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Crazy Like Us is a truly enlightening and profound book about how Western biomedical concepts of mental illness are gaining ground in various parts of the world in an unquestioning manner that is not always particularly culturally sensitive or beneficial for locals in those settings. The author, Ethan Watters is a journalist who has previously authored 'Urban Tribes: Are Friends the New Family' and is a frequent contributor to the 'New York Times Magazine' and many other magazines. In Crazy Like Us Watters quotes some key research from the field of cross-cultural psychiatry to build a case for that biomedical paradigm of mental illness comprise an ultimately narrow view of the psychological life of individuals. This view is built on notions typical to Western medicine including dualism between mind and body, and a Western form of individualism. He exemplifies his story with four cases; 1) how anorexia nervosa in its particularly Western form came to Hong Kong together with other Western influences, 2) How Western trauma counselors rushed to Sri Lanka in large numbers after the tsunami and brought the diagnosis and treatment methods for PTSD with them, with a near to total lack of understanding about the cultural intricacies of how trauma is dealt with in the country; 3) How western versus local views on schizophrenia management can possibly affect the course of illness in Zanzibar and; 4) How GlaxoSmnithKline through aggressive mega-marketing brought both the diagnosis or depression and its treatment with Selective Serotonin Reuptake Inhibitors (SSRIs) to Japan. The narrative of the book is rendered interesting and lively through a number or interview extracts with researchers and clinicians recounting their experiences from the field.
The latest developments in biomedical psychiatry have often been in the direction of attempting to find an underlying biological cause for the illness which is then treated with targeted pharmaceuticals. However, this approach undermines much of what is essential in the causation and management of mental illness, such as individual psychology and well as interpersonal social, cultural and philosophical/religious aspects. Much could be learnt if Western psychiatry were to look more to the ways in which mental illness is managed within other cultures, and other medical systems, and this is a message that seems to lie implicit in the book. At times, however, Watters seems to excessively idealize the ways in which mental illness is dealt with in other cultures. Specifically in the chapters about PTSD in Sri Lanka and schizophrenia in Zanzibar the accounts of the local ways to manage mental illness can seem at times somewhat lopsided to the positive side. It is also known that oftentimes the mentally ill in poor countries are treated in very inhumane ways, including being locked up and restrained in terrible conditions, and none of this is ever taken up in the book. This skewdness is balanced out in the conclusion by the statement that the author has "…tried to avoid making the clichéd argument that other, more traditional cultures necessarily have it right when it comes to treating mental illness". However, the book may have gained in balanced realism by being explicit in this standpoint from the very start. Indeed, some things that are done for mental illness in other cultures could be teaching for us living in the West, such as a philosophically/religiously accepting approach to suffering as can be learnt through the ways in which Sri Lankans manage trauma and loss. Also, valuing of the importance of interconnectedness with other people in society and a belief in fate can be beneficial, instead of seeing the individual and her mental illness as a purely isolated problem accounted for by individual biology, as seen in the chapter about schizophrenia in Zanzibar.
Nevertheless, the book lacks any statement about the prognosis of the World Health Organization that major depression will become the global leader in causing disability world-wide in the next 20 years -that is more disability than that caused by communicable diseases like HIV/Aids. Thus, the treatment and management of mental illness will be a challenge to tackle in Western and non-Western countries alike, and resources in most countries for handling the burden are scarce and should be up-scaled. However, with this in mind Crazy Like Us is a particularly timely and important book due to that it enlightens the reader about the real problems that are encountered if the Western biological/individualistic concept of mental illness is globalised to other cultures, and the true shortcomings of treating depression with SSRIs. It is important to bring into light the terrible skewing of scientific results by drug companies, such as detailed by Watters in the case of selective publication of positive research results on SSRIs while negative results have often been left unpublished. A positive step towards an increased cultural sensitivity in mental illness diagnosis is that an effort is being made to bring cultural viewpoints into the new, fifth version of the Diagnostic and Statistical Manual for Mental Disorders that is widely used internationally. This is being done through consultation with key researchers in cross-cultural psychiatry, including some of which Watters has interviewed for this book. Overall, Crazy Like Us is a book to be recommended to anyone either suffering from, treating, doing research on, or otherwise interested in mental illness, as it is a well-informed review of important issues in global mental health.
© 2010 Maria Niemi
Maria Niemi, MSc, PhD student, Unit for Studies of Integrative Health Care; Division of Nursing; NVS; Karolinska Institutet, Sweden