I have just finished reading ‘Crazy Like Us’ by Ethan Watters, and although published 5 years ago, its critical perspective on the spread of the DSM IV’s definitions of mental health throughout the rest of the world, is critically pertinent to current discourses within mental health.
The book covers four common possible diagnoses found in the DSM IV; Anorexia, PTSD, schizophrenia and depression, and describes how significant environmental and social events were used by proponents of the western diagnosis model to spread DSM IV diagnostic criteria, and treatment interventions. Although initially suspicious of what appeared to be a conspiracy type perspective, I soon became fearfully aware of the truth within Ethan’s arguments. A strong current that flows through most of the book, is the idea that existing mental health symptoms and definitions are characterised largely by culture. So what the wider society considers as being relevant for defining a mental illness, dictates whether a person has, or hasn’t got a mental illness. Emphasised were cultures which did not have pre-determined definitions of disorder, such as PTSD or schizophrenia, until the arrival of western ‘professionals’ who characterised and labelled them according the DSM IV.
Ethan also proposed how physical and emotional symptoms changed, depending on dominant narratives within cultures. He argued that western professionals took advantage of this by creating symptom pools, which given enough media and social credence, often resulted in a mirroring of these behavioral and emotional expressions throughout that society. He gave an example of how anorexia played some part in ‘replacing’ hysteria in the late 19th century, and how the expectations and beliefs of the medical establishment at the time actually played a significant role in changing the physical symptoms of what was then hysteria, to what we now see as anorexia nervosa.
I found these observations useful, particularly within my work with asylum seekers and refugees, as often people will present with physical pain and ailments in various parts of the body sometimes with an unrecognisable organic cause. Although this will be partly due to medical technology being insufficiently advanced to detect neurological damage, I do suspect that at times what is witnessed is a different presentation of psychological distress, indicative of a different cultural way of responding to trauma when compared to western presentations. The western concept of a mind / body distinction is actually quite unique when compared to many other cultures.
It also encouraged reflection on the way I intervene with asylum seekers and refugees experiencing distress. The author described historical events, where PTSD therapists rushed over to treat victims of natural disasters in other countries, but neglected to consider existing important cultural approaches to responding to trauma. For example, some cultures place great credence to responding to trauma by getting involved and enmeshed in social activities and necessities, and place little worth on one 2 one discussion around their feelings or difficulties. PTSD therapists who attempted to treat people through this one to one therapy, were criticised for taking people away from their traditional cultural response to trauma, and failed to appreciate that they may be further emphasising experiences of isolation and loss of community.
As well as my work with asylum seekers and refugees, the book also encouraged reflection on my other work within CAMHS and previous roles as a youth worker. A current debate within the mental health profession is between the medical model, where an organic cause for mental illness is attributed, versus a more psychological and social approach, which attributes psychological distress to being symptomatic of wider systemic factors, such as poverty and deprivation. The obvious critical reflection that this book could have prompted, would have been around how much do we as a CAMHS team tackle mental distress from a disease oriented ethos, when compared to a more holistic systemically minded approach. However this wasn’t my thinking. Instead, it brought to mind overheard conversations between frustrated CAMHS professionals, expressing angst at referrals pleading for mental health treatment for children, often enmeshed in situations of gigantic stress.
I remember initially feeling unsympathetic to these views, and recalled previous experiences when I was on the referring end, feeling amazed that a mental health service wouldn’t accept a referral. I remember how as youth workers we would often refer into CAMHS on behalf of young people, and often would place great importance in encouraging young people to consent to referrals, or attend CAMHS appointments. My criticism though was not directed at CAMHS. As a youth worker, reasons for referral were often because we felt like the young person needed help, or that if we didn’t make a referral then we would be placing that young person at risk. However, what ‘Crazy like us’ encouraged me to question was the message that I was communicating to these children and young people. Often they were in the midst of homelessness, abuse, crime, or other social and familial upheaval, and so consequently psychological distress was often prevalent in one form or another. Was I communicating that there was something wrong with them? That they had another ‘problem’? That there was something within them that needed to be ‘fixed’ or ‘treated’. Was I pathologising? Was I doing what the mental health professionals in ‘Crazy Like Us’ were criticized of doing, of imposing and attributing an illness on someone, when the real problem lied elsewhere? So surprisingly, my criticism of pathologising and medicalising people’s distress was not directed towards the medical profession, but towards community and social organisations.
What this highlighted to me is that there is a narrative to be challenged, not just within the medical profession, but also within wider society. Yes there needs to be increased funding to tackle mental health problems, but I think there is also a role for challenging a narrative in society around what mental health, is and how to deal with mental health difficulties. This can be tackled firstly by training community and social organisations using approaches from a ‘Recovery Model’ perspective. I would also suggest that increases in funding is directed towards primary mental health services, to facilitate this training, and that service users are a significant part of the delivery of this training. Secondly I would suggest that media is used as much as possible as a platform to help facilitate a change in narrative around mental health in society. We need to focus our energies not just on challenging oppressive discourses within the mental health profession, but also within schools, social services, and throughout wider society.