Mental illness and the concept of mental health are not new.
They have existed as long as we have. There exist accounts from as early as the
third century CE of the confinement of mentally ill people in Syrian Catholic churches.
Institutional care for the mentally ill can be traced back as early as the
1400s, and the first psychiatric hospital in North America opened in 1773 in
the colony of Virginia1.
One would think that this history, along with the later
development of effective pharmacological and psychosocial interventions for a
range of conditions, might have resulted in the recognition that mental
disorders were a public health priority. This, unfortunately, is not true. The
key impetus for the emergence of the field of global mental health did not come
until the publication of the World Development Report 1993. This report
featured the initial findings of the Global Burden of Disease study, the first
study to use DALYs to measure the global burden of disease. Much to the
surprise of many people, computation with DALYs showed that approximately 8% of
the global burden of disease was due to mental health problems2. Several other publications
followed, culminating with the publication of the Lancet series on global mental
health in September 2007. Only then was the global mental health movement
officially launched.
In the eight years since the Lancet series, the field has
experienced a surge of attention, research, and public support. One of the most
interesting, and most controversial, pieces of literature to come out of this
surge is the 2010 New York Times piece by Ethan Watters entitled “The
Americanization of Mental Illness.” In the piece, Watters suggests that a kind
of psychiatric-cultural imperialism has been foisted on other countries and
cultures by “the West.” Specifically, Watters claims that, “For more than a
generation now, we in the West have aggressively spread of our modern knowledge
of mental illness around the world… There is not good evidence to suggest that
in the process of teaching the rest of the world to think like us, we’ve been
exporting our Western “symptom repertoire” as well. That is, we’ve been
changing not only the treatments, but also the expression of mental illness in
other cultures3.”
Though the Watters thesis has its merits, it is also shallow
and simplistic in many of its assumptions and conclusions. I
found it hard to agree completely in light of several unfounded claims. In
discussing anorexia in Hong Kong, for example, Watters fails to consider
alternative explanations for the rise in “westernized” anorexia presentation.
Could it perhaps be attributed to better understanding and recognition of a
disorder that had not been fully studied or appreciated in the past?
Considering the history of PTSD in the United States, wherein clinical
presentation has been described for centuries, while the diagnosis has been
clarified and categorized only recently (the 1980s)4, this is
certainly possible. Additionally, I found Watters’ claim that a biological
interpretation of mental illness results in harsher treatment of the mentally
ill shortsighted. Were those thought to have a biological determinant of
disease really treated more harshly, or were they treated like someone without
a mental illness? It is important to consider this control (or lack thereof) in
analyzing his claim.
The rise of the global mental health movement has greatly
helped to publicize, personify, and reduce global suffering due to mental
illness. It has also, however, shown the limitations of the current approach to
global mental health care. There is thus an urgent need for continuing
research, in low-/middle-income and high-income countries alike, that addresses
the questions of etiology, treatment, and cultural variations that scholars
such as Watters have brought to light.
References
- Cohen, A., Patel, V., and Minas, H. (2014). A brief history of global mental health. In V. Patel, H. Minas, A. Cohen, and M. Prince (Ed.), Global Mental Health: Principles and Practice (pp. 3-26). New York: Oxford University Press.
- World Bank. (1993). World development 1993: Investing in health. New York: Oxford University Press.
- Watters, E. (2010, Jan 8). The Americanization of mental illness. The New York Times. Retrieved from http://www.nytimes.com/2010/01/10/magazine/10psyche-t.html
- Friedman, M.J. (2013). History of PTSD in veterans: Civil War to DSM-5. Retrieved from http://www.ptsd.va.gov/public/PTSD-overview/basics/history-of-ptsd-vets.asp
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ReplyDeleteWatters seems to suggest that significant portion of mental illness burden would not exist without globalization. I don't agree that the US and the rest of the West are responsible for the mental health problems of entire globe, but it is difficult to deny our role in many negative political outcomes, and thus, it is worth questioning our potential contribution. Watters claims, "Mental health professionals in the West, and in the United States in particular, create official categories of mental diseases and promote them in a diagnostic manual that has become the worldwide standard, " and I think he is right. Although, diagnostic values carry value, in the case of mental health, symptoms for the same condition may manifest themselves differently in varying settings. I think the larger problem may be applying Western ideals to non-Western problem outputs. Like with anything in global health, it is important to consider context.
ReplyDeleteGreat class on global mental health and great blog post. I read around this topic a bit for a class last year, and I'm really interested in the finding of increased stigma associated with a biomedical model of diseases vs more traditional models. For what it's worth, in response to a question posed in the original blog post: the study Watters cites (by Mehta & Farina) did include a control for "no mental illness", and found that group was treated less harshly than the "biomedical determinant", or equally as harshly as the "psychosocial determinant" group. That said, it's also important to mention this experiment took place in a highly contrived laboratory setting that involved a learning task in which correction was administered in the form of very small electric shocks... not exactly the real world.
ReplyDeleteI find the "field studies" he cites much more compelling, such as one by Dietrich et al, in which survey respondents who attributed mental illness to biomedical causes demonstrated greater social distance to individuals with schizophrenia than those who attributed it to psychosocial causes, across multiple countries. In some ways this finding makes sense to me: it seems that biomedical ailments could suggest a sort of permanence or chronicity that psychosocial models (or spiritual or other disease models) do not, which could contribute to stigmatization (I'm also thinking of non-mental illnesses that are highly stigmatized, such as HIV or TB, and their chronicity). Of course, this is just my own introspection and not the result of any real study. I feel like the issue particularly tough with schizophrenia, a disease for which biomedical treatment is very important. Regardless, just as Happy noted above for diagnostics, I certainly think there is a need to consider context when thinking of stigma as well.
Studies mentioned:
Mehta, S., & Farino, A. (1997). Is Being "Sick" Really Better? Effect of the Disease View of Mental Disorder on Stigma. Journal of Social and Clinical Psychology, 16(4), 405-419.
Dietrich, S., et al. (2004). The relationship between public causal beliefs and social distance toward mentally ill people. Australian and New Zealand Journal of Psychiatry, 38, 348-354.
Thank you for the insightful blog posting. It shocked me when I read that the global mental health movement was not officially launched until mid-90s. When I was reading articles about dementia care in developing countries, I found that lack of awareness and knowledge go hand in hand with stigmatization and I believe it can also be identified here with mental illnesses. I do not fully agree with Watters' opinion that"a kind of psychiatric-cultural imperialism has been foisted on other countries and cultures by “the West.” He used the word "aggressively" to emphasize that the West imposed their modern knowledge of mental illness on people living in the third world. In fact, I would like to say that thanks to the efforts made by researchers and media in western countries, people in my country gradually got to know mental illnesses and started to face up to it. When I was young, mental illnesses to me and to most people in China equal to schizophrenia and mania, which means persons with mental illnesses are crazy and can be offensive so that we need to admit them to institutions and constrain them. Such ridiculous thoughts were well accepted at that time and even till now. If it were not for the study and dissemination of mental illnesses knowledge, the global mental health movement would still not be launched yet. But we should not overly impose or standardize the categories because we do need to leave some space for cultural differences and translation.
ReplyDeleteThank you for this wonderful post. From my perspective, it is important to take consideration of the culture piece when we talk about mental health issues. Take PTSD or trauma exposure as an example, global diversity in geography, climate, government, politics, and social structures could contribute to variation in types and patterns of trauma exposure. For example, women living in San Fransisco might experience a serious disaster because of the frequency of earthquakes in the Bay Area. While trauma events that people living in Colombia experienced may due to the on going political conflict there. Thus, traumatic events will likely have different significance, meaning, and consequence for people in different locations and cultures. As health care providers, it is important to being aware of this diversity while making diagnosis as well as providing care.
ReplyDeleteI found that this post offered an excellent example of the need to be aware of cultural context when working with mental health issues. The discussion around perceptions of "anorexia" in Hong Kong as influenced by Western standards is spot on. I wanted to consider a slightly different angle that focuses even more on the need to understand cultural differences when working in mental health. In the past, I've worked with several community health organizations that primarily served Latino-identified populations who spoke Spanish as their first language. While using a standard mental health questionnaire might seem like the appropriate starting place to assess baseline depression, for example, language and cultural barriers quickly get in the way. A simple question such as "I feel blue" turns into a nonsensical "Me siento azul" if translated literally, not to mention differences in norms regarding discussing emotions and mistrust regarding health care providers. Studies of well-being of Latino communities (living in the United States) have found that protective effects against adverse health outcomes (both mental and physical) often relate to high levels of social support from within communities and families. In fact, different social structures based on culture might suggest that Western approaches to treating mental illness (such as going to talk to a therapist) might not work for cultures who are skeptical of formal health settings. In these places, community-based programs or interventions that relay on existing social networks would likely be much more effective. While Western vs. non-Western approaches are not mutually exclusive, and suggesting though would create a false dichotomy likely to hinder progress, the need for greater cultural competency in public and global health efforts is indisputable.
ReplyDeleteAdditional sources:
Mulvaney-Day, Norah E., Margarita AlegrÃa, and William Sribney. “Social Cohesion, Social Support, and Health among Latinos in the United States.” Social Science & Medicine 64, no. 2 (January 2007): 477–95. doi:10.1016/j.socscimed.2006.08.030.
Gallo et al., “Associations of Structural and Functional Social Support with Diabetes Prevalence in U.S. Hispanics/Latinos: Results from the HCHS/SOL Sociocultural Ancillary Study.”
I feel as if Watters incorrectly presented his argument by assuming that globalization has caused Westerners to impose the ideo of mental illnesses in other countries where they did not exist before. This is untrue, however I do think that something can be said about cultural definitions of an argument.
ReplyDeleteI agree with Adriana in that people are taking Western definitions of things and applying them to other countries.
For example, there are actually studies that show that in many Polynesian areas there were not reported cases of anorexia/ bulimia until the introduction of the television- when young girls were seeing western women and aspiring to be them. However, the studies only focus on the onset of A/B, not in previous body image problems. So to say that globalization brought body image problems to these countries is wrong, it just heightened the awareness of the body image problems that plagued the west.
Definitions and titles are very important to the conversation about global mental health. They help us understand what persons of other countries are suffering from. What we diagnose as autism spectrum disorder other countries may see as "misbehaved" children. The symptoms and problems are still there- they are just called something. (This brings to mind a very famous quote by William Shakespeare).
Thanks for the thoughtful blog. It is good to know that there are some controversial perspectives on global mental health. Culture diversity should definitely be considered when talking about global mental health. In China, there are a large proportion of people who have stigma on mental disease patients. It is hard for them to get appropriate treatment and social status as in America. Although I agree that Watters has some exaggeration on the impact of western concepts, it is good to introduce some of the successful achievements to underdeveloped countries.
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