It's taken me a while to process my impressions and thoughts about Ethan Watters' provocative essay The Americanization of Mental Illness that ran in last Sunday's New York Times Magazine.
If you want to know the truth, I've been living with him – or it feels that way – all week. Initially, his article excited me, especially in its criticism of the way American psychiatry is "homogenizing the way the world goes mad."
Of course, this isn't entirely true. Nor is it new. Here's what I wrote in an article titled "My Life in Labels" in the Spring/Summer 2007 issue of the Canadian Mental Health Association magazine Network:
"Years ago, a diagnosis could depend on where you lived. In the 1970s, the joke among North American psychiatrists was that ''you could cure schizophrenia if you could fly to Europe,'" where psychiatrists there, using the tighter diagnostic criteria of the World Health Organization's International Classification of Diseases or ICD, would more likely diagnose you with bipolar disorder, which was more treatable. Here, where the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders or DSM is the standard reference, you would most likely get stuck with schizophrenia – then, much harder to treat and often considered hopeless. Now, such discrepancies are less likely as diagnostics have become more globally understood."
Watters essay was adapted from his brand new book Crazy Like Us: The Globalization of the American Psyche, which was published last Tuesday and which I haven't yet read.
That, in itself, is a problem.
Several writers have reacted to this story over the past week and there are links to their posts in the comments to my last post. I wanted to know how a Western-trained psychiatrist would react to Watters blistering critique of Western – read American – psychiatry and it's global reach. I fired off an email to my friend and mentor, Tufts University clinical psychiatrist and researcher Dr. Ron Pies.
A couple of points were of interest to me and Ron addressed them in a way that I found both wise and humane. After all, I take a holistic approach to health and well-being that encompasses mind, body, soul and spirit. The whole package. So does he. As does my psychiatrist.
"BRAIN DISEASE" VERSUS "MENTAL ILLNESS"
On the subject of "brain disease" vs. "mental illness" – here's what Dr. Pies wrote in his response to my email:
"I think this is a sterile debate that has plagued the field for decades, and is the baneful legacy of our friend Rene Descartes, with his mind/body dualism! My own view, which was anticipated by the late Robert Kendall, M.D., is that 'disease' is properly attributed to persons – not 'minds' or 'bodies.' As Kendall puts it in J. Schaler's book, Szasz Under Fire, p. 41)...
"Neither minds nor bodies suffer from diseases. Only people ... do so, and when they do both mind and body, psyche and soma, are usually involved."
Pies added, "The idea actually goes back to the great physician Maimonides, who said, "The physician does not cure a disease, but a diseased person."
I am comfortable with the person I am, warts and all. Though I'm no cultural anthropologist, when it comes to psychiatry, in all honesty, I've been studying it from the inside for close to 50 years as a patient. No formal training, just one long extended, sometimes bumpy but endlessly fascinating field trip that began in 1960.
In those days you rarely ever saw the word "psychiatry" in a daily newspaper or magazine. Psychiatry was almost unmentionable. It seemed to be more black magic than medicine. It was just a few years into its "chemical" age and just out of the age of the frontal lobotomy.
Also, I'm Canadian, with a slightly different take on some things, including psychiatry and medicine. I've grown up in a family of doctors, most of them specialists and academics. I've also learned that one's family culture, perhaps more than one's national, ethnic or even religious cultures, is astoundingly powerful in determining how you see yourself, your beliefs, your values and your personal outlook on life – especially if it is determined that you have a "mental illness."
Case in point. Until about four years ago, I really bought into the "Western Biomedical Model" of mental illnesses – hook, line and sinker. I was convinced that my mental illness was chronic, like diabetes (ugh!) and I was, indeed, deficient in some deep-seated way. I knew the chemical imbalance theory of the causes of mental illnesses is just that – a theory and unproven, according to Dr. Bob – still, I function best with a medication, one tool in many I use to stay as healthy as I can. (I have a large toolbox.)
Still, I believed that there was something wrong with my mind. This, despite a successful journalistic career, a wonderful new marriage and a good life. I believed that there was something terribly wrong with me but that through my therapy, I was righting it.
INTERNALIZING YOUR DIAGNOSIS
Long ago, I internalized my diagnoses – and oh, what damage that does to one's psyche, let me tell you, especially when you're 18 and you discover have schizophrenia. It took another seven years to right that misdiagnosis. All this was part of my family's culture, too. After all, I am still seen as The Family's Resident Nut Case and recently, one of my relatives said, in a rather accusatory tone, "You've made a career out of your mental illness."
Several things have happened to change that. Now, I know I'm okay. And I choose to believe that we're all "next to normal."
First, I was asked to speak to a group of psychosocial rehabilitation specialists and in doing my homework, I discovered the mental health recovery movement.
This was an epiphany for me. A seismic shift in my consciousness. It was possible to be in recovery. I could recover. In fact, I already was in recovery. I didn't even know it. Can you believe how stupid I was?
I had known there were other non-psychiatric mental health models like Fountain House, which started the International Clubhouse Movement, but this time, the reality that you can recover from schizophrenia and bipolar disorder and other serious mental health problems and live a meaningful life – like mine – really sank in.
So I started seriously researching.
Around the same time, my mother told me about a Benedict Carey story in the New York Times. "You must read it. It sounds just like you," she said. The headline – Hypomanic? Absolutely. But Oh So Productive! When I showed it to Dr. Bob, initially he resisted, but ultimately, he agreed and changed my diagnosis. After all, I've been manic, psychotic, but never depressed. I'm unipolar with a vulnerability to mania. Where's the bipolarity in that?
Though Dr. Bob wasn't enthusiastic about the idea of mental health recovery when we first discussed it, he's gradually changed his mind about its potential power and the way it transforms people's lives. I've grown increasingly recovery-oriented and also increasingly skeptical of the way the American biomedical model operates. For many reasons. Diagnosing young children with psychiatric conditions and prescribing powerful medications for them – medications untested for children – is criminal, as far as I'm concerned. There are other tools, other ways, other approaches.
PEOPLE IN THE INTERNATIONAL RECOVERY MOVEMENT DEMANDING CHANGE
The point is, I started doing my own cross-cultural research about what was happening in other countries and cultures and I discovered that the American way is light years behind a significant majority of people in the recovery movement around the world demanding change.
Take Britain's Time to Change. Last week, this program to end discrimination "faced by people who experience mental health problems" (I love the language they use) announced another new ambitious community in Islington mounting a campaign to promote mental health equality.
Community Mental Health and Recovery is a growing global movement in the world even though much of the medical establishment doesn't recognize it or simply pays lip service to it. Watters doesn't even mention recovery in his article, though he's right, according to Pies, "to call attention to the ways that culture and ethnicity can shape both diagnosis and expression of psychiatric symptoms."
I guess the main problem I have with his essay is that I don't like generalizing about people and mental health and well being and diagnostics. Mental health is not a constant state for anyone, ever. Nor is having a mental health issue. We, individuals, are changing all the time. Our lives, our circumstances, our work environments, our relationships are in constant flux. We're all different, every day, and no diagnostic label is really 100% accurate. It's a ball park. A designation for a doctor to use. A place to start. Also, it's very useful for insurance companies.
We're all unique, despite our diagnoses. As I've said for years, "I'm not my mental illness." Labels are for jars, not people.
MANY PROBLEMS PLAGUE MODERN PSYCHIATRY
There are many problems plaguing modern psychiatry. Every psychiatrist has his or her own approach. Even Watters' wife, who is a psychiatrist, and a very good psychiatrist, he says. There's the rocky modern landscape of psychiatry, influenced by new medications and new technologies. There's the pull of the neurosciences against and not always in concert with the healing powers of the psychotherapies. There's our quick fix, pill-popping culture. And there's the discrimination and negative stereotyping and prejudice that we must continue to fight with education. And open minds.
Lots to think about and to ponder. But I will add this. On his Psychiatric Times blog The Couch in Crisis Dr. Ron Pies posted about the Watters essay, too. It's worth a read.
I'm still processing. Today, I'm seeing Dr. Bob. We'll have lots to talk about.
Take care.
Speak soon!
When talking about the "Americanization" of mental illness, it's hard to overlook the "Criminalization" of the same as an off-shoot. The prison industry is big bucks in the USA and no doubt anything Big Brother America does is going to be duplicated here to some extent. Remember, we're approaching the second generation brought up in a post-COPS-ON-FOX era promoting some of the scary attitudes that uniformed police can carry.
If we mirror the institutional efforts found south of the border, we're going to be facing more drug-dependence and less community care. The Centre for Addictions and Mental Illness in Toronto, although world-renowned, is already stressed to the max with ol' Courtroom 102 at Old City Hall pushing the mentally ill into prisons before treatment. An orange jumpsuit and a prison nurse pushing a cartful of meds is obviously a less than ideal situation.
Posted by: Peter Harris | January 18, 2010 at 04:54 PM
Hi Peter,
Thanks for raising this very valid point. It's an old and very sad story. Prisons becoming holding tanks for people with mental health issues. No rehabilitation. Rough conditions. No compassion.
Except there is a light at the end of the tunnel, though it's very tiny. The Justice System and particularly police are not equipped or trained to discern the difference between a mental health problem and a criminal problem. However, in several cities, Toronto, Hamilton, Newmarket and no doubt more, especially with youth crime, inner city hospital psychiatric nurses and doctors are teaming up with police to try to determine how to help people who are involved in crimes. They go out together to patrol the streets. They work the front lines.
This is an excellent pairing because in many cases, young people especially, can benefit from the therapies available to them through psychiatric services. Better to keep them out of the justice system, prevent problems from arising and rehabilitate then. If drugs are an issue, these problems have therapeutic solutions.
It's not as black and white and it may seem. There are concerted efforts to help youth stay out of the criminal justice system if there are mental health issues that can be investigated.
Sadly, the media often diagnoses people based on old and erroneous stereotypes and misconceptions about mental illnesses. Headline writers will diagnose before someone ever sees a psychiatrist. Sometimes they're right. Sometimes they're wrong and it's not fair.
I am more hopeful than you are in all this. Interventions to help prevent serious problems later in life are very much a part of the protocol at CAMH and other psychiatric centres. We are not the U.S.A. here in Canada.
Our culture and our healthcare system is far more humane.
Thanks for raising this point. It's valid. And CBS "Sixty Minutes" has documented some horrific situations in U.S. prisons. However, I don't think we mirror that culture.
Take care and be well.
sln
Posted by: Sandy Naiman | January 19, 2010 at 07:49 PM
"Several things have happened to change that. Now, I know I'm okay. And I choose to believe that we're all "next to normal."|
I have always maintained that being normal is not what I want to be. A very good friend once said to me `why be a turnip when you can be a rutabega` I think she made an excellent point ... LOL
Posted by: Serendopeity.wordpress.com | February 10, 2010 at 11:47 PM