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on the americanization of mental illness

January 18, 2010

Nifty article from the NY Times Magazine recently: “The Americanization of Mental Illness.” It’s long, but it’s a fascinating read you should definitely check out if you have the time (I was at the lab, clearly doing lots and lots of science when I read it).  It’s also been all over the web since it was published last weekend, which makes me feel pretty savvy for picking it up before it ended up on blogs ranging from local newspapers’ mental health blogs to Infoshop.  And by “makes me feel pretty savvy,” I mean “makes me feel like I spend way too much time perusing the internet.”

Anyhow, the gist of the essay (taken from an upcoming book, Crazy Like Us: The Globalization of the American Psyche) is that American cultural dominance is doing more than putting McDonald’s restaurants in exotic locales; it’s actually affecting the way mental illness is understood, diagnosed, and treated.  The author goes through several striking examples, and proceeds into a comparison of prognosis via more traditional culture-specific ideas about illness compared to the American way of thinking about things.  For all our historic dominance in medical matters, turns out many people could perhaps be better off if they stuck with their culture’s traditional way of thinking about mental illness.  “Better off” is, of course, subjective, but he definitely raises some points that bear thinking about.

Here’s one bit that stuck with me in particular.  The example discussed is schizophrenia, but the application to other illnesses can easily be imagined.  The emphasis is mine.

The course of a metastasizing cancer is unlikely to be changed by how we talk about it. With schizophrenia, however, symptoms are inevitably entangled in a person’s complex interactions with those around him or her. In fact, researchers have long documented how certain emotional reactions from family members correlate with higher relapse rates for people who have a diagnosis of schizophrenia. Collectively referred to as “high expressed emotion,” these reactions include criticism, hostility and emotional overinvolvement (like overprotectiveness or constant intrusiveness in the patient’s life). In one study, 67 percent of white American families with a schizophrenic family member were rated as “high EE.” (Among British families, 48 percent were high EE; among Mexican families the figure was 41 percent and for Indian families 23 percent.)

Does this high level of “expressed emotion” in the United States mean that we lack sympathy or the desire to care for our mentally ill? Quite the opposite. Relatives who were “high EE” were simply expressing a particularly American view of the self. They tended to believe that individuals are the captains of their own destiny and should be able to overcome their problems by force of personal will. Their critical comments to the mentally ill person didn’t mean that these family members were cruel or uncaring; they were simply applying the same assumptions about human nature that they applied to themselves. They were reflecting an “approach to the world that is active, resourceful and that emphasizes personal accountability,” Prof. Jill M. Hooley of Harvard University concluded. “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. Many traditional cultures regard the self in different terms — as inseparable from your role in your kinship group, intertwined with the story of your ancestry and permeable to the spirit world. What McGruder found in Zanzibar was that families often drew strength from this more connected and less isolating idea of human nature. Their ability to maintain a low level of expressed emotion relied on these beliefs. And that level of expressed emotion in turn may be key to improving the fortunes of the schizophrenia sufferer.

The quote’s a bit long just to give you enough context, but the key part for me is what I highlighted — the American view of the self, that we should be able to overcome all of our problems by force of will, can lead to a level of involvement from the family/friend group of an ill person that can actually be destructive to the sufferer.

I’d like to put forward another reason it can be destructive.  Not only does this view increase the external pressure to “make yourself get well,” it’s a belief commonly held by the sufferers themselves, and it ramps up the internal criticism and pressure to just fix things by force of will.  And sometimes, that just isn’t possible.  It seems to be a fairly common problem (though I am citing anecdotal and personal experience here) for folks suffering to have enormous trouble seeking help, as it means admitting that there’s something wrong with them that they can’t fix, which in our individualistic make-your-own-success American values system, means that they are a failure in more ways than one.  It’s incredibly destructive to self-esteem, which is just not helpful on top of any mental illness.

Then again, I’m not sure I would prefer thinking that I am possessed by evil spirits, or any of the various other culture-specific conceptions of mental illness.  It’s certainly an interesting thing to ponder, though.

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