Readings. Crazy Like Us. Part Three: Schizophrenia in Zanzibar.

Back again to a look at Ethan Watters' book Crazy Like Us: The Globalization of the American Psyche (2010, Free Press). Previously we looked at Anorexia in Hong Kong and PTSD in Sri Lanka.

Watters’ third example of the export of western ideas about mental illness focuses on schizophrenia in Zanzibar. He contrasts families treating afflicted members using traditional concepts, including spirit possession, with those that have adopted more western notions.

As with his other examples, western exports do not come off well. Whatever their level of accuracy, traditional views enabled families to accept and incorporate members prone to psychotic episodes. Adopting a western notion of mental illness as a biological affliction effectively invalidated families’ roles and created more stigma.

Yes, we might think, but if schizophrenia really is a biological illness, then it would be important to acknowledge this fact anyway so that effective care could be provided, no?

Well, perhaps not. Watters points to a widely-known phenomenon in the epidemiology of schizophrenia. Those with the disorder in western countries with fully-equipped healthcare systems have poorer outcomes than those in many developing nations.

It’s possible that western models of treatment actually do more harm than good, though even in developing countries patients are typically provided with antipsychotic medication of some sort.

A more likely explanation is that the social structure of developing nations naturally provides a more inclusive environment for people with certain difficulties in functioning than does the individualistic and isolating style of western culture. To the extent that their cultural styles for dealing with psychosis are impaired by the imposition of western ideas, exporting our knowledge and practices may be damaging rather than helpful.

In considering these issues, Watters points to a distortion in western ideas that transcends the issue of exporting North American mental health practices.  

For decades practitioners have attempted to reduce the stigma associated with mental illness. To this end, there have been widespread attempts to train the public to think of mental illness as “just like physical illness.” The idea has been that if we see depression, schizophrenia, or OCD as illnesses not dissimilar from mumps, breast cancer, or HIV infection, then stigma will evaporate.

This reasoning seems to have missed the fact that those with physical illnesses, too, experience stigma, but never mind.

Luckily, the question is testable. We can survey populations to see how they feel about people with various psychological ailments, and we can assess the degree to which they equate physical and mental problems. Presumably, the more the mumps metaphor sinks in, the less the stigma.

Nice idea. But the results turn out the wrong way. In fact, the more people see psychological difficulties as being like physical issues, the less they want to be around the sufferers. Stigma increases rather than decreases.

Once again, we westerners may have put our foot in it. It’s possible that the destigmatization campaigns of the last few decades have actually worked against the goal of increasing societal acceptance of mental illness. If acceptance of some issues seems to have gone up, it may be in spite of our efforts, not because of them.

Intuitively-appealing ideas about how to reduce stigma are sometimes stronger than the data backing them up. They have momentum.

A new Canadian federal body, the Mental Health Commission of Canada, has been established with the mandate to improve mental health care throughout the country. The Commission has adopted a broad – one is tempted to say unrealistically broad – mandate, of which a major plank is the reduction of stigma. Although little appears to have been accomplished as yet, it will be interesting to watch the strategies taken. Hopefully these will be based on the data, not on ideas that seem obvious but may work in the wrong direction.

Next, Watters’ final focus: the marketing of the concept of depression in Japan. (Previously we looked at Anorexia in Hong Kong and PTSD in Sri Lanka.)