ALSO BY ETHAN WATTERS

Urban Tribes:

A Generation Redefines Friendship,

Family, and Commitment WITH RICHARD OFSHE

Makings Monsters:

False Memories, Psychotherapy, and Sexual Hysteria

C RAZY

L IKE

U S

THE GLOBALIZATION OF

THE AMERICAN PSYCHE

ETHAN WATTERS

FREE PRESS

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Copyright © 2010 by Ethan Watters

All rights reserved, including the right to reproduce this book or

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Manufactured in the United States of America

1 3 5 7 9 10 8 6 4 2

Library of Congress Cataloging-in-Publication Data

Watters, Ethan.

Crazy like us: the globalization of the American psyche / Ethan Watters.

p. cm.

1. Mental illness—Cross-cultural studies. 2. Psychology, Pathological—

Cross-cultural studies. 3. Irish—Race identity. 4. Mental illness—

United States. 5. Globalization—Psychological aspects. 6. Psychiatric

epidemiology. I. Title.

RC455.4.E8W38 2010

616.89—dc22 2009030661

ISBN 978-1-4165-8708-8

ISBN 978-1-4165-8719-4 (ebook) For my mother, Mary Pulliam Watters

Contents

Introduction

Chapter 1

The Rise of Anorexia in Hong Kong

Chapter 2

The Wave That Brought PTSD to Sri Lanka

Chapter 3

The Shifting Mask of Schizophrenia in Zanzibar

Chapter 4

The Mega-Marketing of Depression in Japan

Conclusion

The Global Economic Crisis and the Future of Mental Illness

Sources

Acknowledgments

Index

C RAZY

L IKE

U S

Introduction

To travel internationally is to become increasingly unnerved

by the way American culture pervades the world. We cringe

at the new indoor Mlimani shopping mall in Dar es Salaam,

Tanzania. We shake our heads at the sight of a McDonald’s

on Tiananmen Square or a Nike factory in Malaysia. The

visual landscape of the world has become depressingly

familiar. For Americans the old joke has become bizarrely

true: wherever we go, there we are.

We have the uneasy feeling that our influence over the

rest of the world is coming at a great cost: loss of the

world’s diversity and complexity. For all our self-

incrimination, however, we have yet to face our most

disturbing effect on the rest of the world. Our golden arches

do not represent our most troubling impact on other

cultures; rather, it is how we are flattening the landscape of

the human psyche itself. We are engaged in the grand

project of Americanizing the world’s understanding of the

human mind.

This might seem like an impossible claim to back up, as

such a change would be happening inside the conscious and

unconscious thoughts of more than six billion people. But

there are telltale signs that have recently become

unmistakable. Particularly telling are the changing

manifestations of mental illnesses around the world. In the

past two decades, for instance, eating disorders have risen

in Hong Kong and are now spreading to inland China. Post-

traumatic stress disorder (PTSD) has become the common

diagnosis, the lingua franca of human suffering, following

wars and natural disasters. In addition, a particularly

Americanized version of depression is on the rise in

countries across the world.

What is the pathogen that has led to these outbreaks and

epidemics? On what currents do these illnesses travel?

The premise of this book is that the virus is us.

Over the past thirty years, we Americans have been

industriously exporting our ideas about mental illness. Our

definitions and treatments have become the international

standards. Although this has often been done with the best

of intentions, we’ve failed to foresee the full impact of these

efforts. It turns out that how a people in a culture think

about mental illnesses—how they categorize and prioritize

the symptoms, attempt to heal them, and set expectations

for their course and outcome—influences the diseases

themselves. In teaching the rest of the world to think like us,

we have been, for better and worse, homogenizing the way

the world goes mad.

There is now a remarkable body of research that suggests

that mental illnesses are not, as sometimes assumed,

spread evenly around the globe. They have appeared in

different cultures in endlessly complex and unique forms.

Indonesian men have been known to experience amok, in

which a minor social insult launches an extended period of

brooding punctuated by an episode of murderous rage.

Southeastern Asian males sometimes suffer from koro, the

debilitating certainty that their genitals are retracting into

their body. Across the Fertile Crescent of the Middle East

there is zar, a mental illness related to spirit possession that

brings forth dissociative episodes of crying, laughing,

shouting, and singing.

The diversity that can be found across cultures can be

seen across time as well. Because the troubled mind has

been perceived in terms of diverse religious, scientific, and

social beliefs of discrete cultures, the forms of madness

from one place and time in history often look remarkably

different from the forms of madness in another. These

differing forms of mental illness can sometimes appear and

disappear within a generation. In his book Mad Travelers, Ian

Hacking documents the fleeting appearance in Victorian

Europe of a fugue state in which young men would walk in a

trance for hundreds of miles. Symptoms of mental illnesses

are the lightning in the zeitgeist, the product of culture and

belief in specific times and specific places. That thousands

of upper-class women in the mid-nineteenth century

couldn’t get out of bed due to the onset of hysterical leg

paralysis gives us a visceral understanding of the

restrictions set on women’s social roles at the time.

But with the increasing speed of globalization, something

has changed. The remarkable diversity once seen among

different cultures’ conceptions of madness is rapidly

disappearing. A few mental illnesses identified and

popularized in the United States—depression, post-

traumatic stress disorder, and anorexia among them—now

appear to be spreading across cultural boundaries and

around the world with the speed of contagious diseases.

Indigenous forms of mental illness and healing are being

bulldozed by disease categories and treatments made in the

USA.

There is no doubt that the Western mental health

profession has had a remarkable global influence over the

meaning and treatment of mental illness. Mental health

professionals trained in the West, and in the United States in

particular, create the official categories of mental diseases.

The American Psychiatric Association’s Diagnostic and

Statistical Manual of Mental Disorders, the DSM (the “bible”

of the profession, as it is sometimes called), has become the

worldwide standard. In addition American researchers and

organizations run the premier scholarly journals and host

top conferences in the fields of psychology and psychiatry.

Western universities train the world’s most influential

clinicians and academics. Western drug companies dole out

the funds for research and spend billions marketing

medications for mental illnesses. Western-trained

traumatologists rush in wherever war or natural disasters

strike to deliver “psychological first aid,” bringing with them

their assumptions about how the mind becomes broken and

how it is best healed.

These ideas and practices represent much more than the

symptom lists that describe these conditions. Behind the

promotion of Western ideas of mental health and healing

lies a variety of cultural assumptions about human nature

itself. Westerners share, for instance, beliefs about what

type of life event is likely to make one psychologically

traumatized, and we agree that venting emotions by talking

is more healthy than stoic silence. We are certain that

humans are innately fragile and should consider many

emotional experiences as illnesses that require professional

intervention. We’re confident that our biomedical approach

to mental illness will reduce stigma for the sufferer and that

our drugs are the best that science has to offer. We promise

people in other cultures that mental health (and a modern

style of self-awareness) can be found by throwing off

traditional social roles and engaging in individualistic quests

of introspection. These Western ideas of the mind are

proving as seductive to the rest of the world as fast food

and rap music, and we are spreading them with speed and

vigor.

What motivates us in this global effort to convince the

world to think like us? There are several answers to this

question, but one of them is quite simple: drug company

profits. These multibillion-dollar conglomerates have an

incentive to promote universal disease categories because

they can make fortunes selling the drugs that purport to

cure those illnesses.

Other reasons are more complex. Many modern mental

health practitioners and researchers believe that the

science behind our drugs, our illness categories, and our

theories of the mind have put the field beyond the influence

of constantly shifting cultural trends and beliefs. After all,

we now have machines that can literally watch the mind at

work. We can change the chemistry of the brain in a variety

of ways and examine DNA sequences for abnormalities. For

a generation now we have proudly promoted the biomedical

notion of mental illness: the idea that these diseases should

be understood clinically and scientifically, like physical

illnesses. The assumption is that these remarkable scientific

advances have allowed modern-day practitioners to avoid

the biases and mistakes of their predecessors.

Indeed modern-day mental health practitioners often look

back at previous generations of psychiatrists with a mixture

of scorn and pity, wondering how they could have been so

swept away by the cultural beliefs of their time. Theories

surrounding the epidemic of hysterical women in the

Victorian era are now dismissed as cultural artifacts. Even

recent iatrogenic contagions, such as the sudden rise of

multiple personality disorder just fifteen years ago, are

considered ancient history, harmful detours but safely in the

past. Similarly, illnesses found only in other cultures are

often treated like carnival sideshows. Koro and amok and

the like can be found far back in the American diagnostic

manual (DSM-IV, pages 845–849) under the heading

“Culture-Bound Syndromes.” They might as well be labeled

“Psychiatric Exotica: Two Bits a Gander.”

Western mental health practitioners are prone to believe

that, unlike those culturally contrived manifestations of

mental illness, the 844 pages of the DSM-IV prior to the

inclusion of culture-bound syndromes describe real

disorders of the mind, illnesses with symptomatology and

outcomes relatively unaffected by shifting cultural beliefs.

And, the logic goes, if they are unaffected by culture, then

these disorders are surely universal to humans everywhere.

Their application around the world therefore represents

simply the brave march of scientific knowledge.

But the cross-cultural researchers and anthropologists

profiled in this book have a different story to tell. They have

shown that the experience of mental illness cannot be

separated from culture. We can become psychologically

unhinged for many reasons, such as personal trauma, social

upheaval, or a chemical imbalance in our brain. Whatever

the cause, we invariably rely on cultural beliefs and stories

to understand what is happening. Those stories, whether

they tell of spirit possession or serotonin depletion, shape

the experience of the illness in surprisingly dramatic and

often counterintuitive ways. In the end, all mental illnesses,

including such seemingly obvious categories such as

depression, PTSD, and even schizophrenia, are every bit as

shaped and influenced by cultural beliefs and expectations

as hysterical leg paralysis, or the vapors, or zar, or any

other mental illness ever experienced in the history of

human madness.

The cultural influence on the mind of a mentally ill person

is always a local and intimate phenomenon. So although this

book describes a global trend, it is not told from a global

perspective. In the hopes of keeping the human-scale

impact in sight, I have chosen to tell the stories of four

diseases in four different countries. I picked these tales

because each illustrates how the globalization of Western

beliefs about mental health travel on different currents.

From the island of Zanzibar, where beliefs in spirit

possession are increasingly giving way to biomedical

notions of mental illness, I tell the story of two families

struggling with schizophrenia. To document the rise of

anorexia in Hong Kong, I retrace the last steps of 14-year-old

Charlene Hsu Chi-Ying and show how the publicity

surrounding her death introduced the province to a

particularly Western form of the disease. I deconstruct the

mega-marketing of the antidepressant Paxil in Japan to

illustrate how drug companies often sell the very disease for

which their drug purports to be a cure. The aftermath of the

2004 tsunami in Sri Lanka provides the opportunity to

examine the impact of trauma counselors who rush into

disaster zones armed with the diagnosis of posttraumatic

stress and Western certainties about the impact of trauma

on the human psyche.

At the end of each of these chapters I turn the focus back

to the West, and to the United States in particular. When

viewed from a far shore, the cultural assumptions and

certainties that shape our own beliefs about mental illness

and the human mind often become breathtakingly clear.

From this perspective, it is often our own assumptions about

madness and the self that begin to appear truly strange.

The cross-cultural psychiatrists and anthropologists

featured in this book have convinced me that we are living

at a remarkable moment in human history. At the same time

they’ve been working hard to document the different

cultural understandings of mental illness and health, those

differences have been disappearing before their eyes. I’ve

come to think of them as psychology’s version of botanists

in the rain forest, desperate to document the diversity while

staying only a few steps ahead of the bulldozers.

We should worry about this loss of diversity in the world’s

differing conceptions and treatments of mental illness in

exactly the same way we worry about the loss of biological

diversity in nature. Modes of healing and culturally specific

beliefs about how to achieve mental health can be lost to

humanity with the grim finality of an animal or plant lapsing

into extinction. And like those plants and animals, the

diversity in the human understanding of the mind can

disappear before we’ve truly comprehended its value.

Biologists suggest that within the dense and vital

biodiversity of the rain forest are chemical compounds that

may someday cure modern plagues. Similarly, within the

diversity of different cultural understandings of mental

health and illness may exist knowledge that we cannot

afford to lose. We erase this diversity at our own peril.

1

The Rise of Anorexia in Hong Kong

Psychiatric theory cannot deny its participation in the social

trajectory of the anorectic discourse, which articulates

personal miseries as much as it does public concerns.

SING LEE

On the morning of my visit to Dr. Sing Lee, China’s

preeminent researcher on eating disorders, I took the

subway a few stops north of downtown Hong Kong to the

Prince of Wales Hospital in the suburb of Shatin. In the clean

and well-lit subway corridors, I passed several large posters

featuring outlandishly slender, bikinied young women

promoting a variety of health care regimens, cellulite-

removing creams, and appetite-suppressant supplements.

The advertisements over the handrails in the subway cars

repeated the offers. The magazines and newspapers being

read by the commuters were filled with similar pitches,

often featuring before and after photos, young women

becoming little more than skin and bones after the offered

treatment. Such products are a huge business in Hong Kong

and increasingly in mainland China. Over the past few years

the beauty industry in Hong Kong (including dieting,

cosmetics, skin care, and fitness) has outspent every other

business sector on advertising. In that week’s issue of the

popular weekly magazine Next, a remarkable 110 of the

publication’s 150 ads were for slimming or beauty products

and services.

The reporting and photojournalism that appeared

alongside those ads had a slightly different obsession:

telling tales of young women celebrities. That morning’s

Standard, one of Hong Kong’s English dailies, prominently

reported the recent misadventures of several famous young

women, including Britney Spears, who had that week been

held against her will at the UCLA Medical Center. She had

been “5150ed,” which is the code for a California statute

that allows doctors to hold a patient involuntarily if she is

deemed a danger to herself or others. On the opposing page

was an article about the Japanese pop idol Kumi Koda, who

lost her job as a spokesmodel for Japan’s third largest

cosmetics company, Kose Corp., after making pejorative

comments about the fertility of older women. The cute and

perky 25-year-old had gone on a popular radio show and

given her medical opinion that a “mother’s amniotic fluid

turns rotten once a woman reaches about thirty-five . . . It

gets dirty.”

The biggest story in The Standard, in fact the front-page

story in every paper in Hong Kong that morning, was a sex

scandal involving a handful of the region’s best-known

female pop stars and a young actor. Hundreds of very

explicit nude photos had been posted on the Internet of

singer Gillian Chung and actresses Bobo Chen and Cecilia

Cheung Pak-chi, among a dozen others. That same week a

humanitarian crisis was erupting along the Gaza-Egyptian

border and a severe snowstorm was sweeping across much

of eastern China, threatening to strand millions of holiday

travelers, yet no other story could compete with this sex

scandal. Everyone, from politicians to op-ed writers, felt the

need to criticize the behavior of the young women. Even

Hong Kong’s Catholic bishop John Tong weighed in on the

subject of celebrity sin and cyber etiquette, saying that it

was important to “keep our minds decent” and “not post or

circulate these pictures.”

Of course it’s not possible to say exactly what these

advertisements, images, and stories of celebrity

misadventures might have been adding up to in the minds

of average adolescent girls in Hong Kong. It didn’t take

much reading between the lines, however, to perceive a

high degree of confusion and ambivalence surrounding the

issues of female body image, sexuality, youth, beauty, and

aging. Young women in some contexts were worshipped for

their attractiveness, while in other situations they were

humiliated and publicly vilified with a vitriol that would be

hard to overstate. Whatever understanding Hong Kong

teenage girls were piecing together about the

postadolescent world from these sources, it is safe to say

that it was not unconflicted.

Given this environment, it would make sense to most

Americans and Europeans that occurrences of anorexia and

bulimia have spiked here in the past fifteen years. Nor

would it likely be a surprise that Gillian Chung, one of those

young celebrities in the sex scandal, had herself battled

bulimia. Most well-educated Westerners understand that

anorexia is sparked by cultural cues, but they often have a

fairly narrow conception of what those cues might be. Most

assume that anorexia, with its attendant fear of fatness and

body dysmorphic disorder, is born of a peculiar modern

fixation with a slender, female body type, and that popular

culture transmits this fetish to young women. As we’ve

exported our obsessions with slender models—our Barbie

dolls and our Kate Moss fashions—it makes sense to us that

eating disorders have followed in their wake.

But although this commonsense cause and effect might

be part of the story, Sing Lee’s research shows that there

have been other, more subtle, cross-cultural forces at work

here. The full story of how anorexia spread from the

American suburbs to Hong Kong is more complex and, in

many ways, more troubling. It turns out that the West may

indeed be culpable for the rise in eating disorders in Asia,

but not for the obvious reasons.

After making my way across Shatin, I found Lee’s small

suite of offices among the labyrinth of midrise buildings that

make up the Prince of Wales Hospital. Introduced by his

assistant, Dr. Lee was younger than I expected. At 49 years

old, he’s had a remarkable output as a scholar despite the

fact that he has split his time between seeing patients at

the public hospital, teaching, and running a mood disorders

center. He admits that at times he has been accused of

being a workaholic. “I do work long hours, but I’ve never

experienced much work stress,” he said to me in what I

would come to know as his characteristic humble manner.

“I’ve wanted to be a psychiatrist since high sch

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