misconceptions, and true genesis and nature of “mental illness” – both in graduate school and beyond. My discussion here is based on sources such as 1) Possibly the most famous, cross-cultural, study in psychiatry’s history – the World Health Organization’s 25-year global tracking of individuals with schizophrenia, which found that people diagnosed with schizophrenia in poor or developing countries do far better over time than schizophrenics in Western, industrialized nations, 2) The large body of research conducted by “labeling theorists” such as Erving Goffman, Patrick Corrigan, Petra Kleinlein, Gerald O’Brian, Anthony Taylor and Palmer Reg Orovwuje, and 3) Ethan Watters’ magnificently-researched, 2010 book, Crazy Like Us – which initially received a decent amount of notice by media (including an interview on NPR’s “Fresh Air”) but for some unfathomable reason has been severely overlooked ever since. I consider it one of the most important books in the field mental health today.
(You can read an excerpt of the book’s intro here, from the Jan. 8, 2010 issue of the New York Times Magazine).
So let’s start this discussion with Watters’ chapter on schizophrenia, because his fascinating findings bear implications for how we view and treat any “mental illness” today. I could talk at length about this chapter’s research (his book also includes chapters on anorexia, PTSD, and depression) but will try to limit myself to briefly summarizing Watters’ chapter on schizophrenia here. (I really encourage you to get his book if you are interested in the role culture plays in “mental illness,” as my summary is far from adequate. Crazy Like Us includes chapters on anorexia, PTSD, and depression as well).
What Watters found, by spending time with the aforementioned McGruder, a cultural anthropologist who moved to Zanzibar years ago to study and solve the schizophrenia mental health conundrum, was this: 1) While Western psychologists almost-uniformly attribute schizophrenia’s causes to the purely biologic – abnormalities in brain structure, biochemistry, or genes – hence dooming those diagnosed with it to poor outcomes, there are in fact too many variations in experiences approximating schizophrenia globally to reduce its causes to the purely biologic. And 2) Watters learned that how families, treatment providers and local culture understand, view and explain a “schizophrenic’s” experience, and how they talk about and treat those family members as a result, plays a huge role in how the illness impacts a person’s behaviors and self-conception and, therefore, their long-term prognosis.
In Zanzibar, for example, McGruder found that most of its population, including its doctors, had not yet been contaminated (my wording) by the Western view that schizophrenia is a purely biological disease from which there is no escape. Zanzibar people are more likely to attribute the experience of schizophrenia instead to spirit possession or the “permeability of the human consciousness by magical forces,” Watters wrote. Spirit possession in Zanzibar is viewed as a relativiely common experience which everyone experiences at some point in their lives. For example, said Amina, a mother whose household included both an ex-husband and daughter (Kimwana) with schizophrenia, we all have “creatures in our heads.” Those with schizophrenia were seen to simply experience spirit possession more often and to a more extreme degree than others. Spirits were also known to to be rude and to violate social norms; thus when Kimwana acted out, it was seen as the spirit acting out, rather than her behaving badly. Amina harbored no judgment or frustration toward her daughter’s delusions, and never pressured Kimwana to display “normal” behaviors. She was not stigmatized, remained just as much a part of the family unit as any other member, and was allowed to fluctuate back and forth between health and periods of illness: “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,” wrote Watters.
To Watters Zanzibar families provided a quintessential example of how merely the way in which a culture names a disease can impact how the “disease” plays out in the person themselves. Mexican-Americans studied in Southern California, for example, have a way of labeling experiences approximating schizophrenia – called nervios – which keeps the family member stigma-free. Nervios, a “catchcall diagnosis for feelings of disquiet or distress” in that culture, does not bring with it the negative connotations associated with schizophrenia; it is viewed as something all people experience, in milder forms, at one time or another. It is also viewed as a transitory state. As one researcher put it, the Mexican-American families studied view individuals with “schizophrenia” as simply “just like us only more so.” Therefore, as in Zanzibar, the nervios framework kept the individual within the family and social group, as opposed to setting him/her apart as an “other” with a lower status level.
The normalizing frameworks families used by the above two culture lies in stark contrast to how families in industrialized Western societies – particularly Anglo-American families – view their schizophrenic members. Western families are more prone to view the individual as an ‘other” and to show what’s known in psycho-lingo as “high expressed emotion (EE)”. High EE, demonstrated by such things as over-intrusiveness into a family member’s life, expressions of self-sacrifice or burden, etc., has been associated in research studies with poorer outcomes for those with mental illness.
Watters attributes the difference to the way in which families across cultures view and treat schizophrenic members to the ascendance of the biomedical model – also referred to as simply the “medical model” as well as “biological reductionism” by those at odds with it – of mental illness. Having evolved over the past fifty years, the biomedical model, which now reigns throughout psychiatry, views mental illness primarily as a “brain disease” resulting from abnormalities in genes, brain structure or biochemistry.