Posts Tagged ‘Mental Illness’
Posted on May 19, 2010 - by David
Does Ethan Watters Believe Culture Can Cause Mental Illness?
Ethan Watters, author of Crazy Like Us (see my commentary), was on PRI the other day (listen to the audio here). I was pleased to get a prompt response to my comments, which I’ve copied below. Go here to follow the entire discussion in the PRI science forum.
Posted on March 22, 2010 - by David
Not Sick: The 1973 Removal of Homosexuality from the DSM
81 Words, a 2002 episode of NPR’s This American Life that was recently rebroadcast, tells the story behind the removal of the homosexuality diagnosis from the DSM-II in 1973. You can download the audio or read a transcript of the show here: part 1, part 2.
The report is given by Alix Spiegel, whose grandfather, Dr. John P. Spiegel, was president-elect of the American Psychiatric Association in 1973 when this historic change took place. Alix describes the family myth – that grandpa had single-handedly changed the APA’s position on homosexuality and removed one of the major barriers to equal rights for homosexuals in America. The truth, she says, is actually much more complicated. Though he did play a role in this historic change, ‘grandpa’ was not the driving force his family believed him to be, nor were his motives simply those of dedicated psychiatrist and champion of human rights. In Alix Spiegel’s words:
… this version of events was discarded anyway. Discarded after the family went on vacation to the Bahamas to celebrate my grandfather’s 70th birthday. I remember it well. I also remember my grandfather stepping out from his beach front bungalow on that first day followed by a small well-built man, a man that later during dinner my grandfather introduced to a shocked family as his lover, David. David was the first of a long line of very young men that my grandfather took up with after my grandmother’s death. It turned out that my grandfather had had gay lovers throughout his life, had even told his wife-to-be that he was homosexual, two weeks before their wedding. And so in 1981 the story that my family told about the definition in the DSM changed dramatically.
According to Alix Spiegel, from the 40’s through the early 60’s, the APA was a very conservative organization, largely uninterested in “weighing in on the issues of the day.” In her interviews with psychiatrists who were members of the APA in 1970, when the forces behind the definition change began to take shape, she was told that the overwhelming majority of the APA believed that homosexuality was indeed a mental illness – “even the ones of us who were gay,” added Dr. John Fryer.
Fryer was not alone in the APA. Because homosexuals were not allowed to practice psychiatry, Fryer and others like him had to hide their sexual preference, but they began to meet informally at APA conventions, calling themselves the Gay PA. There may have been a sense of solidarity among them, but they were not questioning the official psychiatric stance on homosexuality. Fryer told Spiegel, “because of our own internalized homophobia, most of us probably agreed that it was OK to be a disease.”
The idea that homosexuality was a form of insanity rather than a ‘moral abomination’ was first put forth in the 19th century, and Spiegel notes that many homosexuals actually saw this as a step forward. In the early 70’s, psychoanalysis, Freud’s great gift to psychiatry, was still the dominant form of therapy and mode of theoretical understanding in the profession. The two psychoanalytic authorities on homosexuality were Dr. Irving Bieber and Dr. Charles Socarides. Bieber, who was later demonized by gay activists, actually became interested in the subject of homosexuality after working as an army psychiatrist during WWII, when soldiers who were found to be homosexual were dishonorably discharged. Bieber believed they should receive treatment instead of being discharged, and because of this position, he was never promoted from his rank of Captain during his four years of service. Returning home, he began to research and write about this topic, which culminated in the 1962 publication of Homosexuality: A Psychoanalytic Study. As Spiegel says, this book, which analyzes the work of 77 doctors and over 100 of their gay patients, “concluded that the cause of homosexuality was a combination of what they termed close-binding mothers – which is overprotective women who made their children weak and feminine – and detached, rejecting fathers.”
Of course, there was other data used to argue against the idea of homosexuality as a mental illness. Alfred Kinsey’s famous and highly controversial report on male sexuality, published in 1948, found that 37% of American men had had physical contact to the point of orgasm with another man. Some opponents of the diagnosis used Kinsey’s work to claim that an experience so common could not be reasonably considered pathological.
The work of Evelyn Hooker, a psychologist from UCLA, was first made public in 1956, and addressed one of the main criticisms leveled against psychiatrists like Dr. Irving Bieber, whose study subjects consisted only of homosexuals who were imprisoned, in mental hospitals, had been discharged from the military, or had otherwise sought treatment on their own. Hooker’s aim was to examine gay men who weren’t troubled by their own sexuality. She administered psychological tests to 30 homosexuals who had never sought therapy, as well as 30 heterosexuals who were matched for comparable age, IQ, and education. The disguised results were then given to three experienced psychiatrists who were asked to identify the homosexuals. They were unable to distinguish between the two groups, and categorized two-thirds of both groups as “perfectly well-adjusted, normally functioning human beings.”
In 1970, the APA held their convention in San Francisco, probably an ill-advised choice of location. Gay rights activists showed up, some of whom had apparently obtained press passes from people within the APA, and made their feelings known. Bieber was a particular target, and they effectively broke up the meeting where he was trying to give a talk. The ’71 convention was much the same story.
While there was obvious pressure coming from the gay community to change the DSM, there was also something happening inside the APA. It seems from Spiegel’s story that the psychiatrists of the Gay PA were for the most part content to gather in secret and accept the traditional designation of homosexuals as sick, but others had begun to mobilize. In Dr. John P. Spiegel’s Cambrige, MA home, a small group of psychiatrists, ‘the young turks,’ began to meet:
The young turks were all psychiatrists, all members of the APA and all liberal-minded easterners who had decided to reform the American Psychiatric Association from the inside. Specifically they had decided to replace all the grey-haired conservatives who ran the organization with a new breed of psychiatrist; more sensitive to the social issues of the day with liberal opinions on Kent State, Vietnam, feminism. They figured that once they got this new breed into office they could fundamentally transform American psychiatry. And one of the things this group was keen to transform was American psychiatry’s approach to homosexuality.
Spiegel is quick to clarify that this group and others like it by no means constituted a “homosexual cabal,” but “several of the key players were gay,” and the young turks were able to use their influential positions as members of the Committee for Concerned Psychiatry to propose candidates for office. Despite all the visible and colorful protests of the APA by gay activists, Spiegel maintains that if it weren’t for the internal changes set into motion by these psychiatrists, the DSM diagnosis would have gone untouched.
At the 1972 convention, the efforts of those working for change both inside and outside the APA were joined for the first time. Gay psychiatrist Dr. John Fryer, recently ousted from his job at UPenn and apparently unemployable due to the rumors of his homosexuality, was recruited by activists to give a speech about the damaging effects of the DSM diagnosis. Though he initially refused the offer, after being rejected by one university after another as he looked for a new job, Fryer accepted the second request on the condition that his identity remain a secret. He appeared as ‘Dr. Anonymous,’ wearing a loud suit several sizes too big, his face hidden behind a distorted Nixon mask, hair covered by a wig, speaking into a special microphone to alter his voice. “He explained to his fellow psychiatrists how these [81] words had harmed him, and others like him,” and when he was through, received a standing ovation.
Independent of the changes already underway on the inside, there was another chance encounter involving an APA psychiatrist and a gay activist which proved to be instrumental in this process. During a behavioral therapy conference in New York City in ‘72, Dr. Robert Spitzer, a member of the APA’s committee on nomenclature and subscriber to the standard psychiatric view of homosexuality, was sitting in a meeting when Ron Gold stood up and spoke out against psychiatry’s oppression of gays. Spitzer made a point of speaking to Gold after the meeting ; he wanted to express his annoyance at the inappropriateness of the interruption. But when Gold discovered that Spitzer was on the nomenclature committee – the group that first decides what should and shouldn’t end up in the DSM – the conversation went in a different direction. The two men parted ways with Spitzer agreeing to set up a meeting for Gold with the committee as well as a panel discussion at the next convention where gay activists could participate.
At the 1973 APA convention in Honolulu, a few months after the requested audience with the nomenclature committee left the psychiatrists at a loss as to what should be done about the diagnosis, “The old guard, Charles Socarides and Irving Bieber, publicly met the new school, Ronald Gold, Judd Marmor [a future president of the APA] and several other psychiatrists in front of a room filled to capacity.” The showdown was a resounding victory for the gay activists. Even Socarides admits that the reception to his speech, (which Gold referred to as “his ‘they’re betraying their mammalian heritage’ number”), hardly qualified as warm. “A lot of people booed,” he told Spiegel, “some people clapped.”
Perhaps the most surprising part of this story, the last shove leading to the change, came later that night in a Honolulu bar. Gold, as the hero of the day, was invited to a covert Gay-PA celebration, and decided to bring Spitzer, who still didn’t personally know of any gay psychiatrists, along with him. Spitzer was supposed to be playing the role of a closeted gay man, but when he realized some of the big names who had been part of this underground group for years, he was shocked, and started asking questions that gave his true identity away. A psychiatrist Gold described as “the grand dragon of the Gay PA” wanted Spitzer out of there, but Gold refused on the grounds that Spitzer was actually doing something to help homosexuals, while the Gay PA had done nothing. In the middle of this encounter, a man in full army uniform walked into the bar, looked around, and fell weeping into Gold’s arms. As Gold tells Spiegel:
Well I had no idea who he was. It turned out he was a psychiatrist, an army psychiatrist based in Hawaii who was so moved by my speech, he told me, that he decided he had to go to a gay bar for the first time in his life. And somehow or other he got directed to this particular bar and saw me and all the gay psychiatrists and it was too much for him, he just cracked up. And it was a very moving event, I mean this man was awash in tears. And I believe that that was what decided Spitzer, right then and there, let’s go. Because it was right after that that he said, ‘Let’s go write the resolution.’ And so we went back to Spitzer’s hotel room and wrote the resolution.
While obviously we don’t have the original text composed by Gold and Spitzer in Honolulu– perhaps scrawled on some long lost sheets of hotel stationary –I’m guessing that much of what was written that night ended up here, in this position statement proposing a change in diagnosis from homosexuality to ‘Sexual Orientation Disturbance’ with homosexuality bracketed. This change was to be put into effect for the 6th printing of the DSM II and read as follows:
302.0 Sexual orientation disturbance (Homosexuality)
This category is for individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation. This diagnostic category is distinguished from homosexuality, which by itself does not constitute a psychiatric disorder. Homosexuality per se is one form of sexual behavior and, like other forms of sexual behavior which are not by themselves psychiatric disorders, is not listed in this nomenclature of mental disorders.
In this paper, Spitzer basically states that homosexuality is a normal variant of human sexuality. He writes that “for a mental or psychiatric condition to be considered a psychiatric disorder, it must either regularly cause subjective distress, or regularly be associated with some generalized impairment in social effectiveness or functioning,” and because many homosexuals do not meet these criteria, homosexuality should not be considered an illness. Spitzer clearly understood that this change was in part a political action, stating that “we will be removing one of the justifications for the denial of civil rights to individuals whose only crime is that their sexual orientation is to members of the same sex.” However, he writes that the removal of the homosexuality diagnosis does not amount to “saying that it is ‘normal’ or as valuable as heterosexuality,” and maintains that “this change should in no way interfere with or embarrass those dedicated psychiatrists and psychoanalysts who have devoted themselves to understanding and treating those homosexuals who have been unhappy with their lot.” The idea, in the end, was that if someone was bothered by their own homosexual thoughts, impulses, or behavior, the DSM still had them covered.
This initial change, officially announced by Dr. Alfred Friedman, president of the APA, on December 15, 1973, may have allowed psychoanalysts to continue treating gay patients for a time, but in less than 15 years, the DSM would be wiped clean of the last traces of the idea that homosexuality could be a mental illness. Spitzer’s original change had been rewritten as ‘ego-dystonic homosexuality’ for the DSM-III, but was removed altogether in 1987.
Dr. Charles Socarides, the most prominent player on the losing team, responded to the change in a 1978 article titled ‘The Sexual Deviations and the Diagnostic Manual,’ published in the American Journal of Psychotherapy. In protest of further proposed revisions for the soon to be published DSM-III, Socarides wrote, “these changes would remove from psychoanalysis and psychiatry entire areas of scientific progress, rendering chaotic fundamental truths about unconscious psychodynamics, as well as the interrelationship between anatomy and psychosexual identity.” In particular, Socarides objected to the fact that the heading ‘Sexual Deviations,’ under which the homosexuality diagnosis had once was fallen, was going to be entirely removed from the DSM-III. Proponents of this change pointed to reports like Kinsey’s, arguing that a phenomenon as common as homosexuality shouldn’t be understood as a deviation, but Socarides believed this was faulty reasoning:
To form conclusions as to the specific meaning of an event simply because of its frequency of occurrence is to the psychoanalyst scientific folly. Only in the consultation room, using the techniques of introspective reporting and free association, protected by the laws of medicine and professional ethics, will an individual, pressed by his suffering and pain, reveal the hidden (even from himself) meaning and reasons behind his acts.
When I read Socarides’ paper, I noticed that he repeatedly summons the name of science, even while his argument belies a dogmatic faith in psychoanalysis –an approach that has been waning in popularity for decades, suffering from the criticism that it lacks scientific validity. Regardless of who is right or wrong in this argument, (or any similar argument for that matter), what I find most interesting is how it is imperative for each party to claim the support of science. One of the last people Spiegel speaks to in her report is Ronald Bayer, a public health historian from Columbia who wrote a history of this change titled Homosexuality and American Psychiatry. Bayer tells Spiegel that “the nature of these controversies,” is that “both sides wrap themselves in the mantle of science and both sides charge that the other side is being unscientific.”
While developments in medicine and advances in genetic study and different brain imaging technologies have no doubt increased the importance of being aligned with “science” when it comes to psychiatric debate, this is not a new phenomenon, nor was it new in the ‘70’s. At the same time, stories like this one makes it plain that the progress of certain disciplines may be driven just as much by personal and political factors as it is by actual scientific progress. I wonder if the removal of the homosexuality diagnosis in 1973 wasn’t the beginning of the end for psychoanalysis, as well as the first move towards the more standardized, symptom-based diagnoses of the 1980 DSM-III. This seems reasonable, considering that Robert Spitzer was chairman of the task force responsible for creating the new edition and directed the development of the revised edition published in 1987 (DSM-III-R).
As the APA prepares for the publication of the DSM-V in 2013, I believe it’s worthwhile to keep this story in mind. Some of the proposed changes seem to have more to do with a desire to remove a stigmatizing label than real “scientific” evidence. And like homosexuality, the pathology of which was for a many years assumed but never proven, the scientific understanding of some of the older DSM diagnoses is not particularly strong. Studying the history of psychiatry can’t necessarily prove or disprove the validity of a diagnosis, but it may help us to remain cautious as we go forward.
Posted on February 24, 2010 - by David
A response to Dr. Sally Satel’s review of ‘The Loss of Sadness’
I was happy to see that Dr. Sally Satel commented on Monday’s post which linked to her WSJ article about the proposed revisions for the DSM-V. She posted a link to this article, written two years ago, which is actually a review of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder, by Allan Horwitz and Jerome Wakefield. Written from the perspective of a psychiatrist critical of the direction the field is moving in, it’s plenty more than a book review. Dr. Satel incorporates her own knowledge of the history of psychiatry and the difficulties of diagnosis and treatment as she considers the book’s contributions and shortcomings.
I realize that some of my criticisms are really directed at Horwitz and Wakefield, and I may be repeating some of things I wrote in my post on the Horwitz interview, but here goes anyway:
Satel gives some valuable history on the state of affairs in psychiatry during the 60’s and 70’s leading up to the publication of DSM-III. I’ll just say that Horwitz and Wakefield identify the publication of the DSM-III in 1980 with a shift towards symptom-based diagnosis which effectively eliminated considerations of context. The biggest problem they see resulting from this, (as the title of their book implies), is that the normal expression of sorrow in the wake of difficult life events is being diagnosed as depression. They believe this leads to unnecessary prescription of medication, inflated rates of mental illness, and a culture-wide loss of the ability to integrate hardship and sadness into a normal, healthy life.
The book seems to argue (as Horwitz stated in the contexts interview) that there are two types of real depression. 1. Depression that appears without cause or context, and 2. Depression which begins with an apparent cause or context but persists longer than appropriate with more severe symptoms than normal.
From Satel’s article:
In the classic form of uncaused depression — referred to in the pre-DSM-III days as endogenous depression or melancholia — symptoms arise mysteriously out of the blue when life is otherwise good. It seems clear that whatever biological mechanism that regulates mood has gone badly awry.
Yet clinical depression need not always have a spontaneous onset; it can also arise in the aftermath of loss. The important distinction between normal sorrow and major depression, the authors say, is that in the latter the symptoms triggered by circumstances eventually lose their contextual moorings. Either they persist long beyond the resolution of the stressful situation, or the point at which an otherwise healthy person would have adapted to a new condition; or they mutate into overt psychosis, suicidal impulses or actions, or physical immobilization. A patient in the pathological realm is beset by self-reproach and ruminations. He does not brighten when, say, a beloved grandchild visits, and he cannot imagine anything ever making him happy again.
While I would agree that this idea makes sense on the surface, I see a real problem. When someone reacts too strongly for too long to some loss or crisis, we might say something went wrong to make this person overly-sensitive to either loss in general, or the particular loss that was suffered. But this is still much different from depression which arises “mysteriously out of the blue when life is otherwise good.” Perhaps the way we look at context or what we consider “context” to mean leads us to see symptoms arising from nowhere which actually do have an explanation outside of a brain malfunction.
The argument presented in The Loss of Sadness seems to rest on the claim that real depression is the same today as it was over 2000 years ago – that culture has changed our understanding of mental illness but mental illness itself (assumed to be biologically caused) has not changed. To me, this implies that “normal sorrow” should look similar between cultures and over time, with some differences that can be accounted for by cultural and historical context.
I believe this view obscures the dramatic cultural change that modernity brings. We may take it for granted that a certain type of loss is difficult and a cause for deep sadness, but to extend this response to all of history and humanity is ignorant. (I think Ethan Watters chapter on PTSD in Sri Lanka is helpful in looking at cultural differences in response to tragedy). Sure, some depression might be easier for us (as modern people) to understand given the context or spark. But if our “normal responses” to loss closely resemble pathological states, perhaps Horwitz’s conclusion isn’t the only one that can be drawn. The authors are saying we have pathologized normal human emotions, but perhaps our responses to “normal life events” have actually become more pathological. Of course, if the broad cultural changes that accompany the rise of modernity are not considered important and human emotions and attitudes (or even Western emotions and attitudes) are seen as historically consistent, then this second possibility doesn’t even show up on the radar.
The principles inherent in nationalism provide the basis for modern culture – the only form of consciousness most people reading this blog have ever known. As defined by Liah Greenfeld, “nationalism is a fundamentally secular and humanistic consciousness based on the principles of popular sovereignty and egalitarianism.” For this discussion, it is important to recognize two aspects of modern culture: 1. It’s openness gives individuals great freedom, but very little guidance in forming identity 2. It changes what we hope for and what we expect out of life, therefore changing the nature of what constitutes “loss” and interfering with our ability to accept loss. Consider the following from Greenfeld’s essay, Nationalism and the Mind:
The focus on the life in this world dramatically increases the value of this life to the individual and inevitably leads to the insistence on a good life, however defined. One is no longer expected to submit to suffering or deprivation, unless one has special reasons to do so, for the general reasons for such submission – the expectation of rewards in the beyond, transmutation and migration of the souls, the duty to serve witness to the glory of God wherever one is called, or the sheer impossibility to change one’s condition – no longer apply.
Moreover, in a self-sufficient world, changeable and shaped by people, suffering is generally believed to be man-made. Even natural disasters are likely to be so interpreted: a famine, an earthquake, or an epidemic are as often as not attributed to some human agent’s withholding of the needed but available resources or negligence; personal misfortunes, such as debilitating, life-threatening, and incurable illnesses are blamed on artificially-created environmental conditions (second-hand smoke, lead paint, etc.) or on doctors’ incompetence. None of these natural disasters, it is said, “have to happen”: they are no longer believed to be in the nature of things. Of course, the right to a life free of suffering is most clearly asserted when suffering is caused – as it is mostly, in modern societies — by social evils: war, economic or political conditions, competition for precedence, and so forth. Humiliation, rejection, thwarted ambition are felt as unjust – as contrary to expectations and thus resulting from illegitimate intervention of malicious others.
Greenfeld’s argument is that modern culture causes problems with identity formation which can lead to “biologically real” mental illness. She is therefore arguing that diseases like schizophrenia, bipolar, and depression are not as old as humanity, but really began appearing about 500 years ago with the rise of nationalism.
Her work proceeds from the view that culture- the symbolic process by which human ways of life are transmitted historically, is an emergent phenomenon, logically consistent with the laws of physics and biology, but nonetheless autonomous. This is absolutely critical. It is this first view which distinguishes Greenfeld from the many biologists and anthropologists who see human culture as dictated by biologically evolved brain mechanisms and natural selection.
For Greenfeld, the mind is the individualized cultural process, or “culture in the brain.” The individualized cultural process is therefore dependent upon, but not determined by, the biological functions of the brain. Just as organic brain damage can cause symptoms of mental illness- problems with thought, mood, and speech for example – Greenfeld believes that problems with the mind (problems with culture, that is) can lead to problems with brain function.
Obviously, all I can do here is prevent a bare-bones, unsupported version of Greenfeld’s theory and set in against the dominant view of the day. She is well along in the process of writing a book on this very subject and I look forward to its publication. Her work is not meant to go against, but to complement and elucidate research on the biology and genetics of mental illness. Genetic susceptibility probably goes a long way in explaining why only certain individuals experience mental illness, but it is important to acknowledge, (as Dr. Satel’ article does) that the extensive research to date hasn’t revealed a genetic cause of mental illness:
Psychiatry, alas, has a long way to go. “Although the past two decades have produced a great deal of progress in neurobiological investigations,” notes a recent paper written to guide preparation of the forthcoming DSM-V, “the field has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder or for predicting response to psychopharmacological treatment.” Indeed, almost all of the recent genetic findings are not specific. A particular gene associated with bipolar illness was later discovered to occur in people with schizophrenia. The same goes for almost every other major finding — leading to the current hypothesis that these various genes confer risk for psychopathology, but not for any specific kind.
Nevertheless, the dogmatic view that true, serious mental illnesses are caused by a problem in the brain hasn’t lost any steam. Satel writes:
As brain-based etiologies of classic serious mental illnesses, such as schizophrenia and bipolar illness, are uncovered, psychiatry will probably lose those diagnoses to neurology. Perhaps one day psychiatry will cater only to patients suffering from existential crises. But not anytime soon.
Dr. Satel seems to feel that as a psychiatrist, her job is not to figure out the exact nature and cause of mental illness, but to provide the best patient-care possible, and I guess I can’t argue with this.
… in his essay the weary Dr. Spitzer admitted that, “I doubt that clinicians will ever be very concerned with what illness itself is…. Concerns with defining medical or psychiatric illness or disorder are generally left to sociologists, psychologists, philosophers of science, and members of the legal profession.” This is deeply true. Front-line clinicians will not be joining the fray anytime soon. The academic debate over the evolutionary history of their patients’ woes is irrelevant to everyday practice.
I suppose that so far, academic attempts to define mental illness have been “irrelevant to everyday practice” because they haven’t resulted in any understanding of etiology or pathogenesis that could be translated into treatment and prevention strategies. But just because nothing has been solved so far, doesn’t mean a radical new approach might not prove to be more than added noise in the “academic debate.”
Satel concludes that “in the end, the most we can say about mental illnesses is that they are the result of various interrelated causes unfolding at different levels of explanation: biological (genetic or cellular), cognitive (information processing), and psychological (the generation of meanings in contexts).” I believe Greenfeld’s view of the mind as the individualized cultural process can help put together this causal puzzle that Dr. Satel describes. But this can only begin if we allow for the possibility that human experience is not determined by our biology. If we persist in the hope, (which I believe Satel holds), that we will one day grasp “how those swirling galaxies of neurons and molecules make us who we are, both in sickness and in mental health,” we will never stop “struggling in the dark.”
Thanks again to Dr. Sally Satel for the comment that sparked this post. You can read more of her writing here.
Posted on February 22, 2010 - by David
More on the DSM-V Changes
I regret how spotty my posts have been lately, but if I’m not writing something new every day the best thing I can do is point you to someone else’s work. With the proposed changes for the DSM-V being made public last week, there are plenty of opinions floating around on the internet. I found this op-ed piece from the Wall Street Journal by Yale psychiatrist Dr. Sally Satel interesting.
She points out that many of the proposed changes, (as well as the opposition to those changes), have more to do with stigma, labels, and identity issues than actual advances in the understanding of mental illness. Satel also mentions the common overlap in symptoms and diagnoses within individual patients, and underlines our relative ignorance as to how genes are actually related to mental illness:
The other problem that confounds psychiatry is how to draw boundaries around diagnostic categories, given that we rarely know the cause of mental illness at the neural level. Mental illnesses are the product of numerous genes that interact with one another, with the environment and also with experience. (A recent study by the National Institute of Mental Health found that 80 genes could be associated with bipolar disorder.) Add to this the miasma of social and personal encounters that impinge upon the genetically vulnerable individual—stress, poverty, family instability, drug or alcohol use, and so forth—and the causal mechanisms of any mental illness become staggeringly complex and elusive. Moreover, the “psychopathological pie,” as a colleague calls it, is rarely divided up as tidily as the manual implies. Patients often have symptoms that sprawl across several diagnostic categories. For example, half of kids who receive the diagnosis of bipolar disorder also have ADHD.
Of course, if you’ve been a regular reader of this blog you won’t be surprised that I take slight issue with her explanation of mental illness, (even though it might not be totally fair to judge her based on one sentence in a WSJ op-ed piece). The inadequacy of her own definition is made clear when she mentions that “80 genes could be associated with bipolar disorder,” but says nothing about how these genes “interact with each other.” Also, what is meant by “environment” and “experience” is unclear and could be taken in a variety of ways. She seems to offer a broad explanation for mental illness and demonstrates well that there major issues with the way we classify symptoms as disorders which often overlap, but like a good psychiatrists she still locates cause with genetics or “at the neural level.”
MindHacks has an extensive summary of the DSM-V changes with links to other major media coverage. I found his comments on the restructuring of the schizophrenia diagnosis and the addition of ‘psychosis risk syndrome’ particularly interesting. His article suggests that a lot of the more subtle changes are aimed at “de-freuding” the DSM. Definitely worth your time to check this out.
Posted on February 12, 2010 - by David
The Children Formerly Known as Bipolar
According to an article I read on Wednesday, a new diagnostic category is expected to be included in the upcoming DSM-V which may provide psychiatrists with an alternative to diagnosing the most troubled kids they see with bipolar disorder. The creation of the new diagnosis, called temper dysregulation disorder with dysphoria, seems aimed at dealing with concerns over the growing prevalence of the lifelong, stigmatizing bipolar label among children.
Back in the 90’s, thanks largely to the work of one Dr. Janet Wozniak, an assistant professor of psychiatry at Harvard, the bipolar diagnosis was stripped of one of its most defining characteristics as professionals puzzled over what to do with children with ADHD who were prone to particularly persistent and disruptive outbursts. The traditional definition of bipolar was closely tied to the presence of alternating periods of mania and depression, but these kids rarely if ever experienced the typical episodic fluctuations. In order to make the new use of the diagnosis stick, some argued that in children, the episodes might be very brief and occur many times throughout the day. Critics of the extended application complained that “there wasn’t good evidence that these kids grew up to be bipolar, and that if you looked backward at bipolar adults, they didn’t necessarily have these uncontrolled anger issues when they were young.” Nevertheless, the pediatric bipolar diagnosis quickly spread, and Wozniak maintains this is “because it made clinical sense.”
The article suggests that part of the shift to childhood bipolar diagnoses may have been related to a desire to treat this kind of behavior as a disease which could be dealt with via medicine. The only other diagnostic option seemed to be conduct disorder, which usually wasn’t treated with medication and seemed to imply a parental failure. Now, with TDD, the behavioral and mood problems can still considered a medical illness, but those diagnosed aren’t necessarily lumped into a category of people required to take drugs for the rest of their lives.
What really struck me when reading this article was how the language used to talk about this stuff makes it so plainly obvious that these psychiatrists and researchers really don’t know what it is they are dealing with. First of all, the shift in diagnosis in the 90’s had nothing to do with any breakthrough discovery about how the brains of children with behavior problems function. Basically, the symptom-based definition of a particular mental illness was revised or expanded to fit the troubling phenomenon that psychiatrists were observing. That is not how science is supposed to be done. To quote the article: “research psychiatrists worried that the children were being given a label that wasn’t right for them, and saddled with the sentence of a serious mental illness for the rest of their lives.” A label? Is it an illness, or just a label? Does the naming of the thing determine its nature? And if people have a serious illness of any kind, doesn’t it exist independently of any “sentence”?
I find it strange that the word ‘label’ is used over and over again and there’s all this talk about categories or diagnoses being created and changed in order to deal with stigma and avoid offending parents, and yet these psychiatrists believe that whatever it is they are talking about is unquestionably a problem with the brain. I mean, isn’t the reason they can’t decide what to call it that they can’t pin down what is actually happening with these kids? I can’t help but shake my head when I read that “it will be seen as a brain or biological dysfunction, but not as a necessarily lifelong condition like bipolar?” How exactly did they determine that this is a biological dysfunction? Is it just the assumption that if symptoms are severe and difficult to manage, it must be a brain malfunction?
The article ends with the following two paragraphs:
Of course there is no way to predict what practical effects creating the TDD category might have. For instance, Carlson points out that even if they are successful at changing the label that clinicians use, it could be that the kids all get the same medications as before. “They may get many of the same. Absolutely,” she says. “But the difference is going to be that you won’t have to take this for the rest of your life.”
Carlson doesn’t necessarily see this as a bad thing. She emphasizes that these children have very serious problems, and though there’s been trouble naming it, there’s clearly some sort of dysfunction in their brain. Shaffer agrees. “I don’t think anyone is arguing that these are perfectly normal children that get the label [bipolar] — far from it,” he says. “We’re saying these kids are very sick. But they probably don’t have bipolar disorder. And they probably do deserve a name that adequately describes what they’re doing.”
I’m not arguing that these kids are “perfectly normal,” but I do take issue with the idea that a team of psychiatrists can create a new category and say without any evidence that the problem they are attempting to describe has its root causes in biological dysfunction. Am I the only one who finds this approach both arbitrary and dogmatic? I believe these kids deserve more than a name that fits their symptoms. They deserve an approach directed at understanding the nature and cause of whatever it is they are suffering from.
We still have another 3 years to go before the DSM-V is published. It will be interesting to see if this the unofficial diagnosis comes into common use before then.
Posted on February 9, 2010 - by David
Allan Horwitz on the Medicalization of Depression
A few weeks ago a friend of mine sent me a link to a podcast interview with sociologist Allan Horwitz, author of a book called The Loss of Sadness which looks at the medicalization of depression. If you’re going to listen to the podcast, skip ahead to 4:51, where the interview (which lasts about 20 minutes) actually begins.
at 6:50 into the podcast, Horwitz says:
… In the current environment, genetic explanations are, one, given tremendous credibility, so if you can link things to genes that somehow makes it more important explanation than linking them to life histories or linking them to social circumstances… and that’s a cultural phenomenon, [there’s] no reality that they’re more important… And the second important phenomenon, which I also think is purely social, is that if phenomena are linked to gene it makes them seem as if they’re disorders whereas in fact there’s genes for perfectly normal personality dispositions or there’s probably genes that make us grieve when somebody close to us dies, certainly doesn’t mean bereavement is a disorder, but that the cultural valence of genes associates them with mental disorders..
At first, I was happy to hear someone point out that the prominence of genetic explanations of mental illness is a cultural phenomenon, not a reflection that they are actually more important than other perspectives. However, I got more and more confused as I considered what Horwitz actually says in this interview. Let’s just look at the above statement piece by piece.
1. It is a cultural phenomenon that genetic explanations of mental illness are given such prominence. Ok, check, I follow.
2. Linking phenomena to genes makes it seem as if they are disorders. Ok, I think I’m still with you, but are you telling me they have succesfully linked specific genes to mental disorders?
3. There are genes for behavior which we would consider normal, such as expressing grief when someone close to us dies. Wait, so are you saying there’s a gene for everything I do? Have they even linked sarcasm in blog posts to genes?
Let’s look at another piece of the interview, at 12:36
Horwitz: Depression is probably one of the very few psychiatric illnesses that’s been recognized for thousands of years, so it’s certainly not something that’s a new condition. From the ancient Greek philosophers, through the renaissance period, through the early psychiatrists, even through Sigmund Freud and the DSM I and the DSM II – it had always been a contextualized illness so that the people who become sad or even intensely sad in contexts where we would expect people to be sad – the loss of intimates, diagnoses of a serious physical condition, serious economic difficulties- these sorts of things were always clearly distinguished from the mental illness of depression, which either arises with no context or persists longer than the original context in which it arose or features extremely severe symptoms- vegetative symptoms, hallucinations and delusions, these sorts of things.
Interviewer: So you’re saying that there’s been this historical legacy of seeing depression as a pathology only when it doesn’t fit the context, when it doesn’t fit the situation.
Horwitz: Precisely, the symptoms are identical but one is contextually appropriate and the other is without cause or without reason.
Now I guess I’ll have to read his book to see if he gives evidence for his claim that depression has been recognized for thousands of years and has “always been clearly distinguished” from normal, “contextually appropriate” sadness. (I will point out that all the examples he rattles off are clearly part of Western culture). It’s a bit confusing that he says the symptoms of “the mental illness of depression” are more severe than expressions of normal sadness, and then later says “the symptoms are identical” but in some cases they are not contextually appropriate. I do get the point he is trying to argue- that social and other contexts should be taken into consideration when making a diagnosis of depression- but I’m don’t think he’s being very clear or convincing.
He is critical of the emphasis on genetic explanations of mental illness because it confuses normal reactions to life with disorders, but at the same time he claims that the “the mental illness of depression,” where the symptoms are severe and not contextually appropriate, has been recognized for thousands of years. So his argument basically amounts to a claim that the prevalence of depression is greatly overestimated because context is no longer considered when diagnoses are made. But where does this leave us with regards to the real, true cases of depression? Apparently, context can help explain why some reactions aren’t disorders, but Horwitz says nothing about how cultural context can account for the phenomena which actually are disorders. In fact, Horwitz seems to inadvertently reaffirm the prominence of the biomedical/genetic account of mental illness. By essentially suggesting that phenomena which can be explained by social and cultural contexts are not actually disorders, he places the true, severe, undeniable forms of mental illness in a category which only biology and medicine can touch.
Posted on February 2, 2010 - by David
Fish Oil the Latest in Psychiatric Treatment?
This article summarizes the results of a study from the University of Melbourne, which suggests that the omega-3 fatty acids found in fish oil may help prevent psychosis in adolescents and young adults who have been identified as “at-risk.”
The study involved 81 individuals ages 13-25 “who met at least one of the following three criteria: having low-level psychotic symptoms; having transient psychotic symptoms; or having a schizophrenia-like personality disorder or a close relative with schizophrenia, along with a sharp decline in mental function within the past year.”
For 12 weeks, half the group was given fish oil capsules and the other half recieved placebo. Participants were then monitored for next 40 weeks. Only 2 of the 41 people given fish oil developed a psychotic disorder compared to 11 of 40 of the placebo group. The omega-3 group also “also showed significant reductions in their psychotic symptoms and improvements in function.” The researchers hope to replicate the findings in a multicenter trial involving 320 people.
Certainly, the lack of adverse side effects compared to the commonly used anti-psychotic medications would make this treatment a much preferred choice for patients. While these findings are definitely positive, it was a very small and relatively short-term study, so further research is obviously needed to determine the value of fish oil as a treatment or preventitive measure for serious mental illness. Also, this once again highlights how little is understood about what is happening in the brain of the schizophrenic patient. The article mentions some of the potential reasons this novel treatment may be effective:
There are a number of mechanisms through which omega-3s could protect the brain, Amminger said; they are a major component of brain cells. They are also key to the proper function of two brain chemical signaling systems, dopamine and serotonin, which have been implicated in schizophrenia. Fish oil also boosts levels of glutathione, an antioxidant that protects the brain against oxidative stress.
In the quest to understand the cause and progression of this illness, nearly every neurotransmitter and every part of the brain has been implicated in some way or another. While hopefully this study will lead to new ways of dealing with the symptoms of schizophrenia without the devastating side-effects of many commonly prescribed drugs, it seems to be another example of a “scientific” answer which amounts to, “this might work, and if it does, these might be some of the reasons why.”
Posted on January 29, 2010 - by David
Ethan Watters on the Daily Show
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The other night, Ethan Watters appeared on the Daily Show with Jon Stewart to talk about his new book, Crazy Like Us: The Globalization of the American Psyche.
At a little past 4 minutes into the clip, Stewart says:
We could make the argument that when we went over into parts of the undeveloped world with vaccines, and they thought we were poisoning them, you know, we weren’t, we were just trying to cure some diseases, why should we neccesarily give deference to something that might be a superstition, only because it has the value of “well it’s their culture” ?
Watters response echoes one idea which is central to the book: In our attempts to share medical knowledge and treatment with the world “we often bring cultural ideas that may be replacing ideas that actually are helpful in those other places…”
This answer glosses over the main difference between sharing vaccines and sharing treatments for mental illness: Our vaccines actually worked! And they are used to prevent illnesses which we actually understand! Unfortunately, Watters misses his chance to make a bigger point about differences in the nature of mental illness from culture to culture. Still, I think he’s doing a lot to shift the focus of the discussion towards cultural factors.
Posted on January 28, 2010 - by David
Crazy Like Us, Part 4: Depression in Japan
Chapter 4 – The Mega-Marketing of Depression in Japan
One of the main ideas in Ethan Watters’ book, Crazy Like Us: The Globalization of the American Psyche is obviously that the active exportation of Western conceptions of mental illness has had a largely negative effect of the expression of these illnesses in other cultures. Nowhere is his criticism of this process more evident than in the final chapter on depression in Japan. Watters shows how drug companies went about actively creating a market for their products by both determining effective, culturally specific messages and ghostwriting research studies which would give credence to their claims of the need for, and efficacy of the SSRI anti-depressants. But what I’m most interested in looking at in this chapter is the evidence that depression as we know it is still missing from Japan.
At the end of the chapter, Watters concludes that the “mega-marketing” scheme seems to have worked in terms of profit. In its debut year in Japan , sales GlaxoSmithKline’s Paxil (the main drug discussed in the chapter) brought in over a hundred million dollars. By 2008, less than ten years after it was introduced, sales had grown to over a billion. This kind of gives the impression that depression, or at least its treatment, is now nearly the same in Japan as in the U.S. However the results of one small, impromptu survey I’ve been a part of twice suggest that the prevalence of depression in Japan is still nothing compared to America. Once a few years ago, and again this past November, I was present in Liah Greenfeld’s modernity seminar at Boston University when professor Chikako Takeishi of Chuo University in Tokyo brought a group of her students to class as part of larger U.S visit to cultural sites and institutions. Greenfeld asked her American students if they were friends with someone who had been depressed, and every hand went up. She then asked how many of us had been depressed ourselves, and I’d say a third, if not more of us, (including myself), raised our hands again. The responses of the Japanese students were strikingly different. Out of about 20 students, I believe no more than 3 said they had friends who had been depressed, and none of them had been depressed themselves. These were our Japanese counterparts – university students from an industrialized and technologically advanced nation under as much, if not more, pressure to succeed than we were. Of course, a number of objections could be made regarding the methodology of our little study, but Watters book makes one thing clear: thanks in large part to the efforts of companies like GlaxoSmithKline, it was no longer possible for these students to be ignorant of what we were talking about when we used the word “depression.” They knew conceptually, but none of them knew intuitively, experientially, like we did, what it was to suffer from this illness.
One of the reasons depression might appear to be a problem in Japan is the cultural prominence of the melancholic personality type. While in the West, we associate melancholy with depression to such a degree that the two are almost synonymous, this is not so in Japan. The typus melancholicus was adapted into Japanese psychiatry in the 1960’s from a German professor named Hubert Tellenbach. It seems the idea caught on not as a result of any forceful marketing but because the description of this personality type corresponded to certain highly valued characteristics. As Watters writes, “its association with such prized Japanese traits as orderliness and high achievement meant that having such a sadness-prone personality was something not to be feared but aspired to” (208). Some have identified the importance of Buddhist beliefs about suffering as an explanation for the value placed on sadness in Japanese culture. So while on the outside, Japanese sadness may look like our depression, the difference seems to be that, for the most part, the Japanese experience is not maladaptive to the culture or a cause of dysfunction. Watters quotes professor Margaret Lock of McGill University, who believes that some experiences which we see as negative symptoms may actual serve to strengthen social ties among the Japanese:
Feeling sad and reacting sensitively to losses, particularly of loved ones, is an idea that has singular appeal in Japanese. The theater, a range of literature and indigenous popular songs, traditional and modern, positively wallow in nostalgia, sensation of grief and loss, and a sense of the impermanence of things. People cry freely (by North American and northern European standards) about separation and lost loved ones, but at the same time they seem to draw strength from these experiences, to tighten their bonds with those who remain living, and to reaffirm group solidarity (212)
While this tendency towards melancholy may account for some of the confusion, there is an even greater reason why many see the Japanese as a deeply depressed culture: the astounding suicide rate. I agree with Watters, who writes that “most Americans would certainly assume that suicidal acts are nearly always caused by mental illness, most commonly depression” (218). The Japanese, though, have a long cultural history of suicide for reasons other than what we might expect. Watters references psychiatrist Masao Miyamoto, who has argued against the notion that the rise in suicide is related to depression. “A peculiarity of the Japanese is that they often die for the sake of the group,… They die for shame” (219)
In his classic study on suicide, sociologist Emile Durkheim identified altruistic suicide as one of three definitive types of suicide. In contrast to egoistic suicide, which results when society is not well-integrated and is unable to hold the individual members together, altruistic suicide occurs when the individual is so totally absorbed in the group that his own life loses value. A suicide “for the sake of the group” falls into the altruistic category. We can see in the story of young Oshima Ichiro, (featured prominently in this chapter), how excessive social integration and lack of individual identity can lead to suicide. In 1990, Ichiro, 24, joined the Dentsu advertising agency, which Watters describes as “the largest company of its kind in the world” (214). The Japanese market was in the midst of a dramatic economic downturn, while only a few months earlier it had been the envy of the world. By Watters’ description, Ichiro pretty much handed his life over to the company. Apparently, he was working an average of 47 overtime hours a week, though interestingly, based on his time sheets he only averaged 12 to 20 hours overtime. This suggests to me that he saw it as his duty to put in the time necessary to help his company succeed without demanding excessive compensation. Also, it seems the treatment he received at work was by American standards far below acceptable. Watters writes:
At one late-night drinking binge at the office, Oshima’s boss poured beer into his own shoe and demaned that Oshima drink it down. When he momentarily refused the request, his boss beat him. (216)
Also striking is the fact that an hour before his family found him hanging in the bathroom, Ichiro called the office to tell them he was sick and wouldn’t be making it in. Obviously his identity had been completely absorbed by the Dentsu advertising agency. Even in the moments before his death he could not forgo his duty to at least notify the company that he would be absent that day. While many American identities are wrapped up in work, Oshima Ichiro’s identity belonged to the company that employed him, and I believe this is an important difference. Perhaps the most typical question asked when two Americans meet for the first time is ‘what do you do?’ , and we all understand that this means ‘what do you, as an individual, do for work?’ While our identities are linked to our individually chosen pursuits, it seems for the Japanese, identity is much more about who you are connected to. For Ichiro, failure would not be merely personal, it would mean letting all the other members of his company down, as well as his family and society as a whole.
While I’ve tried to show that suicide in Japan is not necessarily the result of depression, there are ways in which it may be related to modern societal changes. The third type of suicide which Durkheim mentions, anomic suicide, is caused by a lack of regulation in society. While this type is closely related to egoistic suicide, (and Greenfeld’s definition of anomie goes a long way towards reconciling the two into one), Durkheim focuses much of his discussion of anomic suicide specifically on lack of economic regulation. It seems likely that the huge economic swings related to competition in the global marketplace introduced a new level of stress to the Japanese workforce, further augmenting the cultural tendency towards suicide. For centuries, the Japanese have been dying for shame and the sake of the group, and their marriage to the modern economy seems to be a deadly union.
These two articles from the New York Times archives give some relevant background information on the topic of depression in Japan, as well as introduce what I see as one of the major problems with the whole discussion of depression in general. The first I believe is representative of the “depression is a serious brain disease” camp, while the second tends towards the “we have medicalized sadness” stance. For some reason, it seems that the implied middle view- the possibility that something is indeed seriously wrong, but the root causes of the problem are not simply biological or genetic- hardly even exists in the discussion. I guess I’m trying to do what little I can to change that.
Posted on January 24, 2010 - by David
Crazy Like Us, Part 3: Schizophrenia in Zanzibar
Chapter 3- The Shifting Mask of Schizophrenia in Zanzibar
In the first two chapters of Ethan Watters’ new book, Crazy Like Us: The Globalization of the American Psyche, we encounter the idea that differences in source of identity and social integration between cultures may account for differences in the expression, (and prevalence), of mental illness. The third chapter suggests that cultural differences may also explain the rather enigmatic finding that those diagnosed with schizophrenia in the “developing” world seem to fare better than their Western counterparts. I found anthropologist Juli McGruder’s case studies particularly interesting, as they raise the possibility that the cause, or at least trigger, for schizophrenia may lie in cultural conditions.
I think it’s worth noting, as Watters points out, that despite the privileged position science has been given in the study of schizophrenia and all the technological advances of the last few decades, we still know very little about the causes of this strange affliction.
More than any other mental illness in the Western world, this one belonged to the “hard scientists” who looked for the causes in bad genes, biochemistry, and the structure of the brain. The advent of brain scans – allowing a researcher to see into the head of live patients – brought with it a seemingly endless series of theories about the root cause of the illness. Abnormalities supposedly key to schizophrenia have been reported in the frontal cortex, the prefrontal cortex, the basal ganglia, the hippocampus, the thalamus, the cerebellum – and pretty much every other corner of the brain as well. No firm consensus had emerged about the location or cause, but there was wide agreement that the exciting advances in understanding the disease were coming from the laboratories of brain researchers.(134)
In the meantime, there are others like Juli McGruder who, (like sociologist Liah Greenfeld), believes that “culture and social setting play a more complicated role in the disease than simply influencing the content of the delusions.” (136) Scholars on the cultural side of the fence point to the results of two international studies by the World Health Organization. The WHO research, which began in the 1960’s and lasted 25 years, suggests that the severity of schizophrenia is not the same worldwide. Watters summarizes the findings:
What they found was that those diagnosed with schizophrenia living in India, Nigeria, and Colombia often experienced a less severe form of the disease (had longer periods of remission and higher levels of social functioning) than those living in the United States, Denmark, or Taiwan. Whereas over 40 percent of schizophrenics in industrialized nations were judged to be “severely impaired,” only 24 percent of patients in the poorer countries ended up similarly disabled. (137)
Liah Greenfeld believes that anomie, which she considers a built-in feature of modern culture, causes problems with identity formation which often lead to mental illness. In Nationalism and the Mind, she describes this phenomenon and its effects on individuals:
Anomie, commonly translated as “normlessness,” refers to a condition of cultural insufficiency, a systemic problem which reflects inconsistency, or lack of coordination, between various institutional structures, as a result of which they are likely to send contradictory messages to individuals within them. On the psychological level anomie produces a sense of disorientation, of uncertainty as to one’s place in society, and therefore as to one’s identity: of what one is expected to do under the circumstances of one sort or another, of the limits to one’s possible achievement… (14)
The chronic, modern state of anomie may not (yet) be a built-in a feature of Zanzibari culture, but when we use the word “developing” to describe a country or culture, we imply that they are developing into something more like us, i.e moving towards modernity. This process of modernization is necessarily anomic:
Anomie, is, in fact, the ultimate cause of cultural change. It both breaks the old cultural routine and encourages the formation of a new one. The general pattern of human history can be imagined as an alteration between relatively brief and rare periods of widespread (though culturally localized) anomie and cultural routine. Widespread anomie, most commonly implying gross inconsistencies between elements of culture impinging on individual identities, specifically inconsistencies within the system of social stratification which defines a person’s position in the social world in general and vis-à-vis particular others, affects large groups of individuals and expresses itself in social turmoil. (14-15)
I wasn’t surprised, then, to see the title ‘Revolution and Madness’ above the section introducing McGruder’s first case study. Watters describes the state of affairs in the country at the time when Hemed began to experience symptoms of schizophrenia:
After years of being a British colony, Zanzibar embarked on the uncertain path to self-governance. There were three political parties, twenty-two trade unions, and sixteen partisan newspapers stirring up anger and resentment on all sides. Hemed’s first experience of derangement, McGruder believes, was sparked by the social upheaval of the time. (142)
Given what was going on in that moment in the history of Zanzibar, the amount of stress felt by Hemed must have been intense. He was a middle-class man from a high-profile Arab minority at a time of growing racial and class distrust. His curly dark hair and facial features made him identifiably Arab. There seemed to be no safe political refuge. Even the political party he belonged to, the Zanzibar Nationalist Party, was internally split between those who considered themselves African and those of Arab heritage. No one knew whom to trust. (143)
We can also see how conflicting cultural messages may have played a role in the experience of Kimwana, Hemed’s daughter who suffered from the same illness.
She was a happy child even though her early years were turbulent times for the island. Her mother and classmates remember her as the brightest student in the class. Particularly skilled with numbers, she graduated from secondary school and took a job with the Ministry of Finance. This was 1983, a time of rapid change for women on the island. To fill in for the many educated men who had fled the political upheaval, women were beginning to enter the professional workforce by the thousands. (144)
While we in the West would see these new opportunities for women aa a change for the better, there still existed traditional guidelines on behavior which seemed to contradict this elevation in social status. It was only a few months after Kimwana started her new job that she began to hear male voices “gossiping that she was a disloyal and disrespectful daughter and sister” (146). Before the cultural changes which led to an influx of women into the workplace, Kimwana’s identity would have been based primarily on her relationship to her family and in behaving according to the prescriptions of the Islamic religion.
Much of the torment of having these male presences in her head related to Islamic rules of female modesty. While the voices were with her, she felt she must respect the codes of conduct as is she were actually in the presence of a man. At such times she could not bathe or undress and she tried not to go to the bathroom. Although she sometimes found it helpful to argue with the voices when they became critical, her sense of decorum made it difficult to do this out loud. (146-147)
In this section of the chapter, Watters highlights McGruder’s amazement at the ability of Amina, the mother and effectively the head of the household, to care for the large family and its two sick members. Her daily activities seem to far surpass western notions of busyness, and she takes the extra load created by mental illness in stride. This is possible, I believe, because she is secure in her identity in a way that neither Hemed nor her daughter Kimwana could be. She was raised to serve her family and God, and that is what she does. McGruder compares the Western, Christian attitude towards adversity to Amina’s stance and sees an importance difference.
In the cosmology of Western Christians, life’s challenges provide opportunities to become stronger and to have a closer relationship with God. The burdens God sends to Christians in the Western world are incitements to self-improvement. The comforts that Amina found in her religious belief, by contrast, were not in an encouragement to overcome or learn from hardships. Rather, simply accepting her burden was a continuous act of penance. (155)
In other words, the challenge of caring for her sick relatives did not provide a reason to change her identity. Her identity was essentially unchanged since childhood, she was merely to continue behaving and believing as she always knew she should. Unfortunately for her daughter, the conflict between the new cultural value of work for women, and the traditional emphasis on family and religion proved too much for her mind to handle.
The chapter also describes the damage often done by family members’ emotional over-involvement in the lives of their schizophrenic loved ones. This cultural tendency, according to Watters, is closely related to the Western emphasis on individual identity and the belief that individuals should be able to control their own destinies. As in the previous two chapters, the resounding message is that the highly individualistic nature of identity in modern societies and the lack of clear, shared cultural beliefs and practices lead to more widespread and more severe forms of mental illness.
Exploring modern culture and its effects on the mind