Western Psychiatric Imperialism, or Something Else?

In a very long essay in the Sunday (1/10/10) New York Times Magazine, entitled, “The Americanization of Mental Illness,” Ethan Watters suggests that a kind of psychiatric-cultural imperialism has been foisted on other countries and cultures by “the West.”

Specifically, Watters claims that, “For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world…. There is now good evidence to suggest that in the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures.”

Watters claims, for example, that as the general public and mental health professionals in Hong Kong “…came to understand the American diagnosis of anorexia,, the presentation of the illness in Hong Kong actually became more “virulent.”

Though the Watters thesis has its merits, it is also glib and simplistic in many of its assumptions and conclusions. To be fair: Watters rightly calls attention to the ways that culture and ethnicity can shape both the diagnosis and expression of psychiatric conditions and symptoms. But this is hardly news to psychiatrists: the late Dr Ari Kiev advanced much the same thesis in his 1972 book, Transcultural Psychiatry.

Watters’ more controversial claim is that the exportation of American psychiatric nosology and “biomedical ideas” has changed the way symptoms are diagnosed and expressed in some other cultures. But this claim is very hard to validate. The “American” diagnostic system is, in the first place, not terribly different from the World Health Organization’s International Classification of Disease (ICD), whose descriptions of “mental and behavioral disorders” evolved almost contemporaneously with those of the last two DSMs. It would be very hard to tease out the cross- cultural influence of the DSM classification from that of the ICD, over the past 30 years. More important, Watters fails to consider alternative explanations for his “findings”; for example, rising rates of DSM-type anorexia nervosa in Hong Kong could be due largely to increased recognition of a long-standing, indigenous disorder that heretofore had not been fully appreciated by Chinese clinicians.

An example from American history helps make the point. Many of the basic symptoms of post-traumatic stress disorder (PTSD) have been recognized for centuries—at least since the U.S. Civil War, and probably much earlier—and have gone by various names, such as “soldier’s heart,” “combat fatigue," “shell-shock,” etc. But it took the efforts of troops returning from the Vietnam War to “push” psychiatry toward recognition of PTSD as a bona fide disorder. Understandably, apparent PTSD prevalence rates have soared since the diagnosis entered American nosology in 1980, with the advent of DSM-III. But it is entirely possible that the actual prevalence of PTSD symptoms in the U.S. has not changed markedly over many generations.

So, to return to Mr. Watters’ thesis: it would not be surprising to find that, as clinicians in other cultures began to familiarize themselves with DSM or ICD psychiatric disease criteria, the apparent prevalence rates of certain psychiatric conditions increased in those countries. It is quite another thing to imply that the actual prevalence of these conditions has increased—and that their morphology has changed--as a result of Western influences. Yet Watters seems to imply just this, when he asserts that

“…a handful of mental-health disorders — depression, post-traumatic stress disorder and anorexia among them — now appear to be spreading across cultures with the speed of contagious diseases. These [Western-based] symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness.”

We would need several generations of very sophisticated epidemiological studies, carried out using identical diagnostic criteria, to substantiate this “contagion-replacement” hypothesis. Anecdotal data, such as those presented in the Watters article, are inadequate. But even if Watters is correct, his claims do not answer the fundamental medical-ethical question: will adopting “Western” diagnostic criteria ultimately lead to a net reduction in suffering, and a net increase in well-being, in other cultures? If, after careful systematic study, the answer to this question turns out to be no, our Western paradigms will have failed. If the answer turns out to be yes, we may conclude that we have been exporting a very valuable commodity.

Ronald Pies, MD

Dr. Pies would like to acknowledge both Rakesh Jain MD and Sandy Naiman for inspiring this blog.