm in the headlines and the leads of
the stories was often contradicted by quotes from local
experts near the bottom of the story. On the stand, the
pathologist Dr. Au Kam-wah testified that he had seen only
one other possible case of anorexia in his ten years of
practice. Nevertheless the jury at the inquest recommended
that schools provide counseling and education on eating
disorders and their consequences. The papers followed suit.
“Teachers, social workers, parents and schoolmates should
make a combined effort to detect anorexia among
secondary school girls before it is too late,” began one
follow-up story in The Standard.
Lies about Beauty
It is difficult to document when a psychosomatic symptom
such as self-starvation worms its way into the unconscious
minds of a population. There is, of course, no single moment
when a behavior enters the symptom pool of a culture.
Looking back over time, however, it is often possible to
identify a tipping point, the period after which the public’s
knowledge and acceptance of a symptom or disorder begins
to grow exponentially. There is little doubt that the year of
Charlene’s death represented that crucial tipping point for
anorexia in Hong Kong.
The day before I visited Dr. Lee during my visit to Hong
Kong, I spent an afternoon flipping through the press
clipping files of the Hong Kong Eating Disorders Association
with the organization’s clinical psychologist, Celia Wu. The
popular press articles that were published about anorexia
after 1994 were remarkable both in their volume and in how
similar they were to Western popular press articles on the
topic. Within a few years of Charlene’s death, there were
several Hong Kong actresses and pop singers telling
harrowing stories of becoming anorexic. In one article
Western celebrity anorexics were compared side-by-side
with their Hong Kong counterparts.
The cultural trends identified as the cause of the disorder
were familiar as well. “Swallowing Lies about Beauty Can
Make You Sick,” read a headline in The Standard in 1995.
“Western influence,” the article claims, “brings with it the
notion of ‘happy go skinny.’ Supermodels on catwalks,
Hollywood stars at the Oscars, and even the slender legs in
beer and automobile adverts all promote the anorexic look
as sexy and glamorous.” “Teenagers Risk Health in Quest for
Beauty: Expert Blames Social Pressures for Eating Disorders
as Patient Numbers Soar,” read another typical headline.
Remarkably, the pieces in both Chinese-language and
English-language papers often relied exclusively on Western
psychologists and psychiatrists to explain the illness. The
Western experts quoted in these popular articles repeated
variations on the common themes that dieting and pop
cultural trends caused anorexia and that fear of being fat
was central to the illness. None suggested that there might
be meaningful distinctions between the manifestation of
anorexia in the West and East.
Quoting Western sources, the media coverage in Hong
Kong repeated several ideas, including the following:
That anorexia was a threat to young women who were
prone to anxiety or depression or facing problems in
school or in their families.
That severe food restriction in young women should be
read as a cry for help.
That a key spark for the disorder lay in shifting cultural
ideas of thinness and beauty.
That fat phobia and a distorted body image defined the
disorder.
That anorexia usually attacked the most promising
young women.
This conception of anorexia mirrors fairly well the
understanding one would find in the West among educated
people and non–eating disorder specialists in the medical
and mental health fields.* The idea that anorexia is tied to
culturally imposed notions of female beauty has become
conventional wisdom in the West. “In casual conversation
we hear this idea expressed all the time: Anorexia is caused
by the incessant drumbeat of modern dieting, by the erotic
veneration of sylphlike women,” writes Joan Jacobs
Brumberg in her masterpiece Fasting Girls: The History of
Anorexia Nervosa.
The problem was that many of these Western assumptions
had little meaning for most of the anorexics Lee saw in his
practice. Those women were not motivated by ideas of
thinness and beauty. They were not fat phobic, nor did they
have a distorted body image. They were not the “golden
girls” of their schools or workplace. The mental health
experts quoted in the Hong Kong papers and magazines
confidently reported that anorexia in Hong Kong was the
same disorder that appeared in the United States and
Europe. In Lee’s experience, this was simply not the case.
Western assumptions about the disease were spread not
only through the popular press and television. Western
academic researchers also took up the charge. Shirley Geok-
Lin Lim, a professor of English at the University of California,
Santa Barbara and a visiting professor at the University of
Hong Kong, wrote in the journal American Studies
International that the rise in anorexia in Hong Kong was due
to a “globalization of a visual culture in which women’s
bodies and appearances are homogenized and fetishized as
childlike or waif-like, subordinate and vulnerable.”
Although Lee was trained in the West, his frustration at
this lopsided emphasis on Western knowledge when it came
to anorexia sometimes boiled over. “It is sobering to
recognize that although the non-Western cultures are sub-
dominant and ill-prepared to publish, they make up 80% of
the world,” Lee wrote testily in an article published in 1995.
Indeed the unthinking adoption of the DSM diagnosis of
anorexia threatened to turn the very act of disease labeling
into a meaningless abstraction, one that could harm the
doctor-patient relationship by blinding them both to the
more subtle and complex realities of the patient’s history
and her local experience of culture. Lee wrote, “By
intentionally replacing native metaphors with experience-
distancing jargons and by unintentionally demolishing
cultures, the imposition of universalizing biomedical
categories may imperil illness negotiation on the one hand,
and curtail local healing opportunities on the other.”
Lee’s effort to alert the world to the important differences
in local expressions of anorexia in Hong Kong did not go
unheard, at least within the community of those who
seriously study eating disorders. Beginning with his early
research, his papers on the topic appeared in the top
international journals and received wide praise from other
scholars. But in terms of influencing the general
population’s understanding of the meaning of anorexia,
Lee’s work appeared to have little effect.
In the wake of Charlene’s death educational programs
were launched in schools, further spreading news of the
disorder. A youth support organization called Kids
Everywhere Like You (KELY) announced that it was going to
set up special counseling programs to focus on the threat of
eating disorders. They also announced a twenty-four-hour
hotline in both English and Cantonese to provide information
and counseling.
All these avenues for information fed the general public’s
understanding of the disease. Hong Kong teenagers became
increasingly aware that eating disorders were no longer a
Western phenomenon. They now understood that they were
at risk as well.
What happened over the next few years mirrors what
happened in the United States and Europe after the naming
of the disease. As the public became aware that anorexia
was in the symptom pool, local clinicians, including Lee,
noticed an increase in cases of eating disorders. Where Lee
was once seeing two or three anorexic patients a year, he
was now seeing that many new cases each week. The
increase sparked a new series of newspaper, magazine, and
television reports. One typical article noted that eating
disorders were “twice as common as shown in earlier
studies and that the incidence is increasing rapidly.” In the
late 1990s, studies reported that between 3 and 10 percent
of young women in Hong Kong showed disordered eating
behavior. “Children as Young as 10 Starving Themselves as
Eating Ailments Rise,” announced a headline in The
Standard. The lead stated: “A university yesterday produced
figures showing a 25-fold increase in cases of such
disorders.”
Amid all the finger-pointing at diet fads and the influence
of Western fashion and pop culture, few considered the
possibility that the idea of anorexia nervosa itself—
prepackaged in its DSM diagnosis and explained by readily
available Western experts—might have been part of the
reason the disorder caught on so quickly in Hong Kong. This
possibility, however, fits well with Shorter’s theory of how
symptom pools change over time. At another point in
history, the population of troubled teenage girls might be
drawn to a different unconscious behavior to express their
internal distress. But starting in 1994 a new belief became
prominent in the culture of Hong Kong. Each newspaper
article, magazine essay, and television show that depicted
anorexia as a valid and dramatic expression of mental
distress for young women made that conclusion self-
fulfilling. Each repetition of this idea incrementally increased
the gravitational pull of the disorder on the unconscious
minds of the population, making it ever more likely that a
teenager would try food restriction as a method of
communicating her internal distress. The greater the
number of women who experienced the symptom, the more
public concern and media attention was directed toward the
disease.
Of course, over time a public interest in disordered eating
might have evolved in Hong Kong without Western ideas.
The critical question is, however, Would the cultural
feedback loop have spun into motion so quickly without the
importation of the Western template for the disease? It
seems unlikely. Beginning with the scattered European
cases in the early nineteenth century, it took more than fifty
years for the disease to be named, categorized, and
popularized by Western mental health professionals. By
contrast, after Charlene fell onto the sidewalk on Wan Chai
Road on November 24, 1994, it was just a matter of hours
before the Hong Kong population learned the name of the
disease, who was at risk, and what it meant. The people of
Hong Kong did not come to these conclusions without help.
Rather, they imported the meaning of anorexia from the
West—no assembly required.
“Me-Too” Anorexics
The increase in cases of the disorder was not the only
remarkable thing that happened after Charlene’s death. At
the same time that Lee was trying to alert the world that
anorexia in Hong Kong had its own distinct expression, the
disease presentation among young women in Hong Kong
began to change.
A survey of adolescent anorexics between 1992 and 1997
showed a clear shift in the anorexic patients’ explanation for
their behavior. Unlike Lee’s earlier patients, by 1997 fat
phobia had become the single most important reason given
for their self-starvation. Eighty percent of these young
eating disordered patients, in fact, said that their key reason
for self-starvation was the fear of becoming fat. By 2007
almost all the anorexics he treated reported fat phobia. New
patients were increasingly conforming their experience of
anorexia to the Western version of the disease.
Were doctors and patients reporting fat phobia and body
image distortion simply to put the condition in line with the
DSM? Lee believes the shifting social understanding of
anorexia actually influenced the expression of the disease
on the deeper level of the patient’s experience. Patients
were not simply reporting fat phobia and body image
distortion but actually experiencing those symptoms.
Aspects of the disease seen in Lee’s early patients, such as
the feeling of fullness or bloating in the stomach, lost their
cultural salience, their ability to communicate internal
distress. The importation of the Western diagnosis was not
only changing the way patients and doctors talked about
the disorder—it was changing the disease experience itself.
Lee came to believe that there are basically two
populations from which eating disordered patients come. A
small percentage begin to self-starve on their own. These
women unconsciously choose self-starvation because of
some set of experiences and unconscious currents that are
unique to their particular lives. (It is likely, he believes, that
there have been a small number of self-styled anorexics
throughout history.) These are the sorts of patients that
Shorter wrote about from the mid-nineteenth century and
Bruch saw in the 1940s.
But at different moments in history there arises another
population of eating disordered patients; they come to the
behavior with a cultural understanding of how it is acted
out, who is at risk, and what attitudes and behaviors result
from the condition. The “holy anorexics” of late medieval
times would fall into this category, as would those women
with hysteria in the late nineteenth century.
Bruch saw the distinction between these two groups
during her research. The rare anorexic patient she met in
1940s New York, she reports, was distinct from the dozens
of young anorexic women she treated starting in the 1970s.
“Those who had developed the illness during the 1970s
often had ‘known’ about the illness, or even knew someone
who had it . . . [or] deliberately ‘tried it out’ after having
watched a TV program,” she wrote in one of her final papers
before her death in 1984. “Instead of the fierce search for
independence [which defined earlier patients] these ‘me-
too’ anorexics compete with or cling to each other.”
The different characteristics of these two groups are
interesting but less important than another fact: the women
attracted to the disorder when there exists a cultural
template for the behavior inevitably far outnumber the
women who come to food restriction on their own. Once an
eating disorder becomes an accepted “pattern of
misconduct,” Richard Gordon writes in Eating Disorders:
Anatomy of a Social Epidemic, “individuals with pre-existing
mood or anxiety disorders, or a whole host of underlying
psychopathologies or developmental vulnerabilities,
histories of sexual abuse or familial concerns with weight
control, may be predisposed to adopting such culturally
sanctioned behaviors as modes of managing unbearable
levels of distress.”
The patients Lee documented in the second half of the
1990s appeared to be mostly of the “me-too” type. Lee
believes that stress from the rapid social changes occurring
in Hong Kong led to a “general loading of psychopathology”
within the population. At such moments there is no
universal way for psychological distress to express itself; the
manifestation of such stress reflects the symptom pool of
the time. Once the idiom of eating disorders became
understood, many of these young women used the behavior
to express their inchoate anxiety and unhappiness. “When
there is a cultural atmosphere in which professionals, the
media, schools, doctors, psychologists all recognize and
endorse and talk about and publicize eating disorders,” Lee
explains, “then people with a certain loading of this general
psychopathology can be triggered to consciously or
unconsciously pick eating disorder pathology as a way to
express that conflict.”
As if to prove the point that eating disorders can act like
contagions that blow across national boundaries on the
cultural currents, the late 1990s saw the rapid rise of
another type of eating disorder. In late 1995 Princess Diana
gave her famous interview confirming the rumors that she
had suffered from bulimia for more than four years. “You
inflict it upon yourself because your self-esteem is at a low
ebb, and you don’t think you’re worthy or valuable,” she
said during the interview, which was carried on Hong Kong
television and widely discussed in the press. “I was crying
out for help.” The newspapers again blared headlines
warning about the new disorder.
Once again an eating disorder symptom had arrived in
Hong Kong’s symptom pool with cultural momentum it had
gained elsewhere. Purging behaviors, including self-induced
vomiting and the use of laxatives and diuretics, quickly
spread among the adolescent population. Patients
themselves often reported to their doctors that the impetus
to try these techniques came from reading or hearing about
others with the disorder. Although dieting was usually the
expressed goal, it was hearing or reading about bulimia
itself that was often the spark for the pathological behavior.
“In line with trends witnessed in Western countries,” Lee
wrote at the time, “bulimia is likely to become an
increasingly ‘fashionable’ mode of coping with distress
among young Chinese women in the coming decade.”
Meeting an Atypical Anorexic
In 1907 Picasso created a painting of five nude women he
titled Les Demoiselles d’Avignon. Now famous for being an
early work of the cubist period that was about to blossom in
Paris, the painting is initially disorienting. Each of the
women’s figures is distorted in some manner: breasts and
elbows are at sharp angles, feet and arms are out of
proportion compared to heads; the faces of two of the
women depicted on the left of the painting look like African
masks. The painting has a strange mismatch of styles, at
once representative, impressionistic, and abstract.
Melanie Katzman, a feminist medical scholar from Cornell
Medical School, and Sing Lee wrote about that painting in a
joint paper they published in 1997. In their view, the image
is a metaphor for the approach that must be taken when
trying to understand women suffering from eating disorders
in general and anorexia nervosa in particular. Just as Picasso
used different artistic styles to depict his subjects, the
meaning behind eating disorders can be understood only
when approached cross-disciplinarily. This would be tragic,
they argued, if researchers failed to see the cross-cultural
differences in anorexic behavior and instead put all such
women in a Western mold. Katzman and Lee were writing
not just of what had happened in Hong Kong. In Tokyo,
Singapore, Cape Town, and Jerusalem the discovery of
eating disorders was quickly followed by the arrival of
American-made knowledge that defined what an eating
disorder was and what it meant.
Katzman and Lee hoped that mental health professionals
would “break through the constraints of current ‘bodily
obsessed analysis’ in which fat phobia and body image
distortion are esteemed as the universal driving force
behind food refusal.” The DSM version of the disorder was
obscuring the indigenous distresses and patterns of
behavior that led young women to adopt self-starvation. If
clinicians around the world could avoid the quick and easy
adoption of Western assumptions about anorexia, they
might be able to hear the complex truths individual women
were trying to communicate. Anorexia and eating disorders
could tell us much about the pressures on women in
different cultures if only their voices weren’t being drowned
out by Western narratives about the power of fashion,
dieting, and pop culture.
Wanting me to understand this point on a personal level,
Lee let me spend an afternoon with one of his long-term
patients whom I’ll call Ling. I knew something about Ling
before I met her; Lee had written about her case
prominently over the years.
During our interview, which was facilitated by a translator,
Ling stayed bundled in an oversized ski jacket with a Pink
Panther logo. Even so, it was clear from her frail hands and
the prominent tendons in her neck that she was seriously
underweight. Throughout our interview she sat almost
perfectly still, with her hands clasped in her lap and her
knees held tightly together. Her expression was sad, and
she often looked at the floor while she talked.
Ling had grown up in an unhappy lower-class family. Her
father, who worked off and on as a glass cutter, was a bad-
tempered alcoholic who violently abused his wife and
children. Ling told me that her father had sexually fondled
her on several occasions when she was 12. Not surprisingly,
she hated him and secretly fantasized about his death. She
had repeated nightmares in which she was weeping and
running away from her father as he “chased her like the
devil.”
Ling’s troubles with food began at the dinner table, where
her siblings, her mother, and she had to tolerate the angry
and often drunken tirades of her father. To describe the
experience of eating with her father she used the Chinese
saying, “being forced to drink bitter tea.” In hopes of getting
the ordeal over as quickly as possible, she would sometimes
bolt her food, willfully scalding the inside of her mouth. More
often she simply found that she had no appetite when she
sat down at the family table.
The second of four siblings, she had been plagued by
feelings of insecurity and low self-esteem her entire life.
When she was in her late teens and studying for her Hong
Kong Certificate Examination she began to experience
headaches and insomnia. Her menstrual cycle became
irregular and then stopped altogether. She had stomach
pains that were so intense that a doctor removed her
appendix, but to no avail. Not surprisingly, she performed
poorly on the test and had to quit school to take a job in a
factory calculating wages. She cried often during this time
and began to lose interest in everyone and everything
around her, including eating. She made a half-hearted
suicide attempt by drinking detergent. She tried to join a
church but found her fellow worshippers no more kind or
accepting than her coworkers or strangers on the subway.
Ling led a life of utter social disconnection. For months she
would go to work and then straight home, speaking to no
one.
Like many anorexics of that time, she took a circuitous
path to Lee’s door. Her last stop in the medical system
before Lee was to a gynecologist, where she was hoping to
get help restarting her menstrual cycle. She admitted that
this was her mother’s concern more than her own. Her
mother thought her lack of menstruation made her
unsuitable for marriage. Ling herself had no interest in sex,
marriage, or having children.
Lee first met Ling in 1992 when she was 29 years old. At
that time she weighed 70 pounds, far below her ideal body
weight of 101 pounds. He gave her a standard test used in
the West to diagnose disordered eating behavior. From her
answers it was clear that Ling did not fit the Western
conception of anorexia.
When Ling first became aware that there was a disease
category called anorexia, she couldn’t see how it applied to
her. From her perspective, her behavior wasn’t focused on
food. She protested that her problem was that her life
lacked meaning. She didn’t care about food in the same way
she didn’t care about her career or love life or maintaining
social connections. If she didn’t want to live, why would she
be hungry?
While being treated by Lee in the early 1990s, she moved
from her family home to the thirty-second floor of one of
Hong Kong’s many slender apartment high-rises. Even by
Hong Kong standards she lived in a cramped space: less
than 280 square feet. Her tiny bed was shorter than her
height and she slept curled up. The bathtub was just three
feet long. She often bruised herself while laundering clothes
in the cramped bathroom. Living alone, she was something
of a rebel. The tradition at the time for unmarried women in
Hong Kong was to live with family.
In 2000, when her weight again dropped to 70 pounds,
she was briefly hospitalized. By this time there were enough
anorexics in Hong Kong that they had their own hospital
ward. Meeting these other women, she again questioned
her diagnosis. She learned that other anorexics misused
laxatives and diuretics and were intentionally dieting to lose
weight. “These behaviors sounded strange and awful to
me,” Ling told me. “I was not on a diet and I did not have a
tendency of wanting to lose weight. I didn’t have any of
these behaviors, so I thought, ‘I must not have this illness.’”
To this day Ling is still confused about what ails her. After
meeting other anorexics and reading more about the
disorder in the papers, she continues to wonder whether the
disorder describes her condition. This reaction to the
diagnosis, common among his atypical patients, has led Lee
to ask a rather radical question: Is there any therapeutic
value to categorizing patients such as Ling under one
unifying disease label?
“You might want to group patients under a universal
diagnosis if you faced a condition for which a particular drug
had proved effective,” Lee told me. “But there is no
effective drug treatment for anorexia. The only meaningful
components of treatment are understanding the patient’s
life and creating a motivation for the person to change.
Does a medical diagnosis help with these goals? I am not
convinced it does.” A diagnosis such as anorexia,
particularly if that diagnosis comes prepackaged with ideas
and beliefs from a foreign land, can easily obscure the
complex realities of the individual.
Ling, 44 when I interviewed her, expressed deep shame
over a life she feels she has wasted and the burden she has
caused her family. The one bright spot in life, she reported,
was that she has begun to attend church again. “I feel it is
important to have a religion,” she told me. “I feel some
motivation to do things now.”
The Commodification of Anorexia
The rise of eating disorders in Hong Kong reveals an
uncomfortable truth: our cultural fascination with the
meaning of the eating disorders—our natural desire to
understand the lesson behind them and alert the world to
their danger—can become part of the feedback loop by
which the disease goes forward and claims new victims.
That there is a connection between public and professional
attention to such disorders and their spread within a
community is an idea that is only rarely whispered in the
professional literature on the topic. Not surprisingly, popular
book writers, researchers, and mental health educators are
loath to see themselves as a vector transmitting the disease
they hope to eradicate.
Regardless, it is important to look back at the recent
increase in the number of cases of the disorder in the West
and try to trace this effect. To begin with, there is no doubt
that anorexia became iconic, a cause célèbre, within the
feminist movement of the 1970s and 1980s. Whatever else
can be said about the disorder, anorexia packs a wallop of a
metaphoric punch. As the feminist philosopher Susan Bordo
pointed out, anorexia calls attention to “the central ills of
our culture.” The disease has been endlessly employed to
illustrate the social plight of women. In various writings on
the topic, anorexia has been used to decry unrealistic body
image standards, patriarchal family structures, the
subjugation of women by postindustrial capitalism,
unrealistic ideals of perfection, and more.
Unfortunately, in making these arguments writers have
often unintentionally glamorized the disease and elevated
the social role of the sufferer. Law professor Roberta Dresser
argued in the Wisconsin Law Review in 1984 that medical
and parental efforts to forcibly renourish anorexics should
be challenged as a violation of the patient’s civil liberties.
She made the case that anorexics were similar to political
hunger strikers, bravely challenging social injustice. They
should be allowed to starve as a matter of free expression.
Joan Jacobs Brumberg, the feminist author of Fasting Girls:
The History of Anorexia Nervosa, saw such “romanticization
of anorexia” as deeply problematic, as did many of the most
insightful feminist writers on the topic. She worried that the
promotion of anorexia as a “protest against patriarchy”
would overwhelm the more subtle and nonpolitical
psychological realities of the women caught in the throes of
the disease. “As a feminist,” Blumberg writes, “I believe that
the anorexic deserves our sympathy but not necessarily our
veneration.” Although it was seldom acknowledged, the
worry behind such statements seems clear: veneration
encourages imitation.
With the maturing of the feminist movement, this siren
song to potential anorexics has largely died away. No recent
feminist writers that I’m aware of have argued like Dresser
that anorexics should be allowed to starve themselves to
death to prove a political point. Still, anorexia and bulimia
remain in the symptom pool of our time for more subtle and
intractable reasons.
Those who devote their lives to treating disease are in a
conundrum that has rarely gained public attention. At the
same time that they are researching, publishing, and
publicly speaking about these eating disorders, they are
both molding the public’s understanding of the behavior and
keeping it in the symptom pool of our time. The South
African psychologist Lesley Swartz is one of a very few who
have addressed this difficult issue. “Regardless of the
amount of care taken in education about any condition,
professionals are inevitably involved in maintaining and
shaping it,” he writes. “We must allow that an environment
receptive to the understanding of eating disorders may be
one in which they will flourish.”
Sometimes the extent to which researchers avoid this
troubling issue is startling. A recent study by several British
researchers showed a remarkable parallel between the
incidence of bulimia in Britain and Princess Diana’s struggle
with the condition. The incidence rate rose dramatically in
1992, when the rumors were first published, and then again
in 1994, when the speculation became rampant. It rose to
its peak in 1995, when she publicly admitted the behavior.
Reports of bulimia started to decline only after the
princess’s death in 1997. The authors consider several
possible reasons for these changes. It is possible, they
speculate, that Princess Di’s public struggle with an eating
disorder made doctors and mental health providers more
aware of the condition and therefore more likely to ask
about it or recognize it in their patients. They also suggest
that public awareness might have made it more likely for a
young woman to admit her eating behavior. Further, the
apparent decline after 1997 might not indicate a true drop
in the numbers, but only that fewer people weren’t
admitting their condition. These are reasonable hypotheses
and likely explain part of the rise and fall in the numbers of
bulimics. What is remarkable is that the authors of the study
don’t even mention, much less consider, the obvious fourth
possibility: that the revelation that Princess Di used bulimia
as a “call for help” encouraged other young women to
unconsciously mimic the behavior of this beloved celebrity
to call attention to their own private distress.
The fact that these researchers didn’t address this
possibility is emblematic of a pervasive mistaken
assumption in the mental health profession: that mental
illnesses exist apart from and unaffected by professional
and public beliefs and the cultural currents of the time.
Off the podium, some eating disorder experts will admit to
a deep insecurity about the possibility that their work might
be to some degree counterproductive. I asked Michael
Levine, a prominent researcher and eating disorder
educator, whether he ever worries that his work has
potentially spread the very disease he hopes to eradicate.
“In dark periods I worry about it,” he told me. “This disorder
has given me an identity as a professional. I’m a tenured
professor with an endowed chair. Now, am I helping people
or hurting people? I hope I’m helping. But at the same time I
have to acknowledge that anorexia has given me an identity
in the same way it has given one to so many young girls—
sometimes a deadly one.”
The fact that we have not taken full account of how the
professional discourse on eating disorders keeps these
behaviors in the symptom pool is problematic on a number
of levels. As evidenced in Hong Kong, we are engaged in
globalizing our understanding, treatments, and categories of
mental illness. As of now there is no acknowledgment that
in doing this we may be changing the symptom pools by
which people in other cultures find expression for their
distress.
What does it take for a symptom such as self-starvation to
exit the symptom pool? Looking back at the history of
hysteria may be instructive. It was in the early part of the
twentieth century that many of the symptoms of hysteria
began to disappear. Hysterical fits and seizures became less
common. Women in large numbers stopped reporting leg
paralysis and temporary blindness and stopped collapsing
while trying to walk across a room. They had fewer facial
tics and involuntary muscle spasms in the arms and legs.
These symptoms didn’t disappear all at once, of course, but
over years. During hysteria’s declining years many of the
symptoms seemed, at first, to lose their vigor, becoming a
kind of pale version of their former selves. In France they
called this la petite hysterie. One French doctor described
women “who content themselves with a few gesticulatory
movements, with a few spasms . . . and the like.” So familiar
were the patient and the doctor with the meaning of
hysteric symptoms that little effort was required to
demonstrate them. It is easy to imagine that once this
milder expression of hysteria became common, it began to
lose its power to communicate deep internal distress.
It may have been the very popularity of hysteria that was
critical in its downfall. If part of the unconscious motivation
for the hysteric was to alert the world to her internal
distress, the symptoms of hysteria would lose power as they
became ubiquitous. “Hysteria during the European fin de
siecle came to mean so many different things that by
around 1900 it ceased to mean anything at all,” Mark Micale
writes in his authoritative book Approaching Hysteria:
Disease and Its Interpretations. The disease was suffering
from “extreme clinical overextension.” By 1930 or so, these
dramatic and unmistakable symptoms began to disappear
from the medical and cultural landscape as they failed to
signal the distress in the unconscious minds of a new
generation of women.
The decline of eating disorders may require a similar
diffusion of the meaning we give them. That is to say, if
anorexia and bulimia lose their ability to effectively
communicate interior distress with a meaningful level of
specificity, they will cease, at least for a time, to be
attractive to the unconscious mind.
Looking back at the history of anorexia, it seems likely
that it will someday fall back to its baseline level. But as we
wait for the epidemic to subside in the West, we may have
unintentionally set in motion cultural currents that will see
the rise of anorexia in culture after culture around the globe.
The Lost Battle
After interviewing Ling I spent the rest of the afternoon
discussing the case with Dr. Lee. He admits that she is far
from cured and that his cultural sensitivity to the meaning
of anorexia in Hong Kong has not led to any surefire
treatments. Indeed he notes that he has lost four patients to
the disease, two by starvation and two by suicide. Although
his insights have not revealed a miracle cure, he believes
that the only hope lies in a deep understanding of each
patient’s subjective experience.
At the end of our time together I asked Lee to sum up the
state of the debate. He had spent the better part of two
decades trying to convince the profession of psychiatry that
Western assumptions about eating disorders were not only
steamrolling local variations but also potentially acting as a
vector, both spreading these illnesses and shaping their
expression. Did he believe he had won the intellectual
battle?
“No, I think the battle was lost,” Lee said. “The DSM and
Western categories for disease have gained such
dominance. In the process, microcultures that shape the
illness experiences of individual patients are being
discarded. This is taking place around the world and not just
with anorexia but with other illness categories, such as
depression and ADHD [attention-deficit-hyperactivity
disorder] and psychological trauma. Unfortunately the field
of cross-cultural psychiatry is not doing well in terms of
influencing mainstream psychiatry. I have to admit, we don’t
seem to interest them at all.”
For a few seconds I didn’t ask another question and his
words hung in the air. Then Lee ended the silence. “At some
point in the last ten or fifteen years the current became too
strong,” he said. His tone was not bitter but reflective and
matter-of-fact. “It is, I think, a river of no return.”
2
The Wave That Brought PTSD
to Sri Lanka
Western mental health discourse introduces core
components of Western culture, including a theory of human
nature, a definition of personhood, a sense of time and
memory, and a source of moral authority. None of this is
universal.
DEREK SUMMERFIELD
Debra Wentz, the executive director of the New Jersey
Association of Mental Health Agencies, arrived in Sri Lanka
on Christmas Day 2004, one day before the tsunami that
would drown more than a quarter-million people. She had
traveled to the shores of the Indian Ocean for a vacation
and to attend a friend’s daughter’s wedding. She was
looking forward to a long-awaited and well-earned vacation.
She spent her first night in a cliff-side room at the Mount
Lavinia Hotel just south of the capital city of Colombo. The
next morning she strolled along the white sand shores below
the hotel. She had planned with another wedding guest to
get up early for a day trip to the historic town of Galle, a
former Dutch fortress. But, tired from the previous day’s
travel, the pair left the hotel an hour later than they had
intended. On the drive south to Galle, they stopped for a
few minutes to buy some bottled water. Many lives turned
on such small choices on that day.
As they were approaching Galle, a smaller wave in
advance of the killer tsunami flooded the road and forced
their driver to turn inland and toward higher ground. As the
driver maneuvered to escape the incoming water, Wentz
could see whole families running for safety. She could tell
that many were in shock. “I don’t think they knew they were
running,” she remembers. She watched helplessly as a bus
struggled through the mud and rising water, unable to
escape the flood. Just a few hundred yards away a train
packed with travelers was swept off the tracks, killing more
than eight hundred people. Wentz remembers briefly
glimpsing a young woman struggling to haul an aged
woman in an antiquated wheelchair away from the incoming
water. The scene seemed unreal. For brief moments she felt
as though she were watching an action sequence from an
epic movie, something like Gone with the Wind. “It was like
you were watching these things from outside yourself,” she
remembers. “I wasn’t really grasping what was going on.”
They were soon inland and out of sight of the water.
Wentz and her companion at first had little comprehension
of the magnitude of what had taken place. It was only when
her driver called relatives in Galle with his cell phone that
they learned that whole sections of the town had been
inundated. Hundreds of people at the local bus stop had
been drowned. When she finally made it back to her hotel,
she took a few deep breaths to process what she had seen
and consider what she could do to help. Between the
rumors and news reports, she gradually became aware of
the extent of the disaster. Hundreds of thousands of people
had died and tens of millions had witnessed the tsunami or
the death and destruction it had wrought. It was then that it
dawned on her how unprepared the region was for the
psychological trauma that was to come.
It was obvious to Wentz that the events of that day would
have a severe, lifelong impact on the mental health of the
survivors—long after their physical needs were met. As
Wentz put it, “staggering acute and long-term mental health
needs would remain.” She had been at the helm of the New
Jersey Association of Mental Health Agencies during the
time of the 9/11 terrorist attacks, and from that experience
she had learned a valuable lesson: the real problems with
grief and post-traumatic stress disorder would come long
after the event. Wentz herself could already feel the
psychological effects of the tragedy she had witnessed. Her
sleep became erratic and she was very emotional about the
horror she had witnessed.
In the ten days she remained in the country, Wentz
worked tirelessly. She moved to a hotel that had computers
she could use to communicate with colleagues in the United
States. Initially she focused on alerting the drug companies
she worked with to the medical needs of the population. She
then turned her efforts to alerting the Sri Lankan population
about the devastating psychological impact that would soon
be felt.
Although not a clinician herself, as head of a statewide
association of 125 nonprofit behavioral health organizations,
she had overseen several public service campaigns with the
goal of lessening the stigma of mental illness and educating
populations unaccustomed to seeking professional help. A
well-connected Sri Lankan friend helped her contact the
office of the prime minister. She informed an official there of
the impending mental health disaster the country was
facing. “I told them that this was going to be unlike anything
they had experienced before,” she recalls. “The
psychological damage in terms of the PTSD and the anxiety
and depression was only going to grow as a problem. I told
them that the impact could be multigenerational.”
She also contacted the Sri Lankan news media. In an
interview that ran repeatedly on Sri Lankan national
television in the days and weeks after the tsunami, Wentz
told the population of how the symptoms of PTSD cluster in
three different categories: avoidance, numbness, and
hyperarousal. She advised everyone to be on the lookout for
this pathological behavior in both adults and children. She
told them that PTSD requires professional attention.
“I knew that the mental health needs after the tsunami
would be unlike anything the world had ever seen,” she
recounted. “But without a sophisticated mental health
system or trained counselors, where were the survivors
going to turn? They had almost no psychiatrists, and most
primary care doctors were not trained in psychiatry or
mental health education. They didn’t have a system in place
to care for these people.” She began to hatch a plan by
which she would collect money in the United States to send
American trauma experts to Sri Lanka to train local
counselors how to spot and treat PTSD.
Looking back on Wentz’s efforts in the hours and days
after the disaster, one has to be impressed with her
selflessness and genuineness of spirit. Her efforts were
clearly motivated by a set of assumptions and beliefs about
the nature of psychological trauma and its appropriate
treatments. Wentz assumed, as do many Western mental
health specialists who focus on trauma, that the
psychological reaction to horrible events is fundamentally
the same around the world. Had she believed otherwise, it is
unlikely that she would have angled to get on Sri Lankan
television to describe the coming impact of widespread
PTSD. From her own recounting of the events, it is also clear
that she believed that the Western world, in particular the
United States, had more and better resources than the
people of Sri Lanka to both understand and respond to the
coming mental health crisis. Wentz’s concern that Sri
Lankans would have to face the psychological impact of the
disaster without a “sophisticated” mental health system or
“trained counselors” was repeated in many quarters during
the days and months after the disaster. In every way Wentz
was acting like a health professional ready to share her
advanced training and knowledge to fight illness—in this
case psychic wounds—in a place that lacked the knowledge
and resources to care for its own.
Although Wentz was in the remarkable position of
communicating directly to the Sri Lankan population in the
immediate aftermath of the disaster, she was far from the
only one sounding the alarm about the impending mental
health epidemic. Mental health professionals around the
world were telling reporters that millions of people would
soon be suffering the debilitating effects of PTSD.
“Traumatized Tsunami Survivors to Take Years to Heal,” read
the headline to a Reuters newswire story filed less than ten
days after the disaster. As many as 15 to 20 percent of
survivors would develop PTSD, said one expert in the
Reuters story. The same expert warned that without
professional counseling, as many as 16 percent of those
PTSD sufferers might commit suicide. Noting that Sri Lanka
already had endured much trauma from its protracted
thirty-year-long civil war, Dr. Sean Scott of St. Vincent’s
Hospital in Sydney told a reporter from Australia’s largest
daily paper that the tsunami would only add to the country’s
psychological burden. “I believe that in the next months,”
Scott said, “the biggest health problem Sri Lanka and all of
the region is going to be faced with is depression and post-
traumatic stress disorder.” Jonathan Davidson, a professor
at Duke University, told a reporter, “Based on prior
experience from other mass disasters, we can expect that
between 50 and 90 percent of the affected population will
experience conditions like post-traumatic stress disorder
and depression which, if untreated, may last for years.”
Although the estimated percentage of people who would
be affected varied widely from expert to expert, there was a
clear consensus among those experts that the need for
psychological treatment services would overwhelm the
available providers in the region. Those experts also
generally agreed that getting to the scene quickly was
critical. “Psychological scarring needs to be dealt with as
quickly as possible,” a psychologist told the Washington
Post in the days after the tsunami. “The longer we wait, the
more damage.” The metaphor of a wave was unavoidable.
Many Western reporters and experts talked about a “second
tsunami” of mental illness that could be avoided only if
proper support and treatment were given. Responding to
the dire warnings, hundreds of nongovernmental
organizations, universities, and private groups quickly
began to gather resources and make plans to send an army
of trauma counselors in teams of various sizes to the coastal
areas of the Indian Ocean.
What happened over the next months in Sri Lanka,
Indonesia, India, and Thailand was likely the largest
international psychological intervention of all time. Trauma
counselors and researchers poured into the region not only
from the United States, but also from Britain, France,
Australia, and New Zealand. As part of its billion-dollar
pledge of assistance, Australia sent multiple teams of
counselors with the intent to bring the mental health
services in the region “into the modern era.” The director of
AusAID, Robin Davies, said that the effort was not intended
to restore or rebuild the mental health care capacity in the
country. “Restore is the wrong word,” Davies was quoted as
saying, “because there was nothing much there before.”
Given the certainty surrounding the need for such an
effort, it is remarkable to remember that we are the first
generation to include psychological first aid with other forms
of assistance after wars and disasters. As late as the mid-
1980s, in fact, the manuals for postdisaster relief focused
exclusively on medicine, food, and shelter and contained no
advice for treating the psychological wounds of a
population.
It’s only been in the past twenty years that the diagnosis
of PTSD has caught the world’s attention. It first gained
critical momentum in the United States and then began
leapfrogging the globe, being put to use after wars,
genocides, and natural disasters. By 2004 PTSD was on the
cusp of becoming the international lingua franca of human
suffering. We were suddenly in a time when, as one
psychiatrist put it, the concern over psychological trauma
had “displaced hunger as the first thing the Western general
public thinks about when a war or other emergency is in the
news.”
“We were spreading these ideas around the globe so
effectively that PTSD was becoming the way the entire
world conceived of psychological trauma,” said Allan Young,
a medical anthropologist at McGill University who has
studied the history of PTSD. “The spread of the PTSD
diagnosis to every corner of the world may, in the end, be
the greatest success story of globalization.”
Seldom considered in our rush to help treat the psychic
wounds of traumatized people was the question of whether
PTSD was a diagnosis that could be usefully applied in all
human cultures.
The idea that people from different cultures might have
fundamentally different psychological reactions to a
traumatic event is hard for Americans to grasp. The human
body’s visceral reaction to trauma—adrenaline, fear, and
the fight-or-flight response—is so primal that we assume
that the aftereffects of such events would also be the same
everywhere. The symptoms that make up PTSD, which
include intrusive thoughts and dreams, memory avoidance,
and uncontrollable anxiety and arousal when the victim is
reminded of the event,* seem utterly commonsensical.
But PTSD isn’t just a list of symptoms. Since PTSD was
added to the DSM in 1980, Western mental health
researchers and clinicians have devoted vast amounts of
time and energy researching and treating psychological
trauma. Indeed if you were an ambitious researcher in
psychology or psychiatry during the 1990s, PTSD was where
the action was; by 2004 more than twenty thousand
articles, books, and reports had been indexed in the
National Center for Post-Traumatic Stress Disorder’s
database. Just as hysteria was the archetypal disorder of the
Victorian era, PTSD speaks volumes about how Americans
and the Western world conceive of the self.
Those mental health professionals who formed our
generation’s understanding of PTSD have created an
intricate labyrinth of ideas that includes explicit and implicit
assumptions about what type of event will damage the
human mind and who will be most affected. Within the
literature of this movement are prescriptions for how, as
individuals and as a society, we should react to horrible
events and what types of resources we should devote to the
victims. Farther back in this labyrinth of meaning one
encounters still other ideas: calls for solidarity with the
survivors of violence; incitements to share an enlightened
moral outrage against the atrocities of war and social
injustice; the belief that the study of PTSD has made us
more attuned and sensitive to the world’s suffering. Taken
as a whole, this body of knowledge goes far beyond
describing a disorder with a symptom cluster. It describes a
worldview.
Western traumatologists have also developed a set of
beliefs about how best to heal from the psychological
effects of trauma. They have proposed that speedy
interventions to counsel survivors within hours or days of
the event are crucial; that retelling or reworking the
memories of the trauma, often in emotionally charged group
settings, promotes mental health; and that truth telling is
better for the mind than stoic silence. Against a growing
body of evidence, traumatologists assume these ideas to be
universally true.
Traumatologists have also advanced the idea that
psychological rehabilitation is best managed by mental
health experts, certified in and sensitized to the Western
understanding of how humans suffer and heal. The post-
tsunami intervention would prove to be a crucible for these
Western certainties.
Kate Chaos
One of the traumatologists who heard the call to help those
suffering in Sri Lanka was Kate Amatruda, a therapist from
northern California. Just days after the tsunami she found a
message in her email in-box from the Association for Play
Therapy seeking volunteers for an urgent mission to the
disaster zone. She immediately faxed her application and
was selected to be part of a team of a dozen play therapists
who would be dispatched to help children suffering mental
trauma in orphanages and local community centers. She
was expected to be on a plane within ten days.
Among the many letters representing her credentials
(MFT, CST-T, DMAT, DSHR-DMH) Amatruda is a BCETS, a
Board Certified Expert in Traumatic Stress. Seen in a broader
context, she is one of thousands of American therapists and
mental health professionals who, in the past twenty-five
years, tied their careers to the remarkable ascendancy of
PTSD in American psychiatry and public consciousness.
Amatruda had become well known in the field. She regularly
gave speeches and taught courses on the subject at local
universities and online, training young therapists to
recognize PTSD. She also taught the techniques for how
best to heal from the disorder, usually through measured
reexposure or retelling of the traumatic event in counseling
with a trained therapist. Amatruda was traveling to Sri
Lanka to apply her knowledge where it was needed most.
Amatruda is a short woman with bubbly energy and a
mane of long, curly, graying blond hair. She self-effacingly
admits that her family often calls her “Kate Chaos,” a
reference to the fact that she is not the most organized
person. In the week before her departure, she worked
frantically to put her professional and personal life on hold.
Preparing for her mission, she bought mosquito repellant,
antacids, antidiarrhea pills, Advil, anti-itch cream, Wet
Wipes, toilet paper, and hand sanitizer—enough supplies,
she said, to “feel like a walking pharmacy.” She also
collected donations of art supplies from several schools in
her town. In one large suitcase she packed sixty-nine
pounds of balloons, scissors, paper and paper punches,
pens, glue, stickers, and “zillions” of children’s Band-Aids.
Through bake sales she also raised two hundred dollars that
she planned to take with her and donate to a worthy local
group.
Like many Western counselors on the way to the scene,
Amatruda believes that trauma forms a kind of psychic
infection in the mind and the best way to drain that
infection is through retelling the story. This is sometimes
difficult because, she explains, in extreme trauma the
human mind often regresses to the point where “we lose our
words.” The purpose of play and art therapy is therefore to
open nonverbal ways of mastering the traumatic memory.
“For children, play is their first language,” she told me.
“They may not have the words for something, but they can
play out their stories with blocks or toys.”
Such techniques, which emphasize retelling or reworking
the trauma verbally or otherwise in the days immediately
after a horror, are in the tradition of what has been called
“psychological first aid,” or sometimes “critical incident
debriefing.” The basic idea, developed and promoted in the
United States throughout the 1990s, is that the earlier a
victim begins to “process” or “master” the memory of the
trauma, the less likely that memory will form the kind of
mental abscess that results in PTSD. Counselors clearly see
themselves as akin to emergency medical professionals
treating wounds at the scene of the accident. Their charge
is to deliver the psychological equivalent of applying clean
dressings to fresh wounds.
In this way of thinking, it seemed to matter very little that
most of the trauma counselors headed to Sri Lanka had no
understanding of the culture they were entering. Like
Amatruda, few could comprehend the local languages, and
for the most part they were unfamiliar with the population’s
religious beliefs, its grieving and burial rituals, or the
country’s long and complicated history of civil war.
In Amatruda’s conception of her job, this lack of
knowledge could even be seen as something of a strength.
In one of the training manuals she authored, she states
emphatically, “One of the requirements of disaster trauma
counseling is to be non-political and non-denominational.
We must not be influenced by religion, ethnicity or political
affiliation.” If you’re doing the mental health equivalent of
applying a compress to someone’s injured head, why would
you need to know his or her religious beliefs, traditions, or
social structures?
Clearly in Denial
The assumption that traumatic reactions exist outside and
unaffected by culture was common among both individual
trauma counselors and the relief organizations sponsoring
them. Dr. Sebastian von Peter, from the Hospital of Neukölln
in Berlin, took the time to read through all the advisory texts
and manuals related to the treatment of trauma after the
tsunami. Mostly written by teams of international mental
health experts to help train relief workers and volunteers,
these texts were produced by CARE, the Red Cross
International, the World Health Organization (WHO), the
Global Development Group, the National Center for Post-
Traumatic Stress Disorder, and the European Society for
Traumatic Event Studies, among others. These organizations
and agencies, he wrote, assume that “at root, people
throughout the world are the same in their emotional
experience and expressions.” Taken together, von Peter
concluded, these manuals imply a universal metaphysic of
emotional experience. In the face of horror, these manuals
assume, all humans are fundamentally the same.
Despite these certainties, there were signs early on after
the tsunami of a cultural disconnect between the ideas
surrounding the Western conception of PTSD and Sri Lankan
beliefs. There was, for instance, a remarkable memo
emailed just days after the disaster by faculty members
from the University of Colombo in Sri Lanka. The professors
acknowledged that “disaster zones attract ‘trauma’ and
‘counseling projects,’” but they pleaded with the arriving
army of counselors not to reduce survivors’ experiences “to
a question of mental trauma” and the survivors themselves
to “psychological casualties.”
They went on to make an argument that fundamentally
undercut the certainty that Western ideas about trauma are
universal. “A victim processes a traumatic event as a
function of what it means,” they wrote. “This meaning is
drawn from their society and culture and this shapes how
they seek help and their expectation of recovery.” Trauma
reactions aren’t automatic physiological reactions inside the
brain, they suggested, but rather cultural communications.
They have nuance and meaning that can be misinterpreted
or overlooked unless observers have a deep understanding
of the culture at hand. What was required before any
organization could offer meaningful help, the professors
wrote, was a deep understanding of “what the affected
people were signaling by this distress.”
In the days after the disaster, reporters and clinicians
arriving from the United States and elsewhere sometimes
seemed confused, even concerned, when the local
population didn’t behave the way they’d expected. One
trauma counselor being interviewed on BBC radio from a
small coastal village expressed his worry that the local
children appeared more interested in returning to school
than discussing their experience of the tsunami. These
children were “clearly in denial,” the expert told the
listening audience. The host of the program concurred,
saying, “Of course, everyone knows that children are the
most vulnerable to trauma such as this.” The expert then
confidently concluded that only later would the children
“experience the full emotional horror of what has happened
to them.” Similarly CNN reporters expressed their
amazement when tens of thousands of Sri Lankans
attempted to abandon their refugee camps just days after
the disaster, preferring to go back to their devastated
villages or depend on friends or family. A New York Times
reporter wrote that it would be only “a matter of time”
before the “wall of determination and denial, which has
enabled so many to cope in the days immediately after the
Dec. 26 tsunami disaster, begins to break down.”
With so many counseling and trauma treatment programs
and PTSD researchers arriving in the country every day, the
situation on the ground soon turned chaotic. Shekhar
Saxena, from the World Health Organization, was disturbed
by the scene he saw in the days and weeks after the
tsunami. “Two weeks after the tsunami there were hundreds
of counselors doing nothing or getting in the way,” he told a
reporter from Reuters. He pointed out that sending mental
health workers who didn’t speak the local language or
understand the culture was as useless as sending the wrong
medicines.
Dr. Mahesan Ganesan, who was the only psychiatrist in all
of eastern Sri Lanka, desperately tried to keep track of the
various organizations arriving to give psychological aid. For
a few days he managed to keep a tally of the dozens of
groups on a large whiteboard in his office, but he soon lost
count.
Looking back, it’s hard to escape the feeling that these
various efforts had about them the energy and excitement
of a gold rush. The tsunami was one of the most devastating
natural disasters in recorded history, and everyone who
wanted to demonstrate their acumen in healing trauma or
perform large-scale studies of PTSD felt obligated to be on
the scene. If a technique was to be taken seriously as a
treatment for psychological trauma, its adherents had to be
part of the action.
Within days bitter rivalries broke out between counseling
groups over which populations would receive which
services. As one journalist documented, different support
services attempted to “stake their claim to refugee camps.”
The haggling between groups vying to help sometimes
caused confusion and bad feelings among the survivors.
One Sri Lankan health care worker described how children
were lured away from one set of volunteer mental health
care providers by other groups with toys and other
incentives. “Children are torn between these loyalties, and it
can be traumatic,” said T. Gadambanathan, a Sri Lankan
psychiatrist from Trincomalee.
Similarly Ganesan watched with a mixture of horror and
fascination as several organizations offering counseling
services to one camp fought among themselves for the
attention of the children. “It was common for the
[facilitators] to differentiate between ‘our’ children and
‘their’ children,” he reports. “At times children were asked
not to play with children belonging to other groups. This
often led to conflicts . . . and at times brought about
animosity between the children themselves.”
Ganesan noted a key difference between the aid groups
offering medicine, food, and shelter and those offering
trauma counseling. The groups focusing on basic material
needs would immediately meet with local officials and
families to try to assess what the community was lacking.
Was shelter the first priority, or food, or first aid? In contrast,
those setting up PTSD counseling services seldom asked
leaders in the local community what they needed or desired
in terms of help. Thinking back, Ganesan’s considered
several possible reasons for this lack of consultation.
Perhaps these traumatologists felt that the local community
did not understand their own psychological needs, and
therefore “getting their opinion would be a pointless waste
of time.” More likely, he’s concluded, these trauma
counselors shared the “idea that all persons would respond
in a psychologically known manner to trauma and loss, and
a particular universal method existed to help these people
whoever they were and whatever their culture.” Such a
belief would make consultation with the local population
unnecessary.
There were other problems. Translators had to be
employed, as nearly none of the trauma counselors arriving
from Western countries spoke the local languages. Given all
the foreign activity in the country, the most proficient
translators were in high demand. This meant that
counselors often relied on those with marginal translation
skills, such as local drivers who plied the tourist trade, to
facilitate their therapy sessions. “At best [these translators]
had very limited capacity to translate the very complicated
and sensitive communication that takes place during a
counseling session,” noted one local health worker.
Despite such difficulties, the pace of counseling often
rivaled the speed of an emergency room. Over two four-day
periods in late January and February, one organization
reported giving “psychotherapy and counseling” to 1,724
people, including 631 children. This was an impressive feat
given that they had only two dozen counselors to do the
work. Another group of Western counselors debriefed
twenty-five traumatized survivors at a time, with the goal of
one hundred treated for each five hours of work.
The drug company Pfizer was quick to get in the mix as
well. In early February 2005, just over a month after the
disaster, the company sponsored a symposium in Bangkok
titled “After the Tsunami: Mental Health Challenges to the
Community for Today and Tomorrow.” Professor Davidson,
quoted earlier predicting pathology rates of 50 to 90
percent, helped organize the conference with an
“unrestricted grant” from the company.
The paper Davidson presented at the conference was
titled “Pharmacologic Treatment of Acute and Chronic Stress
Following Trauma.” He described PTSD as “a severe,
chronic, and disabling condition with major consequences
for the individual and society,” but assured his audience
that antidepressants such as Pfizer’s Zoloft could become
“an effective tool in promoting the long-term psychological
and psychosocial health, and economic recovery, of those in
the region affected by the tsunami.” Zoloft, he reported, had
been shown to reduce anger after the first week of
treatment and lessen “emotional upset” by week six. By the
tenth week of treatment, those who took the drug were less
likely to avoid trauma-related activities. Although Zoloft had
been approved for PTSD only a few years prior, Davidson
described the drug treatment as “currently recommended
as first-line therapy for the treatment of PTSD” in the United
States.
According to World Health Organization observers, fewer
than half of the trauma counseling groups that flooded the
country bothered to register with the government. Fewer
still worked to coordinate their efforts with each other.
“There was no checking,” John Mahoney, the director of the
World Health Organization’s mental health initiative in Sri
Lanka, told a reporter. “We found one organization just
handing out anti-depressants to people.”
A People’s Army of Trauma Therapists
In addition to the assembly-line counseling, Western experts
on the ground in Sri Lanka took to training the locals in the
latest techniques of treating PTSD. Sri Lankans, generally
speaking, have an intense hunger and respect for
education. That these Westerners, with their impressive
credentials, would be offering free training in modern
healing methods seemed a stroke of good fortune.
Thousands of Sri Lankans took advantage of the offer,
packing the training sessions, which were sometimes as
long as two weeks but often as brief as a day.
A team of educators from the University of Pennsylvania
and Swarthmore traveled to the region to train one hundred
master teachers in a child-centered brand of educational
psychology that uses the creation of illustrated storybooks
to give survivors a method to retell their stories. A group of
American therapists and social workers calling itself the
Heart Circle Sangha also arrived to “train Sri Lankan
counselors and leave in Sri Lanka a cadre of skilled
clinicians” who would have “techniques for working with
intense grief and Post-traumatic Stress Disorder.” According
to their literature, the group taught “skills of deep listening,
empathy, the healing power of connection. . . . The project
emphasizes counseling skills that empower clients.” The
Humanitarian Committee of the Association for
Comprehensive Energy Psychology, sometimes called
thought field therapy, sent counselors to Sri Lanka to
provide free treatment and training for the local population.
These energy psychologists tapped on parts of the body
while encouraging the patient to bring up anxious thoughts
and traumatic memories. Practitioners of eye movement
desensitization and reprocessing (EMDR) also offered
training sessions to locals. In EMDR, which is supposed to
resolve symptoms of PTSD, the therapist instructs patients
to follow a moving object from side to side with their eyes
while holding a mental picture of the disturbing life event in
their mind.
The Western experts leading these sessions often reported
frustration at having to school their trainees in the most
basic concepts of Western therapy. Mary Cattan, who was
part of another training effort in Sri Lanka, found the locals
eager but psychologically unsophisticated. They were so
interested in giving practical advice, she recounts, that
“their listening skills were not very good.” More problematic
still was the fact that the local trainees were “not
particularly self-aware.”
Usually, everyone was invited to attend these trainings,
including children. “After a while, most youngsters in
Batticaloa had acquired certificates which indicated that
they had received training in counseling,” noted one Sri
Lankan observer.
The effectiveness of this new people’s army of trauma
counselors concerned some. There simply wasn’t enough
time or resources to provide supervision for these newly
minted counselors or to put in place safeguards should they
run into difficult or dangerous clinical situations. Asked
about these issues, the foreign trainers would wave off the
concern by assuring the questioner that they weren’t, in
fact, training “counselors.” Rather, they said, these were
“befrienders” or “community support officers,” as if the
renaming solved the inherent problem. It’s clear, however,
that these freshly trained locals often believed that they
were now armed with Western-tested knowledge about how
to treat those in distress.
Mixed in among the therapists and counselors was
another large contingent of Western PTSD specialists: the
trauma researchers. Like the counselors, those who
specialized in the scientific study of psychological trauma
couldn’t afford to miss this once-in-a-lifetime disaster. One
of the first research groups on the scene, from the
University of Konstanz in Germany, looked for posttraumatic
stress disorder among children in Sri Lanka starting just
three weeks after the disaster. Studying several locations,
they soon reported finding PTSD rates between 14 and 39
percent.*
Some of the researchers employed cutting-edge
technology. One team went to various refugee camps
shortly after the disaster collecting blood samples to
measure chemicals indicative of stress reactions. Another
group of researchers used a polygraph machine to record
heart rate, breathing, and skin resistance. Researchers
interested in genetic predispositions for PTSD were
particularly keen about the opportunity the tsunami
presented. They noted that because whole families were
simultaneously exposed to the tsunami, the event provided
a unique opportunity to look at subtle differences in genes
that would lead one family member to develop PTSD and
another family member to psychologically recover in short
order. In one multimillion-dollar study three thousand
tsunami survivors were interviewed and more than six
hundred sufferers of PTSD identified. Researchers then drew
blood from those afflicted as well as their healthy siblings in
hopes of finding gene sequences to explain their differing
psychological reactions.
From the perspective of the locals, there was a good deal
of confusion regarding the trauma researchers, who were
suddenly swarming refugee camps asking deeply personal
questions, requesting samples of their blood, and
sometimes hooking them up to strange machines. To begin
with, the distinction between those who came to treat them
and those who came primarily to study them was often
unclear. The researchers appeared to be just one more tent
of concerned foreigners set up on the periphery of a refugee
camp.
In a report to the Sri Lankan Parliament, Dr. Athula
Sumathipala pointed out the ethical problems inherent in
such a situation: “When research is combined with aid, relief
and at times clinical care, there is undue inducement for
participation in this vulnerable population.” Because Sri
Lanka lacked any comprehensive process to review and
approve research involving humans, the country was being
invaded by what he called “parachute researchers.”
Sumathipala pointed out that many Sri Lankans who had
never participated in a research study before didn’t fully
understand that they had the choice not to answer the
questions of the investigators. More disturbing still, locals
sometimes assumed their participation would lead to some
financial assistance or other help. From the perspective of
the victims, it made sense that those gathering such
detailed information about their hardships would be
connected to some form of assistance down the road. Why
else would they be so interested?
One American observer, who asked to remain anonymous,
sat in on a seminar held by a large international
nongovernmental organization that promised to train
teachers how to counsel children with posttraumatic stress
disorder. In reality, the actual focus of the two-day session
was to show the teachers how to complete a PTSD symptom
checklist. Although attendees thought they were learning
new skills in dealing with traumatized children, they were
actually being trained in data collection for a study of the
prevalence of PTSD. Within weeks of the tsunami these
trainees were sent into classrooms to collect data not only
on the children’s reactions to the trauma but also on their
history of domestic violence and sexual abuse.
Further blurring the line between research and assistance
was the fact that dozens of the studies were designed to
assess the validity of one treatment or another. Which is to
say that groups of locals were encouraged to participate in
some style of experimental counseling or therapy for the
purposes of determining that treatment’s efficacy. One
research group, for instance, conducted a study in which
they organized groups of adult and child tsunami survivors
to revisit the exact locations where they experienced the
disaster. The idea was that reexposing them to the scenes
where they witnessed the disaster would help them process
the experience. Afterward the study’s authors reported
somewhat cryptically, “No certain cases of retraumatization
occurred [among the participants].” Nowhere did they make
clear whether the participants understood there was such a
risk.
Most of the studies conducted in the weeks and months
after the tsunami were of a simple nature. With local
assistance, Western researchers translated up-to-date PTSD
questionnaires and employed them to assess the mental
health of a given population. These surveys were designed
mostly by researchers in the United States to quickly
determine—usually with fewer than two dozen questions—if
the symptoms of PTSD were present. Children in Phuket and
Krabi, Thailand, were studied with the UCLA PTSD Reaction;
children in the Ranong province of Thailand and others in
Tangalle in the southern province of Sri Lanka were assessed
with the Children’s Impact Events Scale 13, which is referred
to among trauma specialists as the CRIES-13. The
population of northern Sumatra and Aceh, Indonesia, were
assessed using the Post-traumatic Stress Disorder Checklist–
Civilian Version. Adults in Tamil Nadu, India, were given the
Harvard Trauma Questionnaire. The resulting studies
published in peer-reviewed journals universally reported
significant rates of PTSD among the cohorts studied.
For many trauma researchers, these results
unambiguously settle the question of whether PTSD was
present after the tsunami. But there is a more difficult and
telling question here: Did the information gathered from
those PTSD surveys accurately represent the distress being
experienced by these populations?
“When you ask [the] whole checklist, the classical PTSD
criteria would be there, but these are all leading questions,”
one Sri Lankan medical specialist was quoted as observing.
“When you ask ‘do you have intrusive memories?’. . . It is
easier to say ‘intrusive memory’ in English, but [try] to put it
into Sinhala or Tamil. You see, is very difficult and by the
time you have explained all that, they know that they have
to answer in the positive.”
The very act of asking survivors to describe their
psychological response to a horrible experience by choosing
among only a few reactions would seem to unavoidably bias
the outcome. Adding to this problem was the common
misperception on the part of those being studied that
answering such questions “correctly” would result in
assistance for oneself or one’s family.
Further complicating matters was an implicit assumption
imbedded in these PTSD checklists: that the traumatic event
in question was a one-off experience safely in the past and
that life had otherwise gone back to normal. It might indeed
be pathological to be constantly on the watch for danger six
months after an anomalous event, such as witnessing a
violent crime. But for those living with their children in the
squalor and discord of a refugee camp, being vigilant about
safety would certainly have a different meaning.
Unfortunately it was impossible for any of the PTSD surveys
to make a meaningful distinction between the psychological
reaction to the tsunami and the ongoing strains of the social
and economic turmoil caused by that event.
In the end these trauma checklists simply had no ability to
discover what might be culturally unique to the experience
of living through horror in Sri Lanka. These surveys weren’t
designed to discover anything new, but rather to confirm
similarities. Did the population have other reactions to the
trauma not included in the symptom lists? Were the
behaviors on the checklists the reactions that caused the
most concern to the Sri Lankans? Such questions didn’t
seem to occur to the researchers, who appeared to believe
wholeheartedly in the universality of the PTSD construct.
Resilience in Sri Lanka
Dr. Gaithri Fernando, a young assistant professor of
psychology at California State University in Los Angeles, was
with her son in Sri Lanka on high ground when the tsunami
of 2004 rolled ashore. In a bizarre coincidence, she was in
the region preparing a study on the psychological impact of
a 2001 earthquake. After the wave receded, she traveled to
the fishing village of Moratuwa, where she saw people
frozen in disbelief and horror. It was clear that the wave had
inflicted both psychological and physical damage.
Fernando watched with increasing unease as scores of
Western psychologists, counselors, and PTSD researchers
arrived in the disaster zone. A native of Sri Lanka, and a mix
of Tamil and Sinhalese, Fernando moved to the United
States when she was 21 to help her husband, a Tamil,
escape persecution. Since then she has returned often to
conduct research on the psychological impact of the long
civil war. The wave of aid that rolled in on Sri Lanka after the
tsunami, she suspected, had the power to change the
culture of the island country as much as the tsunami itself.
Few understand better than Fernando the Sri Lankan
capacity to live in the face of horror. Her research prior to
the tsunami documents a people with remarkable
psychological resilience. Even through decades of war,
youth uprisings, and poverty, most Sri Lankans have
managed to remain functional and hopeful. This is a
population, she has shown, that seldom needed outside
encouragement or counseling to get back on its feet even
after the most punishing hardships.
Many of the Western counselors and experts who rushed
in after the tsunami assumed that the long and brutal civil
war had made the individuals in the population ever more
psychologically vulnerable and therefore more likely to
experience PTSD after the tsunami. There was, of course, an
alternative possibility: that the Sri Lankans—because of their
intimate familiarity with poverty, hardship, and war—had
evolved a culture better able to integrate and give meaning
to terrible events. In this conception it was the Western
counselors, arriving from communities and enclaves
unfamiliar with the immediate experience of violence and
deprivation, who were uniquely vulnerable.
Fernando knows how Sri Lankans turn to their rich cultural
traditions in times of hardship. Religion is a particularly
important cornerstone in the lives of most. There are
Buddhist traditions for the majority Sinhalese, Hinduism for
the Tamils, Islam for the Moors, and Christianity for the rest.
The notion of karma, central to both Buddhist and Hindu
beliefs, is shared by Sri Lankans across ethnic and religious
lines. Overlapping and weaving together these different
traditions is the shared ethnocultural belief in spirits and the
palpable nearness of the spirit world.
Often closely tied to religious traditions is a wide variety of
healing customs. Health care in Sri Lanka is remarkably
pluralistic. There are Ayurvedic practitioners, doctors,
astrologers, religious leaders, mediums, and faith healers of
various types. The lines between these practices,
delineating, for instance, traditional healing from modern
medicine, are not clearly drawn. A Sri Lankan often consults
two or more of these traditions in search of relief from
illness or psychological distress.
Having watched at close quarters the suffering of children
and their parents caught in the violence of the civil war,
Fernando intimately understands that these cultural
traditions have an impact not only on the ways this
population talks about the psychological aftermath of horror
but on the deeper level of how it is felt and experienced.
She understands, as those Colombo professors said
immediately after the tsunami, that victims process
traumatic events as a product of what they mean.
Indeed Fernando’s earlier work on war trauma in Sri Lanka
had uncovered fascinating connections between religious
beliefs and differences in the ability to recover from the
trauma of war. In one pre-tsunami study she found that
Buddhist and Hindu children who experienced war and
violence were less vulnerable to depression than Christian
children, even though the Buddhist and Hindu kids reported
more personal exposure, witnessing bomb blasts and the
like. She speculated that there might be protective beliefs in
Hindu and Buddhist traditions, such as the active
acceptance of pain and suffering or the beliefs in rebirth and
recompense through reincarnation, that steadied these
children in the wake of terror.
Watching the aftermath of the tsunami, Fernando couldn’t,
of course, predict the psychological consequences. This was
an unprecedented event that could overtax the religious
institutions and healing traditions that the population relied
on. Still, the idea, often repeated by Western experts, that
Sri Lankans had few local resources for psychological
healing (because they lacked trauma counselors) seemed to
simply ignore or discount the cultural traditions, beliefs, and
rituals that Sri Lankans had so long relied on. Similarly the
idea common to many Western traumatologists, that
psychological treatments could be easily divorced from
religion, ethnicity, and the cultural history of the country,
was hard for Fernando to understand.
Most important, Fernando worried that the PTSD symptom
checklists did not reflect the culturally particular ways that
Sri Lankans experience psychological suffering after trauma.
She worried that by using these checklists mental health
professionals from Western countries would be ineffective—
or even do harm—unless they understood that Sri Lankans
had culturally distinct reactions to traumatic events as well
as culturally specific modes of healing. She believed that
unless these local idioms of distress were understood,
appropriate interventions could not be formulated. Without
a deep understanding of the illness, in other words, it would
be impossible to treat the disease.
Fernando took on the task of trying to understand the
local meaning of trauma in post-tsunami Sri Lanka. She
began by gathering a sample of local informants from a
rural area in the southern province of the country. All were
Sinhalese Buddhists, most from poor families. All had
personally witnessed the tsunami, and fifteen of the twenty
had lost family members.
Instead of quizzing these subjects with a predetermined
set of PTSD symptoms, Fernando asked each person to tell
her two open-ended stories in their own language. First she
asked participants to think of someone they knew who had
experienced some type of suffering but was now functioning
well. After that story was finished, the subject was asked to
describe a person who was functioning poorly after a
traumatic event.
Not surprisingly, of the forty stories she collected, thirty-
five were related to the tsunami. With the help of a
researcher and a local community leader, she began to
examine the narratives for similarities in themes and
expressions of wellness and distress. In the end she
collected more than two dozen symptoms and behaviors
that were mentioned by fifteen or more participants. She
then validated the results by conducting a large-scale
survey. She ended up with what she calls the Sri Lankan
Index of Psychosocial Status, a twenty-six-item measure of
the local indicators of distress.
Fernando came to the conclusion that Sri Lankans’
experience of trauma differed from Americans’ in two main
ways. Unlike the PTSD symptomatology, Sri Lankans were
much more likely to experience physical symptoms after
horrible events. Sri Lankans who lost family members or
whose lives were otherwise devastated by the tsunami were
more likely to complain of aches in the joints or muscles or
pain in the chest. Without the mind-body disconnect
common in Western thinking, these Sri Lankans reacted to
the disaster as if they had experienced a physical blow to
the body.
In addition to these somatic symptoms, there was
another, more subtle and pervasive difference. By and large
Sri Lankans didn’t report pathological reactions to trauma in
line with the internal states (anxiety, fear, numbing, and the
like) that make up most of the PTSD symptom checklist.
Rather Sri Lankans tended to see the negative
consequences of an event like the tsunami in terms of the
damage it did to social relationships. Those who continued
to suffer long after a horrible experience, her research
showed, were those who had become isolated from their
social network or who were not fulfilling their role in kinship
groups. In short, they conceived of the damage done by the
tsunami as occurring not inside their mind but outside the
self, in the social environment.
Such social problems are also common in Western
sufferers of PTSD, but Fernando’s research highlighted a
subtle but important distinction. In Western thinking
surrounding PTSD a trauma causes psychological damage
that then results in social problems. A Westerner might, for
instance, assume that depression or anxiety brought on by
PTSD would cause people to fail in their role as a parent. For
a Sri Lankan, this did not appear to be a cause-and-effect
phenomenon. The failure to manage one’s social
responsibilities—to find and fulfill a place in the group—was
identified as the primary symptom of distress and not a
consequence of an internal psychological problem. As she
concluded in her paper on the subject, “The data empirically
support the theory that intra-psychic functioning is not
independent from interpersonal functioning for this
community.” On examination of the interviews, Fernando
realized that every one of the twenty-six symptoms
described by these Sri Lankans was to some extent bound
to this idea that the social trumped the psychological. More
precisely, Sri Lankans interwove the social and the
psychological—to the point where the two could not be
teased apart. Because the Western conception of PTSD
assumes the problem, the breakage, is primarily in the mind
of the individual, it largely overlooks the most salient
symptoms for a Sri Lankan, those that exist not in the
psychological but in the social realm.
This is one of those subtle cultural differences that is hard
to point to at any given time. In trying to describe the
interconnection between the social and the individual sense
of well-being, Fernando told me of interviewing a young boy
in a village that had been the scene of several massacres.
The boy was 8 years old, and his father had been killed
during one of the periods of violence. Fernando was working
with another researcher who didn’t speak the local
language, and so she was translating the questions and
answers so the other professor could understand. At one
point she asked the boy what makes him feel better when
he gets worried about the violence in his community, and
the boy answered that it was the things his mother says to
him. “This boy told me that he feels better when his mother
promises him that if they are attacked and killed that they
would all die together,” Fernando recalls. The answer struck
her so deeply that for several moments she couldn’t
translate the response for the other researcher. The mother
offered no promise of protection or even survival, only
togetherness in the face of violence and death. The boy, for
his part, appeared deeply reassured by his mother’s
promise.
This emphasis on the social over the psychological
becomes critical when one considers how one might heal
from tragic events. If depression, anxiety, or hypervigilance
are the primary symptoms (which then lead to social
problems in one’s family or social group), it might make
sense to take time to work though the psychological
symptoms away from one’s social responsibilities. This is a
common pattern of mental health healing in the West: take
a sick leave from the stresses in your life in order to heal. If,
however, the social difficulties are the primary symptom of
distress, taking time away from one’s duties and social roles
to pursue something like individual counseling may actually
exacerbate the problem. In a culture such as Sri Lanka’s, an
emphasis on healing the individual away from the group,
particularly in one-on-one counseling with strangers, is
problematic.
Kate Chaos, Part II
When I interviewed Kate Amatruda it was several years after
the tsunami. Since that trip she had continued to teach and
visit other disaster zones. Asking her about her experience
at the refugee camps in Sri Lanka, I wanted to know if she
felt any cultural disconnect between her ministrations and
the local ideas of trauma and healing. In response, she
made every effort to assure me of how culturally sensitive
she remained. She recalled that, on arrival, she was given a
full day’s training in Sri Lankan customs and history. Local
officials instructed her to wear her hair up and to eat only
with her right hand. She was also told that she couldn’t ask
children to play a card game called Go Fish because of the
associations with ocean fish eating the bodies of those
washed out to sea; in addition, she was told that all card
games or other activities that might be construed as
gambling were forbidden among Muslims. She tried, she
says, not to refer to the tsunami as “bad” or “mean” for fear
of alienating the Buddhists, who believe in karma.
When I asked her whether she thought that people around
the world differ in their reaction to trauma she told of seeing
striking similarities between the pictures drawn by children
in Sri Lanka and those drawn by children in post-Katrina
New Orleans. “Those pictures are absolutely
indistinguishable,” she said. “You cannot tell the difference.
On some human level, our reaction is probably universal.”
On a personal level, she reports experiencing some
culture shock on her arrival. The normal discomforts of
traveling in a developing nation were heightened in the
aftermath of the disaster. The lack of showers and Western-
style toilets also took some getting used to, and the curry
dishes for breakfast didn’t agree with her stomach. She
remembers being constantly anxious about contracting
head lice from the children in the camps. But overall she has
fond memories of the week she spent leading dances with
children, handing out art supplies, and organizing games.
She is also particularly proud of the training sessions she
helped conduct with local teachers and health care workers.
Despite her obvious enthusiasm for her work, I found it
difficult to get Amatruda to tell me what particular practices
or ideas she brought with her to Sri Lanka. What, I wanted
to know, were the theories behind the activities she
organized during her stay? What information had she
passed on during the time she spent “training the trainers”?
For instance, when I asked her what sort of techniques she
taught to the local health care workers, she told me, “The
trainings were important but not necessarily for what we
taught them as for the fact that we were there for them.
They knew people had flown all across the world to help
them.”
I suggested to Amatruda that beyond her admirable desire
to show solidarity with the victims of the tsunami she must
have felt that she had some specific knowledge that she
wanted to impart. She was, after all, leading training
sessions. But each time I tried to turn the conversation to
the question of what that knowledge might be, she
retreated into generalities. “It almost doesn’t matter what
you do,” she insisted. “So much of it is showing up. It
matters that you’re there and that you’re really there and
you’re able to witness the pain and the horror. You’re there
to witness and receive.”
Amatruda wasn’t alone in her reticence. Many counselors
returning from their work in Sri Lanka were loath to be seen
as part of some hegemonic West-to-East, rich-to-poor
transfer of knowledge. Recounting their counseling and
training work after the tsunami, some Western
traumatologists went to almost comic extremes to assure
their readers or questioners that they were sensitive to the
local culture. Dr. John R. Van Eenwyk, the founder and
clinical director of the International Trauma Treatment
Program, curiously insisted that the best role for Western
trauma trainers was to prove that they had nothing to offer
their trainees. The intent of the trainings he conducted in Sri
Lanka was to reveal himself to be as powerless as the
Wizard of Oz. “Our job is to reveal ourselves as ‘the man
behind the curtain,’” he explained. “Then we help them see
that what they seek from us they already possess. Like the
scarecrow, they already have brains. . . . We don’t
indoctrinate. We empower.”
Still hoping to hear the specific techniques she employed
while in Sri Lanka, I asked Amatruda to tell me of a moment
during her trip when she felt her presence there was
effective in helping heal the psychological wounds of the
tsunami. She told me of sitting with a child who used the art
supplies she had lugged across the world to make a
drawing. During this encounter she helped the child “feel
important,” she said. When I asked her how, she said, “The
child felt important because this blonde person had come all
the way across the world to see her.”
One day, not long after her arrival, Amatruda was
counseling a woman named Selvie-amah, who was the
housemother for an orphanage of girls. When Selvie-amah
revealed that she had lost two brothers in the civil war,
Amatruda asked how she managed to keep herself mentally
healthy so that she could care for her girls. The very
question seemed difficult for Selvie-amah to understand.
Amatruda explained that it is important for the healer to
stay healthy herself. She is used to explaining this idea by
employing the metaphor of being on an airplane when the
oxygen masks come down: “If you are sitting with a child or
someone who can’t take care of themselves, put on your
mask first, then take care of them.” Selvie-amah appeared
baffled by this idea. Amatruda’s notion of posttraumatic
stress had led her to a key assumption about the meaning
and impact of trauma that her Sri Lankan counterpart didn’t
share: she assumed that the mental distress experienced by
survivors of horror comes from damage to the individual
psyche and that that damage makes it difficult to help
others. But, as Fernando’s studies showed, Sri Lankans’
sense of well-being emanates from their connection to the
social network around them. For a Sri Lankan, the very
expression and experience of mental health might be
embodied in the act of fulfilling one’s role and helping
others. To repurpose Amatruda’s modern metaphor, putting
the oxygen mask over the mouth of the child in the next
seat would be the very thing that would allow Selvie-amah
to breathe.
Parading Certainties
It is unclear what the Sri Lankans thought of Amatruda, this
energetic Western woman lugging her suitcase full of art
supplies and Band-Aids into refugee camps. Amatruda
reports that she felt welcomed and appreciated. From her
perspective the local population certainly seemed to
recognize the genuine spirit of caring that brought her to
their doorstep in that dark time.
The juxtaposition of these well-meaning Western healers
with the devastated landscape was sometimes
breathtaking. Here, for instance is how Jennifer Baggerly, an
assistant counseling professor at the University of Florida,
recounted arriving in the remote village of Kalladi, where
215 families were living in a refugee camp. “The suffering
here was clear,” she writes. “Rows of white canvas tents in
the sweltering sun face a water tank that has been empty
for a month and a half. Clean water access is a long walk
away so children were thirsty and had unwashed clothes
and hair. Some children had a chronic cough while others
had sores on their bodies.” She then describes her team’s
psychological intervention, providing “temporary relief from
the suffering by conducting our puppet show, helping them
make coping bracelets and magazine collages, playing
active games, teaching them yoga, and passing out candy
and toys to each child.”
Dr. Ganesan, who observed many such Western
interventions, noted that these relief workers, with their
strange behavior, their puppet shows and handcrafts and
interactive games, often did liven the mood of the camps
they visited. “In many instances these sessions, in which
whole communities participated, offered comic relief for the
survivors even though it was probably not intended as
such,” he recalls.
The term “psychosocial aid” has gained great currency
among international trauma counselors who like to believe
that their interventions are sensitive to cultural differences.
In its most promising use, psychosocial aid acknowledges
that helping the culture get back to normal functioning is
the key to maintaining the mental health of the people. The
assumption is that the local people will look to their
churches, mosques, schools, and social networks to find
support and make meaning of what happened to them.
Psychosocial support (again in its most progressive use)
suggests that every effort should be made to put these local
institutions and networks back in working order so that the
people can heal and make meaning in their own way.
In practice, however, it is clear that “psychosocial aid” is
often little more than a buzzword. Although many
interventions talk of psychosocial aid, local religions and
forms of healing are given only lip service or, worse yet, are
used as the proverbial spoonful of sugar that helps the
Western medicine go down. “Trauma victims in disaster
situations may not actively seek mental health services for
various reasons,” wrote David Surface in Social Work Today.
“Some may be in denial or simply not aware of the extent to
which they’ve been traumatized, while others may not seek
out therapy because of social or cultural stigmas. Therefore,
the goal of many disaster mental health workers is to have
therapy be seamless, integrated . . . and, whenever
possible, incorporate familiar community settings and
rituals.” In this way of thinking, it is not the community
traditions or rituals that are seen as healing but the Western
therapy that has been stirred in among local practices.
Some trauma counselors in Sri Lanka all but ignored local
custom and practices and stridently asserted that they knew
better than the locals how to handle the psychological
aftermath of the disaster. William Yule, a child psychologist
from King’s College in London, expressed with particular
certainty that he knew what was best for the population. He
reported with concern that orphaned children were
sometimes coaxed through the experience by relatives who
told them that their parents hadn’t in fact drowned but had
taken jobs that required them to travel to foreign lands. Yule
made it clear that this lack of disclosure would
psychologically damage the children. He writes that he had
to have long discussions with locals “to clarify . . . the need
to be honest with children.”
It’s true that the period after the tsunami was filled with
such hopeful lies and misinformation told not only to
orphaned children but often to desperate parents looking for
missing offspring. Neighbors or relatives would sometimes
tell frantic parents of having seen a missing child or heard
that the child had shown up in a neighboring village.
Following such rumors, one after the next, some parents
traveled hundreds of miles up or down the coast. These
well-meaning lies are certainly heartbreaking and clearly go
against many assumptions of Western mental health
treatment, which values facing and “working through” or
“processing” unhappy experiences. But was Yule’s
insistence that these stories were psychologically damaging
a universal truth or a culturally based assumption?
What Yule didn’t comprehend was that these sorts of
stories are not particular to Sri Lanka or the tsunami.
Anthropologists working in poor or war-torn nations have
documented similar narratives. Based on her work with
Somali refugees, for instance, the anthropologist Christina
Zarowsky wrote that if a person goes missing and is almost
surely dead, it is socially acceptable to lie to family
members to “ease their mind” and say that the missing
person has gone abroad. This is a story born of poverty-
stricken places where people die young or disappear just as
completely through emigration to far-off lands. Dismissing
such stories as psychologically beyond the pale ignores the
tragic social forces from which they spring. In the end all
stories about where parents or children “go” when they die
are, to varying degrees, wishful and culturally bound. How,
one might reasonably ask, is Yule’s insistence on the “need
to be honest” in this sad situation any less culturally
imperialistic than a Christian missionary trying to disabuse
some far-flung population of a local notion of reincarnation?
But regardless of whether trauma counselors tried to be
culturally sensitive or, like Yule, paraded their certainties,
the result was likely the same. Dr. Siddharth Ashvin Shah,
who traveled from his home in the United States to Sri
Lanka after the tsunami to try to help, reports that he
arrived determined to let local healers take the lead. What
he discovered was that the social forces at play made this
approach nearly impossible. “The recipients are driven by a
belief that they lack things, concepts, and behaviors that
the West can supply,” Shah recounts. “The non-West craves
our technology because it anticipates good innovation from
the West. We produce information that verifies its
effectiveness. . . . We are confident that we have something
exceptional to offer and not the other way around.”
Try as he might to be respectful of local beliefs, Shah
found that it was impossible to abdicate the role he was
expected to fill, that of “Western expert” bringing advanced
knowledge. “The attention experts like myself command is
triumphalist,” he wrote, “blinding the relief workers and
myself to the culturally embedded self-concepts and healing
practices.” As much as trauma counselors talked of
“psychosocial approaches” or “cultural competency,” the
obvious preference given to the Western ideas of
psychological suffering often overwhelmed their best
intentions.
Global Differences in Suffering
A careful look at other cultures and moments in human
history shows that there is little about the human reaction to
trauma that is universal. For instance, the assumption that
each generation of soldiers reacts the same way to combat
is turned on its head by even the briefest look at history.
There is no doubt that soldiers often come back from battle
with psychological as well as physical injuries; the fear and
horror of direct combat can clearly damage the psyche of
men and women. But the medical records of war veterans
kept over the past centuries show that the manifestation of
the injury is always tied up with cultural beliefs
contemporaneous to the time. British soldiers in the Boer
Wars were likely to complain of joint pain and muscle
weakness, a condition their doctors called “debility
syndrome.” In the American Civil War, soldiers often reacted
to the psychological trauma of battle by experiencing an
aching in the left side of the chest and having the feeling of
a weak heartbeat, labeled “Da Costa’s syndrome.” Or they
experienced a withdrawal and lethargy thought to be a type
of pathological nostalgia caused by being far from home. In
the First World War, British and American soldiers commonly
experienced “shell shock,” with symptoms that included
nervous tics, grotesque body movements, and even
paralysis. So although the potential psychic damage of war
is indisputable, the process by which that damage becomes
an outward symptom is a reflection of the cultural beliefs in
a particular time and place. The unconscious mind of a
soldier latches onto culturally current symptoms of distress
(chest pain for the Civil War soldier and muscle spasms for
the World War I soldier) because those symptoms are
recognized as legitimate during a particular time.
It is important to emphasize that even though symptoms
change over time, this is not a matter of faking or play-
acting on the part of those psychologically traumatized.
Rather, soldiers from different times are unconsciously
internalizing cultural expectations and then experiencing
them as unavoidable and real. The simple but mind-bending
truth is that mental illnesses such as PTSD can be both
culturally shaped and utterly real to the sufferer. Therefore,
as the medical anthropologist Allan Young explained to me,
a diagnosis of PTSD “can be real in a particular place and
time, and yet not be true for all places and times.”
What is true across time is also true across cultures.
Researchers studying psychological reactions to trauma in
cultures around the world have found remarkable deviations
from the PTSD symptom list. Salvadoran women refugees
who endured a protracted civil war, for example, often
experience something called calorias, a feeling of intense
heat in their body. Although these women did experience
sleep disturbances, which is one symptom of PTSD, they did
not, for the most part, report increased startle responses or
other physical reactions when reexposed to symbols of the
trauma. For some Cambodian refugees, the most pressing
psychological impact of trauma was being visited by
vengeful spirits and the accompanying feeling of intense
distress that, in escaping from the country, they had not
been able to perform rituals for the dead.
“The meaning of a horrible event has a tremendous
impact on the human psyche, and that meaning differs
across the world,” says psychology professor Ken Miller of
Pomona College. “The meaning matters as much as the
event itself.” Applying the same interviewing techniques
Fernando used in Sri Lanka, Miller has studied psychological
reactions to war trauma in Afghanistan. His analysis yielded
many reactions not on the PTSD symptom list, and several
that had no ready translation in English. There was, for
instance asabi, a type of nervous anger, and fisha-e-bala,
the sensation of internal stress or pressure. The only way for
aid providers to be effective, Miller believes, is for them to
understand the local idioms of distress—the particular ways
psychological trauma is understood, experienced, and
expressed in specific cultural contexts.
Duncan Pedersen from McGill University found unique
expressions of psychological trauma among the Quechua
natives in the southern central Peruvian Andes who were
caught up in the brutality of the Maoist guerrilla movement
the Shining Path and the Peruvian army. The estimated
death toll during the period topped sixty-nine thousand,
with more than half a million internally displaced. The horror
they suffered was remarkable both for its severity and its
unrelenting nature. As Pedersen notes, this was the
“destruction of ways of life—targeting and attempting to
eliminate entire ethnic groups, eradicating cultures and
social systems, thus undermining the critical means
whereby people can endure and recover from suffering and
loss.” The Shining Path even enforced strict rules for how
victims of the conflict were to be mourned, deeming the
traditional public tears of women to be “a sign of
weakness.”
Pedersen and his fellow researchers discovered that the
people of the Ayacucho highlands have two distinct
semantic categories to describe their suffering. Nakary
conveys the notion of collective suffering, often described
with the metaphor “it’s like carrying the cross on the
shoulders of everyone,” and includes the notion that this
suffering is a punishment for wrongdoings in the past. Llaki,
on the other hand, refers to the individual experience of
sorrow and distress. In its extreme form, llaki is seen as an
illness with symptoms that include a variety of physical
pains, such as headaches, stomach pains, and body aches.
Critically, neither llaki nor nakary is thought to be related
to specific experiences of trauma or discrete periods of
upheaval. These are experiences of distress indicative of the
long-term nature of the conflict. Because PTSD connects
symptoms to specific moments of trauma, the diagnosis
does not take account of the indirect and ongoing
consequences of violence that were most troubling to this
population: the destruction of important social networks and
their webs of reciprocity, the impact on the local economy,
the malnutrition, and the spread of disease.
The researchers concluded that the diagnosis of PTSD
could not effectively communicate this type of shared
cultural suffering, “given the multiplicity of ways peoples
and societies live through massive trauma, express their
distress and suffering, and assign meaning to the human
experience.” Insisting on employing Western assumptions
about trauma, the researchers wrote, potentially
“undermined indigenous health systems and largely
discredited the power of local healing practices, as well as
resiliency, coping and survival strategies.” In short, using
the PTSD diagnosis and foreign notions of trauma
counseling in this situation had the potential to continue, in
a new form, the very cultural demolition that had caused
the population its greatest distress.
The argument that the insertion of Western PTSD beliefs
might actually undercut and disempower the local culture
has been made by other researchers as well. In East Timor
two researchers, Kathleen Kostelny and Michael Wessells,
visited the war-torn area around the capital of Dili and saw a
population pushed to the breaking point by war and the
increased sexual violence and poverty that came with it.
Most distressingly, the Indonesian militias often destroyed
or ransacked sacred structures where families and clan
members performed rituals and kept their sacred objects.
This amounted to a “spiritual calamity,” according to
Kostelny and Wessells. The insertion of trauma counseling
and PTSD didn’t ameliorate this problem; it heightened it.
“In a situation of desperation, local people often silence
their own cultural practices, cling to Western approaches
that have the imprimatur of science, or ‘play along’ by
giving the appearance of accepting outside approaches in
hopes of getting food or money from powerful outsiders,”
Kostelny and Wessells conclude. They note that this
undermining of local pathways to recovery can happen so
subtly as to escape the notice of both the caregivers and
those being provided for. “Tacitly, a damaging message sent
is that local views and practices are inferior. In the authors’
field experience, this message can strengthen a colonially
implanted sense of inferiority and weaken local people’s
belief that they have the capacity to build their own positive
future.”
Education or Indoctrination?
Such concerns about the use of PTSD and Western beliefs
surrounding trauma have done little to stem the efforts of
Western traumatologists to intervene in other cultures after
times of crisis. Why, one might reasonably ask, are we so
certain that the rest of the world needs our help in this
regard?
A look at the one of the first cross-cultural applications of
PTSD—in response to the 1995 earthquake in Kobe, Japan—
sheds some light on this question. It was only a matter of
days after the disaster when a team of PTSD experts from
Harvard University arrived in the city to collect data on the
psychological damage caused by the quake. As with other
international PTSD research that was to come, it was clear
from the start that this was far from a dry exercise in
epidemiology. The survey and the results were overtly
intended to advocate for a dramatic shift in thinking on the
part of the Japanese mental health system. The fact that the
report was as much a call to arms as an academic document
could be seen in its title: “The Invisible Human Crisis.”
“The PTSD concept was used to point to the reality of a
field of suffering recognized by the more psychologically
advanced culture of the United States but ignored in Japan,”
reported the anthropologist Joshua Breslau, who studied the
aftermath of the Kobe quake. Behind this effort to influence
the Japanese response to the disaster was a deep certainty
commonly shared by traumatologists that the rest of the
world doesn’t pay nearly enough attention to mental health
and that other cultures lack crucial knowledge that
Americans possess.
Although undertaken as humanitarian outreach, these
efforts often look more like massive attempts at
indoctrination. To accept the ideas of PTSD, other cultures
first had to be “educated” in the appropriate symptoms of
PTSD and modern modes of healing. After the genocidal
killings in Rwanda one nongovernmental organization (NGO)
quickly produced seventy-five thousand copies of a brochure
on the signs and symptoms of traumatic stress. Foreign
trauma counselors gave interviews to local journalists on
the psychological sequelae of trauma, and public health
campaigns were undertaken to educate the benighted
population in the symptoms of PTSD. Within two years of the
killings more than six thousand “trauma advisors” had been
trained in the country. Less than two years later, they
reported that more than 144,000 children had been
counseled.
Similarly, within hours of the bombing of the U.S. Embassy
in Nairobi, Kenya, in 1998, a trauma counseling program
called Operation Recovery was put into motion. “Mental
health experts used local and national radio and television
broadcasts to discuss the symptoms of acute stress
reactions, and these broadcasts continued for 2 weeks after
the bombing,” wrote two psychiatrists of the project. More
than seven hundred counselor-trainees were given a two-
day seminar on PTSD within a week of the bombings.
An equally impressive intervention came the next year,
when trauma counselors went to the mountainous area on
the northern coast of Venezuela after a massive flood and
landslide claimed more than fifty thousand lives. A radio,
TV, and newspaper ad campaign was launched to make the
population aware of what psychological consequences to
expect, and posters of the PTSD symptom list were placed in
schools, community buildings, police stations, churches, and
grocery stores.
Often these campaigns seemed to imply that the
psychological consequences of trauma were similar to a
newly discovered disease, and that local populations were
utterly unaware of what happens to the human mind after
terrible events. That implicit assumption often left
anthropologists shaking their heads in disbelief. It takes a
willful blindness to believe that other cultures lack a
meaningful framework for understanding the human
response to trauma.
“Most of the disasters in the world happen outside of the
West,” says Arthur Kleinman, a medical anthropologist from
Harvard University. “Yet we come in and we pathologize
their reactions. We say: ‘You don’t know how to live with this
situation.’ We take their cultural narratives away from them
and impose ours. It’s a terrible example of dehumanizing
people.”
Once one comprehends the cultural differences in
psychological reactions to trauma, the efforts of the Western
traumatologists who rush into disaster zones on a few days’
notice begin to look somewhat absurd. To drive this point
home, Miller asked me to consider the scenario reversed.
“Imagine our reaction,” he said, “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? Would that make sense?”
The Rise of Fearlessness
The mistake in applying Western notions of trauma without
consideration for local beliefs goes beyond just being
ineffective: there is real danger of doing harm. This lesson
should have been learned long before the tsunami in, of all
places, Sri Lanka.
For over a year and a half starting in 1996, Alex Argenti-
Pillen, now an anthropology professor at University College
London, spent time in a poor Sri Lankan village trying to
make sense of the local modes of psychological suffering
while at the same time documenting the impact of the rising
influx of Western ideas about trauma.
In response to the ongoing civil war, organizations such as
the UN High Commission for Refugees, UNICEF, Oxfam, and
the International Rehabilitation Council for Victims of Torture
organized workshops and training seminars in the country,
and international trauma specialists spoke about PTSD and
Western-style trauma counseling. It was commonly asserted
at the time that helping war-torn populations heal from
PTSD could slow or stop the cycles of violence. Researching
the effects of these efforts in small villages, Argenti-Pillen
came to the opposite conclusion. She became concerned
that these Western ideas of trauma and healing had the
potential to destabilize fragile local truces that existed
among families, clans, and ethnic groups.
The social and economic situation in the Sinhalese
Buddhist village she studied was indeed dismal. There was
desperate poverty, and many local men and boys had been
drawn into the civil war between the Sri Lankan government
and the separatist Liberation Tigers of Tamil. Many of those
drafted into the Sri Lankan army deserted from military
service, forcing them to lead itinerant lives to avoid arrest.
In addition to the civil war, a violent youth revolt by the
Janatha Vimukthi Peramuna between 1988 and 1991
brought on a harsh crackdown by the government. Villagers
had been brutalized by literally all sides in these conflicts.
Neighbors often informed on each other, leading to
kidnapping, torture, and murder.
But as bad as the situation was, Argenti-Pillen was
interested in what kept the violence from spinning even
further out of control. What were the factors that kept
villages from undergoing a conflagration of revenge and
ethnic violence such as that seen in Rwanda and Bosnia? In
the village she studied, there remained boundaries on the
violence. Although many men had been killed, their wives
and children were usually left physically unharmed. In the
aftermath of the violence, perpetrators were clearly
disassociated from their families and revenge killings didn’t
target relatives. In many cases, the family of the killer and
the family of the victim (or the informant and the informed
upon) remained living side by side.
Argenti-Pillen documented the villagers’ remarkably
complex way of talking and thinking about the experience of
violence that, in several key respects, contradicted
assumptions about PTSD. In the cosmology of these
villagers, humans are vulnerable to what they call the “gaze
of the wild,” the experience of being looked in the eye by a
wild spirit, which can take the form of a human being intent
on violence. According to this belief it is not witnessing
violence that is destructive. Rather, the moments of terror
that come from violence leave one vulnerable to being
afflicted by the gaze. Struck by such a gaze, one enters an
altered state of consciousness and can become violent
oneself, behave lasciviously, become physically
immobilized, or in other ways step outside of normal modes
of social behavior. Somatic symptoms, including chronic
headaches, stomach aches, and loss of bodily strength, are
also common. Someone in this sort of semitrance may
speak in the voice of the spirit or alternate between the
perspective of the wild spirit and a human state called inna
barikama, which roughly translates as “can’t stay here.”
Often those experiencing inna barikama will yell for hours
variations on “I can’t stay,” “can’t live,” “can’t be,” or they
will simply repeatedly moan “Can’t.”
Those afflicted by the gaze of the wild might also express
their distress by “becoming closed off” or having “a terrified
heart,” which can lead to any number of somatic symptoms,
including vomiting and physical aches and pain. These
semitrance states are treated in the village with a long and
arduous cleansing ritual. Such ceremonies often last up to
thirty hours, during which the afflicted person is encouraged
to dance, tremble, and speak in tongues at specific times
during the ceremony. The rituals themselves are designed to
elicit fear. Healers elaborately disguised as wild spirits visit
the sick, often in the early hours of the morning, in order to
frighten the subject as severely as possible. Often those
who complete these cleansings show dramatic recoveries.
Interestingly, it doesn’t necessarily require a violent event
to spark a terrified heart. Simply speaking directly about a
recent act of violence, with words that graphically or
emotionally evoke the experience, is also considered
potentially pathological. Because most villagers hid in their
houses during the periods of intense violence, their
experience of terror was largely through what they heard.
The shouts of the attackers and the cries of the wounded
and tortured were the soundscape of the wild spirits and
could bring on the fear-related illness of “a terrified heart.”
“Just as the soundscapes of violence and civil war affect
people, so do the words used to represent this reality,”
Argenti-Pillen concluded. “In other words, discourses about
the wild act as agents of the wild.”
Stories or even words describing the violence were
considered literally dangerous. Because of this, the
community had established a complex set of rules for how
villagers are allowed to talk about or remember the
violence. Argenti-Pillen had to learn a complex dialect of
“cautious words” that allow someone to reference a
horrifying event without explicitly bringing it to mind. On
examining these local euphemisms, she began to see that
they were intentionally replacing words or phrases that
might invoke fear or moral anger with those that connote
safety and trust. Torture, for example, was evoked with a
word that also means a child’s mischief.
Unraveling this secret code, Argenti-Pillen filled her
notebooks with these euphemisms. “Those and these”
meant quarrels and fights. “The confusion and mistakes of
people who hurry too much” referred to the brutal civil war.
A “place that takes sacrifices” indicated a location where
many people died. “Funny nonsense” was a way of invoking
the disorientation and confusion of the terrified. To “bother”
could mean anything from child abuse to bombing. “Rowdy
sons” were the perpetrators of violence.
Argenti-Pillen also noticed that women in the village who
had suffered from terrified hearts often took it upon
themselves to be the enforcers of such indirect speech.
While this use of indirect language could easily be filed
under the rubric of “psychological avoidance” in the style of
the PTSD diagnosis, that would miss the fact that this local
custom had a specific purpose. Only gradually did Argenti-
Pillen come to understand that the prohibitions on speech
were a kind of “acoustic cleansing” by which people
protected themselves and others from spreading the gaze of
the wild and avoiding a potentially exponential rise in
revenge violence. These people weren’t avoiding talking
about what had happened to them because they were
psychologically blocked or traumatized; rather, they were
attempting, as best they could, to keep the violence under
control.
There was another local reaction to horrible events that
ran counter to the idea of the terrified heart. Some women
believed that the atrocities they had witnessed or endured
had made them become “fearless.” Usually “fearlessness”
applied to men who acted violently or yaka-like (like an evil
spirit), but over the years of the civil war women were
increasingly embodying the trait as well. These fearless
women attested that they were no longer susceptible to
having a terrified heart and that they no longer needed the
domestic cleansing rituals. It was these fearless women who
often violated the rules of cautious speech. They were said
to speak with “sharp tongues” and carelessly. Such women
often found themselves socially marginalized by those in the
village, seen as akin to wild spirits themselves. Fearless
women were likely to intentionally raise their children to be
fearless as well. Often sons of such mothers were the boys
who became yaka-like, prone to violence and terrifying the
community.
Into this delicate and intricate social and psychological
landscape began to flow Western ideas about trauma and
healing. This transmission of knowledge was not as direct as
it was in the aftermath of the tsunami. No Western
counselors set up tents on the outskirts of Argenti-Pillen’s
village. Rather, these ideas trickled down from training
programs sponsored by NGOs in Colombo. Western trauma
specialists would train regional health care workers; that
knowledge would then flow down to rural health care
workers, who then treated and sometimes trained local
villagers in these methods.
The problem was that the central tenet of Western trauma
counseling—that traumatic experiences must be retold and
mastered—ran counter to the local customs regarding the
use of euphemistic speech. Rural health care workers were
suddenly insisting that experiences of trauma be spoken
about directly. One Sri Lankan health care provider told
Argenti-Pillen that she had learned from Western experts
that it was important not to allow the traumatized individual
to keep secrets or talk around traumatic events. “There is a
method of talking,” she said, “talking with our eyes, our
face, with our whole posture, we must tie them to us. . . .
We take the information out of the clients. . . . We put them
in a position in which they can’t keep any secrets.”
The Western-trained counselors saw it as their job to
reorient the population’s beliefs about trauma and healing.
Many counselors expressed certainty that their new
counseling methods proved that the traditional local rituals
were ineffective. “A terrified heart cannot be cured by
means of domestic cleansing rituals,” one Western-trained
counselor told Argenti-Pillen. “The illness that has hit the
mind can sometimes not be cured even if you danced a
thousand cleansing rituals, let alone one. So, if you don’t
give counseling . . . in the correct way, that person will stay
in the same condition.”
However, it was rarely the women with terrified hearts
who were first in line for this new method of counseling.
After all, it was their job in the community to ensure that
people were circumspect in telling stories of violence.
Rather, it was the fearless women, with their penchant for
telling unambiguous stories of the violence, who embraced
the new healing methods. Whereas from the villagers’
perspective fearless women were potentially dangerous,
from the perspective of the Western-trained counselors they
were “empowered.” Not only were fearless women often the
first to accept trauma counseling; they were also the first to
accept training as counselors themselves.
“While the majority of the community consider
fearlessness an aberration . . . the NGO activities now
provide an outside legitimization for fearlessness,” Argenti-
Pillen writes. “The NGOs now support fearlessness as a
viable form of sociability.”
By encouraging fearlessness and pathologizing the local
custom of using ambiguous speech, this intervention was
tampering with a delicate social balance. Argenti-Pillen’s
concern was that Western-style trauma counseling was
undermining a fragile social stopgap that kept violence in
these tight communities from spiraling out of control. These
counselors were playing with fire. “Tales of ‘traumatized
survivors’ fail to provide a much-needed framework in which
local techniques for containing violence can be
safeguarded,” she concludes. “They also fail to assess the
potential risks of the introduction of the discourse on trauma
to such local techniques.” Trauma counseling services had
the potential to have the exact opposite effect intended.
Instead of ending the social cycles of violence, they were
potentially removing the brakes. The risk, she concluded, is
that “trauma counseling services will further destabilize a
local cycle of containment of major outbreaks of violence.”
The American Way to Suffer
It would be hard to overstate the certainty that most
Americans currently place in the diagnosis of PTSD.
Although it has been officially recognized for only twenty-
five years, it is reflexively evoked after school shootings,
natural disasters, and terrorist attacks. It has become part
of our common parlance and conventional wisdom. With so
many soldiers serving in the long-term conflicts in Iraq and
Afghanistan, PTSD has become a national touchstone in the
debate regarding the costs of war. PTSD is as real in our
time as fisha-e-bala is to an Afghani, as calorias is to a
Salvadoran, and as terrified heart is to a Sri Lankan.
It is real, that is, but not timeless.
Looking back at the brief history of the disorder, it is
remarkable to see how much it has changed even within a
generation. A soldier given the diagnosis today would be
hard-pressed to recognize it as the same one that was first
formulated in the 1970s for soldiers coming home from
Vietnam.
The movement to recognize PTSD began as a political as
much as a psychiatric movement. Originally called post-
Vietnam syndrome, the idea came out of the hothouse of
rap sessions held by Vietnam Veterans Against the War and
supervised by antiwar psychoanalysts. Dr. Chaim Shatan,
who was codirector of the postdoctoral psychoanalytic
training clinic at New York University, was one of the first to
help find the professional volunteers to sit in on the rap
sessions. In a memo he circulated to colleagues his politics
were clear: “This is an opportunity to apply our professional
expertise and anti-war sentiments to help some of those
Americans who have suffered most from the war.”
These psychoanalysts and veterans had no intention of
carving out a diagnosis that could be applied to all victims
of terrifying events, or even all soldiers who experience
battle. The original idea was to show that being a soldier in
the Vietnam War was an experience utterly distinct from
that of being a soldier in any other military conflict. Listen to
one of the first descriptions of post-Vietnam syndrome,
written by Shatan and published in the New York Times in
the spring of 1972. According to Shatan, these veterans felt
upset because they had been “deceived, used and
betrayed” by both the military and society at large.
Although Shatan did mention that these veterans
experienced “rage,” he did not link this or any psychological
reaction to particular traumatic battlefield experiences.
Instead the rage, as Shatan described it, “follows naturally
from the awareness of being duped and manipulated” by
the military and the U.S. government. It was the moral
ambiguity of the Vietnam War and the deceitfulness of the
U.S. government and military, not the trauma of battle, that
damaged the psyche of the soldier.
In their push to gain official diagnostic status in the DSM,
the advocates for recognition of post-Vietnam syndrome
found it necessary to cede some ground. Despite the early
arguments intent on carving out a disorder specific to the
experience of Vietnam veterans, it proved politically
expedient to make alliances with other researchers and
clinicians who wanted to extend the concept to include
those who suffered psychologically after surviving other
horrors, including fires, natural disasters, and accidents. The
earlier argument that the psychological trauma suffered by
Vietnam veterans was utterly specific to soldiers in that
conflict was put aside and then forgotten.
As PTSD expanded in influence, more and more advocates
were making the argument that the disorder had an
immutable objective existence independent of culture, time,
or place. This left the obvious question: If it was so timeless,
why had it only recently been recognized?
In a history of the International Society for Traumatic
Stress Studies, written by one of the group’s former
presidents, Dr. Sandra Bloom, the early advocates of the
disorder are portrayed as the first to bravely overcome the
social pressure to ignore the psychological reaction to
trauma. Forces in our society, Bloom writes, have a stake in
“denying the profound and long-term effects of trauma. . . .
The larger society will continue to deny the magnitude of
the problem not only because of the emotional arousal
exposure causes, but because it is becoming increasingly
clear that fixing the problems and actually preventing
trauma, will cost a great deal.” PTSD has always been with
us, the argument went, but we were just now raising our
consciousness to the point that we could face its
devastation.
As the diagnosis expanded in the West, encompassing
more and more experiences, there grew a market for those
claiming to have the latest techniques for treating the
condition. These techniques, in turn, began to shape our
cultural expectations and understanding of how trauma
affects the mind. Few were more influential in creating the
American style of PTSD than a former paramedic named
Jeffrey T. Mitchell, who created a seven-step regimen called
Critical Incident Debriefing. Mitchell’s debriefings were
intended to be performed in the first hours or days after a
threatening event. Led by a trained facilitator, groups of
survivors would be first informed of the common reactions
to traumatic stress. Each participant was then encouraged
to describe his or her perspective on the trauma in order to
“make the whole incident come to life again in the room.”
The metaphor of trauma creating a “psychic wound” was
taken quite literally. It just made sense that the quicker
debriefers got to the scene, the more they could do for the
victims. Beginning in the late 1980s counselors armed with
this new knowledge were rushed to the scenes of school
shootings, train wrecks, fires, maritime disasters, and all
manner of other calamity. In 1989 Mitchell founded an
organization called the International Critical Incident Stress
Foundation to teach debriefing as a method of heading off
PTSD. The foundation grew quickly and was soon training
tens of thousands of debriefers each year.
The fall of 1989 proved to be a watershed moment for the
American public’s awareness of trauma counseling and the
ideas behind critical incidence debriefing. In September of
that year Hurricane Hugo made landfall on the coast of
South Carolina, pushing a twenty-foot wall of water over
coastal communities. Disaster counseling and critical
incident debriefers were included in the response to the
devastation, to the fascination of the journalists and public
who followed the events.
Just a month later, on the other side of the country, the
Loma Prieta earthquake struck the San Francisco Bay Area.
Occurring during the pregame warm-up to the third game of
the World Series, the quake was broadcast live to the
nation. The first pictures of the collapsed section of the Bay
Bridge were sent from the Goodyear Blimp, which had been
hovering over Candlestick Park to cover the game. Many
mental health workers who had been providing debriefing
and trauma counseling in the coastal towns of South
Carolina got on planes and flew directly to San Francisco to
set up counseling services for quake victims. Again,
reporters and TV crews focused a great deal of attention on
these efforts.
By the time Hurricane Andrew sliced through the southern
tip of Florida and crashed into the south central portion of
Louisiana three years later, the public’s respect for the PTSD
diagnosis and the need for trauma counseling had solidified.
That new certainty could be heard in a Knight Ridder/Tribune
news service story filed in Miami: “Hurricane Andrew’s
biggest impact wasn’t its physical destruction. That was
only $20 billion. What it wrought in South Floridians’ minds
is incalculable.” By this point Mitchell’s International Critical
Incident Stress Foundation was training upwards of thirty
thousand debriefers each year.
Despite the public and professional certainty that
counselors and debriefers should rush in after disasters to
treat traumatized populations, there was one problem: there
was little evidence that such efforts helped. In fact study
after study published during the 1990s, the heyday of
trauma counseling, showed that early interventions were
either ineffective or actually caused harm. One study
followed several hundred car accident victims over a three-
year period. At random, some of the victims were debriefed
or given no immediate psychological treatment. Interviewed
three years later, victims displayed a remarkable difference:
the people who were debriefed were more likely to be
anxious and depressed and harbor a nagging fear of riding
in cars. The study, which was published in the British
Medical Journal in 1996, concluded, “Psychological
debriefing is ineffective and has adverse long-term effects.
It is not an appropriate treatment for trauma victims.”
Another study of burn victims showed a similar effect:
measured after a year, those who had been debriefed were
much more likely to qualify for the diagnosis of PTSD and to
express hostility, feel depressed and anxious, and report a
lower quality of life than those who received no help. The
conclusion was that the early interventions were actually
impeding the mind’s natural healing process.
Early interventions sometimes appeared to be priming
victims to experience certain symptoms. “When dealing
with people after an accident we need to remember that
emotionally aroused people are suggestible,” David Brown,
a psychologist from Australia, wrote later in the British
Medical Journal. “If we suggest they might feel angry, it is
likely to come true.”
Others have noticed the same phenomenon. “Sometimes
when we put people in a group and debriefed them, we
gave them memories that they didn’t have,” Malachy
Corrigan, the director of the Counseling Service Unit of the
New York City Fire Department, told the New Yorker. “We
didn’t push them to psychosis or anything, but, because
these guys were so close and they were all at the fire, they
eventually convinced themselves that they did see
something or did smell something when in fact they didn’t.”
Looking back, it is remarkable that so little attention was
paid to the danger that debriefing might be shaping and
suggesting reactions in the minds of distressed individuals.
Social psychology has a rich literature on group belief-
building and social contagion that could have been well
employed here. If you take a group of disoriented and
unsettled victims mere hours or days after a life-altering
tragedy, put them in a highly charged encounter where they
are told to expect certain psychological symptoms, and then
they share their experiences, you are creating the perfect
setting by which emotions are likely to spread and intensify.
Why didn’t these practices cease in the face of the
evidence that they might actually be harming those they
intended to treat? Dr. Richard Gist of the Kansas City Fire
Department, who researched the impact of debriefing,
noted that the evidence for and against trauma counseling
was beside the point because debriefing was, he told a
journalist, “more of a social movement.” Indeed the
evolution of the ideas behind PTSD and the promotion of
modern ideas of trauma counseling have been social
movements from the beginning. This fact, however, is
seldom acknowledged by the evangelical trauma counselors
who travel the world to inform other populations about the
modern treatments for PTSD.
It is a psychological truism that those who display dead
certainty in their convictions are often hiding or covering up
for deep insecurities. Professor Vanessa Pupavac, writing
from the School of Politics at the University of Nottingham,
links the rise in our international trauma interventions—our
confident assertions that we must teach the world how to
respond to horrible events—with a period of time when we
in the West had become increasingly uncertain about how to
help the developing world.
The 1990s was a period when our efforts to help other
countries with money and aid began to seem impossibly
complex and fraught. Book after book took to task
humanitarian efforts for bureaucratic waste, having
shortsighted goals, and encouraging dependence. This crisis
of confidence in the humanitarian community was, Pupavac
argues, a reflection of a deep post–cold war uncertainty at
home. We had become, she writes, “bereft of convictions
and disposed to introspection. . . . The erosion of previous
political or communal affiliations [had] not resulted in a
vigorous individualism, but anxious insecure individuals.”
When we looked out at the violence and hardship in the
rest of the world and knew that our psychological assistance
was desperately needed, we may have been simply
projecting our own postmodern insecurities.
Trauma Stripped of Meaning
In reading the best anthropological writing on the “idioms of
distress” in other cultures, one is often struck by the
richness of these psychological and social landscapes. The
experience of horror or violence in these places is
interwoven into religions, social networks, traditions, and
rituals of burial and grieving. When one comes back home
to PTSD, the starkness and thinness of the idea become
glaringly apparent. In the modern Western world, the idea of
PTSD is that of a broken spring in a clockwork brain.
PTSD researchers would certainly object to this
characterization. They would point to the tens of thousands
of research papers, monographs and books on the topic.
How could so much research be characterized as “thin”? But
I’m not talking about the research, but rather the
experience of the PTSD sufferer. By isolating trauma as a
malfunction of the mind that can be connected to discrete
symptoms and targeted with new and specialized
treatments, we have removed the experience of trauma
from other cultural narratives and beliefs that might
otherwise give meaning to suffering. Being value-neutral to
cultural beliefs is problematic given that these beliefs—be it
God’s plan for someone who’s lost a child or patriotism for
the soldier crippled in battle—are the very places where we
once found solace and psychological strength.
Think back to the ideas surrounding post-Vietnam
syndrome. The original intent of that designation was to
create a social narrative to prove that being a soldier in the
Vietnam War was different from being a soldier in other wars
at other times. Proponents were searching for meaning and
coming up with stories of government betrayal and the
destruction of social trust. Beliefs that had sustained many
of their fathers in World War II were suddenly insufficient
and meaningless to these soldiers. They replaced those
beliefs with another, angrier set of ideas that might give
meaning to their experience. But as it evolved into its
modern clinical form, PTSD left behind such quests for social
meaning in tragedy. In doing so, it has set adrift those
struggling in the aftermath of trauma. In contrast to those
angry but socially engaged Vietnam War veterans, the
personal accounts of current-day soldiers returning from
Afghanistan and Iraq often seem pigeonholed into a PTSD
diagnosis that is tied to a particularly modern style of lonely
hyperintrospection.
Here’s one soldier blogging on a popular website devoted
to PTSD:
I constantly doubt how I feel. I don’t know if it’s real or if I’m making it up. . .
. I feel guilty. When I was in the service, the Air Force therapist said that it
was PTSD . . . but I don’t know if he was right. I worry that I’m trying to fool
everyone, even myself. I didn’t do anything. I never fired a weapon in
combat. I missed everything, I feel guilty about it, and I feel ashamed that I
even consider that PTSD might be the problem. I feel like I don’t deserve to
think this is what is wrong with me. I can’t bring myself to read up on PTSD
on the internet, because I’m worried that the more I know about it, the more
likely I am to make it be the problem subconsciously. . . . I feel like I’ve
fooled myself into playing a character and I don’t know how to just put it
down.
PTSD is clearly too narrow a category to give meaning to
this soldier’s experience, but he worries it like a bone
because he doesn’t appear to have other options; the
frustration, anger, and unhappiness of modern soldiers have
been moved from the social (where one might find moral
anger, nationalistic justification, or religious meaning to
justify the sacrifice) to the biopsychomedical. Because PTSD
largely focuses on internal states and chemical imbalances
within the individual brain, this explanation for psychological
problems often leaves the soldier, to borrow a recent
military marketing slogan, feeling like “an army of one.”
Looking at ourselves through the eyes of those living in
places where human tragedy is still embedded in complex
religious and cultural narratives, we get a glimpse of our
modern selves as a deeply insecure and fearful people. We
are investing our great wealth in researching and treating
this disorder because we have rather suddenly lost other
belief systems that once gave meaning and context to our
suffering.
Patrick Bracken, a senior research fellow at Bradford
University’s Department of Health Studies, argues that the
emergence of PTSD is a symptom of a troubled postmodern
world. “In most Western societies there has been a move
away from religious and other belief systems which offered
individuals stable pathways through life, and meaningful
frameworks with which to encounter suffering and death,”
Bracken writes. “The meaningful connections of the social
world are rendered fragile.” Although we might be able to
ignore the absence of these belief systems during our
normal day-to-day lives, truly traumatic events have the
power to startle us into awareness of a heart-stopping
emptiness. The diagnosis of PTSD can categorize some of
our reactions to trauma, but in the end it is cold comfort. It
cannot replace what we’ve lost.
Without social mechanisms to cope, we’ve become
increasingly vulnerable and fearful. Indeed many have
pointed out that we are now a culture that has a suspicion
of resilience and emotional reserve. “In a momentous shift,
contemporary Western culture now emphasizes not
resilience but vulnerability,” says Derek Summerfield, of
Kings College, who has worked extensively with victims of
war and genocide. “We’ve invited people to see a widening
range of experiences as liable to make them ill. This
becomes a problem because we are globalizing our culture.
We are presenting just one version of human nature—one
set of ideas about pain and suffering—as being definitive. In
truth, there is no one psychology.”
The Civil War Reignites
Seven months after the tsunami, Lakshman Kadirgamar, the
Sri Lankan foreign minister, was murdered in his home by a
sniper. The precarious cease-fire between the government
and the separatist rebels began to destabilize. By the end of
that year the guerrillas in the north of the country were
again fighting the government both on land and at sea. The
conflicts escalated until, in January 2008, the government
officially withdrew from the cease-fire agreement. The battle
in the next year would not go well for the Tamil Tigers. By
the end of spring 2009 the government forces had routed
the Tamil rebels from their last stronghold.
The reality for the civilian population caught in the
fighting on the ground became so grim that Gaithri
Fernando found that for the first time she had to avoid all
news of her home country. She had heard too many stories
of mothers digging shallow graves for their children and
families trying to escape the fighting by fleeing deep into
the jungle, only to lose family members to animal predators.
In the uneasy peace after the fighting, there was again
much interest in psychological healing and the damage of
PTSD. Having alerted the Sri Lankan Parliament of the
abuses of parachute researchers after the tsunami, Dr.
Athula Sumathipala published a series of articles in the
Island newspaper asking again for restraint on the part of
globe-trotting trauma counselors. “Undue emphasis on
counseling or medicalizing the psychological, sociological
and political implications of the displaced population should
not be promoted,” he wrote. “What [the displaced
populations] need is not ‘therapy’ but provision of basic
needs, care with dignity, respect, reassurance to avoid
uncertainty and move them to accommodation as soon as
possible so that they will have some privacy and also the
opportunity to reintegrate to ‘normal’ life. The best therapy
will be a sound social policy.”
Whether his voice will be heard is not yet clear. Thanks to
the many training seminars set up after the tsunami, there
are now thousands of Sri Lankans who believe they are
trained in trauma counseling and the Western ideas behind
PTSD. In addition, there will undoubtedly be new efforts by
international aid agencies to provide psychological therapy.
Whether these efforts will heal these communities or, as
Argenti-Pillen fears, unintentionally destabilize them
remains to be seen. It would be tragic and ironic if Western-
style trauma counseling ends up sparking violence between
ethnic groups and clans that already have reason to hate
each other. Intending to break cycles of violence, Western
beliefs about trauma and healing may be poised to spin
them back into motion.
3
The Shifting Mask of Schizophrenia
in Zanzibar
What we say about mental illness reveals what we value and
what we fear.
JULI MCGRUDER
On my first night in Zanzibar I was awakened by the distant
sound of a telephone ringing. I came to consciousness
fitfully, puzzling out where I was. I was bone-tired from two
days of red-eye plane travel and a rough ferry crossing to
the island from mainland Tanzania, disoriented by the ten-
hour time change and, possibly, by the side effects of the
prophylactic malaria medication I had begun taking a few
days before. I checked the bedside clock: 3 a.m. I could hear
my hosts, Juli McGruder and her partner, Ahmed Kassim, in
the upstairs room of the house as one of them answered the
phone. As in most houses in Zanzibar, there was no glass in
the windows—better to let the steady trade winds sweep
out the stuffy air during the night—and I could hear their
voices talking low and intently in Kiswahili. I stood at the
window, listening and looking out into the night. It was a full
moon and there was a racket of premorning birdsong
coming from the thick, low brush beyond the cinderblock
wall that surrounded the house. After a few minutes Kassim
came downstairs, walked across the sandy driveway, and
drove off in his rattletrap Toyota van. I got back in bed,
retucked the mosquito netting, and lay awake wondering
what might have occasioned the call. I was new to the local
customs, but I suspected that Americans and Zanzibaris
shared at least this cultural truism in common: no good
news comes in a phone call at 3 a.m.
I had come to Zanzibar, a sixty-mile long coral island off
the Swahili coast of East Africa, to spend some time with
McGruder. She had recently retired from her teaching
position at the University of Puget Sound in Washington and
had opened a guesthouse at the very northern tip of the
island with Kassim, a younger local man who was both her
romantic and her business partner. She had been a
professor of occupational therapy, and late in her career she
had received a PhD in anthropology from the University of
Washington. Her field research focused on three families
struggling with schizophrenia in Zanzibar, where she went
to figure out a puzzle that has baffled cross-cultural
researchers in mental illness for twenty years: Why did
people diagnosed with schizophrenia in developing nations
have a better prognosis over time than those living in the
most industrialized countries in the world?
In the morning I met McGruder in the kitchen, where she
was brewing a pot of strong cowboy coffee, boiling the
grounds directly in a pot of water. “I need the real thing this
morning,” she said by way of greeting. “Instant is not going
to do it.” She told me the news before I could ask. The early
morning phone call had been for Kassim. His 10-year-old
daughter, Latifa, a child from an early marriage, had died
suddenly in the night. The family had known that the girl
had an enlarged heart, but she had recently been healthy
and happy. Just that day she had been to Koran school,
played with her friends, and eaten well. But that night she
woke up vomiting blood. The family had rushed her to the
hospital, where she died shortly after being admitted.
Kassim had gone south to assist with the burial, which,
according to Muslim custom, would happen that day.
After a moment I asked how Kassim was holding up.
McGruder shrugged as she stirred the coffee. “It’s hard to
say,” she said. “Swahili men tend not to show a lot of
emotion when things like this happen.”
When I saw Kassim late the next day, I shook his hand and
told him how sorry I was to hear about his daughter. He
smiled weakly and said only, “That is life.” Later at dinner
he told McGruder and me how the women cried during the
day. He described how the crying would reach a crescendo
and then die down, only to be started again when a new
woman showed up and saw the body.
Kassim’s own demeanor remained a mystery to me. At
first I assumed that he was just in shock and would be
overcome with emotion when he had time to reflect on the
event. It would be unfortunate, I also found myself thinking,
if some notion of local machismo made him push his true
feelings aside. He would certainly pay a steep psychological
price for such repressing of his feelings.
Although I had traveled here with the intention of learning
about the different ways people in Swahili culture express
emotion in the face of mental illness and other difficult life
challenges, I couldn’t let go of my assumption that the
healthy reaction to the loss of a child would be abject
displays of grief. I believed the natural—the truly human—
reaction to such an event was the way I imagined I would
have reacted if the 3 a.m. phone call had carried tragic
news about my own daughter back in San Francisco. I was
as unable to understand what Kassim was feeling from his
outward affect as I was to understand the meaning of his
words when he spoke Kiswahili; he was expressing himself
in an emotional language that I did not comprehend.
Even anthropologists, who diligently train themselves to
be nonjudgmental observers of cultural differences, have
trouble when it comes to recognizing and allowing for
cultural differences in emotions. Because our emotions
come into our consciousness unbidden and often surprise us
with their intensity, we often assume that they are not
influenced by cultural cues or social scripts. But with careful
study, anthropologists have learned that emotions are not
like muscle reflexes; rather, they are communications with
deep and sometimes obscure meanings. Cultures differ not
only in their response to specific events (as we’ve seen with
reactions to trauma) but also in more global ways.
Describing and understanding these differences has in
fact been central to McGruder’s research on Zanzibari
families who struggle with schizophrenia. During her
research she began to suspect that the emotional tenor of
families dealing with mental illness in Zanzibar was
qualitatively different from that of families in the
industrialized world. Subtle differences in this emotional
temperature of households, she theorized, might go a long
way to explaining why a schizophrenic patient in Zanzibar
will often do better than someone diagnosed with the
disease in the United States.
From the Clouds to the Equatorial Sun
McGruder is of a type common among the faculty of West
Coast colleges. Her politics are liberal and she is prone to
antiestablishment and contrarian thinking. She is short with
spiked blond hair and a friendly but no-nonsense demeanor.
As a child she was smart and rebellious, a difficult
combination for a Catholic schoolgirl growing up in northern
Indiana in the 1950s. When she was a teenager she dated
African American men despite her parents’ strenuous
objections. One of her first encounters with the mental
health profession was when her parents forced her to see a
psychologist to cure her of her “pathological” romantic
behavior. At one point she was even threatened with
incarceration in a mental hospital.
Despite her parents’ efforts, she got married at age 18 to
an African American man. This was just one year after the
Supreme Court’s 1967 ruling Loving v. Virginia, which
effectively ended race-based restrictions on marriage in the
United States. McGruder’s first job after college was in the
mid-1970s at the Hudson River Psychiatric Center in
Poughkeepsie, where she witnessed what passed for mental
health treatment at the time. As she remembers, the
doctors relied heavily on sedating antipsychotics such as
Thorazine, Stelazine, and Haldol and some early tricyclic
antidepressants. She couldn’t help but notice the way some
of the drugs knocked the patients for a loop. “These drugs
worked like big hammers,” she told me. “They just snowed
people. They would make the patients shake and drool and
feel miserable.”
After that she went back to school for a degree in science
education and became a teacher, eventually finding a post
teaching occupational therapy at the University of Puget
Sound. On the side she worked as a private therapist and
guardian with elderly and institutionalized schizophrenic
clients. After a decade of teaching and making her way up
the university’s academic ladder, she got bored with the
routine and found herself reading feminist philosophical
tracts on science and gender. With a sabbatical coming up,
she sent out dozens of letters to international aid agencies
offering her services. For months she heard nothing. Then
came a lone reply from a Danish international development
organization that had an office in Dar es Salaam, Tanzania.
They offered her a year-long post at the Kidongo Chekundu
Mental Hospital on the island of Zanzibar with a salary of
forty-two dollars a month. She jumped at the chance and
immersed herself in learning Kiswahili. Once she got to
Zanzibar, she helped establish an occupational center at the
hospital where patients could learn carpentry skills and
practice art therapy.
The Western-trained doctors she met at the hospital in
Zanzibar had access to the basic arsenal of Western
antipsychotic drugs. However, the idea that diseases such
as schizophrenia spring from chemical imbalances or brain
abnormalities had not yet been accepted by most of the
population of Zanzibar. Much more salient were beliefs in
spirit possession and the permeability of the human
consciousness by magical forces.
McGruder became fascinated by the ways these beliefs in
spirits shaped the experience of mental illness both for the
families and the patients themselves. She was also
interested in how these local ideas were beginning to
intermingle and sometimes compete with the imported
Western idea that mental illnesses were caused by
biological brain malfunctions. At the end of her sabbatical,
she decided to pursue a doctoral degree in anthropology so
she could dive further into these questions. After finishing
her course work in anthropology at the University of
Washington, she couldn’t wait to escape the dreary Pacific
Northwest and get back to the island.
Zanzibar lies at the midpoint of the Swahili Coast, a 1,800-
mile stretch of coastline straddling the Equator from Kenya
to Mozambique. For millennia it was to this coastline that all
of Central Africa brought its goods in order to trade them
with the world. The predictable monsoon trade winds were
key to its culture. From November to March those winds
blew steadily down the coast, bringing merchants and
traders from India and the Persian Gulf. From July to
September they shifted northward, sending the traders
home. On the northbound winds small lateen-sailed boats
called dhows traveled up the coast with sturdy mangrove
wood, aromatic tree resins, gold, ivory, clove, and the fine,
multipurpose fibers of the raffia palm. On the southbound
winds they brought back manufactured goods from Arabia,
India, and China in the form of carpets, incense, glassware,
and cloth. The months between the shifts in the trade winds
gave merchants from the Middle East time to sell their
goods and buy their new cargo. It also gave them time to
share their ideas and religious beliefs and to infuse Swahili
with Arabic words. The months in foreign harbors also
allowed for merchants and sailors to take wives and
otherwise leave their genetic mark on the population.
The resulting cultural texture of Zanzibar was endlessly
interesting to McGruder. She enjoyed the smell and the
sound of the place, the way the echoing calls to prayer
broke up the day, and the constant commotion of children at
play. She even liked the way the names of things felt on her
tongue. The place-names Kisimkazi, Manzi Moja, and
Kakunduchi felt good to say. She particularly liked saying the
name of the local public transport along one of the main
roads: the Bububu daladala.
Not that life there was a tropical paradise. Although her
memory of that first year has sweetened, her field notes
attest to the frustrations of living in a developing country.
There were outbreaks of cholera, and the dust whipped up
by the constant trade winds during the dry season often
contained enough bacteria to cause epidemics of
conjunctivitis. Raw sewage sometimes fouled the white
beaches and the baby-blueness of the ocean. Fishermen had
recently taken to using sticks of dynamite to fish the reefs,
and the joy of speaking the words Bububu daladala was
offset by the sheer terror she felt while actually riding these
speeding minibuses.
In the end, however, her desire to return and study mental
illness in Zanzibar came not simply out of an abstract
pursuit of knowledge or the social good that might come of
her findings, but because she felt a deep affinity for the
people and the place.
Incidental Content versus Essential Form
McGruder was well aware that the cutting-edge research on
schizophrenia was not coming out of the field of
anthropology. More than any other mental illness in the
Western world, this one belonged to the “hard scientists”
who looked for the causes in bad genes, biochemistry, and
the structure of the brain. The advent of brain scans—
allowing a researcher to see into the head of live patients—
brought with it a seemingly endless series of theories about
the root cause of the illness. Abnormalities supposedly key
to schizophrenia have been reported in the frontal cortex,
the prefrontal cortex, the basal ganglia, the hippocampus,
the thalamus, the cerebellum—and pretty much every other
corner of the brain as well. No firm consensus had emerged
about the location or cause, but there was wide agreement
that the exciting advances in understanding the disease
were coming from the laboratories of brain researchers.
Although far from the limelight, there were scholars and
researchers looking at the disease from other perspectives
as well. McGruder found perplexing data and fascinating
theories in cross-cultural studies of the disease. Although
something approximating schizophrenia could be found in
populations at every corner of the globe, there were enough
variations to suggest that the disease was shaped by
something besides the purely genetic or biological.
The most obvious differences between cultures were in
the delusions and hallucinations experienced by those with
schizophrenia. These harrowing visions and disembodied
voices were often distorted reflections of the phobias and
fascinations of specific cultures. No one, after all, endures
the psychotic delusion that the CIA is beaming microwave
signals into his or her fillings unless that person is culturally
acquainted with the CIA, modern dentistry, and the
disquieting idea that our bodies are constantly permeated
by unseen electromagnetic waves.
Those who have studied these differences have noted,
among other things, that delusional guilt is most often
associated with Judeo-Christian cultures, as are religious
hallucinations such as hearing the voice of God. Such
hallucinations are rarer in Islamic, Hindu, and Buddhist
populations. Schizophrenic patients from Pakistan are more
likely to have visual hallucinations of ghosts and spirits than
are British schizophrenics, who are more prone to hearing
persecuting voices. In traditional Southeast Asian villages,
where it is often frowned upon to strive willfully for personal
status, delusions of grandeur are rare. In the United States,
where celebrity, wealth, and power are popular fetishes,
people with schizophrenia commonly believe that they are
famous or all-powerful.
It is also clear that delusional content in any particular
culture can change over time. In Austria, to take one
example, cases of delusions of grandeur, hearing the voice
of God, and feeling persecuted have been steadily
increasing over the past fifty years, while delusional guilt
and psychotic hypochondria are on the decline.
Researchers who focused on the biomedical or genetic
linchpins of the disorder often dismissed these differences.
The fact that the “delusions of schizophrenics in
industrialized societies will concern television sets and x-
rays rather than ghosts and spirits . . . [is] often considered
to be of secondary importance,” writes Rutgers professor of
psychology Louis Sass. “They are presumed to have little to
do with the illness’s genesis or essential form.”
Does it really matter that a person with schizophrenia in
one culture talks with a dead relative, while someone in
another culture believes he is receiving communications
from an extraterrestrial? The distinction that often gets
made in this debate is between pathoplastic aspects of the
disease, which vary from person to person, and the
pathogenic cause, which is assumed to be the root cause of
the disorder. Pathoplastic symptoms are often dismissed for
describing only the coloring and content of an illness but not
its fundamental nature. The true prize—the quest of the
brain researchers—was to get past the cultural noise and
discover the pathogenic factors that are the universal cause
of the illness. They wanted to weed out the “incidental
content” and get to the “essential form.”
But McGruder kept coming across research suggesting
that culture and social setting play a more complicated role
in the disease than simply influencing the content of the
delusions. Studies showed, for instance, that prevalence
rates vary from place to place. Those living in urban settings
in the United States and Europe appear to suffer more often
from the disease than those living in the country or the
suburbs. These curious spikes in the disorder remain even
when researchers took migration, drug use, and poverty out
of the equation. Men living in the most densely populated
areas of Sweden, for instance, are at a 68 percent higher
risk of being admitted for psychosis—often the first sign of
schizophrenia—than those who live in the countryside. For
women the risk is 77 percent higher. Something about city
living seems to spark the harrowing delusions,
hallucinations, and disorganized thinking characteristic of a
schizophrenic break. Stranger still, some neighborhoods in
cities produce more schizophrenics, to such a degree that
scientists have wondered about the environmental
pathogens that might exist in one place and not another.
The more McGruder read of the cross-cultural research on
the disorder, the more it appeared to shape-shift from place
to place, and no one seemed to have a clear explanation for
this. Janis Hunter Jenkins and Robert John Barrett, two of the
premier researchers in the field, describe the general state
of affairs.
In sum, what we know about culture and schizophrenia is . . . [that] culture
is critical in nearly every aspect of schizophrenic illness experience: the
identification, definition and meaning of the illness during the primordial,
acute, and residual phases; the timing and type of onset; symptom
formation in terms of content, form, and constellation; clinical diagnosis;
gender and ethnic differences; the personal experience of schizophrenic
illness; social response, support, and stigma; and perhaps most important,
the course and outcome with respect to symptomatology, work, and social
functioning.
By “course and outcome,” Jenkins and Barrett are referring
to that most perplexing finding in the epidemiology on the
disease: people with schizophrenia in developing countries
appear to do better over time than those living in
industrialized nations.
McGruder read with fascination the startling results of two
huge international studies carried out by the World Health
Organization over the course of twenty-five years starting in
the late 1960s. These two studies, which had follow-up
periods of two and five years, took place in a dozen sites
around the world, taking into account ten countries and
following more than a thousand patients from both rural and
urban settings. What they found was that those diagnosed
with schizophrenia living in India, Nigeria, and Columbia
often experienced a less severe form of the disease (had
longer periods of remission and higher levels of social
functioning) than those living in the United States,
Denmark, or Taiwan. Whereas over 40 percent of
schizophrenics in industrialized nations were judged over
time to be “severely impaired,” only 24 percent of patients
in the poorer countries ended up similarly disabled.
That result, which is perhaps the most famous finding in
the field of cross-cultural psychiatry, was widely discussed
and debated in part because of its obvious irony: 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.
McGruder found it remarkable that even in the face of
these cross-cultural differences in outcome, some
researchers still seemed uninterested. As with the
differences in the content of the delusion, these variations
in course and outcome were considered in some quarters to
be beside the point. Ignoring the WHO studies might make
sense to a brain scientist or geneticist looking for the first
trigger for schizophrenia, but for someone like McGruder,
who had worked closely with and cared for schizophrenic
patients, there was nothing—save a miracle cure—more
important than the question of the disease’s course and
outcome.
As McGruder read more about the WHO studies she
became fascinated by the debate within psychiatry over the
possible reasons for these differences. Some researchers
suggested that the demands placed on a person in a poorer
nation to be productively employed were lighter and easier
to meet. Perhaps there were more opportunities to feel
productive by engaging in work with one’s family, such as
gardening and child care. Others put forward the idea that
the expectations for appropriate behavior were clearer and
simpler in nonindustrialized, traditional, or premodern
cultures. The rules of behavior for living in the modern world
simply overwhelmed schizophrenics, causing them
increasing distress. Perhaps, suggested others, it was
traditional beliefs in supernatural agents and spirit
possession that removed the weight of blame and guilt from
both the person experiencing psychosis and the family. Still
another set of scholars thought that families in certain
cultures might express less highly charged attention and
criticism toward the ill family member. This research into
what was called “expressed emotion” suggested that
schizophrenics often got worse when surrounded by family
members who were constantly critical of their behavior or
showed intense and intrusive concern about their condition.
Given all the different theories that attempted to explain
the WHO studies, McGruder could immediately see one
truth: no one had yet found a convincing explanation for the
cross-cultural differences. Indeed the researchers who
conducted the WHO studies admitted as much. Although a
“strong case can be made for a real pervasive influence of a
powerful factor which can be referred to as ‘culture,’” one of
the WHO researchers concluded, none of the WHO studies
was designed to “penetrate in sufficient depth” to
understand what might be happening. This left researchers
guessing which cultural factors might be ameliorating this
devastating disease.
The fact that researchers couldn’t offer meaningful or
specific conclusions about the effect of different cultures on
schizophrenia didn’t surprise McGruder. Culture, as she was
learning to understand it as an anthropologist, did not exist
in large data sets. The word can be defined in broad terms
as, say, the “the intellectual, moral, and aesthetic standards
prevalent in a community” or as the “shared symbols and
meanings that people create in the process of social
interaction.” Yet anthropologists firmly hold that culture can
be truly understood only in the particular. Culture, especially
as it shapes and informs the consciousness of a mentally ill
person, is a local phenomenon.
Again and again in the debate surrounding the WHO study
McGruder saw researchers pleading for anthropologists to
pick up the ball and run. “More ethnography is needed,”
concluded one well-known researcher, “if only to elucidate
those aspects of everyday practice that remain obscure.” All
the way back in 1987 the Harvard medical anthropologist
Arthur Kleinman wrote with obvious frustration about the
lack of anthropological attention to the WHO data on
schizophrenia: “For over ten years this finding has been the
most provocative to emerge in cross-cultural psychiatry . . .
[Yet] the most important finding of cultural difference—
arguably the single most important finding in the study—
receives scant attention.”
McGruder saw the window of opportunity presented by the
WHO study. What was clearly missing was an on-the-ground
examination of the ways patients in a developing country
are treated by their families and caregivers. What ideas and
beliefs do family members in developing nations use to
understand the delusional behavior of a loved one? How do
they talk about this behavior—what specific words and ideas
do they employ? And, critically, how does the local
understanding of the illness impact the beliefs, behaviors,
and self-conception of the ill family member?
Given the importance of the questions posed by the WHO
studies, it was surprising that droves of young
anthropologists hadn’t heeded the call. Then again,
considering the scope of the challenge, this reticence is
perhaps understandable. Even observable public aspects of
culture are difficult to understand and describe in depth;
elucidating the cultural currents that affect the functioning
of a mentally ill person would be much more difficult. The
challenge of McGruder’s research went beyond describing
what people did. She had to explain, on a nearly existential
level, who they were. A younger PhD candidate would have
been well advised to pick a topic that had firmer boundaries.
Fortunately McGruder was not at the beginning of her career
but closer to its end, and so she had no need for a safe
research topic. She brought to her research the particular
type of passion that comes when one picks a topic that is
the confluence of one’s life interests.
Revolution and Madness
On my fourth day in Zanzibar, McGruder walked me through
a maze of narrow alleys in Stone Town to the house of one
of the three families she studied. It was a low white building
facing a small public square, in the center of which stood a
large shade tree. The house was not much to look at: a
single-story cement structure with four square columns
supporting the roof over a small porch. The windows were
shuttered behind steel bars. The family had moved a few
years ago and the house was empty. A message in red spray
paint read in Kiswahili, “This house is not for sale.” This,
McGruder told me, was where Hemed and his daughter
Kimwana, both diagnosed with schizophrenia, had lived with
their family.* The head of the household was Amina,
Hemed’s ex-wife and Kimwana’s mother.
As with most Zanzibari families, these three did not live as
a nuclear family unit. During the year McGruder spent
visiting the family, the household included Amina’s mother;
her two married daughters and their children; one
unmarried daughter, who was sometimes away at college;
one unmarried son, who was studying at the local Islamic
teacher’s college; Hemed’s half-brother, who was a deaf-
mute; plus his adopted sister and her children. At night the
600-square-foot, eight-room structure slept as many as ten
adults and ten children.
As we sat on a low brick wall at the edge of the square
nearest the house, I asked McGruder if her memory of the
place was of rooms constantly packed with people. “No, my
impression of the place was of traffic; constant streams
coming and going,” she told me. She described how women
would converse and do chores indoors or in the small walled
courtyard. Men and children would be outside on the
covered baraza, the cement bench that ran along the front
of the house. The kitchen would be in constant use, as
household members cared for and fed each other in a bustle
of steady activity. One of McGruder’s favorite words in
Kiswahili is onomatopoeic for such managed chaos:
zogozogo.
The sheer number of people in the household posed a
challenge to her research. She had hoped to tell the history
and take the emotional temperature of the family, but even
a rough sketch of the family tree of this pulsing kinship
group proved complicated. Amina, the mother, seemed the
obvious focal point for her study. The swirl of activity in the
household revolved around her. She was the rock.
Like many Zanzibaris, Amina was of mixed Swahili and
Arab descent. She was married at 18 in an arranged union
to Hemed, the older son of the plantation owner for whom
her father worked. Like many Arab families who had
immigrated from the Middle East over the centuries,
Hemed’s father owned a clove plantation and traded in the
spice business. During their courtship in 1960 and the
months after their marriage that year, Amina remembered,
Hemed was lighthearted and charming. Sadly, it was less
than a year after their marriage that he experienced his first
psychotic episode.
The period in which Hemed began to experience
symptoms of schizophrenia was, not coincidentally, a time
of political upheaval on the island. After years of being a
British colony, Zanzibar embarked on the uncertain path to
self-governance. There were three political parties, twenty-
two trade unions, and sixteen partisan newspapers stirring
up anger and resentment on all sides. Hemed’s first
experience of derangement, McGruder believes, was
sparked by the social upheaval of the time.
As Amina remembered, Hemed loved to talk politics, and
he would often come back from political meetings so wound
up that he couldn’t sleep. He would talk all night about the
various faction leaders and the ever-changing alliances.
Over the months, these ramblings became tinged with fear
of political persecution. His worries were not mere paranoia,
given the ethnic and political killings that were to come.
Soon Hemed’s political monologues transformed into
fretful discussions with unseen interlocutors. He began to
frighten his new wife with his unpredictable behavior.
Such an onset of schizophrenia can be explained by the
stress-diathesis model, the theory that biological factors
make one vulnerable to schizophrenia, but stress in one’s
environment may set off the illness. Stress may come from
any number of sources, but researchers have paid particular
attention to conflict within a person’s social world. Given
what was going on in that moment in the history of
Zanzibar, the amount of stress felt by Hemed must have
been intense. He was a middle-class man from a high-profile
Arab minority at a time of growing racial and class distrust.
His curly dark hair and facial features made him identifiably
Arab. There seemed to be no safe political refuge. Even the
political party he belonged to, the Zanzibar Nationalist
Party, was internally split between those who considered
themselves African and those of Arab heritage. No one knew
whom to trust.
At the end of the year Hemed broke down. Soon after his
first son was born, in September, he was admitted to the
local mental hospital after beating his great-aunt during a
delusional episode. Early the next year he was certified as a
person of unsound mind. His medical charts reported that
he had a “shallowness of emotion, visual hallucinations and
aggressiveness, tend[ed] to lose temper, ha[d] delusions.”
The New Year brought no relief from the political turmoil.
Violent riots followed the elections, prompting the British to
send in soldiers from the mainland and declare a state of
emergency. Dozens of foreign-born Arabs were murdered
and more than a thousand people were arrested. During this
time Hemed returned to the mental hospital and stayed
there for six months. He was released around the time his
daughter Kimwana was born.
Over the next two decades Hemed was hospitalized eight
times for various periods and twice given electroconvulsive
treatments. As McGruder examined his hospital records, it
became clear that the dates of his worst episodes were
during or right after periods of political strife or family
stress.
In 1970, when Hemed was hospitalized for nearly an
entire year, Amina divorced him, employing an Islamic law
that allows divorce for reasons of nonsupport. Still, Hemed
eventually came back to live with the family, and he and
Amina even had a sixth child together. Later he suffered a
stroke that paralyzed one side of his body. In the end Amina
saw Hemed’s stroke as something of a blessing. Although it
made him an invalid, she told McGruder, “it has broken the
strength of his anger, his wanting to beat people.”
Kimwana, their daughter, showed no signs of the illness
during childhood. Amina remembers her daughter’s early
years with the compliment that she was “not a heavy load.”
She was a happy child even though her early years were
turbulent times for the island. Her mother and classmates
remember her as the brightest student in the class.
Particularly skilled with numbers, she graduated from
secondary school and took a job with the Ministry of
Finance. This was 1983, a time of rapid change for women
on the island. To fill in for the many educated men who had
fled the political upheaval, women were beginning to enter
the professional workforce by the thousands.
One Saturday night, just a few months after starting her
new job, Kimwana was restless and couldn’t sleep. Late in
the evening she wandered outside the house and in a loud
voice began asking for forgiveness. “Forgive me!” she
yelled. “Oh God, what have I done wrong!” When the family
couldn’t calm her, they assumed it was a case of spirit
possession. The family debated two theories. Perhaps, they
thought, she had been possessed by a spirit from a
deceased ancestor who had not been acknowledged for
watching over Kimwana, had not been shown the proper
gratitude for all the success she had experienced up to that
point. The other possibility was that a jealous coworker had
sent the spirit with the use of witchcraft.
At 1 a.m. Kimwana’s ranting hadn’t yet subsided, and the
family took her to the local hospital. Amina remembers that
she was examined, given antimalaria pills, and admitted for
four days.* At the end of the week, Amina recalls, Kimwana
came back home, slept well, and was able to go to work
again on Sunday.
She worked that week, but the following Monday again
became upset and refused to go to work. This time Amina
employed a traditional remedy. She burned a mixture of
leaves, flowers, grasses, and seaweed, whose strong odor is
believed to repel many types of weak spirits. Amina
remembers taking her daughter to the hospital, where she
again “became herself.” But even with periods of remission,
the delusions of hearing disembodied voices came back on
a regular basis.
He Sees Me up to My Heart
Fifteen years later, when McGruder began to spend time
with the family, her goal was not to show that Kimwana’s or
Hemed’s mental illness would have had a different course in
a different cultural setting; that would be impossible to
prove as there are no control groups in ethnographic
scholarship. Rather, she set about trying to record how
cultural beliefs and practices contributed to the family’s
understanding of the illness and to their treatment of
Kimwana and Hemed.
McGruder first wanted to get an idea of what the
experience of madness felt like. Hemed was so disabled by
his schizophrenia and the stroke that it was not possible to
get a sense of what was happening in his mind. Kimwana,
however, had periods of relatively high functioning and
could tell McGruder her impressions.
Kimwana told McGruder that the voices she heard in her
head were usually male, and they spoke to her as if they
could “see to my very soul.” These voices told her variations
on the theme of what a bad person she was. Sometimes she
heard two or more men gossiping that she was a disloyal
and disrespectful daughter and sister. The chorus could be
relentless: “She doesn’t love her mother,” one voice would
say to the other. “She doesn’t love her brothers and sisters.
She is not a person of God, just a useless person.”
Sometimes they would curse her in riddles or make negative
but oblique statements such as “Abhorrent badness even to
the soul.”
Although Kimwana understood that her thoughts were
unstable and disorganized, she often insisted the voices
were of real people and not delusional. And although she
sometimes believed that the voices came from outside the
window, her subjective experience was that the person
speaking was seeing into her thoughts and feelings. “I don’t
see him but he does [see me],” she told McGruder. “He
really sees me a lot. Actually he sees me up to my heart, up
to my mind. He has the ability to speak to me because he is
able to see me because whatever I think about he sees it.”
Much of the torment of having these male presences in
her head related to Islamic rules of female modesty. While
the voices were with her, she felt she must respect the
codes of conduct as if she were actually in the presence of a
man. At such times she could not bathe or undress and she
tried not to go to the bathroom. Although she sometimes
found it helpful to argue with the voices when they became
critical, her sense of decorum made it difficult for her to do
this out loud.
This sense of decorum also made Kimwana reluctant at
first to name her tormentors, for it turned out that she
recognized the voices. They were, she admitted to
McGruder, the voices of the bicycle repairmen who worked
in front of the house. This bit of reality left McGruder in a
quandary over Kimwana’s perceptions. For most of the day
and often into the evening the voices of the bicycle
repairmen could be heard quite clearly in the house. It was
often difficult to tell to what extent Kimwana’s delusions
were jumping off of actual conversations drifting through
the window and to what extent they existed exclusively in
her mind.
That Kimwana’s delusions would come in the form of
intrusive auditory hallucinations made sense given the
location of the household. The roiling, pulsing sound that
filled the square during the day was remarkable for its
volume, texture, and complexity. Across the square from the
house was the Bakathrir Muslim School for Girls, and directly
to the right of the house was the Al Nour Islamic School for
Boys. At any given moment the undulating, overlapping
choruses of hundreds of children chanting in Arabic could be
heard.* The noise that emanated from the schools created a
kind of hypnotic background sound, like breaking surf.
On top of that sound could be heard the single voices of
individual children teasing and playing with each other or
calling out to people in the courtyard. Then there were the
voices and footsteps of adults heading across the square on
their errands and the constant squawk of crows in the shade
tree. In that cacophony of sounds reverberating and echoing
off tin roofs and cement surfaces, the only discernable
individual voices were those of the bicycle repairmen
chatting among themselves or with their customers as they
did their work.
Considering the additional commotion of the comings and
goings of the members of the household, the noise must
have been unrelenting. The many small children, though
well behaved in the manner of most Zanzibari children,
created a racket. Hemed, even though he could not walk or
even bathe himself, could yell and often did for long
stretches without ceasing. Several of the family members
shared with McGruder their belief that the noise itself was
exacerbating Kimwana’s illness. Bimkubwa, the most
Westernized of the siblings, told McGruder that Europeans
have much smaller families and that their houses were
much quieter. “There are too many of us and this place is
too noisy,” she said emphatically.
Kimwana often asserted that she felt better when she was
alone. But given her auditory hallucinations and the general
noisiness of her surroundings it was clear that she was
talking not just about a desire for physical solitude but also
for quiet. “I do like being on my own,” she once told
McGruder. “Being with people I feel like I am tangled with
them. I feel like calming myself, just silently. Just quiet and
silent.” Unfortunately time alone was a scarce commodity in
the packed household. And silence was all but unavailable.
The Emotional Temperature of the Household
It didn’t take long for McGruder to sense that Amina’s family
displayed an amazing tolerance for the difficulties of having
two severely mentally ill people (not to mention a deaf-
mute) in their household. It was a testament to the strength
of this family unit that Hemed, even after the divorce for
nonsupport and the years of violent psychotic episodes, was
still taken care of by Amina and the family.
McGruder noted that the family took a remarkably relaxed
stance toward Kimwana’s illness in particular. When asked
about Kimwana’s symptoms, Amina gave matter-of-fact
answers. When McGruder wanted to know what Amina
thought of Kimwana’s central delusion, all she could elicit
was the simple declaration that her daughter felt that the
“bicycle repairmen concern themselves with her affairs.”
Amina told McGruder that she did not share her daughter’s
belief, but there was no judgment or frustration attached to
the delusions. To many questions Amina would only answer,
“I am unable to know” or “I take it as one of God’s mercies,
one of God’s wishes.”
To try to give me a sense of the emotional tone in this
house, McGruder recounted a day in late September after a
particularly difficult few months for the household. Kimwana
was recovering after taking an overdose of her medication,
and a bad cold had sickened nearly everyone in the family.
Amina had admitted to McGruder that they were too poor
even to buy aspirin. Although each family member had
mostly recovered from the illness, the family unit was still
trying to regain its normal rhythm.
When McGruder arrived in midmorning she went right to
work in the kitchen. She had found that participating in the
daily chores was a much less intrusive way to observe the
goings-on in the household than sitting in a corner with a
notebook. Over the course of the morning she watched
Amina prepare food for a dozen hungry mouths, negotiate
the payment of school fees with a local official, send family
members on a variety of errands, and deal with minor
setbacks, including a large pot of ginger tea that had
unexpectedly curdled. On top of this she did her best to
keep the children (and McGruder) from disturbing Hemed or
Kimwana, both of whom were more upset that morning than
usual.
In her notebook McGruder listed the stressors Amina dealt
with that day. There were the relentless financial worries,
three family members who needed constant care, over a
dozen mouths to feed, and a small pack of children to be
protected and cared for. McGruder crossed off one theory
that might account for the differences in outcome of
schizophrenia between developing and industrialized
nations: the idea that life was simpler and less stressful for
poor people living in more traditional cultures. McGruder
suspects that this theory springs from a fantasy on the part
of Westerners, who are soul-weary from lives of commuting,
competing, and trying to find time for family. We want there
to be a place in the world where our life might distill to a
simple combination of satisfying work and close human
interaction. In reality, a stress-free life was as elusive in
Zanzibar as anywhere else in the world.
Despite the zogozogo and the hardships, however,
Kimwana’s behavior and her deficits were tolerated with
remarkable equanimity. While Kimwana’s activities and
social interactions were often reported to McGruder as a
gauge of her wellness, McGruder rarely witnessed Amina or
anyone else in the family pressure Kimwana into displaying
normal behaviors. During periods when Kimwana was
feeling well, for instance, Amina would report that she had
washed the dishes or swept the house. But Amina didn’t
assume a cause and an effect between productivity and
wellness. This goes against some basic tenets of Western
occupational therapy, which suggests that the path to
mental health can be found in productivity and participation
in group activity. Although the family viewed her
participation in household chores as a sign of health, they
didn’t pressure her to perform chores with the assumption
that they were curative. Indeed, when Kimwana was doing
poorly, the family allowed and even encouraged her to
withdraw from activity and to rest. Often, when she tried to
help out during such times, her family cautioned her not to
overextend herself.
For the most part, however, Kimwana was allowed to drift
back and forth from illness to relative health without much
monitoring or comment by the rest of the family. Periods of
troubled behavior were not greeted with expressions of
concern or alarm, and neither were times of wellness
celebrated. As such, Kimwana felt little pressure to self-
identify as someone with a permanent mental illness. This
stood in contrast with the diagnosis of schizophrenia as
McGruder knew it was used in the West. There the diagnosis
carries the assumption of a chronic condition, one that often
comes to define a person.
The prizing of rest over work and passive acceptance of
abnormal behavior versus active encouragement or
criticism were representative of an overall calm emotional
tone in the household. Even on difficult days there was an
air of tolerance when dealing with Hemed’s and Kimwana’s
disturbed behavior. McGruder believed that this tone
emanated not simply from the personalities in this particular
family but from cultural cues in Zanzibar, and she took it as
her mission to find the sources that created this emotionally
even atmosphere.
Emotional Expression and Schizophrenia
The early research into the relationship between the
emotional temperature within families and the long-term
course of schizophrenia took place in England in the 1950s.
Clinicians had anecdotally observed that some patients with
schizophrenia released from hospital care came back within
a short period of time, whereas other patients managed to
stay out of inpatient care for longer periods. A team of
researchers led by the psychiatrist George Brown decided to
try to figure out what factors might distinguish the two
groups. They conducted lengthy open-ended interviews
designed to encourage first-person stories from family
members. There were no right or wrong answers;
researchers attempted only to elicit rich descriptions of daily
life with the mentally ill family member. After categorizing
all the emotional reactions they could identify, they tracked
the patients over time, noting their rates of relapse and
general levels of functioning.
Initially they looked at the families of the patients who
fared better, but they could find no behavior that had
significant predictive value. Studying the families of the
high-relapse patients, however, they did find factors that
appeared to predict outcomes. Three emotional reactions
from family members showed a relationship with the
patients with higher relapse rates. Collectively referred to as
“high expressed emotion” they were criticism, hostility, and
emotional overinvolvement. In particular, high-relapse
patients tended to live in an environment where at least one
relative routinely criticized and attempted to control the
patient’s behavior.*
Criticism and hostility are relatively self-explanatory.
“Emotional overinvolvement,” however, is a term of art that
requires a little explanation. It describes a range of
behaviors that may include dramatic expressions of self-
sacrifice, extreme devotion, overprotectiveness, or
intrusiveness in the patient’s life. One mother, for instance,
was rated as emotionally overinvolved when she reported
that she was so concerned with her son’s condition that she
had dropped all other interests from her life. Her sole
activity, she reported, was to take care of him and protect
him, “like a pearl or a diamond.” This same mother said that
she often became so distraught over her son’s plight that
she considered committing suicide by shooting herself,
running out into traffic, and throwing herself down the
family staircase.
Researchers have found a connection with high expressed
emotion (EE) and poorer outcomes with some other mental
illnesses, but nowhere is it as pronounced as with
schizophrenia. Why is there such a strong connection?
Researchers believe that the experience of being criticized
or constantly observed and judged parallels the experience
of the disease itself. It is not coincidence, in other words,
that one of the central symptoms of schizophrenia is
hearing demanding, critical, or disparaging voices. Social
stress is a known trigger for psychotic episodes, and a
number of studies testing diastolic blood pressure, skin
conductance, and electrodermal reactivity all pointed to the
connection between high-expressed-emotion relatives and
increased feelings of stress in a patient. When confronted
with relatives known for their high levels of expressed
emotion, researchers could watch as dials measuring bodily
stress rose in the patient.
This connection between high-expressed-emotion
households and relapse rates proved true across cultures.
Over the course of the 1970s and 1980s dozens of studies
were conducted on populations in Denmark, Italy, Germany,
Spain, France, North America (including both Anglos and
Mexican Americans), China, Taiwan, India, North Africa, and
Australia. In a paper that aggregated the data from a dozen
studies, researchers noted that the relapse rates were three
to seven times greater for patients from high-expressed-
emotion families. The connection remained even when the
severity of the initial symptoms and drug compliance were
taken into account. In another paper that brought together
the data from twenty-five studies, researchers found that
the relapse rate was 50 percent for high-expressed-emotion
families and 21 percent for low-expressed-emotion families.
God’s Blessings
McGruder could sense that Amina’s household had a low
level of expressed emotion when it came to dealing with
Hemed and Kimwana, but it took her quite a while to
understand the cultural sources of that tone. She spent a
good deal of her time trying to tease out the local religious
beliefs that wove themselves around the ideas of madness
in Zanzibar. Like 90 percent of Zanzibaris, Amina’s family
belonged to the Sunni Shafi’ites sect. This is an Islamic sect
that believes in adhering faithfully to the teachings of the
Koran and the stories collected by Al-Bukhari that recount
the life of the Prophet Mohammed. It is from these stories,
collectively called a hadith, that many Zanzibaris draw
wisdom to manage the everyday challenges of life.
Both the Koran and Al-Bukhari’s hadith recount ideas
about suffering and hardship that McGruder could see had
deeply informed the family’s treatment of Kimwana and
Hemed. Amina and other family members often repeated
the belief that Allah would never put more burdens on a
person than he or she could bear. “In our family we have
this challenge but this is just life,” Amina would tell
McGruder when talking about Kimwana and Hemed. “Other
people have other problems. Maybe their house has burned
down. Everyone knows their own burden best.”
McGruder came to understand that these were not just
bromides. In the family’s Muslim belief, managing hardships
provided a way to pay the debt of sinfulness. Illness or bad
turns of fortune were seen as neither arbitrary nor a
punishment. Rather, they believed that God’s grace awaited
those who not only endured suffering but were grateful for
the opportunity to prove their ability to endure it. In this way
Amina’s remarkable ability to stay steady and resolute in
the presence of sick and disabled family members was an
expression of her religious belief.
McGruder had heard similar “God willed it” sentiments
repeated among Christians in the United States, but the
embrace of hardships in Zanzibar was qualitatively different.
Although American Christians might believe that God had
sent a challenge or a misfortune, they were also likely to
believe that God had given them the strength not just to
embrace the difficulty but to overcome it or learn a valuable
lesson. In the cosmology of Western Christians, life’s
challenges provide opportunities to become stronger and to
have a closer relationship with God. The burdens God sends
to Christians in the Western world are incitements to self-
improvement. The comforts that Amina found in her
religious belief, by contrast, were not in an encouragement
to overcome or learn from hardships. Rather, simply
accepting her burdens was a continuous act of penance.
“Religion as I understood it as a child had more to do with
what you believed than what you did during your day,”
McGruder told me. “Here in Zanzibar religion has much
more to do with what you do. You can see it in how people
live their lives, how they pray five times a day and fast
during Ramadan.” In McGruder’s view, the steady care
given to Kimwana and especially Hemed seemed to come
out of the family’s religious desire to prove worthy of the
burden God had given them.
Sometimes it seemed that their acceptance of burdens
bordered on the fatalistic. “Fatalism” is not a word McGruder
would employ, given that its negative connotations violate
the anthropologist’s credo to remain judgment-neutral. Still,
McGruder found herself using such phrases as
“acquiescence in the face of adversity” and “embracing
difficulties as a natural part of life” almost as euphemisms.
She remembers times when she tried not to let her jaw drop
at the family’s lack of upset. One such moment came when
Kimwana took an overdose of her medication and ended up
in the hospital. “There was no noisy woe-is-me talk or
dramatic wringing of hands. They seemed to take it in stride
like everything else,” McGruder recalls. “When I asked what
I could do, Amina told me that I could take a carton of milk
to Kimwana in the hospital. So I took the milk.” For
McGruder, a fighter and problem solver by nature, it took
some time to recognize the benefits of such acceptance of
life’s difficulties.
The Creatures in Our Heads
The other religious belief that was central to the family’s
conception of the illness was spirit possession. It would be
easy for a Westerner to assume that belief in spirit
possession would almost certainly increase the stigma for a
mentally ill person. McGruder remembered the horror
stories of spirit possession she learned as a child in the
United States. Those beliefs were informed more by pop
cultural representations (such as the movie The Exorcist)
than by what she heard in church. Nevertheless her cultural
understanding of these devil-focused narratives about spirit
possession included dramatic suffering and ostracism for
the person believed to be possessed. In the Christian
context, possession is nearly always thought of as a
profoundly disturbing experience, usually requiring dramatic
and sometimes violent interventions. Given the choice
between the biomedical understanding of schizophrenia and
the spirit possession narrative, most Westerners assume the
drier science-bound explanation for the disease would
certainly inflame less emotion and stigma. As McGruder
came to understand the spirit possession beliefs of families
like Amina’s, however, she found them to be very different
from Christian beliefs in the West. To begin with, spirit
possession in Zanzibar was not an uncommon or necessarily
an extreme experience. As Amina explained to McGruder,
we all have “creatures in our heads.”
The beliefs surrounding spirit possession in Zanzibar arose
from the complex combination of traditional Swahili culture
and Arabic beliefs about jinns. These spirits that often
inhabit living individuals aren’t uniformly good or bad but
can cause problems if they are not dealt with in appropriate
ways. A spirit handed down from one’s ancestor is generally
thought to have a protective effect for the person who
carries it. Such an entity will cause difficulties only if it is
ignored or not properly appeased. These spirits can have an
ethnicity, gender, and religious affiliation of their own. A
spirit might be picked up accidentally or through witchcraft.
Sorcerers are said to raise and feed spirits, which they use
to harm their enemies.
The main difference between the character of spirits and
of humans, McGruder learned, is that spirits are often
autonomous, rude, selfish, and not given to concealing their
emotions. (In this way they are sometimes compared to
tourists who intrude but do not greet.) When a spirit
possesses someone, he or she often violates the social
norms. A sister momentarily influenced by a spirit may
strike a brother who is harassing or threatening her, for
instance.
Because nearly everyone on the island believed in spirit
possession and had a personal experience with it, the
application of the belief to mental illness had the
counterintuitive effect of lessening the stigma attached to
the behavior of the mentally ill person. It made bizarre or
disruptive behavior more understandable and forgivable.
Like the sister who has a ready explanation for hitting her
brother, mentally ill persons and their family can evoke the
narrative of spirit possession to explain unusual or antisocial
behavior.
Belief in spirit possession also gives the family a sense of
agency in that it allows for a variety of socially accepted
interventions. “Spirits causing problems are not exorcised in
the Christian sense of casting out demons,” McGruder
explains. “Rather they are coaxed with food and goods,
feted with song, dance. They are placated, settled, reduced
in malfeasance.” It was common, for instance, to write
phrases from the Koran on the inside edges of a teacup with
saffron paste and then to dissolve the writing so that the ill
person could literally imbibe the holy words. Similarly the
Koran might be read over water before it was used for
bathing. Pagan spirits would be driven away by such acts,
and Muslim spirits would become subdued. Kimwana found
such activities calming. She especially enjoyed it when
family members read to her the short verses from the Koran
that children learn to read and memorize early in school. “If
someone reads and I listen, then my mind clears,” Kimwana
said. “It tells us to become compliant and wait patiently. I
listen to the Koran and then I rest.”
For McGruder the point was not that these practices were
effective in combating the biological causes of
schizophrenia. Rather, they were simple examples of how
the spirit possession narratives kept the sick person within
the social group. Importantly, the idea that spirits could
come and go allowed the person with schizophrenia a
cleaner bill of health when the illness went into remission.
An ill individual enjoying a time of relative health could
employ the spirit possession story to, at least temporarily,
retake his or her responsibilities in the kinship group.
In all these ways the belief in spirit possession could
decrease the sense of blame or shame carried by the family
or the ill individual. The blessings and burdens of God and
the mysteries of the spirit world were, after all, beyond the
ability of the individual or family to effectively control. As
McGruder observed, “When humans do not assume they
have rather complete control of their experience, they do
not so deeply fear those who appear to have lost it.”
In some ways the low expressed emotional atmosphere in
the family stood in contrast to McGruder’s work as a
Western anthropologist trying diligently to understand it. At
times she had to remind herself to turn off her analytical
gaze, her desire to document and categorize the behavior
she was there to witness.
She remembers one day when Kimwana invited her to sit
with her on the steps of the family’s interior courtyard.
McGruder could tell from the liveliness in her eyes that
Kimwana was more fully present than she had been
recently. Kimwana sat, barefoot, with her back against the
door frame, and talked of how enjoyable it was to feel the
breeze. McGruder asked her what she had been doing prior
to her arrival that day and Kimwana told her that she had
been resting but not sleeping.
“When you rest, do you think a lot?” McGruder asked.
“Yes, I think so much,” Kimwana admitted.
“What do you think about?”
“For example,” Kimwana answered, “just now I was
thinking if I would get better.”
It was a promising opening. McGruder sensed that it
would be a good time to ask her more questions about her
disease experience. But then she found she could not bring
herself to risk breaking the peacefulness of the moment.
Making the ill individual aware that his or her behavior and
cognition are being monitored and judged was, she knew, a
sign of emotional overinvolvement. So as much as she
wanted to question Kimwana more, McGruder turned the
conversation back to the quality of the breeze and how cool
it was to sit in the shade of the house, trying, as best she
could, not to document the low emotional intensity of the
household but instead to manifest it.
Emotion across Cultures
McGruder’s intent in describing Amina and her family was
not to make them into heroes. Indeed what made them
remarkable in her eyes was just how unremarkable they
considered their sacrifice. Amina never suggested that the
care she gave her crippled and mentally ill ex-husband was
praiseworthy or particularly out of the ordinary. Because
many other families subscribed to similar religious and
cultural beliefs about the need to accept God’s burdens,
Amina’s family’s unemotional self-sacrifice was the norm in
Zanzibar.
Because different cultures around the world view mental
illness in different cultural contexts, the intensity of emotion
attached to these experiences often varies. Researchers
have found different average levels of expressed emotion
not just among families but also among cultures and even
among different subcultures in the same city. “To be
specific,” Janis Hunter Jenkins writes, “a culture provides its
members with an available repertoire of affective and
behavioral responses to the human condition, including
illness. . . . It offers models of how people should or might
feel and act in response to the serious illness of a loved
one.” Individuals in a given place and time will react to
illness similarly, in other words, because they share the
same limited repertoire of cultural scripts for how to play
their part.
The different ways that cultures communicate
expectations for behavior are often quite subtle. Seemingly
small differences, such as the disease’s name, can make a
difference. Jenkins noticed, for instance, that Mexican
American families in southern California, who had lower
expressed emotion scores than Anglo-American families
tended to use the term nervios to describe the illness of the
relative with schizophrenia. This seemed at first an
inappropriate word; nervios is a folk term often used as a
generic way to describe any one of a whole range of
symptoms, including headaches, dizziness, sleeping
disorders, aggressive or grumpy behavior as well as feelings
of anxiety, insecurity, or fear. Nervios is a catchall diagnosis
for feelings of disquiet or distress. The use of the term
appeared to be a kind of culturally inspired, willful blindness
for these family members. Calling schizophrenia nervios was
the equivalent of telling someone with cancer that he is just
feeling under the weather.
On closer examination, though, there appeared to be a
subtle purpose behind the misnomer. Jenkins saw that the
use of the word was part of a strategy by which the family
jointly downplayed the gravity of the illness. Nervios carried
little of the dire connotations an Anglo-American would
associate with schizophrenia. Nervios, like spirit possession,
is thought of as a transitory state. This allowed relatives and
the ill family member to regard periods of remission in a
more favorable light.
This hopeful naming also fostered feelings of empathy.
Many of the Mexican American family members in one of
Jenkins’s studies told her that they too had suffered from
nervios, in a milder form, and so could empathize with the
relative’s distress. “In this way,” Jenkins concluded,
“conception of the illness as nervios enables the
maintenance of close identification of family members by
fostering the view that the relative is ‘just like us only more
so.’” The label and its connotations allowed family members
to keep the relative within the fold.
That the very naming of the disease could have an impact
on its outcome again highlights the distinction between a
medical illness and a mental illness. The course of a
metastasizing cancer is unlikely to be changed by how we
talk about it. With schizophrenia, however, symptoms are
largely expressed within the person’s complex interactions
with those around them. The key to the emotional tenor of
those interactions lies to some extent in the words and
cultural beliefs that surround the disease.
Because these words and narratives are shared by
cultures, it is not surprising that the average level of
expressed emotion varies from place to place. Comparing
different groups around the world, it turns out that urban
Anglo-Americans have the highest level of expressed
emotion on average. In one study over 67 percent of Anglo-
American families with a schizophrenic family member were
rated as “high-EE.” Of the other groups studied:
Among British families 48 percent were high EE
Among Chinese families 42 percent
Among American families of Mexican descent 41 percent
Among British Sikh families 30 percent
Among Indian families 23 percent
What does it mean that European American families have
the highest average levels of expressed emotion? Is this an
indication that white Americans lack the sympathy or the
kindness to care for their mentally ill?
Professor Jill Hooley of Harvard University conducted a
study to understand what distinguishes high-EE relatives
from their less emotionally intense counterparts. She gave
both high- and low-EE relatives a simple test that measures
what psychologists call “locus of control.” Basically she
wanted to know to what extent these relatives believed they
had individual control over their own lives. To determine this
she asked them whether they agreed or disagreed with
statements such as the following:
When I make plans, I am almost certain that I can make
them work.
I believe a person really can be a master of his fate.
I can control my own problems only if I have outside
support.
A great deal of what happens to me is probably a matter
of luck.
Those who tended to agree with statements such as the first
two were thought to have an internal locus of control. They
were the type of people who thought of themselves as
captains of their own destiny, able to shape their future
through force of will. Those who agreed with statements
similar to the second two were thought to have an external
locus of control, meaning they believed that the course of
their lives was largely influenced by factors outside
themselves.
Hooley found that relatives who were highly critical of the
mentally ill family members were those with an internal
locus of control. Their critical comments to the mentally ill
person didn’t mean that they were cruel or uncaring; they
were simply applying to their relative the same assumptions
about human nature that they applied to themselves. “An
internal based locus of control reflects an approach to the
world that is active, resourceful, and that emphasizes
personal accountability,” concluded Hooley. “Thus, far from
high criticism reflecting something negative about the
family members of patients with schizophrenia, high
criticism (and hence high EE) was associated with a
characteristic that is widely regarded as positive.”
Widely regarded as positive, that is, in the United States.
It has long been noted that countries and cultures differ in
their shared beliefs about locus of control and related
measures such as scales of individualism versus collectivism
or egocentric versus sociocentric conceptions of self. In
many cross-cultural studies, the cliché that Americans are
more individualistic proves to be true. In a masterful meta-
analysis of dozens of cross-cultural studies performed over
the past fifty years, professor of psychology Daphna
Oyserman and colleagues from the University of Michigan
concluded that, compared with other groups around the
world, European Americans are indeed “more individualistic
—valuing personal independence more. . . . To
contemporary Americans, being an individualist is not only a
good thing; it is a quintessentially American thing.”
Viewed in the most positive light, these highly emotionally
involved relatives were more hopeful about the disease
because they remained convinced that the ill family
member should be able to overcome the symptoms with an
application of personal will. “It is plausible to speculate,”
Hooley and a colleague in another paper on the topic
concluded, “that certain cultural values (e.g., fatalism) in
traditional groups might engender more benign and less
blaming attributions toward those with mental illnesses. In
contrast, cultural values that emphasize individuality,
achievement, and personal accountability might be
expected to facilitate more attributions of responsibility and
control in the context of disturbed behavior.”
In his book Crazy: A Father’s Search through America’s
Mental Health Madness, Pete Earley vividly documents a
common response among Western parents when faced with
the onset of a severe mental illness in their child. One
typical father described his reaction to the schizophrenic
break of his son: “I went to the library and began reading
books about mental illness. . . . I thought: ‘No, I’m going to
fix this.’ That is your first instinct as a parent. You’re going
to fix it. I thought, ‘I can get him help. I can get him cured.’”
This intense can-do spirit is admirable and often
heartbreaking. Because there is no silver bullet cure for
schizophrenia, families who attack the problem looking to fix
it are often frustrated by the results. That intense focus,
even when it springs from a hopeful engagement of the
problem, might be the very thing that exacerbates the
illness.
“Mental illness is feared and has such a stigma because it
represents a reversal of what Western humans have come
to value as the essence of human nature,” McGruder
believes. “Because our culture so highly values self-control
and control of circumstances, we become abject when
contemplating mentation that seems more changeable, less
restrained and less controllable, more open to outside
influence, than we imagine our own to be.”
When the Biomedical Narrative Comes to Town
All of the patients with schizophrenia that McGruder
interviewed in Zanzibar received at least some treatment
from doctors trained in other countries. During the country’s
communist years, foreign doctors came from East Germany
and China. More recently they hail from the United States
and Britain. Over that time chronically mentally ill patients
in Zanzibar were prescribed a wide range of the
psychopharmacological drugs that are now ubiquitous
around the world.
During the years that McGruder studied mental illness in
Zanzibar, she watched as traditional beliefs began to mix
with biomedical explanations of mental illness. For some
families, such as Amina’s, those two understandings didn’t
necessarily compete with each other. The idea that spirit
possession was causing bizarre behavior coexisted with the
notion that the pills from the doctors might help her
daughter’s quality of life. One does not have to believe the
“brain disease” explanation, after all, to take a pill.
In some families that McGruder studied, however, the
introduction of Western ideas about schizophrenia had a
more complicated and problematic effect.
Shazrin al-Mitende was 43 when McGruder began visiting
her family. She lived with five adult relatives and ten
children, one of whom was developmentally disabled.
Shazrin’s half-brother, Abdulridha, was her main caretaker,
devoting much of his life to the task. The male nurse who
suggested Shazrin and her family for inclusion in
McGruder’s study thought of Abdulridha as an excellent
caretaker.
Abdulridha himself certainly agreed with this assessment.
In their first meeting he listed for McGruder all the ways that
he had taken charge of his sister’s life. “It is necessary that I
give up my own activities so much in order to care for her,”
he said. At another point he told McGruder, “I am like her
slave now. She says ‘bring me some water.’ I go and fetch it.
It is she who should be bringing me water.”
As McGruder got to know the family, she learned Shazrin’s
history. Trouble began in 1968, when Shazrin was just 13, on
the night of the new moon that signals the end of Ramadan.
Shazrin was sitting with a group of women relatives applying
henna designs to each other’s hands. This group
beautification was in preparation for the feasting and
gathering of relatives that followed the end of the month-
long daylight fast. As she sat with the other women, the
sight of a black cat walking through the room startled her.
During the feasting the next day, she told her family that
she felt unwell and overheated. When her mother told her to
lie down and tried to help her out of her new dress, Shazrin
began to scream uncontrollably. She was inconsolable for
several days.
Because her behavior could be traced to the sighting of
the black cat, it was at first agreed that spirit possession
was behind her strange and disruptive behavior. Shazrin’s
grandfather had been a spirit cult practitioner, who, it was
said, conjured spirits in the family courtyard. Some family
members and neighbors assumed that one of those spirits,
set free of the grandfather’s control at his death, had
alighted on the soul of Shazrin.
Shazrin’s family took her to see several traditional
doctors. They traveled up and down the Swahili Coast
consulting with healers in Dar es Salaam, Bagamoyo, and
Tanga in Tanzania and traveling as far away as Mombasa in
Kenya. In one instance her hair was shaved and small cuts
were made in her scalp into which herbal medicines were
rubbed. Other healers used techniques intended to call forth
the spirit so it could be negotiated with and placated.
Another healer was skilled in diagnosing ailments by
drawing pictures of the patient. Despite these efforts,
Shazrin improved little.
As it happened, a young neighbor had recently become a
doctor at the local mental hospital. He persuaded the family
that Shazrin should be taken to Kidongo Chekundu Mental
Hospital the next time her behavior became difficult to
control. And so, when Shazrin became disturbed a few
weeks later, the family called the police, who took her to be
admitted. She was still only 13 years old, a frightened girl in
a locked ward for adults with severe mental illnesses. In
those first hospital records, the staff noted that she was
restless and preoccupied but mostly rational.
It was during this time that she briefly came under the
care of an American psychiatrist named Charles Swift, who
was having a dramatic impact on Tanzania’s evolving
treatment of the mentally ill. He had come to the newly
formed country in 1966 intending to stay only two years but
ended up staying eight, working mostly in hospitals on the
mainland. From the perspective of Tanzania’s Ministry of
Health, Swift was a godsend. When he arrived he was the
only trained psychiatrist in the country.
Once a month Swift would fly from Dar es Salaam to
Zanzibar and visit the mental hospital, where the medical
director put him to work diagnosing difficult cases. One of
those patients was the young Shazrin. She remembers
being frightened in the presence of this American. “He was
very fierce,” she says. It was Swift who first diagnosed her
condition as schizophrenia.
Shazrin’s assessment of Swift as “fierce” stands in sharp
contrast to the caring and rather humble man he presents
to the reader in Dar Days, his memoir of his time in
Tanzania. He reports having disdained the superior attitude
of the former British colonialists he met in the country. But
while it is clear that Swift took pains to be culturally
sensitive, he also had a great certainty in the value of the
expertise he brought to the country. He clearly saw his
service as parallel to medical doctors who brought state-of-
the-art practices and medication to places where local
clinicians had little knowledge or resources to battle
disease.
Humble as he may have been, he did not turn down the
status he was granted as a mental health professional from
the Western world. Looking back at Swift’s tenure in
Tanzania, it is not surprising that he extended his stay by six
years. Back in New Jersey he worked for a medium-size child
development center, but in Tanzania he was a central player
in establishing the mental health system for the entire
country. His advice was sought in every aspect of the
country’s approach to mental illness, and he dined regularly
with politicians and dignitaries.
In his memoir Swift makes it clear that the pervasive
beliefs in spirits and witchcraft were a problem for the
population. Replacing such native beliefs with clear and
unemotional Western diagnoses seemed to him an obvious
improvement. It was Swift’s hope that by providing Western
knowledge he could help erase these myths that he
believed brought stigma to the mentally ill. For Shazrin, his
diagnosis would have long-lasting effects.
For the next two decades Shazrin was in and out of the
mental hospital dozens of times, for both long and short
stays. Overall she spent nearly one-fifth of her young
adulthood at Chekundu. Her records show that she took a
variety of medications during that period, including, for a
time, a large fifty-milligram dose of the antipsychotic
fluphenazine every two weeks. During another period the
doctors prescribed her a nightly dose of the barbiturate
sodium amytal. In the late 1970s she also underwent a
series of electroconvulsive treatments. Some of the
medication brought on epileptic-like fits and made her lips
and hands tremble uncontrollably.
Shazrin’s treatment at the hospital wasn’t the only way
that Western medicine affected her life. Over the course of
her illness her half-brother, Abdulridha, increasingly
distanced himself from the beliefs of traditional healers and
aligned himself more and more with Western notions and
treatments of his sister’s condition. He associated Western
medicine and Western beliefs about mental illness with his
self-conception of being a modern and educated man.
Abdulridha acquired his knowledge about Western
understandings of mental illness from a variety of sources.
He learned much from the doctors at the hospital. Of all the
family members McGruder interviewed, Abdulridha was the
only one who understood the distinction between the
symptoms of schizophrenia and the side effects, including
tremors and weight gain, of the antipsychotic medication.
He was also the only one to understand that some of
Shazrim’s medications were taken to control the side effects
of other drugs.
He picked up information from other sources as well. For
instance, from a Voice of America program about drugs that
treat depression he came to the conclusion that Western
doctors had a medicine that would cure his sister’s
uncontrollable bouts of crying. As understood by Abdulridha,
the biomedical approach implied that his sister’s mind was
broken but fixable through medication.
McGruder began to think that she was watching a classic
display of emotional overinvolvement as she observed
Abdulridha attempt to manage every aspect of his sister’s
existence. What particularly intrigued McGruder was how
Abdulridha used his biomedical orientation toward the
disease to justify his control over Shazrin. Aligning himself
with the Western doctors, he allowed himself to express
intense frustration at his sister for her apparently stubborn
refusal to get better. Shazrin’s lack of recovery despite his
efforts and those of the doctors appeared to embarrass and
infuriate him. “I tell her, ‘I do everything for you,’” he
recounted to McGruder. “ ‘You should stop all those
behaviors in order to give me some encouragement.’”
McGruder had a front-row seat in witnessing how the
biomedical explanation affected Abdulridha’s treatment of
his sister. She was even, at times, recruited against her will
into the dynamic. For Abdulridha, McGruder was a
representative of modern Western knowledge and authority,
and he attempted to co-opt her presence in the life of the
family to prove that his opinions and actions were backed
up by doctors and educated people.
When McGruder came to visit, Abdulridha took pride in
reciting for her every detail of Shazrin’s daily activities. He
was particularly forthcoming about his knowledge of her
menstrual cycle, detailing the precise dates menses began
and ended. He would then tell her of any recent bad
behavior. “She has finished bleeding some three days ago
now, but her condition is still bad,” he said in one typical
encounter. That he openly talked about such aspects of
Shazrin’s life startled McGruder. A brother talking about
such things was a clear violation of the rules of modesty she
had observed elsewhere in Zanzibar. Abdulridha’s
biomedical conception of his sister’s illness appeared to
invalidate normal rules of conduct. Similarly he would often
talk about Shazrin as if she could not hear him. At these
times she would go blank and stare at the floor, refusing to
respond to anyone. “This is the problem,” Abdulridha said at
one point when his sister’s affect went flat. “She is not here
at all now; she has been completely covered. I told you you
would see it.”
Needless to say, being forced into an alliance that
excluded Shazrin was uncomfortable for McGruder; she
worried that her presence was actually helping Abdulridha
stigmatize his sister. In her field notes she wrote, “I am
finding it progressively harder to write about this family and
harder still to visit them. The events . . . have convinced me
that family interactions definitely increase Shazrin’s
suffering and I am now included against my will in that
process.”
In the end Abdulridha’s increasing alliance with Western
medicine had the effect of stripping away the local beliefs
held by other families McGruder had studied in Zanzibar.
Unlike Kimwana’s family, there was no safe harbor in the
belief that God had sent the illness as a blessing, a burden
to be embraced. Those beliefs were replaced by a set of
ideas that appeared to allow Abdulridha to dehumanize his
sister and justify his harsh control over her life.
The Rise of the Biomedical Narrative in the West
Over the past two generations, Western psychologists and
psychiatrists have promoted the biomedical approach to
mental illness around the world with the argument that
adopting this way of thinking would lessen the stigma
surrounding these conditions. Even patient and family
advocacy groups such as the National Alliance for the
Mentally Ill in the United States and SANE in the United
Kingdom have consistently promoted the idea that mental
illnesses should be viewed as medical illnesses, as
“diseases of the brain.”
Western mental health professionals coined the term
“mental health literacy” to describe the set of ideas they’ve
promoted around the world. Populations are considered
more “literate” if they adopt Western biomedical
conceptions of these diseases. A study from the World
Psychiatric Association, for instance, identified respondents
as “knowledgeable” and “sophisticated” when they
identified schizophrenia as a “debilitating disease.” Another
study portrayed those who endorsed the statement that
“mental illness is an illness like any other” as having a
“knowledgeable, benevolent, supportive orientation towards
the mentally ill.”
The logic seemed unassailable: once people believed that
the symptoms of mental illnesses such as schizophrenia
were not the choice of the individual and did not spring from
supernatural forces, the sufferer would be protected from
blame. The brain disease narrative would make it less likely
that the public would attribute the onset of mental illness to
an individual’s life choices or a weakness of character. In
addition, people would be less likely to connect the difficulty
of recovery to a patient’s lack of personal will or motivation.
By pushing the blame onto the functioning of genes or
broken biochemistry in the brain, the individual could
escape stigma.
Studies show that over the past fifty years the world has
steadily adopted this medical model of mental illness.
Although these changes have happened most dramatically
in the United States and Europe, similar shifts have been
documented around the world. When asked to name the
sources of mental illness, people from every country studied
are increasingly likely to mention “chemical imbalance” or
“brain disease” or “genetics” as part of the cause of mental
illness. These global changes in belief represent a hard-won
victory on the part of mental health care providers, drug
companies, and advocacy organizations.
Unfortunately, as mental health professionals and
advocates for the mentally ill have been winning this
rhetorical and conceptual battle, they’ve been
simultaneously losing the war against stigma. Studies of
attitudes in the United States between the 1950s and 1996
have demonstrated that the perception of dangerousness
surrounding the mentally ill has steadily increased over this
time. Similarly a study in Germany found that the public’s
desire to maintain distance from those diagnosed with
schizophrenia increased between 1990 and 2001.
Researchers hoping to figure out what was causing this
rise in stigma found a startling connection. It turns out that
those who adopted the biomedical and genetic beliefs about
mental illness were most often those who wanted less
contact with the mentally ill or thought of them as
dangerous and unpredictable. This unfortunate cause-and-
effect relationship has held up in numerous studies around
the world. In a study conducted in Turkey, for example,
those who labeled schizophrenic behavior as akil hastaligi
(illness of the brain or reasoning abilities) were more
inclined to assert that schizophrenics were aggressive and
should not live free in the community than those who saw
the disorder as ruhsal hastagi (a disorder of the spiritual or
inner self). Another study, which looked at populations in
Germany, Russia, and Mongolia, found that “irrespective of
place . . . endorsing biological factors as the cause of
schizophrenia was associated with a greater desire for social
distance.” The authors of that study concluded that
“promulgating biological concepts among the public might
not contribute to a desired reduction in social distance
towards people with mental disorders.”
The problem, it appears, is that the biomedical or genetic
narrative about an illness such as schizophrenia carries with
it the subtle assumption that a brain made ill through
biomedical or genetic abnormalities is more thoroughly
broken and permanently abnormal compared to one made
ill though life events. “Genetic arguments may work in an
asymmetric fashion,” wrote researcher Jason Schnittker
from the University of Pennsylvania. “They encourage the
view that mental illness is impersonal and uncontrollable in
its development, but more stable and unyielding in its
course. By the same token genetic arguments inflate
perception of dangerousness in so far as [they imply that]
the mentally ill are always at risk for violence even when
treated. . . . Genetic arguments make the person appear
even more ‘at risk’ and threatening.”
In a dramatic experiment, Professor Sheila Mehta from
Auburn University in Montgomery, Alabama, effectively
answered the question of how these beliefs about mental
illness can translate into behaviors between people. In her
study, subjects were led to understand that they were
participating in a simple learning task with a partner, who
was actually a confederate in the study. Before the
experiment started, the two partners exchanged some
biographical data, during which the confederate told the
test subject that he suffered from a mental illness.
Confederates then stated either “[The illness occurred due
to] some things that happened to me as a kid” (the
psychosocial explanation) or “I had a disease just like any
other which affected my biochemistry” (the disease
explanation). The learning experiment called for the test
subject to supposedly teach the confederate a certain
pattern of button presses. The only feedback the test
subject could give to incorrect button pushes was a mild to
“somewhat painful” electrical shock.
Analyzing the data, Mehta found a dramatic difference
between the group of subjects given the psychosocial
explanation for their partner’s mental illness history and
those given the brain disease explanation. Those who
believed that their partner suffered an “illness like any
other” increased the severity of the shocks at a faster rate
than those who believed they were partnered with someone
who had a mental disorder caused by childhood events.
Mehta concluded, “The result of the study suggests that we
may actually treat people more harshly when their problem
is described in disease terms. . . . We say we are being kind
but our actions suggest otherwise. . . . The disease view
engenders a less favorable estimation of the mentally
disordered than the psychosocial view.” She added,
“Viewing those with mental disorders as diseased sets them
apart and may lead to our perceiving them as physically
distinct. Biochemical aberrations make them almost a
different species.”
Indeed it was just this dynamic that McGruder witnessed
between Shazrin and her brother. Remarkably, despite more
than forty years of evidence suggesting that the biomedical
or brain disease belief increases stigma, the Western mental
health professionals continue to promote these ideas with
vigor.
Just Chemistry
One afternoon McGruder took me to the Kidongo Chekundu
Mental Hospital, a few miles from downtown Stone Town.
The compound was made up of several single-story white
stucco structures with tiled roofs surrounding a large
courtyard. There was an intake area where patients and
their families sat on benches waiting to be seen, a
documents room, and an area where meals were prepared
over a wood fire. McGruder showed me the occupational
therapy room she had helped establish many years ago.
Hundreds of paintings and drawings by former patients
hung on the wall.
The facility for housing the patients was separated into an
open ward for patients considered to be of no danger to
themselves or others and two locked areas for the women
and men who were more seriously disturbed. In the
courtyard I talked with a young man who was lighting a
small cooking fire to boil water for tea. His English was
perfect, with an American accent. I assumed he was a
doctor or a caretaker until he told me he had come from the
mainland for a long stay at the hospital while the doctors
attempted to find the right balance of medication for his
manic depression. He was excited to talk to me. He had
gone to college in Arizona and had fond memories of the
States.
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 a barred window talked animatedly
at me in Kiswahili. Behind them I could see a half dozen
other men in the open area. Some were sleeping, and others
rocked restlessly.
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. But as I later
thought of my brief visit to the locked ward at Kidongo
Chekundu I began to wonder about the meaning behind
these certainties.
If you ask me what it means that schizophrenia is related
to genes, for instance, I will say that people with a family
history of schizophrenia are at greater risk. Although this
appears to be statistically true, that is pretty much the
extent of my actual knowledge on the topic of the genetic
precursors to schizophrenia. My scientific understanding of
abnormalities in brain chemistry related to the disease is
similarly limited. So although I deeply believe that the
biomedical explanation for mental illness is likely true, that
certainty does not come with a degree in biochemistry or
genetics.
If these beliefs have so little weight, why do I continue to
hold to them so tightly? Beliefs about mental illness—and
this is as true in the United States as it is in Zanzibar—are
first and foremost testaments to group membership. By
attesting to my biomedical orientation, I am placing myself
in that group of people who I believe have a “sophisticated”
and “knowledgeable” orientation to the mentally ill. I am
placing myself in the group of doctors, biomedical
researchers, clinicians, and scientists. Note that, unlike the
spirit possession belief common in Zanzibar, the group I’m
affiliating myself with does not include the mentally ill
themselves.
Aside from their objective truth or falsehood, one
meaningful way to compare cultural beliefs about mental
illness is to ask this simple question: Which cultural beliefs
tend to exclude the sufferer from the social group and which
allow the ill individual to remain part of the group?
Accounts written by patients themselves and their loved
ones make it clear just how stigmatizing the biomedical
explanation can be. Here, for example, is D. A. Granger
writing of his experiences years after being diagnosed with
schizophrenia in his first year of Harvard Medical School:
I have spent years . . . clinging to the understanding that I was a defective
biological unit. . . . This may truly be a valuable perspective for those who
observe mental illness, but for me, as a subject, this tree bore only dry and
tasteless fruit. . . .
I have a chemical imbalance; I really didn’t feel those things.
I have a chemical imbalance; I didn’t really experience those things.
I have a chemical imbalance; I didn’t really think those things . . .
Here is an insight! The entire human drama of love, suffering, ecstasy, and
joy, just chemistry.
Jay Neugeboren, writing about his schizophrenic brother,
similarly asked, “[If he] . . . doesn’t hold onto his illness and
its history as a legitimate, real and unique part of his
ongoing self—what of him, at fifty-two years old, will be
left?”
We ask people diagnosed with schizophrenia and those
who love and care for them to adopt the brain chemistry
narrative without consideration of the cost: the devaluing of
the perceptions that make up the ill individual’s very sense
of self. Indeed, as Granger suggests, the fact that healthy
people do not dwell on the “brain chemistry” story as an
explanation for their own moods and feelings should be an
indication of how unappealing and dehumanizing the idea
is. When we fall in love, get jealous, feel the joy of playing
with a child, or experience religious ecstasy we do not
describe the experience to friends as a fortunate or
unfortunate confluence of brain chemicals. Yet we continue
to suggest that the narrative of brain chemistry will be
useful in lessening the stigma associated with a mentally ill
person. What could be more stigmatizing than to reduce a
person’s perceptions and beliefs to the notion that they are
“just chemistry”? It is a narrative that often pushes the ill
individual outside the group, allowing those who remain in
the social circle to, as Mehta observed, view the ill person as
“almost a different species.”
What We Can and Can’t Learn
I asked McGruder on several occasions what we might learn
from her research on schizophrenia in Zanzibar. She offered
various possible lessons, the most obvious being a
cautionary one. Simply put, we might reconsider our
interventions in the parts of the world that appear to have
better outcomes than we can manage in the industrialized
world.
But coming away with only that warning was unsatisfying.
It is part of my American character that I’m not much
interested in being told what not to do. Like those highly
emotionally involved caretakers, I’m interested in how to fix
the problem. I wanted a positive take-away message, some
recommendation for action or change. So I kept pestering
McGruder, trying to get her to be prescriptive. What had she
learned from her Zanzibari research that we might be able
to use in the United States to help the mentally ill?
One late afternoon, a week into my visit to Zanzibar,
McGruder and I were sitting in her small apartment in Stone
Town waiting for Kassim to get back from the final day of
mourning his daughter. McGruder was folding laundry. By
this point in the trip we had an easy rapport, although I was
feeling like a houseguest who had overstayed. I turned on
my tape recorder and again quizzed her on what we might
learn from the way the locals address and deal with serious
mental illness. Instead of answering the question on a
theoretical level, this time she told me a story.
After she and her former husband, an African American
whom I’ll call Ed, returned from her year of research in
Zanzibar they had difficulty settling back into their American
lives. McGruder was back teaching and trying to bang out
her dissertation. Their marriage was in a rough patch and
they fought about money.
Ed, McGruder told me, had been discontent since
returning from Africa. He tried out a couple of different
businesses but struggled to get them off the ground. At
some point he got hooked up with an aggressive multilevel
financial marketing group. He went to seminars that were
like revival meetings, where motivational speakers told the
attendees that they could achieve financial success by
selling the company’s life insurance and recruiting others
into the business. McGruder sensed it was a shady outfit—
their promises were too good to be true—but she deeply
wanted her husband to find success and happiness. At the
same time Ed started a janitorial business. With McGruder’s
help he bought a van and cleaning supplies and he landed
some contracts with area restaurants. “He was running full
speed, night and day,” McGruder told me. “At the same time
we were going ever further into debt because we were
throwing money at the startup costs of the businesses.”
Around this time McGruder went to a conference in
Philadelphia. While she was away she had trouble getting Ed
on the phone, which was unusual. When she landed at Sea-
Tac, he came to the airport to pick her up and they went out
to dinner. Ed didn’t say much at dinner and seemed to be in
an unusually somber mood. When they got home McGruder
came down with something like food poisoning. Looking
back, she wonders whether her body was picking up on
something her mind couldn’t yet accept.
The next morning Ed told her that he was going out. She
said she was going to stay in bed and try to get some rest.
Hours went by and he didn’t return. At one that afternoon
the police called and informed her that her husband’s car
had been abandoned on a local street with the motor
running and doors opened.
Fearing that he had been the victim of a robbery,
McGruder immediately got on the phone and called some
friends for help. After retrieving the car, she called the
hospitals and police stations, asking if there were any
reports of injured people. It was more than twenty-four
hours before they discovered that Ed had been arrested and
had spent the night in the Pierce County Jail howling
incoherently and ripping his clothes to shreds.
McGruder later pieced together the missing hours. After
abandoning the car, Ed had jogged down the middle of a
busy street. After that he switched to the railroad tracks,
walking more than ten miles to the nearby town of
Lakewood. Once there he entered someone’s backyard,
climbed into the bed of a pickup, and started throwing the
contents all over the lawn. “These are the kinds of things
people do when they have mania of psychotic proportions,”
McGruder told me. “They just don’t make any sense and
they can’t explain to you why it seemed like a good idea at
the time.”
It took a full day to find Ed in the legal system because he
had thrown away his identification and when asked his
name would only say, “They call me Mr. Edwards.”
McGruder immediately understood this. “Mr. Edwards” was
the name he was called by friends and neighbors during
their stay in Zanzibar.
Once she found him, McGruder spent the rest of the day
figuring out how to get him out on bail. After finishing the
paperwork, she was told to go home and wait for a phone
call, which she did. Late that afternoon her husband showed
up at the door. He had been released, but no one had called
her to pick him up. He had walked miles in freezing rain in
nothing but a jail-issued jumpsuit.
She put him in a warm bath, where he rocked back and
forth alternately crying and laughing. She tried to calm him
and get him to sleep but he was restless and confused. She
stayed up with him as late as she could but finally fell
asleep herself. She woke to find Ed on a rampage. He had
pulled out several saplings in the backyard and was in the
middle of knocking everything off shelves in the kitchen and
living room.
She called friends to come over and help calm Ed down
and keep him from tearing apart the rest of the house. They
tried to convince him that he needed to see a doctor, but he
didn’t seem to comprehend what they were saying. At times
he would go blank; at other times he would howl and make
animal noises. Finally the friends distracted Ed while
McGruder called for help.
Having taught many classes on mental health and the
law, McGruder believed she knew the system she was
entering. She understood, for instance, that in order for Ed
to be put in the hospital against his will she had to attest
that he posed a danger to people or property. That part of
the process turned out to be easy, and Ed was admitted into
Puget Sound Hospital. Knowing what to say to get him out
proved to be the hard part.
The next day McGruder went to the hospital. It was a
rundown place. (It would soon be shut down by the Health
Department for multiple violations, including chronic
overcrowding, sexual assault in the mental wards, and dead
bugs and mouse droppings in a supposedly sterile supply
room.) Like many acute psychotic manias, Ed’s suddenly
ebbed. He was now calm and spoke rationally, telling
McGruder that he was afraid to stay in the hospital. He said
he was ready to go home and start seeing a doctor for his
illness. McGruder was certain he had a better chance of
regaining his balance if she could manage his behavior
outside the hospital. She thought, “Okay, let’s get him out of
this place.”
But the system she had triggered was not ready to let him
go. Over the next two weeks she struggled with doctors,
lawyers, and judges. The first doctor she met with wanted to
start Ed on five different psychiatric medications at once.
McGruder knew that he could be helped by medication but
argued for a more conservative approach. She was
particularly put off by the judge at the commitment hearing,
who appeared to be making assumptions based on Ed’s
race. “Has a toxicology screen been done on this man?” he
asked repeatedly, even though there was no indication that
the mania had been drug-induced.
Her reaction to the crisis couldn’t have been more distinct
from Amina’s passive acceptance. McGruder was a
passionate advocate for her husband at every turn. She
could tell that she annoyed many of the doctors, lawyers,
nurses, and clerks she interacted with. “They treated me
like a nuisance for the most part,” she remembers. “They
treated me like I was emotionally overinvolved.”
In the end, the insights she had gained while studying
mental illness in Zanzibar were of little help. She was back
in her own culture, and many of the Zanzibari beliefs and
practices she had witnessed and so carefully documented
simply didn’t apply. This was true down to the level of
simple logistics. McGruder and her husband lived alone and
had no close kinship groups on which they could rely. They
had devoted friends, but those friends all had jobs and other
commitments and most lived dozens of miles away; they
couldn’t be counted on to care for or watch over Ed for
significant periods of time. McGruder and her husband were,
for the most part, alone with their burden.
McGruder did try one gambit. Ed had once been a
religious man, and he began to believe that his psychotic
break might have been part of God’s plan. Perhaps, he
suggested, God had caused the psychotic break because He
wanted McGruder to better understand mental illness. “I
thought that that was a little egocentric to believe that God
up in heaven decided, ‘She needs a little more insight,’”
McGruder recalled. “But I said okay, if Ed thinks it’s helpful
for us to consider this possibility, I’m cool with that. That is
useful. My experience in Zanzibar helped me avoid saying
‘That’s a crock of shit.’”
She offered to start going to church with Ed, but the
religious narrative she tried to help create was an
ineffective balm. Religion is a difficult palliative to employ
on an as-needed basis. It either exists in one’s life and
surrounding culture, shaping one’s conception of the self, or
it does not. For Amina and her family, religion and spiritual
belief permeated their lives in the same way the Koranic
chants of the schoolchildren washed over their household.
McGruder and her husband had no such ambient, pervasive
faith to rely on, and, not surprisingly, the Christian beliefs
McGruder and her husband belatedly tried to adopt proved
to be of little comfort.
Try as she might, McGruder couldn’t mimic the calm
acquiescence Amina managed. Instead she found herself
constantly monitoring Ed’s behavior for signs of his mental
illness. When he left the cap off the toothpaste, she found
herself wondering, “Is he unable to put the cap back on
because his mind is running too fast?” She began to
reconsider their whole life together. She second-guessed her
fond memories from their first years of dating. Had he been
so charming and fun to be with because he was prone to
mania? In the end the marriage failed under the pressure of
Ed’s illness. “Once you start looking at a loved one through
the lens of a Western psychiatric diagnosis,” McGruder said,
“it is really hard to stop.”
When McGruder finished telling me this story she was
sitting on the daybed in the living room in complete
darkness. The sun sets fast near the Equator, and the
electricity had been out on the entire island for over a week.
The air was hot and still. We sat for a time listening to the
sound of footsteps echo up from the stone alleyways
outside the apartment window.
“The Hallmark movie ending would be that I had learned
something about mental illness in Zanzibar that I was able
to use in my own time of crisis,” McGruder said. “But stories
of mental illness don’t often have Hallmark endings.”
The Transliteration
After traveling back to the United States, I kept in touch with
McGruder by email. Every so often I would ask after her
partner, Kassim, to see how he was dealing with the loss of
his daughter. McGruder admitted in this correspondence
that she herself was still trying to figure out what was going
on inside his head. Despite everything she knew about
different emotional expressions between cultures, she
couldn’t help but be concerned about his emotional flatness
in the days after his daughter’s death.
McGruder told me that a few days after the funeral she
overheard a phone call Kassim received from a relative who
had just heard about the death and wanted to travel from
mainland Tanzania to offer her condolences. McGruder
listened as he told the relative “Tumeshapao,” meaning “We
have already cooled down” or “We have healed, we are
okay.” When he hung up the phone, McGruder felt
compelled to ask him if he really had already healed. Unable
to read his outward emotions, she wanted to know whether
he felt he was still grieving. She had not witnessed him
weep over his daughter’s death.
He explained that in the phone call he was only trying to
save the relative the cost and trouble of traveling to the
island. He told McGruder that he thought of his daughter
often but was comforted by the fact that he had performed
all of the religiously required rituals after her passing. Her
body had been properly wrapped in a winding cloth and
sewn into a flexible reed mat. He had carried her to the
cemetery and had gotten down into the grave and arranged
her body so that she was lying on her side, facing Mecca.
Later, in a different conversation, he told McGruder that
since his daughter’s death he had been unaccountably
waking in the middle of the night, at about the time he got
the telephone call, and had trouble getting back to sleep.
When he finally did sleep again he was assaulted with vivid
and disturbing dreams.
McGruder wondered whether his unexpressed grief was
souring into depression. Kassim had a different explanation.
He believed he had picked up some troubling spirits while at
the graveyard burying his daughter. A few days later he
went to a Koran school and paid a small fee to have a group
of boys sing some Arabic prayers to the soul of his daughter.
The teacher at the Koran school gave him a transliteration
of the prayers so that he could pronounce the Arabic words
in Kiswahili. After that, every night he recited the prayer in
words he could not understand and slept soundly.
4
The Mega-Marketing of Depression
in Japan
One of the chilling things about these events, whether a
puzzle or a scandal, is how a very few people in key
positions can determine the course of events and shape the
consciousness of a generation.
DAVID HEALY
I went to visit Dr. Laurence Kirmayer in his book-lined office
at McGill University in Montreal because he had a
particularly good story to tell. I’d heard that a few years
ago, Kirmayer had a personal brush with the pharmaceutical
giant GlaxoSmithKline and the remarkable resources that
the company employed to create a market for their
antidepressant pill Paxil in Japan.
In person Kirmayer is the picture of a tweedy academic.
He speaks in complete paragraphs in a deep authoritative
voice. He has a large head and a broad face that is covered
nearly to the cheekbones in a thick light-gray beard. His
slightly wandering left eye suits his demeanor. If you look at
the left side of his face his expression is attentive and
focused on the conversation. If you look at the right side of
his face he appears to be looking past you into the middle
distance, as if searching for a word or pondering a thought.
In telling his story of being feted by GlaxoSmithKline,
Kirmayer likes to point out that he is unaccustomed to the
trappings of great wealth. Not that he’s doing badly. As the
director of the Division of Social and Transcultural Psychiatry
at McGill, he makes a respectable living and adds to his
income with a private psychiatric practice. As editor in chief
of the journal Transcultural Psychiatry, he is well known in
certain circles and can draw a crowd of admiring grad
students and colleagues at an anthropology or mental
health conference. But to get to those conferences he flies
coach.
It was in the fall of 2000, as he tells it, that he came to
understand just how un spectacularly rich he was. That was
when he accepted an invitation from something called the
International Consensus Group on Depression and Anxiety
to attend two all-expenses-paid conferences, the first in
Kyoto and the second a few months later on the shores of
Bali.
Accepting the invitation didn’t at first seem like a difficult
decision. Although he knew that the conference was
sponsored by an educational grant from the drug maker
GlaxoSmithKline,* such industry funding wasn’t unusual for
academic conferences in the field of psychiatry. When he
checked out the list of other invitees, he recognized all the
names. It was an extremely exclusive group of highly
influential clinicians and researchers from France, the United
States, and Japan, among other countries. The topic,
“Transcultural Issues in Depression and Anxiety,” was right
up his alley. Even better, he had an eager young graduate
student named Junko Kitanaka who was in Japan finishing
her dissertation on the history of depression in the country;
such a gathering of luminaries would be a boon to her
research. In addition to those incentives, attendees would
be given the chance to publish their presentations in a
supplement of the prestigious Journal of Clinical Psychiatry.
“I wouldn’t say it was a no-brainer, but it wasn’t very hard
for me to say yes,” Kirmayer remembers. “How much
trouble could I get in?”
His first inkling that this wasn’t a run-of-the-mill academic
conference came when the airline ticket arrived in the mail.
This ticket was for a seat in the front of the plane and cost
nearly $10,000. The next hint came when one of the
conference organizers told him in no uncertain terms that
these would be closed-door meetings. His grad student,
Kitanaka, would not be allowed to attend. There would be no
uninvited colleagues and no press.
On arrival in Kyoto in early October 2000 he found the
luxury of the accommodations to be beyond anything he
had personally experienced. He was ushered into an
exclusive part of the hotel, where he was given a drink while
an attractive woman filled out the hotel forms. His room was
a palatial suite. The bath was drawn and strewn with rose
petals and dosed with frangipani oil. There was a platter on
the credenza filled with fruits so exotic that he could identify
only the mangosteens.
“This was Gordon Gekko treatment—the most deluxe
circumstances I have ever experienced in my life,” Kirmayer
says, smiling at the memory. This was how the other half
lived, he realized—or, rather, how the other .01 percent
lived. “The luxury was so far beyond anything that I could
personally afford, it was a little scary. It didn’t take me long
to think that something strange was going on here. I
wondered: What did I do to deserve this?”
Kirmayer was well aware that drug companies routinely
sponsor professional conferences and educational seminars
and that these events do double duty as marketing
seminars. It was also common knowledge that drug makers
use enticements to encourage both researchers and
practitioners to attend. A prescribing doctor might be
treated to a round of golf or a fancy dinner in exchange for
attending an hour-long seminar about the effectiveness of
some new drug. These practices are the medical equivalent
of what real estate agents do to sell vacation timeshares.
But it was clear from the start that the gatherings of the
International Consensus Group on Depression and Anxiety
were different from the normal drug company dog and pony
show, and not simply because the enticements being
offered were so dear. Once the group of academics actually
gathered in a plush conference room and began their
discussions, Kirmayer realized quickly that the
GlaxoSmithKline representatives in attendance had no
interest in touting their products to the group. Indeed there
was little mention of the company’s antidepressant drug
Paxil, which was just a few months away from hitting the
market in Japan. Instead they seemed much more interested
in hearing from the assembled group. They were there to
learn. “The focus was not on medications,” Kirmayer
remembers. “They were not trying to sell their drugs to us.
They were interested in what we knew about how cultures
shape the illness experience.”
As Kirmayer got to know them during the conference, he
realized that the drug company representatives weren’t
from the ranks of the advertising or marketing departments
or the peppy salespeople. As best he could tell, these were
highly paid private scholars who could hold their own in the
most sophisticated discussion of postcolonial theory or the
impact of globalization on the human mind. “These guys all
had PhDs and were versed in the literature,” Kirmayer said.
“They were clearly soaking up what we had to say to each
other on these topics.”
The intense interest the GlaxoSmithKline brain trust
showed in the topic of how culture shapes the illness
experience made sense given the timing of the meeting.
The class of antidepressant drugs known as selective
serotonin reuptake inhibitors (SSRIs) had become the
wonder drug of the 1990s, at least in terms of the profits
they’d garnered for the drug companies. That year alone, in
the leading regions for SSRIs, sales grew by 18 percent and
totaled over thirteen billion dollars. Most of those sales were
still in the United States, but there was wide agreement that
lucrative international markets had yet to be tapped.
Indeed it was somewhat remarkable that none of the best-
selling SSRIs had been launched in Japan. This was more
than twelve years after Prozac became available for
prescription in the United States. What caused this
uncharacteristic timidity on the part of these
pharmaceutical giants? It certainly wasn’t that the Japanese
eschewed Western drugs. To the contrary, U.S.-based
companies at the time were exporting upwards of fifty
billion dollars in medications to the country each year. It was
said that Japanese patients felt underserved if they didn’t
come away from a doctor’s visit with at least a couple of
prescriptions.
But Eli Lilly, then the out-front world leader in the SSRI
horse race with Prozac, had decided in the early 1990s not
to pursue the Japanese market because executives in the
company believed that the Japanese people wouldn’t accept
the drug. More precisely, they wouldn’t want to accept the
disease. “The people’s attitude toward depression was very
negative,” explained a spokeswoman for Eli Lilly to the Wall
Street Journal. She was referring to the fact that the
Japanese had a fundamentally different conception of
depression than in the West, one that made it unlikely that a
significant number of people in Japan would want to take a
drug associated with the disease.
Most other SSRI manufacturers followed Eli Lilly’s lead and
held off as well. Getting drugs approved in Japan was a
costly gamble. The rules at the time required that drugs
already on the market in Western countries had to be
retested in large-scale human trials using an exclusively
Japanese population. That meant years of effort and millions
of dollars spent, with the distinct possibility that the drug
might fail the trial. No company wanted to make such an
investment if no market existed for the drug.
The Japanese pharmaceutical company Meiji Seika was
the first to break from the pack, working through the decade
to run Japanese trials on the SSRI Luvox, which it had
licensed from the Swedish company Solvay. After reading
Peter Kramer’s 1993 book Listening to Prozac, Meiji’s
president, Ichiro Kitasato, sensed an unexplored opportunity
in the Japanese marketplace. “People in the company said
there are too few patients in Japan,” he told a reporter in
1996. “But I looked at the U.S. and Europe and thought this
is sure to be a big market.”
GlaxoSmithKline was the next to get in the race. In the
years prior to the 2000 conference in Kyoto, the company
had spent an immense amount of money and resources
jumping through the regulatory and bureaucratic hoops to
get the green light to put Paxil on the market in the country.
Having watched Prozac dominate the American market in
the late 1980s, drug company executives knew the
advantages of early market share, and GlaxoSmithKline
didn’t want Luvox to be the only SSRI in Japan.
But both companies faced the same problem: there was
no guarantee that Japanese doctors would prescribe the
drug or that the population would be interested in taking it.
The problem was that the profession of psychiatry in Japan,
unlike in the West, seldom ministered to the walking
worried; rather they focused almost exclusively on the
severely mentally ill. Consequently, talk therapy was all but
nonexistent in the country. For the small percentage of the
population diagnosed with a debilitating mental illness, long
hospital stays were the norm. The average stay in a mental
hospital in Japan was over a year, versus just ten days in the
United States. So although there was a psychiatric term for
depression in Japan, utsubyô, what it described was a
mental illness that was as chronic and devastating as
schizophrenia. Utsubyô was the sort of illness that would
make it impossible to hold down a job or have a semblance
of a normal life. Worse yet, at least for the sales prospects
of Paxil in Japan, utsubyô was considered a rare disorder.
At the Kyoto meeting Kirmayer began to understand the
company’s intense interest in the question of how cultures
shape the illness experience. To make Paxil a hit in Japan, it
would not be enough to corner the small market of those
diagnosed with utsubyô. The objective was to influence, at
the most fundamental level, the Japanese understanding of
sadness and depression. In short, they were learning how to
market a disease.
To have the best chance of shifting the Japanese public’s
perception about the meaning of depression,
GlaxoSmithKline needed a deep and sophisticated
understanding of how those beliefs had taken shape. This
was why, Kirmayer came to realize, the company had
invited him and his colleagues and treated them like royalty.
GlaxoSmithKline needed help solving a cultural puzzle that
might be worth billions of dollars.
Judging from the records of the conference, it’s clear that
the company got its money’s worth. During the meetings
eminent scholars and researchers gave insightful
presentations on subjects ranging from the history of
psychiatry in Japan to the Japanese public’s changing
attitudes about mental illness. The prominent Japanese
psychiatrists in attendance were particularly helpful in
framing the state of the public’s current beliefs about
depression and anxiety disorders.
Osamu Tajima, a professor at the Department of Mental
Health at Kyorin University and a leading Tokyo psychiatrist,
told the assembled group of a rising public concern about
the high suicide rates in Japan. He described how dozens of
middle-aged men each year hike deep into the so-called
suicide forests in the foothills of Mt. Fuji with lengths of rope
to hang themselves. He described how service along the
Central Line Railway in Tokyo was routinely disrupted by
office workers leaping in front of commuter trains.
Tajima also gave a detailed description of how psychiatric
services were structured within the overall health care
apparatus of Japan. Services were in the midst of a critical
change, he reported. There was a burgeoning concern in the
population about mood disorders and the need for social
attention to suicide rates and depression. He also
documented how the Western definition and symptom
checklist for depression—thanks to the influence of the DSM
in the profession—was steadily gaining ground among
younger psychiatrists and doctors in Japan. “Japanese
psychiatry is undergoing a period of important change,” he
concluded, which was certainly good news for
GlaxoSmithKline. He was upbeat about the changes
heralded by the standardization of psychiatry around the
world. “Adoption of internationally standardized diagnostic
criteria and terminology in psychiatry will provide additional
advances in assessing prevalence and facilitating accurate
diagnosis.” He was also clearly impressed with the scientific
advances in drug treatments that were soon to come to his
country. “New and effective treatment options,” he said,
“most notably the SSRIs, will contribute to reducing the
burden of depression and anxiety disorders in Japanese
society.”
After lunch on the second day of the conference, it was
Kirmayer’s turn to speak. He had written many papers in his
career documenting the differing expressions of depression
around the world and the meaning hidden in those
differences. He had found that every culture has a type of
experience that is in some ways parallel to the Western
conception of depression: a mental state and set of
behaviors that relate to a loss of connectedness to others or
a decline in social status or personal motivation. But he had
also found that cultures have unique expressions,
descriptions, and understandings for these states of being.
He told the assembled scholars and drug company
representatives of how a Nigerian man might experience a
culturally distinct form of depression by describing a
peppery feeling in his head. A rural Chinese farmer might
speak only of shoulder or stomachaches. A man in India
might talk of semen loss or a sinking heart or feeling hot. A
Korean might tell you of “fire illness,” which is experienced
as a burning in the gut. Someone from Iran might talk of
tightness in the chest, and an American Indian might
describe the experience of depression as something akin to
loneliness.
Kirmayer had observed that cultures often differ in what
he called “explanatory models” for depression-like states.
These cultural beliefs and stories have the effect of directing
the attention of individuals to certain feelings and
symptoms and away from others. In one culture someone
feeling an inchoate distress might be prompted to search for
feelings of unease in his gut or in muscle pain; in another
place or time, a different type of symptom would be
accepted as legitimate. This interplay between the
expectations of the culture and the experience of the
individual leads to a cycle of symptom amplification. In
short, beliefs about the cause, symptomatology, and course
of an illness such as depression tended to be self-fulfilling.
Explanatory models created the culturally expected
experience of the disease in the mind of the sufferer. Such
differences, Kirmayer warned the group, tended to be
overlooked when clinicians or researchers employed the
symptom checklists relating to the DSM diagnosis of
depression.
Understanding these differences is critical, however,
because culturally distinct symptoms often hold precious
clues about the causes of the distress. The American Indian
symptom of feeling lonely, for instance, likely reflects a
sense of social marginalization. A Korean who feels the
epigastric pain of fire illness is expressing distress over an
interpersonal conflict or a collective experience of injustice.
The wide variety of symptoms wasn’t the only difference.
Critically, not everyone in the world agreed that thinking of
such experiences as an illness made sense. Kirmayer
documented how feelings and symptoms that an American
doctor might categorize as depression are often viewed in
other cultures as something of a “moral compass,”
prompting both the individual and the group to search for
the source of the social, spiritual, or moral discord. By
applying a one-size-fits-all notion of depression around the
world, Kirmayer argued, we run the risk of obscuring the
social meaning and response the experience might be
indicating.
Indeed, around the world, it is the Western conception of
depression, in particular the American version of the
disease, that is the most culturally distinctive. Kirmayer told
the group that Americans are unique both in being willing to
openly express distressful emotions and feelings to
strangers and in our penchant for viewing psychological
suffering as a health care issue. Because people in other
cultures find social and moral meaning in such internal
distress, they often seek relief exclusively from family
members or community elders or local spiritual leaders. The
idea of seeking help from a doctor or mental health
professional outside one’s social circle has traditionally
made little sense.
The drug company representatives listened closely to
Kirmayer’s presentation and thanked him heartily afterward.
To this day, he’s not entirely sure what they took away from
his presentation. In the end Kirmayer’s comments could
have been taken in two ways. On the one hand, they could
be seen as a warning to respect and protect the cultural
diversity of human suffering. In this way, he was like a
botanist presenting a lecture to a lumber company on the
complex ecology of the forest. On the other hand, he might
have told the GlaxoSmithKline representatives exactly what
they wanted to hear: that cultural conceptions surrounding
illnesses such as depression could be influenced and shifted
over time. He made that point clearly in the conclusion of
the paper he wrote based on his presentation:
The clinical presentation of depression and anxiety is a function not only of
patients’ ethnocultural backgrounds, but of the structure of the health care
system they find themselves in and the diagnostic categories and concepts
they encounter in mass media and in dialogue with family, friends and
clinicians.
In the globalizing world, he reported, these conceptions are
in constant transaction and transformation across boundaries of race,
culture, class, and nation. In this context, it is important to recognize that
psychiatry itself is part of an international subculture that imposes certain
categories on the world that may not fit equally well everywhere and that
never completely captures the illness experience and concerns of patients.
In other words, cultural beliefs about depression and the self
are malleable and responsive to messages that can be
exported from one culture to another. One culture can
reshape how a population in another culture categorizes a
given set of symptoms, replace their explanatory model,
and redraw the line demarcating normal behaviors and
internal states from those considered pathological.
Kirmayer’s appreciation of the irony of his brief encounter
with GlaxoSmithKline has only grown over the years since
he gave that presentation. “People like me got into cultural
psychiatry because we were interested in differences
between cultures—even treasured those differences in the
same way a biologist treasures ecological diversity,”
Kirmayer told me. “So it’s certainly ironic that cultural
psychiatrists sometimes end up being handmaidens to
these global marketing machines that are intent on
manipulating cultural differences . . . in order to capitalize
on those changes.”
I asked Kirmayer how clear it was to him that
GlaxoSmithKline was interested in changing notions of
depression in Japan. “It was very explicit. What I was
witnessing was a multinational pharmaceutical corporation
working hard to redefine narratives about mental health,”
he said. “These changes have far-reaching effects, informing
the cultural conceptions of personhood and how people
conduct their everyday lives. And this is happening on a
global scale. These companies are upending long-held
cultural beliefs about the meaning of illness and healing.”
The consensus paper produced to summarize the Kyoto
conference provided both an action plan and a marketing
piece for GlaxoSmithKline. In that paper the International
Consensus Group on Depression and Anxiety warned that
depression was vastly underestimated in Japan but that
Western scientific advances would soon be on hand to help.
“Clinical evidence supports the use of SSRIs as first-line
therapy for depression and anxiety disorders,” the paper
concludes.
Looking back, Kirmayer can now see how the company
used the conference as the beginning of its broader
marketing strategy; its representatives identified the
cultural challenges and fleshed out the resonant cultural
notes the company would attempt to play in the critical
coming months and years. Among those themes were that
suicide in Japan was an indicator of undertreated
depression; that Western SSRIs represented proven
scientific advances in treatment; that primary care
physicians should use simple three-minute surveys to help
diagnose mental illness; that patients not meeting the
criteria for depression should still be considered sick; and
that the Japanese should be helped to reconceive social
stress related to work and industrialization as signs of
depression that should be treated with SSRIs. These
confident conclusions would prove the foundation on which
GlaxoSmithKline would begin to change the culture of Japan.
Psychiatry in the Time of Cholera
The rapid rise of the depression narrative in Japan, which
took place over the next few years, is remarkable in many
respects. The marketing campaign of GlaxoSmithKline and
other SSRI makers set off a seismic shift in the culture, the
aftershocks of which are still being felt. And just as
earthquakes are the expression of tectonic pressures that
build slowly over decades, there were unseen forces in the
cultural history of Japan that laid the groundwork for Glaxo-
SmithKline’s remarkable success.
To understand how GlaxoSmithKline was so successful in
selling depression in Japan at the beginning of this
millennium, it’s important to spend some time with a guide
who knows the historical lay of the land. Ironically the
person who best understands the cultural history of
depression in Japan turns out to be none other than Junko
Kitanaka, the grad student who was barred from the
conference in 2000. In the years since, she finished her
award-winning dissertation, “Society in Distress: The
Psychiatric Prod-uction of Depression in Contemporary
Japan,” and has taken up an associate professorship at Keio
University, often called “the Harvard of Japan.”
A visitor to the university will quickly notice that Keio’s
architects were intent on giving the place an Oxford–Ivy
League flavor. At the Mita campus where Kitanaka works,
campus gates are set in arches in red brick buildings and
paths run into open courtyards filled with huge ginkgo trees
that turn a luminescent yellow in the fall. As the style of the
architecture suggests, Western influence on Japanese
academia, particularly science and medicine, is hardly new.
When I asked Kitanaka how far back in time it was
necessary to go to begin tracking the Western influence on
mental health trends in Japan, she suggested that a good
starting point was the mid-nineteenth century. This was
when ideas of German neuropsychiatry and notions of
neurasthenia—the disease of frayed nerves—first began to
filter into Japanese professional and popular culture.
Cultures are most susceptible to outside ideas about the
nature of the human mind at times of social change and
upheaval, and the second half of the nineteenth century
was just such a time in Japan. The Edo era—the rule of the
shogun warlords—was at an end. For the previous 250 years
Japan had stayed relatively isolated from many cultural
trends and forces in the West, including those in science and
medicine. During the long Edo era the population of Japan
had thought of health mostly in terms of yojo, a set of
concepts imported from China sometime between the
seventh and tenth centuries. Yojo connected health with
diet, mental control, exercise, and sexual restraint. It
focused less on the control of disease or longevity and more
on issues of social health, including morality, culture, and
education.
During this time the concept that most closely tracked
modern notions of depression would have been utsushô,
which described the stagnation of vital energy, or qi. This
stagnation or blockage could come from a combination of
emotions, social conflict, loss, or the changing physiology of
the body. Critically, however, utsushô was not thought of as
an illness. As portrayed in plays and popular books of the
time, utsushô described a nonpathological—indeed, a
respected—way of being. The person affected by utsushô
was not considered sick and did not necessarily seek a cure
for his symptoms; rather it was expected that those affected
would have to look for the social or moral meaning in their
distress.
As the rule of the shoguns was replaced with that of the
emperor, Japan began to open up to ideas from Europe and
the United States. The Japanese public’s acceptance of
psychiatry as a legitimate field of science and mental health
largely paralleled the growing influence of Western
medicine.
It was the cholera epidemics, which began in 1859 and
plagued the nation for the rest of the century, that were
critical in breaking the hold of the yojo beliefs regarding
health. These deadly epidemics terrified the population.
Thousands died. The sick and those thought to be infected
were hauled away to hospitals under police guard. Whole
neighborhoods were sealed off and quarantined. According
to Kitanaka, the state used the outbreaks to justify the
creation of an imposing network of local government
controls that claimed authority from Western advances in
medicine. Improvements in sanitary conditions and public
hygiene did appear to limit the cholera epidemics, and the
success was taken as proof that European and Western
knowledge about health and illness had validity. Traditional
beliefs surrounding yojo were increasingly replaced by
newer ideas of eisei, which encouraged the population to
think of health as something that must be actively and
carefully cultivated by following scientifically approved
hygienic practices.
In choosing which Western public health models to follow,
health ministers in the Japanese government were
particularly taken with the German model, which promoted
the idea that the individual and the society were best
thought of as a single organism, each dependent on the
health of the other. As more and more Japanese doctors and
public health officials studied advances in German medical
practices, the burgeoning science of neuropsychiatry was
bound to follow. It wasn’t long before many of Japan’s most
promising psychiatrists were making pilgrimages to
Germany to find mentors among the ranks of the famous
neuropsychiatrists of the day.
Those German doctors were focusing their attention on
the severely mentally ill, especially patients with psychotic
symptoms related to schizophrenia or manic depression. For
the most part they believed that such dramatic mental
illnesses were caused by malfunctions somewhere in the
brain or nervous system and were likely the result of
inherited predispositions. Following these interests, the first
psychiatrists in Japan also focused their ministrations on
those with severe psychotic symptoms.
As the cholera epidemic introduced the Japanese public to
Western notions of medicine, Western psychiatry was
carried into public consciousness through crisis. That crisis
was the combination of rapid social changes at the end of
the nineteenth century that included urbanization, the
Industrial Revolution, and three wars within thirty years.
Government officials and social commentators expressed
increasing concern during this time over rising social
problems such as increased juvenile delinquency and the
disappearance of traditional practices and values. The
government produced reports on rising suicide rates and the
discontent of the working class. And just as Western-
oriented medical doctors consulted with government
officials to control the outbreaks of cholera, psychiatrists
gave advice on the social discontent of the time. Newly
minted psychiatrists in Japan, trained in German
neuropsychiatry, suddenly found that they had a voice in
these public debates.
In popular lectures and newspaper and magazine articles,
these psychiatrists began to introduce new ideas into the
popular culture. The people learned about hysteria in
women, mental hygiene, and antisocial personalities. Given
the uneasiness about the new realities of industrialization
and urban living, there was intense interest and debate on
these topics. One prominent intellectual wrote in the early
part of the twentieth century that the new medical
knowledge had brought to light many ailments that the
people had never heard of and that had previously gone
unnoticed. The people, he said, were now “constantly
worried over the slightest changes in their health” and had
consequently become “more vulnerable to illness.”
Japan’s First Mental Health Epidemic
Of the many ideas being imported from those Western
advances in psychiatric thinking, one in particular struck a
chord with the Japanese population. Riding on its recent
popularity in the United States and Europe, neurasthenia
was introduced to the Japanese public as an illness of
modernity.
Writing in professional and popular forums, Japanese
psychiatrists and others knowledgeable about Western
illness categories carefully explained to the public that
neurasthenia (translated as shinkeisuijaku) was a disease of
the nerves. The idea that the body had nerve pathways,
often described as tiny electrical cables, was a new one for
the Japanese, but the notion quickly became conventional
wisdom. The metaphor often employed to describe this new
condition was that of electric streetcars. Just as a trolley
would fail to function if its electric cables became worn or
broken, so too could human wiring fray and malfunction
from overuse.
What made neurasthenia different from other psychiatric
illnesses studied by Japanese psychiatrists at the time was
that it was not a disorder of the severely mentally ill but of
the common man. “The rise of neurasthenia,” Kitanaka
says, “was the first instance of the broad-scale
medicalization of everyday distress in Japan.” She found
remarkable parallels between the rise of neurasthenia at the
beginning of the twentieth century and the introduction of
the Western conception of depression at the beginning of
the twenty-first.
Neurasthenia, she believes, became a compelling social
narrative in Japan because it distilled and gave a name to
the inchoate anxiety of the times. Commentators connected
the disease with all manner of troubling trends, including
increased marketplace competition, excessive studying,
smoking, drug abuse, labor inequities, rising crime rates,
and juvenile delinquency.
The excitement surrounding the diagnosis of neurasthenia
came not only from the mental health professionals of the
time but from popular culture as well. Articles, pamphlets,
and books provided guides to self-diagnosis, symptom lists,
and suggestions for which specific groups should be
considered particularly vulnerable. People were told to be on
the lookout for symptoms: insomnia, ringing in the ears, lack
of concentration, stomach pains, eye fatigue, and the
feeling that a heavy pot covered one’s head. A brisk market
in pills and potions to cure the illnesses soon sprang up.
Unlike other mental illnesses being discussed in popular
culture at the time, this one carried little social stigma.
Indeed, because neurasthenia was at first considered an
illness of the elites, the diagnosis became somewhat trendy.
An article in an intellectual magazine circa 1902 was
headlined “Neurasthenia: Operators, Writers, Government
Officials, and Students, Read This.” The assumption was
that those employed in positions requiring strenuous
intellectual labor were dangerously taxing their nerves. “The
media initially depicted it as an inevitable outcome for
people on the forefront of the process of modernization, for
whom exhausted nerves even became a mark of
distinction,” Kitanaka explains. “An unprecedented number
of cases of neurasthenia among elites, including
government officials, company executives, university
professors and artists began to be reported.”
The belief that neurasthenia was a disease of the elites
and intellectuals no doubt helped with the wide acceptance
of the illness in Japan. By the early years of the twentieth
century, however, it was not only the elites on the front
lines of cultural change who were claiming this disease of
modernity. In 1902 an article reported that fully one-third of
patients visiting hospitals for consultations were suffering
from this new disease. Large and diverse segments of the
population were also reporting or being diagnosed as having
frayed nerves. Neurasthenia was suddenly being referred to
as Japan’s “national disease.”
But although the Japanese people seemed willing to
accept, even idolize, this disease when it was only in an
elite population, they were less sanguine when large
numbers of regular citizens also invoked the diagnosis. With
tens of thousands claiming the illness, the country was
poised for a backlash.
An early sign of that change could be heard in the debate
surrounding a single suicide that caught the public’s
attention. In 1903 a young student named Misao Fujimura
carved a poem in a tree near Nikko, a popular scenic area
north of Tokyo. The message in the brief verse was that life
was “incomprehensible.” When he finished, he walked to a
local waterfall renowned for its beauty and leaped to his
death.
Those who wrote about his suicide in the years afterward
fell into two broad categories. There were many artists and
intellectuals who saw such suicides as having great social
and philosophical meaning. Fueling the rise of the
neurasthenia diagnosis was a popular idea that some
Japanese were too pure of heart to live with the conflicts,
compromises, and demands of modern life. Misao’s suicide
was a brave act, some prominent thinkers suggested,
committed by a young man freeing himself from the mental
torture of modernity. This understanding of his actions was
in line with a long Japanese tradition of viewing suicide as
an act of personal resolve. Just as neurasthenia was
considered a mark of distinction among certain elite groups,
suicides among similar groups were often excused or even
admired as expressions of the purity of the Japanese
character.
But as the diagnosis of neurasthenia began to rise
exponentially, some prominent doctors and officials stepped
forward to challenge the social status given individuals like
poor Misao. In a speech to psychiatrists reprinted in a 1906
issue of the Journal of Neurology, the statesman Shigenobu
Okuma took a harder line:
These days, young students talk about such stuff as the “philosophy of life”
[applause from the floor]. They confront important and profound problems
of life, are defeated, and develop neurasthenia. Those who jump off of a
waterfall or throw themselves in front of a train are weak-minded. They do
not have a strong mental constitution and develop mental illness, dying in
the end. How useless they are! Such weak-minded people would only cause
harm even if they remained alive [applause].
Prominent psychiatrists also began to question the
diagnosis. In a book on mental illness published in 1912 a
professor at Kyushu University wrote that those who
suffered from neurasthenia were “born with an inherent
weakness in the brain” and had only “half the mental
capacity of a normal person.” Not everyone who had a
mentally taxing job, other psychiatrists pointed out,
developed the disease; thus there must be something
fundamentally wrong with the affected individuals to make
them vulnerable.
Psychiatrists began to offer up new categories and
formulations. They began to talk of the difference between
the few who had “true neurasthenia” and a larger number
of people who were burdened with a type of nervous
disposition. This sort of disposition was not caused by the
overwork and mental stress that came with high-profile elite
jobs but came from an inherited abnormal personality that
made the sufferer incapable of withstanding the everyday
challenges of a normal life.
Looking back on the debate, it seems as if acceptance of
neurasthenia had been so successful that psychiatrists felt
obligated to restigmatize this mental disorder in hopes of
limiting its adoption. By the end of World War II the
diagnosis had almost completely gone out of style among
both psychiatrists and the population at large. A new
generation of psychiatrists wrote papers and gave
presentations dismissing neurasthenia by suggesting that
the thousands of patients who had claimed to suffer from
the illness had either been misdiagnosed by uninformed
doctors or were malingerers trying to get time off work.
The Culture of Sadness
During the early part of the twentieth century the concept of
depression remained attached to the diagnosis of severe
manic depression imported from those German
neuropsychiatrists. It wasn’t until after World War II that
depression became a disease category of its own. There was
nothing mild about this conception of depression. This so-
called endogenous depression was a crippling type of
psychosis believed to be caused by a genetic abnormality.
Professors of psychiatry at the time often explained
endogenous depression using the metaphor of an internal
alarm clock. “According to this model, the depressed person
is like someone carrying a psychotic time bomb, for whom
depression begins when the internal clock goes off and ends
after it runs its course,” Kitanaka explains. Endogenous
depression expressed itself only in individuals with that
ticking alarm clock and wasn’t connected to external
causes.
At the same time another idea was gaining ground in
Japan’s mental health community. The personality typus
melancholicus was introduced in the early 1960s by a
professor of clinical psychopathology from Heidelberg
named Hubert Tellenbach. This idea never caught on in the
United States and rather quickly became dated in Germany,
but it influenced psychiatric thinking in Japan. As Tellenbach
first described it, someone with a melancholic personality
possessed a highly developed sense of orderliness as well
as “exceptionally high demands regarding one’s own
achievements.” Typus melancholicus mirrored a particularly
respected personality style in Japan: those who were
serious, diligent, and thoughtful and expressed great
concern for the welfare of other individuals and the society
as a whole. Such people, the theory went, were prone to
feeling overwhelming sadness when cultural upheaval
disordered their lives and threatened the welfare of others.
Neither endogenous depression nor the melancholic
personality type were of great concern to the general public
at the time. Because endogenous depression was thought of
as a psychotic state, akin to schizophrenia in severity, it
carried a severe stigma and was considered rare. As for the
melancholic personality type, its association with such
prized Japanese traits as orderliness and high achievement
meant that having such a sadness-prone personality was
something not to be feared but aspired to.
This absence of a category parallel with the modern
Western-style depression persisted for many years. When
the DSM-III was first translated into Japanese in 1982, the
diagnosis of depression, with its two-week threshold for low
mood, was widely criticized among Japanese psychiatrists as
far too expansive and vague to be of any use. Prominent
psychiatrists believed, in short, that the description did not
amount to a meaningful mental illness.
Indeed, as Kirmayer has pointed out, in the late twentieth
century no word in Japanese had the same connotations as
the word “depression” in English. Consider the various
words and phrases that have often been translated into
English as “depression.” Utsubyô describes a severe, rare,
and debilitating condition that usually required inpatient
care and thus was not much of a match for the common
English word “depression.” Yuutsu, which describes grief as
well as a general gloominess of the body and spirit, was in
common use. There was also ki ga fusagu, which refers to
blockages in vital energy. Similarly, ki ga meiru is the
leakage or loss of such energy. Although each of these
words and phrases had overlaps with the English word
“depression,” there were also critical differences. The
experiences these words describe do not exist only in the
thoughts and emotions but encompass full-body sadness. As
such, the Japanese person who felt yuutsu or ki ga fusagu
was likely to describe it in terms of bodily sensations, such
as having headaches or chest pains or feeling heavy in the
head.
Not only did Japanese ideas of sadness include both the
body and the mind but, metaphorically at least, they
sometimes existed beyond the self. The experience of
yuutsu in particular contained connotations of the physical
world and the weather. A young Japanese researcher named
Junko Tanaka-Matsumi, studying at the University of Hawaii
in the mid-1970s, conducted a simple word-association test
on a group of Japanese college students and compared the
results to Caucasian American college students. The
American students were asked to respond with three words
that they connected with “depression.” The Japanese
students were asked to do the same with yuutsu.
The top ten word associations for the native Japanese
were
1. Rain
2. Dark
3. Worries
4. Gray
5. Suicide
6. Solitude
7. Exams
8. Depressing
9. Disease
10. Tiredness
For the Caucasian Americans, the top ten word associations
were
1. Sad or sadness
2. Lonely or loneliness
3. Down
4. Unhappy
5. Moody
6. Low
7. Gloom
8. Failure
9. Upset
10. Anxious
Comparing these answers, Tanaka-Matsumi saw a notable
difference. In the responses given by the Japanese natives,
only a few of the words (such as “worries” and “solitude”)
were related to internal emotional states. On the other
hand, the majority of the word associations supplied by the
American students related to internal moods. The Japanese,
in short, were looking outward to describe yuutsu, and the
Americans were looking inward to describe depression.
Tanaka-Matsumi believed that these were not simply
linguistic differences but cultural “variations in the
subjective meanings and experience of depression.”
The Japanese and Americans weren’t just talking about
depression and sadness differently, she believed; they were
feeling these states differently as well. What she saw
reflected in the language was a difference between how
Japanese and Americans conceived of the nature of the self.
The word associations suggested that Americans experience
the self as isolated within the individual mind. The Japanese,
on the other hand, conceive of a self that is less
individuated and more interconnected and dependent on
social and environmental contexts. Feelings that Americans
associate with depression have, in Japan, been wrapped up
in a variety of cultural narratives that altered their meaning
and the subjective experience for the individual.
Even as the DSM diagnosis of depression became more
widely employed around the world during the 1980s, the
experience of deep sadness and distress in Japan retained
the characteristics of the premodern conception of both
utsushô and the mid-twentieth-century idealization typus
melancholicus, the idea that overwhelming sadness was
natural, quintessentially Japanese, and, in some ways, an
enlightened state.
As Kirmayer has documented, this was a culture that often
idealized and prized states of melancholy. Feelings of
overwhelming sadness were often venerated in television
shows, movies, and popular songs. Kirmayer noted that
yuutsu and other states of melancholy and sadness have
been thought of as jibyo, that is, personal hardships that
build character. Feelings that we might pathologize as
depressive were often thought of in Japan as a source of
moral meaning and self-understanding. He and others have
connected this reverence to the Buddhist belief that
suffering is more enduring and more definitive of the human
experience than transient happiness.
Other cross-cultural scholars have also noticed this
Japanese affinity for states of sadness. Studying menopause
in Japan, McGill Social Studies of Medicine professor
Margaret Lock wrote:
Feeling sad and reacting sensitively to losses, particularly of loved ones, is
an idea that has a singular appeal in Japanese. The theater, a range of
literature and indigenous popular songs, traditional and modern, positively
wallow in nostalgia, sensation of grief and loss, and a sense of the
impermanence of things. People cry freely (by North American and northern
European standards) about separation and lost loved ones, but at the same
time they seem to draw strength from these experiences, to tighten their
bonds with those who remain among the living, and to reaffirm group
solidarity.
This cultural embrace of sadness, Lock believes, might have
been motivated by society’s discouragement of other
emotional states.
Unlike anger and irritability, which both disrupt harmony and threaten the
social order, sadness, grief, and melancholy are accepted as an inevitable
part of human life and even welcomed at times for their symbolic value, as
a reminder of the ephemeral nature of this world. An association between
melancholy and the weather reinforces sad feelings as natural and
unavoidable and hence as states not induced solely through human
exchange.
Given these cultural currents, it makes sense that the first
popular psychopharmacological medications adopted in the
1960s and 1970s were sedatives, whereas amphetamines
and early mood enhancers were viewed with suspicion. As
Lock implies, culturally designated pathological states are
often the flipside of states a culture values. Along with the
sedating drugs, Japanese quickly adopted disease
categories describing social anxiety or aggression but
resisted viewing deep and extended periods of sadness as a
mental illness.
When the first SSRIs came online in the West,
consequently, Japanese considered them harsh medications
that exaggerated types of personality valued in the United
States. A leading Japanese psychopharmacologist described
how classes of drugs matched or ran afoul of different
cultural narratives: “The Japanese system is much more
modest and co-operative—people work together more.
Against this background, amphetamines are much more of a
problem than are the benzodiazepines; we are much more
sensitive to the changes, the exaggeration of behavior,
produced by the amphetamines. Sedative agents are seen
as much less of a problem in Japan. . . . There is something
of a preference for an agent that will be sedative rather than
arousing, like, perhaps, Prozac.”
“One society’s enhancement of personality can be
another’s pathology or provocation,” remarks Kirmayer.
“Something like this may occur with Prozac, where the
extraversion, gregariousness and pushiness that typify the
life of a salesman in the USA may be associated with
inappropriately brash and insensitive social behavior in
Japan.”
Given all these cultural forces, it is not surprising that
major drug companies at first saw no market for SSRIs in
Japan at the beginning of the 1990s. The psychiatric
category of depression was not a widespread public
concern, and the capacity to experience great sadness was
considered not a burden but a mark of strength and
distinction. That belief, combined with a suspicion of drugs
that heightened moods or extraverted personality traits,
made the market for SSRIs unpromising. Those public
perceptions, however, were soon to change.
In the Lost Decade a Young Man Joins an Ad Firm
In the spring of 1990, 24-year-old Oshima Ichiro joined the
Dentsu advertising agency, the largest company of its kind
in the world. When he first showed up at Dentsu, Oshima
was healthy and athletic. His fellow employees described
him as honest, happy, and committed. Like many unmarried
men, he lived with his mother, father, and brother. He had a
girlfriend but no immediate plans to get married;
establishing his career would come first. At Dentsu he was
assigned the daunting task of handling public relations for
more than forty corporate clients.
Because Oshima would come to symbolize a new
understanding of depression among corporate workers in
Japan, it is worth pausing to note the timing of his hiring in
relation to the trajectory of the economy of Japan.
It was on the last trading day of 1989, just three months
before Oshima started his new job, that the Japanese Nikkei
index hit an all-time high. That index had nearly quadrupled
in value over the previous five years. At the end of those go-
go days, choice apartments in the Ginza district of Tokyo
were going for nearly $100,000 per square foot. The
Japanese economy was the envy of the world. It was a time
when it seemed that any business could secure a loan and
everyone with the willingness to work hard could ride the
wave of prosperity.
But when stock traders got back to their posts at the
beginning of January 1990, something had shifted. In the
next days and weeks stocks began to slide, and then free-
fall. By the time Oshima started his job in April there was
something approaching panic in the financial markets.
As was true of many new hires, the sudden economic
downturn steeled Oshima’s resolve to prove his worth. He
showed right away that he was willing to roll up his sleeves
and dig into his considerable workload. He often spent the
first eight hours of his workday just trying to juggle
meetings and field phone calls. Staying at work after hours
was the only way he could write the press releases and
proposals his clients required. Just a few months into his job,
he was coming home past midnight on most nights. On
some mornings, when his colleagues showed up for work, it
was clear that the hard-driving Oshima had been at his desk
the entire night. He took no days off.
In November 1990 his mother and father began to worry
about his health. Oshima’s eyes looked unfocused and he
sometimes fell asleep while sitting with them at the kitchen
table. In his contract, Oshima was promised ten days of
vacation each year, and his parents suggested that he
schedule some days to rest. But he refused. He felt that any
days off would only increase the burden he would face when
he got back to work. Anyway, he told them, he didn’t think
his boss would allow him the time off. Not knowing what
else to do, his mother made him nutritious breakfasts in the
morning and drove him to the train station to ease the
burden of his hour-long commute.
After months at this sprinter’s pace, cracks began to show
in his behavior. At work small setbacks and mistakes
brought on waves of self-loathing. “I’m no good as a human
being,” coworkers sometimes heard him saying out loud to
himself. “I’m of no use.”
The New Year brought no relief from the economic bad
news or from Oshima’s burdens. From its high in 1989, the
Nikkei had lost nearly half of its value. Home prices were
plummeting just as precipitously. The normally hardworking
life in corporate Japan became even more intense. The
frustration of Dentsu executives at their declining profits
rolled down the chain of command, putting ever more
pressure on the rank and file. At one late-night drinking
binge at the office, Oshima’s boss poured beer into his own
shoe and demanded that Oshima drink it down. When he
momentarily refused the request, his boss beat him.
By the summer of that year Oshima’s workload had only
gotten worse. On top of his regular duties, he was put in
charge of a four-day conference for a client to be held in
August. If he got home at all that summer, his parents
remember, it was often simply to clean himself up before
getting back on the train to the office. On the night before
the beginning of the conference he managed to get home at
6 a.m. He was back at work less than four hours later to
drive his boss to the site of the conference.
As they drove, his boss couldn’t help but notice that
Oshima seemed troubled. He drifted and swerved erratically
from lane to lane. He mumbled incoherently, something
about being possessed by spirits.
After a grueling four days at the conference, Oshima
finally made his way back home at 6 a.m. on August 26. He
looked so drawn and haggard that he promised his brother
that he would go to the hospital that day. He called the
office at 9 a.m. to tell them that he was sick and would not
be in that day. Less than an hour later, his family found him
dead. He had hanged himself in the bathroom.
When Oshima’s parents’ lawsuit against Dentsu came to
court a few years after his death, newspaper editors and
television producers featured the story prominently. It was
an easy pick, given that the story had a clear antecedent. In
the boom years of the 1980s hardworking Japanese
businessmen sometimes collapsed and died at their desks
after putting in weeks or months of overtime. In the press
this was called karoshi, death from overwork, and reports on
the trend had become popular. In the early 1990s suicides
topped thirty thousand a year. This was between three and
four times the number of Japanese killed in car accidents.
The suicide trend became a concern to the general public
and there was much debate over who or what was
responsible. When Oshima’s suicide came to light,
journalists and editors immediately saw the story’s
potential. Headlines announced the new trend: karojisatsu,
suicide from overwork. Because the Oshima family’s lawsuit
sought to assign blame for his death, it was tailor-made to
become the focus of this public debate.
The lawyers for Oshima’s parents argued that the stress of
his job and his long hours brought on a depression that
caused his death. This form of depression was different from
the endogenous depression in the Japanese psychological
literature because it hadn’t resulted from an inherited
defect in Oshima’s brain; rather it was brought on by the
circumstances of his life. This was a type of depression that
could strike anyone.
The newspapers followed each revelation of the case.
There was, for instance, the mystery of just how many
overtime hours young Oshima worked during his time at
Dentsu. According to the time sheets he submitted to the
company, his overtime ranged between twelve and twenty
hours each week. Lawyers for the company pointed out that
that level of commitment was hardly unusual in hardworking
Japan, and it was certainly not the sort of workload that
you’d expect would drive a healthy and ambitious young
man to hang himself in the bathroom. To prove that he had
worked much longer than he claimed, the lawyers for his
parents relied on the records of the office night guards, who
were required to make frequent checks of each floor of the
building, noting the names of the employees at their desks.
Based on that evidence, it was clear that Oshima was
clocking a much more problematic average of forty-seven
overtime hours per week.
Oshima’s parents won their case. As the Dentsu lawyers
appealed the verdict through the courts they continued to
argue that the company should not be held liable because
Oshima’s depression was a result of a preexisting mental
weakness. They were, in effect, arguing for a pre–DSM-III
version of endogenous depression: Oshima wouldn’t have
become sick had he not had that alarm clock ticking inside
his brain.
The different rulings of the higher courts rather neatly
reflect a culture in the process of changing its collective
mind. The Tokyo High Court first reduced the amount of the
compensation, concluding that Oshima’s inborn mental
stamina was at least part of the cause in his death. “Not
everyone becomes depressed from being overworked or
being in a stressful situation,” the verdict read. “It cannot be
denied that his . . . premorbid personality resulted in
increasing the amount of his own work.” Here the court held
onto earlier notions prominent in Japanese psychiatry: that
inborn pathological characteristics were the psychiatric
equivalent of fate. The Supreme Court, however, rejected
that lower court’s ruling and argued that individual
character—as long as it is within a normal spectrum—should
not be considered in such a case. The ruling suggested that
anyone, put under enough stress, could succumb to
depression.
Thanks partly to the debate over Oshima’s suicide, the
shift in public opinion during this period couldn’t have been
more dramatic. “When people first heard about the
litigation, they would ask if it was the company, not the
family, that was suing for the damage caused by the
employee’s suicide,” said Kitanaka, who studied the case
closely. “When Japanese heard in the media of the plaintiff’s
victory, many came to hear, probably for the first time, that
suicide could be caused by a mental illness called
depression.”
That Oshima’s lawsuit might be the first time many
Japanese connected suicide with depression is hard for a
Westerner to comprehend. Most Americans would certainly
assume that suicidal acts are nearly always caused by
mental illness, most commonly depression. Indeed the
Western SSRI manufacturers who were eyeing the Japanese
market in the 1990s routinely invoked the high suicide rate
as proof positive of an epidemic of depression in Japan.
Yet the Japanese public remained split as to whether
suicide was an intentional act with moral or philosophical
meaning or a desperate act of a mentally ill person. In many
ways the public debate regarding why Oshima hanged
himself picked up the public dialogue that took place almost
a hundred years before, when Misao Fujimura jumped off
the waterfall. Although many Japanese agreed that the high
rate of suicide was a legitimate public health concern, there
was not yet a consensus that the epidemic, or the act of
suicide itself, was the result of mental illness. In Japanese
history, literature, and movies there were many stories of
the noble suicide, such as when Samurai warriors
committed seppuku and World War II soldiers killed
themselves to avoid capture. Psychiatrist Masao Miyamoto
was not alone when he remarked in 1998 that he didn’t see
much of a connection between the rise of suicide and
depression. Most of the reasons Japanese people kill
themselves have nothing to do with depression, he argued.
“A peculiarity of the Japanese is that they often die for the
sake of the group,” he said. “They die for shame.” Wataru
Tsurumi’s Complete Manual of Suicide, published in 1993,
was the modern embodiment of the Japanese public’s
intense interest in suicide. The book, written in flat,
unemotional tones, is a guide to the ten most popular
methods of suicide, including hanging, drowning,
electrocution, and jumping from heights. The author awards
a number of skulls to rate each method in categories such
as painfulness, how much a nuisance you’ll cause others,
how much effort is required, and the likelihood of success.*
The remarkable sales of the book speak to a uniquely
Japanese fascination. During the 1990s the book sold more
than 1.2 million copies. If we can believe the author, the
book was written not for shock value but from a deeply
philosophical belief that suicide is a legitimate—and
perfectly sane—act of personal will.
The story of young Oshima and several other prominent
suicides from overwork put faces and personal stories on
the growing public concern that Japan had ignored the
mental health consequences of overwork. As was true at the
turn of the nineteenth century, the end of the twentieth
century was a disconcerting time for the people of Japan.
Shameful bankruptcies were common and divorce and
unemployment were on the rise. Just as at the end of the
Edo era a hundred years before, the public was on the hunt
to explain the distress being felt during these uncertain
times.
The Japanese public’s impression that the country was
behind the times in addressing mental health got a boost
after the devastating earthquake in the city of Kobe in
January 1995.* The government response to the disaster
was criticized by Western mental health experts for being
lackluster on many fronts. Researchers from the United
States were soon on the scene and garnered much press
attention by suggesting that the population needed not just
food and shelter but more attention paid to their emotional
and mental health.
Several prominent Japanese psychiatrists and mental
health advocates used the authority of the visiting mental
health experts to make a broad argument that Japanese
culture discouraged talking about emotionally loaded issues.
“The comparison, quite unfavorable to Japan, was often
made to the United States, where the emphasis on
psychological issues is generally believed to be culturally
strong and given proper priority,” the anthropologist Joshua
Breslau reported. “One well-known newspaper critic noted
that his friend told him how nearly everyone in U.S. cities
has a psychological counselor.”
A critical turning point came just three months after the
Kobe quake. A TV producer named Kenichiro Takiguchi was
browsing through the English-language section of a Tokyo
bookstore and started to flip through a paperback copy of
Peter Kramer’s American best seller Listening to Prozac.
Always on the lookout for good ideas for programs, he took
the book to his bosses at Japan’s largest television network
and persuaded them to let him produce a fifty-minute
special. The message of the special was similar to the
beliefs made popular after the Kobe earthquake, namely,
that Americans were far advanced in their recognition and
treatment of emotional disorders such as depression and
anxiety. The show hit a nerve. Millions watched and more
than two thousand viewers called in afterward to praise the
network for running the program.
Japanese psychiatrists were largely taken by surprise at
this turn in public interest. Up to that point the public had
eschewed the intrusion of psychiatry into daily life. As the
small population of psychiatrists had mostly limited their
practice to the severely mentally ill, the call to address
common unhappiness and anxiety that came with bad
economic times caught them off-guard. Like many people in
the country up to that point, they had not considered
unhappiness (or divorce or suicide) a mental health issue.
They were in need of a new and compelling explanation for
what was going on. Fortunately for them, GlaxoSmithKline
and several other major psychopharmaceutical companies
were just then preparing to throw them a lifeline.
Junk Science and First World Medicine
Kalman Applbaum, a professor at the University of
Wisconsin in Milwaukee, is an anthropologist, but he doesn’t
study little-known tribes in far-off lands. His interest is closer
at hand: the rituals and practices of international
corporations. His specialty, the anthropology of the
boardroom, has led to teaching posts both in anthropology
departments and at business schools, including Harvard and
Kellogg. He is also fluent in Japanese and often consults with
companies interested in the Asian markets. When he heard
in the late 1990s that major players in the pharmaceutical
industry were attempting to introduce SSRIs to Japan, he
knew he had the topic for his next set of research papers.
At the beginning of the new millennium, Applbaum went
out of his way to visit the headquarters of GlaxoSmithKline,
Lilly, and Pfizer, the major international players who were at
various stages of trying to get their drugs into Japan. At the
time both Pfizer and Lilly were playing catch-up to
GlaxoSmithKline, which was just then launching Paxil in the
country. Although he had to sign nondisclosure agreements
promising that he wouldn’t identify the executives by name
or company affiliation, Applbaum managed to get
remarkable access to the inner workings of these
companies. Several of his former MBA students who were
then working in these firms helped make key introductions,
but in the end these executives proved more than willing to
talk. When I asked Applbaum why they were so forthcoming,
he told me it was simple: because of his business school
credentials and his extensive experience in the Japanese
market, they thought he might be able to give them some
free advice.
Applbaum discovered that the companies intent on
entering the SSRI market in Japan were not battling each
other like Coke and Pepsi for market share—or at least not
at the beginning. Instead he found wide acknowledgment
within the ranks of drug company executives that the best
way for companies to create a market was for competing
companies to join forces.
A critical player in this joint effort was the trade
organization Pharmaceutical Manufacturers of America, or
PhRMA, which functions as the national and international
lobby and public relations organization for a coalition of
major drug companies. In the late 1990s Applbaum found
PhRMA working on a number of levels in Japan to influence
what they considered to be a backward and bureaucratic
drug approval process. As one PhRMA executive based in
Chiyoda-Ku, Tokyo, told Applbaum, their job was to create “a
market based upon competitive, customer choice and a
transparent pricing structure that supports innovation.” The
lobby wanted drugs such as Paxil to be able to enter new
markets based on “global, objective, scientific standards.”
The more Applbaum talked to drug company insiders, the
more righteous frustration he found. When he visited the
offices of a leading SSRI manufacturer in November 2001,
he discovered a wellspring of anger directed at what they
perceived as Japanese resistance to pharmaceutical
progress. These executives criticized scientific standards for
clinical testing in Japan as “quite poor” and asserted that
there was no “good clinical practice” in the country. Why,
they asked Applbaum rhetorically, should their company be
forced to retest these drugs in exclusively Japanese
populations? The assumption was that the science behind
the American human trials was unassailable—certainly
better than anything the Japanese would attempt.
No doubt that annoyance at having to retest drugs was so
intense because a couple of recent large-scale human trials
of SSRIs in Japan had failed to show any positive effects.
Drugs such as Pfizer’s Zoloft, which were widely prescribed
in the United States, had at least one large-scale human
trial failure in Japan in the 1990s. Instead of considering the
meaning of such results, the drug company executives
railed at Japanese testing practices, calling them second
rate. “There is no sense of urgency about patient need in
Japan,” one executive complained to Applbaum.
The Mega-Marketing of Depression
Although drug company executives clearly would have
preferred to avoid the expensive and time-consuming
process of retesting their SSRIs in Japan, they ultimately
found a way to put those trials to good use as the first step
in their marketing campaign. The drug makers often bought
full-page ads in newspapers in the guise of recruiting test
subjects. Applbaum believes that this was one of several
savvy methods the drug companies employed to sidestep
the prohibitions in Japan on marketing prescription drugs
directly to the consumer. These advertisements, supposedly
designed only to recruit people for the trials, were well
worth the cost, as they both featured the brand name of the
drug and promoted the idea of depression as a common
ailment. One company scored even more public attention
when it recruited a well-known actress to take part in the
trials.
But getting the drug approved for market was only the
first step. Talking with these executives, it became clear to
Applbaum that they were intent on implementing a complex
and multifaceted plan to, as he put it, “alter the total
environment in which these drugs are or may be used.”
Applbaum took to calling this a “mega-marketing” campaign
—an effort to shape the very consciousness of the Japanese
consumer.
The major problem GlaxoSmithKline faced was that
Japanese psychiatrists and mental health professionals still
translated the diagnosis of “depression” as utsubyô, and in
the mind of many Japanese that word retained its
association with an incurable and inborn depression of
psychotic proportions. In hopes of softening the
connotations of the word, the marketers hit upon a
metaphor that proved remarkably effective. Depression,
they repeated in advertising and promotional material, was
kokoro no kaze, like “a cold of the soul.” It is not clear who
first came up with the phrase. It is possible that it originated
from Kenichiro Takiguchi’s prime-time special on depression.
In that show, it was said that Americans took anti-
depressants the way other cultures took cold medicine.
Whatever its origin, the line kokoro no kaze appealed to
the drug marketers, as it effectively shouldered three
messages at the same time. First, it implied that utsubyô
was not the severe condition it was once thought to be and
therefore should carry no social stigma. Who would think
less of someone for having a cold? Second, it suggested
that the choice of taking a medication for depression should
be as simple and worry-free as buying a cough syrup or an
antihistamine. Third, the phrase communicated that, like
common colds, depression was ubiquitous. Everyone, after
all, from time to time suffers from a cold.
Although advertising couldn’t mention particular drugs,
companies could run spots in the guise of public service
announcements encouraging people to seek professional
help for depression. In these ads SSRI makers attempted to
distance depression further from the endogenous
depression as it was understood by Japanese psychiatrists
for most of the century. One GlaxoSmithKline television
advertisement showed an attractive young woman standing
in a green field, asking, “How long has it been? How long
has it been since you began to worry that it might be
depression?” The scene then shows a woman on an
escalator and then a middle-aged office worker staring out a
bus window. The voiceover then recommends that if you’ve
been feeling down for a month, “do not endure it. Go see a
doctor.”
The subtext of the ad is clear to Kitanaka. It presents
depression as “intentionally ambiguous and ill-defined,
applicable to the widest possible population and to the
widest possible range of discomforts. . . . The only feature
that distinguishes depression as a ‘disease’ from an ordinary
depressed mood seems to be the length of time (one
month) that the person has experienced these ‘symptoms.’”
Depression was so broadly defined by the marketers that
it clearly encompassed classic emotions and behaviors
formerly attributed to the melancholic personality type. The
label of depression then took on some laudable
characteristics, such as being highly sensitive to the welfare
of others and to discord within the family or group. Being
depressed in this way became a testament to one’s deeply
empathic nature.
To get these messages out to the Japanese public, the
SSRI makers employed a variety of techniques and avenues.
Company marketers quickly reproduced and widely
disseminated articles in newspapers and magazines
mentioning the rise of depression, particularly if those
pieces touted the benefits of SSRIs. The companies also
sponsored the translation of several best-selling books first
published in the United States on depression and the use of
antidepressants.
Given all the ways that GlaxoSmithKline and the other
SSRI makers managed to make the average Japanese aware
of their drugs, the official ban on direct-to-consumer
marketing became almost meaningless. If there was any
doubt about this, one only had to look at how these
companies used the Internet. “The best way to reach
patients today is not via advertising but the Web,” one
Tokyo-based marketing manager told Applbaum. “The Web
basically circumvents [direct-to-consumer advertising] rules,
so there is no need to be concerned over these. People go to
the company website and take a quiz to see whether they
might have depression. If yes, then they go to the doctor
and ask for medication.”
The mega-marketing campaign often came in disguised
forms, such as patient advocacy groups that were actually
created by the drug companies themselves. The website
utu-net.com, which appeared to be a coalition of depressed
patients and their advocates, was funded by
GlaxoSmithKline, although visitors to the site would have
had no clue of the connection. What they would have found
was a series of articles on depression driving home the key
points of the campaign, including the idea that it was a
common illness and that antidepressants bring the brain’s
natural chemistry back into balance.
The public interest in the new diagnosis brought a
remarkable amount of media attention. Often in back-to-
back months, the major magazines Toyo Keizai and DaCapo
ran pieces on depression and the new drugs. In 2002 a
leading Japanese business magazine ran a twenty-six-page
cover story encouraging businesspeople to seek
professional help for depression. The article rather perfectly
mirrored the key points of the SSRI makers’ mega-marketing
campaign and in many ways reflected the early conceptions
of neurasthenia a century before. The article suggested that
it was the more talented and hard-charging workers who
were the most susceptible to depression. Estimates of how
many Japanese secretly suffered from depression, which
ranged from 3 to 17 percent of the population, seemed to
increase every month.
The distress caused by the long-ailing economy also
proved to be a useful selling point. GlaxoSmithKline
promoted the idea that there was an enormous economic
cost for untreated depression, which could be counted in
lost man-hours and decreased productivity. In this way, the
lure of the drug, especially to the younger generation, was
tied to ideas about competition in the global marketplace.
One Japanese psychiatrist was quoted in a local newspaper
describing SSRIs as “drugs that can transform minus
thinking into plus thinking” and that “can help a person live
tough,” like financially successful Americans.
The SSRI makers made much of one public relations
windfall in particular. It was rumored for years (and finally
confirmed by the Imperial Household Agency) that Crown
Princess Masako suffered from depression. Soon it was
revealed that she was taking antidepressants as part of her
treatment. This was a huge boost for the profile of
depression and SSRIs in the country. Princess Masako’s
personal psychiatrist was none other than Yutaka Ono, one
of the field’s leaders that GlaxoSmithKline had feted at the
Kyoto conference in 2001.
As a marketing line, there was one problem with the
phrase kokoro no kaze: the metaphor lacked a sense of
urgency about the condition. After all, one rarely rushes to
the doctor with a cold. Worse yet, medicating a cold was
always optional, as the illness goes away rather quickly on
its own.
To counter this aspect of the metaphor, the drug
companies leveraged the population’s growing concern over
the high suicide rates. The medical anthropologist Emiko
Namihira reported that SSRI makers were funding studies to
prove the link between depression and suicide. Those
studies that showed a connection were reprinted in
pamphlet form and reported to national media outlets as
breaking news. Studies that failed to show a connection
could simply be ignored. The founder of the Mood Disorders
Association of Japan claimed in the Japan Times that “90
percent of those who commit suicide are considered to
suffer from one kind of mental illness or another, and 70
percent of suicides are attributable to depression.” Without
medical attention, the message went, this “cold of the soul”
could kill you.
When taken together, the messages advanced by
GlaxoSmith-Kline during their rollout of Paxil don’t always
make sense. Previous notions of endogenous depression
were employed only sparingly in order to evoke the
seriousness of the disorder. On the other hand, they were
happy to associate this new conception of depression with
the Japanese veneration of the melancholic personality,
even though that didn’t particularly jibe with the parallel
message that this was an illness caused by an imbalance of
serotonin. Neither did the message that overwork could
spark depression mesh with the idea that individuals should
counter such social distress by taking a medication that
changed their brain chemistry. If it was unrealistic social
demands that were the cause of distress in the population,
why should the individual be taking the pills? In the end,
however, the coherence of these various messages took
second place to their effectiveness.
Speeding the Evolution
After the Kobe earthquake in Japan there was growing
consensus in the country that the West, and the United
States in particular, had a deeper scientific understanding of
pathological emotional states such as PTSD and depression.
Responding to this insecurity, the advertisements, websites,
waiting room brochures, and other materials produced by
the drug companies played up the idea that SSRIs
represented the cutting edge of medical science. These
drugs, which were said to rebalance the natural chemicals in
the brain, would bring Japan up to date.
GlaxoSmithKline worked very hard to win over the most
prominent medical researchers and psychiatrists in the
country and keep them on message. Their inclusion at lavish
conferences such as the one Kirmayer attended was just a
taste of the incentives offered. Drug companies offered
grants to sponsor research on their drugs; those researchers
who produced results favorable to the drugs found
themselves with new offers of research funding. Research
that showed the drug in question to be both safe and
effective was trumpeted by the company and the
researchers often paid as consultants. In addition,
researchers were given honoraria for speaking about their
findings at drug company–sponsored professional
conferences. Influence over the prominent scientists and
researchers in Japan was so pervasive that Applbaum
concluded that these scientists and doctors had been
basically “commandeered into a kind of market research by
pharmaceutical companies. The research simultaneously
serves as publicity for the essentially predetermined
consumer need.”
It is important to note that the drug company executives
whom Applbaum interviewed didn’t present themselves as
people driven only by profits. Rather these men and women
saw themselves as acting with the best of intentions,
motivated by the belief that their drugs represented the
proud march of scientific progress across the world. They
styled themselves as people fighting depression, anxiety,
and social phobia—diseases that remained cruelly untreated
in Japan and elsewhere. Applbaum could see that this
mixture of moral certainty and the lure of billions of dollars
in potential profits was a potent force.
“These executives seemed to believe that they are
straightforwardly trying to heal the world,” said Applbaum.
When he was meeting them in 2000 and 2001 he had no
reason to doubt these self-assessments. “They seemed to
believe their products were effective and they were baffled
that anyone should question their value. The
pharmaceutical industry, more than other industries, can
link its marketing activities to ethical objectives. The result
is a marriage of the profit-seeking scheme in which disease
is regarded as ‘an opportunity’ to the ethical view that
mankind’s health hangs in the balance. This helps even the
most aggressive marketers trust that they are performing a
public service.”
Bolstering their certainty was their faith in the science
behind these drugs. The fact that these SSRIs had proven
clinically effective made it morally imperative that they be
introduced into other cultures. The drug companies were
replacing what one executive referred to as “junk science”
in Japan with “first world medicine.”
During his talks with the executives, consultants, and
marketers for the drug companies, Applbaum heard a
repeated theme. These men and women kept talking about
different cultures as if they were at different stages of a
predetermined evolution. The American market, with its the
brand recognition, high rates of prescriptions (by specialists
and nonspecialists alike), and free market pricing, was seen
as the most modern and advanced of markets. Japan was
fifteen years behind the United States, executives would
say. Or China was five years behind Japan. The lucrative U.S.
market, Applbaum could see, was the standard against
which all others were measured. We were the most
“evolved” culture and, as one executive said to Applbaum,
their job was to “speed the evolution along,” that is, to
move other countries along the path to be like us.
This talk of evolutionary process wasn’t idle chatter, for it
was often the same executives and marketing specialists
who went from country to country waiting for the right
moment to make their push. “Pharmaceutical manufacturers
. . . circulate internal instructional materials regarding
experiences with the same product in what they consider
similar markets,” Applbaum said. “Managers fly about the
world to training conferences where such archetypes are
hardened. And old advertisements and communications
strategies from the earlier stage of more ‘advanced’
markets are imported.” With each new implementation of
the mega-marketing campaign, these drug companies
learned new maneuvers and strategies. They got better at
helping along the evolution.
The reasons these executives were so open about this
endeavor goes back to their shared belief that the evolution
in question was toward higher quality science. Westerners
may have lost their sense of moral authority in many areas
of human endeavor, but we can still get our blood up
defending our science. We lead the world in scientific
discovery and medical breakthroughs, so why shouldn’t the
citizens of Japan and other countries around the world have
access to the newest brand-name antidepressants? These
molecules were created using the latest advances in science
and technology. They had been reviewed by the leading
researchers at the world’s most famous universities and
found effective in studies published in the most prestigious
scientific journals. The latest antidepressants, in this moral
logic, were akin to antiretrovirals, polio vaccine, and
penicillin. Everyone in the world deserved access to the
fruits of our scientific discoveries as a human right.
It is not an argument without merit, but it depends rather
critically on the accuracy and validity of the science behind
the medical advance being touted. If the science is
overblown, skewed, or downright wrong, then the moral
certainty that fuels the charge into other cultures becomes
suspect.
Blinding Them with Science
Of all the luxuries provided him during that Glaxo-sponsored
Kyoto conference in 2001, Kirmayer remembers one evening
with particular relish. On the second night of the conference
he was instructed to dress in a “smart suit” and was taken
to the Tsuruya restaurant, one of the most exclusive and
expensive restaurants in Japan. At the restaurant he was
shown the guest book, where Henry Kissinger and other
world leaders had left their compliments. During dinner a
personal geisha sat at his arm smiling and pouring his tea
and sake. After trying to make small talk with this young
woman in his limited Japanese, he turned to James Ballenger
to bring up a question that had been on his mind.
Ballenger was the head of the International Consensus
Group on Depression. For three years he and a group of
other academic researchers hosted seven meetings at
various luxury resorts and hotels around the world. At these
conferences, funded by GlaxoSmithKline, Ballenger
gathered prominent scholars and researchers to consider
the best treatments for PTSD, panic disorder, and
generalized anxiety disorder. In the end these supposedly
independent scholars, with their affiliations to some of the
world’s finest universities, recommended that SSRIs be
prescribed for all of these conditions. Tellingly, the only SSRI
mentioned by name in the Consensus Group’s summation
paper was paroxetine, aka Paxil.
Kirmayer was curious about the relationship between the
drug companies and academics like Ballenger who
published the papers recommending these drugs. Wanting
to be polite, he thanked Ballenger for the remarkable
accommodations and treatment he was receiving. Kirmayer
was, of course, in no position to take the moral high road, as
he was at that very moment enjoying the splendor and
luxury for which GlaxoSmithKline was picking up the tab.
Nevertheless he felt compelled to ask Ballenger, as nicely as
he could: Isn’t this something of a conflict of interest?
Although he can’t remember what Ballenger said word for
word, he remembers the gist.* “He told me, ‘Look, I’ve
made my peace with this a long time ago. The drug
companies are going to do this anyway—they are going to
market drugs and produce guidelines, so they can either do
it with input of good people who are knowledgeable and
scientifically sophisticated and evenhanded or not,’”
Kirmayer remembers.
“In their heart of hearts,” Kirmayer said, “I think
academics who have consulted with drug companies think
that they are doing good and that they deserve the
consulting fees and perks.” In short, no one seemed to be
losing any sleep over the ethics of such a luxurious meeting
being sponsored by a drug company. No doubt the thread
count in the sheets helped in this regard.
At the time Ballenger’s response did not seem
unreasonable to Kirmayer. This was before it was revealed
that many of the most influential studies on SSRIs,
supposedly written by prominent academics, were in fact
ghostwritten by private firms hired by drug companies. This
was before it was widely known that many academics had
taken hundreds of thousands of dollars (sometimes millions)
in consulting and speaking fees while at the same time
helping to hide or disguise negative data on the very drugs
they were supposedly evaluating.
It has been only in the past few years, in fact, that these
issues have become a public scandal prompting ongoing
litigation and an investigation in the U.S. Senate. Many
drugs and companies have been implicated in this recent
upheaval, but one company and one drug have been at the
very heart of the scandal: GlaxoSmithKline and Paxil.
Under even the mildest scrutiny, the confident marketing
messages proclaiming the scientific validity of SSRIs begin
to break down. Take for instance the idea, often repeated in
the ads and promotional material surrounding the launch of
SSRIs in Japan, that a depletion of serotonin is the root
cause of depression and that SSRIs reestablish the
“balance” of the “natural” chemicals in the brain.
Pharmaceutical companies have been repeating this idea
ever since SSRIs came on the market twenty years ago. On
their website the makers of the SSRI Lexapro are still telling
the story: “The naturally occurring chemical serotonin is
sent from one nerve cell to the next. . . . In people with
depression and anxiety, there is an imbalance of serotonin—
too much serotonin is reabsorbed by the first nerve cell, so
the next cell does not have enough; as in a conversation,
one person might do all the talking and the other person
does not get to comment, leading to a communication
imbalance.”
Here’s how GlaxoSmithKline describes the same idea on
its website advertising Paxil CR: “Normally, a chemical
neurotransmitter in your brain, called serotonin, helps send
messages from one brain cell to another. This is how the
cells in your brain communicate. Serotonin works to keep
the messages moving smoothly. However, if serotonin levels
become unbalanced, communication may become disrupted
and lead to depression. . . . Paxil CR helps maintain a
balance of serotonin levels.”
As often repeated as this story is, it turns out that there is
currently no scientific consensus that depression is linked to
serotonin deficiency or that SSRIs restore the brain’s normal
“balance” of this neurotransmitter. The idea that depression
is due to deficits of serotonin was first proposed by George
Ashcroft in the 1950s, when he thought he detected low
levels in the brains of suicide victims and in the spinal fluid
of depressed patients. Later studies, however, performed
with more sensitive equipment and measures, showed no
lower levels of serotonin in these populations. By 1970
Ashcroft had publicly given up on the serotonin-depression
connections. To date, no lower levels of serotonin or
“imbalance” of the neurotransmitter have been
demonstrated in depressed patients. The American
Psychiatric Press Textbook of Clinical Psychiatry states
simply, “Additional experience has not confirmed the
monoamine [of which serotonin is a subgroup] depletion
hypothesis.”
SSRIs don’t bring a patient’s brain chemistry back into
balance, but rather broadly alter brain chemistry. Although
that change may sometimes help a depressed patient, the
idea that SSRIs restore a natural balance of serotonin is a
theory without evidence. Put another way, this idea is more
of a culturally shared story than a scientific fact, in the exact
same way neurasthenia’s invocation of “frayed nerves” was
a story.
What made this story so popular was that it turned out to
be an effective marketing line, first employed in the United
States and Europe and then around the world. SSRIs came
on the heels of the public scandal about the overprescribing
of benzodiazepines. These drugs, including Valium and
Librium, were initially embraced by the medical
establishment until they were revealed to be highly
addictive. As SSRIs came to market, the public was
understandably wary of psychopharmacological agents. The
story that SSRIs only helped balance natural chemicals in
the brain, therefore, was just what the public needed to
hear. This marketing line was useful in a similar way in
Japan, where many considered Western psychiatric
medicines to be harsh and unnatural.
In the end, to judge the value of a drug, its benefits must
be considered in light of its risks. Unfortunately, in judging
the benefit-risk balance of SSRIs one immediately runs into
an even more complicated and thorny question: To what
extent can the Western scientific literature describing the
risks and benefits of these drugs be trusted? What worries
many researchers is that the makers of pharmaceutical
drugs such as SSRIs have gained remarkable control over
the creation and presentation of the scientific data that
purport to show that these drugs are safe and effective.
No man has fought harder to expose the process by which
pharmaceutical makers control the knowledge pipeline
behind their drugs than David Healy, a psychiatrist in the
North Wales Department of Psychological Medicine and a
professor at the University of Cardiff. Healy’s particular
crusade is not against SSRIs or the use of any drug in
particular, but for the full and unbiased accounting of the
data.* Because GlaxoSmithKline and other drug companies
have control over the creation of the science, Healy argues,
“there is almost no possibility of discrepant data emerging
to trigger a thought that might be unwelcome to the
marketing department of a pharmaceutical company.”
This skewing and shaping of the data becomes more
confounding as the information gets transmitted across
cultures and languages by the marketers intent on selling
the medication.
According to Healy, drug companies first started
ghostwriting scientific papers for university researchers in
the 1950s. Back then it was seen as a marginally
disreputable practice, and these papers usually appeared
only in obscure journals with little prestige or influence. But
by the 1970s the drug companies had taken control of
funding the major randomized control studies, and by the
mid-1990s, Healy estimates, over half of the studies in the
most prestigious journals were being drafted not by the
university researchers supposedly heading the studies but
by medical writing companies paid by the drug companies.
Once this became an accepted practice, the drug
companies found that they not only had control over what
information made it into print but they also had remarkable
power over which university researchers rose to become
stars in their field. “In effect,” writes Nassir Ghaemi, director
of the Mood Disorders and Psychopharmacology Programs
at Tufts Medical Center, “ghost authorship is the steroid
problem of academia; some of our experts get their fame
artificially, their achievements appearing greater than they
really are.” Those who take the high ground and refuse to
be part of this process run the risk of falling behind their
colleagues who are, so to speak, on the juice.
In the scientific and public discussion that surrounds these
drugs, it is usually only the published results that influence
opinion. Unfortunately, negative results almost never see
print and therefore rarely become part of the debate. A
recent review of seventy-four studies of antidepressants
found that nearly all (thirty-seven out of thirty-eight) of the
positive studies were published in professional journals. Of
the thirty-six negative studies, only three managed to make
it to print. The other thirty-three negative studies either
went unpublished or were reported in a form that claimed a
positive outcome different from the one the study intended
to examine.*
When the raw data from the published and unpublished
studies are examined together, the SSRIs begin to look
nothing like the miracle drug being promoted in Japan and
elsewhere. An analysis of the clinical trial data submitted to
the U.S. Food and Drug Administration shows that about five
out of ten test subjects given an SSRI improve over a couple
of weeks on the depression rating scale. This at first seems
like a fantastic outcome, until one considers the placebo
group, those people in the trial who were given a sugar pill.
On average, four out of ten patients taking a fake pill
improve. Indeed, in many of the unpublished studies, SSRIs
have failed to outperform placebos.
This means that only one in ten test subjects shows a
positive response that can be attributed to the effect of the
SSRI. This is hardly impressive, especially when one
considers the fact that “improvement” doesn’t mean that
the depression goes away but often only indicates a change
on a symptom rating scale. A person who is still depressed
but sleeping better, for instance, might be seen as
improved. Indeed with enough test subjects, even minor
changes in one or two of the checklist items can appear to
be significant.
This rather anemic level of effectiveness would certainly
surprise many Japanese who have been subject to the
mega-marketing campaign promoting SSRIs as a cure for
depression. Negative data get weeded out or spun, while
even small beneficial results zoom through the supposedly
scientific gatekeepers (the academics “authoring” the
studies and the journal editors) to the salespeople, the
marketers, and the public relations firms and out of the
mouths of credulous journalists. Each stage of the process
by which this information is manufactured distances the
doctor and the depressed patient from the actual benefits
and risks of the drug. When this information pipeline crosses
cultural boundaries under the auspices of a mega-marketing
campaign funded by the drug maker, the relation between
the consumer’s perception of the product and the science
behind the drug becomes all but illusory.
In judging just how honest drug companies are being with
the data, one example stands out. In July 2001, just as
GlaxoSmithKline’s marketing campaign in Japan was
ramping up, a paper titled “Efficacy of Paroxetine [Paxil] in
the Treatment of Adolescent Major Depression: A
Randomized, Controlled Trial” was published in the Journal
of the American Academy of Child and Adolescent
Psychiatry, the most influential journal in the field. Among
the half dozen authors were many prominent names,
including lead author Dr. Martin Keller, the chairman of
psychiatry at Brown University. The study had been
conducted between 1994 and 1997 and included almost
three hundred depressed adolescents. It was a double-blind
study—the gold standard—meaning that neither the patient
nor the doctor giving the pills knew which of the subjects
were getting the drug being tested rather than the placebo.
In the paper the authors gave their hearty approval, writing
that Paxil was “generally well tolerated and effective for
major depression in adolescents.”
Within a month of the publication of the study, the
company sales reps were alerted to the good news. A memo
dated August 2001 from Paxil Product Management to “all
sales representatives selling Paxil” trumpeted “this ‘cutting
edge,’ landmark study” as having “demonstrated remarkable
Efficacy and Safety in the treatment of adolescent
depression.”
Internal company documents that have come to light
through lawsuits and government investigations report
remarkably different results. Those internal memos suggest
that the study had in fact failed to show a significant
difference between Paxil and the placebo on any of the
eight measures the study had set out to use. A company
memo reported that the results had proven “insufficiently
robust” and recommended that the company “effectively
manage the dissemination of these data in order to
minimize any potential commercial impact.” The memo
went on: “It would be commercially unacceptable to include
a statement that efficacy had not been demonstrated, as
this would undermine the profile of paroxetine (aka Paxil).”
Needless to say, this in-house assessment by
GlaxoSmithKline staff stands in remarkable contrast to the
published conclusion that Paxil was “well tolerated and
effective for major depression in adolescents.” But more
disturbing still is that the published study apparently
downplayed or hid the drug’s side effects. Early drafts of the
study, which came to light during lawsuits, show that
serious side effects (including hospitalizations and suicide
attempts) were more than five times more likely in the teens
taking Paxil than in those taking the placebo. In addition,
severe and often incapacitating problems with the nervous
system were four times more likely for those on the drug.
Nevertheless, in the first version of the study submitted for
publication there was no mention of any serious adverse
side effects. In a subsequent version there was a sentence
suggesting that “worsening depression, emotional lability,
headache, and hostility” were possible side effects. Even
that acknowledgment was left out of the final published
version of the paper that reports the side effects as only one
“headache.”
So here is an example of the knowledge pipeline created
by Glaxo-SmithKline. From the company’s own internal
documents we see that the study data that entered the
pipeline showed that the effect of the drug on depression in
teens was “insufficiently robust” and that some of those
teens on the drug showed dramatic increases in
hospitalizations and suicide attempts over those given the
placebo. At the other end of the pipeline comes the
marketing claim that the study “demonstrated remarkable
Efficacy and Safety.”
The story of this study, and the problem that it highlights,
is not isolated. After two decades of working at the
esteemed New England Journal of Medicine, Dr. Marcia
Angell became convinced that the system by which these
drugs gain scientific status is broken. “It is simply no longer
possible to believe much of the clinical research that is
published, or to rely on the judgment of trusted physicians
or authoritative medical guidelines,” she wrote in 2009 in
the New York Review of Books. The problems of ghostwriting
and payments to researchers from the drug companies
have, she said, reached their most florid form in the field of
psychiatry and the studies of SSRIs.* The science behind
SSRIs used to justify their sale in other cultures has proven
to be suspect at best.
Suicides and SSRIs
The question of whether these drugs can, in some patients,
increase thoughts of suicide has become a contentious
public debate. Given that GlaxoSmithKline was leveraging
the suicide-depression connection to sell Paxil in Japan, this
question becomes even more salient. Healy estimates that
SSRI trials, when taken together, show that about one in
twenty patients become extremely agitated on these drugs.
For some, that agitation will be so disquieting that it will
spark suicidal thoughts or behavior. The likelihood is that
these drugs are ineffective in most patients, work well for a
small percentage of patients, and spark suicidal thoughts or
behaviors in another small segment. Two well-designed
studies conducted fifteen years apart both point to this
conclusion. In 1993 three researchers from the Department
of Psychiatry at Harvard concluded that antidepressants,
including the SSRI Prozac, likely lessened the chances of
suicide in some patients while raising it in others. “These
observations suggest that antidepressants may redistribute
the risk, attenuating risk in some patients who respond well,
while possibly enhancing risk in others who respond more
poorly.”
Fully fifteen years later another set of researchers, these
from the College of Physicians and Surgeons of Columbia
University, came to a similar but more refined conclusion.
This study looked closely at two years’ worth of patient data
and found that in adults there was no significant difference
between the group that got the drug and the group that
didn’t. In teenagers and children, however, those who took
the drug were significantly more likely than those who didn’t
to attempt suicide within four months after being started on
the drug. Looking at the data further, researchers found one
group in which the drug had a protective effect against
suicidal behavior: adult men. The redistribution of the risk,
in this case, appeared to be away from adult males and
toward teenagers and children.
In the end it is possible that both the critics of SSRIs and
their promoters might have legitimate points on the suicide
question. The agitation and aggression sometimes noted in
association with these drugs are most pronounced early in
the treatment, the very period often focused on in clinical
trials. In real-world use such negative reactions to the drug
may lessen or disappear after this early period. In addition,
attentive doctors may quickly take a patient off the drug, so
that only patients who respond well (or at least don’t spiral
into suicidal behavior) continue taking the drug. Thus it is
possible that these drugs increase suicidality in test subjects
in short-term clinical trials, as critics have contended, and
yet, when judged over years, reduce suicide in the overall
population.
Even if it proves to be true that SSRIs reduce suicidality in
large populations, the drug companies and the researchers
who helped them distort or underreport negative data might
still be culpable. Had those early treatment risks been
accurately reported in the published research on these
drugs, doctors would have had a chance to change the way
they monitored their patients and been better prepared to
spot a patient having a bad reaction. Because suicidal
behavior has been demonstrated even in healthy subjects
(those taking the drug with no symptoms of depression),
doctors almost certainly would have second-guessed
prescribing this medication to those with only mild
symptoms of depression.
The timing of who knew what and when regarding the
risks associated with Paxil is a critical issue because Japan
was so late in adopting the drug. Was GlaxoSmithKline
hiding or downplaying side-effect risks at the same time it
was rolling out its mega-marketing campaign in Japan?
Internal company documents that surfaced in a recent
lawsuit appear to answer that question quite clearly. Data
originally submitted to the U.S. Food and Drug
Administration back in the late 1980s and early 1990s, but
never published, appear to have been presented to
intentionally hide results that test subjects on the drug had
an eightfold increase in the risk of suicidality. “It looks like
GlaxoSmithKline bamboozled the FDA,” Senator Charles
Grassley said in a speech on the floor of the Senate after he
examined the evidence. “We cannot live in a nation where
drug companies are less than candid, hide information and
attempt to mislead the FDA and the public.”
The extent to which the SSRI makers have manufactured
and systematically controlled the creation, flow, and
international distribution of the science is hard to overstate.
Take a step back and look at the system as a whole, and you
can suddenly see it in a different light, as a massive
interconnected marketing system. Applbaum, the
anthropologist who documented the SSRI invasion of Japan,
puts it this way:
Actors traditionally found outside the “distribution channel” of the market
are now incorporated into it as active proponents of exchange. Physicians,
academic opinion leaders, patient advocacy groups and other grass roots
movements, nongovernmental organizations, public health bodies, and
even ethics overseers, through one means or another, have one by one
been enlisted as vehicles in the distribution chain. . . .
In our pursuit of the near-utopian promisea of perfect health, we have,
without realizing it, given corporate marketers free rein to take control of
the true instruments of our freedom: objectivity in science, ethics and
fairness in health care, and the privilege to endow medicine with the
autonomy to fulfill its oath to work for the benefit of the sick.
Even the patient, often now referred to as the
“consumer,” has been enlisted in the distribution chain. In
marketing directly to the consumer through the Internet and
various other avenues, drug companies can claim to be
treating patients as informed consumers. Such informed
consumers can be enlisted to petition their doctors and drug
review boards for access to the drugs. This has been
heralded as a positive change: no longer is the patient a
passive recipient of the doctor’s privileged knowledge.
Unfortunately, the patients, particularly those living outside
the United States, are often the last to know that the
knowledge they are acquiring may have been manipulated
to create specific beliefs and desires.
Early Adopters Have Second Thoughts
There is no doubt that the efforts of GlaxoSmithKline in
Japan proved profitable. In just the first year on the market
Paxil sales brought in over 100 million dollars. At the end of
2002 the company reported, “Sales of Seroxat/Paxil, GSK’s
leading product for depression and anxiety disorders, was
the driver of growth in the CNS (Central Nervous System)
therapy area, with sales of 3.1 billion, up 15% globally and
18% in the USA. International Sales of Paxil Grew 27% to
$401 million led by continued strong growth in Japan, where
the product was launched only two years ago.” By 2008
sales of Paxil were over one billion dollars per year in Japan.
Kitanaka has been stunned to see how fast things have
changed in Japan since SSRIs were introduced. “The whole
culture surrounding psychiatry has changed drastically,” she
told me. “From a stigmatizing notion that no one talked
about, depression has become one of the top concerns of
people. It has become a legitimate disease at so many
different levels and at the same time these changes have
transformed the nature of depression as an experience
itself.”
Some Japanese psychiatrists, even Ono and Tajima, whom
the company feted in 2000, felt they were not leading this
new trend but reacting to it. Ono reports that starting in
2001 he suddenly had a rush of patients showing up at his
office with either a magazine article or an advertisement in
hand and wanting to talk about their depression. It was
clear to him that the mild symptoms these patients
described would not previously have been considered an
illness. As more and more Japanese began to identify
themselves as depressed and as the risks of SSRIs came to
his attention, he has wondered if there were ways to reverse
the trend.
“The marketing campaign has been in many ways too
successful. The slogan, depression is like a ‘cold of the soul,’
has convinced far too many people to seek medical
treatment for something that is often not an illness,” Ono
told me. “Perhaps we could start saying that depression is
like a ‘cancer of the soul.’ That would be more accurate and
perhaps not so many people would be willing to adopt that
belief.”
Dr. Tajima has come even further in his thinking. Tajima is
the prominent psychiatrist who made such encouraging
remarks in Kyoto in 2000 about the adoption of international
diagnostic standards that would “facilitate accurate
diagnosis.” At the time he welcomed the introduction of
SSRIs, saying that they would “contribute to reducing the
burden of depression and anxiety disorders in Japanese
society.” For several years after the conference, Tajima was
a central figure in the company’s attempt to win over other
psychiatrists in Japan. He was paid well by GlaxoSmithKline
to give speeches and appear at conferences. The paper
based on his talk at the Kyoto conference was widely used
in the company’s educational material.
But in the past few years he has become concerned as
he’s watched just how many of his countrymen have been
diagnosed with depression and started on Paxil. Revelations
made public by David Healy and others have caused him to
become skeptical as to whether GlaxoSmithKline has
accurately reported the scientific data regarding the drug’s
effectiveness and risks. He has taken it upon himself to
translate one of Healy’s books into Japanese and now jokes
that he is going to become “the David Healy of Japan.”
In discussing the remarkable changes that he’s seen in
Japan over the past ten years, Tajima does not come off as a
man who is angry with GlaxoSmithKline. Indeed, in
recounting his own participation in these changes, he often
laughs heartily, like a man telling the story of how he was
thoroughly fooled by a talented magician or card shark. His
laughter communicates “I have only myself to blame.”
He maintains that Paxil is helpful for some anxiety
disorders and can be used in serious cases of depression so
long as the patient is monitored closely through the early
days of treatment. However, he has come to believe that
the drug is massively overprescribed and that it can
sometimes spark suicidal thoughts in patients. “After the
Ministry of Health in Japan issued a warning of a suicide risk
with this drug for patients under twenty-five, many doctors
and patients are now aware of this risk,” says Tajima. What
he can’t understand, however, is why the drug remains so
widely prescribed for patients with depressive symptoms
that are transient and relatively mild. The warning about the
risk of suicide seemed not to have had much effect against
the forces of the mega-marketing campaign sponsored by
GlaxoSmithKline in the years since 2000.
Tajima has also come to mistrust the confident science
presented by the pharmaceutical manufacturers. Although
he is aware that the drug companies don’t take kindly to
criticism, he is committed to fighting the good fight and
getting the best information to the Japanese people any way
he can.
Did he have any hope, I asked him, of challenging the
imported ideas that helped popularize depression in Japan?
“The force of this tide is still very strong,” Tajima said. He
did point to some signs that might indicate a lessening of
the momentum. The marginal effectiveness of the drug has
not gone unnoticed. “There are so many patients in Japan
who have not improved and not recovered,” he told me.
“Many ordinary people now have questions about these so-
called magic drugs.”
As journalists often do, I saved the most uncomfortable
question for the very end of my interview with Dr. Tajima. I
told him that I did not want to pry too far into his personal
finances, but I wanted to know how he felt about the money
he had taken from GlaxoSmithKline over the years. “Yes,” he
said, laughing again. “This is a very important question.
Some people say that this relationship between the
researchers and the drug companies is a kind of
prostitution. I agree. But I am not a puritan. I am a very
realistic man. This is very problematic. We have to change
the current situation not only in Japan but also in the United
States and other countries. The strong force of the
pharmaceutical industry threatens to turn medicine into a
pseudoscience in the same way they have made opinion
leaders in the field of Japanese psychiatry into a type of
prostitute.”
Then he paused, laughed again, and added, “We were
very cheap prostitutes.”
Conclusion
The Global Economic Crisis
and the Future of Mental Illness
Cultures become particularly vulnerable to new beliefs
about the mind and madness during times of social anxiety
or discord. It is no surprise that the Western form of
anorexia was able to worm its way into the unconscious
minds of young Hong Kong women in the uneasy years
between the Tiananmen Square massacre and the British
handover of the province to China. As demonstrated in Sri
Lanka, the Western notion of PTSD often gains a hold
because it is deployed in populations that are disoriented
and reeling from wars or natural disasters. It is also no
coincidence that the GlaxoSmithKline version of depression
caught hold in Japan during that country’s lengthy and
painful recession. Ongoing economic upheaval can be
particularly unsettling because the unrelenting threat to
one’s status, security, and future seems to come from
everywhere and nowhere at the same time.
In early 2009, as I was researching the chapter on
depression and Japan, the world economy went into a
tailspin. What happened to the Nikkei in 1990 appeared to
be happening to every major stock index, from the S&P 500
to the OMX Copenhagen 20. The globalization of the world
economy, which had wrought a great many disorienting
changes, had now brought us something new: a truly global
economic crisis. The social upheaval that made Japan
vulnerable to GlaxoSmithKline’s mega-marketing campaigns
was now prevalent in pretty much every country in the
world.
As the crisis grew I listened for the first mental health
experts to step forward with warnings about the
psychological consequences of the crisis. Quick on their
heels, I was sure, would come the promise of new medicines
and perhaps even a new category of mental illness to
explain our distress.
I didn’t have to wait long.
In early February articles about the downturn’s effect on
mental health began to appear in major publications.
“Suicides: Watching for a Recession Spike” was one headline
at Time magazine. “Suicide experts say there is a strong
correlation between acute financial strains and depression,”
the article reported. Near the same time, USA Today
reported, “Signs abound that the battered economy is
causing serious damage to mental health. . . . Nearly half of
Americans said they were more stressed than a year ago,
and about one third rated their stress level as ‘extreme’ in
surveys conducted by the American Psychological
Association.”
The New York Times soon had its own front-page story:
“Recession Anxiety Seeps into Everyday Lives.” Quoting
experts and individuals, the article listed over two dozen
mental health problems caused by economic worries. These
symptoms ranged from the mundane (sleeplessness,
anxiety, constant worrying) to the severe and sometimes
bizarre (struggling to breathe, rapid heartbeat, chills,
choking sensation, numbness and tingling in the fingers,
and arthritis). Such a wide-ranging list of potential
symptoms suggested that we were in the midst of creating
the symptom pool for the current economic crisis. We were
publicly debating, as a culture, which symptoms and
pathologies we would jointly recognize as legitimate
expressions of economic anxiety.
Many of these articles pointed out that our national
mental health was already poor and was now certain to get
worse. The National Institute of Mental Health announced
that one in every four Americans age 18 and older suffers
from a diagnosable mental disorder each year. Among
young adults mental illnesses had become the leading
cause of disability. There were other troubling signs: a study
came out suggesting that the mental disorders sparked by
Hurricane Katrina were proving strangely resistant to both
treatment and the healing effect of time; fully three years
after the fact, the incidence of mood disorders and PTSD
linked to the disaster was still rising in Louisiana.
To counter such bad news, Senior Vice President Ken
Johnson of the pharmaceutical advocacy group PhRMA
announced that no fewer than 301 new medicines were in
development to treat mental illnesses, including sixty-six for
depression and fifty-four for anxiety disorders. It was
important, given the worrisome trends, that the public knew
that new medications were on the way to help people “live
longer, happier, healthier lives.”*
Of course, just what types of disorders those 301 new
drugs will be tasked to treat depends largely on the
American Psychiatric Association, which will soon publish a
new edition of its influential diagnostic manual, the DSM-V.
The research journals have been filled with suggestions for
changes and additions and APA work groups are currently in
the process of hashing out which disorders will be included,
changed, or cut.
As if to demonstrate the point that the creation of mental
illness categories remains as much a social and cultural
endeavor as a scientific process, the APA is soliciting input
from the public. As of this writing there is still a “Make a
Suggestion” link on the association’s website describing the
DSM-V project. Click on that link and you are presented with
a number of options, including “Submit suggestions for
deletion of an existing disorder” and “Submit suggestions
for a new disorder to be considered for addition to DSM-V.”
All suggestions, the public is promised, will be routed to the
proper DSM-V work group for debate.
If I had to lay a bet on which new disorder recently
discussed in the psychiatric literature has the most
promising future, it would be “post-traumatic embitterment
disorder.” PTED describes the reaction to an exceptionally
negative but not life-threatening event, such as conflict in
the workplace, sudden unemployment, the loss of social
status, and separation from one’s social group. Symptoms
include embitterment, feelings of injustice, and
helplessness.
If PTED can get enough allies on the right DSM-V work
groups and a multinational drug company with a new drug
targeting the condition, this disorder has the chance to be
the next PTSD, for it seems well suited to describe many of
the reactions to the precipitous cultural changes during this
time of globalization and economic crisis. Indeed the
disorder was first “discovered” among East Germans who
had become unmoored, unemployed, and insecure in the
social upheaval following the fall of the Berlin Wall.
Whatever new disorders end up in the DSM-V and
whatever new drugs and treatments are declared
scientifically proven to be effective for treating them, there
is no doubt that the American public will show intense
interest. We are a psychologically oriented people. Experts
will appear on talk shows and provide quotes and
commentary for journalists. Over time these new
discoveries will become cultural certainties, conventional
wisdom. In this process these new disorders will further
shape our conscious and unconscious senses of self.
Then the Western mental health profession will take the
show on the road. At international conferences in exotic
locales professionals will train foreign healers in these new
disease categories. Drug companies lured by potential
profits will engage in ever more sophisticated mega-
marketing campaigns. In cultures made vulnerable by the
global financial crisis and the speed of social change, the
seeds of these ideas will no doubt find fertile ground.
If the irony isn’t already obvious, let me make it clear:
offering the latest Western mental health theories in an
attempt to ameliorate the psychological stress caused by
globalization is not a solution; it is a part of the problem. By
undermining both local beliefs about healing and culturally
created conceptions of the self, we are speeding along the
disorienting changes that are at the very heart of much of
the world’s mental distress. It is the psychiatric equivalent
of handing out blankets to sick natives without considering
the pathogens that hide deep in the fabric.
While I was in Zanzibar researching how Swahili beliefs were
mixing with Western biomedical notions of mental illness,
my wife, who is a psychiatrist, sent me a text message from
our home in San Francisco. The brief note told of a tough
day. A patient in her private practice had suffered a
psychotic break and had to be admitted to a psychiatric
ward.
The note reminded me of a point my wife had made often:
while I was traveling the world documenting how Western-
born cultural currents are altering beliefs about the mind,
mental health professionals in the United States and
elsewhere had little choice but to do the best they could
with the knowledge and technology they had at hand. She
worried, you see, that this book would unfairly disparage the
mental health profession, a group of people, including
herself, who are doing their best to heal troubled minds.
Keeping that concern in mind, I have tried to avoid making
the clichéd argument that other, more traditional cultures
necessarily have it right when it comes to treating mental
illness. All cultures struggle with these intractable diseases
with varying degrees of compassion and cruelty, equanimity
and fear. My point is not that they necessarily have it right—
only that they have it different.
It is not surprising that we want to believe everyone is just
like us. As with any generation in human history, we have
little awareness of how our culture shapes our mental life
because it so envelops us, informing both our conscious and
our unconscious thinking. We are like swimmers out of sight
of land: it is difficult to gauge the direction and strength of
the cultural current that carries us along. Difficult, certainly,
but not impossible. As this book suggests, deep explorations
into the beliefs of other cultures can reveal our own cultural
biases in startling ways.
So what does a cross-cultural perspective reveal about our
conception of the mind?
The ideas we export to other cultures often have at their
heart a particularly American brand of hyperintrospection
and hyperindividualism. These beliefs remain deeply
influenced by the Cartesian split between the mind and the
body, the Freudian duality between the conscious and
unconscious, as well as teeming numbers of self-help
philosophies and schools of therapy that have encouraged
us to separate the health of the individual from the health of
the group. Even the fascinating biomedical scientific
research into the workings of the brain has, on a cultural
level, further removed our understanding of the mind from
the social and natural world it navigates. On its website
advertising its antidepressant, one drug company illustrates
how far this reductive thinking has gone: “Just as a cake
recipe requires you to use flour, sugar, and baking powder
in the right amounts, your brain needs a fine chemical
balance in order to perform at its best.” The Western mind,
endlessly parsed by generations of philosophers, theorists,
and researchers, has now been reduced to a batter of
chemicals we carry around in the mixing bowl of our skulls.
What is certain 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.
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Chapter 1
The Rise of Anorexia in Hong Kong
This chapter relied heavily on the work and generosity of Sing Lee and his
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his introduction to other experts in Hong Kong and elsewhere were beyond the
call of duty. I am grateful also for the honesty and openness of the patients who
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Chapter 2
The Wave That Brought PTSD to Sri Lanka
I owe a great many debts on this chapter, and they go back many years. In
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Chapter 3
The Shifting Mask of Schizophrenia in Zanzibar
It perhaps goes without saying that the work of Juli McGruder has been central
to my thinking on schizophrenia. Her dissertation brought me to Zanzibar; her
hospitality when I visited her was very gracious. A small group of researchers—
Kim Hopper, Janis Hunter Jenkins, Robert John Barret, Byron Good, Sue Esteroff,
Louis Sass, and Nancy Scheper-Hughes—formed the intellectual foundation on
which McGruder built. All of these scholars, save the last, contributed to a
remarkable book of papers entitled Schizophrenia, Culture, and Subjectivity: The
Edge of Experience, which I highly recommend.
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Chapter 4
The Mega-Marketing of Depression in Japan
The scholars at McGill University are overrepresented in this book because that
university is a hotbed for the study of cross-cultural psychiatry. That fact, I
believe, has much to do with Larry Kirmayer, whose work and leadership in the
field informs not just this chapter but this entire book. Junko Kitanaka,
Kirmayer’s former graduate student, was as generous as her mentor with her
time and guidance. Her book on the history of depression in Japan will be out
within a year or two, and I will be first in line at the bookstore to snap it up.
David Healy was an inspiration both for his research on the science behind SSRIs
and for his dogged courage.
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Acknowledgments
I had several insightful readers at critical stages of this
project. Po Bronson, Charis Conn, Rob Riddell, and my wife,
Rebecca Watters, assisted me with everything from word
choice to finding my way out of the conceptual labyrinths
that these long chapters sometimes created. Others read
portions as needed, including Alan Burdick, Laura Fraser,
Michal Story, Todd Oppenheimer, and Eleanor Wendell. I’m
indebted to my agent, Chris Calhoun, a champion for this
project from the very beginning. At Free Press I’ve been
pleased to work with Dominick Anfuso, who gave this book
his thoughtful attention during a challenging year. Leah
Miller was critically important in the creation of this book.
My thanks also go to copyeditor Judith Hoover. Michal Story
transcribed many of the interviews and gave me moral
support as well. Kasie Cheung provided Chinese translation.
Joelle Jaffe worked as my researcher on the anorexia and
schizophrenia chapters and helped me think through the
approach for the rest of the book. Encouragement from my
mother, Mary Pulliam Watters, and my brother, Aaron
Watters, was essential. This book was written at the San
Francisco Writers’ Grotto.
Index
Adolescence and Emerging Adulthood: A Cultural Approach (Arnett), 40
Adolescents
SSRI use in, 239–41, 242–43
storm and stress view of, 39–41
Afghanistan, 102, 114, 121
Africa
eating disorders in, 24
schizophrenia in, 153
“After the Tsunami” (symposium), 80
Akil hastaligi, 173
Amatruda, Kate, 73–75, 93–97
American Indians, 195
American Psychiatric Association, 3, 251–52
American Psychiatric Press, 235
American Psychological Association, 250
American Studies International, 47
Amina (family caretaker), 141, 142–43, 144, 145, 148–50, 154–55, 156, 157,
160, 165, 182, 183
Amok, 2, 5
Amphetamines, 212, 213
Angell, Marcia, 241
Anorexia, 3, 6, 9–63. See also Hong Kong changing presentation of, 13, 50–53
Chinese language translation, 43
commodification of, 57–62
debate on reasons for spread, 24–26
educational programs on, 48
feedback loop in, 33, 48–49, 58
feminist perspective on, 58–59
formal recognition of, 30–31
historically low rate (Hong Kong), 14–15
historical perspective on, 26–31
increase in (Hong Kong), 48–49
increase in (nineteenth century), 31–32, 33
inverse relationship with acculturation, 25
media on, 42–47, 48
“me-too,” 50–53
natural vs. social history of, 34–35
physiological experience of, 22–24
research on, 47
social stress and, 38–41, 249
somatic symptoms, 27, 35–36
symptomology (Hong Kong), 12–13, 15–19, 27, 35–36
symptomology (Western), 11, 17, 36–37, 45–47
in the symptom pool, 31–34, 48, 49, 59, 61–62
trigger/tipping point for, 37, 44
two patient populations identified, 50–51
“Anorexia Nervosa in Hong Kong: Why Not More in Chinese?” (Lee), 14
Antidepressants. See Selective serotonin reuptake inhibitors
Applbaum, Kalman, 222–24, 226, 230–31, 244
Approaching Hysteria: Disease and Its Interpretations (Micale), 62
Argenti-Pillen, Alex, 108–14, 125
Arnett, Jeffrey Jensen, 40
Asabi, 102
Ashcroft, George, 235
Association for Play Therapy, 73
Astasia-abasia, 28
Auburn University, 173–74
Au Kam-wah, 42, 44
AusAID, 70
Australia, 70, 153
Austria, 135
Autumn Moon (film), 39
Ayurvedic medicine, 89
Baggerly, Jennifer, 97
Ballenger, James, 232–34
Barrett, Robert John, 136–37
BBC, 77
Beauty industry, 9–10
Benzodiazepines, 236
Berlin Wall, fall of, 252
Biomedical narrative of schizophrenia, 4, 5, 176–78
case history, 165–71
rise of, 171–75
Bloom, Sandra, 116
Boer Wars, 101
Bordo, Susan, 58
Bosnia, 109
Bracken, Patrick, 122–23
Bradford University, 122–23
Breslau, Joshua, 105, 221
British Journal of Psychiatry, 15
British Medical Journal, 118
Brown, David, 118–19
Brown, George, 151
Brown University, 239
Bruch, Hilde, 18, 34, 51
Brumberg, Joan Jacobs, 46, 58–59
Buddhism, 88, 89, 94, 135, 211
Al-Bukhari, 154
Bulimia, 11, 52–53, 59–60, 62
California State University in Los Angeles, 87
Calorias, 102, 114
Cambodian refugees, 102
CARE, 76
Carpenter, Karen, 34
Case histories
of anorexia (see Hsu Chi-Ying, Charlene; Jiao [anorexic woman]; Ling [anorexic
woman]) of depression, 214–21
of schizophrenia (see Al-Mitende, Shazrin [schizophrenic woman]; Zanzibar,
schizophrenic family) Catalepsy, 28
Cattan, Mary, 82
Celebrities and eating disorders, 10–11, 14, 43, 45
Chan Suk-kuen, 42
Charcot, Jean-Martin, 28, 29
Chen, Bobo, 10
Cheung Pak-chi, Cecilia, 10
Children. See also Adolescents
PTSD and, 73–75, 77, 78–79, 82, 83, 84–86, 89, 94, 99, 106
SSRI use in, 242–43
Children’s Impact Events Scale 13 (CRIES-13), 85–86
China, 1, 9, 200
anorexia in, 14
depression in, 195
expressed emotion in, 162
Hong Kong sovereignty transfer, 38–39, 249
schizophrenia in, 153
Cholera epidemic, 201, 202
Christianity, 88, 89, 155, 156
Chung, Gillian, 10, 11
Civil wars
American, 101
Salvadoran, 102
Sri Lankan, 69, 87, 88, 89, 96, 108–14, 123–25
Clark University, 40
CNN, 77
Colombia, 137
Columbia University, 242
Complete Manual of Suicide (Tsurumi), 219–20
Cornell Medical School, 53
Corrigan, Malachy, 119
Crazy: A Father’s Search through America’s Mental Health Madness (Earley), 164
Critical incident debriefing, 75, 116–19
Culture of sadness, 207–13
DaCapo (magazine), 227
Da Costa’s syndrome, 101
Dar Days (Swift), 167–68
Data torturing, 238n
Davidson, Jonathan, 69, 80–81
Davies, Robin, 70
Debility syndrome, 101
Debriefing. See Critical incident debriefing
Demoiselles d’Avignon, Les (Picasso), 53
Denmark, 137, 153
Dentsu advertising agency, 214–19
Depression, 2, 3, 6, 32, 187–248, 249, 250. See also Japan; Selective serotonin
reuptake inhibitors diversity of cultural expression, 193–98
endogenous, 207, 208, 218, 225
explanatory models of, 195, 197
Japanese view of, 192–93, 208–11
media on, 221, 227
mega-marketing of, 224–29
moral compass for, 196
social and moral meaning of, 196, 201
somatic symptoms, 209
stigma of, 208, 225
Western view of, 194, 209–11
Dhows, 132
Diagnostic and Statistical Manual of Mental Disorders (DSM), 3
anorexia in, 17, 19, 36, 37, 43, 47, 48, 50, 54, 63
Culture-Bound Syndromes, 5
depression in, 194, 195, 208, 211
Japanese translation, 208
new edition, 251–52
PTSD in, 71–72n, 115
Diana, Princess, 52, 59–60
Dresser, Roberta, 58, 59
Drug companies, 4. See also specific companies ghostwritten studies of, 234,
237–38, 241
marketing enticements used by, 189–90
motivations given by, 230
researchers paid by, 234, 241, 248
research sponsored by, 229–30
DSM. See Diagnostic and Statistical Manual of Mental Disorders
Duke University, 69
Earley, Pete, 164
Earthquakes
in Japan (Kobe), 105–6, 220–21, 229
Loma Prieta, 117
in Sri Lanka, 87
Eastern Europe, 13
East Germany, 252
East Timor, 104–5
Eating disorders. See Anorexia; Bulimia
Eating Disorders: Anatomy of a Social Epidemic (Gordon), 51–52
Economic crises
global, 249–53
Japanese, 214–15, 227–28, 249
Edo era (Japan), 200, 220
Eisei, 201
Eli Lilly, 191, 222
Emotional expression. See Expressed emotion
Empathy, 161
Endogenous depression, 207, 208, 218, 225
European Society for Traumatic Event Studies, 76
Explanatory models of depression, 195, 197
Expressed emotion, 138–39, 151–54, 160–65
Eye movement desensitization and reprocessing (EMDR), 82
False memories, 119
Fasting Girls: The History of Anorexia Nervosa (Brumberg), 46, 58–59
Fatalism, 155–56, 164
Fatness
admiration for, 14
fear of, 11, 13, 17, 18, 35, 36, 46, 50
Fernando, Gaithri, 87–93, 96, 102, 124
Fertile Crescent (Middle East), 2
Fire illness, 195, 196
Fisha-e-bala, 102, 114
Fluphenazine, 145n, 168
Food and Drug Administration (FDA), U.S., 238, 243–44
France, 70, 153
Fujimura, Misao, 205–6, 219
Gadambanathan, T., 79
Ganesan, Mahesan, 78, 79, 97
Gaze of the wild, 109–11
Geok-Lin Lim, Shirley, 47
Germany, 208
East, 252
neuropsychiatry in, 200, 201–2, 207
schizophrenia in, 153, 172, 173
Ghaemi, Nassir, 237–38
Gist, Richard, 119
GlaxoSmithKline (GSK), 187, 192, 221, 222, 224–36, 239–44, 245–48, 249, 250
conferences hosted by, 188–90, 193–99, 229, 232–34, 246
marketing campaign of, 224–29
U.S. market for products, 188n
Global Development Group, 76
Golden Cage, The (Bruch), 18
Gordon, Richard, 51–52
Granger, D. A., 177
Grassley, Charles, 244
Great Britain
bulimia in, 59–60
expressed emotion in, 162
schizophrenia in, 135
trauma counselors from, 70
Hacking, Ian, 3
Hadith, 154
Haldol, 131
Harvard Medical School, 177
Harvard Trauma Questionnaire, 86
Harvard University, 107, 139, 162, 222, 242
Healing, indigenous. See Indigenous healing techniques
Healy, David, 187, 236–37, 247
Heart Circle Sangha, 81–82
Hemed (schizophrenic man), 141–46, 148, 149, 150, 151, 154, 155
Hinduism, 88, 89, 135
Holy anorexics, 51
Hong Kong, 1, 6, 9–26, 33, 34–57, 61, 62–63. See also Anorexia beauty industry
in, 9–10
bulimia in, 11, 52–53
celebrity culture and, 10–11, 14, 43, 45
educational programs in, 48
media of, 42–47, 48
social stress in, 38–41, 249
sovereignty transfer, 38–39, 249
Hong Kong Eating Disorders Association, 44
Hooley, Jill, 162–63, 164
Hospital of Neukölln, 76
Hsu Chi-Ying, Charlene, 6, 37–38, 41–45, 48, 49, 50
Hudson River Psychiatric Center, 131
Humanitarian Committee of the Association for Comprehensive Energy
Psychology, 82
Hurricane Andrew, 117–18
Hurricane Hugo, 117
Hurricane Katrina, 94, 251
Hysteria, 3, 5, 6, 27–31, 33, 51, 61–62, 202
debate on meaning and cause of, 29–30
PTSD compared with, 72
symptoms of, 28
waning of, 34
Ichiro, Oshima, 214–21
Idioms of distress, 120
Illness negotiation, 33
India
depression in, 195
eating disorders in, 24
expressed emotion in, 162
PTSD in, 70
schizophrenia in, 137, 153
Indigenous healing techniques, 3
in Japan, 20
in Sri Lanka, 88–89
in Zanzibar, 145
Individualism, 163–64
Indonesia, 2, 70
Inna barikama, 109
International Consensus Group on Depression and Anxiety, 188, 190, 198, 233
International Critical Incident Stress Foundation, 117, 118
International Rehabilitation Council for Victims of Torture, 108
International Society for Traumatic Stress Studies, 116
International Trauma Treatment Program, 95
Internet marketing, 226–27
“Invisible Human Crisis, The” (report), 105
Iran, 195
Iraq, 114, 121
Islam, 88, 94, 129, 135, 146–47, 154–55, 158
Island (newspaper), 124
Italy, 153
Japan, 6, 32, 187–248, 250. See also Depression anorexia in, 14, 24
cholera epidemic in, 201, 202
cultural history of, 199–203
culture of sadness in, 207–13
drug approval process in, 191–92, 223–24
drug imports, 191
earthquake in, 105–6, 220–21, 229
economic crisis in, 214–15, 227–28, 249
Japan, contd.
“evolution” analogy and, 231–32
first mental health epidemic in, 203–7
media of, 221, 227
menopause in, 211–12
psychiatric profession and services in, 192–93, 194, 201
PTSD counseling in, 105–6
sedative use in, 212–13
suicide in, 193–94, 198, 202, 205–6, 216–20, 228
workload in, 214–20, 229
Japan Times, 228
Jenkins, Janis Hunter, 136–37, 160–61
Jiao (anorexic woman), 15–22
Jibyo, 211
Jinns, 157
Johnson, Ken, 251
Journal of Clinical Psychiatry, 189
Journal of Neurology, 206
Journal of the American Academy of Child and Adolescent Psychiatry, 239
Judeo-Christian cultures, 135
Kadirgamar, Lakshman, 123
Kansas City Fire Department, 119
Karma, 88, 94
Karojisatsu, 217
Karoshi, 216
Kassim, Ahmed, 127–29, 178, 184–85
Kassim, Latifa, 128–29
Katzman, Melanie, 53–54
Keio University, 199
Keller, Martin, 239
Kellogg School of Management, 222
Kenya, U.S. embassy bombing in, 106
Kidongo Chekundu Mental Hospital, 131, 167, 168, 175–76
Kids Everywhere Like You (KELY), 48
Ki ga fusagu, 209
Ki ga meiru, 209
Kimwana (schizophrenic woman), 141, 144–51, 154, 155, 156, 158, 159, 171
King’s College, 98, 123
Kirmayer, Laurence, 187–90, 193, 194–98, 208, 211, 213, 229, 232–34
Kissinger, Henry, 232
Kitanaka, Junko, 188–89, 199–200, 201, 203, 204, 207, 218, 226, 245
Kitasato, Ichiro, 192
Kleinman, Arthur, 107, 139–40
Knight Ridder/Tribune news service, 117–18
Koda, Kumi, 10
Kokoro no kaze, 225, 228
Koran, 154, 158
Korea
anorexia in, 14
depression in, 195–96
Koro, 2, 5
Kose Corp., 10
Kostelny, Kathleen, 104–5
Kramer, Peter, 192, 221
Kyorin University, 193
Kyushu University, 206
Lancet, 28
Laségue, Charles, 28, 29, 30
Law, Clara, 39
Lee, Sing, 9, 11–24, 26–27, 32, 33, 34–37, 44, 46–58, 62–63
anorexic behavior mimicked by, 22–24
anorexic populations identified by, 50–51
early research of, 13–15
patient deaths from anorexia, 22, 62
scholarly output of, 12
Levine, Michael, 60–61
Lexapro, 234
Liberation Tigers of Tamil, 108, 124
Librium, 236
Ling (anorexic woman), 54–57
Listening to Prozac (Kramer), 192, 221
Llaki, 103
Lock, Margaret, 211–12
Locus of control, 162–63
Loving v. Virginia, 131
Luvox, 192
Mad Travelers (Hacking), 3
Mahoney, John, 81
Malaysia, 24
Manic depression, 175, 202, 207
Marce, Louis-Victor, 29
Masako, Crown Princess of Japan, 228
McGill University, 71, 103, 187, 188, 211
McGruder, Juli, 127–34, 136–42, 144–51, 154–60, 175, 178–85
background, 128, 130–31
biomedical narrative and, 165–66, 169–71, 174
ex-husband’s breakdown, 179–83
love of Zanzibar culture, 133
Media
on anorexia, 42–47, 48
on depression, 221, 227
on PTSD, 67–68, 69, 77, 117–18
Medications, 3–4
for depression (see Selective serotonin reuptake inhibitors)
for PTSD, 80–81
for schizophrenia, 131, 145n, 165, 168–69
Mehta, Sheila, 173–74, 178
Meiji Seika, 192
Melancholic personality (typus melancholicus), 208, 211, 229
Menopause, 211–12
Mental health literacy, 171
“Me-too” anorexics, 50–53
Mexican Americans, 160–61, 162
Micale, Mark, 62
Middle East, 2, 24
Miller, Ken, 102, 107
Mitchell, Jeffrey T., 116–17, 118
Al-Mitende, Shazrin (schizophrenic woman), 165–71, 174
Miyamoto, Masao, 219
Mohammed (prophet), 154
Mongolia, 173
Monoamine depletion hypothesis, 234–36
Mood Disorders Association of Japan, 228
Moral compass, 196
Moss, Kate, 11
Multiple personality disorder, 5, 32
Nakary, 103
Namihira, Emiko, 228
National Alliance for the Mentally Ill, 171
National Center for Post-Traumatic Stress Disorder, 72, 76
National Institute of Mental Health, 251
Nervios, 160–61
Neugeboren, Jay, 177
Neurasthenia, 200, 203–7, 227, 236
Neuropsychiatry, 200, 201–2, 207
New England Journal of Medicine, 28, 241
New Jersey Association of Mental Health Agencies, 65, 67
New York City Fire Department, 119
New Yorker, 119
New York Review of Books, 241
New York Times, 77, 115, 250
New York University, 114
New Zealand, 70
Next (magazine), 10
Nigeria
depression in, 195
eating disorders in, 24
schizophrenia in, 137
Nikkei index, 214, 215, 249
North Africa, 153
North Wales Department of Psychological Medicine, 236
Okuma, Shigenobu, 206
Ono, Yutaka, 228, 246
Operation Recovery, 106
Oppenheim, Janet, 28
Oxfam, 108
Oyserman, Daphna, 163–64
Pakistan, 135
Pantoliano, Joe, 251n
Parachute researchers, 84, 124
Paxil, 6, 187, 190, 192, 193, 222, 223, 229, 233, 239–41. See also Selective
serotonin reuptake inhibitors double-blind study of, 239–41
ghostwritten studies of, 234
manufacturer description, 235
sales revenue, 245
second thoughts on, 245–48
side effects of, 240–41
suicide and, 240, 242–44, 247
Pedersen, Duncan, 103
Peramuna, Janatha Vimukthi, 108
Petite hysterie, la, 61
Pfizer, 80, 222, 223
Pharmaceutical Manufacturers of America (PhRMA), 223, 251
“Pharmacologic Treatment of Acute and Chronic Stress Following Trauma”
(Davidson), 80
Picasso, Pablo, 53
Play therapy, 73–75
Pomona College, 102
Post-traumatic embitterment disorder (PTED), 252
Post-traumatic stress disorder (PTSD), 1–2, 3, 6–7, 32, 65–125, 220n, 249, 251,
252. See also Sri Lanka critical incident debriefing for, 75, 116–19
“denial” of, 77, 98
education vs. indoctrination on, 105–7
global differences in, 100–105
history of, 70–71, 114–18
hopeful lies and, 99–100
literature on, 72
meaning stripped from, 120–23
media on, 67–68, 69, 77, 117–18
medication for, 80–81
play therapy for, 73–75
somatic symptoms, 91, 103
symptom checklists, 84–86, 90
symptomology (Sri Lanka), 91–93
symptomology (Western), 68, 71
treatment risks, 107–14, 118–19
wave metaphor, 70
worldview described by, 73
Post-traumatic Stress Disorder Checklist—Civilian Version, 86
Post-Vietnam syndrome, 114–15, 121
Presbyterian Hospital (New York City), 34
Prince of Wales Hospital, 9, 12, 13, 14, 21
Prozac, 191, 192, 213, 242
Psychological first aid, 4, 75
Psychosocial aid, 97–98
PTSD. See Post-traumatic stress disorder
Pupavac, Vanessa, 119–20
Qi, 20, 200
Qigong, 20
Quechua natives, 103–4
Red Cross International, 76
Religion. See also Spirit possession; specific religions
schizophrenic hallucinations and, 135
in Sri Lanka, 88, 89, 94
in Zanzibar, 146–47, 154–59
Reuters newswire service, 69, 70, 78
Ruhsal hastagi, 173
Russia, 13, 173
Rutgers University, 135
Rwanda, 106, 109
Salvadoran refugees, 102, 114
Samurai warriors, 219
SANE, 171
Sass, Louis, 135
Saxena, Shekhar, 78
Schizophrenia, 6, 127–85. See also Zanzibar culture and content of, 134–36
culture and naming of, 160–61
culture and prognosis, 128, 130, 137–40
expressed emotion and, 138–39, 151–54, 160–65
medication for, 131, 145n, 165, 168–69
neuropsychiatric view of, 202
pathoplastic vs. pathogenic aspects, 135–36
prevalence rates, 136
scientific explanations of, 134
social stress and, 153
stigma of, 172–75, 176–78
stress-diathesis model of, 143
Schnittker, Jason, 173
Scientology, 237n
Scott, Sean, 69
Sedatives, 212–13
Selective serotonin reuptake inhibitors (SSRIs), 191–92, 194, 198–99, 218, 222–
48. See also Lexapro; Luvox; Paxil; Prozac; Zoloft benefit-risk balance, 236–38
clinical trial results, 223–24
cooperation among manufacturers, 222–23
early Japanese view of, 213
effectiveness level of, 238–39
ghostwritten studies of, 234, 237–38, 241
marketing of, 224–29
monoamine depletion hypothesis, 234–36
negative results withheld, 238
placebo compared with, 238, 240
sales growth, 191
scientific data, 230–41
side effects of, 240–41
suicide and, 240, 242–44, 247
Selvie-amah (Sri Lankan woman), 96
Seppuku, 219
September 11 terrorist attacks, 67, 107
Serotonin depletion hypothesis. See Monoamine depletion hypothesis
Shah, Siddharth Ashvin, 100
Shatan, Chaim, 114–15
Shell shock, 101
Shining Path, 103
Shinkeisuijaku, 203
Shorter, Edward, 26–27, 29–31, 32–33, 34, 49, 51
Sikhs, 162
Singapore, 24
Social Work Today, 98
“Society in Distress” (Kitanaka), 199
Sodium amytal, 168
Soldiers, reactions to combat trauma in, 101, 114–15, 121–22
Solvay, 192
Somali refugees, 99
Somatic symptoms
of anorexia, 27, 35–36
of depression, 209
of PTSD, 91, 103
South China Morning Post, 42–43
Southeastern Asians, 2
South Korea, 14
Spain, 153
Spears, Britney, 10
Spirit possession
in the Middle East, 2
in Zanzibar, 6, 132, 145, 156–59, 165, 166–67
Sri Lanka, 6–7, 32, 65–100, 102, 249. See also Post-traumatic stress disorder
certainty of trauma workers in, 97–100
civil war in, 69, 87, 88, 89, 96, 108–14, 123–25
cultural/language deficiencies of therapists, 75, 78, 79–80
earthquake in, 87
extent of psychological intervention in, 70
“gaze of the wild” in, 109–11
media of, 67–68, 69, 77
pace of counseling in, 80
religious beliefs in, 88, 89, 94
resilience in, 87–93
rise of fearlessness in, 107–14
rivalries among counseling groups, 78–79
social relationships in, 91–93, 96
trauma researchers in, 83–87, 124
trauma training for locals, 81–83, 95, 124
Sri Lankan Index of Psychosocial Status, 91
SSRIs. See Selective serotonin reuptake inhibitors
St. Vincent’s Hospital (Sydney, Australia), 69
Standard, The (Hong Kong newspaper), 10, 44, 45, 48
Stelazine, 131
Stiebel, Salomon, 27
Stigma
of depression, 208, 225
of neurasthenia, 204, 207
of schizophrenia, 172–75, 176–78
Stotland, Nada, 241n
Stress-diathesis model of schizophrenia, 143
Suicide
economic conditions and, 250
in Japan, 193–94, 198, 202, 205–6, 216–20, 228
serotonin levels and, 235
SSRIs and, 240, 242–44, 247
Suicide forests, 193–94
Sumathipala, Athula, 84, 124
Summerfield, Derek, 65, 123
Sunni Shafi’ites sect, 154
Surface, David, 98
Swartz, Lesley, 59
Sweden, 136
Swift, Charles, 167–68
Taiwan
anorexia in, 24
schizophrenia in, 137, 153
Tajima, Osamu, 193–94, 246–48
Takiguchi, Kenichiro, 221, 225
Tanaka-Matsumi, Junko, 209–11
Tanzania, 167
Tellenbach, Hubert, 208
Textbook of Clinical Psychiatry, 235
Thailand, 70
Thorazine, 131
Thought field therapy, 82
Tiananmen Square protests, 38, 249
Time (magazine), 250
Ting Yi, 41
Tong, John, 10–11
Toyo Keizai (magazine), 227
Transcultural Psychiatry (journal), 188
Tsunami, 6
description of, 65–66
as metaphor for PTSD, 70
Tsurumi, Wataru, 219–20
Tufts Medical Center, 237
Turkey, 173
Typus melancholicus. See Melancholic personality
UCLA PTSD Reaction, 85
UNICEF, 108
United Nations High Commission for Refugees, 108
United States Embassy bombing (Kenya), 106
University College London, 108
University of California, Santa Barbara, 47
University of Cardiff, 236
University of Colombo, 76–77, 89
University of Florida, 97
University of Hawaii, 209
University of Hong Kong, 47
University of Konstanz, 83
University of Michigan, 163
University of Nottingham, 119–20
University of Pennsylvania, 81, 173
University of Puget Sound, 128, 131
University of Washington, 128, 132
University of Wisconsin, 222
USA Today, 250
Utsubyô, 193, 209, 225
Utsushô, 200–201, 211
Utu-net.com, 227
Valium, 236
Van Eenwyk, John R., 95
Venezuela, 106–7
Victorian era, 3, 5, 28–29, 72
Vietnam Veterans Against the War, 114
Vietnam War, 114–15, 121
Vomiting epidemic, 29
Von Peter, Sebastian, 76
Wall Street Journal, 191
Washington Post, 70
Wentz, Debra, 65–69
Wessells, Michael, 104–5
Wisconsin Law Review, 58
World Health Organization (WHO), 76, 78, 81, 137–40
World Psychiatric Association, 171
World War I, 101
World War II, 121, 207, 219
Wu, Celia, 44
Yaka, 111, 112
Yan shi zheng, 43
Yin-yang balance, 20
Yojo, 200, 201
Young, Allan, 71, 102
Yule, William, 98–100
Yuutsu, 209–11
Zanzibar, 6, 127–51, 154–60, 165–71, 178–85. See also Schizophrenia author’s
stay in, 127–29, 141, 175–76, 178–79, 253
lessons learned from research, 178–84
monsoon effect on culture, 132–33
Zanzibar, contd.
schizophrenic family, 141–51, 154–60, 171, 182, 183
social upheaval in, 142–44
Zar, 2, 6
Zarowsky, Christina, 99
Zogozogo, 142, 150
Zoloft, 80–81, 223–24
* Not that an eating disorder specialist would necessarily disagree with these
items. I mean to point out only that the Western research literature on anorexia
goes far beyond these baseline assumptions in both complexity and diversity of
opinion. What was being transmitted to Hong Kong in the mid-1990s, in other
words, was a lay Westerner’s view of anorexia, the sort of information you’d
glean if you read about anorexia in a weekly news magazine.
* As the DSM-IV describes PTSD: “The essential feature of Post-traumatic Stress
Disorder is the development of characteristic symptoms following exposure to
an extreme traumatic stressor involving direct personal experience of an event
that involves actual or threatened death or serious injury, or other threat to
one’s physical integrity; or witnessing an event that involves death, injury, or a
threat to the physical integrity of another person; or learning about unexpected
or violent death, serious harm, or threat of death or injury experienced by a
family member or other close associate (Criterion A1). The person’s response to
the event must involve intense fear, helplessness, or horror (or in children, the
response must involve disorganized or agitated behavior) (Criterion A2). The
characteristic symptoms resulting from the exposure to the extreme trauma
include persistent reexperiencing of the traumatic event (Criterion B), persistent
avoidance of stimuli associated with the trauma and numbing of general
responsiveness (Criterion C), and persistent symptoms of increased arousal
(Criterion D). The full symptom picture must be present for more than 1 month
(Criterion E), and the disturbance must cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning
(Criterion F).”
* For some critics, this very first study became emblematic of the rush to
diagnose PTSD. How could PTSD have been diagnosed starting at three weeks,
some wondered, when the definition of the disorder requires the symptoms to
last for longer than one month?
* All the names of the African families mentioned in this chapter are
pseudonymous.
* When McGruder compared Amina’s memory to the records in the hospital,
there were considerable differences. The pills she had been given were not,
according to the chart, antimalaria medication but an antispasm drug called
trihexyphenidyl hydrochloride, used to counter facial muscle spasms that can be
a side effect of a powerful antipsychotic called fluphenazine that had been given
to Kimwana in an injection.
* I’ve placed an audio recording of the sound of the square on www.crazy
likeus.com if you’d like to listen to the soundscape Kimwana lived in.
* Expressed emotion researchers have been careful to point out that they were
not tying emotional temperatures in families to the onset of schizophrenia. High
emotion was not a cause of the disease, but rather appeared to be a factor that
greatly influenced its course and outcome. While there is a significant difference
between families with high emotional temperatures and those with low, this is
not true in every case. Many high-expressed-emotion families care for
schizophrenics with low incidence of relapse, and vice versa. It should also be
noted that it is not only relatives who have been studied. Similar results have
come from research into high and low emotionality expressed by caretakers in
group homes and mental institutions.
* Although headquartered in the UK, GlaxoSmithKline has much of its operations
in the United States, where its consumer products division is based. The United
States is the single largest market for GSK drugs.
* The instructions are given in great detail. For potential jumpers, for example,
the book recommends the Takashimadaira housing project and provides a map
to help the reader find the place. The chapter on throwing oneself in front of a
train recommends precisely where to stand on the platform and which express
trains will do the quickest work. To combat these instructions, the transit
authority has placed mirrors at strategic spots, following the theory that seeing
one’s reflection may dissuade one from jumping.
* As discussed in chapter 2 this disaster also played a key role in the
international spread of the PTSD diagnosis.
* Ballenger did not return phone calls requesting an interview for this book.
* In the debate over the risks and benefits of SSRIs there are few people in the
middle ground and a wealth of easily accessible information designed to appear
evenhanded that is, in fact, secretly produced by the drug companies or the
most extreme critics. For instance, both the drug companies and Scientologists
(who believe psychiatric drugs are basically poison) sponsor websites that
appear to the reader to be created by patient advocates or impartial experts in
mental health. Although the SSRI makers have actively tried to portray Healy as
a man of radical opinions, the facts of Healy’s professional life speak for
themselves. Not only was he the former secretary of the British Association of
Psychopharmacology and a professor in psychological medicine at Cardiff
University, but in his medical practice he continues to use antidepressants with
patients who he believes can benefit from the drugs.
* Searching for some secondary positive aspect in otherwise negative data is
referred to as “data torturing” and is often criticized as being the statistical
equivalent of placing the target after throwing the darts.
* In defending her members against Angell’s charges, Dr. Nada Stotland,
president of the American Psychiatric Association, replied to Angell’s criticism,
“It is unfair to suggest physicians are ‘corrupt’ for activities that were virtually
universal when they occurred.’ ” Such a sentence can stop one cold. Is the
president of the APA really falling back on that old chestnut of an excuse for bad
behavior, “Everyone was doing it”? And what definition of corruption is she
relying on that ensures that those in the majority cannot be at fault?
* In the same release, PhRMA announced that it had helped launch a new
consumer advocacy site featuring the well-known actor from The Sopranos, Joe
Pantoliano, who had publicly admitted to struggling with depression. “The goal,”
according to the No Kidding, Me Too website, was to “make brain dis-ease cool
and sexy.”
Cover Page
Title Page
Copyright Page
Dedication
Contents
Introduction
1 The Rise of Anorexia in Hong Kong
2 The Wave That Brought PTSD to Sri Lanka
3 The Shifting Mask of Schizophrenia in Zanzibar
4 The Mega-Marketing of Depression in Japan
Conclusion The Global Economic Crisis and the Future of Mental Illness
Sources
Acknowledgments
Index
Footnotes
Page 46
Page 71
Page 83
Page 141
Page 145
Page 147
Page 152
Page 188
Page 219
Page 220
Page 233
Page 236
Page 238
Page 241
Page 251
ALSO BY ETHAN WATTERS
Urban Tribes:
A Generation Redefines Friendship,
Family, and Commitment WITH RICHARD OFSHE
Makings Monsters:
False Memories, Psychotherapy, and Sexual Hysteria
C
RAZY
L
IKE
U
S
THE GLOBALIZATION OF
THE AMERICAN PSYCHE
ETHAN WATTERS
FREE PRESS
A Division of Simon & Schuster, Inc.
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www.SimonandSchuster.com
Copyright © 2010 by Ethan Watters
All rights reserved, including the right to reproduce this book or
portions thereof in any form whatsoever. For information address
Free Press Subsidiary Rights Department, 1230 Avenue of the Americas, New
York, NY 10020
First Free Press hardcover edition January 2010
FREE PRESS and colophon are trademarks of Simon & Schuster, Inc.
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Manufactured in the United States of America
1 3 5 7 9 10 8 6 4 2
Library of Congress Cataloging-in-Publication Data
Watters, Ethan.
Crazy like us: the globalization of the American psyche / Ethan Watters.
p. cm.
1. Mental illness—Cross-cultural studies. 2. Psychology, Pathological—
Cross-cultural studies. 3. Irish—Race identity. 4. Mental illness—
United States. 5. Globalization—Psychological aspects. 6. Psychiatric
epidemiology. I. Title.
RC455.4.E8W38 2010
http://www.simonandschuster.com/
616.89—dc22 2009030661
ISBN 978-1-4165-8708-8
ISBN 978-1-4165-8719-4 (ebook) For my mother, Mary Pulliam Watters
Contents
Introduction
Chapter 1
The Rise of Anorexia in Hong Kong
Chapter 2
The Wave That Brought PTSD to Sri Lanka
Chapter 3
The Shifting Mask of Schizophrenia in Zanzibar
Chapter 4
The Mega-Marketing of Depression in Japan
Conclusion
The Global Economic Crisis and the Future of Mental Illness
Sources
Acknowledgments
Index
C
RAZY
L
IKE
U
S
Introduction
To travel internationally is to become increasingly unnerved
by the way American culture pervades the world. We cringe
at the new indoor Mlimani shopping mall in Dar es Salaam,
Tanzania. We shake our heads at the sight of a McDonald’s
on Tiananmen Square or a Nike factory in Malaysia. The
visual landscape of the world has become depressingly
familiar. For Americans the old joke has become bizarrely
true: wherever we go, there we are.
We have the uneasy feeling that our influence over the
rest of the world is coming at a great cost: loss of the
world’s diversity and complexity. For all our self-
incrimination, however, we have yet to face our most
disturbing effect on the rest of the world. Our golden arches
do not represent our most troubling impact on other
cultures; rather, it is how we are flattening the landscape of
the human psyche itself. We are engaged in the grand
project of Americanizing the world’s understanding of the
human mind.
This might seem like an impossible claim to back up, as
such a change would be happening inside the conscious and
unconscious thoughts of more than six billion people. But
there are telltale signs that have recently become
unmistakable. Particularly telling are the changing
manifestations of mental illnesses around the world. In the
past two decades, for instance, eating disorders have risen
in Hong Kong and are now spreading to inland China. Post-
traumatic stress disorder (PTSD) has become the common
diagnosis, the lingua franca of human suffering, following
wars and natural disasters. In addition, a particularly
Americanized version of depression is on the rise in
countries across the world.
What is the pathogen that has led to these outbreaks and
epidemics? On what currents do these illnesses travel?
The premise of this book is that the virus is us.
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 has often been 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—influences the diseases
themselves. In teaching the rest of the world to think like us,
we have been, for better and worse, homogenizing the way
the world goes mad.
There is now a remarkable body of research that suggests
that mental illnesses are not, as sometimes assumed,
spread evenly around the globe. They have appeared in
different cultures in endlessly complex and unique forms.
Indonesian men have been known to experience amok, in
which a minor social insult launches an extended period of
brooding punctuated by an episode of murderous rage.
Southeastern Asian males sometimes suffer from koro, the
debilitating certainty that their genitals are retracting into
their body. Across the Fertile Crescent of the Middle East
there is zar, a mental illness related to spirit possession that
brings forth dissociative episodes of crying, laughing,
shouting, and singing.
The diversity that can be found across cultures can be
seen across time as well. Because the troubled mind has
been perceived in terms of diverse religious, scientific, and
social beliefs of discrete cultures, the forms of madness
from one place and time in history often look remarkably
different from the forms of madness in another. These
differing forms of mental illness can sometimes appear and
disappear within a generation. In his book Mad Travelers, Ian
Hacking documents the fleeting appearance in Victorian
Europe of a fugue state in which young men would walk in a
trance for hundreds of miles. Symptoms of mental illnesses
are the lightning in the zeitgeist, the product of culture and
belief in specific times and specific places. That thousands
of upper-class women in the mid-nineteenth century
couldn’t get out of bed due to the onset of hysterical leg
paralysis gives us a visceral understanding of the
restrictions set on women’s social roles at the time.
But with the increasing speed of globalization, something
has changed. The remarkable diversity once seen among
different cultures’ conceptions of madness is rapidly
disappearing. A few mental illnesses identified and
popularized in the United States—depression, post-
traumatic stress disorder, and anorexia among them—now
appear to be spreading across cultural boundaries and
around the world with the speed of contagious diseases.
Indigenous forms of mental illness and healing are being
bulldozed by disease categories and treatments made in the
USA.
There is no doubt that the Western mental health
profession has had a remarkable global influence over the
meaning and treatment of mental illness. Mental health
professionals trained in the West, and in the United States in
particular, create the official categories of mental diseases.
The American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders, the DSM (the “bible”
of the profession, as it is sometimes called), has become the
worldwide standard. In addition American researchers and
organizations run the premier scholarly journals and host
top conferences in the fields of psychology and psychiatry.
Western universities train the world’s most influential
clinicians and academics. Western drug companies dole out
the funds for research and spend billions marketing
medications for mental illnesses. Western-trained
traumatologists rush in wherever war or natural disasters
strike to deliver “psychological first aid,” bringing with them
their assumptions about how the mind becomes broken and
how it is best healed.
These ideas and practices represent much more than the
symptom lists that describe these conditions. Behind the
promotion of Western ideas of mental health and healing
lies a variety of cultural assumptions about human nature
itself. Westerners share, for instance, beliefs about what
type of life event is likely to make one psychologically
traumatized, and we agree that venting emotions by talking
is more healthy than stoic silence. We are certain that
humans are innately fragile and should consider many
emotional experiences as illnesses that require professional
intervention. We’re confident that our biomedical approach
to mental illness will reduce stigma for the sufferer and that
our drugs are the best that science has to offer. We promise
people in other cultures that mental health (and a modern
style of self-awareness) can be found by throwing off
traditional social roles and engaging in individualistic quests
of introspection. These Western ideas of the mind are
proving as seductive to the rest of the world as fast food
and rap music, and we are spreading them with speed and
vigor.
What motivates us in this global effort to convince the
world to think like us? There are several answers to this
question, but one of them is quite simple: drug company
profits. These multibillion-dollar conglomerates have an
incentive to promote universal disease categories because
they can make fortunes selling the drugs that purport to
cure those illnesses.
Other reasons are more complex. Many modern mental
health practitioners and researchers believe that the
science behind our drugs, our illness categories, and our
theories of the mind have put the field beyond the influence
of constantly shifting cultural trends and beliefs. After all,
we now have machines that can literally watch the mind at
work. We can change the chemistry of the brain in a variety
of ways and examine DNA sequences for abnormalities. For
a generation now we have proudly promoted the biomedical
notion of mental illness: the idea that these diseases should
be understood clinically and scientifically, like physical
illnesses. The assumption is that these remarkable scientific
advances have allowed modern-day practitioners to avoid
the biases and mistakes of their predecessors.
Indeed modern-day mental health practitioners often look
back at previous generations of psychiatrists with a mixture
of scorn and pity, wondering how they could have been so
swept away by the cultural beliefs of their time. Theories
surrounding the epidemic of hysterical women in the
Victorian era are now dismissed as cultural artifacts. Even
recent iatrogenic contagions, such as the sudden rise of
multiple personality disorder just fifteen years ago, are
considered ancient history, harmful detours but safely in the
past. Similarly, illnesses found only in other cultures are
often treated like carnival sideshows. Koro and amok and
the like can be found far back in the American diagnostic
manual (DSM-IV, pages 845–849) under the heading
“Culture-Bound Syndromes.” They might as well be labeled
“Psychiatric Exotica: Two Bits a Gander.”
Western mental health practitioners are prone to believe
that, unlike those culturally contrived manifestations of
mental illness, the 844 pages of the DSM-IV prior to the
inclusion of culture-bound syndromes describe real
disorders of the mind, illnesses with symptomatology and
outcomes relatively unaffected by shifting cultural beliefs.
And, the logic goes, if they are unaffected by culture, then
these disorders are surely universal to humans everywhere.
Their application around the world therefore represents
simply the brave march of scientific knowledge.
But the cross-cultural researchers and anthropologists
profiled in this book have a different story to tell. They have
shown that the experience of mental illness cannot be
separated from culture. We can become psychologically
unhinged for many reasons, such as personal trauma, social
upheaval, or a chemical imbalance in our brain. Whatever
the cause, we invariably rely on cultural beliefs and stories
to understand what is happening. Those stories, whether
they tell of spirit possession or serotonin depletion, shape
the experience of the illness in surprisingly dramatic and
often counterintuitive ways. In the end, all mental illnesses,
including such seemingly obvious categories such as
depression, PTSD, and even schizophrenia, are every bit as
shaped and influenced by cultural beliefs and expectations
as hysterical leg paralysis, or the vapors, or zar, or any
other mental illness ever experienced in the history of
human madness.
The cultural influence on the mind of a mentally ill person
is always a local and intimate phenomenon. So although this
book describes a global trend, it is not told from a global
perspective. In the hopes of keeping the human-scale
impact in sight, I have chosen to tell the stories of four
diseases in four different countries. I picked these tales
because each illustrates how the globalization of Western
beliefs about mental health travel on different currents.
From the island of Zanzibar, where beliefs in spirit
possession are increasingly giving way to biomedical
notions of mental illness, I tell the story of two families
struggling with schizophrenia. To document the rise of
anorexia in Hong Kong, I retrace the last steps of 14-year-old
Charlene Hsu Chi-Ying and show how the publicity
surrounding her death introduced the province to a
particularly Western form of the disease. I deconstruct the
mega-marketing of the antidepressant Paxil in Japan to
illustrate how drug companies often sell the very disease for
which their drug purports to be a cure. The aftermath of the
2004 tsunami in Sri Lanka provides the opportunity to
examine the impact of trauma counselors who rush into
disaster zones armed with the diagnosis of posttraumatic
stress and Western certainties about the impact of trauma
on the human psyche.
At the end of each of these chapters I turn the focus back
to the West, and to the United States in particular. When
viewed from a far shore, the cultural assumptions and
certainties that shape our own beliefs about mental illness
and the human mind often become breathtakingly clear.
From this perspective, it is often our own assumptions about
madness and the self that begin to appear truly strange.
The cross-cultural psychiatrists and anthropologists
featured in this book have convinced me that we are living
at a remarkable moment in human history. At the same time
they’ve been working hard to document the different
cultural understandings of mental illness and health, those
differences have been disappearing before their eyes. I’ve
come to think of them as psychology’s version of botanists
in the rain forest, desperate to document the diversity while
staying only a few steps ahead of the bulldozers.
We should worry about this loss of diversity in the world’s
differing conceptions and treatments of mental illness in
exactly the same way we worry about the loss of biological
diversity in nature. Modes of healing and culturally specific
beliefs about how to achieve mental health can be lost to
humanity with the grim finality of an animal or plant lapsing
into extinction. And like those plants and animals, the
diversity in the human understanding of the mind can
disappear before we’ve truly comprehended its value.
Biologists suggest that within the dense and vital
biodiversity of the rain forest are chemical compounds that
may someday cure modern plagues. Similarly, within the
diversity of different cultural understandings of mental
health and illness may exist knowledge that we cannot
afford to lose. We erase this diversity at our own peril.
1
The Rise of Anorexia in Hong Kong
Psychiatric theory cannot deny its participation in the social
trajectory of the anorectic discourse, which articulates
personal miseries as much as it does public concerns.
SING LEE
On the morning of my visit to Dr. Sing Lee, China’s
preeminent researcher on eating disorders, I took the
subway a few stops north of downtown Hong Kong to the
Prince of Wales Hospital in the suburb of Shatin. In the clean
and well-lit subway corridors, I passed several large posters
featuring outlandishly slender, bikinied young women
promoting a variety of health care regimens, cellulite-
removing creams, and appetite-suppressant supplements.
The advertisements over the handrails in the subway cars
repeated the offers. The magazines and newspapers being
read by the commuters were filled with similar pitches,
often featuring before and after photos, young women
becoming little more than skin and bones after the offered
treatment. Such products are a huge business in Hong Kong
and increasingly in mainland China. Over the past few years
the beauty industry in Hong Kong (including dieting,
cosmetics, skin care, and fitness) has outspent every other
business sector on advertising. In that week’s issue of the
popular weekly magazine Next, a remarkable 110 of the
publication’s 150 ads were for slimming or beauty products
and services.
The reporting and photojournalism that appeared
alongside those ads had a slightly different obsession:
telling tales of young women celebrities. That morning’s
Standard, one of Hong Kong’s English dailies, prominently
reported the recent misadventures of several famous young
women, including Britney Spears, who had that week been
held against her will at the UCLA Medical Center. She had
been “5150ed,” which is the code for a California statute
that allows doctors to hold a patient involuntarily if she is
deemed a danger to herself or others. On the opposing page
was an article about the Japanese pop idol Kumi Koda, who
lost her job as a spokesmodel for Japan’s third largest
cosmetics company, Kose Corp., after making pejorative
comments about the fertility of older women. The cute and
perky 25-year-old had gone on a popular radio show and
given her medical opinion that a “mother’s amniotic fluid
turns rotten once a woman reaches about thirty-five . . . It
gets dirty.”
The biggest story in The Standard, in fact the front-page
story in every paper in Hong Kong that morning, was a sex
scandal involving a handful of the region’s best-known
female pop stars and a young actor. Hundreds of very
explicit nude photos had been posted on the Internet of
singer Gillian Chung and actresses Bobo Chen and Cecilia
Cheung Pak-chi, among a dozen others. That same week a
humanitarian crisis was erupting along the Gaza-Egyptian
border and a severe snowstorm was sweeping across much
of eastern China, threatening to strand millions of holiday
travelers, yet no other story could compete with this sex
scandal. Everyone, from politicians to op-ed writers, felt the
need to criticize the behavior of the young women. Even
Hong Kong’s Catholic bishop John Tong weighed in on the
subject of celebrity sin and cyber etiquette, saying that it
was important to “keep our minds decent” and “not post or
circulate these pictures.”
Of course it’s not possible to say exactly what these
advertisements, images, and stories of celebrity
misadventures might have been adding up to in the minds
of average adolescent girls in Hong Kong. It didn’t take
much reading between the lines, however, to perceive a
high degree of confusion and ambivalence surrounding the
issues of female body image, sexuality, youth, beauty, and
aging. Young women in some contexts were worshipped for
their attractiveness, while in other situations they were
humiliated and publicly vilified with a vitriol that would be
hard to overstate. Whatever understanding Hong Kong
teenage girls were piecing together about the
postadolescent world from these sources, it is safe to say
that it was not unconflicted.
Given this environment, it would make sense to most
Americans and Europeans that occurrences of anorexia and
bulimia have spiked here in the past fifteen years. Nor
would it likely be a surprise that Gillian Chung, one of those
young celebrities in the sex scandal, had herself battled
bulimia. Most well-educated Westerners understand that
anorexia is sparked by cultural cues, but they often have a
fairly narrow conception of what those cues might be. Most
assume that anorexia, with its attendant fear of fatness and
body dysmorphic disorder, is born of a peculiar modern
fixation with a slender, female body type, and that popular
culture transmits this fetish to young women. As we’ve
exported our obsessions with slender models—our Barbie
dolls and our Kate Moss fashions—it makes sense to us that
eating disorders have followed in their wake.
But although this commonsense cause and effect might
be part of the story, Sing Lee’s research shows that there
have been other, more subtle, cross-cultural forces at work
here. The full story of how anorexia spread from the
American suburbs to Hong Kong is more complex and, in
many ways, more troubling. It turns out that the West may
indeed be culpable for the rise in eating disorders in Asia,
but not for the obvious reasons.
After making my way across Shatin, I found Lee’s small
suite of offices among the labyrinth of midrise buildings that
make up the Prince of Wales Hospital. Introduced by his
assistant, Dr. Lee was younger than I expected. At 49 years
old, he’s had a remarkable output as a scholar despite the
fact that he has split his time between seeing patients at
the public hospital, teaching, and running a mood disorders
center. He admits that at times he has been accused of
being a workaholic. “I do work long hours, but I’ve never
experienced much work stress,” he said to me in what I
would come to know as his characteristic humble manner.
“I’ve wanted to be a psychiatrist since high school and I still
love the work of meeting patients and writing about ideas.”
Given the amount of time he spends in his office, he’s
allowed himself to build a comfortable environment. The
place has the feel of a stylish bachelor pad. The bucket seat
and gearshift of a sports car sat on the floor next to the
couch. Directly across from his desk was one of his prized
possessions: an antique vacuum tube stereo connected to
two imposingly large speakers. The tuner was made in the
early 1960s and at the time cost as much as a VW Beetle
and requires vacuum tubes the size of small lightbulbs to
operate. For a true classical music audiophile such as Lee,
however, there is no substitute for the resonant tones it
produces.
Even after two decades of charting the cultural currents
that have brought the American version of anorexia to these
shores, Lee remains passionately interested in talking about
the puzzle. He was the first scholar to document anorexia in
Chinese women. The remarkable thing he found was that
before the illness was well known in the province, Chinese
anorexia was unlike that found in the West. These atypical
anorexics, as he calls them, displayed a different cluster of
symptoms than their Western counterparts. Most, for
instance, did not display the classic fear of fatness common
among Western anorexics, nor did they misperceive the frail
state of their body by believing they were overweight. It was
while he was trying to puzzle out these differences that he
witnessed something remarkable.
Over a short period of time the presentation of anorexia in
Hong Kong changed. The symptom cluster that was unique
to his Hong Kong patients began to disappear. What was
once a rare disorder was replaced by an American version of
the disease that became much more widespread.
Understanding the forces behind that change may not only
explain why anorexia became common in Hong Kong, but it
may also lead us to reconsider the momentum behind the
disease in the West.
The Death of a Patient
When Sing Lee came back to Hong Kong from his training in
England in the mid-1980s, he took a job at the Prince of
Wales Hospital and began looking for Chinese anorexics.
Having been introduced to the disorder while in England he
was, like many young psychiatrists, fascinated by the
fundamental conundrum of the disease: Why would healthy
young women with plenty of resources starve themselves?
At the time Lee began his search, the long-held belief that
eating disorders were confined to American and Western
European populations was just beginning to show cracks.
Even though prominent eating disorder researchers were
making the argument as late as 1985 that anorexia didn’t
exist outside of the United States, cases were beginning to
show up in Russia and Eastern Europe. Although it was still
believed to be rare in Latin American countries, researchers
and clinicians also began discovering young women with
anorexia in Japan and South Korea.
In China and Hong Kong the disorder remained all but
unknown. Searching the two major psychiatric journals
published in China, Lee found not a single paper
documenting a Chinese woman with anorexia. With little to
go on, he got to work searching the databases at the Prince
of Wales Hospital. After an exhaustive search, he managed
to identify just ten possible cases in the five years from
1983 to 1988. Given the thousands of patients seen at the
hospital, he determined that anorexia was an exceedingly
rare disorder in Hong Kong. His first paper on the topic,
published in 1989 in the British Journal of Psychiatry, was
titled “Anorexia Nervosa in Hong Kong: Why Not More in
Chinese?”
The low rate of anorexia was a mystery that Lee wanted
to figure out. Perhaps Chinese cultural beliefs or practices
contained protective mechanisms. He knew, for instance,
that historically there was little Chinese stigma surrounding
larger body shapes. In fact popular Chinese sayings
suggested that “being able to eat is to have luck,” “gaining
weight means good fortune,” and “fat people have more
luck.” He also considered that the later onset of puberty in
Chinese girls compared to girls in the West might be a
preventive factor. The physical changes that come with
puberty might be less psychologically stressful when
experienced with an added year or two of emotional
maturity.
But even taking these differences into account, Lee
couldn’t quite understand why the behavior was so
uncommon among local adolescents. In many ways Hong
Kong seemed primed for the disorder. It was a modern
region that, thanks to years of British rule, had incorporated
many Western values as well as styles of dress and eating.
There were fast-food restaurants and health clubs. Thin
Western and Chinese celebrities were idolized. It was a
patriarchal culture, in which parents and teachers put
intense pressure on students to compete. The Chinese
obsession with food and the layered meanings of sharing
meals within a family should have made food refusal a
dangerously attractive behavior for an adolescent looking to
send a distress signal to those around her.
All the triggers for anorexia that had been identified in
Western literature seemed to be present in full force, and
yet eating disorders remained rare. Lee suspected that
there was something else, some factor that hadn’t been
fully considered in the Western literature, that remained
absent in Hong Kong. What that factor might be he could
only guess.
Treating the few cases he could find, Lee discovered
another puzzle. He noticed that the women who starved
themselves in Hong Kong were different from the anorexics
he had studied while training in England. The variations
were sometimes so pronounced he wondered if he was
seeing the same disease. To illustrate those differences, Lee
recounted to me the story of one of the first patients he
personally treated, a 31-year-old saleswoman I’ll call Jiao.
Lee still clearly remembers the first time he met Jiao in a
hospital examination room in 1988. Although he knew from
his research how thin anorexic patients could become, he
couldn’t help but be taken aback at the sight of her. “She
was shockingly emaciated—virtually a skeleton,” he recalls.
“She had sunken eyes, hollow cheeks and pale, cold skin.”
She was alert but uncommunicative. At 5 feet 3 inches, her
ideal body weight should have been in the neighborhood of
110 pounds. Indeed, she had been that weight four years
earlier, before she began to waste away. By the time she
sought medical treatment she weighed just 48 pounds.
During his physical exam of Jiao, Lee noted that she had
dry skin and a subnormal body temperature. More
concerning, her blood pressure was low and her heartbeat
was a plodding 60 beats per minute. He took X-rays after
giving her a drink laced with barium so he could examine
her esophagus. He also used an endoscope to examine her
upper gastrointestinal system for blockages or lesions.
Convinced the disorder wasn’t organic in origin, he began to
piece together her personal history.
Jiao was the youngest child of three living children (two of
her brothers died soon after birth). She had grown up in a
working-class family in a rural village near Hong Kong,
where she still lived. Like many in the Hong Kong area, her
family was both emotionally enmeshed and yet physically
disjointed. To earn a living, her father had lived apart from
the family for many years at a time, and yet, when he was
present, he demanded the absolute loyalty he felt was his
traditional due as head of the household. During his visits
home he often berated Jiao and her mother for small
infractions, such as interrupting him when he spoke, and he
freely expressed his disappointment that Jiao had not
performed better in school. Her mother was a traditional
housewife who was subservient to her husband and was
socially isolated because she spoke only a Chinese dialect
called Hakka. Although it was not a happy home, there was
no history of mental illness, sexual or physical abuse, or
eating disorders.
Jiao’s struggles with eating had begun in earnest four
years earlier, in 1984, when her boyfriend deserted her by
emigrating to England. She was devastated by his departure
and began to refuse food and skip meals. Explaining her
change in eating patterns to her family, she complained of
pain and discomfort in her abdomen. During this time she
became increasingly socially withdrawn and lost her job.
Over those first years of the illness she saw various doctors.
She was encouraged by health professionals as well as her
family to eat more. Nevertheless she steadily lost weight
year after year.
While relating her personal history to Lee during that first
interview, Jiao cried at times but for the most part just
looked sad and tired.
“What do you think is your main problem?” Lee finally
asked her.
“Abdominal fullness and thinness,” she replied.
“What else?”
“A bad mood, it’s hard to describe. . . . It is no use talking
about it anymore,” she said and began to weep.
“Is there a name for your condition?” Lee asked her.
“I don’t know,” she said. “Can you tell me what kind of
disease it is?”
Lee had her draw a picture of herself. This technique is
often used to assess whether anorexic patients have a
distorted perception of their emaciated condition. The stick
figure sketch she handed back to Lee, however, closely
matched her skeletal condition.
Jiao’s presentation left Lee in a quandary. On the one
hand, she was clearly starving herself to the point of death.
On the other hand, she didn’t fit many of the American
diagnostic criteria for anorexia. The Diagnostic and
Statistical Manual of Mental Disorders, published by the
American Psychiatric Association—the third edition released
in the late 1980s had quickly become the worldwide
standard—stated that someone suffering from anorexia not
only rigidly maintains an abnormally low body weight but
expresses an “intense fear of becoming obese, even when
underweight,” and has a disturbed self-image, such as
claiming to “feel fat when emaciated.”
But Jiao did not express a fear of being overweight. In
addition, she didn’t have any misperception about the
emaciated condition of her body. She described herself
pretty much exactly as Lee saw her: as a very sick and
dangerously thin young woman.
When he gave her the standard eating disorder
questionnaire of the time, it also showed clear differences
from what one would expect of an anorexic in the West. For
instance, Jiao insisted that she never consciously restricted
the amount of food she ate. Western anorexics, he knew,
usually admitted to obsessing over food portions and
quantities. When asked why she often went for whole days
without eating, Jiao would say only that she felt no hunger
and, pointing to the left side of her abdomen, describe how
her stomach often felt distended.
These deviations from the Western diagnosis weren’t
unique to Jiao. Most of the Hong Kong anorexics Lee was
able to interview or treat around this time similarly denied
any fear of being fat or of intending to lose weight to
become more attractive. They often spoke of their desire to
get back to a normal body weight. When explaining their
refusal to eat, they most often ascribed the behavior to
physical causes such as bloating, blockages in their throat
or digestion, or the feeling of fullness in their stomach and
abdomen. Their often repeated claim that they had no
appetite also ran counter to conceptions of the disease put
forward by Western experts. Psychiatrist Hilde Bruch, who
wrote one of the seminal books on anorexia, The Golden
Cage, asserted that “patients with anorexia nervosa do not
suffer from loss of appetite; on the contrary, they are
frantically preoccupied with food and eating. In this sense
they resemble other starving people.”
As a group, these Hong Kong anorexics were different
from their American counterparts in other ways as well.
These were not the “golden girls” described in Western
literature on eating disorders. Anorexia in the West was
known to afflict well-to-do, popular, and promising young
women who were sometimes perfectionists in other parts of
their lives, such as school or sports. But Lee’s patients were
often from poor families and among the lower achievers in
their schools. They also did not give any hint of the moral
superiority sometimes observed in Western anorexics.
Most curiously, they were often from outlying villages, not
a population that Lee suspected would be most influenced
by the globalization of Western pop culture. They had not
begun their self-starvation after reading diet books or
engaging in the exercise fads of the day. His atypical
anorexics were not among the young women in Hong Kong
adopting Flashdance fashions or going to Jazzercise classes.
If Western pop cultural influences were at the heart of this
disorder, there were certainly populations in Hong Kong who
should have been harder hit. Hong Kong was, and remains,
the most international of cities, and there were plenty of
groups of adolescents and young women fully engaging in
Western fashion and pop culture. But Lee’s patients did not
come from these jet-setting subcultures.
While Lee had great respect for the clinical knowledge he
had gained during his training in the West, he knew it posed
a challenge as well. With the DSM becoming the world’s
diagnostic manual for mental illness, it was easy to gloss
over different disease presentations to make them fit the
Western standard. But Lee was convinced that the
distinctions between the American presentation of anorexia
and what he was witnessing in Hong Kong was a meaningful
difference that could lead to new insights into the disorder.
He knew that if he was going to understand what was
happening with his Hong Kong patients, he was going to
have to get to the bottom of those differences.
Yin, Yang, and Qi
Despite Lee’s uncertainty about the diagnosis of anorexia,
Jiao was clearly in need of immediate attention. With Lee’s
encouragement she checked into the hospital, but she
proved to be a difficult patient. She used a shifting series of
excuses to refuse the food offered by the dietitian. Lee
speculated that her resistance to his ministrations might be
bound up in the culture clash between Western and Chinese
medicine. Hoping to hit a resonant cultural note that would
lessen her resistance, he called in a Chinese herbalist and
then a qigong master to participate in her treatment. The
herbalist reported to Lee that Jiao’s condition involved a
variety of imbalances between the liver, the spleen, and the
stomach. Her extreme sadness over her lost love had
caused her liver function to break down, the herbalist
explained, which in turn had thrown off the workings of her
spleen and stomach. This had resulted in poor absorption of
food nutrition, limiting her body’s ability to transform food
into qi, the flow of energy that animates all living things.
These problems had led to a weak heart and ineffective
kidneys. In addition, the herbalist found a general imbalance
in her system that he described as an excess of yin and a
depleted reserve of yang.
Because the liver malfunction was at the beginning of the
cascade of internal distress, the herbalist recommended a
mixture of herbs he said would selectively soothe and repair
that organ. The treatment, Jiao was told, would allow her to
let go of the unhealthy energy that surrounded the memory
of her lost love. Jiao refused to drink the concoction.
The qigong master was even less successful. He also
believed that Jiao’s flow of qi was dangerously low. He
performed rituals to unblock her pent-up qi. By the third
treatment, the qigong master quit the case, telling Lee that
the patient was “not willing to recover.”
With neither Western nor Eastern healing modalities
having much impact, Jiao decided to leave the hospital. She
was discharged just before Christmas of 1988. Although she
had gained weight during her hospital stay, from 48 pounds
to 59 pounds, in a checkup two weeks later she had already
dropped four of those pounds. She refused readmission to
the hospital and began to avoid outpatient visits as well.
Over the next few years Lee twice visited her at home,
hoping to lure her back into treatment. During this time her
weight dropped back down to 50 pounds.
In 1992 Lee once again visited Jiao at home, taking two
female medical students with him. Jiao looked as skeletal as
ever and told of heart palpitations and lower limb weakness.
Two of her front teeth had decayed to the point that they
had been removed. Jiao’s mother gestured to Lee that she
was still not eating much. Because of the mother’s language
barrier, a neighbor was brought in to explain the need for
inpatient treatment to her. The neighbor said that many in
the village had tried unsuccessfully to encourage Jiao to eat
more. The neighbor wanted to know from Lee what this
mysterious disease was called and what caused it.
After the visit Lee and the two medical students took Jiao
for a short walk in the village. She showed the students a
picture of herself before the onset of the illness and seemed
happy when they said she was pretty in the photos. She
asked the students if they would reject her as a friend
because of her current terrible appearance. At the end of
the visit, Jiao agreed to consider returning to the hospital,
but when Lee phoned her a few days later she declined
again.
It was only two weeks later that Jiao showed up in the
emergency room of the Prince of Wales Hospital. She was in
terrible shape. She weighted only 42 pounds, her blood
pressure was low, and sacral bedsores were appearing on
her skin. She gasped for breath at the slightest exertion. To
Lee’s relief, Jiao agreed to hospitalization.
During her first day in the hospital, Lee noticed a positive
turn in her outlook. Jiao asked for a referral to the
occupational therapy department so that she could learn
typing and computer skills. She hoped this would put her in
line for a better job later in life. Some of the medical
students who had been following her case with Dr. Lee gave
her a present of a hat and scarf. The gift pleased Jiao. She
asked to get a haircut and began to talk of “making a new
beginning.” She began to take small amounts of food orally.
Two days later, at four in the morning, Jiao’s heart gave
out. The autopsy showed no specific pathology other than
multiple organ atrophy due to her self-starvation.
His failure to help Jiao recover fueled Lee’s passion to
figure out the meaning of anorexia in Hong Kong. Thinking
back on the case, he became convinced that the Western
understanding of the disease, focusing on body image and
fat phobia, was of little use in cases like Jiao’s. What was
needed was not a global template for anorexia, but a much
more local understanding of the personal and cultural forces
at play. Relying on a global template, he believed, could be
worse than just ineffective. The increasingly wide use of the
Western diagnostic categories and the many assumptions
that lay behind them had the potential of blinding local
clinicians to the unique realities of patients in different
cultures.
A Personal Test and Global Spread
Lee knew that he had to understand anorexia on two
different levels. There was the question of why women
began the behavior of self-starvation, and then there was
the question of what happened to their mind and body as
the regimen of starvation gained momentum in their daily
life. Lee felt it was critically important to understand what
anorexia felt like on a physiological level. “I was curious
about the basic question: How can they eat so little?” Lee
recalls. “Why did lunchtime make no difference to them?
What did it mean to turn off the biological clock that
signaled the body to eat?”
Empathy is prized among all mental health providers, but
it’s an ephemeral and untestable quality. A doctor may think
he or she is sensing the internal world of the patient, but
how can one really know? This is especially problematic
when facing a patient with a severe mental illness. Can a
doctor who treats a schizophrenic empathically connect with
the workings of that patient’s mind? Lee realized that, unlike
in other mental disorders, a doctor treating an anorexic
patient had some opportunity to share in the patient’s
experience. Because the key symptom—restricting one’s
eating—was an external behavior, Lee saw an opening to do
an experiment. He decided to mimic the behavior of an
anorexic in the early stages of the disorder.
“I got it in my head,” says Lee, “that if I wanted to truly be
an expert on this condition, I needed to experience it for
myself.” So he began to severely cut back on his food intake
and skip lunch entirely. He also began an intense exercise
routine. Like all dieters, at first he felt the normal drop in
energy and mood as his body struggled to make it through
the day with a depleted supply of calories. After a few weeks
he had lost five pounds, but he still felt like he was dragging
himself through his daily routine. After a month and a half of
restricting food, he was another five pounds lighter but felt
no better. His stomach ached and growled for food.
It was around the three-month mark that some gear
shifted in his physiology. His energy began to return and his
mood improved—more than improved, actually: he felt
great. He was going to bed later and waking up earlier. He
performed behaviors that he would have identified in a
patient as potentially pathological. As he rode the elevator
up to his office every morning, for instance, he did arm
exercises on the handrails. He began to feel a
hyperalertness and sense of mastery over his body and his
life. For much of the day he was on the sort of pleasant
runner’s high that one feels in the middle of a good workout.
His hunger, which for months had been sounding a
deafening alarm, had become a background whisper that he
could easily ignore.
He found himself feeling somewhat superior to other
people, who seemed to be ruled by their incessant need for
food. He couldn’t understand why so many people who tried
to diet lacked the willpower to do so. He found that he was
inordinately pleased that he had the strength of will to see
his project through. The next ten pounds came off with little
effort and his friends and family began to comment on how
thin he was. He had lost over 12 percent of his body weight.
Although Lee felt the desire to stay on his restrictive diet,
he managed to shake himself out of the behavior. His
excuse to himself at the time was that he needed to go to
London for an intense exam at the Royal College of
Psychiatry, and he worried that his lack of nutrition would
limit his mental abilities. It had been a dangerous
experiment but a successful one; he had heard a bit of the
siren song that patients with anorexia often follow to their
death.
One of his patients once told him that anorexia felt like
getting on a train, only to discover too late that she was
headed in the wrong direction. This patient felt she had little
choice but to stay on that train to the final destination. Lee
now had some idea what she meant when she used that
metaphor to describe the psychological momentum that can
build behind anorexia. He had starved himself to the point
where the behavior can turn from a willful choice into a
dangerous addiction.
As Lee’s first papers on anorexia in Hong Kong moved
toward publication, much was changing in the world of
eating disorder research. Scattered case reports had been
followed by outbreaks of eating disorders reported in Africa,
India, and the Middle East. One study showed that students
in Nigeria were scoring as high as Westerners on disordered
eating scales. In the East, anorexia had become increasingly
common in Taiwan, Malaysia, Singapore, and Japan.
The popular explanation at the time was that Western
media were influencing the way women around the world
viewed their bodies; as Western movie stars and models
became the world standard for glamour and attractiveness,
it appeared that eating disorders followed. Although that
seemed like common sense, researchers who tried to prove
a connection between Western acculturation and eating
disorders were often frustrated. Usually these studies
involved giving a group of immigrant women a test to
measure abnormal eating attitudes, along with a set of
questions intended to gauge their level of acculturation to
their new home. The assumption was that women who had
adopted Western norms would have higher scores on the
disordered eating tests.
For the most part, however, these studies failed to make
this seemingly commonsense cause-and-effect connection.
In a review of eighteen such studies, a team of American
researchers concluded, “Despite the long-standing
hypothesis that a greater exposure to Western values leads
to an increased risk for eating disorders, this review of
acculturation research presents no compelling evidence for
such a relationship.” These researchers noted that the
majority of studies failed to find a connection, and the few
that did were offset by studies showing that immigrant
women who were assimilated into Western culture
sometimes had lower scores on disordered eating scales
than women who held to their traditional beliefs and habits.
These latter studies that showed an inverse relationship
between acculturation and disordered eating were the most
controversial because they directly challenged the accepted
wisdom that the true pathogen for eating disorders hid
within Western attitudes toward the female body.
Regardless, studies of British schoolgirls from South Asia
consistently showed that those with a lower level of Western
acculturation had higher levels of body dissatisfaction and
eating disordered behavior. Strikingly similar results were
found among Hong Kong–born women who moved to
Australia.
It was clear that the pathogens that were spreading eating
disorders around the world were not as simple as exposure
to Western fashion, diets, or popular culture. What exactly
was motivating the spread of the disorder remained a hot
topic of debate. If, as Lee had discovered, local forms of
anorexia were often markedly different from the DSM
version of the disease, perhaps there weren’t any universal
causes for anorexia because it wasn’t a single, unified
disease. Or perhaps there was another spark for the spread
of the disease that hadn’t yet been considered.
The Mirror of History
Lee realized that his handful of Hong Kong patients
represented a unique opportunity to examine an expression
of anorexia divorced from Western cultural beliefs about the
condition. Whereas it was all but impossible for a woman
with an eating disorder in the United States to remain
unaware of the various cultural meanings behind the
behavior, Lee’s Hong Kong atypicals often knew of no other
sufferers and lacked even a name for their condition. They
had come to the disease on their own and were negotiating
a private meaning for their refusal to eat.
Hoping to glimpse the disease from a new perspective,
Lee dove into the early history of the disorder. He became
particularly interested in the work of a Canadian scholar
named Edward Shorter, a medical historian who had
recently written several influential papers on the history of
anorexia. Reading the description of young women who
starved themselves in the early to mid-nineteenth century,
long before there was an official category for the illness, Lee
was taken aback. The descriptions of those early self-
starvers from more than a hundred years ago and half a
world away sounded remarkably similar to the Hong Kong
patients he was seeing in his practice.
Shorter recounts the story of a 16-year-old girl treated in
1823 by a Frankfurt physician named Salomon Stiebel. In
Stiebel’s account, the girl’s troubles started when her
parents insisted she break off a budding romantic
relationship with a suitor they deemed inappropriate. After
the girl was given the bad news “she felt a heavy pressure
on the lower region of her esophagus, became pale and
breathless, was unable to speak, and had to sit down.” This
feeling of pressure on her esophagus returned daily, making
it impossible, she reported, for her to eat solid food.
Although it seems clear that her self-starvation was
psychological in origin—beginning as it did with the
termination of a romance—the girl experienced her refusal
to eat as a physical symptom: a literal blockage in her
throat.
In his research Shorter reported a number of similar
descriptions. Like Lee’s patients in Hong Kong, these early
anorexics reported a range of somatic reasons for refusing
to eat. Echoing the explanations from Lee’s patients, several
nineteenth-century doctors reported that patients ascribed
their food refusal to painful digestion. Many, like the girl in
Frankfurt, told of the sensation of having an impassable
lump in the throat. Food would “not go down,” they would
claim. Others claimed other physiological problems, such as
the inability to chew.
These cases were interesting to Lee for what was absent.
Like his atypical patients in Hong Kong, these early
anorexics did not report a desire to lose weight, nor was
there evidence that they had a fear of becoming fat. In
addition these patients did not have a distorted body image,
such as believing they were fat even though they were
emaciated. Lee began to wonder whether he was seeing in
his Hong Kong patients a rare pre-twentieth-century form of
anorexia.
Shorter argued in his papers that the only way to
understand the Western evolution of anorexia is to see it in
the context of the archetypical psychological diagnosis of
the nineteenth century: hysteria. Along with starving
themselves, early anorexics often presented a number of
classic symptoms of hysteria. This was true of the lovelorn
girl from Frankfurt; her other symptoms of distress included
pain at the slightest pressure on her sternum, numbness in
one hand, and a persistent cough. She developed a facial tic
and skin sensitivity on her face. She also experienced
periods of catalepsy, a zombie-like state in which she heard
what was going on around her but could not move or
respond. Although this cluster of symptoms would look
strange today, it would have been nothing new to the
doctors of her time.
The middle decades of that century were a golden age for
hysteria. At its high-water mark, hysteria could include a
remarkable variety of symptoms: convulsive fits, paralysis,
muscle contractions, linguistic impediments, amnesia,
spinal irritation, day blindness, cold sensitivity,
hallucinations, and astasia-abasia, the inability to stand or
walk. The latest theories about the disease were often
topics of conversations in upper-middle-class drawing
rooms, where the latest editions of the New England Journal
of Medicine and the Lancet could often be found. Like the
Dr. Phils and Dr. Drews of our time, many practitioners in the
Victorian era had a taste for the status and celebrity their
positions offered them. Physicians such as Charles Laségue
and Jean-Martin Charcot made their names by discovering in
their patients novel manifestations of what was then the
quintessential illness of womanhood. These doctors filled
lecture halls to announce their discoveries and were toasted
by royalty.
Documenting the rise of the disorder, historians such as
Janet Oppenheim have given us a glimpse of how deeply
hysteria influenced Victorian culture. Oppenheim found the
disease not only in the mental health and medical literature
of the time, but everywhere she looked. Popular magazines
and newspapers, public hygiene literature, novels, short
stories, personal letters, diaries, and autobiographies—it
was an idea that had a tremendous hold on the population
at the end of the nineteenth century. In the spring of 1881
one popular French journalist wrote, “The illness of our age
is hysteria. One encounters it everywhere. Everywhere one
rubs elbows with it. . . . Studying hysteria, Monsieur
Laségue, the illustrious master, and Monsieur Charcot have
put their finger on the wound of the day. . . . This singular
neurosis with its astonishing effects . . . travels the streets
and the world.”
Although self-starvation resulting from stomach pain, lack
of appetite, vomiting, or the sensation of having a lump in
the throat began as a bit player in the grand drama of
hysteria, it steadily gained prominence in the ranks of
hysterical symptoms in the second half of the century. By
1860 Louis-Victor Marce, the director of a large asylum in
France, reported that it was “very common” to observe
“young women who, just having reached puberty after a
precocious physical development, lose their appetite to an
extreme degree. No matter how long they have abstained
from food, they experience a distaste for it which even the
most insistent urging is unable to reverse.” Between 1860
and 1864 the young women in a Lisbon school alternated in
groups between symptoms of hysteria—leg weakness,
paralysis, and day blindness—and periods of vomiting that
went on for months. At one point 90 out of 114 girls
participated in the epidemic of vomiting.
As eating disordered behavior became increasingly
common among hysterics, doctors began to debate its
meaning and cause. Various labels appeared in the early
literature, all hinting at different root causes: “apepsia
hysterica,” “neuropathic disorders of gastric sensibility,”
“nervous dyspepsia,” “hyperaesthesias of the stomach,”
“gastrodynia,” and “visceral neurosis.” “In the years before
the phenomenon received a formal diagnostic label,”
Shorter writes, “the symptoms tended to be inchoate and
poorly defined because neither doctors nor patients had yet
a clear model of the disease.” This time of uncertainty,
Shorter suggests, made for a kind of incubation period for
the illness of anorexia, a time when the debates among
doctors began to shape the public’s and the patients’
understanding of the behavior.
It wasn’t until 1873 that anorexia nervosa finally received
that formal recognition. That year Laségue, already famous
for his work with hysterical patients, dubbed the disease
“hysterical anorexia.” (A year later the word “hysterical”
would be dropped and the term “anorexia nervosa” would
become standard in the medical literature.) The typical
patient, he reported, was a young woman between 15 and
20 who had recently suffered an emotional trauma and
began a “refusal of food that may be indefinitely
prolonged.” He noted that months might go by without the
patient’s health declining. Indeed she might enjoy a surge of
energy. “Not only does she not sigh for recovery, but she is
not ill pleased with her condition, notwithstanding the
unpleasantness it is attended with.”
For another historical scholar, the moment in time when a
disease became officially recognized and named by the
established medical order might be nothing more than an
interesting historical footnote. Shorter, however, was an
expert in the history of psychosomatic illnesses, and he
knew better than anyone that the pronouncements of
famous doctors could have a powerful, though unconscious,
effect on people. As his body of research shows, history was
full of ever-changing psychosomatic symptoms shaped in
large part by the expectations and beliefs of the current
medical establishment. “As doctors’ own ideas about what
constitutes ‘real’ disease change from time to time due to
theory and practice, the symptoms that patients present will
change as well,” he writes. “These medical changes give the
story of psychosomatic illness its dynamic: the medical
‘shaping’ of symptoms.”
Shorter believes that it was Laségue’s famous paper and
the public interest in the medical debate surrounding the
diagnosis of anorexia that forged a kind of template for self-
starvation. As the medical establishment settled on the
name, the agreed-upon causes, and a specific symptom list
for the disease, they were, Shorter argues, “disseminating a
model of how the patient was to behave and the doctor to
respond.” What was once a mishmash of conflicting medical
theories surrounding self-starvation had now gained the
appearance of a precise disorder with a specific at-risk
population.
That new conception of this illness took hold not only
among women who had already manifested disordered
eating but in the population at large. There are no broad
epidemiologic studies of eating disorders from the time, but
the anecdotal evidence for what happened next is
persuasive: soon after the official designation of anorexia
nervosa, the incidence of the disease began a dramatic
climb. Whereas in the 1850s self-starvation was a rare
symptom associated with hysterics, by the end of the
century the medical literature was littered with references
to full-blown anorexics. As one London doctor reported in
1888, anorexic behavior was “a very common occurrence,”
of which he had “abundant opportunities of seeing and
treating many interesting cases.” In that same year a young
medical student confidently wrote in his doctoral
dissertation, “Among hysterics, nothing is more common
than anorexia.”
A New Behavior Dives into the Symptom Pool
What caused the increase in cases of anorexia in the late
nineteenth century? Does the naming of a disorder allow
doctors to suddenly recognize and report what they had
previously overlooked? Or is there an interplay between the
codification of a new mental illness and the sudden
appearance of those symptoms in the general population?
With the introduction of any new illness category (as we’ll
see in the chapters on depression in Japan and PTSD in Sri
Lanka), there are always those who argue that the apparent
increased incidence of a condition is simply due to the fact
that the disease in question had previously gone unnoticed
or underreported. Although there is often some truth to that
assertion, the other possibility has rarely been squarely
addressed. For his part, Shorter unequivocally argues that
there is a clear connection between the official recognition
of anorexia nervosa and the growing number of women who
began to self-starve in Europe and then the United States.
Shorter believes that psychosomatic illnesses (such as leg
paralysis at the turn of the twentieth century or multiple
personality disorder at the turn of the twenty-first) are
examples of the unconscious mind attempting to speak in a
language of emotional distress that will be understood in its
time. People at a given moment in history in need of
expressing their psychological suffering have a limited
number of symptoms to choose from—a “symptom pool,” as
he calls it. When someone unconsciously latches onto a
behavior in the symptom pool, he or she is doing so for a
very specific reason: the person is taking troubling emotions
and internal conflicts that are often indistinct or frustratingly
beyond expression and distilling them into a symptom or
behavior that is a culturally recognized signal of suffering.
“Patients unconsciously endeavor to produce symptoms that
will correspond to the medical diagnostics of the time,”
Shorter told me when I called him in Montreal to speak with
him about Lee’s work. “This sort of cultural molding of the
unconscious happens imperceptibly and follows a large
number of cultural cues that patients simply are not aware
of.”
Because the patient is unconsciously striving for
recognition and legitimization of internal distress, his or her
subconscious will be drawn toward those symptoms that will
achieve those ends. Such a dynamic makes the official
public naming of a disease such as anorexia nervosa a
perilous event. It is clear to Shorter that psychiatrists and
physicians themselves have long been key players in
validating which new disorders or behaviors appear in the
symptom pool.
In the late nineteenth century the process of adding a new
symptom to the hysteria symptom pool would go like this:
On the basis of a few new and exciting cases, doctors would
publicly describe and debate and then codify the new
pathological behavior. Popular magazines, newspapers, and
journals would write about the new medical findings.
Women in the general population would unconsciously begin
to manifest the behavior and seek help. Patients and
doctors would then engage in what is called “illness
negotiation,” whereby they would together shape each
other’s perceptions of the behavior. In this negotiation the
doctor would provide scientific validation that the symptom
was indeed indicative of a legitimate disease category, and
new patients would increase the attention focused on the
new symptom in the professional and popular press,
creating a feedback loop that further established the
legitimacy of the new symptom.
So although there may have been a small number of
patients who presented novel behaviors without a cultural
template (like Lee’s atypical anorexics in Hong Kong), the
widespread adoption of a new hysterical symptom such as
anorexia or leg paralysis would follow the official
“discovery” of the symptom or disorder and the
establishment of the cultural feedback loop.
Anorexia was rare in the mid-nineteenth century not
because physicians somehow failed to notice their starving
patients, Shorter believes, but because it hadn’t yet been
widely acknowledged as part of the symptom pool of that
time. Only after it became a culturally agreed-upon
expression of internal distress did it become widespread.
Interestingly, pathological behaviors don’t attain a
permanent place in the symptom pool. It takes a certain
amount of public and professional attention to keep
behaviors like those common to hysteria in play in the
minds of a population. And indeed in the middle part of the
twentieth century many of the most dramatic symptoms
connected to hysteria drifted out of the symptom pool.
When the psychiatrist Hilde Bruch began her study of
anorexia in the 1940s, she reported that it was once again
“so rare . . . that it was practically unknown.” Searching the
admissions records at Presbyterian Hospital in New York
during those middle decades of the twentieth century, she
found on average only one case per year. Like Lee’s
anorexics, the patients Bruch saw during those years often
weren’t aware that their condition had a name, nor did they
know others who suffered similarly. Each one, she recalls,
“was an original inventor of this effort at self-assertion.” The
disorder once again became the topic of intense public and
professional interest after February 4, 1983, when the
popular singer Karen Carpenter collapsed from heart failure
brought on by anorexia nervosa. After that jump in interest,
the number of articles on the topic steadily grew throughout
the decade. By the late 1980s you’d have been hard-
pressed to find a Western teenager, especially among those
girls in the high-achieving, upper-middle-class demographic
group, who did not know about anorexia nervosa. It was
back in the symptom pool, luring another generation of
women.
A Clean Slate
Looking at the rise and fall and rise of anorexia over the
century, Lee was convinced, like Shorter, that eating
disorders were not at all like diseases such as the mumps or
polio; they didn’t have a natural history that could be
separated from the specific time and place in which they
existed. “Mental illnesses, specifically anorexia, do not exist
independent of social and historical context,” Lee
concluded. “There may therefore be no true natural history
of [anorexia nervosa], but rather a social history at a given
time and place, a perspective which questions radically the
biomedical assumption that there is a ‘core problem’ with
[anorexia nervosa].”
Lee began to suspect that his handful of atypical cases in
Hong Kong were akin to the rare cases of self-starvation in
the early nineteenth century, before it had been codified by
the prominent psychiatrists and physicians of the day and
publicized around the Western world. “I began to think that
these atypical patients I was seeing might shed some light
on the early appearance of self-starvation before it became
known as anorexia,” he recalls. “You can’t go back a
hundred or two hundred years to re-interview early anorexic
patients.”
He came to believe that the reason his patients didn’t
report their self-starvation as coming from a fear of fatness
was because that explanation would have made no sense in
their cultural surroundings. Fear of fatness wasn’t
recognized in the Hong Kong culture as a legitimate reason
for self-starvation; it was therefore unavailable to the
patient both as a private belief and as an explanation she
might give her doctor.
However, there were other explanations at the time that
did make sense. For instance, the Chinese have historically
looked to bodily sensations to indicate psychological
distress. Because of this long history of somaticizing mental
distress, it made sense to Lee that the atypical anorexics he
was seeing often focused on stomach complaints and the
feeling of bloating as the cause of their behavior. Chinese
philosophical thinking avoided making the Cartesian
distinction between the mind and the body. A Chinese girl’s
complaint of stomach pain might carry as much meaning
and impact as a signal of emotional distress as a Western
teenager’s complaint of anxiety or depression. Lee also saw
in his patients echoes of a certain Confucian asceticism—an
almost monk-like self-denial, asexuality, and lack of worry
about their bodily decline or even death. “Their food denial
communicated powerful cultural symbols, private meanings
and interpersonal messages,” Lee concluded. Decoding
these messages required a deep understanding of the
specific cultural forces influencing the self-conception of
these women.
In trying to parse out these meanings, Lee was racing
against time. Even as he was making progress
understanding the particular cultural meanings behind food
refusal in Hong Kong, the Western diagnosis of anorexia was
becoming accepted across the globe. Lee feared that the
DSM diagnosis of anorexia, with its focus on fat phobia and
body image distortion, would obscure more subtle, culturally
specific forms of self-starvation.
Slowly but steadily, in the early 1990s he noticed mental
health providers around him succumbing to a kind of color-
blindness, an inability to see the cultural and individual
differences in the patients they interviewed. As each year
passed, he could see the influence of the Western diagnostic
manual grow, particularly in younger generations of
clinicians. Reviewing other doctors’ notes on new cases of
anorexia referred to him, he would see such sentences as
“The patient still denied having a fear of fatness or dieting.”
For these younger doctors, it couldn’t be a case of anorexia
unless it conformed to the DSM criteria. Lee worried that
these clinicians were adhering to a foreign diagnostic
manual at the expense of understanding both the patient’s
subjective experience and the cultural meaning specific to
Hong Kong at that time. If they became blind to the local
realities of their patients, he feared, they would have little
hope in treating them.
A Death on Wan Chai Road
Although the psychologists and psychiatrists in Hong Kong
began to adopt the DSM description of anorexia, the general
population of Hong Kong remained largely unaware of the
disease. As of the early 1990s, there had yet to be any
outreach campaigns to local high schools. There had been
no Chinese celebrities afflicted with the disorder and little
reported about the condition in newspaper or magazine
articles.
Lee speculated that this very lack of public awareness
about anorexia might be key to the rarity of the disorder,
reducing the likelihood that distressed individuals would
choose, as he put it, “anorexia as a convenient form of
illness.” Which is another way of saying that anorexia
remained outside the symptom pool for the majority of the
population. Lee had a fear, though. As he wrote
prophetically in 1989, he worried that somewhere there
might be an “epidemiogenic trigger” for anorexia that, once
tripped, would “exert an explosive effect.” Five years later
that fear was realized.
At 1 p.m. on November 24, 1994, the last day of her life,
14-year-old Charlene Hsu Chi-Ying walked past the trophy
case at Saint Paul Secondary School, underneath the banner
of the Virgin Mary, and out into the Happy Valley district of
Hong Kong. Wearing her school uniform and carrying her
school backpack, she was unsteady on her feet. She had
fainted twice in the previous week. Just the day before, she
had blacked out in front of her school and had to be sent to
the nurse’s office with a cut knee.
Heading home from Happy Valley to her family’s
apartment in the Healthy Gardens high-rise complex, she
walked north through a forest of skyscrapers toward the
central business district of Hong Kong. Having grown up in
the city, she found the cultural mélange she passed through
to be quite normal. She passed the Seventh Day Adventist
Pioneer Memorial Church and a Buddhist temple. She
walked by one McDonald’s and another a few blocks later.
She walked past the Hong Kong Cemetery, the Saint Michael
Catholic Cemetery, and then past the Muslim cemetery. She
also passed by the front doors of the hospital where her
lifeless body would soon be delivered.
Charlene was about to become famous in Hong Kong as
the public face of anorexia nervosa. Her death that day
would introduce the disorder into the public consciousness
and be a critical turning point in the evolution and spread of
the illness. It is therefore important to try to understand—
both intellectually and on a gut level—what it meant to be a
14-year-old in Hong Kong at that particular moment in
history.
The mid-1990s were an uncertain and nervous time for
the population of Hong Kong. The transfer of sovereignty
from Britain to China was just three years away. Even before
the 1989 Tiananmen Square protests, many families had
attempted to emigrate. After the massacre the number of
those trying to get out of Hong Kong doubled; before the
handover more than half a million people would leave.
This caused a great deal of stress on family networks.
Most countries allowed families to immigrate only in
Western-style nuclear groups: a set of parents and a set of
children. But traditional Chinese ties to extended families
remained strong. Indeed in the unforgiving and competitive
business environment of Hong Kong, support from extended
families was an important social safety net. The emigration
of each family unit weakened that safety net for the
relatives left behind.
“Through the early 1990s, each time we returned from
summer holidays, a few more children had disappeared to
Canada, Australia, the United States, Britain,” wrote one of
Charlene’s contemporaries. “For us confused adolescents, it
was a blur of hasty farewells to friends pulled out of school
midterm. . . . All around us, people were panicking about the
future of the British colony, stunned by the bloody crushing
of the student-led protests in Beijing.”
One can get a sense of the confluence of these forces in
the Hong Kong of the 1990s by watching movies about teen
life during the period. One in particular, Autumn Moon,
directed by Clara Law in 1992, tells us a great deal. Along
with those of other so-called second-wave directors in Hong
Kong, Law’s films are moody and strive to communicate the
postmodern disconnect of the time. Autumn Moon is about a
15-year-old Hong Kong girl who strikes up an unlikely
friendship with a bored and nihilistic Japanese tourist named
Tokio. The teenage girl, Hui, is caught between two
countries: her parents have already emigrated to Canada,
leaving her in Hong Kong to wait for the death of her
grandmother. Like Tokio, Hui is disconnected from traditional
culture. She can’t cook and believes that McDonald’s
represents traditional Chinese food. The movie also riffs on
the globalization of teen culture; when Hui worries that in
Canada no one will have heard of Madonna, Tokio reassures
her, “Don’t worry. Madonna is everywhere.”
As the movie suggests, no segment of the world’s
population is more vulnerable to being swept away by the
currents of globalization than adolescents. Teenagers are
often the first to adopt Western dress and slang and identify
with movies, music, and television. But Autumn Moon
reveals that teenagers in Hong Kong were not simply
interested in Western pop cultural tastes in music and food.
What was changing was the very nature of adolescence. The
first scene shows Hui standing in front of her bedroom
mirror; in a voiceover she says, “I am fifteen years old. I’ve
only just found out that the cold weather doesn’t start right
after summer. Autumn is in between.”
Social scientists have coined a shorthand for the Western
view of adolescence, calling it “storm and stress.” Research
in the United States and Europe has consistently shown that
the teenage years bring with them the highest prevalence
of risky behavior, including substance abuse, wild driving,
and unprotected sex. Some researchers have assumed that
what we’ve learned about adolescence in the United States
and Europe is true of teenagers around the world.
Cross-cultural research has shown, however, that the
storm and stress assumptions about adolescence are far
from universal. According to Jeffrey Jensen Arnett, a
professor at Clark University and the author of Adolescence
and Emerging Adulthood: A Cultural Approach, at the heart
of the cross-cultural difference is the importance placed on
achieving independence. Our Western conception of
adulthood places a high value on individual identity and self-
sufficiency, and much of the storm and stress of Western
adolescence comes from the push and pull of this
movement toward separation.
However, in many traditional cultures, particularly in Asia,
personal independence has not been the goal of adulthood.
Instead, inter dependence—reliance on and obedience to
one’s family, clan, and village—has been the goal.
Teenagers on their path to adulthood are not expected to
strain the bonds that tie them to their family. Because
traditional cultures have de-emphasized the notion that
adolescence is the road to personal independence, much of
the storm and stress experienced by Western adolescents
has been absent.
But there were signs that this was changing. “If it is true
that cultural values of individualism lie at the heart of
adolescent storm and stress,” Arnett concludes, “it seems
likely that adolescence in traditional cultures will become
more stormy and stressful . . . as the influence of the West
increases.”
So not only were governmental and family structures
undergoing rapid change in the mid-1990s in Hong Kong,
but the very nature of adolescence was in flux. Social stress
on the adolescent population was obvious; what had yet to
be determined was how that inchoate psychological charge
would express itself.
Thinner Than a Yellow Flower
It was during this nervous time in the history of Hong Kong
that Charlene Hsu Chi-Ying began to lose weight. Until late
in the summer of 1994 she had been a parent’s dream. Her
grades and test scores consistently put her in the top
percentile of her school. She had a close group of friends
and was active in sports and afterschool activities. Her
mother was never sure why her daughter started to eat less,
as the incident that seemed to spark her food refusal
seemed trivial: her mother had not let her go on a class trip
to mainland China.
Once her weight loss started in August, her personality
quickly changed as well. By October she had become sullen
and uncommunicative. She never mentioned that she was
trying to diet, nor did she mention believing that she was
overweight. Her classmates noticed the change in her
personality. Once a gregarious girl with a group of friends,
by October of that school year she had taken to sitting in
the corner of the lunch room by herself, reading while the
other students ate.
Although the diagnosis of anorexia never came up, both a
school counselor and an outside social worker met with
Charlene to encourage her to eat more and go to a doctor
for a checkup. The last meeting with school personnel took
place the day she fainted in front of the school. The
schoolmistress, Ting Yi, said that the staff had decided not
to tell Charlene’s parents about the incident but to use the
threat as leverage for change. Charlene had one week, they
told her, to improve herself before they would notify her
parents.
The next day Charlene took her fateful last walk. After
passing by the graveyards and the hospital, she turned onto
the busy Wan Chai Road. This is where she often hopped a
tram to take her home to Healthy Gardens. Before she
reached the tram stop she became unsteady on her feet. A
shopkeeper from across the street named Chan Suk-kuen
spotted Charlene. She would later tell the inquest board that
Charlene caught her attention because she was so
preternaturally thin. The shopkeeper briefly lost sight of her
when a double-decker tram obscured her from view. When
the tram passed, she saw that Charlene had collapsed onto
the sidewalk. Chan Suk-kuen and half a dozen other people
came to her aid. When she didn’t revive, they called the
police and an ambulance.
The policeman who checked her backpack and found her
school identification card at first couldn’t reconcile the
smiling and healthy young woman in the picture with the
emaciated and ghostly figure being loaded onto a gurney.
The coroner who examined Charlene’s body, Dr. Au Kam-
wah, found that she weighed 75 pounds. Her adrenal gland,
thyroid, kidney, and stomach all showed signs of atrophy.
She had virtually no stores of subcutaneous fat. Her heart
was tiny, weighing just three ounces. The policeman’s
confusion was repeated at the hospital, where several of the
nurses, upon seeing the skeletal body on the stretcher,
initially assumed it was the remains of an elderly woman.
Had Charlene made it home and died in her family’s
apartment in Healthy Gardens, her passing might not have
caught the attention of the media. However, because she
collapsed on a busy shopping street in the heart of Hong
Kong, the story was irresistible. All of Hong Kong’s Chinese
and English papers gave prominent placement to the story
of her death. “School Girl Falls on Ground Dead: Anorexia
Made Her Skin and Bones,” read one headline in a Chinese-
language paper. “Girl Who Died in Street Was a Walking
Skeleton,” reported the English-language South China
Morning Post. “Schoolgirl Falls Dead on Street: Thinner Than
a Yellow Flower,” reported another Chinese-language daily.
The Chinese-language papers used the phrase yan shi
zheng for the disorder. Yan means to loathe or to dislike, shi
means eating, and zheng means disease or disorder. The
literal translation of the term for anorexia in both the
Cantonese and Mandarin dialects would be something along
the lines of “the disorder of loathing to eat” or “the disease
of disliking eating.” This was the first time people in Hong
Kong had read about a local case of anorexia in their daily
papers.
Of course all of the articles tried to address the burning
question on everyone’s mind: What was the meaning behind
this strange disease that led a young girl to starve herself to
death?
To answer the question, Chinese reporters looked to
Western sources and experts. One reporter for a Chinese-
language daily was clearly cribbing from the DSM when he
described anorexia this way: “The patients are so afraid of
gaining weight, that even when they are underweight, they
insist that they are fat.” Several papers quoted Western
experts to explain that dieting and the fashion industry were
culpable. “Weight loss became a tragedy!” began one story.
“It was speculated that a 15-year-old girl had been losing
weight with the wrong methods, and her health condition
deteriorated day by day.” Dieting and the beauty industry
were not the only causes cited in the papers. “Besides
weight loss for beauty, other causes of anorexia include
family strife and school pressure,” claimed one article in a
Chinese-language daily. It also noted that the pressure of
being a celebrity sometimes brings on the disorder,
reminding readers that a famous American singer had died
of the disease.
A year later a public inquest was held to determine the
cause of Charlene’s death. Charlene’s mother, schoolmates,
teachers, and counselors all gave testimony. The papers ran
stories emphasizing that anorexia nervosa was a dangerous
disease that threatened young women in Hong Kong.
Headlines read “Call for Vigilance to Prevent Anorexia
Deaths” and “Teen Death Sparks Anorexia Concern.”
There was no evidence at that moment that anorexia was
a widespread disorder among young women in Hong Kong.
Indeed the tone of alarm in the headlines and the leads of
the stories was often contradicted by quotes from local
experts near the bottom of the story. On the stand, the
pathologist Dr. Au Kam-wah testified that he had seen only
one other possible case of anorexia in his ten years of
practice. Nevertheless the jury at the inquest recommended
that schools provide counseling and education on eating
disorders and their consequences. The papers followed suit.
“Teachers, social workers, parents and schoolmates should
make a combined effort to detect anorexia among
secondary school girls before it is too late,” began one
follow-up story in The Standard.
Lies about Beauty
It is difficult to document when a psychosomatic symptom
such as self-starvation worms its way into the unconscious
minds of a population. There is, of course, no single moment
when a behavior enters the symptom pool of a culture.
Looking back over time, however, it is often possible to
identify a tipping point, the period after which the public’s
knowledge and acceptance of a symptom or disorder begins
to grow exponentially. There is little doubt that the year of
Charlene’s death represented that crucial tipping point for
anorexia in Hong Kong.
The day before I visited Dr. Lee during my visit to Hong
Kong, I spent an afternoon flipping through the press
clipping files of the Hong Kong Eating Disorders Association
with the organization’s clinical psychologist, Celia Wu. The
popular press articles that were published about anorexia
after 1994 were remarkable both in their volume and in how
similar they were to Western popular press articles on the
topic. Within a few years of Charlene’s death, there were
several Hong Kong actresses and pop singers telling
harrowing stories of becoming anorexic. In one article
Western celebrity anorexics were compared side-by-side
with their Hong Kong counterparts.
The cultural trends identified as the cause of the disorder
were familiar as well. “Swallowing Lies about Beauty Can
Make You Sick,” read a headline in The Standard in 1995.
“Western influence,” the article claims, “brings with it the
notion of ‘happy go skinny.’ Supermodels on catwalks,
Hollywood stars at the Oscars, and even the slender legs in
beer and automobile adverts all promote the anorexic look
as sexy and glamorous.” “Teenagers Risk Health in Quest for
Beauty: Expert Blames Social Pressures for Eating Disorders
as Patient Numbers Soar,” read another typical headline.
Remarkably, the pieces in both Chinese-language and
English-language papers often relied exclusively on Western
psychologists and psychiatrists to explain the illness. The
Western experts quoted in these popular articles repeated
variations on the common themes that dieting and pop
cultural trends caused anorexia and that fear of being fat
was central to the illness. None suggested that there might
be meaningful distinctions between the manifestation of
anorexia in the West and East.
Quoting Western sources, the media coverage in Hong
Kong repeated several ideas, including the following:
That anorexia was a threat to young women who were
prone to anxiety or depression or facing problems in
school or in their families.
That severe food restriction in young women should be
read as a cry for help.
That a key spark for the disorder lay in shifting cultural
ideas of thinness and beauty.
That fat phobia and a distorted body image defined the
disorder.
That anorexia usually attacked the most promising
young women.
This conception of anorexia mirrors fairly well the
understanding one would find in the West among educated
people and non–eating disorder specialists in the medical
and mental health fields.* The idea that anorexia is tied to
culturally imposed notions of female beauty has become
conventional wisdom in the West. “In casual conversation
we hear this idea expressed all the time: Anorexia is caused
by the incessant drumbeat of modern dieting, by the erotic
veneration of sylphlike women,” writes Joan Jacobs
Brumberg in her masterpiece Fasting Girls: The History of
Anorexia Nervosa.
The problem was that many of these Western assumptions
had little meaning for most of the anorexics Lee saw in his
practice. Those women were not motivated by ideas of
thinness and beauty. They were not fat phobic, nor did they
have a distorted body image. They were not the “golden
girls” of their schools or workplace. The mental health
experts quoted in the Hong Kong papers and magazines
confidently reported that anorexia in Hong Kong was the
same disorder that appeared in the United States and
Europe. In Lee’s experience, this was simply not the case.
Western assumptions about the disease were spread not
only through the popular press and television. Western
academic researchers also took up the charge. Shirley Geok-
Lin Lim, a professor of English at the University of California,
Santa Barbara and a visiting professor at the University of
Hong Kong, wrote in the journal American Studies
International that the rise in anorexia in Hong Kong was due
to a “globalization of a visual culture in which women’s
bodies and appearances are homogenized and fetishized as
childlike or waif-like, subordinate and vulnerable.”
Although Lee was trained in the West, his frustration at
this lopsided emphasis on Western knowledge when it came
to anorexia sometimes boiled over. “It is sobering to
recognize that although the non-Western cultures are sub-
dominant and ill-prepared to publish, they make up 80% of
the world,” Lee wrote testily in an article published in 1995.
Indeed the unthinking adoption of the DSM diagnosis of
anorexia threatened to turn the very act of disease labeling
into a meaningless abstraction, one that could harm the
doctor-patient relationship by blinding them both to the
more subtle and complex realities of the patient’s history
and her local experience of culture. Lee wrote, “By
intentionally replacing native metaphors with experience-
distancing jargons and by unintentionally demolishing
cultures, the imposition of universalizing biomedical
categories may imperil illness negotiation on the one hand,
and curtail local healing opportunities on the other.”
Lee’s effort to alert the world to the important differences
in local expressions of anorexia in Hong Kong did not go
unheard, at least within the community of those who
seriously study eating disorders. Beginning with his early
research, his papers on the topic appeared in the top
international journals and received wide praise from other
scholars. But in terms of influencing the general
population’s understanding of the meaning of anorexia,
Lee’s work appeared to have little effect.
In the wake of Charlene’s death educational programs
were launched in schools, further spreading news of the
disorder. A youth support organization called Kids
Everywhere Like You (KELY) announced that it was going to
set up special counseling programs to focus on the threat of
eating disorders. They also announced a twenty-four-hour
hotline in both English and Cantonese to provide information
and counseling.
All these avenues for information fed the general public’s
understanding of the disease. Hong Kong teenagers became
increasingly aware that eating disorders were no longer a
Western phenomenon. They now understood that they were
at risk as well.
What happened over the next few years mirrors what
happened in the United States and Europe after the naming
of the disease. As the public became aware that anorexia
was in the symptom pool, local clinicians, including Lee,
noticed an increase in cases of eating disorders. Where Lee
was once seeing two or three anorexic patients a year, he
was now seeing that many new cases each week. The
increase sparked a new series of newspaper, magazine, and
television reports. One typical article noted that eating
disorders were “twice as common as shown in earlier
studies and that the incidence is increasing rapidly.” In the
late 1990s, studies reported that between 3 and 10 percent
of young women in Hong Kong showed disordered eating
behavior. “Children as Young as 10 Starving Themselves as
Eating Ailments Rise,” announced a headline in The
Standard. The lead stated: “A university yesterday produced
figures showing a 25-fold increase in cases of such
disorders.”
Amid all the finger-pointing at diet fads and the influence
of Western fashion and pop culture, few considered the
possibility that the idea of anorexia nervosa itself—
prepackaged in its DSM diagnosis and explained by readily
available Western experts—might have been part of the
reason the disorder caught on so quickly in Hong Kong. This
possibility, however, fits well with Shorter’s theory of how
symptom pools change over time. At another point in
history, the population of troubled teenage girls might be
drawn to a different unconscious behavior to express their
internal distress. But starting in 1994 a new belief became
prominent in the culture of Hong Kong. Each newspaper
article, magazine essay, and television show that depicted
anorexia as a valid and dramatic expression of mental
distress for young women made that conclusion self-
fulfilling. Each repetition of this idea incrementally increased
the gravitational pull of the disorder on the unconscious
minds of the population, making it ever more likely that a
teenager would try food restriction as a method of
communicating her internal distress. The greater the
number of women who experienced the symptom, the more
public concern and media attention was directed toward the
disease.
Of course, over time a public interest in disordered eating
might have evolved in Hong Kong without Western ideas.
The critical question is, however, Would the cultural
feedback loop have spun into motion so quickly without the
importation of the Western template for the disease? It
seems unlikely. Beginning with the scattered European
cases in the early nineteenth century, it took more than fifty
years for the disease to be named, categorized, and
popularized by Western mental health professionals. By
contrast, after Charlene fell onto the sidewalk on Wan Chai
Road on November 24, 1994, it was just a matter of hours
before the Hong Kong population learned the name of the
disease, who was at risk, and what it meant. The people of
Hong Kong did not come to these conclusions without help.
Rather, they imported the meaning of anorexia from the
West—no assembly required.
“Me-Too” Anorexics
The increase in cases of the disorder was not the only
remarkable thing that happened after Charlene’s death. At
the same time that Lee was trying to alert the world that
anorexia in Hong Kong had its own distinct expression, the
disease presentation among young women in Hong Kong
began to change.
A survey of adolescent anorexics between 1992 and 1997
showed a clear shift in the anorexic patients’ explanation for
their behavior. Unlike Lee’s earlier patients, by 1997 fat
phobia had become the single most important reason given
for their self-starvation. Eighty percent of these young
eating disordered patients, in fact, said that their key reason
for self-starvation was the fear of becoming fat. By 2007
almost all the anorexics he treated reported fat phobia. New
patients were increasingly conforming their experience of
anorexia to the Western version of the disease.
Were doctors and patients reporting fat phobia and body
image distortion simply to put the condition in line with the
DSM? Lee believes the shifting social understanding of
anorexia actually influenced the expression of the disease
on the deeper level of the patient’s experience. Patients
were not simply reporting fat phobia and body image
distortion but actually experiencing those symptoms.
Aspects of the disease seen in Lee’s early patients, such as
the feeling of fullness or bloating in the stomach, lost their
cultural salience, their ability to communicate internal
distress. The importation of the Western diagnosis was not
only changing the way patients and doctors talked about
the disorder—it was changing the disease experience itself.
Lee came to believe that there are basically two
populations from which eating disordered patients come. A
small percentage begin to self-starve on their own. These
women unconsciously choose self-starvation because of
some set of experiences and unconscious currents that are
unique to their particular lives. (It is likely, he believes, that
there have been a small number of self-styled anorexics
throughout history.) These are the sorts of patients that
Shorter wrote about from the mid-nineteenth century and
Bruch saw in the 1940s.
But at different moments in history there arises another
population of eating disordered patients; they come to the
behavior with a cultural understanding of how it is acted
out, who is at risk, and what attitudes and behaviors result
from the condition. The “holy anorexics” of late medieval
times would fall into this category, as would those women
with hysteria in the late nineteenth century.
Bruch saw the distinction between these two groups
during her research. The rare anorexic patient she met in
1940s New York, she reports, was distinct from the dozens
of young anorexic women she treated starting in the 1970s.
“Those who had developed the illness during the 1970s
often had ‘known’ about the illness, or even knew someone
who had it . . . [or] deliberately ‘tried it out’ after having
watched a TV program,” she wrote in one of her final papers
before her death in 1984. “Instead of the fierce search for
independence [which defined earlier patients] these ‘me-
too’ anorexics compete with or cling to each other.”
The different characteristics of these two groups are
interesting but less important than another fact: the women
attracted to the disorder when there exists a cultural
template for the behavior inevitably far outnumber the
women who come to food restriction on their own. Once an
eating disorder becomes an accepted “pattern of
misconduct,” Richard Gordon writes in Eating Disorders:
Anatomy of a Social Epidemic, “individuals with pre-existing
mood or anxiety disorders, or a whole host of underlying
psychopathologies or developmental vulnerabilities,
histories of sexual abuse or familial concerns with weight
control, may be predisposed to adopting such culturally
sanctioned behaviors as modes of managing unbearable
levels of distress.”
The patients Lee documented in the second half of the
1990s appeared to be mostly of the “me-too” type. Lee
believes that stress from the rapid social changes occurring
in Hong Kong led to a “general loading of psychopathology”
within the population. At such moments there is no
universal way for psychological distress to express itself; the
manifestation of such stress reflects the symptom pool of
the time. Once the idiom of eating disorders became
understood, many of these young women used the behavior
to express their inchoate anxiety and unhappiness. “When
there is a cultural atmosphere in which professionals, the
media, schools, doctors, psychologists all recognize and
endorse and talk about and publicize eating disorders,” Lee
explains, “then people with a certain loading of this general
psychopathology can be triggered to consciously or
unconsciously pick eating disorder pathology as a way to
express that conflict.”
As if to prove the point that eating disorders can act like
contagions that blow across national boundaries on the
cultural currents, the late 1990s saw the rapid rise of
another type of eating disorder. In late 1995 Princess Diana
gave her famous interview confirming the rumors that she
had suffered from bulimia for more than four years. “You
inflict it upon yourself because your self-esteem is at a low
ebb, and you don’t think you’re worthy or valuable,” she
said during the interview, which was carried on Hong Kong
television and widely discussed in the press. “I was crying
out for help.” The newspapers again blared headlines
warning about the new disorder.
Once again an eating disorder symptom had arrived in
Hong Kong’s symptom pool with cultural momentum it had
gained elsewhere. Purging behaviors, including self-induced
vomiting and the use of laxatives and diuretics, quickly
spread among the adolescent population. Patients
themselves often reported to their doctors that the impetus
to try these techniques came from reading or hearing about
others with the disorder. Although dieting was usually the
expressed goal, it was hearing or reading about bulimia
itself that was often the spark for the pathological behavior.
“In line with trends witnessed in Western countries,” Lee
wrote at the time, “bulimia is likely to become an
increasingly ‘fashionable’ mode of coping with distress
among young Chinese women in the coming decade.”
Meeting an Atypical Anorexic
In 1907 Picasso created a painting of five nude women he
titled Les Demoiselles d’Avignon. Now famous for being an
early work of the cubist period that was about to blossom in
Paris, the painting is initially disorienting. Each of the
women’s figures is distorted in some manner: breasts and
elbows are at sharp angles, feet and arms are out of
proportion compared to heads; the faces of two of the
women depicted on the left of the painting look like African
masks. The painting has a strange mismatch of styles, at
once representative, impressionistic, and abstract.
Melanie Katzman, a feminist medical scholar from Cornell
Medical School, and Sing Lee wrote about that painting in a
joint paper they published in 1997. In their view, the image
is a metaphor for the approach that must be taken when
trying to understand women suffering from eating disorders
in general and anorexia nervosa in particular. Just as Picasso
used different artistic styles to depict his subjects, the
meaning behind eating disorders can be understood only
when approached cross-disciplinarily. This would be tragic,
they argued, if researchers failed to see the cross-cultural
differences in anorexic behavior and instead put all such
women in a Western mold. Katzman and Lee were writing
not just of what had happened in Hong Kong. In Tokyo,
Singapore, Cape Town, and Jerusalem the discovery of
eating disorders was quickly followed by the arrival of
American-made knowledge that defined what an eating
disorder was and what it meant.
Katzman and Lee hoped that mental health professionals
would “break through the constraints of current ‘bodily
obsessed analysis’ in which fat phobia and body image
distortion are esteemed as the universal driving force
behind food refusal.” The DSM version of the disorder was
obscuring the indigenous distresses and patterns of
behavior that led young women to adopt self-starvation. If
clinicians around the world could avoid the quick and easy
adoption of Western assumptions about anorexia, they
might be able to hear the complex truths individual women
were trying to communicate. Anorexia and eating disorders
could tell us much about the pressures on women in
different cultures if only their voices weren’t being drowned
out by Western narratives about the power of fashion,
dieting, and pop culture.
Wanting me to understand this point on a personal level,
Lee let me spend an afternoon with one of his long-term
patients whom I’ll call Ling. I knew something about Ling
before I met her; Lee had written about her case
prominently over the years.
During our interview, which was facilitated by a translator,
Ling stayed bundled in an oversized ski jacket with a Pink
Panther logo. Even so, it was clear from her frail hands and
the prominent tendons in her neck that she was seriously
underweight. Throughout our interview she sat almost
perfectly still, with her hands clasped in her lap and her
knees held tightly together. Her expression was sad, and
she often looked at the floor while she talked.
Ling had grown up in an unhappy lower-class family. Her
father, who worked off and on as a glass cutter, was a bad-
tempered alcoholic who violently abused his wife and
children. Ling told me that her father had sexually fondled
her on several occasions when she was 12. Not surprisingly,
she hated him and secretly fantasized about his death. She
had repeated nightmares in which she was weeping and
running away from her father as he “chased her like the
devil.”
Ling’s troubles with food began at the dinner table, where
her siblings, her mother, and she had to tolerate the angry
and often drunken tirades of her father. To describe the
experience of eating with her father she used the Chinese
saying, “being forced to drink bitter tea.” In hopes of getting
the ordeal over as quickly as possible, she would sometimes
bolt her food, willfully scalding the inside of her mouth. More
often she simply found that she had no appetite when she
sat down at the family table.
The second of four siblings, she had been plagued by
feelings of insecurity and low self-esteem her entire life.
When she was in her late teens and studying for her Hong
Kong Certificate Examination she began to experience
headaches and insomnia. Her menstrual cycle became
irregular and then stopped altogether. She had stomach
pains that were so intense that a doctor removed her
appendix, but to no avail. Not surprisingly, she performed
poorly on the test and had to quit school to take a job in a
factory calculating wages. She cried often during this time
and began to lose interest in everyone and everything
around her, including eating. She made a half-hearted
suicide attempt by drinking detergent. She tried to join a
church but found her fellow worshippers no more kind or
accepting than her coworkers or strangers on the subway.
Ling led a life of utter social disconnection. For months she
would go to work and then straight home, speaking to no
one.
Like many anorexics of that time, she took a circuitous
path to Lee’s door. Her last stop in the medical system
before Lee was to a gynecologist, where she was hoping to
get help restarting her menstrual cycle. She admitted that
this was her mother’s concern more than her own. Her
mother thought her lack of menstruation made her
unsuitable for marriage. Ling herself had no interest in sex,
marriage, or having children.
Lee first met Ling in 1992 when she was 29 years old. At
that time she weighed 70 pounds, far below her ideal body
weight of 101 pounds. He gave her a standard test used in
the West to diagnose disordered eating behavior. From her
answers it was clear that Ling did not fit the Western
conception of anorexia.
When Ling first became aware that there was a disease
category called anorexia, she couldn’t see how it applied to
her. From her perspective, her behavior wasn’t focused on
food. She protested that her problem was that her life
lacked meaning. She didn’t care about food in the same way
she didn’t care about her career or love life or maintaining
social connections. If she didn’t want to live, why would she
be hungry?
While being treated by Lee in the early 1990s, she moved
from her family home to the thirty-second floor of one of
Hong Kong’s many slender apartment high-rises. Even by
Hong Kong standards she lived in a cramped space: less
than 280 square feet. Her tiny bed was shorter than her
height and she slept curled up. The bathtub was just three
feet long. She often bruised herself while laundering clothes
in the cramped bathroom. Living alone, she was something
of a rebel. The tradition at the time for unmarried women in
Hong Kong was to live with family.
In 2000, when her weight again dropped to 70 pounds,
she was briefly hospitalized. By this time there were enough
anorexics in Hong Kong that they had their own hospital
ward. Meeting these other women, she again questioned
her diagnosis. She learned that other anorexics misused
laxatives and diuretics and were intentionally dieting to lose
weight. “These behaviors sounded strange and awful to
me,” Ling told me. “I was not on a diet and I did not have a
tendency of wanting to lose weight. I didn’t have any of
these behaviors, so I thought, ‘I must not have this illness.’”
To this day Ling is still confused about what ails her. After
meeting other anorexics and reading more about the
disorder in the papers, she continues to wonder whether the
disorder describes her condition. This reaction to the
diagnosis, common among his atypical patients, has led Lee
to ask a rather radical question: Is there any therapeutic
value to categorizing patients such as Ling under one
unifying disease label?
“You might want to group patients under a universal
diagnosis if you faced a condition for which a particular drug
had proved effective,” Lee told me. “But there is no
effective drug treatment for anorexia. The only meaningful
components of treatment are understanding the patient’s
life and creating a motivation for the person to change.
Does a medical diagnosis help with these goals? I am not
convinced it does.” A diagnosis such as anorexia,
particularly if that diagnosis comes prepackaged with ideas
and beliefs from a foreign land, can easily obscure the
complex realities of the individual.
Ling, 44 when I interviewed her, expressed deep shame
over a life she feels she has wasted and the burden she has
caused her family. The one bright spot in life, she reported,
was that she has begun to attend church again. “I feel it is
important to have a religion,” she told me. “I feel some
motivation to do things now.”
The Commodification of Anorexia
The rise of eating disorders in Hong Kong reveals an
uncomfortable truth: our cultural fascination with the
meaning of the eating disorders—our natural desire to
understand the lesson behind them and alert the world to
their danger—can become part of the feedback loop by
which the disease goes forward and claims new victims.
That there is a connection between public and professional
attention to such disorders and their spread within a
community is an idea that is only rarely whispered in the
professional literature on the topic. Not surprisingly, popular
book writers, researchers, and mental health educators are
loath to see themselves as a vector transmitting the disease
they hope to eradicate.
Regardless, it is important to look back at the recent
increase in the number of cases of the disorder in the West
and try to trace this effect. To begin with, there is no doubt
that anorexia became iconic, a cause célèbre, within the
feminist movement of the 1970s and 1980s. Whatever else
can be said about the disorder, anorexia packs a wallop of a
metaphoric punch. As the feminist philosopher Susan Bordo
pointed out, anorexia calls attention to “the central ills of
our culture.” The disease has been endlessly employed to
illustrate the social plight of women. In various writings on
the topic, anorexia has been used to decry unrealistic body
image standards, patriarchal family structures, the
subjugation of women by postindustrial capitalism,
unrealistic ideals of perfection, and more.
Unfortunately, in making these arguments writers have
often unintentionally glamorized the disease and elevated
the social role of the sufferer. Law professor Roberta Dresser
argued in the Wisconsin Law Review in 1984 that medical
and parental efforts to forcibly renourish anorexics should
be challenged as a violation of the patient’s civil liberties.
She made the case that anorexics were similar to political
hunger strikers, bravely challenging social injustice. They
should be allowed to starve as a matter of free expression.
Joan Jacobs Brumberg, the feminist author of Fasting Girls:
The History of Anorexia Nervosa, saw such “romanticization
of anorexia” as deeply problematic, as did many of the most
insightful feminist writers on the topic. She worried that the
promotion of anorexia as a “protest against patriarchy”
would overwhelm the more subtle and nonpolitical
psychological realities of the women caught in the throes of
the disease. “As a feminist,” Blumberg writes, “I believe that
the anorexic deserves our sympathy but not necessarily our
veneration.” Although it was seldom acknowledged, the
worry behind such statements seems clear: veneration
encourages imitation.
With the maturing of the feminist movement, this siren
song to potential anorexics has largely died away. No recent
feminist writers that I’m aware of have argued like Dresser
that anorexics should be allowed to starve themselves to
death to prove a political point. Still, anorexia and bulimia
remain in the symptom pool of our time for more subtle and
intractable reasons.
Those who devote their lives to treating disease are in a
conundrum that has rarely gained public attention. At the
same time that they are researching, publishing, and
publicly speaking about these eating disorders, they are
both molding the public’s understanding of the behavior and
keeping it in the symptom pool of our time. The South
African psychologist Lesley Swartz is one of a very few who
have addressed this difficult issue. “Regardless of the
amount of care taken in education about any condition,
professionals are inevitably involved in maintaining and
shaping it,” he writes. “We must allow that an environment
receptive to the understanding of eating disorders may be
one in which they will flourish.”
Sometimes the extent to which researchers avoid this
troubling issue is startling. A recent study by several British
researchers showed a remarkable parallel between the
incidence of bulimia in Britain and Princess Diana’s struggle
with the condition. The incidence rate rose dramatically in
1992, when the rumors were first published, and then again
in 1994, when the speculation became rampant. It rose to
its peak in 1995, when she publicly admitted the behavior.
Reports of bulimia started to decline only after the
princess’s death in 1997. The authors consider several
possible reasons for these changes. It is possible, they
speculate, that Princess Di’s public struggle with an eating
disorder made doctors and mental health providers more
aware of the condition and therefore more likely to ask
about it or recognize it in their patients. They also suggest
that public awareness might have made it more likely for a
young woman to admit her eating behavior. Further, the
apparent decline after 1997 might not indicate a true drop
in the numbers, but only that fewer people weren’t
admitting their condition. These are reasonable hypotheses
and likely explain part of the rise and fall in the numbers of
bulimics. What is remarkable is that the authors of the study
don’t even mention, much less consider, the obvious fourth
possibility: that the revelation that Princess Di used bulimia
as a “call for help” encouraged other young women to
unconsciously mimic the behavior of this beloved celebrity
to call attention to their own private distress.
The fact that these researchers didn’t address this
possibility is emblematic of a pervasive mistaken
assumption in the mental health profession: that mental
illnesses exist apart from and unaffected by professional
and public beliefs and the cultural currents of the time.
Off the podium, some eating disorder experts will admit to
a deep insecurity about the possibility that their work might
be to some degree counterproductive. I asked Michael
Levine, a prominent researcher and eating disorder
educator, whether he ever worries that his work has
potentially spread the very disease he hopes to eradicate.
“In dark periods I worry about it,” he told me. “This disorder
has given me an identity as a professional. I’m a tenured
professor with an endowed chair. Now, am I helping people
or hurting people? I hope I’m helping. But at the same time I
have to acknowledge that anorexia has given me an identity
in the same way it has given one to so many young girls—
sometimes a deadly one.”
The fact that we have not taken full account of how the
professional discourse on eating disorders keeps these
behaviors in the symptom pool is problematic on a number
of levels. As evidenced in Hong Kong, we are engaged in
globalizing our understanding, treatments, and categories of
mental illness. As of now there is no acknowledgment that
in doing this we may be changing the symptom pools by
which people in other cultures find expression for their
distress.
What does it take for a symptom such as self-starvation to
exit the symptom pool? Looking back at the history of
hysteria may be instructive. It was in the early part of the
twentieth century that many of the symptoms of hysteria
began to disappear. Hysterical fits and seizures became less
common. Women in large numbers stopped reporting leg
paralysis and temporary blindness and stopped collapsing
while trying to walk across a room. They had fewer facial
tics and involuntary muscle spasms in the arms and legs.
These symptoms didn’t disappear all at once, of course, but
over years. During hysteria’s declining years many of the
symptoms seemed, at first, to lose their vigor, becoming a
kind of pale version of their former selves. In France they
called this la petite hysterie. One French doctor described
women “who content themselves with a few gesticulatory
movements, with a few spasms . . . and the like.” So familiar
were the patient and the doctor with the meaning of
hysteric symptoms that little effort was required to
demonstrate them. It is easy to imagine that once this
milder expression of hysteria became common, it began to
lose its power to communicate deep internal distress.
It may have been the very popularity of hysteria that was
critical in its downfall. If part of the unconscious motivation
for the hysteric was to alert the world to her internal
distress, the symptoms of hysteria would lose power as they
became ubiquitous. “Hysteria during the European fin de
siecle came to mean so many different things that by
around 1900 it ceased to mean anything at all,” Mark Micale
writes in his authoritative book Approaching Hysteria:
Disease and Its Interpretations. The disease was suffering
from “extreme clinical overextension.” By 1930 or so, these
dramatic and unmistakable symptoms began to disappear
from the medical and cultural landscape as they failed to
signal the distress in the unconscious minds of a new
generation of women.
The decline of eating disorders may require a similar
diffusion of the meaning we give them. That is to say, if
anorexia and bulimia lose their ability to effectively
communicate interior distress with a meaningful level of
specificity, they will cease, at least for a time, to be
attractive to the unconscious mind.
Looking back at the history of anorexia, it seems likely
that it will someday fall back to its baseline level. But as we
wait for the epidemic to subside in the West, we may have
unintentionally set in motion cultural currents that will see
the rise of anorexia in culture after culture around the globe.
The Lost Battle
After interviewing Ling I spent the rest of the afternoon
discussing the case with Dr. Lee. He admits that she is far
from cured and that his cultural sensitivity to the meaning
of anorexia in Hong Kong has not led to any surefire
treatments. Indeed he notes that he has lost four patients to
the disease, two by starvation and two by suicide. Although
his insights have not revealed a miracle cure, he believes
that the only hope lies in a deep understanding of each
patient’s subjective experience.
At the end of our time together I asked Lee to sum up the
state of the debate. He had spent the better part of two
decades trying to convince the profession of psychiatry that
Western assumptions about eating disorders were not only
steamrolling local variations but also potentially acting as a
vector, both spreading these illnesses and shaping their
expression. Did he believe he had won the intellectual
battle?
“No, I think the battle was lost,” Lee said. “The DSM and
Western categories for disease have gained such
dominance. In the process, microcultures that shape the
illness experiences of individual patients are being
discarded. This is taking place around the world and not just
with anorexia but with other illness categories, such as
depression and ADHD [attention-deficit-hyperactivity
disorder] and psychological trauma. Unfortunately the field
of cross-cultural psychiatry is not doing well in terms of
influencing mainstream psychiatry. I have to admit, we don’t
seem to interest them at all.”
For a few seconds I didn’t ask another question and his
words hung in the air. Then Lee ended the silence. “At some
point in the last ten or fifteen years the current became too
strong,” he said. His tone was not bitter but reflective and
matter-of-fact. “It is, I think, a river of no return.”
2
The Wave That Brought PTSD
to Sri Lanka
Western mental health discourse introduces core
components of Western culture, including a theory of human
nature, a definition of personhood, a sense of time and
memory, and a source of moral authority. None of this is
universal.
DEREK SUMMERFIELD
Debra Wentz, the executive director of the New Jersey
Association of Mental Health Agencies, arrived in Sri Lanka
on Christmas Day 2004, one day before the tsunami that
would drown more than a quarter-million people. She had
traveled to the shores of the Indian Ocean for a vacation
and to attend a friend’s daughter’s wedding. She was
looking forward to a long-awaited and well-earned vacation.
She spent her first night in a cliff-side room at the Mount
Lavinia Hotel just south of the capital city of Colombo. The
next morning she strolled along the white sand shores below
the hotel. She had planned with another wedding guest to
get up early for a day trip to the historic town of Galle, a
former Dutch fortress. But, tired from the previous day’s
travel, the pair left the hotel an hour later than they had
intended. On the drive south to Galle, they stopped for a
few minutes to buy some bottled water. Many lives turned
on such small choices on that day.
As they were approaching Galle, a smaller wave in
advance of the killer tsunami flooded the road and forced
their driver to turn inland and toward higher ground. As the
driver maneuvered to escape the incoming water, Wentz
could see whole families running for safety. She could tell
that many were in shock. “I don’t think they knew they were
running,” she remembers. She watched helplessly as a bus
struggled through the mud and rising water, unable to
escape the flood. Just a few hundred yards away a train
packed with travelers was swept off the tracks, killing more
than eight hundred people. Wentz remembers briefly
glimpsing a young woman struggling to haul an aged
woman in an antiquated wheelchair away from the incoming
water. The scene seemed unreal. For brief moments she felt
as though she were watching an action sequence from an
epic movie, something like Gone with the Wind. “It was like
you were watching these things from outside yourself,” she
remembers. “I wasn’t really grasping what was going on.”
They were soon inland and out of sight of the water.
Wentz and her companion at first had little comprehension
of the magnitude of what had taken place. It was only when
her driver called relatives in Galle with his cell phone that
they learned that whole sections of the town had been
inundated. Hundreds of people at the local bus stop had
been drowned. When she finally made it back to her hotel,
she took a few deep breaths to process what she had seen
and consider what she could do to help. Between the
rumors and news reports, she gradually became aware of
the extent of the disaster. Hundreds of thousands of people
had died and tens of millions had witnessed the tsunami or
the death and destruction it had wrought. It was then that it
dawned on her how unprepared the region was for the
psychological trauma that was to come.
It was obvious to Wentz that the events of that day would
have a severe, lifelong impact on the mental health of the
survivors—long after their physical needs were met. As
Wentz put it, “staggering acute and long-term mental health
needs would remain.” She had been at the helm of the New
Jersey Association of Mental Health Agencies during the
time of the 9/11 terrorist attacks, and from that experience
she had learned a valuable lesson: the real problems with
grief and post-traumatic stress disorder would come long
after the event. Wentz herself could already feel the
psychological effects of the tragedy she had witnessed. Her
sleep became erratic and she was very emotional about the
horror she had witnessed.
In the ten days she remained in the country, Wentz
worked tirelessly. She moved to a hotel that had computers
she could use to communicate with colleagues in the United
States. Initially she focused on alerting the drug companies
she worked with to the medical needs of the population. She
then turned her efforts to alerting the Sri Lankan population
about the devastating psychological impact that would soon
be felt.
Although not a clinician herself, as head of a statewide
association of 125 nonprofit behavioral health organizations,
she had overseen several public service campaigns with the
goal of lessening the stigma of mental illness and educating
populations unaccustomed to seeking professional help. A
well-connected Sri Lankan friend helped her contact the
office of the prime minister. She informed an official there of
the impending mental health disaster the country was
facing. “I told them that this was going to be unlike anything
they had experienced before,” she recalls. “The
psychological damage in terms of the PTSD and the anxiety
and depression was only going to grow as a problem. I told
them that the impact could be multigenerational.”
She also contacted the Sri Lankan news media. In an
interview that ran repeatedly on Sri Lankan national
television in the days and weeks after the tsunami, Wentz
told the population of how the symptoms of PTSD cluster in
three different categories: avoidance, numbness, and
hyperarousal. She advised everyone to be on the lookout for
this pathological behavior in both adults and children. She
told them that PTSD requires professional attention.
“I knew that the mental health needs after the tsunami
would be unlike anything the world had ever seen,” she
recounted. “But without a sophisticated mental health
system or trained counselors, where were the survivors
going to turn? They had almost no psychiatrists, and most
primary care doctors were not trained in psychiatry or
mental health education. They didn’t have a system in place
to care for these people.” She began to hatch a plan by
which she would collect money in the United States to send
American trauma experts to Sri Lanka to train local
counselors how to spot and treat PTSD.
Looking back on Wentz’s efforts in the hours and days
after the disaster, one has to be impressed with her
selflessness and genuineness of spirit. Her efforts were
clearly motivated by a set of assumptions and beliefs about
the nature of psychological trauma and its appropriate
treatments. Wentz assumed, as do many Western mental
health specialists who focus on trauma, that the
psychological reaction to horrible events is fundamentally
the same around the world. Had she believed otherwise, it is
unlikely that she would have angled to get on Sri Lankan
television to describe the coming impact of widespread
PTSD. From her own recounting of the events, it is also clear
that she believed that the Western world, in particular the
United States, had more and better resources than the
people of Sri Lanka to both understand and respond to the
coming mental health crisis. Wentz’s concern that Sri
Lankans would have to face the psychological impact of the
disaster without a “sophisticated” mental health system or
“trained counselors” was repeated in many quarters during
the days and months after the disaster. In every way Wentz
was acting like a health professional ready to share her
advanced training and knowledge to fight illness—in this
case psychic wounds—in a place that lacked the knowledge
and resources to care for its own.
Although Wentz was in the remarkable position of
communicating directly to the Sri Lankan population in the
immediate aftermath of the disaster, she was far from the
only one sounding the alarm about the impending mental
health epidemic. Mental health professionals around the
world were telling reporters that millions of people would
soon be suffering the debilitating effects of PTSD.
“Traumatized Tsunami Survivors to Take Years to Heal,” read
the headline to a Reuters newswire story filed less than ten
days after the disaster. As many as 15 to 20 percent of
survivors would develop PTSD, said one expert in the
Reuters story. The same expert warned that without
professional counseling, as many as 16 percent of those
PTSD sufferers might commit suicide. Noting that Sri Lanka
already had endured much trauma from its protracted
thirty-year-long civil war, Dr. Sean Scott of St. Vincent’s
Hospital in Sydney told a reporter from Australia’s largest
daily paper that the tsunami would only add to the country’s
psychological burden. “I believe that in the next months,”
Scott said, “the biggest health problem Sri Lanka and all of
the region is going to be faced with is depression and post-
traumatic stress disorder.” Jonathan Davidson, a professor
at Duke University, told a reporter, “Based on prior
experience from other mass disasters, we can expect that
between 50 and 90 percent of the affected population will
experience conditions like post-traumatic stress disorder
and depression which, if untreated, may last for years.”
Although the estimated percentage of people who would
be affected varied widely from expert to expert, there was a
clear consensus among those experts that the need for
psychological treatment services would overwhelm the
available providers in the region. Those experts also
generally agreed that getting to the scene quickly was
critical. “Psychological scarring needs to be dealt with as
quickly as possible,” a psychologist told the Washington
Post in the days after the tsunami. “The longer we wait, the
more damage.” The metaphor of a wave was unavoidable.
Many Western reporters and experts talked about a “second
tsunami” of mental illness that could be avoided only if
proper support and treatment were given. Responding to
the dire warnings, hundreds of nongovernmental
organizations, universities, and private groups quickly
began to gather resources and make plans to send an army
of trauma counselors in teams of various sizes to the coastal
areas of the Indian Ocean.
What happened over the next months in Sri Lanka,
Indonesia, India, and Thailand was likely the largest
international psychological intervention of all time. Trauma
counselors and researchers poured into the region not only
from the United States, but also from Britain, France,
Australia, and New Zealand. As part of its billion-dollar
pledge of assistance, Australia sent multiple teams of
counselors with the intent to bring the mental health
services in the region “into the modern era.” The director of
AusAID, Robin Davies, said that the effort was not intended
to restore or rebuild the mental health care capacity in the
country. “Restore is the wrong word,” Davies was quoted as
saying, “because there was nothing much there before.”
Given the certainty surrounding the need for such an
effort, it is remarkable to remember that we are the first
generation to include psychological first aid with other forms
of assistance after wars and disasters. As late as the mid-
1980s, in fact, the manuals for postdisaster relief focused
exclusively on medicine, food, and shelter and contained no
advice for treating the psychological wounds of a
population.
It’s only been in the past twenty years that the diagnosis
of PTSD has caught the world’s attention. It first gained
critical momentum in the United States and then began
leapfrogging the globe, being put to use after wars,
genocides, and natural disasters. By 2004 PTSD was on the
cusp of becoming the international lingua franca of human
suffering. We were suddenly in a time when, as one
psychiatrist put it, the concern over psychological trauma
had “displaced hunger as the first thing the Western general
public thinks about when a war or other emergency is in the
news.”
“We were spreading these ideas around the globe so
effectively that PTSD was becoming the way the entire
world conceived of psychological trauma,” said Allan Young,
a medical anthropologist at McGill University who has
studied the history of PTSD. “The spread of the PTSD
diagnosis to every corner of the world may, in the end, be
the greatest success story of globalization.”
Seldom considered in our rush to help treat the psychic
wounds of traumatized people was the question of whether
PTSD was a diagnosis that could be usefully applied in all
human cultures.
The idea that people from different cultures might have
fundamentally different psychological reactions to a
traumatic event is hard for Americans to grasp. The human
body’s visceral reaction to trauma—adrenaline, fear, and
the fight-or-flight response—is so primal that we assume
that the aftereffects of such events would also be the same
everywhere. The symptoms that make up PTSD, which
include intrusive thoughts and dreams, memory avoidance,
and uncontrollable anxiety and arousal when the victim is
reminded of the event,* seem utterly commonsensical.
But PTSD isn’t just a list of symptoms. Since PTSD was
added to the DSM in 1980, Western mental health
researchers and clinicians have devoted vast amounts of
time and energy researching and treating psychological
trauma. Indeed if you were an ambitious researcher in
psychology or psychiatry during the 1990s, PTSD was where
the action was; by 2004 more than twenty thousand
articles, books, and reports had been indexed in the
National Center for Post-Traumatic Stress Disorder’s
database. Just as hysteria was the archetypal disorder of the
Victorian era, PTSD speaks volumes about how Americans
and the Western world conceive of the self.
Those mental health professionals who formed our
generation’s understanding of PTSD have created an
intricate labyrinth of ideas that includes explicit and implicit
assumptions about what type of event will damage the
human mind and who will be most affected. Within the
literature of this movement are prescriptions for how, as
individuals and as a society, we should react to horrible
events and what types of resources we should devote to the
victims. Farther back in this labyrinth of meaning one
encounters still other ideas: calls for solidarity with the
survivors of violence; incitements to share an enlightened
moral outrage against the atrocities of war and social
injustice; the belief that the study of PTSD has made us
more attuned and sensitive to the world’s suffering. Taken
as a whole, this body of knowledge goes far beyond
describing a disorder with a symptom cluster. It describes a
worldview.
Western traumatologists have also developed a set of
beliefs about how best to heal from the psychological
effects of trauma. They have proposed that speedy
interventions to counsel survivors within hours or days of
the event are crucial; that retelling or reworking the
memories of the trauma, often in emotionally charged group
settings, promotes mental health; and that truth telling is
better for the mind than stoic silence. Against a growing
body of evidence, traumatologists assume these ideas to be
universally true.
Traumatologists have also advanced the idea that
psychological rehabilitation is best managed by mental
health experts, certified in and sensitized to the Western
understanding of how humans suffer and heal. The post-
tsunami intervention would prove to be a crucible for these
Western certainties.
Kate Chaos
One of the traumatologists who heard the call to help those
suffering in Sri Lanka was Kate Amatruda, a therapist from
northern California. Just days after the tsunami she found a
message in her email in-box from the Association for Play
Therapy seeking volunteers for an urgent mission to the
disaster zone. She immediately faxed her application and
was selected to be part of a team of a dozen play therapists
who would be dispatched to help children suffering mental
trauma in orphanages and local community centers. She
was expected to be on a plane within ten days.
Among the many letters representing her credentials
(MFT, CST-T, DMAT, DSHR-DMH) Amatruda is a BCETS, a
Board Certified Expert in Traumatic Stress. Seen in a broader
context, she is one of thousands of American therapists and
mental health professionals who, in the past twenty-five
years, tied their careers to the remarkable ascendancy of
PTSD in American psychiatry and public consciousness.
Amatruda had become well known in the field. She regularly
gave speeches and taught courses on the subject at local
universities and online, training young therapists to
recognize PTSD. She also taught the techniques for how
best to heal from the disorder, usually through measured
reexposure or retelling of the traumatic event in counseling
with a trained therapist. Amatruda was traveling to Sri
Lanka to apply her knowledge where it was needed most.
Amatruda is a short woman with bubbly energy and a
mane of long, curly, graying blond hair. She self-effacingly
admits that her family often calls her “Kate Chaos,” a
reference to the fact that she is not the most organized
person. In the week before her departure, she worked
frantically to put her professional and personal life on hold.
Preparing for her mission, she bought mosquito repellant,
antacids, antidiarrhea pills, Advil, anti-itch cream, Wet
Wipes, toilet paper, and hand sanitizer—enough supplies,
she said, to “feel like a walking pharmacy.” She also
collected donations of art supplies from several schools in
her town. In one large suitcase she packed sixty-nine
pounds of balloons, scissors, paper and paper punches,
pens, glue, stickers, and “zillions” of children’s Band-Aids.
Through bake sales she also raised two hundred dollars that
she planned to take with her and donate to a worthy local
group.
Like many Western counselors on the way to the scene,
Amatruda believes that trauma forms a kind of psychic
infection in the mind and the best way to drain that
infection is through retelling the story. This is sometimes
difficult because, she explains, in extreme trauma the
human mind often regresses to the point where “we lose our
words.” The purpose of play and art therapy is therefore to
open nonverbal ways of mastering the traumatic memory.
“For children, play is their first language,” she told me.
“They may not have the words for something, but they can
play out their stories with blocks or toys.”
Such techniques, which emphasize retelling or reworking
the trauma verbally or otherwise in the days immediately
after a horror, are in the tradition of what has been called
“psychological first aid,” or sometimes “critical incident
debriefing.” The basic idea, developed and promoted in the
United States throughout the 1990s, is that the earlier a
victim begins to “process” or “master” the memory of the
trauma, the less likely that memory will form the kind of
mental abscess that results in PTSD. Counselors clearly see
themselves as akin to emergency medical professionals
treating wounds at the scene of the accident. Their charge
is to deliver the psychological equivalent of applying clean
dressings to fresh wounds.
In this way of thinking, it seemed to matter very little that
most of the trauma counselors headed to Sri Lanka had no
understanding of the culture they were entering. Like
Amatruda, few could comprehend the local languages, and
for the most part they were unfamiliar with the population’s
religious beliefs, its grieving and burial rituals, or the
country’s long and complicated history of civil war.
In Amatruda’s conception of her job, this lack of
knowledge could even be seen as something of a strength.
In one of the training manuals she authored, she states
emphatically, “One of the requirements of disaster trauma
counseling is to be non-political and non-denominational.
We must not be influenced by religion, ethnicity or political
affiliation.” If you’re doing the mental health equivalent of
applying a compress to someone’s injured head, why would
you need to know his or her religious beliefs, traditions, or
social structures?
Clearly in Denial
The assumption that traumatic reactions exist outside and
unaffected by culture was common among both individual
trauma counselors and the relief organizations sponsoring
them. Dr. Sebastian von Peter, from the Hospital of Neukölln
in Berlin, took the time to read through all the advisory texts
and manuals related to the treatment of trauma after the
tsunami. Mostly written by teams of international mental
health experts to help train relief workers and volunteers,
these texts were produced by CARE, the Red Cross
International, the World Health Organization (WHO), the
Global Development Group, the National Center for Post-
Traumatic Stress Disorder, and the European Society for
Traumatic Event Studies, among others. These organizations
and agencies, he wrote, assume that “at root, people
throughout the world are the same in their emotional
experience and expressions.” Taken together, von Peter
concluded, these manuals imply a universal metaphysic of
emotional experience. In the face of horror, these manuals
assume, all humans are fundamentally the same.
Despite these certainties, there were signs early on after
the tsunami of a cultural disconnect between the ideas
surrounding the Western conception of PTSD and Sri Lankan
beliefs. There was, for instance, a remarkable memo
emailed just days after the disaster by faculty members
from the University of Colombo in Sri Lanka. The professors
acknowledged that “disaster zones attract ‘trauma’ and
‘counseling projects,’” but they pleaded with the arriving
army of counselors not to reduce survivors’ experiences “to
a question of mental trauma” and the survivors themselves
to “psychological casualties.”
They went on to make an argument that fundamentally
undercut the certainty that Western ideas about trauma are
universal. “A victim processes a traumatic event as a
function of what it means,” they wrote. “This meaning is
drawn from their society and culture and this shapes how
they seek help and their expectation of recovery.” Trauma
reactions aren’t automatic physiological reactions inside the
brain, they suggested, but rather cultural communications.
They have nuance and meaning that can be misinterpreted
or overlooked unless observers have a deep understanding
of the culture at hand. What was required before any
organization could offer meaningful help, the professors
wrote, was a deep understanding of “what the affected
people were signaling by this distress.”
In the days after the disaster, reporters and clinicians
arriving from the United States and elsewhere sometimes
seemed confused, even concerned, when the local
population didn’t behave the way they’d expected. One
trauma counselor being interviewed on BBC radio from a
small coastal village expressed his worry that the local
children appeared more interested in returning to school
than discussing their experience of the tsunami. These
children were “clearly in denial,” the expert told the
listening audience. The host of the program concurred,
saying, “Of course, everyone knows that children are the
most vulnerable to trauma such as this.” The expert then
confidently concluded that only later would the children
“experience the full emotional horror of what has happened
to them.” Similarly CNN reporters expressed their
amazement when tens of thousands of Sri Lankans
attempted to abandon their refugee camps just days after
the disaster, preferring to go back to their devastated
villages or depend on friends or family. A New York Times
reporter wrote that it would be only “a matter of time”
before the “wall of determination and denial, which has
enabled so many to cope in the days immediately after the
Dec. 26 tsunami disaster, begins to break down.”
With so many counseling and trauma treatment programs
and PTSD researchers arriving in the country every day, the
situation on the ground soon turned chaotic. Shekhar
Saxena, from the World Health Organization, was disturbed
by the scene he saw in the days and weeks after the
tsunami. “Two weeks after the tsunami there were hundreds
of counselors doing nothing or getting in the way,” he told a
reporter from Reuters. He pointed out that sending mental
health workers who didn’t speak the local language or
understand the culture was as useless as sending the wrong
medicines.
Dr. Mahesan Ganesan, who was the only psychiatrist in all
of eastern Sri Lanka, desperately tried to keep track of the
various organizations arriving to give psychological aid. For
a few days he managed to keep a tally of the dozens of
groups on a large whiteboard in his office, but he soon lost
count.
Looking back, it’s hard to escape the feeling that these
various efforts had about them the energy and excitement
of a gold rush. The tsunami was one of the most devastating
natural disasters in recorded history, and everyone who
wanted to demonstrate their acumen in healing trauma or
perform large-scale studies of PTSD felt obligated to be on
the scene. If a technique was to be taken seriously as a
treatment for psychological trauma, its adherents had to be
part of the action.
Within days bitter rivalries broke out between counseling
groups over which populations would receive which
services. As one journalist documented, different support
services attempted to “stake their claim to refugee camps.”
The haggling between groups vying to help sometimes
caused confusion and bad feelings among the survivors.
One Sri Lankan health care worker described how children
were lured away from one set of volunteer mental health
care providers by other groups with toys and other
incentives. “Children are torn between these loyalties, and it
can be traumatic,” said T. Gadambanathan, a Sri Lankan
psychiatrist from Trincomalee.
Similarly Ganesan watched with a mixture of horror and
fascination as several organizations offering counseling
services to one camp fought among themselves for the
attention of the children. “It was common for the
[facilitators] to differentiate between ‘our’ children and
‘their’ children,” he reports. “At times children were asked
not to play with children belonging to other groups. This
often led to conflicts . . . and at times brought about
animosity between the children themselves.”
Ganesan noted a key difference between the aid groups
offering medicine, food, and shelter and those offering
trauma counseling. The groups focusing on basic material
needs would immediately meet with local officials and
families to try to assess what the community was lacking.
Was shelter the first priority, or food, or first aid? In contrast,
those setting up PTSD counseling services seldom asked
leaders in the local community what they needed or desired
in terms of help. Thinking back, Ganesan’s considered
several possible reasons for this lack of consultation.
Perhaps these traumatologists felt that the local community
did not understand their own psychological needs, and
therefore “getting their opinion would be a pointless waste
of time.” More likely, he’s concluded, these trauma
counselors shared the “idea that all persons would respond
in a psychologically known manner to trauma and loss, and
a particular universal method existed to help these people
whoever they were and whatever their culture.” Such a
belief would make consultation with the local population
unnecessary.
There were other problems. Translators had to be
employed, as nearly none of the trauma counselors arriving
from Western countries spoke the local languages. Given all
the foreign activity in the country, the most proficient
translators were in high demand. This meant that
counselors often relied on those with marginal translation
skills, such as local drivers who plied the tourist trade, to
facilitate their therapy sessions. “At best [these translators]
had very limited capacity to translate the very complicated
and sensitive communication that takes place during a
counseling session,” noted one local health worker.
Despite such difficulties, the pace of counseling often
rivaled the speed of an emergency room. Over two four-day
periods in late January and February, one organization
reported giving “psychotherapy and counseling” to 1,724
people, including 631 children. This was an impressive feat
given that they had only two dozen counselors to do the
work. Another group of Western counselors debriefed
twenty-five traumatized survivors at a time, with the goal of
one hundred treated for each five hours of work.
The drug company Pfizer was quick to get in the mix as
well. In early February 2005, just over a month after the
disaster, the company sponsored a symposium in Bangkok
titled “After the Tsunami: Mental Health Challenges to the
Community for Today and Tomorrow.” Professor Davidson,
quoted earlier predicting pathology rates of 50 to 90
percent, helped organize the conference with an
“unrestricted grant” from the company.
The paper Davidson presented at the conference was
titled “Pharmacologic Treatment of Acute and Chronic Stress
Following Trauma.” He described PTSD as “a severe,
chronic, and disabling condition with major consequences
for the individual and society,” but assured his audience
that antidepressants such as Pfizer’s Zoloft could become
“an effective tool in promoting the long-term psychological
and psychosocial health, and economic recovery, of those in
the region affected by the tsunami.” Zoloft, he reported, had
been shown to reduce anger after the first week of
treatment and lessen “emotional upset” by week six. By the
tenth week of treatment, those who took the drug were less
likely to avoid trauma-related activities. Although Zoloft had
been approved for PTSD only a few years prior, Davidson
described the drug treatment as “currently recommended
as first-line therapy for the treatment of PTSD” in the United
States.
According to World Health Organization observers, fewer
than half of the trauma counseling groups that flooded the
country bothered to register with the government. Fewer
still worked to coordinate their efforts with each other.
“There was no checking,” John Mahoney, the director of the
World Health Organization’s mental health initiative in Sri
Lanka, told a reporter. “We found one organization just
handing out anti-depressants to people.”
A People’s Army of Trauma Therapists
In addition to the assembly-line counseling, Western experts
on the ground in Sri Lanka took to training the locals in the
latest techniques of treating PTSD. Sri Lankans, generally
speaking, have an intense hunger and respect for
education. That these Westerners, with their impressive
credentials, would be offering free training in modern
healing methods seemed a stroke of good fortune.
Thousands of Sri Lankans took advantage of the offer,
packing the training sessions, which were sometimes as
long as two weeks but often as brief as a day.
A team of educators from the University of Pennsylvania
and Swarthmore traveled to the region to train one hundred
master teachers in a child-centered brand of educational
psychology that uses the creation of illustrated storybooks
to give survivors a method to retell their stories. A group of
American therapists and social workers calling itself the
Heart Circle Sangha also arrived to “train Sri Lankan
counselors and leave in Sri Lanka a cadre of skilled
clinicians” who would have “techniques for working with
intense grief and Post-traumatic Stress Disorder.” According
to their literature, the group taught “skills of deep listening,
empathy, the healing power of connection. . . . The project
emphasizes counseling skills that empower clients.” The
Humanitarian Committee of the Association for
Comprehensive Energy Psychology, sometimes called
thought field therapy, sent counselors to Sri Lanka to
provide free treatment and training for the local population.
These energy psychologists tapped on parts of the body
while encouraging the patient to bring up anxious thoughts
and traumatic memories. Practitioners of eye movement
desensitization and reprocessing (EMDR) also offered
training sessions to locals. In EMDR, which is supposed to
resolve symptoms of PTSD, the therapist instructs patients
to follow a moving object from side to side with their eyes
while holding a mental picture of the disturbing life event in
their mind.
The Western experts leading these sessions often reported
frustration at having to school their trainees in the most
basic concepts of Western therapy. Mary Cattan, who was
part of another training effort in Sri Lanka, found the locals
eager but psychologically unsophisticated. They were so
interested in giving practical advice, she recounts, that
“their listening skills were not very good.” More problematic
still was the fact that the local trainees were “not
particularly self-aware.”
Usually, everyone was invited to attend these trainings,
including children. “After a while, most youngsters in
Batticaloa had acquired certificates which indicated that
they had received training in counseling,” noted one Sri
Lankan observer.
The effectiveness of this new people’s army of trauma
counselors concerned some. There simply wasn’t enough
time or resources to provide supervision for these newly
minted counselors or to put in place safeguards should they
run into difficult or dangerous clinical situations. Asked
about these issues, the foreign trainers would wave off the
concern by assuring the questioner that they weren’t, in
fact, training “counselors.” Rather, they said, these were
“befrienders” or “community support officers,” as if the
renaming solved the inherent problem. It’s clear, however,
that these freshly trained locals often believed that they
were now armed with Western-tested knowledge about how
to treat those in distress.
Mixed in among the therapists and counselors was
another large contingent of Western PTSD specialists: the
trauma researchers. Like the counselors, those who
specialized in the scientific study of psychological trauma
couldn’t afford to miss this once-in-a-lifetime disaster. One
of the first research groups on the scene, from the
University of Konstanz in Germany, looked for posttraumatic
stress disorder among children in Sri Lanka starting just
three weeks after the disaster. Studying several locations,
they soon reported finding PTSD rates between 14 and 39
percent.*
Some of the researchers employed cutting-edge
technology. One team went to various refugee camps
shortly after the disaster collecting blood samples to
measure chemicals indicative of stress reactions. Another
group of researchers used a polygraph machine to record
heart rate, breathing, and skin resistance. Researchers
interested in genetic predispositions for PTSD were
particularly keen about the opportunity the tsunami
presented. They noted that because whole families were
simultaneously exposed to the tsunami, the event provided
a unique opportunity to look at subtle differences in genes
that would lead one family member to develop PTSD and
another family member to psychologically recover in short
order. In one multimillion-dollar study three thousand
tsunami survivors were interviewed and more than six
hundred sufferers of PTSD identified. Researchers then drew
blood from those afflicted as well as their healthy siblings in
hopes of finding gene sequences to explain their differing
psychological reactions.
From the perspective of the locals, there was a good deal
of confusion regarding the trauma researchers, who were
suddenly swarming refugee camps asking deeply personal
questions, requesting samples of their blood, and
sometimes hooking them up to strange machines. To begin
with, the distinction between those who came to treat them
and those who came primarily to study them was often
unclear. The researchers appeared to be just one more tent
of concerned foreigners set up on the periphery of a refugee
camp.
In a report to the Sri Lankan Parliament, Dr. Athula
Sumathipala pointed out the ethical problems inherent in
such a situation: “When research is combined with aid, relief
and at times clinical care, there is undue inducement for
participation in this vulnerable population.” Because Sri
Lanka lacked any comprehensive process to review and
approve research involving humans, the country was being
invaded by what he called “parachute researchers.”
Sumathipala pointed out that many Sri Lankans who had
never participated in a research study before didn’t fully
understand that they had the choice not to answer the
questions of the investigators. More disturbing still, locals
sometimes assumed their participation would lead to some
financial assistance or other help. From the perspective of
the victims, it made sense that those gathering such
detailed information about their hardships would be
connected to some form of assistance down the road. Why
else would they be so interested?
One American observer, who asked to remain anonymous,
sat in on a seminar held by a large international
nongovernmental organization that promised to train
teachers how to counsel children with posttraumatic stress
disorder. In reality, the actual focus of the two-day session
was to show the teachers how to complete a PTSD symptom
checklist. Although attendees thought they were learning
new skills in dealing with traumatized children, they were
actually being trained in data collection for a study of the
prevalence of PTSD. Within weeks of the tsunami these
trainees were sent into classrooms to collect data not only
on the children’s reactions to the trauma but also on their
history of domestic violence and sexual abuse.
Further blurring the line between research and assistance
was the fact that dozens of the studies were designed to
assess the validity of one treatment or another. Which is to
say that groups of locals were encouraged to participate in
some style of experimental counseling or therapy for the
purposes of determining that treatment’s efficacy. One
research group, for instance, conducted a study in which
they organized groups of adult and child tsunami survivors
to revisit the exact locations where they experienced the
disaster. The idea was that reexposing them to the scenes
where they witnessed the disaster would help them process
the experience. Afterward the study’s authors reported
somewhat cryptically, “No certain cases of retraumatization
occurred [among the participants].” Nowhere did they make
clear whether the participants understood there was such a
risk.
Most of the studies conducted in the weeks and months
after the tsunami were of a simple nature. With local
assistance, Western researchers translated up-to-date PTSD
questionnaires and employed them to assess the mental
health of a given population. These surveys were designed
mostly by researchers in the United States to quickly
determine—usually with fewer than two dozen questions—if
the symptoms of PTSD were present. Children in Phuket and
Krabi, Thailand, were studied with the UCLA PTSD Reaction;
children in the Ranong province of Thailand and others in
Tangalle in the southern province of Sri Lanka were assessed
with the Children’s Impact Events Scale 13, which is referred
to among trauma specialists as the CRIES-13. The
population of northern Sumatra and Aceh, Indonesia, were
assessed using the Post-traumatic Stress Disorder Checklist–
Civilian Version. Adults in Tamil Nadu, India, were given the
Harvard Trauma Questionnaire. The resulting studies
published in peer-reviewed journals universally reported
significant rates of PTSD among the cohorts studied.
For many trauma researchers, these results
unambiguously settle the question of whether PTSD was
present after the tsunami. But there is a more difficult and
telling question here: Did the information gathered from
those PTSD surveys accurately represent the distress being
experienced by these populations?
“When you ask [the] whole checklist, the classical PTSD
criteria would be there, but these are all leading questions,”
one Sri Lankan medical specialist was quoted as observing.
“When you ask ‘do you have intrusive memories?’. . . It is
easier to say ‘intrusive memory’ in English, but [try] to put it
into Sinhala or Tamil. You see, is very difficult and by the
time you have explained all that, they know that they have
to answer in the positive.”
The very act of asking survivors to describe their
psychological response to a horrible experience by choosing
among only a few reactions would seem to unavoidably bias
the outcome. Adding to this problem was the common
misperception on the part of those being studied that
answering such questions “correctly” would result in
assistance for oneself or one’s family.
Further complicating matters was an implicit assumption
imbedded in these PTSD checklists: that the traumatic event
in question was a one-off experience safely in the past and
that life had otherwise gone back to normal. It might indeed
be pathological to be constantly on the watch for danger six
months after an anomalous event, such as witnessing a
violent crime. But for those living with their children in the
squalor and discord of a refugee camp, being vigilant about
safety would certainly have a different meaning.
Unfortunately it was impossible for any of the PTSD surveys
to make a meaningful distinction between the psychological
reaction to the tsunami and the ongoing strains of the social
and economic turmoil caused by that event.
In the end these trauma checklists simply had no ability to
discover what might be culturally unique to the experience
of living through horror in Sri Lanka. These surveys weren’t
designed to discover anything new, but rather to confirm
similarities. Did the population have other reactions to the
trauma not included in the symptom lists? Were the
behaviors on the checklists the reactions that caused the
most concern to the Sri Lankans? Such questions didn’t
seem to occur to the researchers, who appeared to believe
wholeheartedly in the universality of the PTSD construct.
Resilience in Sri Lanka
Dr. Gaithri Fernando, a young assistant professor of
psychology at California State University in Los Angeles, was
with her son in Sri Lanka on high ground when the tsunami
of 2004 rolled ashore. In a bizarre coincidence, she was in
the region preparing a study on the psychological impact of
a 2001 earthquake. After the wave receded, she traveled to
the fishing village of Moratuwa, where she saw people
frozen in disbelief and horror. It was clear that the wave had
inflicted both psychological and physical damage.
Fernando watched with increasing unease as scores of
Western psychologists, counselors, and PTSD researchers
arrived in the disaster zone. A native of Sri Lanka, and a mix
of Tamil and Sinhalese, Fernando moved to the United
States when she was 21 to help her husband, a Tamil,
escape persecution. Since then she has returned often to
conduct research on the psychological impact of the long
civil war. The wave of aid that rolled in on Sri Lanka after the
tsunami, she suspected, had the power to change the
culture of the island country as much as the tsunami itself.
Few understand better than Fernando the Sri Lankan
capacity to live in the face of horror. Her research prior to
the tsunami documents a people with remarkable
psychological resilience. Even through decades of war,
youth uprisings, and poverty, most Sri Lankans have
managed to remain functional and hopeful. This is a
population, she has shown, that seldom needed outside
encouragement or counseling to get back on its feet even
after the most punishing hardships.
Many of the Western counselors and experts who rushed
in after the tsunami assumed that the long and brutal civil
war had made the individuals in the population ever more
psychologically vulnerable and therefore more likely to
experience PTSD after the tsunami. There was, of course, an
alternative possibility: that the Sri Lankans—because of their
intimate familiarity with poverty, hardship, and war—had
evolved a culture better able to integrate and give meaning
to terrible events. In this conception it was the Western
counselors, arriving from communities and enclaves
unfamiliar with the immediate experience of violence and
deprivation, who were uniquely vulnerable.
Fernando knows how Sri Lankans turn to their rich cultural
traditions in times of hardship. Religion is a particularly
important cornerstone in the lives of most. There are
Buddhist traditions for the majority Sinhalese, Hinduism for
the Tamils, Islam for the Moors, and Christianity for the rest.
The notion of karma, central to both Buddhist and Hindu
beliefs, is shared by Sri Lankans across ethnic and religious
lines. Overlapping and weaving together these different
traditions is the shared ethnocultural belief in spirits and the
palpable nearness of the spirit world.
Often closely tied to religious traditions is a wide variety of
healing customs. Health care in Sri Lanka is remarkably
pluralistic. There are Ayurvedic practitioners, doctors,
astrologers, religious leaders, mediums, and faith healers of
various types. The lines between these practices,
delineating, for instance, traditional healing from modern
medicine, are not clearly drawn. A Sri Lankan often consults
two or more of these traditions in search of relief from
illness or psychological distress.
Having watched at close quarters the suffering of children
and their parents caught in the violence of the civil war,
Fernando intimately understands that these cultural
traditions have an impact not only on the ways this
population talks about the psychological aftermath of horror
but on the deeper level of how it is felt and experienced.
She understands, as those Colombo professors said
immediately after the tsunami, that victims process
traumatic events as a product of what they mean.
Indeed Fernando’s earlier work on war trauma in Sri Lanka
had uncovered fascinating connections between religious
beliefs and differences in the ability to recover from the
trauma of war. In one pre-tsunami study she found that
Buddhist and Hindu children who experienced war and
violence were less vulnerable to depression than Christian
children, even though the Buddhist and Hindu kids reported
more personal exposure, witnessing bomb blasts and the
like. She speculated that there might be protective beliefs in
Hindu and Buddhist traditions, such as the active
acceptance of pain and suffering or the beliefs in rebirth and
recompense through reincarnation, that steadied these
children in the wake of terror.
Watching the aftermath of the tsunami, Fernando couldn’t,
of course, predict the psychological consequences. This was
an unprecedented event that could overtax the religious
institutions and healing traditions that the population relied
on. Still, the idea, often repeated by Western experts, that
Sri Lankans had few local resources for psychological
healing (because they lacked trauma counselors) seemed to
simply ignore or discount the cultural traditions, beliefs, and
rituals that Sri Lankans had so long relied on. Similarly the
idea common to many Western traumatologists, that
psychological treatments could be easily divorced from
religion, ethnicity, and the cultural history of the country,
was hard for Fernando to understand.
Most important, Fernando worried that the PTSD symptom
checklists did not reflect the culturally particular ways that
Sri Lankans experience psychological suffering after trauma.
She worried that by using these checklists mental health
professionals from Western countries would be ineffective—
or even do harm—unless they understood that Sri Lankans
had culturally distinct reactions to traumatic events as well
as culturally specific modes of healing. She believed that
unless these local idioms of distress were understood,
appropriate interventions could not be formulated. Without
a deep understanding of the illness, in other words, it would
be impossible to treat the disease.
Fernando took on the task of trying to understand the
local meaning of trauma in post-tsunami Sri Lanka. She
began by gathering a sample of local informants from a
rural area in the southern province of the country. All were
Sinhalese Buddhists, most from poor families. All had
personally witnessed the tsunami, and fifteen of the twenty
had lost family members.
Instead of quizzing these subjects with a predetermined
set of PTSD symptoms, Fernando asked each person to tell
her two open-ended stories in their own language. First she
asked participants to think of someone they knew who had
experienced some type of suffering but was now functioning
well. After that story was finished, the subject was asked to
describe a person who was functioning poorly after a
traumatic event.
Not surprisingly, of the forty stories she collected, thirty-
five were related to the tsunami. With the help of a
researcher and a local community leader, she began to
examine the narratives for similarities in themes and
expressions of wellness and distress. In the end she
collected more than two dozen symptoms and behaviors
that were mentioned by fifteen or more participants. She
then validated the results by conducting a large-scale
survey. She ended up with what she calls the Sri Lankan
Index of Psychosocial Status, a twenty-six-item measure of
the local indicators of distress.
Fernando came to the conclusion that Sri Lankans’
experience of trauma differed from Americans’ in two main
ways. Unlike the PTSD symptomatology, Sri Lankans were
much more likely to experience physical symptoms after
horrible events. Sri Lankans who lost family members or
whose lives were otherwise devastated by the tsunami were
more likely to complain of aches in the joints or muscles or
pain in the chest. Without the mind-body disconnect
common in Western thinking, these Sri Lankans reacted to
the disaster as if they had experienced a physical blow to
the body.
In addition to these somatic symptoms, there was
another, more subtle and pervasive difference. By and large
Sri Lankans didn’t report pathological reactions to trauma in
line with the internal states (anxiety, fear, numbing, and the
like) that make up most of the PTSD symptom checklist.
Rather Sri Lankans tended to see the negative
consequences of an event like the tsunami in terms of the
damage it did to social relationships. Those who continued
to suffer long after a horrible experience, her research
showed, were those who had become isolated from their
social network or who were not fulfilling their role in kinship
groups. In short, they conceived of the damage done by the
tsunami as occurring not inside their mind but outside the
self, in the social environment.
Such social problems are also common in Western
sufferers of PTSD, but Fernando’s research highlighted a
subtle but important distinction. In Western thinking
surrounding PTSD a trauma causes psychological damage
that then results in social problems. A Westerner might, for
instance, assume that depression or anxiety brought on by
PTSD would cause people to fail in their role as a parent. For
a Sri Lankan, this did not appear to be a cause-and-effect
phenomenon. The failure to manage one’s social
responsibilities—to find and fulfill a place in the group—was
identified as the primary symptom of distress and not a
consequence of an internal psychological problem. As she
concluded in her paper on the subject, “The data empirically
support the theory that intra-psychic functioning is not
independent from interpersonal functioning for this
community.” On examination of the interviews, Fernando
realized that every one of the twenty-six symptoms
described by these Sri Lankans was to some extent bound
to this idea that the social trumped the psychological. More
precisely, Sri Lankans interwove the social and the
psychological—to the point where the two could not be
teased apart. Because the Western conception of PTSD
assumes the problem, the breakage, is primarily in the mind
of the individual, it largely overlooks the most salient
symptoms for a Sri Lankan, those that exist not in the
psychological but in the social realm.
This is one of those subtle cultural differences that is hard
to point to at any given time. In trying to describe the
interconnection between the social and the individual sense
of well-being, Fernando told me of interviewing a young boy
in a village that had been the scene of several massacres.
The boy was 8 years old, and his father had been killed
during one of the periods of violence. Fernando was working
with another researcher who didn’t speak the local
language, and so she was translating the questions and
answers so the other professor could understand. At one
point she asked the boy what makes him feel better when
he gets worried about the violence in his community, and
the boy answered that it was the things his mother says to
him. “This boy told me that he feels better when his mother
promises him that if they are attacked and killed that they
would all die together,” Fernando recalls. The answer struck
her so deeply that for several moments she couldn’t
translate the response for the other researcher. The mother
offered no promise of protection or even survival, only
togetherness in the face of violence and death. The boy, for
his part, appeared deeply reassured by his mother’s
promise.
This emphasis on the social over the psychological
becomes critical when one considers how one might heal
from tragic events. If depression, anxiety, or hypervigilance
are the primary symptoms (which then lead to social
problems in one’s family or social group), it might make
sense to take time to work though the psychological
symptoms away from one’s social responsibilities. This is a
common pattern of mental health healing in the West: take
a sick leave from the stresses in your life in order to heal. If,
however, the social difficulties are the primary symptom of
distress, taking time away from one’s duties and social roles
to pursue something like individual counseling may actually
exacerbate the problem. In a culture such as Sri Lanka’s, an
emphasis on healing the individual away from the group,
particularly in one-on-one counseling with strangers, is
problematic.
Kate Chaos, Part II
When I interviewed Kate Amatruda it was several years after
the tsunami. Since that trip she had continued to teach and
visit other disaster zones. Asking her about her experience
at the refugee camps in Sri Lanka, I wanted to know if she
felt any cultural disconnect between her ministrations and
the local ideas of trauma and healing. In response, she
made every effort to assure me of how culturally sensitive
she remained. She recalled that, on arrival, she was given a
full day’s training in Sri Lankan customs and history. Local
officials instructed her to wear her hair up and to eat only
with her right hand. She was also told that she couldn’t ask
children to play a card game called Go Fish because of the
associations with ocean fish eating the bodies of those
washed out to sea; in addition, she was told that all card
games or other activities that might be construed as
gambling were forbidden among Muslims. She tried, she
says, not to refer to the tsunami as “bad” or “mean” for fear
of alienating the Buddhists, who believe in karma.
When I asked her whether she thought that people around
the world differ in their reaction to trauma she told of seeing
striking similarities between the pictures drawn by children
in Sri Lanka and those drawn by children in post-Katrina
New Orleans. “Those pictures are absolutely
indistinguishable,” she said. “You cannot tell the difference.
On some human level, our reaction is probably universal.”
On a personal level, she reports experiencing some
culture shock on her arrival. The normal discomforts of
traveling in a developing nation were heightened in the
aftermath of the disaster. The lack of showers and Western-
style toilets also took some getting used to, and the curry
dishes for breakfast didn’t agree with her stomach. She
remembers being constantly anxious about contracting
head lice from the children in the camps. But overall she has
fond memories of the week she spent leading dances with
children, handing out art supplies, and organizing games.
She is also particularly proud of the training sessions she
helped conduct with local teachers and health care workers.
Despite her obvious enthusiasm for her work, I found it
difficult to get Amatruda to tell me what particular practices
or ideas she brought with her to Sri Lanka. What, I wanted
to know, were the theories behind the activities she
organized during her stay? What information had she
passed on during the time she spent “training the trainers”?
For instance, when I asked her what sort of techniques she
taught to the local health care workers, she told me, “The
trainings were important but not necessarily for what we
taught them as for the fact that we were there for them.
They knew people had flown all across the world to help
them.”
I suggested to Amatruda that beyond her admirable desire
to show solidarity with the victims of the tsunami she must
have felt that she had some specific knowledge that she
wanted to impart. She was, after all, leading training
sessions. But each time I tried to turn the conversation to
the question of what that knowledge might be, she
retreated into generalities. “It almost doesn’t matter what
you do,” she insisted. “So much of it is showing up. It
matters that you’re there and that you’re really there and
you’re able to witness the pain and the horror. You’re there
to witness and receive.”
Amatruda wasn’t alone in her reticence. Many counselors
returning from their work in Sri Lanka were loath to be seen
as part of some hegemonic West-to-East, rich-to-poor
transfer of knowledge. Recounting their counseling and
training work after the tsunami, some Western
traumatologists went to almost comic extremes to assure
their readers or questioners that they were sensitive to the
local culture. Dr. John R. Van Eenwyk, the founder and
clinical director of the International Trauma Treatment
Program, curiously insisted that the best role for Western
trauma trainers was to prove that they had nothing to offer
their trainees. The intent of the trainings he conducted in Sri
Lanka was to reveal himself to be as powerless as the
Wizard of Oz. “Our job is to reveal ourselves as ‘the man
behind the curtain,’” he explained. “Then we help them see
that what they seek from us they already possess. Like the
scarecrow, they already have brains. . . . We don’t
indoctrinate. We empower.”
Still hoping to hear the specific techniques she employed
while in Sri Lanka, I asked Amatruda to tell me of a moment
during her trip when she felt her presence there was
effective in helping heal the psychological wounds of the
tsunami. She told me of sitting with a child who used the art
supplies she had lugged across the world to make a
drawing. During this encounter she helped the child “feel
important,” she said. When I asked her how, she said, “The
child felt important because this blonde person had come all
the way across the world to see her.”
One day, not long after her arrival, Amatruda was
counseling a woman named Selvie-amah, who was the
housemother for an orphanage of girls. When Selvie-amah
revealed that she had lost two brothers in the civil war,
Amatruda asked how she managed to keep herself mentally
healthy so that she could care for her girls. The very
question seemed difficult for Selvie-amah to understand.
Amatruda explained that it is important for the healer to
stay healthy herself. She is used to explaining this idea by
employing the metaphor of being on an airplane when the
oxygen masks come down: “If you are sitting with a child or
someone who can’t take care of themselves, put on your
mask first, then take care of them.” Selvie-amah appeared
baffled by this idea. Amatruda’s notion of posttraumatic
stress had led her to a key assumption about the meaning
and impact of trauma that her Sri Lankan counterpart didn’t
share: she assumed that the mental distress experienced by
survivors of horror comes from damage to the individual
psyche and that that damage makes it difficult to help
others. But, as Fernando’s studies showed, Sri Lankans’
sense of well-being emanates from their connection to the
social network around them. For a Sri Lankan, the very
expression and experience of mental health might be
embodied in the act of fulfilling one’s role and helping
others. To repurpose Amatruda’s modern metaphor, putting
the oxygen mask over the mouth of the child in the next
seat would be the very thing that would allow Selvie-amah
to breathe.
Parading Certainties
It is unclear what the Sri Lankans thought of Amatruda, this
energetic Western woman lugging her suitcase full of art
supplies and Band-Aids into refugee camps. Amatruda
reports that she felt welcomed and appreciated. From her
perspective the local population certainly seemed to
recognize the genuine spirit of caring that brought her to
their doorstep in that dark time.
The juxtaposition of these well-meaning Western healers
with the devastated landscape was sometimes
breathtaking. Here, for instance is how Jennifer Baggerly, an
assistant counseling professor at the University of Florida,
recounted arriving in the remote village of Kalladi, where
215 families were living in a refugee camp. “The suffering
here was clear,” she writes. “Rows of white canvas tents in
the sweltering sun face a water tank that has been empty
for a month and a half. Clean water access is a long walk
away so children were thirsty and had unwashed clothes
and hair. Some children had a chronic cough while others
had sores on their bodies.” She then describes her team’s
psychological intervention, providing “temporary relief from
the suffering by conducting our puppet show, helping them
make coping bracelets and magazine collages, playing
active games, teaching them yoga, and passing out candy
and toys to each child.”
Dr. Ganesan, who observed many such Western
interventions, noted that these relief workers, with their
strange behavior, their puppet shows and handcrafts and
interactive games, often did liven the mood of the camps
they visited. “In many instances these sessions, in which
whole communities participated, offered comic relief for the
survivors even though it was probably not intended as
such,” he recalls.
The term “psychosocial aid” has gained great currency
among international trauma counselors who like to believe
that their interventions are sensitive to cultural differences.
In its most promising use, psychosocial aid acknowledges
that helping the culture get back to normal functioning is
the key to maintaining the mental health of the people. The
assumption is that the local people will look to their
churches, mosques, schools, and social networks to find
support and make meaning of what happened to them.
Psychosocial support (again in its most progressive use)
suggests that every effort should be made to put these local
institutions and networks back in working order so that the
people can heal and make meaning in their own way.
In practice, however, it is clear that “psychosocial aid” is
often little more than a buzzword. Although many
interventions talk of psychosocial aid, local religions and
forms of healing are given only lip service or, worse yet, are
used as the proverbial spoonful of sugar that helps the
Western medicine go down. “Trauma victims in disaster
situations may not actively seek mental health services for
various reasons,” wrote David Surface in Social Work Today.
“Some may be in denial or simply not aware of the extent to
which they’ve been traumatized, while others may not seek
out therapy because of social or cultural stigmas. Therefore,
the goal of many disaster mental health workers is to have
therapy be seamless, integrated . . . and, whenever
possible, incorporate familiar community settings and
rituals.” In this way of thinking, it is not the community
traditions or rituals that are seen as healing but the Western
therapy that has been stirred in among local practices.
Some trauma counselors in Sri Lanka all but ignored local
custom and practices and stridently asserted that they knew
better than the locals how to handle the psychological
aftermath of the disaster. William Yule, a child psychologist
from King’s College in London, expressed with particular
certainty that he knew what was best for the population. He
reported with concern that orphaned children were
sometimes coaxed through the experience by relatives who
told them that their parents hadn’t in fact drowned but had
taken jobs that required them to travel to foreign lands. Yule
made it clear that this lack of disclosure would
psychologically damage the children. He writes that he had
to have long discussions with locals “to clarify . . . the need
to be honest with children.”
It’s true that the period after the tsunami was filled with
such hopeful lies and misinformation told not only to
orphaned children but often to desperate parents looking for
missing offspring. Neighbors or relatives would sometimes
tell frantic parents of having seen a missing child or heard
that the child had shown up in a neighboring village.
Following such rumors, one after the next, some parents
traveled hundreds of miles up or down the coast. These
well-meaning lies are certainly heartbreaking and clearly go
against many assumptions of Western mental health
treatment, which values facing and “working through” or
“processing” unhappy experiences. But was Yule’s
insistence that these stories were psychologically damaging
a universal truth or a culturally based assumption?
What Yule didn’t comprehend was that these sorts of
stories are not particular to Sri Lanka or the tsunami.
Anthropologists working in poor or war-torn nations have
documented similar narratives. Based on her work with
Somali refugees, for instance, the anthropologist Christina
Zarowsky wrote that if a person goes missing and is almost
surely dead, it is socially acceptable to lie to family
members to “ease their mind” and say that the missing
person has gone abroad. This is a story born of poverty-
stricken places where people die young or disappear just as
completely through emigration to far-off lands. Dismissing
such stories as psychologically beyond the pale ignores the
tragic social forces from which they spring. In the end all
stories about where parents or children “go” when they die
are, to varying degrees, wishful and culturally bound. How,
one might reasonably ask, is Yule’s insistence on the “need
to be honest” in this sad situation any less culturally
imperialistic than a Christian missionary trying to disabuse
some far-flung population of a local notion of reincarnation?
But regardless of whether trauma counselors tried to be
culturally sensitive or, like Yule, paraded their certainties,
the result was likely the same. Dr. Siddharth Ashvin Shah,
who traveled from his home in the United States to Sri
Lanka after the tsunami to try to help, reports that he
arrived determined to let local healers take the lead. What
he discovered was that the social forces at play made this
approach nearly impossible. “The recipients are driven by a
belief that they lack things, concepts, and behaviors that
the West can supply,” Shah recounts. “The non-West craves
our technology because it anticipates good innovation from
the West. We produce information that verifies its
effectiveness. . . . We are confident that we have something
exceptional to offer and not the other way around.”
Try as he might to be respectful of local beliefs, Shah
found that it was impossible to abdicate the role he was
expected to fill, that of “Western expert” bringing advanced
knowledge. “The attention experts like myself command is
triumphalist,” he wrote, “blinding the relief workers and
myself to the culturally embedded self-concepts and healing
practices.” As much as trauma counselors talked of
“psychosocial approaches” or “cultural competency,” the
obvious preference given to the Western ideas of
psychological suffering often overwhelmed their best
intentions.
Global Differences in Suffering
A careful look at other cultures and moments in human
history shows that there is little about the human reaction to
trauma that is universal. For instance, the assumption that
each generation of soldiers reacts the same way to combat
is turned on its head by even the briefest look at history.
There is no doubt that soldiers often come back from battle
with psychological as well as physical injuries; the fear and
horror of direct combat can clearly damage the psyche of
men and women. But the medical records of war veterans
kept over the past centuries show that the manifestation of
the injury is always tied up with cultural beliefs
contemporaneous to the time. British soldiers in the Boer
Wars were likely to complain of joint pain and muscle
weakness, a condition their doctors called “debility
syndrome.” In the American Civil War, soldiers often reacted
to the psychological trauma of battle by experiencing an
aching in the left side of the chest and having the feeling of
a weak heartbeat, labeled “Da Costa’s syndrome.” Or they
experienced a withdrawal and lethargy thought to be a type
of pathological nostalgia caused by being far from home. In
the First World War, British and American soldiers commonly
experienced “shell shock,” with symptoms that included
nervous tics, grotesque body movements, and even
paralysis. So although the potential psychic damage of war
is indisputable, the process by which that damage becomes
an outward symptom is a reflection of the cultural beliefs in
a particular time and place. The unconscious mind of a
soldier latches onto culturally current symptoms of distress
(chest pain for the Civil War soldier and muscle spasms for
the World War I soldier) because those symptoms are
recognized as legitimate during a particular time.
It is important to emphasize that even though symptoms
change over time, this is not a matter of faking or play-
acting on the part of those psychologically traumatized.
Rather, soldiers from different times are unconsciously
internalizing cultural expectations and then experiencing
them as unavoidable and real. The simple but mind-bending
truth is that mental illnesses such as PTSD can be both
culturally shaped and utterly real to the sufferer. Therefore,
as the medical anthropologist Allan Young explained to me,
a diagnosis of PTSD “can be real in a particular place and
time, and yet not be true for all places and times.”
What is true across time is also true across cultures.
Researchers studying psychological reactions to trauma in
cultures around the world have found remarkable deviations
from the PTSD symptom list. Salvadoran women refugees
who endured a protracted civil war, for example, often
experience something called calorias, a feeling of intense
heat in their body. Although these women did experience
sleep disturbances, which is one symptom of PTSD, they did
not, for the most part, report increased startle responses or
other physical reactions when reexposed to symbols of the
trauma. For some Cambodian refugees, the most pressing
psychological impact of trauma was being visited by
vengeful spirits and the accompanying feeling of intense
distress that, in escaping from the country, they had not
been able to perform rituals for the dead.
“The meaning of a horrible event has a tremendous
impact on the human psyche, and that meaning differs
across the world,” says psychology professor Ken Miller of
Pomona College. “The meaning matters as much as the
event itself.” Applying the same interviewing techniques
Fernando used in Sri Lanka, Miller has studied psychological
reactions to war trauma in Afghanistan. His analysis yielded
many reactions not on the PTSD symptom list, and several
that had no ready translation in English. There was, for
instance asabi, a type of nervous anger, and fisha-e-bala,
the sensation of internal stress or pressure. The only way for
aid providers to be effective, Miller believes, is for them to
understand the local idioms of distress—the particular ways
psychological trauma is understood, experienced, and
expressed in specific cultural contexts.
Duncan Pedersen from McGill University found unique
expressions of psychological trauma among the Quechua
natives in the southern central Peruvian Andes who were
caught up in the brutality of the Maoist guerrilla movement
the Shining Path and the Peruvian army. The estimated
death toll during the period topped sixty-nine thousand,
with more than half a million internally displaced. The horror
they suffered was remarkable both for its severity and its
unrelenting nature. As Pedersen notes, this was the
“destruction of ways of life—targeting and attempting to
eliminate entire ethnic groups, eradicating cultures and
social systems, thus undermining the critical means
whereby people can endure and recover from suffering and
loss.” The Shining Path even enforced strict rules for how
victims of the conflict were to be mourned, deeming the
traditional public tears of women to be “a sign of
weakness.”
Pedersen and his fellow researchers discovered that the
people of the Ayacucho highlands have two distinct
semantic categories to describe their suffering. Nakary
conveys the notion of collective suffering, often described
with the metaphor “it’s like carrying the cross on the
shoulders of everyone,” and includes the notion that this
suffering is a punishment for wrongdoings in the past. Llaki,
on the other hand, refers to the individual experience of
sorrow and distress. In its extreme form, llaki is seen as an
illness with symptoms that include a variety of physical
pains, such as headaches, stomach pains, and body aches.
Critically, neither llaki nor nakary is thought to be related
to specific experiences of trauma or discrete periods of
upheaval. These are experiences of distress indicative of the
long-term nature of the conflict. Because PTSD connects
symptoms to specific moments of trauma, the diagnosis
does not take account of the indirect and ongoing
consequences of violence that were most troubling to this
population: the destruction of important social networks and
their webs of reciprocity, the impact on the local economy,
the malnutrition, and the spread of disease.
The researchers concluded that the diagnosis of PTSD
could not effectively communicate this type of shared
cultural suffering, “given the multiplicity of ways peoples
and societies live through massive trauma, express their
distress and suffering, and assign meaning to the human
experience.” Insisting on employing Western assumptions
about trauma, the researchers wrote, potentially
“undermined indigenous health systems and largely
discredited the power of local healing practices, as well as
resiliency, coping and survival strategies.” In short, using
the PTSD diagnosis and foreign notions of trauma
counseling in this situation had the potential to continue, in
a new form, the very cultural demolition that had caused
the population its greatest distress.
The argument that the insertion of Western PTSD beliefs
might actually undercut and disempower the local culture
has been made by other researchers as well. In East Timor
two researchers, Kathleen Kostelny and Michael Wessells,
visited the war-torn area around the capital of Dili and saw a
population pushed to the breaking point by war and the
increased sexual violence and poverty that came with it.
Most distressingly, the Indonesian militias often destroyed
or ransacked sacred structures where families and clan
members performed rituals and kept their sacred objects.
This amounted to a “spiritual calamity,” according to
Kostelny and Wessells. The insertion of trauma counseling
and PTSD didn’t ameliorate this problem; it heightened it.
“In a situation of desperation, local people often silence
their own cultural practices, cling to Western approaches
that have the imprimatur of science, or ‘play along’ by
giving the appearance of accepting outside approaches in
hopes of getting food or money from powerful outsiders,”
Kostelny and Wessells conclude. They note that this
undermining of local pathways to recovery can happen so
subtly as to escape the notice of both the caregivers and
those being provided for. “Tacitly, a damaging message sent
is that local views and practices are inferior. In the authors’
field experience, this message can strengthen a colonially
implanted sense of inferiority and weaken local people’s
belief that they have the capacity to build their own positive
future.”
Education or Indoctrination?
Such concerns about the use of PTSD and Western beliefs
surrounding trauma have done little to stem the efforts of
Western traumatologists to intervene in other cultures after
times of crisis. Why, one might reasonably ask, are we so
certain that the rest of the world needs our help in this
regard?
A look at the one of the first cross-cultural applications of
PTSD—in response to the 1995 earthquake in Kobe, Japan—
sheds some light on this question. It was only a matter of
days after the disaster when a team of PTSD experts from
Harvard University arrived in the city to collect data on the
psychological damage caused by the quake. As with other
international PTSD research that was to come, it was clear
from the start that this was far from a dry exercise in
epidemiology. The survey and the results were overtly
intended to advocate for a dramatic shift in thinking on the
part of the Japanese mental health system. The fact that the
report was as much a call to arms as an academic document
could be seen in its title: “The Invisible Human Crisis.”
“The PTSD concept was used to point to the reality of a
field of suffering recognized by the more psychologically
advanced culture of the United States but ignored in Japan,”
reported the anthropologist Joshua Breslau, who studied the
aftermath of the Kobe quake. Behind this effort to influence
the Japanese response to the disaster was a deep certainty
commonly shared by traumatologists that the rest of the
world doesn’t pay nearly enough attention to mental health
and that other cultures lack crucial knowledge that
Americans possess.
Although undertaken as humanitarian outreach, these
efforts often look more like massive attempts at
indoctrination. To accept the ideas of PTSD, other cultures
first had to be “educated” in the appropriate symptoms of
PTSD and modern modes of healing. After the genocidal
killings in Rwanda one nongovernmental organization (NGO)
quickly produced seventy-five thousand copies of a brochure
on the signs and symptoms of traumatic stress. Foreign
trauma counselors gave interviews to local journalists on
the psychological sequelae of trauma, and public health
campaigns were undertaken to educate the benighted
population in the symptoms of PTSD. Within two years of the
killings more than six thousand “trauma advisors” had been
trained in the country. Less than two years later, they
reported that more than 144,000 children had been
counseled.
Similarly, within hours of the bombing of the U.S. Embassy
in Nairobi, Kenya, in 1998, a trauma counseling program
called Operation Recovery was put into motion. “Mental
health experts used local and national radio and television
broadcasts to discuss the symptoms of acute stress
reactions, and these broadcasts continued for 2 weeks after
the bombing,” wrote two psychiatrists of the project. More
than seven hundred counselor-trainees were given a two-
day seminar on PTSD within a week of the bombings.
An equally impressive intervention came the next year,
when trauma counselors went to the mountainous area on
the northern coast of Venezuela after a massive flood and
landslide claimed more than fifty thousand lives. A radio,
TV, and newspaper ad campaign was launched to make the
population aware of what psychological consequences to
expect, and posters of the PTSD symptom list were placed in
schools, community buildings, police stations, churches, and
grocery stores.
Often these campaigns seemed to imply that the
psychological consequences of trauma were similar to a
newly discovered disease, and that local populations were
utterly unaware of what happens to the human mind after
terrible events. That implicit assumption often left
anthropologists shaking their heads in disbelief. It takes a
willful blindness to believe that other cultures lack a
meaningful framework for understanding the human
response to trauma.
“Most of the disasters in the world happen outside of the
West,” says Arthur Kleinman, a medical anthropologist from
Harvard University. “Yet we come in and we pathologize
their reactions. We say: ‘You don’t know how to live with this
situation.’ We take their cultural narratives away from them
and impose ours. It’s a terrible example of dehumanizing
people.”
Once one comprehends the cultural differences in
psychological reactions to trauma, the efforts of the Western
traumatologists who rush into disaster zones on a few days’
notice begin to look somewhat absurd. To drive this point
home, Miller asked me to consider the scenario reversed.
“Imagine our reaction,” he said, “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? Would that make sense?”
The Rise of Fearlessness
The mistake in applying Western notions of trauma without
consideration for local beliefs goes beyond just being
ineffective: there is real danger of doing harm. This lesson
should have been learned long before the tsunami in, of all
places, Sri Lanka.
For over a year and a half starting in 1996, Alex Argenti-
Pillen, now an anthropology professor at University College
London, spent time in a poor Sri Lankan village trying to
make sense of the local modes of psychological suffering
while at the same time documenting the impact of the rising
influx of Western ideas about trauma.
In response to the ongoing civil war, organizations such as
the UN High Commission for Refugees, UNICEF, Oxfam, and
the International Rehabilitation Council for Victims of Torture
organized workshops and training seminars in the country,
and international trauma specialists spoke about PTSD and
Western-style trauma counseling. It was commonly asserted
at the time that helping war-torn populations heal from
PTSD could slow or stop the cycles of violence. Researching
the effects of these efforts in small villages, Argenti-Pillen
came to the opposite conclusion. She became concerned
that these Western ideas of trauma and healing had the
potential to destabilize fragile local truces that existed
among families, clans, and ethnic groups.
The social and economic situation in the Sinhalese
Buddhist village she studied was indeed dismal. There was
desperate poverty, and many local men and boys had been
drawn into the civil war between the Sri Lankan government
and the separatist Liberation Tigers of Tamil. Many of those
drafted into the Sri Lankan army deserted from military
service, forcing them to lead itinerant lives to avoid arrest.
In addition to the civil war, a violent youth revolt by the
Janatha Vimukthi Peramuna between 1988 and 1991
brought on a harsh crackdown by the government. Villagers
had been brutalized by literally all sides in these conflicts.
Neighbors often informed on each other, leading to
kidnapping, torture, and murder.
But as bad as the situation was, Argenti-Pillen was
interested in what kept the violence from spinning even
further out of control. What were the factors that kept
villages from undergoing a conflagration of revenge and
ethnic violence such as that seen in Rwanda and Bosnia? In
the village she studied, there remained boundaries on the
violence. Although many men had been killed, their wives
and children were usually left physically unharmed. In the
aftermath of the violence, perpetrators were clearly
disassociated from their families and revenge killings didn’t
target relatives. In many cases, the family of the killer and
the family of the victim (or the informant and the informed
upon) remained living side by side.
Argenti-Pillen documented the villagers’ remarkably
complex way of talking and thinking about the experience of
violence that, in several key respects, contradicted
assumptions about PTSD. In the cosmology of these
villagers, humans are vulnerable to what they call the “gaze
of the wild,” the experience of being looked in the eye by a
wild spirit, which can take the form of a human being intent
on violence. According to this belief it is not witnessing
violence that is destructive. Rather, the moments of terror
that come from violence leave one vulnerable to being
afflicted by the gaze. Struck by such a gaze, one enters an
altered state of consciousness and can become violent
oneself, behave lasciviously, become physically
immobilized, or in other ways step outside of normal modes
of social behavior. Somatic symptoms, including chronic
headaches, stomach aches, and loss of bodily strength, are
also common. Someone in this sort of semitrance may
speak in the voice of the spirit or alternate between the
perspective of the wild spirit and a human state called inna
barikama, which roughly translates as “can’t stay here.”
Often those experiencing inna barikama will yell for hours
variations on “I can’t stay,” “can’t live,” “can’t be,” or they
will simply repeatedly moan “Can’t.”
Those afflicted by the gaze of the wild might also express
their distress by “becoming closed off” or having “a terrified
heart,” which can lead to any number of somatic symptoms,
including vomiting and physical aches and pain. These
semitrance states are treated in the village with a long and
arduous cleansing ritual. Such ceremonies often last up to
thirty hours, during which the afflicted person is encouraged
to dance, tremble, and speak in tongues at specific times
during the ceremony. The rituals themselves are designed to
elicit fear. Healers elaborately disguised as wild spirits visit
the sick, often in the early hours of the morning, in order to
frighten the subject as severely as possible. Often those
who complete these cleansings show dramatic recoveries.
Interestingly, it doesn’t necessarily require a violent event
to spark a terrified heart. Simply speaking directly about a
recent act of violence, with words that graphically or
emotionally evoke the experience, is also considered
potentially pathological. Because most villagers hid in their
houses during the periods of intense violence, their
experience of terror was largely through what they heard.
The shouts of the attackers and the cries of the wounded
and tortured were the soundscape of the wild spirits and
could bring on the fear-related illness of “a terrified heart.”
“Just as the soundscapes of violence and civil war affect
people, so do the words used to represent this reality,”
Argenti-Pillen concluded. “In other words, discourses about
the wild act as agents of the wild.”
Stories or even words describing the violence were
considered literally dangerous. Because of this, the
community had established a complex set of rules for how
villagers are allowed to talk about or remember the
violence. Argenti-Pillen had to learn a complex dialect of
“cautious words” that allow someone to reference a
horrifying event without explicitly bringing it to mind. On
examining these local euphemisms, she began to see that
they were intentionally replacing words or phrases that
might invoke fear or moral anger with those that connote
safety and trust. Torture, for example, was evoked with a
word that also means a child’s mischief.
Unraveling this secret code, Argenti-Pillen filled her
notebooks with these euphemisms. “Those and these”
meant quarrels and fights. “The confusion and mistakes of
people who hurry too much” referred to the brutal civil war.
A “place that takes sacrifices” indicated a location where
many people died. “Funny nonsense” was a way of invoking
the disorientation and confusion of the terrified. To “bother”
could mean anything from child abuse to bombing. “Rowdy
sons” were the perpetrators of violence.
Argenti-Pillen also noticed that women in the village who
had suffered from terrified hearts often took it upon
themselves to be the enforcers of such indirect speech.
While this use of indirect language could easily be filed
under the rubric of “psychological avoidance” in the style of
the PTSD diagnosis, that would miss the fact that this local
custom had a specific purpose. Only gradually did Argenti-
Pillen come to understand that the prohibitions on speech
were a kind of “acoustic cleansing” by which people
protected themselves and others from spreading the gaze of
the wild and avoiding a potentially exponential rise in
revenge violence. These people weren’t avoiding talking
about what had happened to them because they were
psychologically blocked or traumatized; rather, they were
attempting, as best they could, to keep the violence under
control.
There was another local reaction to horrible events that
ran counter to the idea of the terrified heart. Some women
believed that the atrocities they had witnessed or endured
had made them become “fearless.” Usually “fearlessness”
applied to men who acted violently or yaka-like (like an evil
spirit), but over the years of the civil war women were
increasingly embodying the trait as well. These fearless
women attested that they were no longer susceptible to
having a terrified heart and that they no longer needed the
domestic cleansing rituals. It was these fearless women who
often violated the rules of cautious speech. They were said
to speak with “sharp tongues” and carelessly. Such women
often found themselves socially marginalized by those in the
village, seen as akin to wild spirits themselves. Fearless
women were likely to intentionally raise their children to be
fearless as well. Often sons of such mothers were the boys
who became yaka-like, prone to violence and terrifying the
community.
Into this delicate and intricate social and psychological
landscape began to flow Western ideas about trauma and
healing. This transmission of knowledge was not as direct as
it was in the aftermath of the tsunami. No Western
counselors set up tents on the outskirts of Argenti-Pillen’s
village. Rather, these ideas trickled down from training
programs sponsored by NGOs in Colombo. Western trauma
specialists would train regional health care workers; that
knowledge would then flow down to rural health care
workers, who then treated and sometimes trained local
villagers in these methods.
The problem was that the central tenet of Western trauma
counseling—that traumatic experiences must be retold and
mastered—ran counter to the local customs regarding the
use of euphemistic speech. Rural health care workers were
suddenly insisting that experiences of trauma be spoken
about directly. One Sri Lankan health care provider told
Argenti-Pillen that she had learned from Western experts
that it was important not to allow the traumatized individual
to keep secrets or talk around traumatic events. “There is a
method of talking,” she said, “talking with our eyes, our
face, with our whole posture, we must tie them to us. . . .
We take the information out of the clients. . . . We put them
in a position in which they can’t keep any secrets.”
The Western-trained counselors saw it as their job to
reorient the population’s beliefs about trauma and healing.
Many counselors expressed certainty that their new
counseling methods proved that the traditional local rituals
were ineffective. “A terrified heart cannot be cured by
means of domestic cleansing rituals,” one Western-trained
counselor told Argenti-Pillen. “The illness that has hit the
mind can sometimes not be cured even if you danced a
thousand cleansing rituals, let alone one. So, if you don’t
give counseling . . . in the correct way, that person will stay
in the same condition.”
However, it was rarely the women with terrified hearts
who were first in line for this new method of counseling.
After all, it was their job in the community to ensure that
people were circumspect in telling stories of violence.
Rather, it was the fearless women, with their penchant for
telling unambiguous stories of the violence, who embraced
the new healing methods. Whereas from the villagers’
perspective fearless women were potentially dangerous,
from the perspective of the Western-trained counselors they
were “empowered.” Not only were fearless women often the
first to accept trauma counseling; they were also the first to
accept training as counselors themselves.
“While the majority of the community consider
fearlessness an aberration . . . the NGO activities now
provide an outside legitimization for fearlessness,” Argenti-
Pillen writes. “The NGOs now support fearlessness as a
viable form of sociability.”
By encouraging fearlessness and pathologizing the local
custom of using ambiguous speech, this intervention was
tampering with a delicate social balance. Argenti-Pillen’s
concern was that Western-style trauma counseling was
undermining a fragile social stopgap that kept violence in
these tight communities from spiraling out of control. These
counselors were playing with fire. “Tales of ‘traumatized
survivors’ fail to provide a much-needed framework in which
local techniques for containing violence can be
safeguarded,” she concludes. “They also fail to assess the
potential risks of the introduction of the discourse on trauma
to such local techniques.” Trauma counseling services had
the potential to have the exact opposite effect intended.
Instead of ending the social cycles of violence, they were
potentially removing the brakes. The risk, she concluded, is
that “trauma counseling services will further destabilize a
local cycle of containment of major outbreaks of violence.”
The American Way to Suffer
It would be hard to overstate the certainty that most
Americans currently place in the diagnosis of PTSD.
Although it has been officially recognized for only twenty-
five years, it is reflexively evoked after school shootings,
natural disasters, and terrorist attacks. It has become part
of our common parlance and conventional wisdom. With so
many soldiers serving in the long-term conflicts in Iraq and
Afghanistan, PTSD has become a national touchstone in the
debate regarding the costs of war. PTSD is as real in our
time as fisha-e-bala is to an Afghani, as calorias is to a
Salvadoran, and as terrified heart is to a Sri Lankan.
It is real, that is, but not timeless.
Looking back at the brief history of the disorder, it is
remarkable to see how much it has changed even within a
generation. A soldier given the diagnosis today would be
hard-pressed to recognize it as the same one that was first
formulated in the 1970s for soldiers coming home from
Vietnam.
The movement to recognize PTSD began as a political as
much as a psychiatric movement. Originally called post-
Vietnam syndrome, the idea came out of the hothouse of
rap sessions held by Vietnam Veterans Against the War and
supervised by antiwar psychoanalysts. Dr. Chaim Shatan,
who was codirector of the postdoctoral psychoanalytic
training clinic at New York University, was one of the first to
help find the professional volunteers to sit in on the rap
sessions. In a memo he circulated to colleagues his politics
were clear: “This is an opportunity to apply our professional
expertise and anti-war sentiments to help some of those
Americans who have suffered most from the war.”
These psychoanalysts and veterans had no intention of
carving out a diagnosis that could be applied to all victims
of terrifying events, or even all soldiers who experience
battle. The original idea was to show that being a soldier in
the Vietnam War was an experience utterly distinct from
that of being a soldier in any other military conflict. Listen to
one of the first descriptions of post-Vietnam syndrome,
written by Shatan and published in the New York Times in
the spring of 1972. According to Shatan, these veterans felt
upset because they had been “deceived, used and
betrayed” by both the military and society at large.
Although Shatan did mention that these veterans
experienced “rage,” he did not link this or any psychological
reaction to particular traumatic battlefield experiences.
Instead the rage, as Shatan described it, “follows naturally
from the awareness of being duped and manipulated” by
the military and the U.S. government. It was the moral
ambiguity of the Vietnam War and the deceitfulness of the
U.S. government and military, not the trauma of battle, that
damaged the psyche of the soldier.
In their push to gain official diagnostic status in the DSM,
the advocates for recognition of post-Vietnam syndrome
found it necessary to cede some ground. Despite the early
arguments intent on carving out a disorder specific to the
experience of Vietnam veterans, it proved politically
expedient to make alliances with other researchers and
clinicians who wanted to extend the concept to include
those who suffered psychologically after surviving other
horrors, including fires, natural disasters, and accidents. The
earlier argument that the psychological trauma suffered by
Vietnam veterans was utterly specific to soldiers in that
conflict was put aside and then forgotten.
As PTSD expanded in influence, more and more advocates
were making the argument that the disorder had an
immutable objective existence independent of culture, time,
or place. This left the obvious question: If it was so timeless,
why had it only recently been recognized?
In a history of the International Society for Traumatic
Stress Studies, written by one of the group’s former
presidents, Dr. Sandra Bloom, the early advocates of the
disorder are portrayed as the first to bravely overcome the
social pressure to ignore the psychological reaction to
trauma. Forces in our society, Bloom writes, have a stake in
“denying the profound and long-term effects of trauma. . . .
The larger society will continue to deny the magnitude of
the problem not only because of the emotional arousal
exposure causes, but because it is becoming increasingly
clear that fixing the problems and actually preventing
trauma, will cost a great deal.” PTSD has always been with
us, the argument went, but we were just now raising our
consciousness to the point that we could face its
devastation.
As the diagnosis expanded in the West, encompassing
more and more experiences, there grew a market for those
claiming to have the latest techniques for treating the
condition. These techniques, in turn, began to shape our
cultural expectations and understanding of how trauma
affects the mind. Few were more influential in creating the
American style of PTSD than a former paramedic named
Jeffrey T. Mitchell, who created a seven-step regimen called
Critical Incident Debriefing. Mitchell’s debriefings were
intended to be performed in the first hours or days after a
threatening event. Led by a trained facilitator, groups of
survivors would be first informed of the common reactions
to traumatic stress. Each participant was then encouraged
to describe his or her perspective on the trauma in order to
“make the whole incident come to life again in the room.”
The metaphor of trauma creating a “psychic wound” was
taken quite literally. It just made sense that the quicker
debriefers got to the scene, the more they could do for the
victims. Beginning in the late 1980s counselors armed with
this new knowledge were rushed to the scenes of school
shootings, train wrecks, fires, maritime disasters, and all
manner of other calamity. In 1989 Mitchell founded an
organization called the International Critical Incident Stress
Foundation to teach debriefing as a method of heading off
PTSD. The foundation grew quickly and was soon training
tens of thousands of debriefers each year.
The fall of 1989 proved to be a watershed moment for the
American public’s awareness of trauma counseling and the
ideas behind critical incidence debriefing. In September of
that year Hurricane Hugo made landfall on the coast of
South Carolina, pushing a twenty-foot wall of water over
coastal communities. Disaster counseling and critical
incident debriefers were included in the response to the
devastation, to the fascination of the journalists and public
who followed the events.
Just a month later, on the other side of the country, the
Loma Prieta earthquake struck the San Francisco Bay Area.
Occurring during the pregame warm-up to the third game of
the World Series, the quake was broadcast live to the
nation. The first pictures of the collapsed section of the Bay
Bridge were sent from the Goodyear Blimp, which had been
hovering over Candlestick Park to cover the game. Many
mental health workers who had been providing debriefing
and trauma counseling in the coastal towns of South
Carolina got on planes and flew directly to San Francisco to
set up counseling services for quake victims. Again,
reporters and TV crews focused a great deal of attention on
these efforts.
By the time Hurricane Andrew sliced through the southern
tip of Florida and crashed into the south central portion of
Louisiana three years later, the public’s respect for the PTSD
diagnosis and the need for trauma counseling had solidified.
That new certainty could be heard in a Knight Ridder/Tribune
news service story filed in Miami: “Hurricane Andrew’s
biggest impact wasn’t its physical destruction. That was
only $20 billion. What it wrought in South Floridians’ minds
is incalculable.” By this point Mitchell’s International Critical
Incident Stress Foundation was training upwards of thirty
thousand debriefers each year.
Despite the public and professional certainty that
counselors and debriefers should rush in after disasters to
treat traumatized populations, there was one problem: there
was little evidence that such efforts helped. In fact study
after study published during the 1990s, the heyday of
trauma counseling, showed that early interventions were
either ineffective or actually caused harm. One study
followed several hundred car accident victims over a three-
year period. At random, some of the victims were debriefed
or given no immediate psychological treatment. Interviewed
three years later, victims displayed a remarkable difference:
the people who were debriefed were more likely to be
anxious and depressed and harbor a nagging fear of riding
in cars. The study, which was published in the British
Medical Journal in 1996, concluded, “Psychological
debriefing is ineffective and has adverse long-term effects.
It is not an appropriate treatment for trauma victims.”
Another study of burn victims showed a similar effect:
measured after a year, those who had been debriefed were
much more likely to qualify for the diagnosis of PTSD and to
express hostility, feel depressed and anxious, and report a
lower quality of life than those who received no help. The
conclusion was that the early interventions were actually
impeding the mind’s natural healing process.
Early interventions sometimes appeared to be priming
victims to experience certain symptoms. “When dealing
with people after an accident we need to remember that
emotionally aroused people are suggestible,” David Brown,
a psychologist from Australia, wrote later in the British
Medical Journal. “If we suggest they might feel angry, it is
likely to come true.”
Others have noticed the same phenomenon. “Sometimes
when we put people in a group and debriefed them, we
gave them memories that they didn’t have,” Malachy
Corrigan, the director of the Counseling Service Unit of the
New York City Fire Department, told the New Yorker. “We
didn’t push them to psychosis or anything, but, because
these guys were so close and they were all at the fire, they
eventually convinced themselves that they did see
something or did smell something when in fact they didn’t.”
Looking back, it is remarkable that so little attention was
paid to the danger that debriefing might be shaping and
suggesting reactions in the minds of distressed individuals.
Social psychology has a rich literature on group belief-
building and social contagion that could have been well
employed here. If you take a group of disoriented and
unsettled victims mere hours or days after a life-altering
tragedy, put them in a highly charged encounter where they
are told to expect certain psychological symptoms, and then
they share their experiences, you are creating the perfect
setting by which emotions are likely to spread and intensify.
Why didn’t these practices cease in the face of the
evidence that they might actually be harming those they
intended to treat? Dr. Richard Gist of the Kansas City Fire
Department, who researched the impact of debriefing,
noted that the evidence for and against trauma counseling
was beside the point because debriefing was, he told a
journalist, “more of a social movement.” Indeed the
evolution of the ideas behind PTSD and the promotion of
modern ideas of trauma counseling have been social
movements from the beginning. This fact, however, is
seldom acknowledged by the evangelical trauma counselors
who travel the world to inform other populations about the
modern treatments for PTSD.
It is a psychological truism that those who display dead
certainty in their convictions are often hiding or covering up
for deep insecurities. Professor Vanessa Pupavac, writing
from the School of Politics at the University of Nottingham,
links the rise in our international trauma interventions—our
confident assertions that we must teach the world how to
respond to horrible events—with a period of time when we
in the West had become increasingly uncertain about how to
help the developing world.
The 1990s was a period when our efforts to help other
countries with money and aid began to seem impossibly
complex and fraught. Book after book took to task
humanitarian efforts for bureaucratic waste, having
shortsighted goals, and encouraging dependence. This crisis
of confidence in the humanitarian community was, Pupavac
argues, a reflection of a deep post–cold war uncertainty at
home. We had become, she writes, “bereft of convictions
and disposed to introspection. . . . The erosion of previous
political or communal affiliations [had] not resulted in a
vigorous individualism, but anxious insecure individuals.”
When we looked out at the violence and hardship in the
rest of the world and knew that our psychological assistance
was desperately needed, we may have been simply
projecting our own postmodern insecurities.
Trauma Stripped of Meaning
In reading the best anthropological writing on the “idioms of
distress” in other cultures, one is often struck by the
richness of these psychological and social landscapes. The
experience of horror or violence in these places is
interwoven into religions, social networks, traditions, and
rituals of burial and grieving. When one comes back home
to PTSD, the starkness and thinness of the idea become
glaringly apparent. In the modern Western world, the idea of
PTSD is that of a broken spring in a clockwork brain.
PTSD researchers would certainly object to this
characterization. They would point to the tens of thousands
of research papers, monographs and books on the topic.
How could so much research be characterized as “thin”? But
I’m not talking about the research, but rather the
experience of the PTSD sufferer. By isolating trauma as a
malfunction of the mind that can be connected to discrete
symptoms and targeted with new and specialized
treatments, we have removed the experience of trauma
from other cultural narratives and beliefs that might
otherwise give meaning to suffering. Being value-neutral to
cultural beliefs is problematic given that these beliefs—be it
God’s plan for someone who’s lost a child or patriotism for
the soldier crippled in battle—are the very places where we
once found solace and psychological strength.
Think back to the ideas surrounding post-Vietnam
syndrome. The original intent of that designation was to
create a social narrative to prove that being a soldier in the
Vietnam War was different from being a soldier in other wars
at other times. Proponents were searching for meaning and
coming up with stories of government betrayal and the
destruction of social trust. Beliefs that had sustained many
of their fathers in World War II were suddenly insufficient
and meaningless to these soldiers. They replaced those
beliefs with another, angrier set of ideas that might give
meaning to their experience. But as it evolved into its
modern clinical form, PTSD left behind such quests for social
meaning in tragedy. In doing so, it has set adrift those
struggling in the aftermath of trauma. In contrast to those
angry but socially engaged Vietnam War veterans, the
personal accounts of current-day soldiers returning from
Afghanistan and Iraq often seem pigeonholed into a PTSD
diagnosis that is tied to a particularly modern style of lonely
hyperintrospection.
Here’s one soldier blogging on a popular website devoted
to PTSD:
I constantly doubt how I feel. I don’t know if it’s real or if I’m making it up. . .
. I feel guilty. When I was in the service, the Air Force therapist said that it
was PTSD . . . but I don’t know if he was right. I worry that I’m trying to fool
everyone, even myself. I didn’t do anything. I never fired a weapon in
combat. I missed everything, I feel guilty about it, and I feel ashamed that I
even consider that PTSD might be the problem. I feel like I don’t deserve to
think this is what is wrong with me. I can’t bring myself to read up on PTSD
on the internet, because I’m worried that the more I know about it, the more
likely I am to make it be the problem subconsciously. . . . I feel like I’ve
fooled myself into playing a character and I don’t know how to just put it
down.
PTSD is clearly too narrow a category to give meaning to
this soldier’s experience, but he worries it like a bone
because he doesn’t appear to have other options; the
frustration, anger, and unhappiness of modern soldiers have
been moved from the social (where one might find moral
anger, nationalistic justification, or religious meaning to
justify the sacrifice) to the biopsychomedical. Because PTSD
largely focuses on internal states and chemical imbalances
within the individual brain, this explanation for psychological
problems often leaves the soldier, to borrow a recent
military marketing slogan, feeling like “an army of one.”
Looking at ourselves through the eyes of those living in
places where human tragedy is still embedded in complex
religious and cultural narratives, we get a glimpse of our
modern selves as a deeply insecure and fearful people. We
are investing our great wealth in researching and treating
this disorder because we have rather suddenly lost other
belief systems that once gave meaning and context to our
suffering.
Patrick Bracken, a senior research fellow at Bradford
University’s Department of Health Studies, argues that the
emergence of PTSD is a symptom of a troubled postmodern
world. “In most Western societies there has been a move
away from religious and other belief systems which offered
individuals stable pathways through life, and meaningful
frameworks with which to encounter suffering and death,”
Bracken writes. “The meaningful connections of the social
world are rendered fragile.” Although we might be able to
ignore the absence of these belief systems during our
normal day-to-day lives, truly traumatic events have the
power to startle us into awareness of a heart-stopping
emptiness. The diagnosis of PTSD can categorize some of
our reactions to trauma, but in the end it is cold comfort. It
cannot replace what we’ve lost.
Without social mechanisms to cope, we’ve become
increasingly vulnerable and fearful. Indeed many have
pointed out that we are now a culture that has a suspicion
of resilience and emotional reserve. “In a momentous shift,
contemporary Western culture now emphasizes not
resilience but vulnerability,” says Derek Summerfield, of
Kings College, who has worked extensively with victims of
war and genocide. “We’ve invited people to see a widening
range of experiences as liable to make them ill. This
becomes a problem because we are globalizing our culture.
We are presenting just one version of human nature—one
set of ideas about pain and suffering—as being definitive. In
truth, there is no one psychology.”
The Civil War Reignites
Seven months after the tsunami, Lakshman Kadirgamar, the
Sri Lankan foreign minister, was murdered in his home by a
sniper. The precarious cease-fire between the government
and the separatist rebels began to destabilize. By the end of
that year the guerrillas in the north of the country were
again fighting the government both on land and at sea. The
conflicts escalated until, in January 2008, the government
officially withdrew from the cease-fire agreement. The battle
in the next year would not go well for the Tamil Tigers. By
the end of spring 2009 the government forces had routed
the Tamil rebels from their last stronghold.
The reality for the civilian population caught in the
fighting on the ground became so grim that Gaithri
Fernando found that for the first time she had to avoid all
news of her home country. She had heard too many stories
of mothers digging shallow graves for their children and
families trying to escape the fighting by fleeing deep into
the jungle, only to lose family members to animal predators.
In the uneasy peace after the fighting, there was again
much interest in psychological healing and the damage of
PTSD. Having alerted the Sri Lankan Parliament of the
abuses of parachute researchers after the tsunami, Dr.
Athula Sumathipala published a series of articles in the
Island newspaper asking again for restraint on the part of
globe-trotting trauma counselors. “Undue emphasis on
counseling or medicalizing the psychological, sociological
and political implications of the displaced population should
not be promoted,” he wrote. “What [the displaced
populations] need is not ‘therapy’ but provision of basic
needs, care with dignity, respect, reassurance to avoid
uncertainty and move them to accommodation as soon as
possible so that they will have some privacy and also the
opportunity to reintegrate to ‘normal’ life. The best therapy
will be a sound social policy.”
Whether his voice will be heard is not yet clear. Thanks to
the many training seminars set up after the tsunami, there
are now thousands of Sri Lankans who believe they are
trained in trauma counseling and the Western ideas behind
PTSD. In addition, there will undoubtedly be new efforts by
international aid agencies to provide psychological therapy.
Whether these efforts will heal these communities or, as
Argenti-Pillen fears, unintentionally destabilize them
remains to be seen. It would be tragic and ironic if Western-
style trauma counseling ends up sparking violence between
ethnic groups and clans that already have reason to hate
each other. Intending to break cycles of violence, Western
beliefs about trauma and healing may be poised to spin
them back into motion.
3
The Shifting Mask of Schizophrenia
in Zanzibar
What we say about mental illness reveals what we value and
what we fear.
JULI MCGRUDER
On my first night in Zanzibar I was awakened by the distant
sound of a telephone ringing. I came to consciousness
fitfully, puzzling out where I was. I was bone-tired from two
days of red-eye plane travel and a rough ferry crossing to
the island from mainland Tanzania, disoriented by the ten-
hour time change and, possibly, by the side effects of the
prophylactic malaria medication I had begun taking a few
days before. I checked the bedside clock: 3 a.m. I could hear
my hosts, Juli McGruder and her partner, Ahmed Kassim, in
the upstairs room of the house as one of them answered the
phone. As in most houses in Zanzibar, there was no glass in
the windows—better to let the steady trade winds sweep
out the stuffy air during the night—and I could hear their
voices talking low and intently in Kiswahili. I stood at the
window, listening and looking out into the night. It was a full
moon and there was a racket of premorning birdsong
coming from the thick, low brush beyond the cinderblock
wall that surrounded the house. After a few minutes Kassim
came downstairs, walked across the sandy driveway, and
drove off in his rattletrap Toyota van. I got back in bed,
retucked the mosquito netting, and lay awake wondering
what might have occasioned the call. I was new to the local
customs, but I suspected that Americans and Zanzibaris
shared at least this cultural truism in common: no good
news comes in a phone call at 3 a.m.
I had come to Zanzibar, a sixty-mile long coral island off
the Swahili coast of East Africa, to spend some time with
McGruder. She had recently retired from her teaching
position at the University of Puget Sound in Washington and
had opened a guesthouse at the very northern tip of the
island with Kassim, a younger local man who was both her
romantic and her business partner. She had been a
professor of occupational therapy, and late in her career she
had received a PhD in anthropology from the University of
Washington. Her field research focused on three families
struggling with schizophrenia in Zanzibar, where she went
to figure out a puzzle that has baffled cross-cultural
researchers in mental illness for twenty years: Why did
people diagnosed with schizophrenia in developing nations
have a better prognosis over time than those living in the
most industrialized countries in the world?
In the morning I met McGruder in the kitchen, where she
was brewing a pot of strong cowboy coffee, boiling the
grounds directly in a pot of water. “I need the real thing this
morning,” she said by way of greeting. “Instant is not going
to do it.” She told me the news before I could ask. The early
morning phone call had been for Kassim. His 10-year-old
daughter, Latifa, a child from an early marriage, had died
suddenly in the night. The family had known that the girl
had an enlarged heart, but she had recently been healthy
and happy. Just that day she had been to Koran school,
played with her friends, and eaten well. But that night she
woke up vomiting blood. The family had rushed her to the
hospital, where she died shortly after being admitted.
Kassim had gone south to assist with the burial, which,
according to Muslim custom, would happen that day.
After a moment I asked how Kassim was holding up.
McGruder shrugged as she stirred the coffee. “It’s hard to
say,” she said. “Swahili men tend not to show a lot of
emotion when things like this happen.”
When I saw Kassim late the next day, I shook his hand and
told him how sorry I was to hear about his daughter. He
smiled weakly and said only, “That is life.” Later at dinner
he told McGruder and me how the women cried during the
day. He described how the crying would reach a crescendo
and then die down, only to be started again when a new
woman showed up and saw the body.
Kassim’s own demeanor remained a mystery to me. At
first I assumed that he was just in shock and would be
overcome with emotion when he had time to reflect on the
event. It would be unfortunate, I also found myself thinking,
if some notion of local machismo made him push his true
feelings aside. He would certainly pay a steep psychological
price for such repressing of his feelings.
Although I had traveled here with the intention of learning
about the different ways people in Swahili culture express
emotion in the face of mental illness and other difficult life
challenges, I couldn’t let go of my assumption that the
healthy reaction to the loss of a child would be abject
displays of grief. I believed the natural—the truly human—
reaction to such an event was the way I imagined I would
have reacted if the 3 a.m. phone call had carried tragic
news about my own daughter back in San Francisco. I was
as unable to understand what Kassim was feeling from his
outward affect as I was to understand the meaning of his
words when he spoke Kiswahili; he was expressing himself
in an emotional language that I did not comprehend.
Even anthropologists, who diligently train themselves to
be nonjudgmental observers of cultural differences, have
trouble when it comes to recognizing and allowing for
cultural differences in emotions. Because our emotions
come into our consciousness unbidden and often surprise us
with their intensity, we often assume that they are not
influenced by cultural cues or social scripts. But with careful
study, anthropologists have learned that emotions are not
like muscle reflexes; rather, they are communications with
deep and sometimes obscure meanings. Cultures differ not
only in their response to specific events (as we’ve seen with
reactions to trauma) but also in more global ways.
Describing and understanding these differences has in
fact been central to McGruder’s research on Zanzibari
families who struggle with schizophrenia. During her
research she began to suspect that the emotional tenor of
families dealing with mental illness in Zanzibar was
qualitatively different from that of families in the
industrialized world. Subtle differences in this emotional
temperature of households, she theorized, might go a long
way to explaining why a schizophrenic patient in Zanzibar
will often do better than someone diagnosed with the
disease in the United States.
From the Clouds to the Equatorial Sun
McGruder is of a type common among the faculty of West
Coast colleges. Her politics are liberal and she is prone to
antiestablishment and contrarian thinking. She is short with
spiked blond hair and a friendly but no-nonsense demeanor.
As a child she was smart and rebellious, a difficult
combination for a Catholic schoolgirl growing up in northern
Indiana in the 1950s. When she was a teenager she dated
African American men despite her parents’ strenuous
objections. One of her first encounters with the mental
health profession was when her parents forced her to see a
psychologist to cure her of her “pathological” romantic
behavior. At one point she was even threatened with
incarceration in a mental hospital.
Despite her parents’ efforts, she got married at age 18 to
an African American man. This was just one year after the
Supreme Court’s 1967 ruling Loving v. Virginia, which
effectively ended race-based restrictions on marriage in the
United States. McGruder’s first job after college was in the
mid-1970s at the Hudson River Psychiatric Center in
Poughkeepsie, where she witnessed what passed for mental
health treatment at the time. As she remembers, the
doctors relied heavily on sedating antipsychotics such as
Thorazine, Stelazine, and Haldol and some early tricyclic
antidepressants. She couldn’t help but notice the way some
of the drugs knocked the patients for a loop. “These drugs
worked like big hammers,” she told me. “They just snowed
people. They would make the patients shake and drool and
feel miserable.”
After that she went back to school for a degree in science
education and became a teacher, eventually finding a post
teaching occupational therapy at the University of Puget
Sound. On the side she worked as a private therapist and
guardian with elderly and institutionalized schizophrenic
clients. After a decade of teaching and making her way up
the university’s academic ladder, she got bored with the
routine and found herself reading feminist philosophical
tracts on science and gender. With a sabbatical coming up,
she sent out dozens of letters to international aid agencies
offering her services. For months she heard nothing. Then
came a lone reply from a Danish international development
organization that had an office in Dar es Salaam, Tanzania.
They offered her a year-long post at the Kidongo Chekundu
Mental Hospital on the island of Zanzibar with a salary of
forty-two dollars a month. She jumped at the chance and
immersed herself in learning Kiswahili. Once she got to
Zanzibar, she helped establish an occupational center at the
hospital where patients could learn carpentry skills and
practice art therapy.
The Western-trained doctors she met at the hospital in
Zanzibar had access to the basic arsenal of Western
antipsychotic drugs. However, the idea that diseases such
as schizophrenia spring from chemical imbalances or brain
abnormalities had not yet been accepted by most of the
population of Zanzibar. Much more salient were beliefs in
spirit possession and the permeability of the human
consciousness by magical forces.
McGruder became fascinated by the ways these beliefs in
spirits shaped the experience of mental illness both for the
families and the patients themselves. She was also
interested in how these local ideas were beginning to
intermingle and sometimes compete with the imported
Western idea that mental illnesses were caused by
biological brain malfunctions. At the end of her sabbatical,
she decided to pursue a doctoral degree in anthropology so
she could dive further into these questions. After finishing
her course work in anthropology at the University of
Washington, she couldn’t wait to escape the dreary Pacific
Northwest and get back to the island.
Zanzibar lies at the midpoint of the Swahili Coast, a 1,800-
mile stretch of coastline straddling the Equator from Kenya
to Mozambique. For millennia it was to this coastline that all
of Central Africa brought its goods in order to trade them
with the world. The predictable monsoon trade winds were
key to its culture. From November to March those winds
blew steadily down the coast, bringing merchants and
traders from India and the Persian Gulf. From July to
September they shifted northward, sending the traders
home. On the northbound winds small lateen-sailed boats
called dhows traveled up the coast with sturdy mangrove
wood, aromatic tree resins, gold, ivory, clove, and the fine,
multipurpose fibers of the raffia palm. On the southbound
winds they brought back manufactured goods from Arabia,
India, and China in the form of carpets, incense, glassware,
and cloth. The months between the shifts in the trade winds
gave merchants from the Middle East time to sell their
goods and buy their new cargo. It also gave them time to
share their ideas and religious beliefs and to infuse Swahili
with Arabic words. The months in foreign harbors also
allowed for merchants and sailors to take wives and
otherwise leave their genetic mark on the population.
The resulting cultural texture of Zanzibar was endlessly
interesting to McGruder. She enjoyed the smell and the
sound of the place, the way the echoing calls to prayer
broke up the day, and the constant commotion of children at
play. She even liked the way the names of things felt on her
tongue. The place-names Kisimkazi, Manzi Moja, and
Kakunduchi felt good to say. She particularly liked saying the
name of the local public transport along one of the main
roads: the Bububu daladala.
Not that life there was a tropical paradise. Although her
memory of that first year has sweetened, her field notes
attest to the frustrations of living in a developing country.
There were outbreaks of cholera, and the dust whipped up
by the constant trade winds during the dry season often
contained enough bacteria to cause epidemics of
conjunctivitis. Raw sewage sometimes fouled the white
beaches and the baby-blueness of the ocean. Fishermen had
recently taken to using sticks of dynamite to fish the reefs,
and the joy of speaking the words Bububu daladala was
offset by the sheer terror she felt while actually riding these
speeding minibuses.
In the end, however, her desire to return and study mental
illness in Zanzibar came not simply out of an abstract
pursuit of knowledge or the social good that might come of
her findings, but because she felt a deep affinity for the
people and the place.
Incidental Content versus Essential Form
McGruder was well aware that the cutting-edge research on
schizophrenia was not coming out of the field of
anthropology. More than any other mental illness in the
Western world, this one belonged to the “hard scientists”
who looked for the causes in bad genes, biochemistry, and
the structure of the brain. The advent of brain scans—
allowing a researcher to see into the head of live patients—
brought with it a seemingly endless series of theories about
the root cause of the illness. Abnormalities supposedly key
to schizophrenia have been reported in the frontal cortex,
the prefrontal cortex, the basal ganglia, the hippocampus,
the thalamus, the cerebellum—and pretty much every other
corner of the brain as well. No firm consensus had emerged
about the location or cause, but there was wide agreement
that the exciting advances in understanding the disease
were coming from the laboratories of brain researchers.
Although far from the limelight, there were scholars and
researchers looking at the disease from other perspectives
as well. McGruder found perplexing data and fascinating
theories in cross-cultural studies of the disease. Although
something approximating schizophrenia could be found in
populations at every corner of the globe, there were enough
variations to suggest that the disease was shaped by
something besides the purely genetic or biological.
The most obvious differences between cultures were in
the delusions and hallucinations experienced by those with
schizophrenia. These harrowing visions and disembodied
voices were often distorted reflections of the phobias and
fascinations of specific cultures. No one, after all, endures
the psychotic delusion that the CIA is beaming microwave
signals into his or her fillings unless that person is culturally
acquainted with the CIA, modern dentistry, and the
disquieting idea that our bodies are constantly permeated
by unseen electromagnetic waves.
Those who have studied these differences have noted,
among other things, that delusional guilt is most often
associated with Judeo-Christian cultures, as are religious
hallucinations such as hearing the voice of God. Such
hallucinations are rarer in Islamic, Hindu, and Buddhist
populations. Schizophrenic patients from Pakistan are more
likely to have visual hallucinations of ghosts and spirits than
are British schizophrenics, who are more prone to hearing
persecuting voices. In traditional Southeast Asian villages,
where it is often frowned upon to strive willfully for personal
status, delusions of grandeur are rare. In the United States,
where celebrity, wealth, and power are popular fetishes,
people with schizophrenia commonly believe that they are
famous or all-powerful.
It is also clear that delusional content in any particular
culture can change over time. In Austria, to take one
example, cases of delusions of grandeur, hearing the voice
of God, and feeling persecuted have been steadily
increasing over the past fifty years, while delusional guilt
and psychotic hypochondria are on the decline.
Researchers who focused on the biomedical or genetic
linchpins of the disorder often dismissed these differences.
The fact that the “delusions of schizophrenics in
industrialized societies will concern television sets and x-
rays rather than ghosts and spirits . . . [is] often considered
to be of secondary importance,” writes Rutgers professor of
psychology Louis Sass. “They are presumed to have little to
do with the illness’s genesis or essential form.”
Does it really matter that a person with schizophrenia in
one culture talks with a dead relative, while someone in
another culture believes he is receiving communications
from an extraterrestrial? The distinction that often gets
made in this debate is between pathoplastic aspects of the
disease, which vary from person to person, and the
pathogenic cause, which is assumed to be the root cause of
the disorder. Pathoplastic symptoms are often dismissed for
describing only the coloring and content of an illness but not
its fundamental nature. The true prize—the quest of the
brain researchers—was to get past the cultural noise and
discover the pathogenic factors that are the universal cause
of the illness. They wanted to weed out the “incidental
content” and get to the “essential form.”
But McGruder kept coming across research suggesting
that culture and social setting play a more complicated role
in the disease than simply influencing the content of the
delusions. Studies showed, for instance, that prevalence
rates vary from place to place. Those living in urban settings
in the United States and Europe appear to suffer more often
from the disease than those living in the country or the
suburbs. These curious spikes in the disorder remain even
when researchers took migration, drug use, and poverty out
of the equation. Men living in the most densely populated
areas of Sweden, for instance, are at a 68 percent higher
risk of being admitted for psychosis—often the first sign of
schizophrenia—than those who live in the countryside. For
women the risk is 77 percent higher. Something about city
living seems to spark the harrowing delusions,
hallucinations, and disorganized thinking characteristic of a
schizophrenic break. Stranger still, some neighborhoods in
cities produce more schizophrenics, to such a degree that
scientists have wondered about the environmental
pathogens that might exist in one place and not another.
The more McGruder read of the cross-cultural research on
the disorder, the more it appeared to shape-shift from place
to place, and no one seemed to have a clear explanation for
this. Janis Hunter Jenkins and Robert John Barrett, two of the
premier researchers in the field, describe the general state
of affairs.
In sum, what we know about culture and schizophrenia is . . . [that] culture
is critical in nearly every aspect of schizophrenic illness experience: the
identification, definition and meaning of the illness during the primordial,
acute, and residual phases; the timing and type of onset; symptom
formation in terms of content, form, and constellation; clinical diagnosis;
gender and ethnic differences; the personal experience of schizophrenic
illness; social response, support, and stigma; and perhaps most important,
the course and outcome with respect to symptomatology, work, and social
functioning.
By “course and outcome,” Jenkins and Barrett are referring
to that most perplexing finding in the epidemiology on the
disease: people with schizophrenia in developing countries
appear to do better over time than those living in
industrialized nations.
McGruder read with fascination the startling results of two
huge international studies carried out by the World Health
Organization over the course of twenty-five years starting in
the late 1960s. These two studies, which had follow-up
periods of two and five years, took place in a dozen sites
around the world, taking into account ten countries and
following more than a thousand patients from both rural and
urban settings. What they found was that those diagnosed
with schizophrenia living in India, Nigeria, and Columbia
often experienced a less severe form of the disease (had
longer periods of remission and higher levels of social
functioning) than those living in the United States,
Denmark, or Taiwan. Whereas over 40 percent of
schizophrenics in industrialized nations were judged over
time to be “severely impaired,” only 24 percent of patients
in the poorer countries ended up similarly disabled.
That result, which is perhaps the most famous finding in
the field of cross-cultural psychiatry, was widely discussed
and debated in part because of its obvious irony: 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.
McGruder found it remarkable that even in the face of
these cross-cultural differences in outcome, some
researchers still seemed uninterested. As with the
differences in the content of the delusion, these variations
in course and outcome were considered in some quarters to
be beside the point. Ignoring the WHO studies might make
sense to a brain scientist or geneticist looking for the first
trigger for schizophrenia, but for someone like McGruder,
who had worked closely with and cared for schizophrenic
patients, there was nothing—save a miracle cure—more
important than the question of the disease’s course and
outcome.
As McGruder read more about the WHO studies she
became fascinated by the debate within psychiatry over the
possible reasons for these differences. Some researchers
suggested that the demands placed on a person in a poorer
nation to be productively employed were lighter and easier
to meet. Perhaps there were more opportunities to feel
productive by engaging in work with one’s family, such as
gardening and child care. Others put forward the idea that
the expectations for appropriate behavior were clearer and
simpler in nonindustrialized, traditional, or premodern
cultures. The rules of behavior for living in the modern world
simply overwhelmed schizophrenics, causing them
increasing distress. Perhaps, suggested others, it was
traditional beliefs in supernatural agents and spirit
possession that removed the weight of blame and guilt from
both the person experiencing psychosis and the family. Still
another set of scholars thought that families in certain
cultures might express less highly charged attention and
criticism toward the ill family member. This research into
what was called “expressed emotion” suggested that
schizophrenics often got worse when surrounded by family
members who were constantly critical of their behavior or
showed intense and intrusive concern about their condition.
Given all the different theories that attempted to explain
the WHO studies, McGruder could immediately see one
truth: no one had yet found a convincing explanation for the
cross-cultural differences. Indeed the researchers who
conducted the WHO studies admitted as much. Although a
“strong case can be made for a real pervasive influence of a
powerful factor which can be referred to as ‘culture,’” one of
the WHO researchers concluded, none of the WHO studies
was designed to “penetrate in sufficient depth” to
understand what might be happening. This left researchers
guessing which cultural factors might be ameliorating this
devastating disease.
The fact that researchers couldn’t offer meaningful or
specific conclusions about the effect of different cultures on
schizophrenia didn’t surprise McGruder. Culture, as she was
learning to understand it as an anthropologist, did not exist
in large data sets. The word can be defined in broad terms
as, say, the “the intellectual, moral, and aesthetic standards
prevalent in a community” or as the “shared symbols and
meanings that people create in the process of social
interaction.” Yet anthropologists firmly hold that culture can
be truly understood only in the particular. Culture, especially
as it shapes and informs the consciousness of a mentally ill
person, is a local phenomenon.
Again and again in the debate surrounding the WHO study
McGruder saw researchers pleading for anthropologists to
pick up the ball and run. “More ethnography is needed,”
concluded one well-known researcher, “if only to elucidate
those aspects of everyday practice that remain obscure.” All
the way back in 1987 the Harvard medical anthropologist
Arthur Kleinman wrote with obvious frustration about the
lack of anthropological attention to the WHO data on
schizophrenia: “For over ten years this finding has been the
most provocative to emerge in cross-cultural psychiatry . . .
[Yet] the most important finding of cultural difference—
arguably the single most important finding in the study—
receives scant attention.”
McGruder saw the window of opportunity presented by the
WHO study. What was clearly missing was an on-the-ground
examination of the ways patients in a developing country
are treated by their families and caregivers. What ideas and
beliefs do family members in developing nations use to
understand the delusional behavior of a loved one? How do
they talk about this behavior—what specific words and ideas
do they employ? And, critically, how does the local
understanding of the illness impact the beliefs, behaviors,
and self-conception of the ill family member?
Given the importance of the questions posed by the WHO
studies, it was surprising that droves of young
anthropologists hadn’t heeded the call. Then again,
considering the scope of the challenge, this reticence is
perhaps understandable. Even observable public aspects of
culture are difficult to understand and describe in depth;
elucidating the cultural currents that affect the functioning
of a mentally ill person would be much more difficult. The
challenge of McGruder’s research went beyond describing
what people did. She had to explain, on a nearly existential
level, who they were. A younger PhD candidate would have
been well advised to pick a topic that had firmer boundaries.
Fortunately McGruder was not at the beginning of her career
but closer to its end, and so she had no need for a safe
research topic. She brought to her research the particular
type of passion that comes when one picks a topic that is
the confluence of one’s life interests.
Revolution and Madness
On my fourth day in Zanzibar, McGruder walked me through
a maze of narrow alleys in Stone Town to the house of one
of the three families she studied. It was a low white building
facing a small public square, in the center of which stood a
large shade tree. The house was not much to look at: a
single-story cement structure with four square columns
supporting the roof over a small porch. The windows were
shuttered behind steel bars. The family had moved a few
years ago and the house was empty. A message in red spray
paint read in Kiswahili, “This house is not for sale.” This,
McGruder told me, was where Hemed and his daughter
Kimwana, both diagnosed with schizophrenia, had lived with
their family.* The head of the household was Amina,
Hemed’s ex-wife and Kimwana’s mother.
As with most Zanzibari families, these three did not live as
a nuclear family unit. During the year McGruder spent
visiting the family, the household included Amina’s mother;
her two married daughters and their children; one
unmarried daughter, who was sometimes away at college;
one unmarried son, who was studying at the local Islamic
teacher’s college; Hemed’s half-brother, who was a deaf-
mute; plus his adopted sister and her children. At night the
600-square-foot, eight-room structure slept as many as ten
adults and ten children.
As we sat on a low brick wall at the edge of the square
nearest the house, I asked McGruder if her memory of the
place was of rooms constantly packed with people. “No, my
impression of the place was of traffic; constant streams
coming and going,” she told me. She described how women
would converse and do chores indoors or in the small walled
courtyard. Men and children would be outside on the
covered baraza, the cement bench that ran along the front
of the house. The kitchen would be in constant use, as
household members cared for and fed each other in a bustle
of steady activity. One of McGruder’s favorite words in
Kiswahili is onomatopoeic for such managed chaos:
zogozogo.
The sheer number of people in the household posed a
challenge to her research. She had hoped to tell the history
and take the emotional temperature of the family, but even
a rough sketch of the family tree of this pulsing kinship
group proved complicated. Amina, the mother, seemed the
obvious focal point for her study. The swirl of activity in the
household revolved around her. She was the rock.
Like many Zanzibaris, Amina was of mixed Swahili and
Arab descent. She was married at 18 in an arranged union
to Hemed, the older son of the plantation owner for whom
her father worked. Like many Arab families who had
immigrated from the Middle East over the centuries,
Hemed’s father owned a clove plantation and traded in the
spice business. During their courtship in 1960 and the
months after their marriage that year, Amina remembered,
Hemed was lighthearted and charming. Sadly, it was less
than a year after their marriage that he experienced his first
psychotic episode.
The period in which Hemed began to experience
symptoms of schizophrenia was, not coincidentally, a time
of political upheaval on the island. After years of being a
British colony, Zanzibar embarked on the uncertain path to
self-governance. There were three political parties, twenty-
two trade unions, and sixteen partisan newspapers stirring
up anger and resentment on all sides. Hemed’s first
experience of derangement, McGruder believes, was
sparked by the social upheaval of the time.
As Amina remembered, Hemed loved to talk politics, and
he would often come back from political meetings so wound
up that he couldn’t sleep. He would talk all night about the
various faction leaders and the ever-changing alliances.
Over the months, these ramblings became tinged with fear
of political persecution. His worries were not mere paranoia,
given the ethnic and political killings that were to come.
Soon Hemed’s political monologues transformed into
fretful discussions with unseen interlocutors. He began to
frighten his new wife with his unpredictable behavior.
Such an onset of schizophrenia can be explained by the
stress-diathesis model, the theory that biological factors
make one vulnerable to schizophrenia, but stress in one’s
environment may set off the illness. Stress may come from
any number of sources, but researchers have paid particular
attention to conflict within a person’s social world. Given
what was going on in that moment in the history of
Zanzibar, the amount of stress felt by Hemed must have
been intense. He was a middle-class man from a high-profile
Arab minority at a time of growing racial and class distrust.
His curly dark hair and facial features made him identifiably
Arab. There seemed to be no safe political refuge. Even the
political party he belonged to, the Zanzibar Nationalist
Party, was internally split between those who considered
themselves African and those of Arab heritage. No one knew
whom to trust.
At the end of the year Hemed broke down. Soon after his
first son was born, in September, he was admitted to the
local mental hospital after beating his great-aunt during a
delusional episode. Early the next year he was certified as a
person of unsound mind. His medical charts reported that
he had a “shallowness of emotion, visual hallucinations and
aggressiveness, tend[ed] to lose temper, ha[d] delusions.”
The New Year brought no relief from the political turmoil.
Violent riots followed the elections, prompting the British to
send in soldiers from the mainland and declare a state of
emergency. Dozens of foreign-born Arabs were murdered
and more than a thousand people were arrested. During this
time Hemed returned to the mental hospital and stayed
there for six months. He was released around the time his
daughter Kimwana was born.
Over the next two decades Hemed was hospitalized eight
times for various periods and twice given electroconvulsive
treatments. As McGruder examined his hospital records, it
became clear that the dates of his worst episodes were
during or right after periods of political strife or family
stress.
In 1970, when Hemed was hospitalized for nearly an
entire year, Amina divorced him, employing an Islamic law
that allows divorce for reasons of nonsupport. Still, Hemed
eventually came back to live with the family, and he and
Amina even had a sixth child together. Later he suffered a
stroke that paralyzed one side of his body. In the end Amina
saw Hemed’s stroke as something of a blessing. Although it
made him an invalid, she told McGruder, “it has broken the
strength of his anger, his wanting to beat people.”
Kimwana, their daughter, showed no signs of the illness
during childhood. Amina remembers her daughter’s early
years with the compliment that she was “not a heavy load.”
She was a happy child even though her early years were
turbulent times for the island. Her mother and classmates
remember her as the brightest student in the class.
Particularly skilled with numbers, she graduated from
secondary school and took a job with the Ministry of
Finance. This was 1983, a time of rapid change for women
on the island. To fill in for the many educated men who had
fled the political upheaval, women were beginning to enter
the professional workforce by the thousands.
One Saturday night, just a few months after starting her
new job, Kimwana was restless and couldn’t sleep. Late in
the evening she wandered outside the house and in a loud
voice began asking for forgiveness. “Forgive me!” she
yelled. “Oh God, what have I done wrong!” When the family
couldn’t calm her, they assumed it was a case of spirit
possession. The family debated two theories. Perhaps, they
thought, she had been possessed by a spirit from a
deceased ancestor who had not been acknowledged for
watching over Kimwana, had not been shown the proper
gratitude for all the success she had experienced up to that
point. The other possibility was that a jealous coworker had
sent the spirit with the use of witchcraft.
At 1 a.m. Kimwana’s ranting hadn’t yet subsided, and the
family took her to the local hospital. Amina remembers that
she was examined, given antimalaria pills, and admitted for
four days.* At the end of the week, Amina recalls, Kimwana
came back home, slept well, and was able to go to work
again on Sunday.
She worked that week, but the following Monday again
became upset and refused to go to work. This time Amina
employed a traditional remedy. She burned a mixture of
leaves, flowers, grasses, and seaweed, whose strong odor is
believed to repel many types of weak spirits. Amina
remembers taking her daughter to the hospital, where she
again “became herself.” But even with periods of remission,
the delusions of hearing disembodied voices came back on
a regular basis.
He Sees Me up to My Heart
Fifteen years later, when McGruder began to spend time
with the family, her goal was not to show that Kimwana’s or
Hemed’s mental illness would have had a different course in
a different cultural setting; that would be impossible to
prove as there are no control groups in ethnographic
scholarship. Rather, she set about trying to record how
cultural beliefs and practices contributed to the family’s
understanding of the illness and to their treatment of
Kimwana and Hemed.
McGruder first wanted to get an idea of what the
experience of madness felt like. Hemed was so disabled by
his schizophrenia and the stroke that it was not possible to
get a sense of what was happening in his mind. Kimwana,
however, had periods of relatively high functioning and
could tell McGruder her impressions.
Kimwana told McGruder that the voices she heard in her
head were usually male, and they spoke to her as if they
could “see to my very soul.” These voices told her variations
on the theme of what a bad person she was. Sometimes she
heard two or more men gossiping that she was a disloyal
and disrespectful daughter and sister. The chorus could be
relentless: “She doesn’t love her mother,” one voice would
say to the other. “She doesn’t love her brothers and sisters.
She is not a person of God, just a useless person.”
Sometimes they would curse her in riddles or make negative
but oblique statements such as “Abhorrent badness even to
the soul.”
Although Kimwana understood that her thoughts were
unstable and disorganized, she often insisted the voices
were of real people and not delusional. And although she
sometimes believed that the voices came from outside the
window, her subjective experience was that the person
speaking was seeing into her thoughts and feelings. “I don’t
see him but he does [see me],” she told McGruder. “He
really sees me a lot. Actually he sees me up to my heart, up
to my mind. He has the ability to speak to me because he is
able to see me because whatever I think about he sees it.”
Much of the torment of having these male presences in
her head related to Islamic rules of female modesty. While
the voices were with her, she felt she must respect the
codes of conduct as if she were actually in the presence of a
man. At such times she could not bathe or undress and she
tried not to go to the bathroom. Although she sometimes
found it helpful to argue with the voices when they became
critical, her sense of decorum made it difficult for her to do
this out loud.
This sense of decorum also made Kimwana reluctant at
first to name her tormentors, for it turned out that she
recognized the voices. They were, she admitted to
McGruder, the voices of the bicycle repairmen who worked
in front of the house. This bit of reality left McGruder in a
quandary over Kimwana’s perceptions. For most of the day
and often into the evening the voices of the bicycle
repairmen could be heard quite clearly in the house. It was
often difficult to tell to what extent Kimwana’s delusions
were jumping off of actual conversations drifting through
the window and to what extent they existed exclusively in
her mind.
That Kimwana’s delusions would come in the form of
intrusive auditory hallucinations made sense given the
location of the household. The roiling, pulsing sound that
filled the square during the day was remarkable for its
volume, texture, and complexity. Across the square from the
house was the Bakathrir Muslim School for Girls, and directly
to the right of the house was the Al Nour Islamic School for
Boys. At any given moment the undulating, overlapping
choruses of hundreds of children chanting in Arabic could be
heard.* The noise that emanated from the schools created a
kind of hypnotic background sound, like breaking surf.
On top of that sound could be heard the single voices of
individual children teasing and playing with each other or
calling out to people in the courtyard. Then there were the
voices and footsteps of adults heading across the square on
their errands and the constant squawk of crows in the shade
tree. In that cacophony of sounds reverberating and echoing
off tin roofs and cement surfaces, the only discernable
individual voices were those of the bicycle repairmen
chatting among themselves or with their customers as they
did their work.
Considering the additional commotion of the comings and
goings of the members of the household, the noise must
have been unrelenting. The many small children, though
well behaved in the manner of most Zanzibari children,
created a racket. Hemed, even though he could not walk or
even bathe himself, could yell and often did for long
stretches without ceasing. Several of the family members
shared with McGruder their belief that the noise itself was
exacerbating Kimwana’s illness. Bimkubwa, the most
Westernized of the siblings, told McGruder that Europeans
have much smaller families and that their houses were
much quieter. “There are too many of us and this place is
too noisy,” she said emphatically.
Kimwana often asserted that she felt better when she was
alone. But given her auditory hallucinations and the general
noisiness of her surroundings it was clear that she was
talking not just about a desire for physical solitude but also
for quiet. “I do like being on my own,” she once told
McGruder. “Being with people I feel like I am tangled with
them. I feel like calming myself, just silently. Just quiet and
silent.” Unfortunately time alone was a scarce commodity in
the packed household. And silence was all but unavailable.
The Emotional Temperature of the Household
It didn’t take long for McGruder to sense that Amina’s family
displayed an amazing tolerance for the difficulties of having
two severely mentally ill people (not to mention a deaf-
mute) in their household. It was a testament to the strength
of this family unit that Hemed, even after the divorce for
nonsupport and the years of violent psychotic episodes, was
still taken care of by Amina and the family.
McGruder noted that the family took a remarkably relaxed
stance toward Kimwana’s illness in particular. When asked
about Kimwana’s symptoms, Amina gave matter-of-fact
answers. When McGruder wanted to know what Amina
thought of Kimwana’s central delusion, all she could elicit
was the simple declaration that her daughter felt that the
“bicycle repairmen concern themselves with her affairs.”
Amina told McGruder that she did not share her daughter’s
belief, but there was no judgment or frustration attached to
the delusions. To many questions Amina would only answer,
“I am unable to know” or “I take it as one of God’s mercies,
one of God’s wishes.”
To try to give me a sense of the emotional tone in this
house, McGruder recounted a day in late September after a
particularly difficult few months for the household. Kimwana
was recovering after taking an overdose of her medication,
and a bad cold had sickened nearly everyone in the family.
Amina had admitted to McGruder that they were too poor
even to buy aspirin. Although each family member had
mostly recovered from the illness, the family unit was still
trying to regain its normal rhythm.
When McGruder arrived in midmorning she went right to
work in the kitchen. She had found that participating in the
daily chores was a much less intrusive way to observe the
goings-on in the household than sitting in a corner with a
notebook. Over the course of the morning she watched
Amina prepare food for a dozen hungry mouths, negotiate
the payment of school fees with a local official, send family
members on a variety of errands, and deal with minor
setbacks, including a large pot of ginger tea that had
unexpectedly curdled. On top of this she did her best to
keep the children (and McGruder) from disturbing Hemed or
Kimwana, both of whom were more upset that morning than
usual.
In her notebook McGruder listed the stressors Amina dealt
with that day. There were the relentless financial worries,
three family members who needed constant care, over a
dozen mouths to feed, and a small pack of children to be
protected and cared for. McGruder crossed off one theory
that might account for the differences in outcome of
schizophrenia between developing and industrialized
nations: the idea that life was simpler and less stressful for
poor people living in more traditional cultures. McGruder
suspects that this theory springs from a fantasy on the part
of Westerners, who are soul-weary from lives of commuting,
competing, and trying to find time for family. We want there
to be a place in the world where our life might distill to a
simple combination of satisfying work and close human
interaction. In reality, a stress-free life was as elusive in
Zanzibar as anywhere else in the world.
Despite the zogozogo and the hardships, however,
Kimwana’s behavior and her deficits were tolerated with
remarkable equanimity. While Kimwana’s activities and
social interactions were often reported to McGruder as a
gauge of her wellness, McGruder rarely witnessed Amina or
anyone else in the family pressure Kimwana into displaying
normal behaviors. During periods when Kimwana was
feeling well, for instance, Amina would report that she had
washed the dishes or swept the house. But Amina didn’t
assume a cause and an effect between productivity and
wellness. This goes against some basic tenets of Western
occupational therapy, which suggests that the path to
mental health can be found in productivity and participation
in group activity. Although the family viewed her
participation in household chores as a sign of health, they
didn’t pressure her to perform chores with the assumption
that they were curative. Indeed, when Kimwana was doing
poorly, the family allowed and even encouraged her to
withdraw from activity and to rest. Often, when she tried to
help out during such times, her family cautioned her not to
overextend herself.
For the most part, however, Kimwana was allowed to drift
back and forth from illness to relative health without much
monitoring or comment by the rest of the family. Periods of
troubled behavior were not greeted with expressions of
concern or alarm, and neither were times of wellness
celebrated. As such, Kimwana felt little pressure to self-
identify as someone with a permanent mental illness. This
stood in contrast with the diagnosis of schizophrenia as
McGruder knew it was used in the West. There the diagnosis
carries the assumption of a chronic condition, one that often
comes to define a person.
The prizing of rest over work and passive acceptance of
abnormal behavior versus active encouragement or
criticism were representative of an overall calm emotional
tone in the household. Even on difficult days there was an
air of tolerance when dealing with Hemed’s and Kimwana’s
disturbed behavior. McGruder believed that this tone
emanated not simply from the personalities in this particular
family but from cultural cues in Zanzibar, and she took it as
her mission to find the sources that created this emotionally
even atmosphere.
Emotional Expression and Schizophrenia
The early research into the relationship between the
emotional temperature within families and the long-term
course of schizophrenia took place in England in the 1950s.
Clinicians had anecdotally observed that some patients with
schizophrenia released from hospital care came back within
a short period of time, whereas other patients managed to
stay out of inpatient care for longer periods. A team of
researchers led by the psychiatrist George Brown decided to
try to figure out what factors might distinguish the two
groups. They conducted lengthy open-ended interviews
designed to encourage first-person stories from family
members. There were no right or wrong answers;
researchers attempted only to elicit rich descriptions of daily
life with the mentally ill family member. After categorizing
all the emotional reactions they could identify, they tracked
the patients over time, noting their rates of relapse and
general levels of functioning.
Initially they looked at the families of the patients who
fared better, but they could find no behavior that had
significant predictive value. Studying the families of the
high-relapse patients, however, they did find factors that
appeared to predict outcomes. Three emotional reactions
from family members showed a relationship with the
patients with higher relapse rates. Collectively referred to as
“high expressed emotion” they were criticism, hostility, and
emotional overinvolvement. In particular, high-relapse
patients tended to live in an environment where at least one
relative routinely criticized and attempted to control the
patient’s behavior.*
Criticism and hostility are relatively self-explanatory.
“Emotional overinvolvement,” however, is a term of art that
requires a little explanation. It describes a range of
behaviors that may include dramatic expressions of self-
sacrifice, extreme devotion, overprotectiveness, or
intrusiveness in the patient’s life. One mother, for instance,
was rated as emotionally overinvolved when she reported
that she was so concerned with her son’s condition that she
had dropped all other interests from her life. Her sole
activity, she reported, was to take care of him and protect
him, “like a pearl or a diamond.” This same mother said that
she often became so distraught over her son’s plight that
she considered committing suicide by shooting herself,
running out into traffic, and throwing herself down the
family staircase.
Researchers have found a connection with high expressed
emotion (EE) and poorer outcomes with some other mental
illnesses, but nowhere is it as pronounced as with
schizophrenia. Why is there such a strong connection?
Researchers believe that the experience of being criticized
or constantly observed and judged parallels the experience
of the disease itself. It is not coincidence, in other words,
that one of the central symptoms of schizophrenia is
hearing demanding, critical, or disparaging voices. Social
stress is a known trigger for psychotic episodes, and a
number of studies testing diastolic blood pressure, skin
conductance, and electrodermal reactivity all pointed to the
connection between high-expressed-emotion relatives and
increased feelings of stress in a patient. When confronted
with relatives known for their high levels of expressed
emotion, researchers could watch as dials measuring bodily
stress rose in the patient.
This connection between high-expressed-emotion
households and relapse rates proved true across cultures.
Over the course of the 1970s and 1980s dozens of studies
were conducted on populations in Denmark, Italy, Germany,
Spain, France, North America (including both Anglos and
Mexican Americans), China, Taiwan, India, North Africa, and
Australia. In a paper that aggregated the data from a dozen
studies, researchers noted that the relapse rates were three
to seven times greater for patients from high-expressed-
emotion families. The connection remained even when the
severity of the initial symptoms and drug compliance were
taken into account. In another paper that brought together
the data from twenty-five studies, researchers found that
the relapse rate was 50 percent for high-expressed-emotion
families and 21 percent for low-expressed-emotion families.
God’s Blessings
McGruder could sense that Amina’s household had a low
level of expressed emotion when it came to dealing with
Hemed and Kimwana, but it took her quite a while to
understand the cultural sources of that tone. She spent a
good deal of her time trying to tease out the local religious
beliefs that wove themselves around the ideas of madness
in Zanzibar. Like 90 percent of Zanzibaris, Amina’s family
belonged to the Sunni Shafi’ites sect. This is an Islamic sect
that believes in adhering faithfully to the teachings of the
Koran and the stories collected by Al-Bukhari that recount
the life of the Prophet Mohammed. It is from these stories,
collectively called a hadith, that many Zanzibaris draw
wisdom to manage the everyday challenges of life.
Both the Koran and Al-Bukhari’s hadith recount ideas
about suffering and hardship that McGruder could see had
deeply informed the family’s treatment of Kimwana and
Hemed. Amina and other family members often repeated
the belief that Allah would never put more burdens on a
person than he or she could bear. “In our family we have
this challenge but this is just life,” Amina would tell
McGruder when talking about Kimwana and Hemed. “Other
people have other problems. Maybe their house has burned
down. Everyone knows their own burden best.”
McGruder came to understand that these were not just
bromides. In the family’s Muslim belief, managing hardships
provided a way to pay the debt of sinfulness. Illness or bad
turns of fortune were seen as neither arbitrary nor a
punishment. Rather, they believed that God’s grace awaited
those who not only endured suffering but were grateful for
the opportunity to prove their ability to endure it. In this way
Amina’s remarkable ability to stay steady and resolute in
the presence of sick and disabled family members was an
expression of her religious belief.
McGruder had heard similar “God willed it” sentiments
repeated among Christians in the United States, but the
embrace of hardships in Zanzibar was qualitatively different.
Although American Christians might believe that God had
sent a challenge or a misfortune, they were also likely to
believe that God had given them the strength not just to
embrace the difficulty but to overcome it or learn a valuable
lesson. In the cosmology of Western Christians, life’s
challenges provide opportunities to become stronger and to
have a closer relationship with God. The burdens God sends
to Christians in the Western world are incitements to self-
improvement. The comforts that Amina found in her
religious belief, by contrast, were not in an encouragement
to overcome or learn from hardships. Rather, simply
accepting her burdens was a continuous act of penance.
“Religion as I understood it as a child had more to do with
what you believed than what you did during your day,”
McGruder told me. “Here in Zanzibar religion has much
more to do with what you do. You can see it in how people
live their lives, how they pray five times a day and fast
during Ramadan.” In McGruder’s view, the steady care
given to Kimwana and especially Hemed seemed to come
out of the family’s religious desire to prove worthy of the
burden God had given them.
Sometimes it seemed that their acceptance of burdens
bordered on the fatalistic. “Fatalism” is not a word McGruder
would employ, given that its negative connotations violate
the anthropologist’s credo to remain judgment-neutral. Still,
McGruder found herself using such phrases as
“acquiescence in the face of adversity” and “embracing
difficulties as a natural part of life” almost as euphemisms.
She remembers times when she tried not to let her jaw drop
at the family’s lack of upset. One such moment came when
Kimwana took an overdose of her medication and ended up
in the hospital. “There was no noisy woe-is-me talk or
dramatic wringing of hands. They seemed to take it in stride
like everything else,” McGruder recalls. “When I asked what
I could do, Amina told me that I could take a carton of milk
to Kimwana in the hospital. So I took the milk.” For
McGruder, a fighter and problem solver by nature, it took
some time to recognize the benefits of such acceptance of
life’s difficulties.
The Creatures in Our Heads
The other religious belief that was central to the family’s
conception of the illness was spirit possession. It would be
easy for a Westerner to assume that belief in spirit
possession would almost certainly increase the stigma for a
mentally ill person. McGruder remembered the horror
stories of spirit possession she learned as a child in the
United States. Those beliefs were informed more by pop
cultural representations (such as the movie The Exorcist)
than by what she heard in church. Nevertheless her cultural
understanding of these devil-focused narratives about spirit
possession included dramatic suffering and ostracism for
the person believed to be possessed. In the Christian
context, possession is nearly always thought of as a
profoundly disturbing experience, usually requiring dramatic
and sometimes violent interventions. Given the choice
between the biomedical understanding of schizophrenia and
the spirit possession narrative, most Westerners assume the
drier science-bound explanation for the disease would
certainly inflame less emotion and stigma. As McGruder
came to understand the spirit possession beliefs of families
like Amina’s, however, she found them to be very different
from Christian beliefs in the West. To begin with, spirit
possession in Zanzibar was not an uncommon or necessarily
an extreme experience. As Amina explained to McGruder,
we all have “creatures in our heads.”
The beliefs surrounding spirit possession in Zanzibar arose
from the complex combination of traditional Swahili culture
and Arabic beliefs about jinns. These spirits that often
inhabit living individuals aren’t uniformly good or bad but
can cause problems if they are not dealt with in appropriate
ways. A spirit handed down from one’s ancestor is generally
thought to have a protective effect for the person who
carries it. Such an entity will cause difficulties only if it is
ignored or not properly appeased. These spirits can have an
ethnicity, gender, and religious affiliation of their own. A
spirit might be picked up accidentally or through witchcraft.
Sorcerers are said to raise and feed spirits, which they use
to harm their enemies.
The main difference between the character of spirits and
of humans, McGruder learned, is that spirits are often
autonomous, rude, selfish, and not given to concealing their
emotions. (In this way they are sometimes compared to
tourists who intrude but do not greet.) When a spirit
possesses someone, he or she often violates the social
norms. A sister momentarily influenced by a spirit may
strike a brother who is harassing or threatening her, for
instance.
Because nearly everyone on the island believed in spirit
possession and had a personal experience with it, the
application of the belief to mental illness had the
counterintuitive effect of lessening the stigma attached to
the behavior of the mentally ill person. It made bizarre or
disruptive behavior more understandable and forgivable.
Like the sister who has a ready explanation for hitting her
brother, mentally ill persons and their family can evoke the
narrative of spirit possession to explain unusual or antisocial
behavior.
Belief in spirit possession also gives the family a sense of
agency in that it allows for a variety of socially accepted
interventions. “Spirits causing problems are not exorcised in
the Christian sense of casting out demons,” McGruder
explains. “Rather they are coaxed with food and goods,
feted with song, dance. They are placated, settled, reduced
in malfeasance.” It was common, for instance, to write
phrases from the Koran on the inside edges of a teacup with
saffron paste and then to dissolve the writing so that the ill
person could literally imbibe the holy words. Similarly the
Koran might be read over water before it was used for
bathing. Pagan spirits would be driven away by such acts,
and Muslim spirits would become subdued. Kimwana found
such activities calming. She especially enjoyed it when
family members read to her the short verses from the Koran
that children learn to read and memorize early in school. “If
someone reads and I listen, then my mind clears,” Kimwana
said. “It tells us to become compliant and wait patiently. I
listen to the Koran and then I rest.”
For McGruder the point was not that these practices were
effective in combating the biological causes of
schizophrenia. Rather, they were simple examples of how
the spirit possession narratives kept the sick person within
the social group. Importantly, the idea that spirits could
come and go allowed the person with schizophrenia a
cleaner bill of health when the illness went into remission.
An ill individual enjoying a time of relative health could
employ the spirit possession story to, at least temporarily,
retake his or her responsibilities in the kinship group.
In all these ways the belief in spirit possession could
decrease the sense of blame or shame carried by the family
or the ill individual. The blessings and burdens of God and
the mysteries of the spirit world were, after all, beyond the
ability of the individual or family to effectively control. As
McGruder observed, “When humans do not assume they
have rather complete control of their experience, they do
not so deeply fear those who appear to have lost it.”
In some ways the low expressed emotional atmosphere in
the family stood in contrast to McGruder’s work as a
Western anthropologist trying diligently to understand it. At
times she had to remind herself to turn off her analytical
gaze, her desire to document and categorize the behavior
she was there to witness.
She remembers one day when Kimwana invited her to sit
with her on the steps of the family’s interior courtyard.
McGruder could tell from the liveliness in her eyes that
Kimwana was more fully present than she had been
recently. Kimwana sat, barefoot, with her back against the
door frame, and talked of how enjoyable it was to feel the
breeze. McGruder asked her what she had been doing prior
to her arrival that day and Kimwana told her that she had
been resting but not sleeping.
“When you rest, do you think a lot?” McGruder asked.
“Yes, I think so much,” Kimwana admitted.
“What do you think about?”
“For example,” Kimwana answered, “just now I was
thinking if I would get better.”
It was a promising opening. McGruder sensed that it
would be a good time to ask her more questions about her
disease experience. But then she found she could not bring
herself to risk breaking the peacefulness of the moment.
Making the ill individual aware that his or her behavior and
cognition are being monitored and judged was, she knew, a
sign of emotional overinvolvement. So as much as she
wanted to question Kimwana more, McGruder turned the
conversation back to the quality of the breeze and how cool
it was to sit in the shade of the house, trying, as best she
could, not to document the low emotional intensity of the
household but instead to manifest it.
Emotion across Cultures
McGruder’s intent in describing Amina and her family was
not to make them into heroes. Indeed what made them
remarkable in her eyes was just how unremarkable they
considered their sacrifice. Amina never suggested that the
care she gave her crippled and mentally ill ex-husband was
praiseworthy or particularly out of the ordinary. Because
many other families subscribed to similar religious and
cultural beliefs about the need to accept God’s burdens,
Amina’s family’s unemotional self-sacrifice was the norm in
Zanzibar.
Because different cultures around the world view mental
illness in different cultural contexts, the intensity of emotion
attached to these experiences often varies. Researchers
have found different average levels of expressed emotion
not just among families but also among cultures and even
among different subcultures in the same city. “To be
specific,” Janis Hunter Jenkins writes, “a culture provides its
members with an available repertoire of affective and
behavioral responses to the human condition, including
illness. . . . It offers models of how people should or might
feel and act in response to the serious illness of a loved
one.” Individuals in a given place and time will react to
illness similarly, in other words, because they share the
same limited repertoire of cultural scripts for how to play
their part.
The different ways that cultures communicate
expectations for behavior are often quite subtle. Seemingly
small differences, such as the disease’s name, can make a
difference. Jenkins noticed, for instance, that Mexican
American families in southern California, who had lower
expressed emotion scores than Anglo-American families
tended to use the term nervios to describe the illness of the
relative with schizophrenia. This seemed at first an
inappropriate word; nervios is a folk term often used as a
generic way to describe any one of a whole range of
symptoms, including headaches, dizziness, sleeping
disorders, aggressive or grumpy behavior as well as feelings
of anxiety, insecurity, or fear. Nervios is a catchall diagnosis
for feelings of disquiet or distress. The use of the term
appeared to be a kind of culturally inspired, willful blindness
for these family members. Calling schizophrenia nervios was
the equivalent of telling someone with cancer that he is just
feeling under the weather.
On closer examination, though, there appeared to be a
subtle purpose behind the misnomer. Jenkins saw that the
use of the word was part of a strategy by which the family
jointly downplayed the gravity of the illness. Nervios carried
little of the dire connotations an Anglo-American would
associate with schizophrenia. Nervios, like spirit possession,
is thought of as a transitory state. This allowed relatives and
the ill family member to regard periods of remission in a
more favorable light.
This hopeful naming also fostered feelings of empathy.
Many of the Mexican American family members in one of
Jenkins’s studies told her that they too had suffered from
nervios, in a milder form, and so could empathize with the
relative’s distress. “In this way,” Jenkins concluded,
“conception of the illness as nervios enables the
maintenance of close identification of family members by
fostering the view that the relative is ‘just like us only more
so.’” The label and its connotations allowed family members
to keep the relative within the fold.
That the very naming of the disease could have an impact
on its outcome again highlights the distinction between a
medical illness and a mental illness. The course of a
metastasizing cancer is unlikely to be changed by how we
talk about it. With schizophrenia, however, symptoms are
largely expressed within the person’s complex interactions
with those around them. The key to the emotional tenor of
those interactions lies to some extent in the words and
cultural beliefs that surround the disease.
Because these words and narratives are shared by
cultures, it is not surprising that the average level of
expressed emotion varies from place to place. Comparing
different groups around the world, it turns out that urban
Anglo-Americans have the highest level of expressed
emotion on average. In one study over 67 percent of Anglo-
American families with a schizophrenic family member were
rated as “high-EE.” Of the other groups studied:
Among British families 48 percent were high EE
Among Chinese families 42 percent
Among American families of Mexican descent 41 percent
Among British Sikh families 30 percent
Among Indian families 23 percent
What does it mean that European American families have
the highest average levels of expressed emotion? Is this an
indication that white Americans lack the sympathy or the
kindness to care for their mentally ill?
Professor Jill Hooley of Harvard University conducted a
study to understand what distinguishes high-EE relatives
from their less emotionally intense counterparts. She gave
both high- and low-EE relatives a simple test that measures
what psychologists call “locus of control.” Basically she
wanted to know to what extent these relatives believed they
had individual control over their own lives. To determine this
she asked them whether they agreed or disagreed with
statements such as the following:
When I make plans, I am almost certain that I can make
them work.
I believe a person really can be a master of his fate.
I can control my own problems only if I have outside
support.
A great deal of what happens to me is probably a matter
of luck.
Those who tended to agree with statements such as the first
two were thought to have an internal locus of control. They
were the type of people who thought of themselves as
captains of their own destiny, able to shape their future
through force of will. Those who agreed with statements
similar to the second two were thought to have an external
locus of control, meaning they believed that the course of
their lives was largely influenced by factors outside
themselves.
Hooley found that relatives who were highly critical of the
mentally ill family members were those with an internal
locus of control. Their critical comments to the mentally ill
person didn’t mean that they were cruel or uncaring; they
were simply applying to their relative the same assumptions
about human nature that they applied to themselves. “An
internal based locus of control reflects an approach to the
world that is active, resourceful, and that emphasizes
personal accountability,” concluded Hooley. “Thus, far from
high criticism reflecting something negative about the
family members of patients with schizophrenia, high
criticism (and hence high EE) was associated with a
characteristic that is widely regarded as positive.”
Widely regarded as positive, that is, in the United States.
It has long been noted that countries and cultures differ in
their shared beliefs about locus of control and related
measures such as scales of individualism versus collectivism
or egocentric versus sociocentric conceptions of self. In
many cross-cultural studies, the cliché that Americans are
more individualistic proves to be true. In a masterful meta-
analysis of dozens of cross-cultural studies performed over
the past fifty years, professor of psychology Daphna
Oyserman and colleagues from the University of Michigan
concluded that, compared with other groups around the
world, European Americans are indeed “more individualistic
—valuing personal independence more. . . . To
contemporary Americans, being an individualist is not only a
good thing; it is a quintessentially American thing.”
Viewed in the most positive light, these highly emotionally
involved relatives were more hopeful about the disease
because they remained convinced that the ill family
member should be able to overcome the symptoms with an
application of personal will. “It is plausible to speculate,”
Hooley and a colleague in another paper on the topic
concluded, “that certain cultural values (e.g., fatalism) in
traditional groups might engender more benign and less
blaming attributions toward those with mental illnesses. In
contrast, cultural values that emphasize individuality,
achievement, and personal accountability might be
expected to facilitate more attributions of responsibility and
control in the context of disturbed behavior.”
In his book Crazy: A Father’s Search through America’s
Mental Health Madness, Pete Earley vividly documents a
common response among Western parents when faced with
the onset of a severe mental illness in their child. One
typical father described his reaction to the schizophrenic
break of his son: “I went to the library and began reading
books about mental illness. . . . I thought: ‘No, I’m going to
fix this.’ That is your first instinct as a parent. You’re going
to fix it. I thought, ‘I can get him help. I can get him cured.’”
This intense can-do spirit is admirable and often
heartbreaking. Because there is no silver bullet cure for
schizophrenia, families who attack the problem looking to fix
it are often frustrated by the results. That intense focus,
even when it springs from a hopeful engagement of the
problem, might be the very thing that exacerbates the
illness.
“Mental illness is feared and has such a stigma because it
represents a reversal of what Western humans have come
to value as the essence of human nature,” McGruder
believes. “Because our culture so highly values self-control
and control of circumstances, we become abject when
contemplating mentation that seems more changeable, less
restrained and less controllable, more open to outside
influence, than we imagine our own to be.”
When the Biomedical Narrative Comes to Town
All of the patients with schizophrenia that McGruder
interviewed in Zanzibar received at least some treatment
from doctors trained in other countries. During the country’s
communist years, foreign doctors came from East Germany
and China. More recently they hail from the United States
and Britain. Over that time chronically mentally ill patients
in Zanzibar were prescribed a wide range of the
psychopharmacological drugs that are now ubiquitous
around the world.
During the years that McGruder studied mental illness in
Zanzibar, she watched as traditional beliefs began to mix
with biomedical explanations of mental illness. For some
families, such as Amina’s, those two understandings didn’t
necessarily compete with each other. The idea that spirit
possession was causing bizarre behavior coexisted with the
notion that the pills from the doctors might help her
daughter’s quality of life. One does not have to believe the
“brain disease” explanation, after all, to take a pill.
In some families that McGruder studied, however, the
introduction of Western ideas about schizophrenia had a
more complicated and problematic effect.
Shazrin al-Mitende was 43 when McGruder began visiting
her family. She lived with five adult relatives and ten
children, one of whom was developmentally disabled.
Shazrin’s half-brother, Abdulridha, was her main caretaker,
devoting much of his life to the task. The male nurse who
suggested Shazrin and her family for inclusion in
McGruder’s study thought of Abdulridha as an excellent
caretaker.
Abdulridha himself certainly agreed with this assessment.
In their first meeting he listed for McGruder all the ways that
he had taken charge of his sister’s life. “It is necessary that I
give up my own activities so much in order to care for her,”
he said. At another point he told McGruder, “I am like her
slave now. She says ‘bring me some water.’ I go and fetch it.
It is she who should be bringing me water.”
As McGruder got to know the family, she learned Shazrin’s
history. Trouble began in 1968, when Shazrin was just 13, on
the night of the new moon that signals the end of Ramadan.
Shazrin was sitting with a group of women relatives applying
henna designs to each other’s hands. This group
beautification was in preparation for the feasting and
gathering of relatives that followed the end of the month-
long daylight fast. As she sat with the other women, the
sight of a black cat walking through the room startled her.
During the feasting the next day, she told her family that
she felt unwell and overheated. When her mother told her to
lie down and tried to help her out of her new dress, Shazrin
began to scream uncontrollably. She was inconsolable for
several days.
Because her behavior could be traced to the sighting of
the black cat, it was at first agreed that spirit possession
was behind her strange and disruptive behavior. Shazrin’s
grandfather had been a spirit cult practitioner, who, it was
said, conjured spirits in the family courtyard. Some family
members and neighbors assumed that one of those spirits,
set free of the grandfather’s control at his death, had
alighted on the soul of Shazrin.
Shazrin’s family took her to see several traditional
doctors. They traveled up and down the Swahili Coast
consulting with healers in Dar es Salaam, Bagamoyo, and
Tanga in Tanzania and traveling as far away as Mombasa in
Kenya. In one instance her hair was shaved and small cuts
were made in her scalp into which herbal medicines were
rubbed. Other healers used techniques intended to call forth
the spirit so it could be negotiated with and placated.
Another healer was skilled in diagnosing ailments by
drawing pictures of the patient. Despite these efforts,
Shazrin improved little.
As it happened, a young neighbor had recently become a
doctor at the local mental hospital. He persuaded the family
that Shazrin should be taken to Kidongo Chekundu Mental
Hospital the next time her behavior became difficult to
control. And so, when Shazrin became disturbed a few
weeks later, the family called the police, who took her to be
admitted. She was still only 13 years old, a frightened girl in
a locked ward for adults with severe mental illnesses. In
those first hospital records, the staff noted that she was
restless and preoccupied but mostly rational.
It was during this time that she briefly came under the
care of an American psychiatrist named Charles Swift, who
was having a dramatic impact on Tanzania’s evolving
treatment of the mentally ill. He had come to the newly
formed country in 1966 intending to stay only two years but
ended up staying eight, working mostly in hospitals on the
mainland. From the perspective of Tanzania’s Ministry of
Health, Swift was a godsend. When he arrived he was the
only trained psychiatrist in the country.
Once a month Swift would fly from Dar es Salaam to
Zanzibar and visit the mental hospital, where the medical
director put him to work diagnosing difficult cases. One of
those patients was the young Shazrin. She remembers
being frightened in the presence of this American. “He was
very fierce,” she says. It was Swift who first diagnosed her
condition as schizophrenia.
Shazrin’s assessment of Swift as “fierce” stands in sharp
contrast to the caring and rather humble man he presents
to the reader in Dar Days, his memoir of his time in
Tanzania. He reports having disdained the superior attitude
of the former British colonialists he met in the country. But
while it is clear that Swift took pains to be culturally
sensitive, he also had a great certainty in the value of the
expertise he brought to the country. He clearly saw his
service as parallel to medical doctors who brought state-of-
the-art practices and medication to places where local
clinicians had little knowledge or resources to battle
disease.
Humble as he may have been, he did not turn down the
status he was granted as a mental health professional from
the Western world. Looking back at Swift’s tenure in
Tanzania, it is not surprising that he extended his stay by six
years. Back in New Jersey he worked for a medium-size child
development center, but in Tanzania he was a central player
in establishing the mental health system for the entire
country. His advice was sought in every aspect of the
country’s approach to mental illness, and he dined regularly
with politicians and dignitaries.
In his memoir Swift makes it clear that the pervasive
beliefs in spirits and witchcraft were a problem for the
population. Replacing such native beliefs with clear and
unemotional Western diagnoses seemed to him an obvious
improvement. It was Swift’s hope that by providing Western
knowledge he could help erase these myths that he
believed brought stigma to the mentally ill. For Shazrin, his
diagnosis would have long-lasting effects.
For the next two decades Shazrin was in and out of the
mental hospital dozens of times, for both long and short
stays. Overall she spent nearly one-fifth of her young
adulthood at Chekundu. Her records show that she took a
variety of medications during that period, including, for a
time, a large fifty-milligram dose of the antipsychotic
fluphenazine every two weeks. During another period the
doctors prescribed her a nightly dose of the barbiturate
sodium amytal. In the late 1970s she also underwent a
series of electroconvulsive treatments. Some of the
medication brought on epileptic-like fits and made her lips
and hands tremble uncontrollably.
Shazrin’s treatment at the hospital wasn’t the only way
that Western medicine affected her life. Over the course of
her illness her half-brother, Abdulridha, increasingly
distanced himself from the beliefs of traditional healers and
aligned himself more and more with Western notions and
treatments of his sister’s condition. He associated Western
medicine and Western beliefs about mental illness with his
self-conception of being a modern and educated man.
Abdulridha acquired his knowledge about Western
understandings of mental illness from a variety of sources.
He learned much from the doctors at the hospital. Of all the
family members McGruder interviewed, Abdulridha was the
only one who understood the distinction between the
symptoms of schizophrenia and the side effects, including
tremors and weight gain, of the antipsychotic medication.
He was also the only one to understand that some of
Shazrim’s medications were taken to control the side effects
of other drugs.
He picked up information from other sources as well. For
instance, from a Voice of America program about drugs that
treat depression he came to the conclusion that Western
doctors had a medicine that would cure his sister’s
uncontrollable bouts of crying. As understood by Abdulridha,
the biomedical approach implied that his sister’s mind was
broken but fixable through medication.
McGruder began to think that she was watching a classic
display of emotional overinvolvement as she observed
Abdulridha attempt to manage every aspect of his sister’s
existence. What particularly intrigued McGruder was how
Abdulridha used his biomedical orientation toward the
disease to justify his control over Shazrin. Aligning himself
with the Western doctors, he allowed himself to express
intense frustration at his sister for her apparently stubborn
refusal to get better. Shazrin’s lack of recovery despite his
efforts and those of the doctors appeared to embarrass and
infuriate him. “I tell her, ‘I do everything for you,’” he
recounted to McGruder. “ ‘You should stop all those
behaviors in order to give me some encouragement.’”
McGruder had a front-row seat in witnessing how the
biomedical explanation affected Abdulridha’s treatment of
his sister. She was even, at times, recruited against her will
into the dynamic. For Abdulridha, McGruder was a
representative of modern Western knowledge and authority,
and he attempted to co-opt her presence in the life of the
family to prove that his opinions and actions were backed
up by doctors and educated people.
When McGruder came to visit, Abdulridha took pride in
reciting for her every detail of Shazrin’s daily activities. He
was particularly forthcoming about his knowledge of her
menstrual cycle, detailing the precise dates menses began
and ended. He would then tell her of any recent bad
behavior. “She has finished bleeding some three days ago
now, but her condition is still bad,” he said in one typical
encounter. That he openly talked about such aspects of
Shazrin’s life startled McGruder. A brother talking about
such things was a clear violation of the rules of modesty she
had observed elsewhere in Zanzibar. Abdulridha’s
biomedical conception of his sister’s illness appeared to
invalidate normal rules of conduct. Similarly he would often
talk about Shazrin as if she could not hear him. At these
times she would go blank and stare at the floor, refusing to
respond to anyone. “This is the problem,” Abdulridha said at
one point when his sister’s affect went flat. “She is not here
at all now; she has been completely covered. I told you you
would see it.”
Needless to say, being forced into an alliance that
excluded Shazrin was uncomfortable for McGruder; she
worried that her presence was actually helping Abdulridha
stigmatize his sister. In her field notes she wrote, “I am
finding it progressively harder to write about this family and
harder still to visit them. The events . . . have convinced me
that family interactions definitely increase Shazrin’s
suffering and I am now included against my will in that
process.”
In the end Abdulridha’s increasing alliance with Western
medicine had the effect of stripping away the local beliefs
held by other families McGruder had studied in Zanzibar.
Unlike Kimwana’s family, there was no safe harbor in the
belief that God had sent the illness as a blessing, a burden
to be embraced. Those beliefs were replaced by a set of
ideas that appeared to allow Abdulridha to dehumanize his
sister and justify his harsh control over her life.
The Rise of the Biomedical Narrative in the West
Over the past two generations, Western psychologists and
psychiatrists have promoted the biomedical approach to
mental illness around the world with the argument that
adopting this way of thinking would lessen the stigma
surrounding these conditions. Even patient and family
advocacy groups such as the National Alliance for the
Mentally Ill in the United States and SANE in the United
Kingdom have consistently promoted the idea that mental
illnesses should be viewed as medical illnesses, as
“diseases of the brain.”
Western mental health professionals coined the term
“mental health literacy” to describe the set of ideas they’ve
promoted around the world. Populations are considered
more “literate” if they adopt Western biomedical
conceptions of these diseases. A study from the World
Psychiatric Association, for instance, identified respondents
as “knowledgeable” and “sophisticated” when they
identified schizophrenia as a “debilitating disease.” Another
study portrayed those who endorsed the statement that
“mental illness is an illness like any other” as having a
“knowledgeable, benevolent, supportive orientation towards
the mentally ill.”
The logic seemed unassailable: once people believed that
the symptoms of mental illnesses such as schizophrenia
were not the choice of the individual and did not spring from
supernatural forces, the sufferer would be protected from
blame. The brain disease narrative would make it less likely
that the public would attribute the onset of mental illness to
an individual’s life choices or a weakness of character. In
addition, people would be less likely to connect the difficulty
of recovery to a patient’s lack of personal will or motivation.
By pushing the blame onto the functioning of genes or
broken biochemistry in the brain, the individual could
escape stigma.
Studies show that over the past fifty years the world has
steadily adopted this medical model of mental illness.
Although these changes have happened most dramatically
in the United States and Europe, similar shifts have been
documented around the world. When asked to name the
sources of mental illness, people from every country studied
are increasingly likely to mention “chemical imbalance” or
“brain disease” or “genetics” as part of the cause of mental
illness. These global changes in belief represent a hard-won
victory on the part of mental health care providers, drug
companies, and advocacy organizations.
Unfortunately, as mental health professionals and
advocates for the mentally ill have been winning this
rhetorical and conceptual battle, they’ve been
simultaneously losing the war against stigma. Studies of
attitudes in the United States between the 1950s and 1996
have demonstrated that the perception of dangerousness
surrounding the mentally ill has steadily increased over this
time. Similarly a study in Germany found that the public’s
desire to maintain distance from those diagnosed with
schizophrenia increased between 1990 and 2001.
Researchers hoping to figure out what was causing this
rise in stigma found a startling connection. It turns out that
those who adopted the biomedical and genetic beliefs about
mental illness were most often those who wanted less
contact with the mentally ill or thought of them as
dangerous and unpredictable. This unfortunate cause-and-
effect relationship has held up in numerous studies around
the world. In a study conducted in Turkey, for example,
those who labeled schizophrenic behavior as akil hastaligi
(illness of the brain or reasoning abilities) were more
inclined to assert that schizophrenics were aggressive and
should not live free in the community than those who saw
the disorder as ruhsal hastagi (a disorder of the spiritual or
inner self). Another study, which looked at populations in
Germany, Russia, and Mongolia, found that “irrespective of
place . . . endorsing biological factors as the cause of
schizophrenia was associated with a greater desire for social
distance.” The authors of that study concluded that
“promulgating biological concepts among the public might
not contribute to a desired reduction in social distance
towards people with mental disorders.”
The problem, it appears, is that the biomedical or genetic
narrative about an illness such as schizophrenia carries with
it the subtle assumption that a brain made ill through
biomedical or genetic abnormalities is more thoroughly
broken and permanently abnormal compared to one made
ill though life events. “Genetic arguments may work in an
asymmetric fashion,” wrote researcher Jason Schnittker
from the University of Pennsylvania. “They encourage the
view that mental illness is impersonal and uncontrollable in
its development, but more stable and unyielding in its
course. By the same token genetic arguments inflate
perception of dangerousness in so far as [they imply that]
the mentally ill are always at risk for violence even when
treated. . . . Genetic arguments make the person appear
even more ‘at risk’ and threatening.”
In a dramatic experiment, Professor Sheila Mehta from
Auburn University in Montgomery, Alabama, effectively
answered the question of how these beliefs about mental
illness can translate into behaviors between people. In her
study, subjects were led to understand that they were
participating in a simple learning task with a partner, who
was actually a confederate in the study. Before the
experiment started, the two partners exchanged some
biographical data, during which the confederate told the
test subject that he suffered from a mental illness.
Confederates then stated either “[The illness occurred due
to] some things that happened to me as a kid” (the
psychosocial explanation) or “I had a disease just like any
other which affected my biochemistry” (the disease
explanation). The learning experiment called for the test
subject to supposedly teach the confederate a certain
pattern of button presses. The only feedback the test
subject could give to incorrect button pushes was a mild to
“somewhat painful” electrical shock.
Analyzing the data, Mehta found a dramatic difference
between the group of subjects given the psychosocial
explanation for their partner’s mental illness history and
those given the brain disease explanation. Those who
believed that their partner suffered an “illness like any
other” increased the severity of the shocks at a faster rate
than those who believed they were partnered with someone
who had a mental disorder caused by childhood events.
Mehta concluded, “The result of the study suggests that we
may actually treat people more harshly when their problem
is described in disease terms. . . . We say we are being kind
but our actions suggest otherwise. . . . The disease view
engenders a less favorable estimation of the mentally
disordered than the psychosocial view.” She added,
“Viewing those with mental disorders as diseased sets them
apart and may lead to our perceiving them as physically
distinct. Biochemical aberrations make them almost a
different species.”
Indeed it was just this dynamic that McGruder witnessed
between Shazrin and her brother. Remarkably, despite more
than forty years of evidence suggesting that the biomedical
or brain disease belief increases stigma, the Western mental
health professionals continue to promote these ideas with
vigor.
Just Chemistry
One afternoon McGruder took me to the Kidongo Chekundu
Mental Hospital, a few miles from downtown Stone Town.
The compound was made up of several single-story white
stucco structures with tiled roofs surrounding a large
courtyard. There was an intake area where patients and
their families sat on benches waiting to be seen, a
documents room, and an area where meals were prepared
over a wood fire. McGruder showed me the occupational
therapy room she had helped establish many years ago.
Hundreds of paintings and drawings by former patients
hung on the wall.
The facility for housing the patients was separated into an
open ward for patients considered to be of no danger to
themselves or others and two locked areas for the women
and men who were more seriously disturbed. In the
courtyard I talked with a young man who was lighting a
small cooking fire to boil water for tea. His English was
perfect, with an American accent. I assumed he was a
doctor or a caretaker until he told me he had come from the
mainland for a long stay at the hospital while the doctors
attempted to find the right balance of medication for his
manic depression. He was excited to talk to me. He had
gone to college in Arizona and had fond memories of the
States.
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 a barred window talked animatedly
at me in Kiswahili. Behind them I could see a half dozen
other men in the open area. Some were sleeping, and others
rocked restlessly.
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. But as I later
thought of my brief visit to the locked ward at Kidongo
Chekundu I began to wonder about the meaning behind
these certainties.
If you ask me what it means that schizophrenia is related
to genes, for instance, I will say that people with a family
history of schizophrenia are at greater risk. Although this
appears to be statistically true, that is pretty much the
extent of my actual knowledge on the topic of the genetic
precursors to schizophrenia. My scientific understanding of
abnormalities in brain chemistry related to the disease is
similarly limited. So although I deeply believe that the
biomedical explanation for mental illness is likely true, that
certainty does not come with a degree in biochemistry or
genetics.
If these beliefs have so little weight, why do I continue to
hold to them so tightly? Beliefs about mental illness—and
this is as true in the United States as it is in Zanzibar—are
first and foremost testaments to group membership. By
attesting to my biomedical orientation, I am placing myself
in that group of people who I believe have a “sophisticated”
and “knowledgeable” orientation to the mentally ill. I am
placing myself in the group of doctors, biomedical
researchers, clinicians, and scientists. Note that, unlike the
spirit possession belief common in Zanzibar, the group I’m
affiliating myself with does not include the mentally ill
themselves.
Aside from their objective truth or falsehood, one
meaningful way to compare cultural beliefs about mental
illness is to ask this simple question: Which cultural beliefs
tend to exclude the sufferer from the social group and which
allow the ill individual to remain part of the group?
Accounts written by patients themselves and their loved
ones make it clear just how stigmatizing the biomedical
explanation can be. Here, for example, is D. A. Granger
writing of his experiences years after being diagnosed with
schizophrenia in his first year of Harvard Medical School:
I have spent years . . . clinging to the understanding that I was a defective
biological unit. . . . This may truly be a valuable perspective for those who
observe mental illness, but for me, as a subject, this tree bore only dry and
tasteless fruit. . . .
I have a chemical imbalance; I really didn’t feel those things.
I have a chemical imbalance; I didn’t really experience those things.
I have a chemical imbalance; I didn’t really think those things . . .
Here is an insight! The entire human drama of love, suffering, ecstasy, and
joy, just chemistry.
Jay Neugeboren, writing about his schizophrenic brother,
similarly asked, “[If he] . . . doesn’t hold onto his illness and
its history as a legitimate, real and unique part of his
ongoing self—what of him, at fifty-two years old, will be
left?”
We ask people diagnosed with schizophrenia and those
who love and care for them to adopt the brain chemistry
narrative without consideration of the cost: the devaluing of
the perceptions that make up the ill individual’s very sense
of self. Indeed, as Granger suggests, the fact that healthy
people do not dwell on the “brain chemistry” story as an
explanation for their own moods and feelings should be an
indication of how unappealing and dehumanizing the idea
is. When we fall in love, get jealous, feel the joy of playing
with a child, or experience religious ecstasy we do not
describe the experience to friends as a fortunate or
unfortunate confluence of brain chemicals. Yet we continue
to suggest that the narrative of brain chemistry will be
useful in lessening the stigma associated with a mentally ill
person. What could be more stigmatizing than to reduce a
person’s perceptions and beliefs to the notion that they are
“just chemistry”? It is a narrative that often pushes the ill
individual outside the group, allowing those who remain in
the social circle to, as Mehta observed, view the ill person as
“almost a different species.”
What We Can and Can’t Learn
I asked McGruder on several occasions what we might learn
from her research on schizophrenia in Zanzibar. She offered
various possible lessons, the most obvious being a
cautionary one. Simply put, we might reconsider our
interventions in the parts of the world that appear to have
better outcomes than we can manage in the industrialized
world.
But coming away with only that warning was unsatisfying.
It is part of my American character that I’m not much
interested in being told what not to do. Like those highly
emotionally involved caretakers, I’m interested in how to fix
the problem. I wanted a positive take-away message, some
recommendation for action or change. So I kept pestering
McGruder, trying to get her to be prescriptive. What had she
learned from her Zanzibari research that we might be able
to use in the United States to help the mentally ill?
One late afternoon, a week into my visit to Zanzibar,
McGruder and I were sitting in her small apartment in Stone
Town waiting for Kassim to get back from the final day of
mourning his daughter. McGruder was folding laundry. By
this point in the trip we had an easy rapport, although I was
feeling like a houseguest who had overstayed. I turned on
my tape recorder and again quizzed her on what we might
learn from the way the locals address and deal with serious
mental illness. Instead of answering the question on a
theoretical level, this time she told me a story.
After she and her former husband, an African American
whom I’ll call Ed, returned from her year of research in
Zanzibar they had difficulty settling back into their American
lives. McGruder was back teaching and trying to bang out
her dissertation. Their marriage was in a rough patch and
they fought about money.
Ed, McGruder told me, had been discontent since
returning from Africa. He tried out a couple of different
businesses but struggled to get them off the ground. At
some point he got hooked up with an aggressive multilevel
financial marketing group. He went to seminars that were
like revival meetings, where motivational speakers told the
attendees that they could achieve financial success by
selling the company’s life insurance and recruiting others
into the business. McGruder sensed it was a shady outfit—
their promises were too good to be true—but she deeply
wanted her husband to find success and happiness. At the
same time Ed started a janitorial business. With McGruder’s
help he bought a van and cleaning supplies and he landed
some contracts with area restaurants. “He was running full
speed, night and day,” McGruder told me. “At the same time
we were going ever further into debt because we were
throwing money at the startup costs of the businesses.”
Around this time McGruder went to a conference in
Philadelphia. While she was away she had trouble getting Ed
on the phone, which was unusual. When she landed at Sea-
Tac, he came to the airport to pick her up and they went out
to dinner. Ed didn’t say much at dinner and seemed to be in
an unusually somber mood. When they got home McGruder
came down with something like food poisoning. Looking
back, she wonders whether her body was picking up on
something her mind couldn’t yet accept.
The next morning Ed told her that he was going out. She
said she was going to stay in bed and try to get some rest.
Hours went by and he didn’t return. At one that afternoon
the police called and informed her that her husband’s car
had been abandoned on a local street with the motor
running and doors opened.
Fearing that he had been the victim of a robbery,
McGruder immediately got on the phone and called some
friends for help. After retrieving the car, she called the
hospitals and police stations, asking if there were any
reports of injured people. It was more than twenty-four
hours before they discovered that Ed had been arrested and
had spent the night in the Pierce County Jail howling
incoherently and ripping his clothes to shreds.
McGruder later pieced together the missing hours. After
abandoning the car, Ed had jogged down the middle of a
busy street. After that he switched to the railroad tracks,
walking more than ten miles to the nearby town of
Lakewood. Once there he entered someone’s backyard,
climbed into the bed of a pickup, and started throwing the
contents all over the lawn. “These are the kinds of things
people do when they have mania of psychotic proportions,”
McGruder told me. “They just don’t make any sense and
they can’t explain to you why it seemed like a good idea at
the time.”
It took a full day to find Ed in the legal system because he
had thrown away his identification and when asked his
name would only say, “They call me Mr. Edwards.”
McGruder immediately understood this. “Mr. Edwards” was
the name he was called by friends and neighbors during
their stay in Zanzibar.
Once she found him, McGruder spent the rest of the day
figuring out how to get him out on bail. After finishing the
paperwork, she was told to go home and wait for a phone
call, which she did. Late that afternoon her husband showed
up at the door. He had been released, but no one had called
her to pick him up. He had walked miles in freezing rain in
nothing but a jail-issued jumpsuit.
She put him in a warm bath, where he rocked back and
forth alternately crying and laughing. She tried to calm him
and get him to sleep but he was restless and confused. She
stayed up with him as late as she could but finally fell
asleep herself. She woke to find Ed on a rampage. He had
pulled out several saplings in the backyard and was in the
middle of knocking everything off shelves in the kitchen and
living room.
She called friends to come over and help calm Ed down
and keep him from tearing apart the rest of the house. They
tried to convince him that he needed to see a doctor, but he
didn’t seem to comprehend what they were saying. At times
he would go blank; at other times he would howl and make
animal noises. Finally the friends distracted Ed while
McGruder called for help.
Having taught many classes on mental health and the
law, McGruder believed she knew the system she was
entering. She understood, for instance, that in order for Ed
to be put in the hospital against his will she had to attest
that he posed a danger to people or property. That part of
the process turned out to be easy, and Ed was admitted into
Puget Sound Hospital. Knowing what to say to get him out
proved to be the hard part.
The next day McGruder went to the hospital. It was a
rundown place. (It would soon be shut down by the Health
Department for multiple violations, including chronic
overcrowding, sexual assault in the mental wards, and dead
bugs and mouse droppings in a supposedly sterile supply
room.) Like many acute psychotic manias, Ed’s suddenly
ebbed. He was now calm and spoke rationally, telling
McGruder that he was afraid to stay in the hospital. He said
he was ready to go home and start seeing a doctor for his
illness. McGruder was certain he had a better chance of
regaining his balance if she could manage his behavior
outside the hospital. She thought, “Okay, let’s get him out of
this place.”
But the system she had triggered was not ready to let him
go. Over the next two weeks she struggled with doctors,
lawyers, and judges. The first doctor she met with wanted to
start Ed on five different psychiatric medications at once.
McGruder knew that he could be helped by medication but
argued for a more conservative approach. She was
particularly put off by the judge at the commitment hearing,
who appeared to be making assumptions based on Ed’s
race. “Has a toxicology screen been done on this man?” he
asked repeatedly, even though there was no indication that
the mania had been drug-induced.
Her reaction to the crisis couldn’t have been more distinct
from Amina’s passive acceptance. McGruder was a
passionate advocate for her husband at every turn. She
could tell that she annoyed many of the doctors, lawyers,
nurses, and clerks she interacted with. “They treated me
like a nuisance for the most part,” she remembers. “They
treated me like I was emotionally overinvolved.”
In the end, the insights she had gained while studying
mental illness in Zanzibar were of little help. She was back
in her own culture, and many of the Zanzibari beliefs and
practices she had witnessed and so carefully documented
simply didn’t apply. This was true down to the level of
simple logistics. McGruder and her husband lived alone and
had no close kinship groups on which they could rely. They
had devoted friends, but those friends all had jobs and other
commitments and most lived dozens of miles away; they
couldn’t be counted on to care for or watch over Ed for
significant periods of time. McGruder and her husband were,
for the most part, alone with their burden.
McGruder did try one gambit. Ed had once been a
religious man, and he began to believe that his psychotic
break might have been part of God’s plan. Perhaps, he
suggested, God had caused the psychotic break because He
wanted McGruder to better understand mental illness. “I
thought that that was a little egocentric to believe that God
up in heaven decided, ‘She needs a little more insight,’”
McGruder recalled. “But I said okay, if Ed thinks it’s helpful
for us to consider this possibility, I’m cool with that. That is
useful. My experience in Zanzibar helped me avoid saying
‘That’s a crock of shit.’”
She offered to start going to church with Ed, but the
religious narrative she tried to help create was an
ineffective balm. Religion is a difficult palliative to employ
on an as-needed basis. It either exists in one’s life and
surrounding culture, shaping one’s conception of the self, or
it does not. For Amina and her family, religion and spiritual
belief permeated their lives in the same way the Koranic
chants of the schoolchildren washed over their household.
McGruder and her husband had no such ambient, pervasive
faith to rely on, and, not surprisingly, the Christian beliefs
McGruder and her husband belatedly tried to adopt proved
to be of little comfort.
Try as she might, McGruder couldn’t mimic the calm
acquiescence Amina managed. Instead she found herself
constantly monitoring Ed’s behavior for signs of his mental
illness. When he left the cap off the toothpaste, she found
herself wondering, “Is he unable to put the cap back on
because his mind is running too fast?” She began to
reconsider their whole life together. She second-guessed her
fond memories from their first years of dating. Had he been
so charming and fun to be with because he was prone to
mania? In the end the marriage failed under the pressure of
Ed’s illness. “Once you start looking at a loved one through
the lens of a Western psychiatric diagnosis,” McGruder said,
“it is really hard to stop.”
When McGruder finished telling me this story she was
sitting on the daybed in the living room in complete
darkness. The sun sets fast near the Equator, and the
electricity had been out on the entire island for over a week.
The air was hot and still. We sat for a time listening to the
sound of footsteps echo up from the stone alleyways
outside the apartment window.
“The Hallmark movie ending would be that I had learned
something about mental illness in Zanzibar that I was able
to use in my own time of crisis,” McGruder said. “But stories
of mental illness don’t often have Hallmark endings.”
The Transliteration
After traveling back to the United States, I kept in touch with
McGruder by email. Every so often I would ask after her
partner, Kassim, to see how he was dealing with the loss of
his daughter. McGruder admitted in this correspondence
that she herself was still trying to figure out what was going
on inside his head. Despite everything she knew about
different emotional expressions between cultures, she
couldn’t help but be concerned about his emotional flatness
in the days after his daughter’s death.
McGruder told me that a few days after the funeral she
overheard a phone call Kassim received from a relative who
had just heard about the death and wanted to travel from
mainland Tanzania to offer her condolences. McGruder
listened as he told the relative “Tumeshapao,” meaning “We
have already cooled down” or “We have healed, we are
okay.” When he hung up the phone, McGruder felt
compelled to ask him if he really had already healed. Unable
to read his outward emotions, she wanted to know whether
he felt he was still grieving. She had not witnessed him
weep over his daughter’s death.
He explained that in the phone call he was only trying to
save the relative the cost and trouble of traveling to the
island. He told McGruder that he thought of his daughter
often but was comforted by the fact that he had performed
all of the religiously required rituals after her passing. Her
body had been properly wrapped in a winding cloth and
sewn into a flexible reed mat. He had carried her to the
cemetery and had gotten down into the grave and arranged
her body so that she was lying on her side, facing Mecca.
Later, in a different conversation, he told McGruder that
since his daughter’s death he had been unaccountably
waking in the middle of the night, at about the time he got
the telephone call, and had trouble getting back to sleep.
When he finally did sleep again he was assaulted with vivid
and disturbing dreams.
McGruder wondered whether his unexpressed grief was
souring into depression. Kassim had a different explanation.
He believed he had picked up some troubling spirits while at
the graveyard burying his daughter. A few days later he
went to a Koran school and paid a small fee to have a group
of boys sing some Arabic prayers to the soul of his daughter.
The teacher at the Koran school gave him a transliteration
of the prayers so that he could pronounce the Arabic words
in Kiswahili. After that, every night he recited the prayer in
words he could not understand and slept soundly.
4
The Mega-Marketing of Depression
in Japan
One of the chilling things about these events, whether a
puzzle or a scandal, is how a very few people in key
positions can determine the course of events and shape the
consciousness of a generation.
DAVID HEALY
I went to visit Dr. Laurence Kirmayer in his book-lined office
at McGill University in Montreal because he had a
particularly good story to tell. I’d heard that a few years
ago, Kirmayer had a personal brush with the pharmaceutical
giant GlaxoSmithKline and the remarkable resources that
the company employed to create a market for their
antidepressant pill Paxil in Japan.
In person Kirmayer is the picture of a tweedy academic.
He speaks in complete paragraphs in a deep authoritative
voice. He has a large head and a broad face that is covered
nearly to the cheekbones in a thick light-gray beard. His
slightly wandering left eye suits his demeanor. If you look at
the left side of his face his expression is attentive and
focused on the conversation. If you look at the right side of
his face he appears to be looking past you into the middle
distance, as if searching for a word or pondering a thought.
In telling his story of being feted by GlaxoSmithKline,
Kirmayer likes to point out that he is unaccustomed to the
trappings of great wealth. Not that he’s doing badly. As the
director of the Division of Social and Transcultural Psychiatry
at McGill, he makes a respectable living and adds to his
income with a private psychiatric practice. As editor in chief
of the journal Transcultural Psychiatry, he is well known in
certain circles and can draw a crowd of admiring grad
students and colleagues at an anthropology or mental
health conference. But to get to those conferences he flies
coach.
It was in the fall of 2000, as he tells it, that he came to
understand just how un spectacularly rich he was. That was
when he accepted an invitation from something called the
International Consensus Group on Depression and Anxiety
to attend two all-expenses-paid conferences, the first in
Kyoto and the second a few months later on the shores of
Bali.
Accepting the invitation didn’t at first seem like a difficult
decision. Although he knew that the conference was
sponsored by an educational grant from the drug maker
GlaxoSmithKline,* such industry funding wasn’t unusual for
academic conferences in the field of psychiatry. When he
checked out the list of other invitees, he recognized all the
names. It was an extremely exclusive group of highly
influential clinicians and researchers from France, the United
States, and Japan, among other countries. The topic,
“Transcultural Issues in Depression and Anxiety,” was right
up his alley. Even better, he had an eager young graduate
student named Junko Kitanaka who was in Japan finishing
her dissertation on the history of depression in the country;
such a gathering of luminaries would be a boon to her
research. In addition to those incentives, attendees would
be given the chance to publish their presentations in a
supplement of the prestigious Journal of Clinical Psychiatry.
“I wouldn’t say it was a no-brainer, but it wasn’t very hard
for me to say yes,” Kirmayer remembers. “How much
trouble could I get in?”
His first inkling that this wasn’t a run-of-the-mill academic
conference came when the airline ticket arrived in the mail.
This ticket was for a seat in the front of the plane and cost
nearly $10,000. The next hint came when one of the
conference organizers told him in no uncertain terms that
these would be closed-door meetings. His grad student,
Kitanaka, would not be allowed to attend. There would be no
uninvited colleagues and no press.
On arrival in Kyoto in early October 2000 he found the
luxury of the accommodations to be beyond anything he
had personally experienced. He was ushered into an
exclusive part of the hotel, where he was given a drink while
an attractive woman filled out the hotel forms. His room was
a palatial suite. The bath was drawn and strewn with rose
petals and dosed with frangipani oil. There was a platter on
the credenza filled with fruits so exotic that he could identify
only the mangosteens.
“This was Gordon Gekko treatment—the most deluxe
circumstances I have ever experienced in my life,” Kirmayer
says, smiling at the memory. This was how the other half
lived, he realized—or, rather, how the other .01 percent
lived. “The luxury was so far beyond anything that I could
personally afford, it was a little scary. It didn’t take me long
to think that something strange was going on here. I
wondered: What did I do to deserve this?”
Kirmayer was well aware that drug companies routinely
sponsor professional conferences and educational seminars
and that these events do double duty as marketing
seminars. It was also common knowledge that drug makers
use enticements to encourage both researchers and
practitioners to attend. A prescribing doctor might be
treated to a round of golf or a fancy dinner in exchange for
attending an hour-long seminar about the effectiveness of
some new drug. These practices are the medical equivalent
of what real estate agents do to sell vacation timeshares.
But it was clear from the start that the gatherings of the
International Consensus Group on Depression and Anxiety
were different from the normal drug company dog and pony
show, and not simply because the enticements being
offered were so dear. Once the group of academics actually
gathered in a plush conference room and began their
discussions, Kirmayer realized quickly that the
GlaxoSmithKline representatives in attendance had no
interest in touting their products to the group. Indeed there
was little mention of the company’s antidepressant drug
Paxil, which was just a few months away from hitting the
market in Japan. Instead they seemed much more interested
in hearing from the assembled group. They were there to
learn. “The focus was not on medications,” Kirmayer
remembers. “They were not trying to sell their drugs to us.
They were interested in what we knew about how cultures
shape the illness experience.”
As Kirmayer got to know them during the conference, he
realized that the drug company representatives weren’t
from the ranks of the advertising or marketing departments
or the peppy salespeople. As best he could tell, these were
highly paid private scholars who could hold their own in the
most sophisticated discussion of postcolonial theory or the
impact of globalization on the human mind. “These guys all
had PhDs and were versed in the literature,” Kirmayer said.
“They were clearly soaking up what we had to say to each
other on these topics.”
The intense interest the GlaxoSmithKline brain trust
showed in the topic of how culture shapes the illness
experience made sense given the timing of the meeting.
The class of antidepressant drugs known as selective
serotonin reuptake inhibitors (SSRIs) had become the
wonder drug of the 1990s, at least in terms of the profits
they’d garnered for the drug companies. That year alone, in
the leading regions for SSRIs, sales grew by 18 percent and
totaled over thirteen billion dollars. Most of those sales were
still in the United States, but there was wide agreement that
lucrative international markets had yet to be tapped.
Indeed it was somewhat remarkable that none of the best-
selling SSRIs had been launched in Japan. This was more
than twelve years after Prozac became available for
prescription in the United States. What caused this
uncharacteristic timidity on the part of these
pharmaceutical giants? It certainly wasn’t that the Japanese
eschewed Western drugs. To the contrary, U.S.-based
companies at the time were exporting upwards of fifty
billion dollars in medications to the country each year. It was
said that Japanese patients felt underserved if they didn’t
come away from a doctor’s visit with at least a couple of
prescriptions.
But Eli Lilly, then the out-front world leader in the SSRI
horse race with Prozac, had decided in the early 1990s not
to pursue the Japanese market because executives in the
company believed that the Japanese people wouldn’t accept
the drug. More precisely, they wouldn’t want to accept the
disease. “The people’s attitude toward depression was very
negative,” explained a spokeswoman for Eli Lilly to the Wall
Street Journal. She was referring to the fact that the
Japanese had a fundamentally different conception of
depression than in the West, one that made it unlikely that a
significant number of people in Japan would want to take a
drug associated with the disease.
Most other SSRI manufacturers followed Eli Lilly’s lead and
held off as well. Getting drugs approved in Japan was a
costly gamble. The rules at the time required that drugs
already on the market in Western countries had to be
retested in large-scale human trials using an exclusively
Japanese population. That meant years of effort and millions
of dollars spent, with the distinct possibility that the drug
might fail the trial. No company wanted to make such an
investment if no market existed for the drug.
The Japanese pharmaceutical company Meiji Seika was
the first to break from the pack, working through the decade
to run Japanese trials on the SSRI Luvox, which it had
licensed from the Swedish company Solvay. After reading
Peter Kramer’s 1993 book Listening to Prozac, Meiji’s
president, Ichiro Kitasato, sensed an unexplored opportunity
in the Japanese marketplace. “People in the company said
there are too few patients in Japan,” he told a reporter in
1996. “But I looked at the U.S. and Europe and thought this
is sure to be a big market.”
GlaxoSmithKline was the next to get in the race. In the
years prior to the 2000 conference in Kyoto, the company
had spent an immense amount of money and resources
jumping through the regulatory and bureaucratic hoops to
get the green light to put Paxil on the market in the country.
Having watched Prozac dominate the American market in
the late 1980s, drug company executives knew the
advantages of early market share, and GlaxoSmithKline
didn’t want Luvox to be the only SSRI in Japan.
But both companies faced the same problem: there was
no guarantee that Japanese doctors would prescribe the
drug or that the population would be interested in taking it.
The problem was that the profession of psychiatry in Japan,
unlike in the West, seldom ministered to the walking
worried; rather they focused almost exclusively on the
severely mentally ill. Consequently, talk therapy was all but
nonexistent in the country. For the small percentage of the
population diagnosed with a debilitating mental illness, long
hospital stays were the norm. The average stay in a mental
hospital in Japan was over a year, versus just ten days in the
United States. So although there was a psychiatric term for
depression in Japan, utsubyô, what it described was a
mental illness that was as chronic and devastating as
schizophrenia. Utsubyô was the sort of illness that would
make it impossible to hold down a job or have a semblance
of a normal life. Worse yet, at least for the sales prospects
of Paxil in Japan, utsubyô was considered a rare disorder.
At the Kyoto meeting Kirmayer began to understand the
company’s intense interest in the question of how cultures
shape the illness experience. To make Paxil a hit in Japan, it
would not be enough to corner the small market of those
diagnosed with utsubyô. The objective was to influence, at
the most fundamental level, the Japanese understanding of
sadness and depression. In short, they were learning how to
market a disease.
To have the best chance of shifting the Japanese public’s
perception about the meaning of depression,
GlaxoSmithKline needed a deep and sophisticated
understanding of how those beliefs had taken shape. This
was why, Kirmayer came to realize, the company had
invited him and his colleagues and treated them like royalty.
GlaxoSmithKline needed help solving a cultural puzzle that
might be worth billions of dollars.
Judging from the records of the conference, it’s clear that
the company got its money’s worth. During the meetings
eminent scholars and researchers gave insightful
presentations on subjects ranging from the history of
psychiatry in Japan to the Japanese public’s changing
attitudes about mental illness. The prominent Japanese
psychiatrists in attendance were particularly helpful in
framing the state of the public’s current beliefs about
depression and anxiety disorders.
Osamu Tajima, a professor at the Department of Mental
Health at Kyorin University and a leading Tokyo psychiatrist,
told the assembled group of a rising public concern about
the high suicide rates in Japan. He described how dozens of
middle-aged men each year hike deep into the so-called
suicide forests in the foothills of Mt. Fuji with lengths of rope
to hang themselves. He described how service along the
Central Line Railway in Tokyo was routinely disrupted by
office workers leaping in front of commuter trains.
Tajima also gave a detailed description of how psychiatric
services were structured within the overall health care
apparatus of Japan. Services were in the midst of a critical
change, he reported. There was a burgeoning concern in the
population about mood disorders and the need for social
attention to suicide rates and depression. He also
documented how the Western definition and symptom
checklist for depression—thanks to the influence of the DSM
in the profession—was steadily gaining ground among
younger psychiatrists and doctors in Japan. “Japanese
psychiatry is undergoing a period of important change,” he
concluded, which was certainly good news for
GlaxoSmithKline. He was upbeat about the changes
heralded by the standardization of psychiatry around the
world. “Adoption of internationally standardized diagnostic
criteria and terminology in psychiatry will provide additional
advances in assessing prevalence and facilitating accurate
diagnosis.” He was also clearly impressed with the scientific
advances in drug treatments that were soon to come to his
country. “New and effective treatment options,” he said,
“most notably the SSRIs, will contribute to reducing the
burden of depression and anxiety disorders in Japanese
society.”
After lunch on the second day of the conference, it was
Kirmayer’s turn to speak. He had written many papers in his
career documenting the differing expressions of depression
around the world and the meaning hidden in those
differences. He had found that every culture has a type of
experience that is in some ways parallel to the Western
conception of depression: a mental state and set of
behaviors that relate to a loss of connectedness to others or
a decline in social status or personal motivation. But he had
also found that cultures have unique expressions,
descriptions, and understandings for these states of being.
He told the assembled scholars and drug company
representatives of how a Nigerian man might experience a
culturally distinct form of depression by describing a
peppery feeling in his head. A rural Chinese farmer might
speak only of shoulder or stomachaches. A man in India
might talk of semen loss or a sinking heart or feeling hot. A
Korean might tell you of “fire illness,” which is experienced
as a burning in the gut. Someone from Iran might talk of
tightness in the chest, and an American Indian might
describe the experience of depression as something akin to
loneliness.
Kirmayer had observed that cultures often differ in what
he called “explanatory models” for depression-like states.
These cultural beliefs and stories have the effect of directing
the attention of individuals to certain feelings and
symptoms and away from others. In one culture someone
feeling an inchoate distress might be prompted to search for
feelings of unease in his gut or in muscle pain; in another
place or time, a different type of symptom would be
accepted as legitimate. This interplay between the
expectations of the culture and the experience of the
individual leads to a cycle of symptom amplification. In
short, beliefs about the cause, symptomatology, and course
of an illness such as depression tended to be self-fulfilling.
Explanatory models created the culturally expected
experience of the disease in the mind of the sufferer. Such
differences, Kirmayer warned the group, tended to be
overlooked when clinicians or researchers employed the
symptom checklists relating to the DSM diagnosis of
depression.
Understanding these differences is critical, however,
because culturally distinct symptoms often hold precious
clues about the causes of the distress. The American Indian
symptom of feeling lonely, for instance, likely reflects a
sense of social marginalization. A Korean who feels the
epigastric pain of fire illness is expressing distress over an
interpersonal conflict or a collective experience of injustice.
The wide variety of symptoms wasn’t the only difference.
Critically, not everyone in the world agreed that thinking of
such experiences as an illness made sense. Kirmayer
documented how feelings and symptoms that an American
doctor might categorize as depression are often viewed in
other cultures as something of a “moral compass,”
prompting both the individual and the group to search for
the source of the social, spiritual, or moral discord. By
applying a one-size-fits-all notion of depression around the
world, Kirmayer argued, we run the risk of obscuring the
social meaning and response the experience might be
indicating.
Indeed, around the world, it is the Western conception of
depression, in particular the American version of the
disease, that is the most culturally distinctive. Kirmayer told
the group that Americans are unique both in being willing to
openly express distressful emotions and feelings to
strangers and in our penchant for viewing psychological
suffering as a health care issue. Because people in other
cultures find social and moral meaning in such internal
distress, they often seek relief exclusively from family
members or community elders or local spiritual leaders. The
idea of seeking help from a doctor or mental health
professional outside one’s social circle has traditionally
made little sense.
The drug company representatives listened closely to
Kirmayer’s presentation and thanked him heartily afterward.
To this day, he’s not entirely sure what they took away from
his presentation. In the end Kirmayer’s comments could
have been taken in two ways. On the one hand, they could
be seen as a warning to respect and protect the cultural
diversity of human suffering. In this way, he was like a
botanist presenting a lecture to a lumber company on the
complex ecology of the forest. On the other hand, he might
have told the GlaxoSmithKline representatives exactly what
they wanted to hear: that cultural conceptions surrounding
illnesses such as depression could be influenced and shifted
over time. He made that point clearly in the conclusion of
the paper he wrote based on his presentation:
The clinical presentation of depression and anxiety is a function not only of
patients’ ethnocultural backgrounds, but of the structure of the health care
system they find themselves in and the diagnostic categories and concepts
they encounter in mass media and in dialogue with family, friends and
clinicians.
In the globalizing world, he reported, these conceptions are
in constant transaction and transformation across boundaries of race,
culture, class, and nation. In this context, it is important to recognize that
psychiatry itself is part of an international subculture that imposes certain
categories on the world that may not fit equally well everywhere and that
never completely captures the illness experience and concerns of patients.
In other words, cultural beliefs about depression and the self
are malleable and responsive to messages that can be
exported from one culture to another. One culture can
reshape how a population in another culture categorizes a
given set of symptoms, replace their explanatory model,
and redraw the line demarcating normal behaviors and
internal states from those considered pathological.
Kirmayer’s appreciation of the irony of his brief encounter
with GlaxoSmithKline has only grown over the years since
he gave that presentation. “People like me got into cultural
psychiatry because we were interested in differences
between cultures—even treasured those differences in the
same way a biologist treasures ecological diversity,”
Kirmayer told me. “So it’s certainly ironic that cultural
psychiatrists sometimes end up being handmaidens to
these global marketing machines that are intent on
manipulating cultural differences . . . in order to capitalize
on those changes.”
I asked Kirmayer how clear it was to him that
GlaxoSmithKline was interested in changing notions of
depression in Japan. “It was very explicit. What I was
witnessing was a multinational pharmaceutical corporation
working hard to redefine narratives about mental health,”
he said. “These changes have far-reaching effects, informing
the cultural conceptions of personhood and how people
conduct their everyday lives. And this is happening on a
global scale. These companies are upending long-held
cultural beliefs about the meaning of illness and healing.”
The consensus paper produced to summarize the Kyoto
conference provided both an action plan and a marketing
piece for GlaxoSmithKline. In that paper the International
Consensus Group on Depression and Anxiety warned that
depression was vastly underestimated in Japan but that
Western scientific advances would soon be on hand to help.
“Clinical evidence supports the use of SSRIs as first-line
therapy for depression and anxiety disorders,” the paper
concludes.
Looking back, Kirmayer can now see how the company
used the conference as the beginning of its broader
marketing strategy; its representatives identified the
cultural challenges and fleshed out the resonant cultural
notes the company would attempt to play in the critical
coming months and years. Among those themes were that
suicide in Japan was an indicator of undertreated
depression; that Western SSRIs represented proven
scientific advances in treatment; that primary care
physicians should use simple three-minute surveys to help
diagnose mental illness; that patients not meeting the
criteria for depression should still be considered sick; and
that the Japanese should be helped to reconceive social
stress related to work and industrialization as signs of
depression that should be treated with SSRIs. These
confident conclusions would prove the foundation on which
GlaxoSmithKline would begin to change the culture of Japan.
Psychiatry in the Time of Cholera
The rapid rise of the depression narrative in Japan, which
took place over the next few years, is remarkable in many
respects. The marketing campaign of GlaxoSmithKline and
other SSRI makers set off a seismic shift in the culture, the
aftershocks of which are still being felt. And just as
earthquakes are the expression of tectonic pressures that
build slowly over decades, there were unseen forces in the
cultural history of Japan that laid the groundwork for Glaxo-
SmithKline’s remarkable success.
To understand how GlaxoSmithKline was so successful in
selling depression in Japan at the beginning of this
millennium, it’s important to spend some time with a guide
who knows the historical lay of the land. Ironically the
person who best understands the cultural history of
depression in Japan turns out to be none other than Junko
Kitanaka, the grad student who was barred from the
conference in 2000. In the years since, she finished her
award-winning dissertation, “Society in Distress: The
Psychiatric Prod-uction of Depression in Contemporary
Japan,” and has taken up an associate professorship at Keio
University, often called “the Harvard of Japan.”
A visitor to the university will quickly notice that Keio’s
architects were intent on giving the place an Oxford–Ivy
League flavor. At the Mita campus where Kitanaka works,
campus gates are set in arches in red brick buildings and
paths run into open courtyards filled with huge ginkgo trees
that turn a luminescent yellow in the fall. As the style of the
architecture suggests, Western influence on Japanese
academia, particularly science and medicine, is hardly new.
When I asked Kitanaka how far back in time it was
necessary to go to begin tracking the Western influence on
mental health trends in Japan, she suggested that a good
starting point was the mid-nineteenth century. This was
when ideas of German neuropsychiatry and notions of
neurasthenia—the disease of frayed nerves—first began to
filter into Japanese professional and popular culture.
Cultures are most susceptible to outside ideas about the
nature of the human mind at times of social change and
upheaval, and the second half of the nineteenth century
was just such a time in Japan. The Edo era—the rule of the
shogun warlords—was at an end. For the previous 250 years
Japan had stayed relatively isolated from many cultural
trends and forces in the West, including those in science and
medicine. During the long Edo era the population of Japan
had thought of health mostly in terms of yojo, a set of
concepts imported from China sometime between the
seventh and tenth centuries. Yojo connected health with
diet, mental control, exercise, and sexual restraint. It
focused less on the control of disease or longevity and more
on issues of social health, including morality, culture, and
education.
During this time the concept that most closely tracked
modern notions of depression would have been utsushô,
which described the stagnation of vital energy, or qi. This
stagnation or blockage could come from a combination of
emotions, social conflict, loss, or the changing physiology of
the body. Critically, however, utsushô was not thought of as
an illness. As portrayed in plays and popular books of the
time, utsushô described a nonpathological—indeed, a
respected—way of being. The person affected by utsushô
was not considered sick and did not necessarily seek a cure
for his symptoms; rather it was expected that those affected
would have to look for the social or moral meaning in their
distress.
As the rule of the shoguns was replaced with that of the
emperor, Japan began to open up to ideas from Europe and
the United States. The Japanese public’s acceptance of
psychiatry as a legitimate field of science and mental health
largely paralleled the growing influence of Western
medicine.
It was the cholera epidemics, which began in 1859 and
plagued the nation for the rest of the century, that were
critical in breaking the hold of the yojo beliefs regarding
health. These deadly epidemics terrified the population.
Thousands died. The sick and those thought to be infected
were hauled away to hospitals under police guard. Whole
neighborhoods were sealed off and quarantined. According
to Kitanaka, the state used the outbreaks to justify the
creation of an imposing network of local government
controls that claimed authority from Western advances in
medicine. Improvements in sanitary conditions and public
hygiene did appear to limit the cholera epidemics, and the
success was taken as proof that European and Western
knowledge about health and illness had validity. Traditional
beliefs surrounding yojo were increasingly replaced by
newer ideas of eisei, which encouraged the population to
think of health as something that must be actively and
carefully cultivated by following scientifically approved
hygienic practices.
In choosing which Western public health models to follow,
health ministers in the Japanese government were
particularly taken with the German model, which promoted
the idea that the individual and the society were best
thought of as a single organism, each dependent on the
health of the other. As more and more Japanese doctors and
public health officials studied advances in German medical
practices, the burgeoning science of neuropsychiatry was
bound to follow. It wasn’t long before many of Japan’s most
promising psychiatrists were making pilgrimages to
Germany to find mentors among the ranks of the famous
neuropsychiatrists of the day.
Those German doctors were focusing their attention on
the severely mentally ill, especially patients with psychotic
symptoms related to schizophrenia or manic depression. For
the most part they believed that such dramatic mental
illnesses were caused by malfunctions somewhere in the
brain or nervous system and were likely the result of
inherited predispositions. Following these interests, the first
psychiatrists in Japan also focused their ministrations on
those with severe psychotic symptoms.
As the cholera epidemic introduced the Japanese public to
Western notions of medicine, Western psychiatry was
carried into public consciousness through crisis. That crisis
was the combination of rapid social changes at the end of
the nineteenth century that included urbanization, the
Industrial Revolution, and three wars within thirty years.
Government officials and social commentators expressed
increasing concern during this time over rising social
problems such as increased juvenile delinquency and the
disappearance of traditional practices and values. The
government produced reports on rising suicide rates and the
discontent of the working class. And just as Western-
oriented medical doctors consulted with government
officials to control the outbreaks of cholera, psychiatrists
gave advice on the social discontent of the time. Newly
minted psychiatrists in Japan, trained in German
neuropsychiatry, suddenly found that they had a voice in
these public debates.
In popular lectures and newspaper and magazine articles,
these psychiatrists began to introduce new ideas into the
popular culture. The people learned about hysteria in
women, mental hygiene, and antisocial personalities. Given
the uneasiness about the new realities of industrialization
and urban living, there was intense interest and debate on
these topics. One prominent intellectual wrote in the early
part of the twentieth century that the new medical
knowledge had brought to light many ailments that the
people had never heard of and that had previously gone
unnoticed. The people, he said, were now “constantly
worried over the slightest changes in their health” and had
consequently become “more vulnerable to illness.”
Japan’s First Mental Health Epidemic
Of the many ideas being imported from those Western
advances in psychiatric thinking, one in particular struck a
chord with the Japanese population. Riding on its recent
popularity in the United States and Europe, neurasthenia
was introduced to the Japanese public as an illness of
modernity.
Writing in professional and popular forums, Japanese
psychiatrists and others knowledgeable about Western
illness categories carefully explained to the public that
neurasthenia (translated as shinkeisuijaku) was a disease of
the nerves. The idea that the body had nerve pathways,
often described as tiny electrical cables, was a new one for
the Japanese, but the notion quickly became conventional
wisdom. The metaphor often employed to describe this new
condition was that of electric streetcars. Just as a trolley
would fail to function if its electric cables became worn or
broken, so too could human wiring fray and malfunction
from overuse.
What made neurasthenia different from other psychiatric
illnesses studied by Japanese psychiatrists at the time was
that it was not a disorder of the severely mentally ill but of
the common man. “The rise of neurasthenia,” Kitanaka
says, “was the first instance of the broad-scale
medicalization of everyday distress in Japan.” She found
remarkable parallels between the rise of neurasthenia at the
beginning of the twentieth century and the introduction of
the Western conception of depression at the beginning of
the twenty-first.
Neurasthenia, she believes, became a compelling social
narrative in Japan because it distilled and gave a name to
the inchoate anxiety of the times. Commentators connected
the disease with all manner of troubling trends, including
increased marketplace competition, excessive studying,
smoking, drug abuse, labor inequities, rising crime rates,
and juvenile delinquency.
The excitement surrounding the diagnosis of neurasthenia
came not only from the mental health professionals of the
time but from popular culture as well. Articles, pamphlets,
and books provided guides to self-diagnosis, symptom lists,
and suggestions for which specific groups should be
considered particularly vulnerable. People were told to be on
the lookout for symptoms: insomnia, ringing in the ears, lack
of concentration, stomach pains, eye fatigue, and the
feeling that a heavy pot covered one’s head. A brisk market
in pills and potions to cure the illnesses soon sprang up.
Unlike other mental illnesses being discussed in popular
culture at the time, this one carried little social stigma.
Indeed, because neurasthenia was at first considered an
illness of the elites, the diagnosis became somewhat trendy.
An article in an intellectual magazine circa 1902 was
headlined “Neurasthenia: Operators, Writers, Government
Officials, and Students, Read This.” The assumption was
that those employed in positions requiring strenuous
intellectual labor were dangerously taxing their nerves. “The
media initially depicted it as an inevitable outcome for
people on the forefront of the process of modernization, for
whom exhausted nerves even became a mark of
distinction,” Kitanaka explains. “An unprecedented number
of cases of neurasthenia among elites, including
government officials, company executives, university
professors and artists began to be reported.”
The belief that neurasthenia was a disease of the elites
and intellectuals no doubt helped with the wide acceptance
of the illness in Japan. By the early years of the twentieth
century, however, it was not only the elites on the front
lines of cultural change who were claiming this disease of
modernity. In 1902 an article reported that fully one-third of
patients visiting hospitals for consultations were suffering
from this new disease. Large and diverse segments of the
population were also reporting or being diagnosed as having
frayed nerves. Neurasthenia was suddenly being referred to
as Japan’s “national disease.”
But although the Japanese people seemed willing to
accept, even idolize, this disease when it was only in an
elite population, they were less sanguine when large
numbers of regular citizens also invoked the diagnosis. With
tens of thousands claiming the illness, the country was
poised for a backlash.
An early sign of that change could be heard in the debate
surrounding a single suicide that caught the public’s
attention. In 1903 a young student named Misao Fujimura
carved a poem in a tree near Nikko, a popular scenic area
north of Tokyo. The message in the brief verse was that life
was “incomprehensible.” When he finished, he walked to a
local waterfall renowned for its beauty and leaped to his
death.
Those who wrote about his suicide in the years afterward
fell into two broad categories. There were many artists and
intellectuals who saw such suicides as having great social
and philosophical meaning. Fueling the rise of the
neurasthenia diagnosis was a popular idea that some
Japanese were too pure of heart to live with the conflicts,
compromises, and demands of modern life. Misao’s suicide
was a brave act, some prominent thinkers suggested,
committed by a young man freeing himself from the mental
torture of modernity. This understanding of his actions was
in line with a long Japanese tradition of viewing suicide as
an act of personal resolve. Just as neurasthenia was
considered a mark of distinction among certain elite groups,
suicides among similar groups were often excused or even
admired as expressions of the purity of the Japanese
character.
But as the diagnosis of neurasthenia began to rise
exponentially, some prominent doctors and officials stepped
forward to challenge the social status given individuals like
poor Misao. In a speech to psychiatrists reprinted in a 1906
issue of the Journal of Neurology, the statesman Shigenobu
Okuma took a harder line:
These days, young students talk about such stuff as the “philosophy of life”
[applause from the floor]. They confront important and profound problems
of life, are defeated, and develop neurasthenia. Those who jump off of a
waterfall or throw themselves in front of a train are weak-minded. They do
not have a strong mental constitution and develop mental illness, dying in
the end. How useless they are! Such weak-minded people would only cause
harm even if they remained alive [applause].
Prominent psychiatrists also began to question the
diagnosis. In a book on mental illness published in 1912 a
professor at Kyushu University wrote that those who
suffered from neurasthenia were “born with an inherent
weakness in the brain” and had only “half the mental
capacity of a normal person.” Not everyone who had a
mentally taxing job, other psychiatrists pointed out,
developed the disease; thus there must be something
fundamentally wrong with the affected individuals to make
them vulnerable.
Psychiatrists began to offer up new categories and
formulations. They began to talk of the difference between
the few who had “true neurasthenia” and a larger number
of people who were burdened with a type of nervous
disposition. This sort of disposition was not caused by the
overwork and mental stress that came with high-profile elite
jobs but came from an inherited abnormal personality that
made the sufferer incapable of withstanding the everyday
challenges of a normal life.
Looking back on the debate, it seems as if acceptance of
neurasthenia had been so successful that psychiatrists felt
obligated to restigmatize this mental disorder in hopes of
limiting its adoption. By the end of World War II the
diagnosis had almost completely gone out of style among
both psychiatrists and the population at large. A new
generation of psychiatrists wrote papers and gave
presentations dismissing neurasthenia by suggesting that
the thousands of patients who had claimed to suffer from
the illness had either been misdiagnosed by uninformed
doctors or were malingerers trying to get time off work.
The Culture of Sadness
During the early part of the twentieth century the concept of
depression remained attached to the diagnosis of severe
manic depression imported from those German
neuropsychiatrists. It wasn’t until after World War II that
depression became a disease category of its own. There was
nothing mild about this conception of depression. This so-
called endogenous depression was a crippling type of
psychosis believed to be caused by a genetic abnormality.
Professors of psychiatry at the time often explained
endogenous depression using the metaphor of an internal
alarm clock. “According to this model, the depressed person
is like someone carrying a psychotic time bomb, for whom
depression begins when the internal clock goes off and ends
after it runs its course,” Kitanaka explains. Endogenous
depression expressed itself only in individuals with that
ticking alarm clock and wasn’t connected to external
causes.
At the same time another idea was gaining ground in
Japan’s mental health community. The personality typus
melancholicus was introduced in the early 1960s by a
professor of clinical psychopathology from Heidelberg
named Hubert Tellenbach. This idea never caught on in the
United States and rather quickly became dated in Germany,
but it influenced psychiatric thinking in Japan. As Tellenbach
first described it, someone with a melancholic personality
possessed a highly developed sense of orderliness as well
as “exceptionally high demands regarding one’s own
achievements.” Typus melancholicus mirrored a particularly
respected personality style in Japan: those who were
serious, diligent, and thoughtful and expressed great
concern for the welfare of other individuals and the society
as a whole. Such people, the theory went, were prone to
feeling overwhelming sadness when cultural upheaval
disordered their lives and threatened the welfare of others.
Neither endogenous depression nor the melancholic
personality type were of great concern to the general public
at the time. Because endogenous depression was thought of
as a psychotic state, akin to schizophrenia in severity, it
carried a severe stigma and was considered rare. As for the
melancholic personality type, its association with such
prized Japanese traits as orderliness and high achievement
meant that having such a sadness-prone personality was
something not to be feared but aspired to.
This absence of a category parallel with the modern
Western-style depression persisted for many years. When
the DSM-III was first translated into Japanese in 1982, the
diagnosis of depression, with its two-week threshold for low
mood, was widely criticized among Japanese psychiatrists as
far too expansive and vague to be of any use. Prominent
psychiatrists believed, in short, that the description did not
amount to a meaningful mental illness.
Indeed, as Kirmayer has pointed out, in the late twentieth
century no word in Japanese had the same connotations as
the word “depression” in English. Consider the various
words and phrases that have often been translated into
English as “depression.” Utsubyô describes a severe, rare,
and debilitating condition that usually required inpatient
care and thus was not much of a match for the common
English word “depression.” Yuutsu, which describes grief as
well as a general gloominess of the body and spirit, was in
common use. There was also ki ga fusagu, which refers to
blockages in vital energy. Similarly, ki ga meiru is the
leakage or loss of such energy. Although each of these
words and phrases had overlaps with the English word
“depression,” there were also critical differences. The
experiences these words describe do not exist only in the
thoughts and emotions but encompass full-body sadness. As
such, the Japanese person who felt yuutsu or ki ga fusagu
was likely to describe it in terms of bodily sensations, such
as having headaches or chest pains or feeling heavy in the
head.
Not only did Japanese ideas of sadness include both the
body and the mind but, metaphorically at least, they
sometimes existed beyond the self. The experience of
yuutsu in particular contained connotations of the physical
world and the weather. A young Japanese researcher named
Junko Tanaka-Matsumi, studying at the University of Hawaii
in the mid-1970s, conducted a simple word-association test
on a group of Japanese college students and compared the
results to Caucasian American college students. The
American students were asked to respond with three words
that they connected with “depression.” The Japanese
students were asked to do the same with yuutsu.
The top ten word associations for the native Japanese
were
1. Rain
2. Dark
3. Worries
4. Gray
5. Suicide
6. Solitude
7. Exams
8. Depressing
9. Disease
10. Tiredness
For the Caucasian Americans, the top ten word associations
were
1. Sad or sadness
2. Lonely or loneliness
3. Down
4. Unhappy
5. Moody
6. Low
7. Gloom
8. Failure
9. Upset
10. Anxious
Comparing these answers, Tanaka-Matsumi saw a notable
difference. In the responses given by the Japanese natives,
only a few of the words (such as “worries” and “solitude”)
were related to internal emotional states. On the other
hand, the majority of the word associations supplied by the
American students related to internal moods. The Japanese,
in short, were looking outward to describe yuutsu, and the
Americans were looking inward to describe depression.
Tanaka-Matsumi believed that these were not simply
linguistic differences but cultural “variations in the
subjective meanings and experience of depression.”
The Japanese and Americans weren’t just talking about
depression and sadness differently, she believed; they were
feeling these states differently as well. What she saw
reflected in the language was a difference between how
Japanese and Americans conceived of the nature of the self.
The word associations suggested that Americans experience
the self as isolated within the individual mind. The Japanese,
on the other hand, conceive of a self that is less
individuated and more interconnected and dependent on
social and environmental contexts. Feelings that Americans
associate with depression have, in Japan, been wrapped up
in a variety of cultural narratives that altered their meaning
and the subjective experience for the individual.
Even as the DSM diagnosis of depression became more
widely employed around the world during the 1980s, the
experience of deep sadness and distress in Japan retained
the characteristics of the premodern conception of both
utsushô and the mid-twentieth-century idealization typus
melancholicus, the idea that overwhelming sadness was
natural, quintessentially Japanese, and, in some ways, an
enlightened state.
As Kirmayer has documented, this was a culture that often
idealized and prized states of melancholy. Feelings of
overwhelming sadness were often venerated in television
shows, movies, and popular songs. Kirmayer noted that
yuutsu and other states of melancholy and sadness have
been thought of as jibyo, that is, personal hardships that
build character. Feelings that we might pathologize as
depressive were often thought of in Japan as a source of
moral meaning and self-understanding. He and others have
connected this reverence to the Buddhist belief that
suffering is more enduring and more definitive of the human
experience than transient happiness.
Other cross-cultural scholars have also noticed this
Japanese affinity for states of sadness. Studying menopause
in Japan, McGill Social Studies of Medicine professor
Margaret Lock wrote:
Feeling sad and reacting sensitively to losses, particularly of loved ones, is
an idea that has a singular appeal in Japanese. The theater, a range of
literature and indigenous popular songs, traditional and modern, positively
wallow in nostalgia, sensation of grief and loss, and a sense of the
impermanence of things. People cry freely (by North American and northern
European standards) about separation and lost loved ones, but at the same
time they seem to draw strength from these experiences, to tighten their
bonds with those who remain among the living, and to reaffirm group
solidarity.
This cultural embrace of sadness, Lock believes, might have
been motivated by society’s discouragement of other
emotional states.
Unlike anger and irritability, which both disrupt harmony and threaten the
social order, sadness, grief, and melancholy are accepted as an inevitable
part of human life and even welcomed at times for their symbolic value, as
a reminder of the ephemeral nature of this world. An association between
melancholy and the weather reinforces sad feelings as natural and
unavoidable and hence as states not induced solely through human
exchange.
Given these cultural currents, it makes sense that the first
popular psychopharmacological medications adopted in the
1960s and 1970s were sedatives, whereas amphetamines
and early mood enhancers were viewed with suspicion. As
Lock implies, culturally designated pathological states are
often the flipside of states a culture values. Along with the
sedating drugs, Japanese quickly adopted disease
categories describing social anxiety or aggression but
resisted viewing deep and extended periods of sadness as a
mental illness.
When the first SSRIs came online in the West,
consequently, Japanese considered them harsh medications
that exaggerated types of personality valued in the United
States. A leading Japanese psychopharmacologist described
how classes of drugs matched or ran afoul of different
cultural narratives: “The Japanese system is much more
modest and co-operative—people work together more.
Against this background, amphetamines are much more of a
problem than are the benzodiazepines; we are much more
sensitive to the changes, the exaggeration of behavior,
produced by the amphetamines. Sedative agents are seen
as much less of a problem in Japan. . . . There is something
of a preference for an agent that will be sedative rather than
arousing, like, perhaps, Prozac.”
“One society’s enhancement of personality can be
another’s pathology or provocation,” remarks Kirmayer.
“Something like this may occur with Prozac, where the
extraversion, gregariousness and pushiness that typify the
life of a salesman in the USA may be associated with
inappropriately brash and insensitive social behavior in
Japan.”
Given all these cultural forces, it is not surprising that
major drug companies at first saw no market for SSRIs in
Japan at the beginning of the 1990s. The psychiatric
category of depression was not a widespread public
concern, and the capacity to experience great sadness was
considered not a burden but a mark of strength and
distinction. That belief, combined with a suspicion of drugs
that heightened moods or extraverted personality traits,
made the market for SSRIs unpromising. Those public
perceptions, however, were soon to change.
In the Lost Decade a Young Man Joins an Ad Firm
In the spring of 1990, 24-year-old Oshima Ichiro joined the
Dentsu advertising agency, the largest company of its kind
in the world. When he first showed up at Dentsu, Oshima
was healthy and athletic. His fellow employees described
him as honest, happy, and committed. Like many unmarried
men, he lived with his mother, father, and brother. He had a
girlfriend but no immediate plans to get married;
establishing his career would come first. At Dentsu he was
assigned the daunting task of handling public relations for
more than forty corporate clients.
Because Oshima would come to symbolize a new
understanding of depression among corporate workers in
Japan, it is worth pausing to note the timing of his hiring in
relation to the trajectory of the economy of Japan.
It was on the last trading day of 1989, just three months
before Oshima started his new job, that the Japanese Nikkei
index hit an all-time high. That index had nearly quadrupled
in value over the previous five years. At the end of those go-
go days, choice apartments in the Ginza district of Tokyo
were going for nearly $100,000 per square foot. The
Japanese economy was the envy of the world. It was a time
when it seemed that any business could secure a loan and
everyone with the willingness to work hard could ride the
wave of prosperity.
But when stock traders got back to their posts at the
beginning of January 1990, something had shifted. In the
next days and weeks stocks began to slide, and then free-
fall. By the time Oshima started his job in April there was
something approaching panic in the financial markets.
As was true of many new hires, the sudden economic
downturn steeled Oshima’s resolve to prove his worth. He
showed right away that he was willing to roll up his sleeves
and dig into his considerable workload. He often spent the
first eight hours of his workday just trying to juggle
meetings and field phone calls. Staying at work after hours
was the only way he could write the press releases and
proposals his clients required. Just a few months into his job,
he was coming home past midnight on most nights. On
some mornings, when his colleagues showed up for work, it
was clear that the hard-driving Oshima had been at his desk
the entire night. He took no days off.
In November 1990 his mother and father began to worry
about his health. Oshima’s eyes looked unfocused and he
sometimes fell asleep while sitting with them at the kitchen
table. In his contract, Oshima was promised ten days of
vacation each year, and his parents suggested that he
schedule some days to rest. But he refused. He felt that any
days off would only increase the burden he would face when
he got back to work. Anyway, he told them, he didn’t think
his boss would allow him the time off. Not knowing what
else to do, his mother made him nutritious breakfasts in the
morning and drove him to the train station to ease the
burden of his hour-long commute.
After months at this sprinter’s pace, cracks began to show
in his behavior. At work small setbacks and mistakes
brought on waves of self-loathing. “I’m no good as a human
being,” coworkers sometimes heard him saying out loud to
himself. “I’m of no use.”
The New Year brought no relief from the economic bad
news or from Oshima’s burdens. From its high in 1989, the
Nikkei had lost nearly half of its value. Home prices were
plummeting just as precipitously. The normally hardworking
life in corporate Japan became even more intense. The
frustration of Dentsu executives at their declining profits
rolled down the chain of command, putting ever more
pressure on the rank and file. At one late-night drinking
binge at the office, Oshima’s boss poured beer into his own
shoe and demanded that Oshima drink it down. When he
momentarily refused the request, his boss beat him.
By the summer of that year Oshima’s workload had only
gotten worse. On top of his regular duties, he was put in
charge of a four-day conference for a client to be held in
August. If he got home at all that summer, his parents
remember, it was often simply to clean himself up before
getting back on the train to the office. On the night before
the beginning of the conference he managed to get home at
6 a.m. He was back at work less than four hours later to
drive his boss to the site of the conference.
As they drove, his boss couldn’t help but notice that
Oshima seemed troubled. He drifted and swerved erratically
from lane to lane. He mumbled incoherently, something
about being possessed by spirits.
After a grueling four days at the conference, Oshima
finally made his way back home at 6 a.m. on August 26. He
looked so drawn and haggard that he promised his brother
that he would go to the hospital that day. He called the
office at 9 a.m. to tell them that he was sick and would not
be in that day. Less than an hour later, his family found him
dead. He had hanged himself in the bathroom.
When Oshima’s parents’ lawsuit against Dentsu came to
court a few years after his death, newspaper editors and
television producers featured the story prominently. It was
an easy pick, given that the story had a clear antecedent. In
the boom years of the 1980s hardworking Japanese
businessmen sometimes collapsed and died at their desks
after putting in weeks or months of overtime. In the press
this was called karoshi, death from overwork, and reports on
the trend had become popular. In the early 1990s suicides
topped thirty thousand a year. This was between three and
four times the number of Japanese killed in car accidents.
The suicide trend became a concern to the general public
and there was much debate over who or what was
responsible. When Oshima’s suicide came to light,
journalists and editors immediately saw the story’s
potential. Headlines announced the new trend: karojisatsu,
suicide from overwork. Because the Oshima family’s lawsuit
sought to assign blame for his death, it was tailor-made to
become the focus of this public debate.
The lawyers for Oshima’s parents argued that the stress of
his job and his long hours brought on a depression that
caused his death. This form of depression was different from
the endogenous depression in the Japanese psychological
literature because it hadn’t resulted from an inherited
defect in Oshima’s brain; rather it was brought on by the
circumstances of his life. This was a type of depression that
could strike anyone.
The newspapers followed each revelation of the case.
There was, for instance, the mystery of just how many
overtime hours young Oshima worked during his time at
Dentsu. According to the time sheets he submitted to the
company, his overtime ranged between twelve and twenty
hours each week. Lawyers for the company pointed out that
that level of commitment was hardly unusual in hardworking
Japan, and it was certainly not the sort of workload that
you’d expect would drive a healthy and ambitious young
man to hang himself in the bathroom. To prove that he had
worked much longer than he claimed, the lawyers for his
parents relied on the records of the office night guards, who
were required to make frequent checks of each floor of the
building, noting the names of the employees at their desks.
Based on that evidence, it was clear that Oshima was
clocking a much more problematic average of forty-seven
overtime hours per week.
Oshima’s parents won their case. As the Dentsu lawyers
appealed the verdict through the courts they continued to
argue that the company should not be held liable because
Oshima’s depression was a result of a preexisting mental
weakness. They were, in effect, arguing for a pre–DSM-III
version of endogenous depression: Oshima wouldn’t have
become sick had he not had that alarm clock ticking inside
his brain.
The different rulings of the higher courts rather neatly
reflect a culture in the process of changing its collective
mind. The Tokyo High Court first reduced the amount of the
compensation, concluding that Oshima’s inborn mental
stamina was at least part of the cause in his death. “Not
everyone becomes depressed from being overworked or
being in a stressful situation,” the verdict read. “It cannot be
denied that his . . . premorbid personality resulted in
increasing the amount of his own work.” Here the court held
onto earlier notions prominent in Japanese psychiatry: that
inborn pathological characteristics were the psychiatric
equivalent of fate. The Supreme Court, however, rejected
that lower court’s ruling and argued that individual
character—as long as it is within a normal spectrum—should
not be considered in such a case. The ruling suggested that
anyone, put under enough stress, could succumb to
depression.
Thanks partly to the debate over Oshima’s suicide, the
shift in public opinion during this period couldn’t have been
more dramatic. “When people first heard about the
litigation, they would ask if it was the company, not the
family, that was suing for the damage caused by the
employee’s suicide,” said Kitanaka, who studied the case
closely. “When Japanese heard in the media of the plaintiff’s
victory, many came to hear, probably for the first time, that
suicide could be caused by a mental illness called
depression.”
That Oshima’s lawsuit might be the first time many
Japanese connected suicide with depression is hard for a
Westerner to comprehend. Most Americans would certainly
assume that suicidal acts are nearly always caused by
mental illness, most commonly depression. Indeed the
Western SSRI manufacturers who were eyeing the Japanese
market in the 1990s routinely invoked the high suicide rate
as proof positive of an epidemic of depression in Japan.
Yet the Japanese public remained split as to whether
suicide was an intentional act with moral or philosophical
meaning or a desperate act of a mentally ill person. In many
ways the public debate regarding why Oshima hanged
himself picked up the public dialogue that took place almost
a hundred years before, when Misao Fujimura jumped off
the waterfall. Although many Japanese agreed that the high
rate of suicide was a legitimate public health concern, there
was not yet a consensus that the epidemic, or the act of
suicide itself, was the result of mental illness. In Japanese
history, literature, and movies there were many stories of
the noble suicide, such as when Samurai warriors
committed seppuku and World War II soldiers killed
themselves to avoid capture. Psychiatrist Masao Miyamoto
was not alone when he remarked in 1998 that he didn’t see
much of a connection between the rise of suicide and
depression. Most of the reasons Japanese people kill
themselves have nothing to do with depression, he argued.
“A peculiarity of the Japanese is that they often die for the
sake of the group,” he said. “They die for shame.” Wataru
Tsurumi’s Complete Manual of Suicide, published in 1993,
was the modern embodiment of the Japanese public’s
intense interest in suicide. The book, written in flat,
unemotional tones, is a guide to the ten most popular
methods of suicide, including hanging, drowning,
electrocution, and jumping from heights. The author awards
a number of skulls to rate each method in categories such
as painfulness, how much a nuisance you’ll cause others,
how much effort is required, and the likelihood of success.*
The remarkable sales of the book speak to a uniquely
Japanese fascination. During the 1990s the book sold more
than 1.2 million copies. If we can believe the author, the
book was written not for shock value but from a deeply
philosophical belief that suicide is a legitimate—and
perfectly sane—act of personal will.
The story of young Oshima and several other prominent
suicides from overwork put faces and personal stories on
the growing public concern that Japan had ignored the
mental health consequences of overwork. As was true at the
turn of the nineteenth century, the end of the twentieth
century was a disconcerting time for the people of Japan.
Shameful bankruptcies were common and divorce and
unemployment were on the rise. Just as at the end of the
Edo era a hundred years before, the public was on the hunt
to explain the distress being felt during these uncertain
times.
The Japanese public’s impression that the country was
behind the times in addressing mental health got a boost
after the devastating earthquake in the city of Kobe in
January 1995.* The government response to the disaster
was criticized by Western mental health experts for being
lackluster on many fronts. Researchers from the United
States were soon on the scene and garnered much press
attention by suggesting that the population needed not just
food and shelter but more attention paid to their emotional
and mental health.
Several prominent Japanese psychiatrists and mental
health advocates used the authority of the visiting mental
health experts to make a broad argument that Japanese
culture discouraged talking about emotionally loaded issues.
“The comparison, quite unfavorable to Japan, was often
made to the United States, where the emphasis on
psychological issues is generally believed to be culturally
strong and given proper priority,” the anthropologist Joshua
Breslau reported. “One well-known newspaper critic noted
that his friend told him how nearly everyone in U.S. cities
has a psychological counselor.”
A critical turning point came just three months after the
Kobe quake. A TV producer named Kenichiro Takiguchi was
browsing through the English-language section of a Tokyo
bookstore and started to flip through a paperback copy of
Peter Kramer’s American best seller Listening to Prozac.
Always on the lookout for good ideas for programs, he took
the book to his bosses at Japan’s largest television network
and persuaded them to let him produce a fifty-minute
special. The message of the special was similar to the
beliefs made popular after the Kobe earthquake, namely,
that Americans were far advanced in their recognition and
treatment of emotional disorders such as depression and
anxiety. The show hit a nerve. Millions watched and more
than two thousand viewers called in afterward to praise the
network for running the program.
Japanese psychiatrists were largely taken by surprise at
this turn in public interest. Up to that point the public had
eschewed the intrusion of psychiatry into daily life. As the
small population of psychiatrists had mostly limited their
practice to the severely mentally ill, the call to address
common unhappiness and anxiety that came with bad
economic times caught them off-guard. Like many people in
the country up to that point, they had not considered
unhappiness (or divorce or suicide) a mental health issue.
They were in need of a new and compelling explanation for
what was going on. Fortunately for them, GlaxoSmithKline
and several other major psychopharmaceutical companies
were just then preparing to throw them a lifeline.
Junk Science and First World Medicine
Kalman Applbaum, a professor at the University of
Wisconsin in Milwaukee, is an anthropologist, but he doesn’t
study little-known tribes in far-off lands. His interest is closer
at hand: the rituals and practices of international
corporations. His specialty, the anthropology of the
boardroom, has led to teaching posts both in anthropology
departments and at business schools, including Harvard and
Kellogg. He is also fluent in Japanese and often consults with
companies interested in the Asian markets. When he heard
in the late 1990s that major players in the pharmaceutical
industry were attempting to introduce SSRIs to Japan, he
knew he had the topic for his next set of research papers.
At the beginning of the new millennium, Applbaum went
out of his way to visit the headquarters of GlaxoSmithKline,
Lilly, and Pfizer, the major international players who were at
various stages of trying to get their drugs into Japan. At the
time both Pfizer and Lilly were playing catch-up to
GlaxoSmithKline, which was just then launching Paxil in the
country. Although he had to sign nondisclosure agreements
promising that he wouldn’t identify the executives by name
or company affiliation, Applbaum managed to get
remarkable access to the inner workings of these
companies. Several of his former MBA students who were
then working in these firms helped make key introductions,
but in the end these executives proved more than willing to
talk. When I asked Applbaum why they were so forthcoming,
he told me it was simple: because of his business school
credentials and his extensive experience in the Japanese
market, they thought he might be able to give them some
free advice.
Applbaum discovered that the companies intent on
entering the SSRI market in Japan were not battling each
other like Coke and Pepsi for market share—or at least not
at the beginning. Instead he found wide acknowledgment
within the ranks of drug company executives that the best
way for companies to create a market was for competing
companies to join forces.
A critical player in this joint effort was the trade
organization Pharmaceutical Manufacturers of America, or
PhRMA, which functions as the national and international
lobby and public relations organization for a coalition of
major drug companies. In the late 1990s Applbaum found
PhRMA working on a number of levels in Japan to influence
what they considered to be a backward and bureaucratic
drug approval process. As one PhRMA executive based in
Chiyoda-Ku, Tokyo, told Applbaum, their job was to create “a
market based upon competitive, customer choice and a
transparent pricing structure that supports innovation.” The
lobby wanted drugs such as Paxil to be able to enter new
markets based on “global, objective, scientific standards.”
The more Applbaum talked to drug company insiders, the
more righteous frustration he found. When he visited the
offices of a leading SSRI manufacturer in November 2001,
he discovered a wellspring of anger directed at what they
perceived as Japanese resistance to pharmaceutical
progress. These executives criticized scientific standards for
clinical testing in Japan as “quite poor” and asserted that
there was no “good clinical practice” in the country. Why,
they asked Applbaum rhetorically, should their company be
forced to retest these drugs in exclusively Japanese
populations? The assumption was that the science behind
the American human trials was unassailable—certainly
better than anything the Japanese would attempt.
No doubt that annoyance at having to retest drugs was so
intense because a couple of recent large-scale human trials
of SSRIs in Japan had failed to show any positive effects.
Drugs such as Pfizer’s Zoloft, which were widely prescribed
in the United States, had at least one large-scale human
trial failure in Japan in the 1990s. Instead of considering the
meaning of such results, the drug company executives
railed at Japanese testing practices, calling them second
rate. “There is no sense of urgency about patient need in
Japan,” one executive complained to Applbaum.
The Mega-Marketing of Depression
Although drug company executives clearly would have
preferred to avoid the expensive and time-consuming
process of retesting their SSRIs in Japan, they ultimately
found a way to put those trials to good use as the first step
in their marketing campaign. The drug makers often bought
full-page ads in newspapers in the guise of recruiting test
subjects. Applbaum believes that this was one of several
savvy methods the drug companies employed to sidestep
the prohibitions in Japan on marketing prescription drugs
directly to the consumer. These advertisements, supposedly
designed only to recruit people for the trials, were well
worth the cost, as they both featured the brand name of the
drug and promoted the idea of depression as a common
ailment. One company scored even more public attention
when it recruited a well-known actress to take part in the
trials.
But getting the drug approved for market was only the
first step. Talking with these executives, it became clear to
Applbaum that they were intent on implementing a complex
and multifaceted plan to, as he put it, “alter the total
environment in which these drugs are or may be used.”
Applbaum took to calling this a “mega-marketing” campaign
—an effort to shape the very consciousness of the Japanese
consumer.
The major problem GlaxoSmithKline faced was that
Japanese psychiatrists and mental health professionals still
translated the diagnosis of “depression” as utsubyô, and in
the mind of many Japanese that word retained its
association with an incurable and inborn depression of
psychotic proportions. In hopes of softening the
connotations of the word, the marketers hit upon a
metaphor that proved remarkably effective. Depression,
they repeated in advertising and promotional material, was
kokoro no kaze, like “a cold of the soul.” It is not clear who
first came up with the phrase. It is possible that it originated
from Kenichiro Takiguchi’s prime-time special on depression.
In that show, it was said that Americans took anti-
depressants the way other cultures took cold medicine.
Whatever its origin, the line kokoro no kaze appealed to
the drug marketers, as it effectively shouldered three
messages at the same time. First, it implied that utsubyô
was not the severe condition it was once thought to be and
therefore should carry no social stigma. Who would think
less of someone for having a cold? Second, it suggested
that the choice of taking a medication for depression should
be as simple and worry-free as buying a cough syrup or an
antihistamine. Third, the phrase communicated that, like
common colds, depression was ubiquitous. Everyone, after
all, from time to time suffers from a cold.
Although advertising couldn’t mention particular drugs,
companies could run spots in the guise of public service
announcements encouraging people to seek professional
help for depression. In these ads SSRI makers attempted to
distance depression further from the endogenous
depression as it was understood by Japanese psychiatrists
for most of the century. One GlaxoSmithKline television
advertisement showed an attractive young woman standing
in a green field, asking, “How long has it been? How long
has it been since you began to worry that it might be
depression?” The scene then shows a woman on an
escalator and then a middle-aged office worker staring out a
bus window. The voiceover then recommends that if you’ve
been feeling down for a month, “do not endure it. Go see a
doctor.”
The subtext of the ad is clear to Kitanaka. It presents
depression as “intentionally ambiguous and ill-defined,
applicable to the widest possible population and to the
widest possible range of discomforts. . . . The only feature
that distinguishes depression as a ‘disease’ from an ordinary
depressed mood seems to be the length of time (one
month) that the person has experienced these ‘symptoms.’”
Depression was so broadly defined by the marketers that
it clearly encompassed classic emotions and behaviors
formerly attributed to the melancholic personality type. The
label of depression then took on some laudable
characteristics, such as being highly sensitive to the welfare
of others and to discord within the family or group. Being
depressed in this way became a testament to one’s deeply
empathic nature.
To get these messages out to the Japanese public, the
SSRI makers employed a variety of techniques and avenues.
Company marketers quickly reproduced and widely
disseminated articles in newspapers and magazines
mentioning the rise of depression, particularly if those
pieces touted the benefits of SSRIs. The companies also
sponsored the translation of several best-selling books first
published in the United States on depression and the use of
antidepressants.
Given all the ways that GlaxoSmithKline and the other
SSRI makers managed to make the average Japanese aware
of their drugs, the official ban on direct-to-consumer
marketing became almost meaningless. If there was any
doubt about this, one only had to look at how these
companies used the Internet. “The best way to reach
patients today is not via advertising but the Web,” one
Tokyo-based marketing manager told Applbaum. “The Web
basically circumvents [direct-to-consumer advertising] rules,
so there is no need to be concerned over these. People go to
the company website and take a quiz to see whether they
might have depression. If yes, then they go to the doctor
and ask for medication.”
The mega-marketing campaign often came in disguised
forms, such as patient advocacy groups that were actually
created by the drug companies themselves. The website
utu-net.com, which appeared to be a coalition of depressed
patients and their advocates, was funded by
GlaxoSmithKline, although visitors to the site would have
had no clue of the connection. What they would have found
was a series of articles on depression driving home the key
points of the campaign, including the idea that it was a
common illness and that antidepressants bring the brain’s
natural chemistry back into balance.
The public interest in the new diagnosis brought a
remarkable amount of media attention. Often in back-to-
back months, the major magazines Toyo Keizai and DaCapo
ran pieces on depression and the new drugs. In 2002 a
leading Japanese business magazine ran a twenty-six-page
cover story encouraging businesspeople to seek
professional help for depression. The article rather perfectly
mirrored the key points of the SSRI makers’ mega-marketing
campaign and in many ways reflected the early conceptions
of neurasthenia a century before. The article suggested that
it was the more talented and hard-charging workers who
were the most susceptible to depression. Estimates of how
many Japanese secretly suffered from depression, which
ranged from 3 to 17 percent of the population, seemed to
increase every month.
The distress caused by the long-ailing economy also
proved to be a useful selling point. GlaxoSmithKline
promoted the idea that there was an enormous economic
cost for untreated depression, which could be counted in
lost man-hours and decreased productivity. In this way, the
lure of the drug, especially to the younger generation, was
tied to ideas about competition in the global marketplace.
One Japanese psychiatrist was quoted in a local newspaper
describing SSRIs as “drugs that can transform minus
thinking into plus thinking” and that “can help a person live
tough,” like financially successful Americans.
The SSRI makers made much of one public relations
windfall in particular. It was rumored for years (and finally
confirmed by the Imperial Household Agency) that Crown
Princess Masako suffered from depression. Soon it was
revealed that she was taking antidepressants as part of her
treatment. This was a huge boost for the profile of
depression and SSRIs in the country. Princess Masako’s
personal psychiatrist was none other than Yutaka Ono, one
of the field’s leaders that GlaxoSmithKline had feted at the
Kyoto conference in 2001.
As a marketing line, there was one problem with the
phrase kokoro no kaze: the metaphor lacked a sense of
urgency about the condition. After all, one rarely rushes to
the doctor with a cold. Worse yet, medicating a cold was
always optional, as the illness goes away rather quickly on
its own.
To counter this aspect of the metaphor, the drug
companies leveraged the population’s growing concern over
the high suicide rates. The medical anthropologist Emiko
Namihira reported that SSRI makers were funding studies to
prove the link between depression and suicide. Those
studies that showed a connection were reprinted in
pamphlet form and reported to national media outlets as
breaking news. Studies that failed to show a connection
could simply be ignored. The founder of the Mood Disorders
Association of Japan claimed in the Japan Times that “90
percent of those who commit suicide are considered to
suffer from one kind of mental illness or another, and 70
percent of suicides are attributable to depression.” Without
medical attention, the message went, this “cold of the soul”
could kill you.
When taken together, the messages advanced by
GlaxoSmith-Kline during their rollout of Paxil don’t always
make sense. Previous notions of endogenous depression
were employed only sparingly in order to evoke the
seriousness of the disorder. On the other hand, they were
happy to associate this new conception of depression with
the Japanese veneration of the melancholic personality,
even though that didn’t particularly jibe with the parallel
message that this was an illness caused by an imbalance of
serotonin. Neither did the message that overwork could
spark depression mesh with the idea that individuals should
counter such social distress by taking a medication that
changed their brain chemistry. If it was unrealistic social
demands that were the cause of distress in the population,
why should the individual be taking the pills? In the end,
however, the coherence of these various messages took
second place to their effectiveness.
Speeding the Evolution
After the Kobe earthquake in Japan there was growing
consensus in the country that the West, and the United
States in particular, had a deeper scientific understanding of
pathological emotional states such as PTSD and depression.
Responding to this insecurity, the advertisements, websites,
waiting room brochures, and other materials produced by
the drug companies played up the idea that SSRIs
represented the cutting edge of medical science. These
drugs, which were said to rebalance the natural chemicals in
the brain, would bring Japan up to date.
GlaxoSmithKline worked very hard to win over the most
prominent medical researchers and psychiatrists in the
country and keep them on message. Their inclusion at lavish
conferences such as the one Kirmayer attended was just a
taste of the incentives offered. Drug companies offered
grants to sponsor research on their drugs; those researchers
who produced results favorable to the drugs found
themselves with new offers of research funding. Research
that showed the drug in question to be both safe and
effective was trumpeted by the company and the
researchers often paid as consultants. In addition,
researchers were given honoraria for speaking about their
findings at drug company–sponsored professional
conferences. Influence over the prominent scientists and
researchers in Japan was so pervasive that Applbaum
concluded that these scientists and doctors had been
basically “commandeered into a kind of market research by
pharmaceutical companies. The research simultaneously
serves as publicity for the essentially predetermined
consumer need.”
It is important to note that the drug company executives
whom Applbaum interviewed didn’t present themselves as
people driven only by profits. Rather these men and women
saw themselves as acting with the best of intentions,
motivated by the belief that their drugs represented the
proud march of scientific progress across the world. They
styled themselves as people fighting depression, anxiety,
and social phobia—diseases that remained cruelly untreated
in Japan and elsewhere. Applbaum could see that this
mixture of moral certainty and the lure of billions of dollars
in potential profits was a potent force.
“These executives seemed to believe that they are
straightforwardly trying to heal the world,” said Applbaum.
When he was meeting them in 2000 and 2001 he had no
reason to doubt these self-assessments. “They seemed to
believe their products were effective and they were baffled
that anyone should question their value. The
pharmaceutical industry, more than other industries, can
link its marketing activities to ethical objectives. The result
is a marriage of the profit-seeking scheme in which disease
is regarded as ‘an opportunity’ to the ethical view that
mankind’s health hangs in the balance. This helps even the
most aggressive marketers trust that they are performing a
public service.”
Bolstering their certainty was their faith in the science
behind these drugs. The fact that these SSRIs had proven
clinically effective made it morally imperative that they be
introduced into other cultures. The drug companies were
replacing what one executive referred to as “junk science”
in Japan with “first world medicine.”
During his talks with the executives, consultants, and
marketers for the drug companies, Applbaum heard a
repeated theme. These men and women kept talking about
different cultures as if they were at different stages of a
predetermined evolution. The American market, with its the
brand recognition, high rates of prescriptions (by specialists
and nonspecialists alike), and free market pricing, was seen
as the most modern and advanced of markets. Japan was
fifteen years behind the United States, executives would
say. Or China was five years behind Japan. The lucrative U.S.
market, Applbaum could see, was the standard against
which all others were measured. We were the most
“evolved” culture and, as one executive said to Applbaum,
their job was to “speed the evolution along,” that is, to
move other countries along the path to be like us.
This talk of evolutionary process wasn’t idle chatter, for it
was often the same executives and marketing specialists
who went from country to country waiting for the right
moment to make their push. “Pharmaceutical manufacturers
. . . circulate internal instructional materials regarding
experiences with the same product in what they consider
similar markets,” Applbaum said. “Managers fly about the
world to training conferences where such archetypes are
hardened. And old advertisements and communications
strategies from the earlier stage of more ‘advanced’
markets are imported.” With each new implementation of
the mega-marketing campaign, these drug companies
learned new maneuvers and strategies. They got better at
helping along the evolution.
The reasons these executives were so open about this
endeavor goes back to their shared belief that the evolution
in question was toward higher quality science. Westerners
may have lost their sense of moral authority in many areas
of human endeavor, but we can still get our blood up
defending our science. We lead the world in scientific
discovery and medical breakthroughs, so why shouldn’t the
citizens of Japan and other countries around the world have
access to the newest brand-name antidepressants? These
molecules were created using the latest advances in science
and technology. They had been reviewed by the leading
researchers at the world’s most famous universities and
found effective in studies published in the most prestigious
scientific journals. The latest antidepressants, in this moral
logic, were akin to antiretrovirals, polio vaccine, and
penicillin. Everyone in the world deserved access to the
fruits of our scientific discoveries as a human right.
It is not an argument without merit, but it depends rather
critically on the accuracy and validity of the science behind
the medical advance being touted. If the science is
overblown, skewed, or downright wrong, then the moral
certainty that fuels the charge into other cultures becomes
suspect.
Blinding Them with Science
Of all the luxuries provided him during that Glaxo-sponsored
Kyoto conference in 2001, Kirmayer remembers one evening
with particular relish. On the second night of the conference
he was instructed to dress in a “smart suit” and was taken
to the Tsuruya restaurant, one of the most exclusive and
expensive restaurants in Japan. At the restaurant he was
shown the guest book, where Henry Kissinger and other
world leaders had left their compliments. During dinner a
personal geisha sat at his arm smiling and pouring his tea
and sake. After trying to make small talk with this young
woman in his limited Japanese, he turned to James Ballenger
to bring up a question that had been on his mind.
Ballenger was the head of the International Consensus
Group on Depression. For three years he and a group of
other academic researchers hosted seven meetings at
various luxury resorts and hotels around the world. At these
conferences, funded by GlaxoSmithKline, Ballenger
gathered prominent scholars and researchers to consider
the best treatments for PTSD, panic disorder, and
generalized anxiety disorder. In the end these supposedly
independent scholars, with their affiliations to some of the
world’s finest universities, recommended that SSRIs be
prescribed for all of these conditions. Tellingly, the only SSRI
mentioned by name in the Consensus Group’s summation
paper was paroxetine, aka Paxil.
Kirmayer was curious about the relationship between the
drug companies and academics like Ballenger who
published the papers recommending these drugs. Wanting
to be polite, he thanked Ballenger for the remarkable
accommodations and treatment he was receiving. Kirmayer
was, of course, in no position to take the moral high road, as
he was at that very moment enjoying the splendor and
luxury for which GlaxoSmithKline was picking up the tab.
Nevertheless he felt compelled to ask Ballenger, as nicely as
he could: Isn’t this something of a conflict of interest?
Although he can’t remember what Ballenger said word for
word, he remembers the gist.* “He told me, ‘Look, I’ve
made my peace with this a long time ago. The drug
companies are going to do this anyway—they are going to
market drugs and produce guidelines, so they can either do
it with input of good people who are knowledgeable and
scientifically sophisticated and evenhanded or not,’”
Kirmayer remembers.
“In their heart of hearts,” Kirmayer said, “I think
academics who have consulted with drug companies think
that they are doing good and that they deserve the
consulting fees and perks.” In short, no one seemed to be
losing any sleep over the ethics of such a luxurious meeting
being sponsored by a drug company. No doubt the thread
count in the sheets helped in this regard.
At the time Ballenger’s response did not seem
unreasonable to Kirmayer. This was before it was revealed
that many of the most influential studies on SSRIs,
supposedly written by prominent academics, were in fact
ghostwritten by private firms hired by drug companies. This
was before it was widely known that many academics had
taken hundreds of thousands of dollars (sometimes millions)
in consulting and speaking fees while at the same time
helping to hide or disguise negative data on the very drugs
they were supposedly evaluating.
It has been only in the past few years, in fact, that these
issues have become a public scandal prompting ongoing
litigation and an investigation in the U.S. Senate. Many
drugs and companies have been implicated in this recent
upheaval, but one company and one drug have been at the
very heart of the scandal: GlaxoSmithKline and Paxil.
Under even the mildest scrutiny, the confident marketing
messages proclaiming the scientific validity of SSRIs begin
to break down. Take for instance the idea, often repeated in
the ads and promotional material surrounding the launch of
SSRIs in Japan, that a depletion of serotonin is the root
cause of depression and that SSRIs reestablish the
“balance” of the “natural” chemicals in the brain.
Pharmaceutical companies have been repeating this idea
ever since SSRIs came on the market twenty years ago. On
their website the makers of the SSRI Lexapro are still telling
the story: “The naturally occurring chemical serotonin is
sent from one nerve cell to the next. . . . In people with
depression and anxiety, there is an imbalance of serotonin—
too much serotonin is reabsorbed by the first nerve cell, so
the next cell does not have enough; as in a conversation,
one person might do all the talking and the other person
does not get to comment, leading to a communication
imbalance.”
Here’s how GlaxoSmithKline describes the same idea on
its website advertising Paxil CR: “Normally, a chemical
neurotransmitter in your brain, called serotonin, helps send
messages from one brain cell to another. This is how the
cells in your brain communicate. Serotonin works to keep
the messages moving smoothly. However, if serotonin levels
become unbalanced, communication may become disrupted
and lead to depression. . . . Paxil CR helps maintain a
balance of serotonin levels.”
As often repeated as this story is, it turns out that there is
currently no scientific consensus that depression is linked to
serotonin deficiency or that SSRIs restore the brain’s normal
“balance” of this neurotransmitter. The idea that depression
is due to deficits of serotonin was first proposed by George
Ashcroft in the 1950s, when he thought he detected low
levels in the brains of suicide victims and in the spinal fluid
of depressed patients. Later studies, however, performed
with more sensitive equipment and measures, showed no
lower levels of serotonin in these populations. By 1970
Ashcroft had publicly given up on the serotonin-depression
connections. To date, no lower levels of serotonin or
“imbalance” of the neurotransmitter have been
demonstrated in depressed patients. The American
Psychiatric Press Textbook of Clinical Psychiatry states
simply, “Additional experience has not confirmed the
monoamine [of which serotonin is a subgroup] depletion
hypothesis.”
SSRIs don’t bring a patient’s brain chemistry back into
balance, but rather broadly alter brain chemistry. Although
that change may sometimes help a depressed patient, the
idea that SSRIs restore a natural balance of serotonin is a
theory without evidence. Put another way, this idea is more
of a culturally shared story than a scientific fact, in the exact
same way neurasthenia’s invocation of “frayed nerves” was
a story.
What made this story so popular was that it turned out to
be an effective marketing line, first employed in the United
States and Europe and then around the world. SSRIs came
on the heels of the public scandal about the overprescribing
of benzodiazepines. These drugs, including Valium and
Librium, were initially embraced by the medical
establishment until they were revealed to be highly
addictive. As SSRIs came to market, the public was
understandably wary of psychopharmacological agents. The
story that SSRIs only helped balance natural chemicals in
the brain, therefore, was just what the public needed to
hear. This marketing line was useful in a similar way in
Japan, where many considered Western psychiatric
medicines to be harsh and unnatural.
In the end, to judge the value of a drug, its benefits must
be considered in light of its risks. Unfortunately, in judging
the benefit-risk balance of SSRIs one immediately runs into
an even more complicated and thorny question: To what
extent can the Western scientific literature describing the
risks and benefits of these drugs be trusted? What worries
many researchers is that the makers of pharmaceutical
drugs such as SSRIs have gained remarkable control over
the creation and presentation of the scientific data that
purport to show that these drugs are safe and effective.
No man has fought harder to expose the process by which
pharmaceutical makers control the knowledge pipeline
behind their drugs than David Healy, a psychiatrist in the
North Wales Department of Psychological Medicine and a
professor at the University of Cardiff. Healy’s particular
crusade is not against SSRIs or the use of any drug in
particular, but for the full and unbiased accounting of the
data.* Because GlaxoSmithKline and other drug companies
have control over the creation of the science, Healy argues,
“there is almost no possibility of discrepant data emerging
to trigger a thought that might be unwelcome to the
marketing department of a pharmaceutical company.”
This skewing and shaping of the data becomes more
confounding as the information gets transmitted across
cultures and languages by the marketers intent on selling
the medication.
According to Healy, drug companies first started
ghostwriting scientific papers for university researchers in
the 1950s. Back then it was seen as a marginally
disreputable practice, and these papers usually appeared
only in obscure journals with little prestige or influence. But
by the 1970s the drug companies had taken control of
funding the major randomized control studies, and by the
mid-1990s, Healy estimates, over half of the studies in the
most prestigious journals were being drafted not by the
university researchers supposedly heading the studies but
by medical writing companies paid by the drug companies.
Once this became an accepted practice, the drug
companies found that they not only had control over what
information made it into print but they also had remarkable
power over which university researchers rose to become
stars in their field. “In effect,” writes Nassir Ghaemi, director
of the Mood Disorders and Psychopharmacology Programs
at Tufts Medical Center, “ghost authorship is the steroid
problem of academia; some of our experts get their fame
artificially, their achievements appearing greater than they
really are.” Those who take the high ground and refuse to
be part of this process run the risk of falling behind their
colleagues who are, so to speak, on the juice.
In the scientific and public discussion that surrounds these
drugs, it is usually only the published results that influence
opinion. Unfortunately, negative results almost never see
print and therefore rarely become part of the debate. A
recent review of seventy-four studies of antidepressants
found that nearly all (thirty-seven out of thirty-eight) of the
positive studies were published in professional journals. Of
the thirty-six negative studies, only three managed to make
it to print. The other thirty-three negative studies either
went unpublished or were reported in a form that claimed a
positive outcome different from the one the study intended
to examine.*
When the raw data from the published and unpublished
studies are examined together, the SSRIs begin to look
nothing like the miracle drug being promoted in Japan and
elsewhere. An analysis of the clinical trial data submitted to
the U.S. Food and Drug Administration shows that about five
out of ten test subjects given an SSRI improve over a couple
of weeks on the depression rating scale. This at first seems
like a fantastic outcome, until one considers the placebo
group, those people in the trial who were given a sugar pill.
On average, four out of ten patients taking a fake pill
improve. Indeed, in many of the unpublished studies, SSRIs
have failed to outperform placebos.
This means that only one in ten test subjects shows a
positive response that can be attributed to the effect of the
SSRI. This is hardly impressive, especially when one
considers the fact that “improvement” doesn’t mean that
the depression goes away but often only indicates a change
on a symptom rating scale. A person who is still depressed
but sleeping better, for instance, might be seen as
improved. Indeed with enough test subjects, even minor
changes in one or two of the checklist items can appear to
be significant.
This rather anemic level of effectiveness would certainly
surprise many Japanese who have been subject to the
mega-marketing campaign promoting SSRIs as a cure for
depression. Negative data get weeded out or spun, while
even small beneficial results zoom through the supposedly
scientific gatekeepers (the academics “authoring” the
studies and the journal editors) to the salespeople, the
marketers, and the public relations firms and out of the
mouths of credulous journalists. Each stage of the process
by which this information is manufactured distances the
doctor and the depressed patient from the actual benefits
and risks of the drug. When this information pipeline crosses
cultural boundaries under the auspices of a mega-marketing
campaign funded by the drug maker, the relation between
the consumer’s perception of the product and the science
behind the drug becomes all but illusory.
In judging just how honest drug companies are being with
the data, one example stands out. In July 2001, just as
GlaxoSmithKline’s marketing campaign in Japan was
ramping up, a paper titled “Efficacy of Paroxetine [Paxil] in
the Treatment of Adolescent Major Depression: A
Randomized, Controlled Trial” was published in the Journal
of the American Academy of Child and Adolescent
Psychiatry, the most influential journal in the field. Among
the half dozen authors were many prominent names,
including lead author Dr. Martin Keller, the chairman of
psychiatry at Brown University. The study had been
conducted between 1994 and 1997 and included almost
three hundred depressed adolescents. It was a double-blind
study—the gold standard—meaning that neither the patient
nor the doctor giving the pills knew which of the subjects
were getting the drug being tested rather than the placebo.
In the paper the authors gave their hearty approval, writing
that Paxil was “generally well tolerated and effective for
major depression in adolescents.”
Within a month of the publication of the study, the
company sales reps were alerted to the good news. A memo
dated August 2001 from Paxil Product Management to “all
sales representatives selling Paxil” trumpeted “this ‘cutting
edge,’ landmark study” as having “demonstrated remarkable
Efficacy and Safety in the treatment of adolescent
depression.”
Internal company documents that have come to light
through lawsuits and government investigations report
remarkably different results. Those internal memos suggest
that the study had in fact failed to show a significant
difference between Paxil and the placebo on any of the
eight measures the study had set out to use. A company
memo reported that the results had proven “insufficiently
robust” and recommended that the company “effectively
manage the dissemination of these data in order to
minimize any potential commercial impact.” The memo
went on: “It would be commercially unacceptable to include
a statement that efficacy had not been demonstrated, as
this would undermine the profile of paroxetine (aka Paxil).”
Needless to say, this in-house assessment by
GlaxoSmithKline staff stands in remarkable contrast to the
published conclusion that Paxil was “well tolerated and
effective for major depression in adolescents.” But more
disturbing still is that the published study apparently
downplayed or hid the drug’s side effects. Early drafts of the
study, which came to light during lawsuits, show that
serious side effects (including hospitalizations and suicide
attempts) were more than five times more likely in the teens
taking Paxil than in those taking the placebo. In addition,
severe and often incapacitating problems with the nervous
system were four times more likely for those on the drug.
Nevertheless, in the first version of the study submitted for
publication there was no mention of any serious adverse
side effects. In a subsequent version there was a sentence
suggesting that “worsening depression, emotional lability,
headache, and hostility” were possible side effects. Even
that acknowledgment was left out of the final published
version of the paper that reports the side effects as only one
“headache.”
So here is an example of the knowledge pipeline created
by Glaxo-SmithKline. From the company’s own internal
documents we see that the study data that entered the
pipeline showed that the effect of the drug on depression in
teens was “insufficiently robust” and that some of those
teens on the drug showed dramatic increases in
hospitalizations and suicide attempts over those given the
placebo. At the other end of the pipeline comes the
marketing claim that the study “demonstrated remarkable
Efficacy and Safety.”
The story of this study, and the problem that it highlights,
is not isolated. After two decades of working at the
esteemed New England Journal of Medicine, Dr. Marcia
Angell became convinced that the system by which these
drugs gain scientific status is broken. “It is simply no longer
possible to believe much of the clinical research that is
published, or to rely on the judgment of trusted physicians
or authoritative medical guidelines,” she wrote in 2009 in
the New York Review of Books. The problems of ghostwriting
and payments to researchers from the drug companies
have, she said, reached their most florid form in the field of
psychiatry and the studies of SSRIs.* The science behind
SSRIs used to justify their sale in other cultures has proven
to be suspect at best.
Suicides and SSRIs
The question of whether these drugs can, in some patients,
increase thoughts of suicide has become a contentious
public debate. Given that GlaxoSmithKline was leveraging
the suicide-depression connection to sell Paxil in Japan, this
question becomes even more salient. Healy estimates that
SSRI trials, when taken together, show that about one in
twenty patients become extremely agitated on these drugs.
For some, that agitation will be so disquieting that it will
spark suicidal thoughts or behavior. The likelihood is that
these drugs are ineffective in most patients, work well for a
small percentage of patients, and spark suicidal thoughts or
behaviors in another small segment. Two well-designed
studies conducted fifteen years apart both point to this
conclusion. In 1993 three researchers from the Department
of Psychiatry at Harvard concluded that antidepressants,
including the SSRI Prozac, likely lessened the chances of
suicide in some patients while raising it in others. “These
observations suggest that antidepressants may redistribute
the risk, attenuating risk in some patients who respond well,
while possibly enhancing risk in others who respond more
poorly.”
Fully fifteen years later another set of researchers, these
from the College of Physicians and Surgeons of Columbia
University, came to a similar but more refined conclusion.
This study looked closely at two years’ worth of patient data
and found that in adults there was no significant difference
between the group that got the drug and the group that
didn’t. In teenagers and children, however, those who took
the drug were significantly more likely than those who didn’t
to attempt suicide within four months after being started on
the drug. Looking at the data further, researchers found one
group in which the drug had a protective effect against
suicidal behavior: adult men. The redistribution of the risk,
in this case, appeared to be away from adult males and
toward teenagers and children.
In the end it is possible that both the critics of SSRIs and
their promoters might have legitimate points on the suicide
question. The agitation and aggression sometimes noted in
association with these drugs are most pronounced early in
the treatment, the very period often focused on in clinical
trials. In real-world use such negative reactions to the drug
may lessen or disappear after this early period. In addition,
attentive doctors may quickly take a patient off the drug, so
that only patients who respond well (or at least don’t spiral
into suicidal behavior) continue taking the drug. Thus it is
possible that these drugs increase suicidality in test subjects
in short-term clinical trials, as critics have contended, and
yet, when judged over years, reduce suicide in the overall
population.
Even if it proves to be true that SSRIs reduce suicidality in
large populations, the drug companies and the researchers
who helped them distort or underreport negative data might
still be culpable. Had those early treatment risks been
accurately reported in the published research on these
drugs, doctors would have had a chance to change the way
they monitored their patients and been better prepared to
spot a patient having a bad reaction. Because suicidal
behavior has been demonstrated even in healthy subjects
(those taking the drug with no symptoms of depression),
doctors almost certainly would have second-guessed
prescribing this medication to those with only mild
symptoms of depression.
The timing of who knew what and when regarding the
risks associated with Paxil is a critical issue because Japan
was so late in adopting the drug. Was GlaxoSmithKline
hiding or downplaying side-effect risks at the same time it
was rolling out its mega-marketing campaign in Japan?
Internal company documents that surfaced in a recent
lawsuit appear to answer that question quite clearly. Data
originally submitted to the U.S. Food and Drug
Administration back in the late 1980s and early 1990s, but
never published, appear to have been presented to
intentionally hide results that test subjects on the drug had
an eightfold increase in the risk of suicidality. “It looks like
GlaxoSmithKline bamboozled the FDA,” Senator Charles
Grassley said in a speech on the floor of the Senate after he
examined the evidence. “We cannot live in a nation where
drug companies are less than candid, hide information and
attempt to mislead the FDA and the public.”
The extent to which the SSRI makers have manufactured
and systematically controlled the creation, flow, and
international distribution of the science is hard to overstate.
Take a step back and look at the system as a whole, and you
can suddenly see it in a different light, as a massive
interconnected marketing system. Applbaum, the
anthropologist who documented the SSRI invasion of Japan,
puts it this way:
Actors traditionally found outside the “distribution channel” of the market
are now incorporated into it as active proponents of exchange. Physicians,
academic opinion leaders, patient advocacy groups and other grass roots
movements, nongovernmental organizations, public health bodies, and
even ethics overseers, through one means or another, have one by one
been enlisted as vehicles in the distribution chain. . . .
In our pursuit of the near-utopian promisea of perfect health, we have,
without realizing it, given corporate marketers free rein to take control of
the true instruments of our freedom: objectivity in science, ethics and
fairness in health care, and the privilege to endow medicine with the
autonomy to fulfill its oath to work for the benefit of the sick.
Even the patient, often now referred to as the
“consumer,” has been enlisted in the distribution chain. In
marketing directly to the consumer through the Internet and
various other avenues, drug companies can claim to be
treating patients as informed consumers. Such informed
consumers can be enlisted to petition their doctors and drug
review boards for access to the drugs. This has been
heralded as a positive change: no longer is the patient a
passive recipient of the doctor’s privileged knowledge.
Unfortunately, the patients, particularly those living outside
the United States, are often the last to know that the
knowledge they are acquiring may have been manipulated
to create specific beliefs and desires.
Early Adopters Have Second Thoughts
There is no doubt that the efforts of GlaxoSmithKline in
Japan proved profitable. In just the first year on the market
Paxil sales brought in over 100 million dollars. At the end of
2002 the company reported, “Sales of Seroxat/Paxil, GSK’s
leading product for depression and anxiety disorders, was
the driver of growth in the CNS (Central Nervous System)
therapy area, with sales of 3.1 billion, up 15% globally and
18% in the USA. International Sales of Paxil Grew 27% to
$401 million led by continued strong growth in Japan, where
the product was launched only two years ago.” By 2008
sales of Paxil were over one billion dollars per year in Japan.
Kitanaka has been stunned to see how fast things have
changed in Japan since SSRIs were introduced. “The whole
culture surrounding psychiatry has changed drastically,” she
told me. “From a stigmatizing notion that no one talked
about, depression has become one of the top concerns of
people. It has become a legitimate disease at so many
different levels and at the same time these changes have
transformed the nature of depression as an experience
itself.”
Some Japanese psychiatrists, even Ono and Tajima, whom
the company feted in 2000, felt they were not leading this
new trend but reacting to it. Ono reports that starting in
2001 he suddenly had a rush of patients showing up at his
office with either a magazine article or an advertisement in
hand and wanting to talk about their depression. It was
clear to him that the mild symptoms these patients
described would not previously have been considered an
illness. As more and more Japanese began to identify
themselves as depressed and as the risks of SSRIs came to
his attention, he has wondered if there were ways to reverse
the trend.
“The marketing campaign has been in many ways too
successful. The slogan, depression is like a ‘cold of the soul,’
has convinced far too many people to seek medical
treatment for something that is often not an illness,” Ono
told me. “Perhaps we could start saying that depression is
like a ‘cancer of the soul.’ That would be more accurate and
perhaps not so many people would be willing to adopt that
belief.”
Dr. Tajima has come even further in his thinking. Tajima is
the prominent psychiatrist who made such encouraging
remarks in Kyoto in 2000 about the adoption of international
diagnostic standards that would “facilitate accurate
diagnosis.” At the time he welcomed the introduction of
SSRIs, saying that they would “contribute to reducing the
burden of depression and anxiety disorders in Japanese
society.” For several years after the conference, Tajima was
a central figure in the company’s attempt to win over other
psychiatrists in Japan. He was paid well by GlaxoSmithKline
to give speeches and appear at conferences. The paper
based on his talk at the Kyoto conference was widely used
in the company’s educational material.
But in the past few years he has become concerned as
he’s watched just how many of his countrymen have been
diagnosed with depression and started on Paxil. Revelations
made public by David Healy and others have caused him to
become skeptical as to whether GlaxoSmithKline has
accurately reported the scientific data regarding the drug’s
effectiveness and risks. He has taken it upon himself to
translate one of Healy’s books into Japanese and now jokes
that he is going to become “the David Healy of Japan.”
In discussing the remarkable changes that he’s seen in
Japan over the past ten years, Tajima does not come off as a
man who is angry with GlaxoSmithKline. Indeed, in
recounting his own participation in these changes, he often
laughs heartily, like a man telling the story of how he was
thoroughly fooled by a talented magician or card shark. His
laughter communicates “I have only myself to blame.”
He maintains that Paxil is helpful for some anxiety
disorders and can be used in serious cases of depression so
long as the patient is monitored closely through the early
days of treatment. However, he has come to believe that
the drug is massively overprescribed and that it can
sometimes spark suicidal thoughts in patients. “After the
Ministry of Health in Japan issued a warning of a suicide risk
with this drug for patients under twenty-five, many doctors
and patients are now aware of this risk,” says Tajima. What
he can’t understand, however, is why the drug remains so
widely prescribed for patients with depressive symptoms
that are transient and relatively mild. The warning about the
risk of suicide seemed not to have had much effect against
the forces of the mega-marketing campaign sponsored by
GlaxoSmithKline in the years since 2000.
Tajima has also come to mistrust the confident science
presented by the pharmaceutical manufacturers. Although
he is aware that the drug companies don’t take kindly to
criticism, he is committed to fighting the good fight and
getting the best information to the Japanese people any way
he can.
Did he have any hope, I asked him, of challenging the
imported ideas that helped popularize depression in Japan?
“The force of this tide is still very strong,” Tajima said. He
did point to some signs that might indicate a lessening of
the momentum. The marginal effectiveness of the drug has
not gone unnoticed. “There are so many patients in Japan
who have not improved and not recovered,” he told me.
“Many ordinary people now have questions about these so-
called magic drugs.”
As journalists often do, I saved the most uncomfortable
question for the very end of my interview with Dr. Tajima. I
told him that I did not want to pry too far into his personal
finances, but I wanted to know how he felt about the money
he had taken from GlaxoSmithKline over the years. “Yes,” he
said, laughing again. “This is a very important question.
Some people say that this relationship between the
researchers and the drug companies is a kind of
prostitution. I agree. But I am not a puritan. I am a very
realistic man. This is very problematic. We have to change
the current situation not only in Japan but also in the United
States and other countries. The strong force of the
pharmaceutical industry threatens to turn medicine into a
pseudoscience in the same way they have made opinion
leaders in the field of Japanese psychiatry into a type of
prostitute.”
Then he paused, laughed again, and added, “We were
very cheap prostitutes.”
Conclusion
The Global Economic Crisis
and the Future of Mental Illness
Cultures become particularly vulnerable to new beliefs
about the mind and madness during times of social anxiety
or discord. It is no surprise that the Western form of
anorexia was able to worm its way into the unconscious
minds of young Hong Kong women in the uneasy years
between the Tiananmen Square massacre and the British
handover of the province to China. As demonstrated in Sri
Lanka, the Western notion of PTSD often gains a hold
because it is deployed in populations that are disoriented
and reeling from wars or natural disasters. It is also no
coincidence that the GlaxoSmithKline version of depression
caught hold in Japan during that country’s lengthy and
painful recession. Ongoing economic upheaval can be
particularly unsettling because the unrelenting threat to
one’s status, security, and future seems to come from
everywhere and nowhere at the same time.
In early 2009, as I was researching the chapter on
depression and Japan, the world economy went into a
tailspin. What happened to the Nikkei in 1990 appeared to
be happening to every major stock index, from the S&P 500
to the OMX Copenhagen 20. The globalization of the world
economy, which had wrought a great many disorienting
changes, had now brought us something new: a truly global
economic crisis. The social upheaval that made Japan
vulnerable to GlaxoSmithKline’s mega-marketing campaigns
was now prevalent in pretty much every country in the
world.
As the crisis grew I listened for the first mental health
experts to step forward with warnings about the
psychological consequences of the crisis. Quick on their
heels, I was sure, would come the promise of new medicines
and perhaps even a new category of mental illness to
explain our distress.
I didn’t have to wait long.
In early February articles about the downturn’s effect on
mental health began to appear in major publications.
“Suicides: Watching for a Recession Spike” was one headline
at Time magazine. “Suicide experts say there is a strong
correlation between acute financial strains and depression,”
the article reported. Near the same time, USA Today
reported, “Signs abound that the battered economy is
causing serious damage to mental health. . . . Nearly half of
Americans said they were more stressed than a year ago,
and about one third rated their stress level as ‘extreme’ in
surveys conducted by the American Psychological
Association.”
The New York Times soon had its own front-page story:
“Recession Anxiety Seeps into Everyday Lives.” Quoting
experts and individuals, the article listed over two dozen
mental health problems caused by economic worries. These
symptoms ranged from the mundane (sleeplessness,
anxiety, constant worrying) to the severe and sometimes
bizarre (struggling to breathe, rapid heartbeat, chills,
choking sensation, numbness and tingling in the fingers,
and arthritis). Such a wide-ranging list of potential
symptoms suggested that we were in the midst of creating
the symptom pool for the current economic crisis. We were
publicly debating, as a culture, which symptoms and
pathologies we would jointly recognize as legitimate
expressions of economic anxiety.
Many of these articles pointed out that our national
mental health was already poor and was now certain to get
worse. The National Institute of Mental Health announced
that one in every four Americans age 18 and older suffers
from a diagnosable mental disorder each year. Among
young adults mental illnesses had become the leading
cause of disability. There were other troubling signs: a study
came out suggesting that the mental disorders sparked by
Hurricane Katrina were proving strangely resistant to both
treatment and the healing effect of time; fully three years
after the fact, the incidence of mood disorders and PTSD
linked to the disaster was still rising in Louisiana.
To counter such bad news, Senior Vice President Ken
Johnson of the pharmaceutical advocacy group PhRMA
announced that no fewer than 301 new medicines were in
development to treat mental illnesses, including sixty-six for
depression and fifty-four for anxiety disorders. It was
important, given the worrisome trends, that the public knew
that new medications were on the way to help people “live
longer, happier, healthier lives.”*
Of course, just what types of disorders those 301 new
drugs will be tasked to treat depends largely on the
American Psychiatric Association, which will soon publish a
new edition of its influential diagnostic manual, the DSM-V.
The research journals have been filled with suggestions for
changes and additions and APA work groups are currently in
the process of hashing out which disorders will be included,
changed, or cut.
As if to demonstrate the point that the creation of mental
illness categories remains as much a social and cultural
endeavor as a scientific process, the APA is soliciting input
from the public. As of this writing there is still a “Make a
Suggestion” link on the association’s website describing the
DSM-V project. Click on that link and you are presented with
a number of options, including “Submit suggestions for
deletion of an existing disorder” and “Submit suggestions
for a new disorder to be considered for addition to DSM-V.”
All suggestions, the public is promised, will be routed to the
proper DSM-V work group for debate.
If I had to lay a bet on which new disorder recently
discussed in the psychiatric literature has the most
promising future, it would be “post-traumatic embitterment
disorder.” PTED describes the reaction to an exceptionally
negative but not life-threatening event, such as conflict in
the workplace, sudden unemployment, the loss of social
status, and separation from one’s social group. Symptoms
include embitterment, feelings of injustice, and
helplessness.
If PTED can get enough allies on the right DSM-V work
groups and a multinational drug company with a new drug
targeting the condition, this disorder has the chance to be
the next PTSD, for it seems well suited to describe many of
the reactions to the precipitous cultural changes during this
time of globalization and economic crisis. Indeed the
disorder was first “discovered” among East Germans who
had become unmoored, unemployed, and insecure in the
social upheaval following the fall of the Berlin Wall.
Whatever new disorders end up in the DSM-V and
whatever new drugs and treatments are declared
scientifically proven to be effective for treating them, there
is no doubt that the American public will show intense
interest. We are a psychologically oriented people. Experts
will appear on talk shows and provide quotes and
commentary for journalists. Over time these new
discoveries will become cultural certainties, conventional
wisdom. In this process these new disorders will further
shape our conscious and unconscious senses of self.
Then the Western mental health profession will take the
show on the road. At international conferences in exotic
locales professionals will train foreign healers in these new
disease categories. Drug companies lured by potential
profits will engage in ever more sophisticated mega-
marketing campaigns. In cultures made vulnerable by the
global financial crisis and the speed of social change, the
seeds of these ideas will no doubt find fertile ground.
If the irony isn’t already obvious, let me make it clear:
offering the latest Western mental health theories in an
attempt to ameliorate the psychological stress caused by
globalization is not a solution; it is a part of the problem. By
undermining both local beliefs about healing and culturally
created conceptions of the self, we are speeding along the
disorienting changes that are at the very heart of much of
the world’s mental distress. It is the psychiatric equivalent
of handing out blankets to sick natives without considering
the pathogens that hide deep in the fabric.
While I was in Zanzibar researching how Swahili beliefs were
mixing with Western biomedical notions of mental illness,
my wife, who is a psychiatrist, sent me a text message from
our home in San Francisco. The brief note told of a tough
day. A patient in her private practice had suffered a
psychotic break and had to be admitted to a psychiatric
ward.
The note reminded me of a point my wife had made often:
while I was traveling the world documenting how Western-
born cultural currents are altering beliefs about the mind,
mental health professionals in the United States and
elsewhere had little choice but to do the best they could
with the knowledge and technology they had at hand. She
worried, you see, that this book would unfairly disparage the
mental health profession, a group of people, including
herself, who are doing their best to heal troubled minds.
Keeping that concern in mind, I have tried to avoid making
the clichéd argument that other, more traditional cultures
necessarily have it right when it comes to treating mental
illness. All cultures struggle with these intractable diseases
with varying degrees of compassion and cruelty, equanimity
and fear. My point is not that they necessarily have it right—
only that they have it different.
It is not surprising that we want to believe everyone is just
like us. As with any generation in human history, we have
little awareness of how our culture shapes our mental life
because it so envelops us, informing both our conscious and
our unconscious thinking. We are like swimmers out of sight
of land: it is difficult to gauge the direction and strength of
the cultural current that carries us along. Difficult, certainly,
but not impossible. As this book suggests, deep explorations
into the beliefs of other cultures can reveal our own cultural
biases in startling ways.
So what does a cross-cultural perspective reveal about our
conception of the mind?
The ideas we export to other cultures often have at their
heart a particularly American brand of hyperintrospection
and hyperindividualism. These beliefs remain deeply
influenced by the Cartesian split between the mind and the
body, the Freudian duality between the conscious and
unconscious, as well as teeming numbers of self-help
philosophies and schools of therapy that have encouraged
us to separate the health of the individual from the health of
the group. Even the fascinating biomedical scientific
research into the workings of the brain has, on a cultural
level, further removed our understanding of the mind from
the social and natural world it navigates. On its website
advertising its antidepressant, one drug company illustrates
how far this reductive thinking has gone: “Just as a cake
recipe requires you to use flour, sugar, and baking powder
in the right amounts, your brain needs a fine chemical
balance in order to perform at its best.” The Western mind,
endlessly parsed by generations of philosophers, theorists,
and researchers, has now been reduced to a batter of
chemicals we carry around in the mixing bowl of our skulls.
What is certain 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.
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Chapter 1
The Rise of Anorexia in Hong Kong
This chapter relied heavily on the work and generosity of Sing Lee and his
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his introduction to other experts in Hong Kong and elsewhere were beyond the
call of duty. I am grateful also for the honesty and openness of the patients who
spoke with me. For those interested in diving into this subject further I highly
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Chapter 2
The Wave That Brought PTSD to Sri Lanka
I owe a great many debts on this chapter, and they go back many years. In
particular I’ve relied on the work of Allan Young and his trenchant book Harmony
of Illusions: Inventing Post-Traumatic Stress Disorder. Two up-and-coming
scholars were particularly giving of their time: Gaithri Fernando and Alex
Argenti-Pillen. It was through the analyses of these two researchers that I saw
the most complex and compelling picture of the mental landscape of the Sri
Lankan people. Many of my ideas about the impact of culture on conceptions of
psychological trauma came from my years chronicling the recovered memory
wars. My former coauthor, Richard Ofshe, as well as Paul McHugh, and Fred
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Chapter 3
The Shifting Mask of Schizophrenia in Zanzibar
It perhaps goes without saying that the work of Juli McGruder has been central
to my thinking on schizophrenia. Her dissertation brought me to Zanzibar; her
hospitality when I visited her was very gracious. A small group of researchers—
Kim Hopper, Janis Hunter Jenkins, Robert John Barret, Byron Good, Sue Esteroff,
Louis Sass, and Nancy Scheper-Hughes—formed the intellectual foundation on
which McGruder built. All of these scholars, save the last, contributed to a
remarkable book of papers entitled Schizophrenia, Culture, and Subjectivity: The
Edge of Experience, which I highly recommend.
Other papers and resources I relied on include the following:
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Chapter 4
The Mega-Marketing of Depression in Japan
The scholars at McGill University are overrepresented in this book because that
university is a hotbed for the study of cross-cultural psychiatry. That fact, I
believe, has much to do with Larry Kirmayer, whose work and leadership in the
field informs not just this chapter but this entire book. Junko Kitanaka,
Kirmayer’s former graduate student, was as generous as her mentor with her
time and guidance. Her book on the history of depression in Japan will be out
within a year or two, and I will be first in line at the bookstore to snap it up.
David Healy was an inspiration both for his research on the science behind SSRIs
and for his dogged courage.
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Acknowledgments
I had several insightful readers at critical stages of this
project. Po Bronson, Charis Conn, Rob Riddell, and my wife,
Rebecca Watters, assisted me with everything from word
choice to finding my way out of the conceptual labyrinths
that these long chapters sometimes created. Others read
portions as needed, including Alan Burdick, Laura Fraser,
Michal Story, Todd Oppenheimer, and Eleanor Wendell. I’m
indebted to my agent, Chris Calhoun, a champion for this
project from the very beginning. At Free Press I’ve been
pleased to work with Dominick Anfuso, who gave this book
his thoughtful attention during a challenging year. Leah
Miller was critically important in the creation of this book.
My thanks also go to copyeditor Judith Hoover. Michal Story
transcribed many of the interviews and gave me moral
support as well. Kasie Cheung provided Chinese translation.
Joelle Jaffe worked as my researcher on the anorexia and
schizophrenia chapters and helped me think through the
approach for the rest of the book. Encouragement from my
mother, Mary Pulliam Watters, and my brother, Aaron
Watters, was essential. This book was written at the San
Francisco Writers’ Grotto.
Index
Adolescence and Emerging Adulthood: A Cultural Approach (Arnett), 40
Adolescents
SSRI use in, 239–41, 242–43
storm and stress view of, 39–41
Afghanistan, 102, 114, 121
Africa
eating disorders in, 24
schizophrenia in, 153
“After the Tsunami” (symposium), 80
Akil hastaligi, 173
Amatruda, Kate, 73–75, 93–97
American Indians, 195
American Psychiatric Association, 3, 251–52
American Psychiatric Press, 235
American Psychological Association, 250
American Studies International, 47
Amina (family caretaker), 141, 142–43, 144, 145, 148–50, 154–55, 156, 157,
160, 165, 182, 183
Amok, 2, 5
Amphetamines, 212, 213
Angell, Marcia, 241
Anorexia, 3, 6, 9–63. See also Hong Kong changing presentation of, 13, 50–53
Chinese language translation, 43
commodification of, 57–62
debate on reasons for spread, 24–26
educational programs on, 48
feedback loop in, 33, 48–49, 58
feminist perspective on, 58–59
formal recognition of, 30–31
historically low rate (Hong Kong), 14–15
historical perspective on, 26–31
increase in (Hong Kong), 48–49
increase in (nineteenth century), 31–32, 33
inverse relationship with acculturation, 25
media on, 42–47, 48
“me-too,” 50–53
natural vs. social history of, 34–35
physiological experience of, 22–24
research on, 47
social stress and, 38–41, 249
somatic symptoms, 27, 35–36
symptomology (Hong Kong), 12–13, 15–19, 27, 35–36
symptomology (Western), 11, 17, 36–37, 45–47
in the symptom pool, 31–34, 48, 49, 59, 61–62
trigger/tipping point for, 37, 44
two patient populations identified, 50–51
“Anorexia Nervosa in Hong Kong: Why Not More in Chinese?” (Lee), 14
Antidepressants. See Selective serotonin reuptake inhibitors
Applbaum, Kalman, 222–24, 226, 230–31, 244
Approaching Hysteria: Disease and Its Interpretations (Micale), 62
Argenti-Pillen, Alex, 108–14, 125
Arnett, Jeffrey Jensen, 40
Asabi, 102
Ashcroft, George, 235
Association for Play Therapy, 73
Astasia-abasia, 28
Auburn University, 173–74
Au Kam-wah, 42, 44
AusAID, 70
Australia, 70, 153
Austria, 135
Autumn Moon (film), 39
Ayurvedic medicine, 89
Baggerly, Jennifer, 97
Ballenger, James, 232–34
Barrett, Robert John, 136–37
BBC, 77
Beauty industry, 9–10
Benzodiazepines, 236
Berlin Wall, fall of, 252
Biomedical narrative of schizophrenia, 4, 5, 176–78
case history, 165–71
rise of, 171–75
Bloom, Sandra, 116
Boer Wars, 101
Bordo, Susan, 58
Bosnia, 109
Bracken, Patrick, 122–23
Bradford University, 122–23
Breslau, Joshua, 105, 221
British Journal of Psychiatry, 15
British Medical Journal, 118
Brown, David, 118–19
Brown, George, 151
Brown University, 239
Bruch, Hilde, 18, 34, 51
Brumberg, Joan Jacobs, 46, 58–59
Buddhism, 88, 89, 94, 135, 211
Al-Bukhari, 154
Bulimia, 11, 52–53, 59–60, 62
California State University in Los Angeles, 87
Calorias, 102, 114
Cambodian refugees, 102
CARE, 76
Carpenter, Karen, 34
Case histories
of anorexia (see Hsu Chi-Ying, Charlene; Jiao [anorexic woman]; Ling [anorexic
woman]) of depression, 214–21
of schizophrenia (see Al-Mitende, Shazrin [schizophrenic woman]; Zanzibar,
schizophrenic family) Catalepsy, 28
Cattan, Mary, 82
Celebrities and eating disorders, 10–11, 14, 43, 45
Chan Suk-kuen, 42
Charcot, Jean-Martin, 28, 29
Chen, Bobo, 10
Cheung Pak-chi, Cecilia, 10
Children. See also Adolescents
PTSD and, 73–75, 77, 78–79, 82, 83, 84–86, 89, 94, 99, 106
SSRI use in, 242–43
Children’s Impact Events Scale 13 (CRIES-13), 85–86
China, 1, 9, 200
anorexia in, 14
depression in, 195
expressed emotion in, 162
Hong Kong sovereignty transfer, 38–39, 249
schizophrenia in, 153
Cholera epidemic, 201, 202
Christianity, 88, 89, 155, 156
Chung, Gillian, 10, 11
Civil wars
American, 101
Salvadoran, 102
Sri Lankan, 69, 87, 88, 89, 96, 108–14, 123–25
Clark University, 40
CNN, 77
Colombia, 137
Columbia University, 242
Complete Manual of Suicide (Tsurumi), 219–20
Cornell Medical School, 53
Corrigan, Malachy, 119
Crazy: A Father’s Search through America’s Mental Health Madness (Earley), 164
Critical incident debriefing, 75, 116–19
Culture of sadness, 207–13
DaCapo (magazine), 227
Da Costa’s syndrome, 101
Dar Days (Swift), 167–68
Data torturing, 238n
Davidson, Jonathan, 69, 80–81
Davies, Robin, 70
Debility syndrome, 101
Debriefing. See Critical incident debriefing
Demoiselles d’Avignon, Les (Picasso), 53
Denmark, 137, 153
Dentsu advertising agency, 214–19
Depression, 2, 3, 6, 32, 187–248, 249, 250. See also Japan; Selective serotonin
reuptake inhibitors diversity of cultural expression, 193–98
endogenous, 207, 208, 218, 225
explanatory models of, 195, 197
Japanese view of, 192–93, 208–11
media on, 221, 227
mega-marketing of, 224–29
moral compass for, 196
social and moral meaning of, 196, 201
somatic symptoms, 209
stigma of, 208, 225
Western view of, 194, 209–11
Dhows, 132
Diagnostic and Statistical Manual of Mental Disorders (DSM), 3
anorexia in, 17, 19, 36, 37, 43, 47, 48, 50, 54, 63
Culture-Bound Syndromes, 5
depression in, 194, 195, 208, 211
Japanese translation, 208
new edition, 251–52
PTSD in, 71–72n, 115
Diana, Princess, 52, 59–60
Dresser, Roberta, 58, 59
Drug companies, 4. See also specific companies ghostwritten studies of, 234,
237–38, 241
marketing enticements used by, 189–90
motivations given by, 230
researchers paid by, 234, 241, 248
research sponsored by, 229–30
DSM. See Diagnostic and Statistical Manual of Mental Disorders
Duke University, 69
Earley, Pete, 164
Earthquakes
in Japan (Kobe), 105–6, 220–21, 229
Loma Prieta, 117
in Sri Lanka, 87
Eastern Europe, 13
East Germany, 252
East Timor, 104–5
Eating disorders. See Anorexia; Bulimia
Eating Disorders: Anatomy of a Social Epidemic (Gordon), 51–52
Economic crises
global, 249–53
Japanese, 214–15, 227–28, 249
Edo era (Japan), 200, 220
Eisei, 201
Eli Lilly, 191, 222
Emotional expression. See Expressed emotion
Empathy, 161
Endogenous depression, 207, 208, 218, 225
European Society for Traumatic Event Studies, 76
Explanatory models of depression, 195, 197
Expressed emotion, 138–39, 151–54, 160–65
Eye movement desensitization and reprocessing (EMDR), 82
False memories, 119
Fasting Girls: The History of Anorexia Nervosa (Brumberg), 46, 58–59
Fatalism, 155–56, 164
Fatness
admiration for, 14
fear of, 11, 13, 17, 18, 35, 36, 46, 50
Fernando, Gaithri, 87–93, 96, 102, 124
Fertile Crescent (Middle East), 2
Fire illness, 195, 196
Fisha-e-bala, 102, 114
Fluphenazine, 145n, 168
Food and Drug Administration (FDA), U.S., 238, 243–44
France, 70, 153
Fujimura, Misao, 205–6, 219
Gadambanathan, T., 79
Ganesan, Mahesan, 78, 79, 97
Gaze of the wild, 109–11
Geok-Lin Lim, Shirley, 47
Germany, 208
East, 252
neuropsychiatry in, 200, 201–2, 207
schizophrenia in, 153, 172, 173
Ghaemi, Nassir, 237–38
Gist, Richard, 119
GlaxoSmithKline (GSK), 187, 192, 221, 222, 224–36, 239–44, 245–48, 249, 250
conferences hosted by, 188–90, 193–99, 229, 232–34, 246
marketing campaign of, 224–29
U.S. market for products, 188n
Global Development Group, 76
Golden Cage, The (Bruch), 18
Gordon, Richard, 51–52
Granger, D. A., 177
Grassley, Charles, 244
Great Britain
bulimia in, 59–60
expressed emotion in, 162
schizophrenia in, 135
trauma counselors from, 70
Hacking, Ian, 3
Hadith, 154
Haldol, 131
Harvard Medical School, 177
Harvard Trauma Questionnaire, 86
Harvard University, 107, 139, 162, 222, 242
Healing, indigenous. See Indigenous healing techniques
Healy, David, 187, 236–37, 247
Heart Circle Sangha, 81–82
Hemed (schizophrenic man), 141–46, 148, 149, 150, 151, 154, 155
Hinduism, 88, 89, 135
Holy anorexics, 51
Hong Kong, 1, 6, 9–26, 33, 34–57, 61, 62–63. See also Anorexia beauty industry
in, 9–10
bulimia in, 11, 52–53
celebrity culture and, 10–11, 14, 43, 45
educational programs in, 48
media of, 42–47, 48
social stress in, 38–41, 249
sovereignty transfer, 38–39, 249
Hong Kong Eating Disorders Association, 44
Hooley, Jill, 162–63, 164
Hospital of Neukölln, 76
Hsu Chi-Ying, Charlene, 6, 37–38, 41–45, 48, 49, 50
Hudson River Psychiatric Center, 131
Humanitarian Committee of the Association for Comprehensive Energy
Psychology, 82
Hurricane Andrew, 117–18
Hurricane Hugo, 117
Hurricane Katrina, 94, 251
Hysteria, 3, 5, 6, 27–31, 33, 51, 61–62, 202
debate on meaning and cause of, 29–30
PTSD compared with, 72
symptoms of, 28
waning of, 34
Ichiro, Oshima, 214–21
Idioms of distress, 120
Illness negotiation, 33
India
depression in, 195
eating disorders in, 24
expressed emotion in, 162
PTSD in, 70
schizophrenia in, 137, 153
Indigenous healing techniques, 3
in Japan, 20
in Sri Lanka, 88–89
in Zanzibar, 145
Individualism, 163–64
Indonesia, 2, 70
Inna barikama, 109
International Consensus Group on Depression and Anxiety, 188, 190, 198, 233
International Critical Incident Stress Foundation, 117, 118
International Rehabilitation Council for Victims of Torture, 108
International Society for Traumatic Stress Studies, 116
International Trauma Treatment Program, 95
Internet marketing, 226–27
“Invisible Human Crisis, The” (report), 105
Iran, 195
Iraq, 114, 121
Islam, 88, 94, 129, 135, 146–47, 154–55, 158
Island (newspaper), 124
Italy, 153
Japan, 6, 32, 187–248, 250. See also Depression anorexia in, 14, 24
cholera epidemic in, 201, 202
cultural history of, 199–203
culture of sadness in, 207–13
drug approval process in, 191–92, 223–24
drug imports, 191
earthquake in, 105–6, 220–21, 229
economic crisis in, 214–15, 227–28, 249
Japan, contd.
“evolution” analogy and, 231–32
first mental health epidemic in, 203–7
media of, 221, 227
menopause in, 211–12
psychiatric profession and services in, 192–93, 194, 201
PTSD counseling in, 105–6
sedative use in, 212–13
suicide in, 193–94, 198, 202, 205–6, 216–20, 228
workload in, 214–20, 229
Japan Times, 228
Jenkins, Janis Hunter, 136–37, 160–61
Jiao (anorexic woman), 15–22
Jibyo, 211
Jinns, 157
Johnson, Ken, 251
Journal of Clinical Psychiatry, 189
Journal of Neurology, 206
Journal of the American Academy of Child and Adolescent Psychiatry, 239
Judeo-Christian cultures, 135
Kadirgamar, Lakshman, 123
Kansas City Fire Department, 119
Karma, 88, 94
Karojisatsu, 217
Karoshi, 216
Kassim, Ahmed, 127–29, 178, 184–85
Kassim, Latifa, 128–29
Katzman, Melanie, 53–54
Keio University, 199
Keller, Martin, 239
Kellogg School of Management, 222
Kenya, U.S. embassy bombing in, 106
Kidongo Chekundu Mental Hospital, 131, 167, 168, 175–76
Kids Everywhere Like You (KELY), 48
Ki ga fusagu, 209
Ki ga meiru, 209
Kimwana (schizophrenic woman), 141, 144–51, 154, 155, 156, 158, 159, 171
King’s College, 98, 123
Kirmayer, Laurence, 187–90, 193, 194–98, 208, 211, 213, 229, 232–34
Kissinger, Henry, 232
Kitanaka, Junko, 188–89, 199–200, 201, 203, 204, 207, 218, 226, 245
Kitasato, Ichiro, 192
Kleinman, Arthur, 107, 139–40
Knight Ridder/Tribune news service, 117–18
Koda, Kumi, 10
Kokoro no kaze, 225, 228
Koran, 154, 158
Korea
anorexia in, 14
depression in, 195–96
Koro, 2, 5
Kose Corp., 10
Kostelny, Kathleen, 104–5
Kramer, Peter, 192, 221
Kyorin University, 193
Kyushu University, 206
Lancet, 28
Laségue, Charles, 28, 29, 30
Law, Clara, 39
Lee, Sing, 9, 11–24, 26–27, 32, 33, 34–37, 44, 46–58, 62–63
anorexic behavior mimicked by, 22–24
anorexic populations identified by, 50–51
early research of, 13–15
patient deaths from anorexia, 22, 62
scholarly output of, 12
Levine, Michael, 60–61
Lexapro, 234
Liberation Tigers of Tamil, 108, 124
Librium, 236
Ling (anorexic woman), 54–57
Listening to Prozac (Kramer), 192, 221
Llaki, 103
Lock, Margaret, 211–12
Locus of control, 162–63
Loving v. Virginia, 131
Luvox, 192
Mad Travelers (Hacking), 3
Mahoney, John, 81
Malaysia, 24
Manic depression, 175, 202, 207
Marce, Louis-Victor, 29
Masako, Crown Princess of Japan, 228
McGill University, 71, 103, 187, 188, 211
McGruder, Juli, 127–34, 136–42, 144–51, 154–60, 175, 178–85
background, 128, 130–31
biomedical narrative and, 165–66, 169–71, 174
ex-husband’s breakdown, 179–83
love of Zanzibar culture, 133
Media
on anorexia, 42–47, 48
on depression, 221, 227
on PTSD, 67–68, 69, 77, 117–18
Medications, 3–4
for depression (see Selective serotonin reuptake inhibitors)
for PTSD, 80–81
for schizophrenia, 131, 145n, 165, 168–69
Mehta, Sheila, 173–74, 178
Meiji Seika, 192
Melancholic personality (typus melancholicus), 208, 211, 229
Menopause, 211–12
Mental health literacy, 171
“Me-too” anorexics, 50–53
Mexican Americans, 160–61, 162
Micale, Mark, 62
Middle East, 2, 24
Miller, Ken, 102, 107
Mitchell, Jeffrey T., 116–17, 118
Al-Mitende, Shazrin (schizophrenic woman), 165–71, 174
Miyamoto, Masao, 219
Mohammed (prophet), 154
Mongolia, 173
Monoamine depletion hypothesis, 234–36
Mood Disorders Association of Japan, 228
Moral compass, 196
Moss, Kate, 11
Multiple personality disorder, 5, 32
Nakary, 103
Namihira, Emiko, 228
National Alliance for the Mentally Ill, 171
National Center for Post-Traumatic Stress Disorder, 72, 76
National Institute of Mental Health, 251
Nervios, 160–61
Neugeboren, Jay, 177
Neurasthenia, 200, 203–7, 227, 236
Neuropsychiatry, 200, 201–2, 207
New England Journal of Medicine, 28, 241
New Jersey Association of Mental Health Agencies, 65, 67
New York City Fire Department, 119
New Yorker, 119
New York Review of Books, 241
New York Times, 77, 115, 250
New York University, 114
New Zealand, 70
Next (magazine), 10
Nigeria
depression in, 195
eating disorders in, 24
schizophrenia in, 137
Nikkei index, 214, 215, 249
North Africa, 153
North Wales Department of Psychological Medicine, 236
Okuma, Shigenobu, 206
Ono, Yutaka, 228, 246
Operation Recovery, 106
Oppenheim, Janet, 28
Oxfam, 108
Oyserman, Daphna, 163–64
Pakistan, 135
Pantoliano, Joe, 251n
Parachute researchers, 84, 124
Paxil, 6, 187, 190, 192, 193, 222, 223, 229, 233, 239–41. See also Selective
serotonin reuptake inhibitors double-blind study of, 239–41
ghostwritten studies of, 234
manufacturer description, 235
sales revenue, 245
second thoughts on, 245–48
side effects of, 240–41
suicide and, 240, 242–44, 247
Pedersen, Duncan, 103
Peramuna, Janatha Vimukthi, 108
Petite hysterie, la, 61
Pfizer, 80, 222, 223
Pharmaceutical Manufacturers of America (PhRMA), 223, 251
“Pharmacologic Treatment of Acute and Chronic Stress Following Trauma”
(Davidson), 80
Picasso, Pablo, 53
Play therapy, 73–75
Pomona College, 102
Post-traumatic embitterment disorder (PTED), 252
Post-traumatic stress disorder (PTSD), 1–2, 3, 6–7, 32, 65–125, 220n, 249, 251,
252. See also Sri Lanka critical incident debriefing for, 75, 116–19
“denial” of, 77, 98
education vs. indoctrination on, 105–7
global differences in, 100–105
history of, 70–71, 114–18
hopeful lies and, 99–100
literature on, 72
meaning stripped from, 120–23
media on, 67–68, 69, 77, 117–18
medication for, 80–81
play therapy for, 73–75
somatic symptoms, 91, 103
symptom checklists, 84–86, 90
symptomology (Sri Lanka), 91–93
symptomology (Western), 68, 71
treatment risks, 107–14, 118–19
wave metaphor, 70
worldview described by, 73
Post-traumatic Stress Disorder Checklist—Civilian Version, 86
Post-Vietnam syndrome, 114–15, 121
Presbyterian Hospital (New York City), 34
Prince of Wales Hospital, 9, 12, 13, 14, 21
Prozac, 191, 192, 213, 242
Psychological first aid, 4, 75
Psychosocial aid, 97–98
PTSD. See Post-traumatic stress disorder
Pupavac, Vanessa, 119–20
Qi, 20, 200
Qigong, 20
Quechua natives, 103–4
Red Cross International, 76
Religion. See also Spirit possession; specific religions
schizophrenic hallucinations and, 135
in Sri Lanka, 88, 89, 94
in Zanzibar, 146–47, 154–59
Reuters newswire service, 69, 70, 78
Ruhsal hastagi, 173
Russia, 13, 173
Rutgers University, 135
Rwanda, 106, 109
Salvadoran refugees, 102, 114
Samurai warriors, 219
SANE, 171
Sass, Louis, 135
Saxena, Shekhar, 78
Schizophrenia, 6, 127–85. See also Zanzibar culture and content of, 134–36
culture and naming of, 160–61
culture and prognosis, 128, 130, 137–40
expressed emotion and, 138–39, 151–54, 160–65
medication for, 131, 145n, 165, 168–69
neuropsychiatric view of, 202
pathoplastic vs. pathogenic aspects, 135–36
prevalence rates, 136
scientific explanations of, 134
social stress and, 153
stigma of, 172–75, 176–78
stress-diathesis model of, 143
Schnittker, Jason, 173
Scientology, 237n
Scott, Sean, 69
Sedatives, 212–13
Selective serotonin reuptake inhibitors (SSRIs), 191–92, 194, 198–99, 218, 222–
48. See also Lexapro; Luvox; Paxil; Prozac; Zoloft benefit-risk balance, 236–38
clinical trial results, 223–24
cooperation among manufacturers, 222–23
early Japanese view of, 213
effectiveness level of, 238–39
ghostwritten studies of, 234, 237–38, 241
marketing of, 224–29
monoamine depletion hypothesis, 234–36
negative results withheld, 238
placebo compared with, 238, 240
sales growth, 191
scientific data, 230–41
side effects of, 240–41
suicide and, 240, 242–44, 247
Selvie-amah (Sri Lankan woman), 96
Seppuku, 219
September 11 terrorist attacks, 67, 107
Serotonin depletion hypothesis. See Monoamine depletion hypothesis
Shah, Siddharth Ashvin, 100
Shatan, Chaim, 114–15
Shell shock, 101
Shining Path, 103
Shinkeisuijaku, 203
Shorter, Edward, 26–27, 29–31, 32–33, 34, 49, 51
Sikhs, 162
Singapore, 24
Social Work Today, 98
“Society in Distress” (Kitanaka), 199
Sodium amytal, 168
Soldiers, reactions to combat trauma in, 101, 114–15, 121–22
Solvay, 192
Somali refugees, 99
Somatic symptoms
of anorexia, 27, 35–36
of depression, 209
of PTSD, 91, 103
South China Morning Post, 42–43
Southeastern Asians, 2
South Korea, 14
Spain, 153
Spears, Britney, 10
Spirit possession
in the Middle East, 2
in Zanzibar, 6, 132, 145, 156–59, 165, 166–67
Sri Lanka, 6–7, 32, 65–100, 102, 249. See also Post-traumatic stress disorder
certainty of trauma workers in, 97–100
civil war in, 69, 87, 88, 89, 96, 108–14, 123–25
cultural/language deficiencies of therapists, 75, 78, 79–80
earthquake in, 87
extent of psychological intervention in, 70
“gaze of the wild” in, 109–11
media of, 67–68, 69, 77
pace of counseling in, 80
religious beliefs in, 88, 89, 94
resilience in, 87–93
rise of fearlessness in, 107–14
rivalries among counseling groups, 78–79
social relationships in, 91–93, 96
trauma researchers in, 83–87, 124
trauma training for locals, 81–83, 95, 124
Sri Lankan Index of Psychosocial Status, 91
SSRIs. See Selective serotonin reuptake inhibitors
St. Vincent’s Hospital (Sydney, Australia), 69
Standard, The (Hong Kong newspaper), 10, 44, 45, 48
Stelazine, 131
Stiebel, Salomon, 27
Stigma
of depression, 208, 225
of neurasthenia, 204, 207
of schizophrenia, 172–75, 176–78
Stotland, Nada, 241n
Stress-diathesis model of schizophrenia, 143
Suicide
economic conditions and, 250
in Japan, 193–94, 198, 202, 205–6, 216–20, 228
serotonin levels and, 235
SSRIs and, 240, 242–44, 247
Suicide forests, 193–94
Sumathipala, Athula, 84, 124
Summerfield, Derek, 65, 123
Sunni Shafi’ites sect, 154
Surface, David, 98
Swartz, Lesley, 59
Sweden, 136
Swift, Charles, 167–68
Taiwan
anorexia in, 24
schizophrenia in, 137, 153
Tajima, Osamu, 193–94, 246–48
Takiguchi, Kenichiro, 221, 225
Tanaka-Matsumi, Junko, 209–11
Tanzania, 167
Tellenbach, Hubert, 208
Textbook of Clinical Psychiatry, 235
Thailand, 70
Thorazine, 131
Thought field therapy, 82
Tiananmen Square protests, 38, 249
Time (magazine), 250
Ting Yi, 41
Tong, John, 10–11
Toyo Keizai (magazine), 227
Transcultural Psychiatry (journal), 188
Tsunami, 6
description of, 65–66
as metaphor for PTSD, 70
Tsurumi, Wataru, 219–20
Tufts Medical Center, 237
Turkey, 173
Typus melancholicus. See Melancholic personality
UCLA PTSD Reaction, 85
UNICEF, 108
United Nations High Commission for Refugees, 108
United States Embassy bombing (Kenya), 106
University College London, 108
University of California, Santa Barbara, 47
University of Cardiff, 236
University of Colombo, 76–77, 89
University of Florida, 97
University of Hawaii, 209
University of Hong Kong, 47
University of Konstanz, 83
University of Michigan, 163
University of Nottingham, 119–20
University of Pennsylvania, 81, 173
University of Puget Sound, 128, 131
University of Washington, 128, 132
University of Wisconsin, 222
USA Today, 250
Utsubyô, 193, 209, 225
Utsushô, 200–201, 211
Utu-net.com, 227
Valium, 236
Van Eenwyk, John R., 95
Venezuela, 106–7
Victorian era, 3, 5, 28–29, 72
Vietnam Veterans Against the War, 114
Vietnam War, 114–15, 121
Vomiting epidemic, 29
Von Peter, Sebastian, 76
Wall Street Journal, 191
Washington Post, 70
Wentz, Debra, 65–69
Wessells, Michael, 104–5
Wisconsin Law Review, 58
World Health Organization (WHO), 76, 78, 81, 137–40
World Psychiatric Association, 171
World War I, 101
World War II, 121, 207, 219
Wu, Celia, 44
Yaka, 111, 112
Yan shi zheng, 43
Yin-yang balance, 20
Yojo, 200, 201
Young, Allan, 71, 102
Yule, William, 98–100
Yuutsu, 209–11
Zanzibar, 6, 127–51, 154–60, 165–71, 178–85. See also Schizophrenia author’s
stay in, 127–29, 141, 175–76, 178–79, 253
lessons learned from research, 178–84
monsoon effect on culture, 132–33
Zanzibar, contd.
schizophrenic family, 141–51, 154–60, 171, 182, 183
social upheaval in, 142–44
Zar, 2, 6
Zarowsky, Christina, 99
Zogozogo, 142, 150
Zoloft, 80–81, 223–24
* Not that an eating disorder specialist would necessarily disagree with these
items. I mean to point out only that the Western research literature on anorexia
goes far beyond these baseline assumptions in both complexity and diversity of
opinion. What was being transmitted to Hong Kong in the mid-1990s, in other
words, was a lay Westerner’s view of anorexia, the sort of information you’d
glean if you read about anorexia in a weekly news magazine.
* As the DSM-IV describes PTSD: “The essential feature of Post-traumatic Stress
Disorder is the development of characteristic symptoms following exposure to
an extreme traumatic stressor involving direct personal experience of an event
that involves actual or threatened death or serious injury, or other threat to
one’s physical integrity; or witnessing an event that involves death, injury, or a
threat to the physical integrity of another person; or learning about unexpected
or violent death, serious harm, or threat of death or injury experienced by a
family member or other close associate (Criterion A1). The person’s response to
the event must involve intense fear, helplessness, or horror (or in children, the
response must involve disorganized or agitated behavior) (Criterion A2). The
characteristic symptoms resulting from the exposure to the extreme trauma
include persistent reexperiencing of the traumatic event (Criterion B), persistent
avoidance of stimuli associated with the trauma and numbing of general
responsiveness (Criterion C), and persistent symptoms of increased arousal
(Criterion D). The full symptom picture must be present for more than 1 month
(Criterion E), and the disturbance must cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning
(Criterion F).”
* For some critics, this very first study became emblematic of the rush to
diagnose PTSD. How could PTSD have been diagnosed starting at three weeks,
some wondered, when the definition of the disorder requires the symptoms to
last for longer than one month?
* All the names of the African families mentioned in this chapter are
pseudonymous.
* When McGruder compared Amina’s memory to the records in the hospital,
there were considerable differences. The pills she had been given were not,
according to the chart, antimalaria medication but an antispasm drug called
trihexyphenidyl hydrochloride, used to counter facial muscle spasms that can be
a side effect of a powerful antipsychotic called fluphenazine that had been given
to Kimwana in an injection.
* I’ve placed an audio recording of the sound of the square on www.crazy
likeus.com if you’d like to listen to the soundscape Kimwana lived in.
* Expressed emotion researchers have been careful to point out that they were
not tying emotional temperatures in families to the onset of schizophrenia. High
emotion was not a cause of the disease, but rather appeared to be a factor that
greatly influenced its course and outcome. While there is a significant difference
between families with high emotional temperatures and those with low, this is
not true in every case. Many high-expressed-emotion families care for
schizophrenics with low incidence of relapse, and vice versa. It should also be
noted that it is not only relatives who have been studied. Similar results have
come from research into high and low emotionality expressed by caretakers in
group homes and mental institutions.
* Although headquartered in the UK, GlaxoSmithKline has much of its operations
in the United States, where its consumer products division is based. The United
States is the single largest market for GSK drugs.
* The instructions are given in great detail. For potential jumpers, for example,
the book recommends the Takashimadaira housing project and provides a map
to help the reader find the place. The chapter on throwing oneself in front of a
train recommends precisely where to stand on the platform and which express
trains will do the quickest work. To combat these instructions, the transit
authority has placed mirrors at strategic spots, following the theory that seeing
one’s reflection may dissuade one from jumping.
* As discussed in chapter 2 this disaster also played a key role in the
international spread of the PTSD diagnosis.
* Ballenger did not return phone calls requesting an interview for this book.
* In the debate over the risks and benefits of SSRIs there are few people in the
middle ground and a wealth of easily accessible information designed to appear
evenhanded that is, in fact, secretly produced by the drug companies or the
most extreme critics. For instance, both the drug companies and Scientologists
(who believe psychiatric drugs are basically poison) sponsor websites that
appear to the reader to be created by patient advocates or impartial experts in
mental health. Although the SSRI makers have actively tried to portray Healy as
a man of radical opinions, the facts of Healy’s professional life speak for
themselves. Not only was he the former secretary of the British Association of
Psychopharmacology and a professor in psychological medicine at Cardiff
University, but in his medical practice he continues to use antidepressants with
patients who he believes can benefit from the drugs.
* Searching for some secondary positive aspect in otherwise negative data is
referred to as “data torturing” and is often criticized as being the statistical
equivalent of placing the target after throwing the darts.
* In defending her members against Angell’s charges, Dr. Nada Stotland,
president of the American Psychiatric Association, replied to Angell’s criticism,
“It is unfair to suggest physicians are ‘corrupt’ for activities that were virtually
universal when they occurred.’ ” Such a sentence can stop one cold. Is the
president of the APA really falling back on that old chestnut of an excuse for bad
behavior, “Everyone was doing it”? And what definition of corruption is she
relying on that ensures that those in the majority cannot be at fault?
* In the same release, PhRMA announced that it had helped launch a new
consumer advocacy site featuring the well-known actor from The Sopranos, Joe
Pantoliano, who had publicly admitted to struggling with depression. “The goal,”
according to the No Kidding, Me Too website, was to “make brain dis-ease cool
and sexy.”
Cover Page
Title Page
Copyright Page
Dedication
Contents
Introduction
1 The Rise of Anorexia in Hong Kong
2 The Wave That Brought PTSD to Sri Lanka
3 The Shifting Mask of Schizophrenia in Zanzibar
4 The Mega-Marketing of Depression in Japan
Conclusion The Global Economic Crisis and the Future of Mental Illness
Sources
Acknowledgments
Index
Footnotes
Page 46
Page 71
Page 83
Page 141
Page 145
Page 147
Page 152
Page 188
Page 219
Page 220
Page 233
Page 236
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Page 241
Page 251
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