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Tuesday 30 August 2011

Readings. Crazy Like Us: The Globalization of the American Psyche. Part One.

We’ve all heard about culturally specific psychological disorders.  Amok, for instance, in which affected Indonesian men withdraw and eventually explode in rage.  Or koro, also specific to parts of Asia, in which men (again) develop the belief that their genitals are receding into the body.

And we know that there seem to be fashions in the expression of disorder.

Women no longer experience hysterical paralysis as they often did in Victorian Europe.

Hebephrenic schizophrenia, characterized by hysterical laughter among other symptoms, is almost unknown today.  But in the early to mid 20th century it was virtually emblematic of madness.  I’ve never seen a case; most modern clinicians haven’t either.

If manifestations of mental distress vary over time and across cultures, how do they shift?  And can cultures contaminate one another, causing manifestations to spread from one to another?

In Crazy Like Us (2010, Free Press), Ethan Watters (who previously excoriated the mental health field with Making Monsters, an analysis of the satanic ritual abuse hysteria of the 1980s and 1990s) looks at the apparent spread of Western – and specifically American – manifestations of mental illness into other cultures.

He suggests that when people are distressed, the form that their symptoms take will be dictated by cultural understandings of what happens to people in untenable situations.  If people in the culture develop glove anaesthesias, you might too.  If they become bulimic, that may be what you experience.

He argues that the rise of American ideas about mental illness, and specifically a belief in the reality of the categories provided in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM; currently in its 4th edition, hence DSM-IV) is causing a shift in the way that mental illness appears in other parts of the world.

Watters focuses on four national case examples of this phenomenon:  Anorexia in Hong Kong, PTSD in post-tsunami Sri Lanka, schizophrenia in Zanzibar, and depression in Japan.

In this and the next few posts, let’s take a look at his arguments.

First up:  Anorexia.

In interviews with local experts, Watters establishes reasonably well that before the early 1990s anorexia was a rarity in Hong Kong.  When it appeared, it tended to be a response to traumatic experiences of various sorts.  The women – and they tended to be women – seldom if ever reported feeling fat or wanting to change their appearance.  Instead, they reported not feeling hungry and sensing a kind of “blockage” that prevented them from eating.

In November of 1994 a schoolgirl with this problem collapsed and died on a busy street.  She turned out to weigh 75 pounds.  The event attracted major attention from the media, who naturally turned to experts on the problem for background.  Overwhelmingly, the experts they chose were Western.

The experts discussed the manifestations of anorexia common in North America, including the fear of fatness and the presumed cause: a societal obsession with thinness, particularly for young women.  Awareness programs sprang up to catch cases of anorexia earlier, to support the sufferers, and to educate young women about the dangers of the problem.

Over the next few years, the clinicians who had treated the few pre-1994 cases noticed a sudden upsurge in the incidence of the problem.  And the disorder seemed to change.  Suddenly young women were presenting with American-style anorexia.  Anorexia researcher Dr Sing Lee reported that 80% of the new cases were now fat phobic.

What are we to make of this?

One possibility is that fat-phobic anorexia occurred with about the same frequency pre-1994, but that clinicians simply failed to recognize it.  This seems unlikely, however.  Anorexia is relatively noticeable by physicians and, left uninterrupted, can cause death.  Deaths tend to attract attention.

Alternatively, clinicians may have changed their practices in the light of American data.  Perhaps they asked about fat phobia more routinely, and noticed it as a motivating factor as a result.  But this doesn’t explain the increased number of cases, and one doesn’t generally need to ask about fat phobia in order to get the story.  All we need to do is ask the client “Why do you think you don’t eat more?” and we will turn up the answer in at least some of the cases.

Or perhaps Hong Kong society itself was changing.  Perhaps there was a sudden upswing in the portrayal of thin models, or a sharp increase in the penetration of North American thin-model imagery. If so, no one seems to have noticed a change as anything more than a gradual shift over time, if that.

It’s hard to escape Watters’ conclusion, which is that cultural awareness of anorexia as a phenomenon caused at least some of these young women to manifest their distress by becoming anorexic.

But there’s something missing from his treatment of the topic.  He assumes that cultural ideas influence the manifestation of anorexia, but doesn’t consider whether they affect the incidence of mental disorder overall.

If distressed girls suddenly began becoming anorexic in the1990s as a language of dissatisfaction, then there should have been a corresponding decline in other manifestations.  Was there?  This isn’t addressed.

If there wasn’t, then there may be an even more significant problem than the one Watters is discussing.

Could it be that by publicizing anorexia, and describing it as a societal problem, we may create the problem in more young women – including women who would not have had an alternative disorder if anorexia were not available?

Put another way:  Might mental health awareness campaigns produce mental illness?

It’s not inconceivable.  There are well-documented cases of mass hysteria in school and community settings, in which large numbers of people suddenly come down with various physical symptoms.  No one believes that if the psychological contagion (the belief in a virus or toxic substance in a building, for example) was not present, the same number of people would have come down with something else.   It is not the type of case, but also the number of cases that is influenced by the belief system.

This raises the disquieting possibility that North America may be influencing not just the form of mental illness (“craziness like our craziness”) but also the amount of mental illness in a culture (“we’ll add our disorders to yours”), in a manner reminiscent of the way that European illnesses were introduced to, and spread among, the aboriginal peoples of the Americas.

More on this later.  Next up:  PTSD in Sri Lanka, followed by Schizophrenia in Zanzibar and Depression in Japan.

Tuesday 23 August 2011

(P)review: Next to Normal

At the Stanley Industrial Alliance Stage in Vancouver September 8 – October 9.

I’ve twice been asked to provide “inside colour” on the role of a psychologist – once for a movie, once for a play.  Both times I’ve secretly cringed.  Mental health doesn’t usually get treated well.

“Please:  all I ask is that the therapist character doesn’t sleep with the patient.”

Well, you can guess.  Both times.

And then, as always, we’re expected to sympathize with the therapist character, despite the fact they’ve just shown themselves to be incompetent, unethical, and a stain on the profession.  So generally I don’t hope for much.

In 2009 I spent a few days at the Stratford Festival in Ontario and met Michael Kuchwara, the Associated Press theatre critic, up from New York to review that season’s productions.  Knowing what I do for a living, he later sent me a CD of the Broadway recording of Next to Normal, a musical about bipolar disorder.

I listened with my usual skepticism, but was struck by how insightful – and entertaining – it was.  When I found myself in New York in 2010, I went to see the production.  Five days later it won the year’s Pulitzer Prize for drama.

I was so impressed with the play that I wrote to the artistic director at the Arts Club in Vancouver advocating for it – something I’ve never done before.  Little did I know, it was already in the works for fall 2011.

Most musicals tend to voyage far from reality.  Their most ardent defenders offer the excuse that they are meant to distract people from the drudgery of everyday life.  The best plays, however, serve as more than distractions.  They illustrate everyday life, including the more painful parts.

Next to Normal is remarkable for cutting closer to the bone than any musical play in recent memory.  It describes the life of an American family, and a woman who has suffered from bipolar disorder for 16 years.  As the play opens the simple act of making lunch provides a hint that things are a bit iffy on the mental health front, and a confrontation with painful reality partway into the play shakes what little stability she has achieved, sending her into a spiral.

This sounds like pretty grim stuff, but the play is surprisingly funny.  A fast-paced recitation of medications (“Zoloft and Paxil and Buspar and Xanax…”) contains an allusion to The Sound of Music (sing it out loud and you can guess) and is followed by an even faster recitation of side effects.  After one “adjustment” the patient fixes her psychiatrist with a stare and says, acidly, “Not a very exact science, is it?”  Her daughter, grasping for an excuse that will allow her boyfriend to avoid the chaos of a family dinner, settles momentarily on rabies.

The humour – much of it of dark - provides welcome relief for some steep dives into the reality of severe mental illness and its treatment.  Mental health professionals may cringe, but for once it isn’t because of the false notes in the writing.  It's in the sharpness of the picture and an awareness of the limitations of our professions.  Hidden in the production there is a kind of emotional code that tells clinicians that the authors, somehow, know whereof they speak.

Professionals are likely to feel moments of surprise at the portrayal of emotions and thoughts that they have never seen portrayed on stage before.  Almost every line brought to mind one or another real person I have seen over the years in my clinical work.  The husband asks  “Who’s crazy?  The one who can’t cope, or maybe, the one who still hopes?  The one who sees doctors or the one who just waits in the car?”  What ensues is more real than any reality show would dare display.  A song about the appeal of self-destruction is startlingly true to life.

One of the most striking aspects of the play is that all of the central characters have an emotional arc.  The mother feels misunderstood and ashamed of her failure to maintain her stability, while missing the emotional peaks and valleys of her life without medication.  The daughter fears that she will wind up like her mother, and buries herself in drugs and Mozart in an attempt to escape the pressure cooker.  The father, who initially seems to be a backdrop for the mother’s drama, reveals how the illness of his wife has enabled him to avoid his own journey.  Even the psychiatrist, initially a cipher, confronts his own limited powers.

Any summary of Next to Normal runs the risk of making it sound like a “cultural vegetable”: something that is good for you but not necessarily entertaining.  Far from it.  The New York Times referred to it as not just a feel-good musical, but a “feel everything musical.”  They were right.  It richly deserved the Pulitzer it earned.  It's hard to imagine anyone seeing this play and remaining unaffected.  I strongly recommend it.

What if the play describes your own challenges - should you see it?  It depends on the person.  I think that the majority of people affected by bipolar disorder (personally or through family) will find it affirming to see it portrayed seriously, sensitively, humourously, and without any sugar-coating.  But Diana doesn't have an easy time of it, and isn't the greatest "treatment responder."  If despair seems too close to home lately, the experience could be a bit intense in certain passages.  If I had to guess, of 100 people with bipolar disorder, 10 will emerge somewhat shaken, 90 will be stirred.

For tickets and information, go to

September 16 update:  I have now seen the Arts Club Production. See the post on it here.

Friday 19 August 2011

Readings: The Advantages of Pessimism

Alain de Botton has written some of the most erudite and funny nonfiction of the last decade.  I strongly recommend his books in the "Life and Change" page of the Changeways Clinic bookstore.

He's recently written an article that neatly parallels a recent talk that I gave at PsychologySalon's lecture series.  Mine was called "Toxic Optimism."  His, which is far more eloquent, is an article for the BBC News Magazine, and is called The Advantages of Pessimism.  It's available here.

Essentially he argues that by setting expectations unrealistically high, optimism brings about the very disappointment that it seeks to dispel.  Pessimism, on the other hand, sets the bar low, enabling reality to surpass expectations (and thereby cause happiness) much more frequently.  Read it and see if you agree.

Tuesday 16 August 2011

Passions Are Built, Not Found

Cognitive therapy emphasizes the idea that we all have characteristic distortions in the way that we view the world.  Some of us automatically assume that everything we do must be perfect.  Others predict catastrophe at every turn.  Still others believe that when something bad happens to them, they must have deserved it.

But it’s not just people that harbour these distortions.  Cultures do too.  People living within these cultures adopt the distorted ideas without thinking, just as we learn about gravity automatically, without thinking too much about gravitational science.

There are many distortions in Western cultures (and doubtless in Eastern, Southern, and Northern cultures as well).  Let’s just consider one of these for now:

"You must discover your passions."

This is a cultural idea that seems to have spread widely in the past 40 years – to the point that young people can hold the idea without recognizing it as just that:  an idea.

Ideas can be wrong.  This is one of them.

The implication is that within each of us there is a pre-existing slot, or desire, of which we can be entirely unaware.  And one day we will discover in the outside world an activity, or career, or sport, or hobby, or role that fits that slot perfectly.

All we need to do is look around and we will suddenly recognize our passion when we see it.  We can then start doing it and find fulfillment in our lives.

The result of holding this view is, paradoxically, the absence of passion.

Because we look around and don’t find that special something that ignites a flame of passion, we assume that we haven’t found “IT” yet and need to keep looking.  Passion, by this model, is a passive process: it sits outside in the world and we just have to find it – or have it given to us.

Eventually we can feel despair: we’ve been looking for years and haven’t found it.  And yet other people seem to have succeeded.  One friend is a marathoner, another obsesses about health policy, a third is a rockhound. They’ve obviously discovered their passions.  What’s wrong with us?  Why are our passions hiding?

Of course, they’re not hiding at all.  They don’t exist.

Until we build them.

Interview some people who have great passions.  Seldom will you hear that the object of their fascination came along and clubbed them over the head one day.  “I was innocently walking along and suddenly realized that my role in life was to do wedding photography.”

Instead, these people didn’t wait for passion.  They detected vague, fleeting interests and tried out a lot of things.  Most of these activities, upon investigation, turned out to be dead ends.  One or more of them resulted in a tiny, insignificant, increase in interest.  So they did them again.  They developed some skill or knowledge in those areas.  A sense of mastery began to develop, and their interest increased some more.

By the time we met these people they had been engaged in the activity for months or decades, and they had, as a result, developed great skill and fascination.  Their interest had become self-sustaining.

But they did not discover their passion.  They built it.

People differ.  Some of us have the temperament that can cultivate a fascination for badminton.  Others are more likely to create an interest in 18th century art.  But we are not wired for passions, and if we go searching for them we will fail – and potentially waste years of our lives.

If we want passion, then oddly enough we need to give up on finding passion.  We have to look for vague, fleeting interest instead.  And we have to push through our tedium and disinterest to do so.  With time we will cultivate our passion.  At some point, it may even seem that we have discovered our passion.

But that will be a distortion.  We didn’t discover anything.  We built it.

Friday 12 August 2011

Rumi's The Guest House, on Youtube

Cognitive behaviour therapists are routinely confronted by writings that beautifully express CBT ideas - and that predate CBT by hundreds or thousands of years.  Whether it is Epictetus or the Buddha, it seems that CBT has seldom broken entirely new ground.

One of the best examples of this principle is the Persian 13th century poet Rumi, and one of the best illustrations of his insight into emotional difficulties is his poem The Guest House.  In it, Rumi suggests that rather than resisting uncomfortable emotions we open up to them and invite them into our lives, as each of them has something to offer us.

Here is a reading (and short commentary) of The Guest House by American poet Coleman Barks, on Youtube:

Tuesday 9 August 2011

But I LIKE soft drinks!

Half of a clinician’s work, it seems, is encouraging clients to adopt a more fulfilling, healthy lifestyle.  Sleep habits, exercise, socializing, valuing enjoyable activity, getting things done, and so on.

One element of this is diet.  And one element of a healthy diet is to limit the amount of sugar we take in.

Where is the excess sugar in people’s diets?  Candy, obviously, and pastries, and chips.  But one of the main sources, for many people, is the not-so-humble soft drink.

If you check the amount of sugar in various name brand soft drinks, you will find that most can-size servings have the equivalent of about 10 teaspoons.  Total calories:  About 130.

To get this idea across to groups I sometimes take a glass that holds about the amount in a can, 355 ml or so, and fill it with water.  Then I drop in a teaspoonful of sugar, and stir.  Then another.  Then another.  Then seven more.

“Would you drink this?” I ask.  Most people say no, but they’re savvy enough to know where I’m headed.

“But you do.  Every time you have a Coke, or a ginger ale, or a Sprite, or a tonic water, or almost any other type of soda, that’s what you’re drinking.”

Don’t try this with children.  They will be delighted at the thought that water could be enriched with 10 teaspoons of sugar.

For clients wanting to lose weight sanely, simply cutting out one or two needless sources of empty calories may be enough to eliminate the margin of intake beyond their needs, and start the process of losing.  Soft drinks are an easy place to start.

One option is to shift to diet drinks.  But these don’t seem to reduce a person’s overall caloric intake.  It seems that by fooling the body into thinking it is getting sugar, and then having it discover that there isn’t much sugar in what we just ingested, the body cleverly compensates by ramping up the desire for calories.  As well, there are constant debates about the healthfulness of artificial sweeteners.

“Why do I want to lose weight?  Well, because it’s healthier.  So how am I doing it?  By drinking a possible carcinogen.”

Let’s face it:  If sweeteners were as toxic as some folks imagine, the population would have been halved by now.  It’s not as though we’re stuffing the drinks with asbestos (our parliament's favourite export).  But still, it may not be such a good idea to be using too much artificial sweetener.

Tell people to shift to water and you will often get some very sour looks.  Is there a way to make it more palatable?

I drink low-sodium Club Soda (available from President’s Choice brands, and doubtless others).  When I open the can there’s always a bit of space inside the top, and I fill this up with bottled lime juice.  Total calories:  Don’t know.  But practically none.  Total sodium:  Allegedly 1% of recommended daily allowance.  Not great, but probably better than 130 calories of sugar.  And many sugared soft drinks have more sodium as well.

I’ve managed to convert many clients to this drink, plus regular water as a main beverage.

Interestingly, tastes seem to shift as you get used to the “new normal.”  When I started buying 1% milk for cereal it seemed thin, but now 2% tastes like unhealthily thick cream to me.  And now when I have the odd regular soft drink, it tastes like I’m drinking sugar syrup.

Which I am.

Sunday 7 August 2011

Vacationing without working

I've taken a brief holiday in Ottawa, where the weather is hot and humid.

My brother in law is in love with his new Ecco sandals.  "It's like walking on kittens," he exclaims.

Am trying valiantly to keep clinical antennae down.  

Have a great August, everyone.

Friday 5 August 2011

Readings: On ghostwritten medical articles

So you read a medical journal and look at the author list to see who produced the research.

But did they really?  Often the listed authors of medical articles had little to do with the actual operation of the study in question.  The real authors are often professional ghostwriters.

Is this a bad thing?  Not necessarily.  Some brilliant researchers can't write comprehensible prose to save their lives.  Professional writers can be invaluable.

But what if the article is an evaluation of a medication, and the ghostwriter is an employee of the pharmaceutical company that stands to benefit if the data are interpreted in a manner that supports that medication's effectiveness?

I've often flipped to the results section of an article to see what actually happened in a study, and then read the article's conclusions only to wonder if they've somehow confused two different studies.  Sometimes the data seem to point clearly one way, but the discussion leads readers off in the opposite direction.  I remember a study in which a doubling of suicide risk among subjects taking a test medication was deemed a "minimal effect."  The distortions in data interpretation often seem motivated by a desire for the results to look a certain way.

The Public Library of Science recently published an argument that ghostwriting "raises serious ethical and legal concerns" and suggests that the "guest authors" - i.e., prominent physicians and academics whose names appear on articles but who did not actually write them - should be subject to legal penalties.  In effect, Simon Stern and Trudo Lemmens, authors (we can safely assume) of the piece suggest that attaching one's name to an article one did not write constitutes legal fraud.

It's an interesting debate, and you can read the full article here:

Tuesday 2 August 2011

Multistrand Depression

Like most psychological disorders, major depression is diagnosed with a checklist of symptoms:  low mood, inability to enjoy former pleasures, fatigue, sleep disruption, difficulties with concentration and memory, and so on.

To this list we can add many symptoms that do not appear in the diagnostic criteria:  an aversion to light, a sense of being easily overwhelmed, a breakdown of automatic behaviour, social withdrawal, and more.

The reason we have a general label, depression, for all of these symptoms is that, although each can happen without the others, they often cluster together.   When you get a “lumpiness” of these symptoms – a number of the more critical ones happening at the same time – we assign the problem an overarching label:  Major depression.  

The moment we give this symptom cluster a name, it begins to seem like a real thing.  We say “Ah, I see your problem.  You have major depression.” And it sounds as though we have explained something and now understand it.  In fact, all we have done is provided a label.  

“I have these five symptoms.” 

“Oh, then you have five-symptom disease.”

Labeling a problem can actually be quite useful, particularly if it points the way toward a treatment plan.  This is less often the case in mental difficulties than in physical ones, but never mind. We practitioners still like sounding bright when we diagnose.

A down side of the label is that it unifies the symptoms into what now seems like a distinct entity. This leads clinician and sufferer into a set of presumptions about the problem, most of which are not helpful.  “One problem, one cause,” for example. 

And then there’s the issue that this post is really all about.  (How’s that for a long lead-in?)  As the depression fades, we tend to assume that all of the symptoms will go away at the same time.

This doesn’t happen.

Rather than seeing depression as a single rope of difficulty, it helps to see it as a multistrand entity.  Take the rope and unravel it.

As the problem itself begins to abate, the different strands begin moving upward (or downward, depending on how you think of such things) at different times.  Some symptoms tend to fade early, others lag.

So which symptoms tend to improve early, and which improve late?  I’m not aware of formal research into this question, though I suspect if I looked a little harder I might find some clues.

I’ve been treating depression for over 25 years now, and for much of that time it has been my primary focus. I try to be cautious about speaking on the basis of what has inevitably been a nonrandom sample observed using a fallible recording instrument (my mind). And in fact the moment anyone says “In my clinical experience…” it’s best to set one’s skepticism to HIGH.

Nevertheless, I think I’ve noticed some consistency as I’ve watched people get better.  First to improve is often the anhedonia – the inability to enjoy things. If we can get people to do at least some of the things they used to enjoy, faint flickers of their former enjoyment begin to return.  

The trick is to avoid dismissing these.  People will say “I used to LOVE doing this, now it just seems faintly amusing. What’s the point?”  The point is that this pale imitation of former passions is a sign of things likely to come. Keep doing those things, and branch out, doing a variety of them, and the volume control on the enjoyment tends to go up.

Eventually people will say that while they are in choir practice, or at the movies, or playing cards, or hiking they are just like their old selves.  But the moment they get home the mood plummets as low as it ever was.  Some would almost prefer not to be lifted up if they are just going to be dropped down again later, but I’m afraid that goes with the territory.

What improves last?

In my clinical experience (did you remember to become skeptical?), the cognitive symptoms – poor memory, concentration, decision making – often lag behind the rest.  

“It’s weird.  I feel mostly like my old self now, and I don’t seem to crash into the pit – not much, anyway – but I still can’t find my car keys, or remember people’s names, or decide what to have in a restaurant.”

Why is this?  I suspect that these cognitive skills are strongly based on practice. After a period of depression our ability to retrieve memories, decide between options, or focus for extended periods becomes, well, flabby.  It’s like a person who lies for weeks in a hospital bed recovering from pneumonia: afterward their muscles are weak.  The illness is over, but their strength is poor.  They need to spend some time building themselves back.

Practice may help – but before I write more on that topic I’d like to see if I can track down some work on cognitive rehabilitation after depression. Certainly it appears that my clients get all of their faculties back with practice and effort – though not necessarily with the simple passage of time.  Reading, puzzles, shopping, testing oneself (quick: who was at that dinner party last Wednesday?), sitting and quietly working on a mental task – all seem to help.

My overall point:  When we recover from depression, the label dissolves and the bundle of symptoms unravels. Some improve early, others late. If you get some signs of improvement but other symptoms persist, take heart: the early improvement likely signals more to come.