Ethan Watters’s 2010 book Crazy Like Us: The Globalization of the American Psyche details how mental health conditions around the world have changed thanks to globalisation. What the American medical establishment understood as the model of an illness, its causes and even its symptoms, became how it was experienced elsewhere.
For example, Sing Lee, a psychiatrist in Hong Kong, spent much of the late 1980s and early 1990s studying anorexia. His patients did not deliberately avoid eating – in fact, “they complained most frequently of having bloated stomachs”. Then, in 1994, a teenage girl collapsed and died in the middle of a busy street, and the local papers reported her anorexia with language straight from American medical dictionaries:
Western ideas did not simply obscure the understanding of anorexia in Hong Kong; they also may have changed the expression of the illness itself. As the general public and the region’s mental-health professionals came to understand the American diagnosis of anorexia, the presentation of the illness in Lee’s patient population appeared to transform into the more virulent American standard. Lee once saw two or three anorexic patients a year; by the end of the 1990s he was seeing that many new cases each month. … By 2007 about 90 percent of the anorexics Lee treated reported fat phobia. New patients appeared to be increasingly conforming their experience of anorexia to the Western version of the disease.”
While cultural conditioning is an easily acceptable notion, the idea that our mental health is similarly conditioned can feel a little strange. This is because it belies our understanding of illness, especially mental illness – with modern medicine, we’re accustomed to thinking of the human body as a machine, and treatment for disease as akin to the physical repair of a worn-out mechanism. Our inability to completely model a human brain means we’re also groping in the dark when it comes to modelling mental health as only a physiological phenomenon.
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders is the most infamous example of this problem – in theory, the definitive catalogue of mental health, and the standard reference for any psychiatric diagnosis. In practice, it conflates everyday personality traits with disorders, relying on changeable mood to decide whether those traits are bad or not. In response to the publication of the most recent edition, DSM-V, the British Psychological Society issued a statement criticising its premise:
The putative diagnoses presented in DSM-V are clearly based largely on social norms, with ‘symptoms’ that all rely on subjective judgements, with little confirmatory physical ‘signs’ or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations. Many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity.”
The manual also “misses the relational context of problems and the undeniable social causation of many such problems”. (This was best skewered by Sam Kriss, who reviewed DSM-V as if it’s a Borgesian dictionary of the dystopian, written by an anonymous author intent on dehumanising its subjects.)
It’s within this context that we should welcome a study, led by anthropologist Tanya Luhrmann of Stanford University, which has found that the nature of aural hallucinations change relative to the local culture of the person experiencing them. Americans who hear disembodied voices are more likely to report them as violent, or “bombardment”; Indian and Ghanian participants more often reported the voices they heard were “playful” or even “entertaining”.
All of the participants in the study had been diagnosed as schizophrenic, with 20 each from San Mateo in California, Accra in Ghana and Chennai in India. All participants, from all three locations, reported both positive and negative experiences with hallucinated voice – yet while the Ghanaians and Indians reported predominantly positive experiences, the Americans all said their experiences were mostly negative.
Crucially, too, Americans perceived their hallucinations as symptomatic of a deeper disease, whether innate or because of a traumatic experience – while 11 of the Indian participants described their voices as deceased relatives giving advice or commands, and 16 of the Ghanaians reported hearing the voice of God.
The voices were treated as a “magic”, “playful” or “entertaining” more often than not, and only some participants saw them as manifestations of a mental illness; the Americans, in contrast, heard voices describing violent imagery, “torturing people” or a “bombardment”, an “assault”, or even a “call to war”. “[The] harsh, violent voices so common in the West may not be an inevitable feature of schizophrenia,” Luhrmann said in a statement.
The study, published in the British Journal of Psychiatry, It gives extra weight to criticisms of mental illness which don’t take account of external, social factors – and to the influence of a model of mental health on the manifestation of an illness. Luhrmann said: “The difference seems to be that the Chennai and Accra participants were more comfortable interpreting their voices as relationships and not as the sign of a violated mind.” As the interpretations didn’t seem to correlate with either religious belief or urbanisation, she suspects the underlying cause for this is that Americans were less community-minded than the others. This is speculation, and requires further investigation, but it does point the way to new possibilities in treating schizophrenia and disembodied voices, with the possibility that “befriending” them could lessen their impact.