Urban Tribes:

A Generation Redefines Friendship,

Family, and Commitment WITH RICHARD OFSHE

Makings Monsters:

False Memories, Psychotherapy, and Sexual Hysteria








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Watters, Ethan.

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

p. cm.

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

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

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

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RC455.4.E8W38 2010

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ISBN 978-1-4165-8708-8

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



Chapter 1

The Rise of Anorexia in Hong Kong

Chapter 2

The Wave That Brought PTSD to Sri Lanka

Chapter 3

The Shifting Mask of Schizophrenia in Zanzibar

Chapter 4

The Mega-Marketing of Depression in Japan


The Global Economic Crisis and the Future of Mental Illness








To travel internationally is to become increasingly unnerved

by the way American culture pervades the world. We cringe

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

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

on Tiananmen Square or a Nike factory in Malaysia. The

visual landscape of the world has become depressingly

familiar. For Americans the old joke has become bizarrely

true: wherever we go, there we are.

We have the uneasy feeling that our influence over the

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

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

incrimination, however, we have yet to face our most

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

do not represent our most troubling impact on other

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

the human psyche itself. We are engaged in the grand

project of Americanizing the world’s understanding of the

human mind.

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

such a change would be happening inside the conscious and

unconscious thoughts of more than six billion people. But

there are telltale signs that have recently become

unmistakable. Particularly telling are the changing

manifestations of mental illnesses around the world. In the

past two decades, for instance, eating disorders have risen

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

traumatic stress disorder (PTSD) has become the common

diagnosis, the lingua franca of human suffering, following

wars and natural disasters. In addition, a particularly

Americanized version of depression is on the rise in

countries across the world.

What is the pathogen that has led to these outbreaks and

epidemics? On what currents do these illnesses travel?

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

Over the past thirty years, we Americans have been

industriously exporting our ideas about mental illness. Our

definitions and treatments have become the international

standards. Although this has often been done with the best

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

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

about mental illnesses—how they categorize and prioritize

the symptoms, attempt to heal them, and set expectations

for their course and outcome—influences the diseases

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

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

the world goes mad.

There is now a remarkable body of research that suggests

that mental illnesses are not, as sometimes assumed,

spread evenly around the globe. They have appeared in

different cultures in endlessly complex and unique forms.

Indonesian men have been known to experience amok, in

which a minor social insult launches an extended period of

brooding punctuated by an episode of murderous rage.

Southeastern Asian males sometimes suffer from koro, the

debilitating certainty that their genitals are retracting into

their body. Across the Fertile Crescent of the Middle East

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

brings forth dissociative episodes of crying, laughing,

shouting, and singing.

The diversity that can be found across cultures can be

seen across time as well. Because the troubled mind has

been perceived in terms of diverse religious, scientific, and

social beliefs of discrete cultures, the forms of madness

from one place and time in history often look remarkably

different from the forms of madness in another. These

differing forms of mental illness can sometimes appear and

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

Hacking documents the fleeting appearance in Victorian

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

trance for hundreds of miles. Symptoms of mental illnesses

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

belief in specific times and specific places. That thousands

of upper-class women in the mid-nineteenth century

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

paralysis gives us a visceral understanding of the

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

But with the increasing speed of globalization, something

has changed. The remarkable diversity once seen among

different cultures’ conceptions of madness is rapidly

disappearing. A few mental illnesses identified and

popularized in the United States—depression, post-

traumatic stress disorder, and anorexia among them—now

appear to be spreading across cultural boundaries and

around the world with the speed of contagious diseases.

Indigenous forms of mental illness and healing are being

bulldozed by disease categories and treatments made in the


There is no doubt that the Western mental health

profession has had a remarkable global influence over the

meaning and treatment of mental illness. Mental health

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

particular, create the official categories of mental diseases.

The American Psychiatric Association’s Diagnostic and

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

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

worldwide standard. In addition American researchers and

organizations run the premier scholarly journals and host

top conferences in the fields of psychology and psychiatry.

Western universities train the world’s most influential

clinicians and academics. Western drug companies dole out

the funds for research and spend billions marketing

medications for mental illnesses. Western-trained

traumatologists rush in wherever war or natural disasters

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

their assumptions about how the mind becomes broken and

how it is best healed.

These ideas and practices represent much more than the

symptom lists that describe these conditions. Behind the

promotion of Western ideas of mental health and healing

lies a variety of cultural assumptions about human nature

itself. Westerners share, for instance, beliefs about what

type of life event is likely to make one psychologically

traumatized, and we agree that venting emotions by talking

is more healthy than stoic silence. We are certain that

humans are innately fragile and should consider many

emotional experiences as illnesses that require professional

intervention. We’re confident that our biomedical approach

to mental illness will reduce stigma for the sufferer and that

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

people in other cultures that mental health (and a modern

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

traditional social roles and engaging in individualistic quests

of introspection. These Western ideas of the mind are

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

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


What motivates us in this global effort to convince the

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

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

profits. These multibillion-dollar conglomerates have an

incentive to promote universal disease categories because

they can make fortunes selling the drugs that purport to

cure those illnesses.

Other reasons are more complex. Many modern mental

health practitioners and researchers believe that the

science behind our drugs, our illness categories, and our

theories of the mind have put the field beyond the influence

of constantly shifting cultural trends and beliefs. After all,

we now have machines that can literally watch the mind at

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

of ways and examine DNA sequences for abnormalities. For

a generation now we have proudly promoted the biomedical

notion of mental illness: the idea that these diseases should

be understood clinically and scientifically, like physical

illnesses. The assumption is that these remarkable scientific

advances have allowed modern-day practitioners to avoid

the biases and mistakes of their predecessors.

Indeed modern-day mental health practitioners often look

back at previous generations of psychiatrists with a mixture

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

swept away by the cultural beliefs of their time. Theories

surrounding the epidemic of hysterical women in the

Victorian era are now dismissed as cultural artifacts. Even

recent iatrogenic contagions, such as the sudden rise of

multiple personality disorder just fifteen years ago, are

considered ancient history, harmful detours but safely in the

past. Similarly, illnesses found only in other cultures are

often treated like carnival sideshows. Koro and amok and

the like can be found far back in the American diagnostic

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

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

“Psychiatric Exotica: Two Bits a Gander.”

Western mental health practitioners are prone to believe

that, unlike those culturally contrived manifestations of

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

inclusion of culture-bound syndromes describe real

disorders of the mind, illnesses with symptomatology and

outcomes relatively unaffected by shifting cultural beliefs.

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

these disorders are surely universal to humans everywhere.

Their application around the world therefore represents

simply the brave march of scientific knowledge.

But the cross-cultural researchers and anthropologists

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

shown that the experience of mental illness cannot be

separated from culture. We can become psychologically

unhinged for many reasons, such as personal trauma, social

upheaval, or a chemical imbalance in our brain. Whatever

the cause, we invariably rely on cultural beliefs and stories

to understand what is happening. Those stories, whether

they tell of spirit possession or serotonin depletion, shape

the experience of the illness in surprisingly dramatic and

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

including such seemingly obvious categories such as

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

shaped and influenced by cultural beliefs and expectations

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

other mental illness ever experienced in the history of

human madness.

The cultural influence on the mind of a mentally ill person

is always a local and intimate phenomenon. So although this

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

perspective. In the hopes of keeping the human-scale

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

diseases in four different countries. I picked these tales

because each illustrates how the globalization of Western

beliefs about mental health travel on different currents.

From the island of Zanzibar, where beliefs in spirit

possession are increasingly giving way to biomedical

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

struggling with schizophrenia. To document the rise of

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

Charlene Hsu Chi-Ying and show how the publicity

surrounding her death introduced the province to a

particularly Western form of the disease. I deconstruct the

mega-marketing of the antidepressant Paxil in Japan to

illustrate how drug companies often sell the very disease for

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

2004 tsunami in Sri Lanka provides the opportunity to

examine the impact of trauma counselors who rush into

disaster zones armed with the diagnosis of posttraumatic

stress and Western certainties about the impact of trauma

on the human psyche.

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

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

viewed from a far shore, the cultural assumptions and

certainties that shape our own beliefs about mental illness

and the human mind often become breathtakingly clear.

From this perspective, it is often our own assumptions about

madness and the self that begin to appear truly strange.

The cross-cultural psychiatrists and anthropologists

featured in this book have convinced me that we are living

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

they’ve been working hard to document the different

cultural understandings of mental illness and health, those

differences have been disappearing before their eyes. I’ve

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

in the rain forest, desperate to document the diversity while

staying only a few steps ahead of the bulldozers.

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

differing conceptions and treatments of mental illness in

exactly the same way we worry about the loss of biological

diversity in nature. Modes of healing and culturally specific

beliefs about how to achieve mental health can be lost to

humanity with the grim finality of an animal or plant lapsing

into extinction. And like those plants and animals, the

diversity in the human understanding of the mind can

disappear before we’ve truly comprehended its value.

Biologists suggest that within the dense and vital

biodiversity of the rain forest are chemical compounds that

may someday cure modern plagues. Similarly, within the

diversity of different cultural understandings of mental

health and illness may exist knowledge that we cannot

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


The Rise of Anorexia in Hong Kong

Psychiatric theory cannot deny its participation in the social

trajectory of the anorectic discourse, which articulates

personal miseries as much as it does public concerns.


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

preeminent researcher on eating disorders, I took the

subway a few stops north of downtown Hong Kong to the

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

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

featuring outlandishly slender, bikinied young women

promoting a variety of health care regimens, cellulite-

removing creams, and appetite-suppressant supplements.

The advertisements over the handrails in the subway cars

repeated the offers. The magazines and newspapers being

read by the commuters were filled with similar pitches,

often featuring before and after photos, young women

becoming little more than skin and bones after the offered

treatment. Such products are a huge business in Hong Kong

and increasingly in mainland China. Over the past few years

the beauty industry in Hong Kong (including dieting,

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

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

popular weekly magazine Next, a remarkable 110 of the

publication’s 150 ads were for slimming or beauty products

and services.

The reporting and photojournalism that appeared

alongside those ads had a slightly different obsession:

telling tales of young women celebrities. That morning’s

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

reported the recent misadventures of several famous young

women, including Britney Spears, who had that week been

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

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

that allows doctors to hold a patient involuntarily if she is

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

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

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

cosmetics company, Kose Corp., after making pejorative

comments about the fertility of older women. The cute and

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

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

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

gets dirty.”

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

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

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

female pop stars and a young actor. Hundreds of very

explicit nude photos had been posted on the Internet of

singer Gillian Chung and actresses Bobo Chen and Cecilia

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

humanitarian crisis was erupting along the Gaza-Egyptian

border and a severe snowstorm was sweeping across much

of eastern China, threatening to strand millions of holiday

travelers, yet no other story could compete with this sex

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

need to criticize the behavior of the young women. Even

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

subject of celebrity sin and cyber etiquette, saying that it

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

circulate these pictures.”

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

advertisements, images, and stories of celebrity

misadventures might have been adding up to in the minds

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

much reading between the lines, however, to perceive a

high degree of confusion and ambivalence surrounding the

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

aging. Young women in some contexts were worshipped for

their attractiveness, while in other situations they were

humiliated and publicly vilified with a vitriol that would be

hard to overstate. Whatever understanding Hong Kong

teenage girls were piecing together about the

postadolescent world from these sources, it is safe to say

that it was not unconflicted.

Given this environment, it would make sense to most

Americans and Europeans that occurrences of anorexia and

bulimia have spiked here in the past fifteen years. Nor

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

young celebrities in the sex scandal, had herself battled

bulimia. Most well-educated Westerners understand that

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

fairly narrow conception of what those cues might be. Most

assume that anorexia, with its attendant fear of fatness and

body dysmorphic disorder, is born of a peculiar modern

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

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

exported our obsessions with slender models—our Barbie

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

eating disorders have followed in their wake.

But although this commonsense cause and effect might

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

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

here. The full story of how anorexia spread from the

American suburbs to Hong Kong is more complex and, in

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

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

but not for the obvious reasons.

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

suite of offices among the labyrinth of midrise buildings that

make up the Prince of Wales Hospital. Introduced by his

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

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

fact that he has split his time between seeing patients at

the public hospital, teaching, and running a mood disorders

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

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

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

would come to know as his characteristic humble manner.

“I’ve wanted to be a psychiatrist since high school and I still

love the work of meeting patients and writing about ideas.”

Given the amount of time he spends in his office, he’s

allowed himself to build a comfortable environment. The

place has the feel of a stylish bachelor pad. The bucket seat

and gearshift of a sports car sat on the floor next to the

couch. Directly across from his desk was one of his prized

possessions: an antique vacuum tube stereo connected to

two imposingly large speakers. The tuner was made in the

early 1960s and at the time cost as much as a VW Beetle

and requires vacuum tubes the size of small lightbulbs to

operate. For a true classical music audiophile such as Lee,

however, there is no substitute for the resonant tones it


Even after two decades of charting the cultural currents

that have brought the American version of anorexia to these

shores, Lee remains passionately interested in talking about

the puzzle. He was the first scholar to document anorexia in

Chinese women. The remarkable thing he found was that

before the illness was well known in the province, Chinese

anorexia was unlike that found in the West. These atypical

anorexics, as he calls them, displayed a different cluster of

symptoms than their Western counterparts. Most, for

instance, did not display the classic fear of fatness common

among Western anorexics, nor did they misperceive the frail

state of their body by believing they were overweight. It was

while he was trying to puzzle out these differences that he

witnessed something remarkable.

Over a short period of time the presentation of anorexia in

Hong Kong changed. The symptom cluster that was unique

to his Hong Kong patients began to disappear. What was

once a rare disorder was replaced by an American version of

the disease that became much more widespread.

Understanding the forces behind that change may not only

explain why anorexia became common in Hong Kong, but it

may also lead us to reconsider the momentum behind the

disease in the West.

The Death of a Patient

When Sing Lee came back to Hong Kong from his training in

England in the mid-1980s, he took a job at the Prince of

Wales Hospital and began looking for Chinese anorexics.

Having been introduced to the disorder while in England he

was, like many young psychiatrists, fascinated by the

fundamental conundrum of the disease: Why would healthy

young women with plenty of resources starve themselves?

At the time Lee began his search, the long-held belief that

eating disorders were confined to American and Western

European populations was just beginning to show cracks.

Even though prominent eating disorder researchers were

making the argument as late as 1985 that anorexia didn’t

exist outside of the United States, cases were beginning to

show up in Russia and Eastern Europe. Although it was still

believed to be rare in Latin American countries, researchers

and clinicians also began discovering young women with

anorexia in Japan and South Korea.

In China and Hong Kong the disorder remained all but

unknown. Searching the two major psychiatric journals

published in China, Lee found not a single paper

documenting a Chinese woman with anorexia. With little to

go on, he got to work searching the databases at the Prince

of Wales Hospital. After an exhaustive search, he managed

to identify just ten possible cases in the five years from

1983 to 1988. Given the thousands of patients seen at the

hospital, he determined that anorexia was an exceedingly

rare disorder in Hong Kong. His first paper on the topic,

published in 1989 in the British Journal of Psychiatry, was

titled “Anorexia Nervosa in Hong Kong: Why Not More in


The low rate of anorexia was a mystery that Lee wanted

to figure out. Perhaps Chinese cultural beliefs or practices

contained protective mechanisms. He knew, for instance,

that historically there was little Chinese stigma surrounding

larger body shapes. In fact popular Chinese sayings

suggested that “being able to eat is to have luck,” “gaining

weight means good fortune,” and “fat people have more

luck.” He also considered that the later onset of puberty in

Chinese girls compared to girls in the West might be a

preventive factor. The physical changes that come with

puberty might be less psychologically stressful when

experienced with an added year or two of emotional


But even taking these differences into account, Lee

couldn’t quite understand why the behavior was so

uncommon among local adolescents. In many ways Hong

Kong seemed primed for the disorder. It was a modern

region that, thanks to years of British rule, had incorporated

many Western values as well as styles of dress and eating.

There were fast-food restaurants and health clubs. Thin

Western and Chinese celebrities were idolized. It was a

patriarchal culture, in which parents and teachers put

intense pressure on students to compete. The Chinese

obsession with food and the layered meanings of sharing

meals within a family should have made food refusal a

dangerously attractive behavior for an adolescent looking to

send a distress signal to those around her.

All the triggers for anorexia that had been identified in

Western literature seemed to be present in full force, and

yet eating disorders remained rare. Lee suspected that

there was something else, some factor that hadn’t been

fully considered in the Western literature, that remained

absent in Hong Kong. What that factor might be he could

only guess.

Treating the few cases he could find, Lee discovered

another puzzle. He noticed that the women who starved

themselves in Hong Kong were different from the anorexics

he had studied while training in England. The variations

were sometimes so pronounced he wondered if he was

seeing the same disease. To illustrate those differences, Lee

recounted to me the story of one of the first patients he

personally treated, a 31-year-old saleswoman I’ll call Jiao.

Lee still clearly remembers the first time he met Jiao in a

hospital examination room in 1988. Although he knew from

his research how thin anorexic patients could become, he

couldn’t help but be taken aback at the sight of her. “She

was shockingly emaciated—virtually a skeleton,” he recalls.

“She had sunken eyes, hollow cheeks and pale, cold skin.”

She was alert but uncommunicative. At 5 feet 3 inches, her

ideal body weight should have been in the neighborhood of

110 pounds. Indeed, she had been that weight four years

earlier, before she began to waste away. By the time she

sought medical treatment she weighed just 48 pounds.

During his physical exam of Jiao, Lee noted that she had

dry skin and a subnormal body temperature. More

concerning, her blood pressure was low and her heartbeat

was a plodding 60 beats per minute. He took X-rays after

giving her a drink laced with barium so he could examine

her esophagus. He also used an endoscope to examine her

upper gastrointestinal system for blockages or lesions.

Convinced the disorder wasn’t organic in origin, he began to

piece together her personal history.

Jiao was the youngest child of three living children (two of

her brothers died soon after birth). She had grown up in a

working-class family in a rural village near Hong Kong,

where she still lived. Like many in the Hong Kong area, her

family was both emotionally enmeshed and yet physically

disjointed. To earn a living, her father had lived apart from

the family for many years at a time, and yet, when he was

present, he demanded the absolute loyalty he felt was his

traditional due as head of the household. During his visits

home he often berated Jiao and her mother for small

infractions, such as interrupting him when he spoke, and he

freely expressed his disappointment that Jiao had not

performed better in school. Her mother was a traditional

housewife who was subservient to her husband and was

socially isolated because she spoke only a Chinese dialect

called Hakka. Although it was not a happy home, there was

no history of mental illness, sexual or physical abuse, or

eating disorders.

Jiao’s struggles with eating had begun in earnest four

years earlier, in 1984, when her boyfriend deserted her by

emigrating to England. She was devastated by his departure

and began to refuse food and skip meals. Explaining her

change in eating patterns to her family, she complained of

pain and discomfort in her abdomen. During this time she

became increasingly socially withdrawn and lost her job.

Over those first years of the illness she saw various doctors.

She was encouraged by health professionals as well as her

family to eat more. Nevertheless she steadily lost weight

year after year.

While relating her personal history to Lee during that first

interview, Jiao cried at times but for the most part just

looked sad and tired.

“What do you think is your main problem?” Lee finally

asked her.

“Abdominal fullness and thinness,” she replied.

“What else?”

“A bad mood, it’s hard to describe. . . . It is no use talking

about it anymore,” she said and began to weep.

“Is there a name for your condition?” Lee asked her.

“I don’t know,” she said. “Can you tell me what kind of

disease it is?”

Lee had her draw a picture of herself. This technique is

often used to assess whether anorexic patients have a

distorted perception of their emaciated condition. The stick

figure sketch she handed back to Lee, however, closely

matched her skeletal condition.

Jiao’s presentation left Lee in a quandary. On the one

hand, she was clearly starving herself to the point of death.

On the other hand, she didn’t fit many of the American

diagnostic criteria for anorexia. The Diagnostic and

Statistical Manual of Mental Disorders, published by the

American Psychiatric Association—the third edition released

in the late 1980s had quickly become the worldwide

standard—stated that someone suffering from anorexia not

only rigidly maintains an abnormally low body weight but

expresses an “intense fear of becoming obese, even when

underweight,” and has a disturbed self-image, such as

claiming to “feel fat when emaciated.”

But Jiao did not express a fear of being overweight. In

addition, she didn’t have any misperception about the

emaciated condition of her body. She described herself

pretty much exactly as Lee saw her: as a very sick and

dangerously thin young woman.

When he gave her the standard eating disorder

questionnaire of the time, it also showed clear differences

from what one would expect of an anorexic in the West. For

instance, Jiao insisted that she never consciously restricted

the amount of food she ate. Western anorexics, he knew,

usually admitted to obsessing over food portions and

quantities. When asked why she often went for whole days

without eating, Jiao would say only that she felt no hunger

and, pointing to the left side of her abdomen, describe how

her stomach often felt distended.

These deviations from the Western diagnosis weren’t

unique to Jiao. Most of the Hong Kong anorexics Lee was

able to interview or treat around this time similarly denied

any fear of being fat or of intending to lose weight to

become more attractive. They often spoke of their desire to

get back to a normal body weight. When explaining their

refusal to eat, they most often ascribed the behavior to

physical causes such as bloating, blockages in their throat

or digestion, or the feeling of fullness in their stomach and

abdomen. Their often repeated claim that they had no

appetite also ran counter to conceptions of the disease put

forward by Western experts. Psychiatrist Hilde Bruch, who

wrote one of the seminal books on anorexia, The Golden

Cage, asserted that “patients with anorexia nervosa do not

suffer from loss of appetite; on the contrary, they are

frantically preoccupied with food and eating. In this sense

they resemble other starving people.”

As a group, these Hong Kong anorexics were different

from their American counterparts in other ways as well.

These were not the “golden girls” described in Western

literature on eating disorders. Anorexia in the West was

known to afflict well-to-do, popular, and promising young

women who were sometimes perfectionists in other parts of

their lives, such as school or sports. But Lee’s patients were

often from poor families and among the lower achievers in

their schools. They also did not give any hint of the moral

superiority sometimes observed in Western anorexics.

Most curiously, they were often from outlying villages, not

a population that Lee suspected would be most influenced

by the globalization of Western pop culture. They had not

begun their self-starvation after reading diet books or

engaging in the exercise fads of the day. His atypical

anorexics were not among the young women in Hong Kong

adopting Flashdance fashions or going to Jazzercise classes.

If Western pop cultural influences were at the heart of this

disorder, there were certainly populations in Hong Kong who

should have been harder hit. Hong Kong was, and remains,

the most international of cities, and there were plenty of

groups of adolescents and young women fully engaging in

Western fashion and pop culture. But Lee’s patients did not

come from these jet-setting subcultures.

While Lee had great respect for the clinical knowledge he

had gained during his training in the West, he knew it posed

a challenge as well. With the DSM becoming the world’s

diagnostic manual for mental illness, it was easy to gloss

over different disease presentations to make them fit the

Western standard. But Lee was convinced that the

distinctions between the American presentation of anorexia

and what he was witnessing in Hong Kong was a meaningful

difference that could lead to new insights into the disorder.

He knew that if he was going to understand what was

happening with his Hong Kong patients, he was going to

have to get to the bottom of those differences.

Yin, Yang, and Qi

Despite Lee’s uncertainty about the diagnosis of anorexia,

Jiao was clearly in need of immediate attention. With Lee’s

encouragement she checked into the hospital, but she

proved to be a difficult patient. She used a shifting series of

excuses to refuse the food offered by the dietitian. Lee

speculated that her resistance to his ministrations might be

bound up in the culture clash between Western and Chinese

medicine. Hoping to hit a resonant cultural note that would

lessen her resistance, he called in a Chinese herbalist and

then a qigong master to participate in her treatment. The

herbalist reported to Lee that Jiao’s condition involved a

variety of imbalances between the liver, the spleen, and the

stomach. Her extreme sadness over her lost love had

caused her liver function to break down, the herbalist

explained, which in turn had thrown off the workings of her

spleen and stomach. This had resulted in poor absorption of

food nutrition, limiting her body’s ability to transform food

into qi, the flow of energy that animates all living things.

These problems had led to a weak heart and ineffective

kidneys. In addition, the herbalist found a general imbalance

in her system that he described as an excess of yin and a

depleted reserve of yang.

Because the liver malfunction was at the beginning of the

cascade of internal distress, the herbalist recommended a

mixture of herbs he said would selectively soothe and repair

that organ. The treatment, Jiao was told, would allow her to

let go of the unhealthy energy that surrounded the memory

of her lost love. Jiao refused to drink the concoction.

The qigong master was even less successful. He also

believed that Jiao’s flow of qi was dangerously low. He

performed rituals to unblock her pent-up qi. By the third

treatment, the qigong master quit the case, telling Lee that

the patient was “not willing to recover.”

With neither Western nor Eastern healing modalities

having much impact, Jiao decided to leave the hospital. She

was discharged just before Christmas of 1988. Although she

had gained weight during her hospital stay, from 48 pounds

to 59 pounds, in a checkup two weeks later she had already

dropped four of those pounds. She refused readmission to

the hospital and began to avoid outpatient visits as well.

Over the next few years Lee twice visited her at home,

hoping to lure her back into treatment. During this time her

weight dropped back down to 50 pounds.

In 1992 Lee once again visited Jiao at home, taking two

female medical students with him. Jiao looked as skeletal as

ever and told of heart palpitations and lower limb weakness.

Two of her front teeth had decayed to the point that they

had been removed. Jiao’s mother gestured to Lee that she

was still not eating much. Because of the mother’s language

barrier, a neighbor was brought in to explain the need for

inpatient treatment to her. The neighbor said that many in

the village had tried unsuccessfully to encourage Jiao to eat

more. The neighbor wanted to know from Lee what this

mysterious disease was called and what caused it.

After the visit Lee and the two medical students took Jiao

for a short walk in the village. She showed the students a

picture of herself before the onset of the illness and seemed

happy when they said she was pretty in the photos. She

asked the students if they would reject her as a friend

because of her current terrible appearance. At the end of

the visit, Jiao agreed to consider returning to the hospital,

but when Lee phoned her a few days later she declined


It was only two weeks later that Jiao showed up in the

emergency room of the Prince of Wales Hospital. She was in

terrible shape. She weighted only 42 pounds, her blood

pressure was low, and sacral bedsores were appearing on

her skin. She gasped for breath at the slightest exertion. To

Lee’s relief, Jiao agreed to hospitalization.

During her first day in the hospital, Lee noticed a positive

turn in her outlook. Jiao asked for a referral to the

occupational therapy department so that she could learn

typing and computer skills. She hoped this would put her in

line for a better job later in life. Some of the medical

students who had been following her case with Dr. Lee gave

her a present of a hat and scarf. The gift pleased Jiao. She

asked to get a haircut and began to talk of “making a new

beginning.” She began to take small amounts of food orally.

Two days later, at four in the morning, Jiao’s heart gave

out. The autopsy showed no specific pathology other than

multiple organ atrophy due to her self-starvation.

His failure to help Jiao recover fueled Lee’s passion to

figure out the meaning of anorexia in Hong Kong. Thinking

back on the case, he became convinced that the Western

understanding of the disease, focusing on body image and

fat phobia, was of little use in cases like Jiao’s. What was

needed was not a global template for anorexia, but a much

more local understanding of the personal and cultural forces

at play. Relying on a global template, he believed, could be

worse than just ineffective. The increasingly wide use of the

Western diagnostic categories and the many assumptions

that lay behind them had the potential of blinding local

clinicians to the unique realities of patients in different


A Personal Test and Global Spread

Lee knew that he had to understand anorexia on two

different levels. There was the question of why women

began the behavior of self-starvation, and then there was

the question of what happened to their mind and body as

the regimen of starvation gained momentum in their daily

life. Lee felt it was critically important to understand what

anorexia felt like on a physiological level. “I was curious

about the basic question: How can they eat so little?” Lee

recalls. “Why did lunchtime make no difference to them?

What did it mean to turn off the biological clock that

signaled the body to eat?”

Empathy is prized among all mental health providers, but

it’s an ephemeral and untestable quality. A doctor may think

he or she is sensing the internal world of the patient, but

how can one really know? This is especially problematic

when facing a patient with a severe mental illness. Can a

doctor who treats a schizophrenic empathically connect with

the workings of that patient’s mind? Lee realized that, unlike

in other mental disorders, a doctor treating an anorexic

patient had some opportunity to share in the patient’s

experience. Because the key symptom—restricting one’s

eating—was an external behavior, Lee saw an opening to do

an experiment. He decided to mimic the behavior of an

anorexic in the early stages of the disorder.

“I got it in my head,” says Lee, “that if I wanted to truly be

an expert on this condition, I needed to experience it for

myself.” So he began to severely cut back on his food intake

and skip lunch entirely. He also began an intense exercise

routine. Like all dieters, at first he felt the normal drop in

energy and mood as his body struggled to make it through

the day with a depleted supply of calories. After a few weeks

he had lost five pounds, but he still felt like he was dragging

himself through his daily routine. After a month and a half of

restricting food, he was another five pounds lighter but felt

no better. His stomach ached and growled for food.

It was around the three-month mark that some gear

shifted in his physiology. His energy began to return and his

mood improved—more than improved, actually: he felt

great. He was going to bed later and waking up earlier. He

performed behaviors that he would have identified in a

patient as potentially pathological. As he rode the elevator

up to his office every morning, for instance, he did arm

exercises on the handrails. He began to feel a

hyperalertness and sense of mastery over his body and his

life. For much of the day he was on the sort of pleasant

runner’s high that one feels in the middle of a good workout.

His hunger, which for months had been sounding a

deafening alarm, had become a background whisper that he

could easily ignore.

He found himself feeling somewhat superior to other

people, who seemed to be ruled by their incessant need for

food. He couldn’t understand why so many people who tried

to diet lacked the willpower to do so. He found that he was

inordinately pleased that he had the strength of will to see

his project through. The next ten pounds came off with little

effort and his friends and family began to comment on how

thin he was. He had lost over 12 percent of his body weight.

Although Lee felt the desire to stay on his restrictive diet,

he managed to shake himself out of the behavior. His

excuse to himself at the time was that he needed to go to

London for an intense exam at the Royal College of

Psychiatry, and he worried that his lack of nutrition would

limit his mental abilities. It had been a dangerous

experiment but a successful one; he had heard a bit of the

siren song that patients with anorexia often follow to their


One of his patients once told him that anorexia felt like

getting on a train, only to discover too late that she was

headed in the wrong direction. This patient felt she had little

choice but to stay on that train to the final destination. Lee

now had some idea what she meant when she used that

metaphor to describe the psychological momentum that can

build behind anorexia. He had starved himself to the point

where the behavior can turn from a willful choice into a

dangerous addiction.

As Lee’s first papers on anorexia in Hong Kong moved

toward publication, much was changing in the world of

eating disorder research. Scattered case reports had been

followed by outbreaks of eating disorders reported in Africa,

India, and the Middle East. One study showed that students

in Nigeria were scoring as high as Westerners on disordered

eating scales. In the East, anorexia had become increasingly

common in Taiwan, Malaysia, Singapore, and Japan.

The popular explanation at the time was that Western

media were influencing the way women around the world

viewed their bodies; as Western movie stars and models

became the world standard for glamour and attractiveness,

it appeared that eating disorders followed. Although that

seemed like common sense, researchers who tried to prove

a connection between Western acculturation and eating

disorders were often frustrated. Usually these studies

involved giving a group of immigrant women a test to

measure abnormal eating attitudes, along with a set of

questions intended to gauge their level of acculturation to

their new home. The assumption was that women who had

adopted Western norms would have higher scores on the

disordered eating tests.

For the most part, however, these studies failed to make

this seemingly commonsense cause-and-effect connection.

In a review of eighteen such studies, a team of American

researchers concluded, “Despite the long-standing

hypothesis that a greater exposure to Western values leads

to an increased risk for eating disorders, this review of

acculturation research presents no compelling evidence for

such a relationship.” These researchers noted that the

majority of studies failed to find a connection, and the few

that did were offset by studies showing that immigrant

women who were assimilated into Western culture

sometimes had lower scores on disordered eating scales

than women who held to their traditional beliefs and habits.

These latter studies that showed an inverse relationship

between acculturation and disordered eating were the most

controversial because they directly challenged the accepted

wisdom that the true pathogen for eating disorders hid

within Western attitudes toward the female body.

Regardless, studies of British schoolgirls from South Asia

consistently showed that those with a lower level of Western

acculturation had higher levels of body dissatisfaction and

eating disordered behavior. Strikingly similar results were

found among Hong Kong–born women who moved to


It was clear that the pathogens that were spreading eating

disorders around the world were not as simple as exposure

to Western fashion, diets, or popular culture. What exactly

was motivating the spread of the disorder remained a hot

topic of debate. If, as Lee had discovered, local forms of

anorexia were often markedly different from the DSM

version of the disease, perhaps there weren’t any universal

causes for anorexia because it wasn’t a single, unified

disease. Or perhaps there was another spark for the spread

of the disease that hadn’t yet been considered.

The Mirror of History

Lee realized that his handful of Hong Kong patients

represented a unique opportunity to examine an expression

of anorexia divorced from Western cultural beliefs about the

condition. Whereas it was all but impossible for a woman

with an eating disorder in the United States to remain

unaware of the various cultural meanings behind the

behavior, Lee’s Hong Kong atypicals often knew of no other

sufferers and lacked even a name for their condition. They

had come to the disease on their own and were negotiating

a private meaning for their refusal to eat.

Hoping to glimpse the disease from a new perspective,

Lee dove into the early history of the disorder. He became

particularly interested in the work of a Canadian scholar

named Edward Shorter, a medical historian who had

recently written several influential papers on the history of

anorexia. Reading the description of young women who

starved themselves in the early to mid-nineteenth century,

long before there was an official category for the illness, Lee

was taken aback. The descriptions of those early self-

starvers from more than a hundred years ago and half a

world away sounded remarkably similar to the Hong Kong

patients he was seeing in his practice.

Shorter recounts the story of a 16-year-old girl treated in

1823 by a Frankfurt physician named Salomon Stiebel. In

Stiebel’s account, the girl’s troubles started when her

parents insisted she break off a budding romantic

relationship with a suitor they deemed inappropriate. After

the girl was given the bad news “she felt a heavy pressure

on the lower region of her esophagus, became pale and

breathless, was unable to speak, and had to sit down.” This

feeling of pressure on her esophagus returned daily, making

it impossible, she reported, for her to eat solid food.

Although it seems clear that her self-starvation was

psychological in origin—beginning as it did with the

termination of a romance—the girl experienced her refusal

to eat as a physical symptom: a literal blockage in her


In his research Shorter reported a number of similar

descriptions. Like Lee’s patients in Hong Kong, these early

anorexics reported a range of somatic reasons for refusing

to eat. Echoing the explanations from Lee’s patients, several

nineteenth-century doctors reported that patients ascribed

their food refusal to painful digestion. Many, like the girl in

Frankfurt, told of the sensation of having an impassable

lump in the throat. Food would “not go down,” they would

claim. Others claimed other physiological problems, such as

the inability to chew.

These cases were interesting to Lee for what was absent.

Like his atypical patients in Hong Kong, these early

anorexics did not report a desire to lose weight, nor was

there evidence that they had a fear of becoming fat. In

addition these patients did not have a distorted body image,

such as believing they were fat even though they were

emaciated. Lee began to wonder whether he was seeing in

his Hong Kong patients a rare pre-twentieth-century form of


Shorter argued in his papers that the only way to

understand the Western evolution of anorexia is to see it in

the context of the archetypical psychological diagnosis of

the nineteenth century: hysteria. Along with starving

themselves, early anorexics often presented a number of

classic symptoms of hysteria. This was true of the lovelorn

girl from Frankfurt; her other symptoms of distress included

pain at the slightest pressure on her sternum, numbness in

one hand, and a persistent cough. She developed a facial tic

and skin sensitivity on her face. She also experienced

periods of catalepsy, a zombie-like state in which she heard

what was going on around her but could not move or

respond. Although this cluster of symptoms would look

strange today, it would have been nothing new to the

doctors of her time.

The middle decades of that century were a golden age for

hysteria. At its high-water mark, hysteria could include a

remarkable variety of symptoms: convulsive fits, paralysis,

muscle contractions, linguistic impediments, amnesia,

spinal irritation, day blindness, cold sensitivity,

hallucinations, and astasia-abasia, the inability to stand or

walk. The latest theories about the disease were often

topics of conversations in upper-middle-class drawing

rooms, where the latest editions of the New England Journal

of Medicine and the Lancet could often be found. Like the

Dr. Phils and Dr. Drews of our time, many practitioners in the

Victorian era had a taste for the status and celebrity their

positions offered them. Physicians such as Charles Laségue

and Jean-Martin Charcot made their names by discovering in

their patients novel manifestations of what was then the

quintessential illness of womanhood. These doctors filled

lecture halls to announce their discoveries and were toasted

by royalty.

Documenting the rise of the disorder, historians such as

Janet Oppenheim have given us a glimpse of how deeply

hysteria influenced Victorian culture. Oppenheim found the

disease not only in the mental health and medical literature

of the time, but everywhere she looked. Popular magazines

and newspapers, public hygiene literature, novels, short

stories, personal letters, diaries, and autobiographies—it

was an idea that had a tremendous hold on the population

at the end of the nineteenth century. In the spring of 1881

one popular French journalist wrote, “The illness of our age

is hysteria. One encounters it everywhere. Everywhere one

rubs elbows with it. . . . Studying hysteria, Monsieur

Laségue, the illustrious master, and Monsieur Charcot have

put their finger on the wound of the day. . . . This singular

neurosis with its astonishing effects . . . travels the streets

and the world.”

Although self-starvation resulting from stomach pain, lack

of appetite, vomiting, or the sensation of having a lump in

the throat began as a bit player in the grand drama of

hysteria, it steadily gained prominence in the ranks of

hysterical symptoms in the second half of the century. By

1860 Louis-Victor Marce, the director of a large asylum in

France, reported that it was “very common” to observe

“young women who, just having reached puberty after a

precocious physical development, lose their appetite to an

extreme degree. No matter how long they have abstained

from food, they experience a distaste for it which even the

most insistent urging is unable to reverse.” Between 1860

and 1864 the young women in a Lisbon school alternated in

groups between symptoms of hysteria—leg weakness,

paralysis, and day blindness—and periods of vomiting that

went on for months. At one point 90 out of 114 girls

participated in the epidemic of vomiting.

As eating disordered behavior became increasingly

common among hysterics, doctors began to debate its

meaning and cause. Various labels appeared in the early

literature, all hinting at different root causes: “apepsia

hysterica,” “neuropathic disorders of gastric sensibility,”

“nervous dyspepsia,” “hyperaesthesias of the stomach,”

“gastrodynia,” and “visceral neurosis.” “In the years before

the phenomenon received a formal diagnostic label,”

Shorter writes, “the symptoms tended to be inchoate and

poorly defined because neither doctors nor patients had yet

a clear model of the disease.” This time of uncertainty,

Shorter suggests, made for a kind of incubation period for

the illness of anorexia, a time when the debates among

doctors began to shape the public’s and the patients’

understanding of the behavior.

It wasn’t until 1873 that anorexia nervosa finally received

that formal recognition. That year Laségue, already famous

for his work with hysterical patients, dubbed the disease

“hysterical anorexia.” (A year later the word “hysterical”

would be dropped and the term “anorexia nervosa” would

become standard in the medical literature.) The typical

patient, he reported, was a young woman between 15 and

20 who had recently suffered an emotional trauma and

began a “refusal of food that may be indefinitely

prolonged.” He noted that months might go by without the

patient’s health declining. Indeed she might enjoy a surge of

energy. “Not only does she not sigh for recovery, but she is

not ill pleased with her condition, notwithstanding the

unpleasantness it is attended with.”

For another historical scholar, the moment in time when a

disease became officially recognized and named by the

established medical order might be nothing more than an

interesting historical footnote. Shorter, however, was an

expert in the history of psychosomatic illnesses, and he

knew better than anyone that the pronouncements of

famous doctors could have a powerful, though unconscious,

effect on people. As his body of research shows, history was

full of ever-changing psychosomatic symptoms shaped in

large part by the expectations and beliefs of the current

medical establishment. “As doctors’ own ideas about what

constitutes ‘real’ disease change from time to time due to

theory and practice, the symptoms that patients present will

change as well,” he writes. “These medical changes give the

story of psychosomatic illness its dynamic: the medical

‘shaping’ of symptoms.”

Shorter believes that it was Laségue’s famous paper and

the public interest in the medical debate surrounding the

diagnosis of anorexia that forged a kind of template for self-

starvation. As the medical establishment settled on the

name, the agreed-upon causes, and a specific symptom list

for the disease, they were, Shorter argues, “disseminating a

model of how the patient was to behave and the doctor to

respond.” What was once a mishmash of conflicting medical

theories surrounding self-starvation had now gained the

appearance of a precise disorder with a specific at-risk


That new conception of this illness took hold not only

among women who had already manifested disordered

eating but in the population at large. There are no broad

epidemiologic studies of eating disorders from the time, but

the anecdotal evidence for what happened next is

persuasive: soon after the official designation of anorexia

nervosa, the incidence of the disease began a dramatic

climb. Whereas in the 1850s self-starvation was a rare

symptom associated with hysterics, by the end of the

century the medical literature was littered with references

to full-blown anorexics. As one London doctor reported in

1888, anorexic behavior was “a very common occurrence,”

of which he had “abundant opportunities of seeing and

treating many interesting cases.” In that same year a young

medical student confidently wrote in his doctoral

dissertation, “Among hysterics, nothing is more common

than anorexia.”

A New Behavior Dives into the Symptom Pool

What caused the increase in cases of anorexia in the late

nineteenth century? Does the naming of a disorder allow

doctors to suddenly recognize and report what they had

previously overlooked? Or is there an interplay between the

codification of a new mental illness and the sudden

appearance of those symptoms in the general population?

With the introduction of any new illness category (as we’ll

see in the chapters on depression in Japan and PTSD in Sri

Lanka), there are always those who argue that the apparent

increased incidence of a condition is simply due to the fact

that the disease in question had previously gone unnoticed

or underreported. Although there is often some truth to that

assertion, the other possibility has rarely been squarely

addressed. For his part, Shorter unequivocally argues that

there is a clear connection between the official recognition

of anorexia nervosa and the growing number of women who

began to self-starve in Europe and then the United States.

Shorter believes that psychosomatic illnesses (such as leg

paralysis at the turn of the twentieth century or multiple

personality disorder at the turn of the twenty-first) are

examples of the unconscious mind attempting to speak in a

language of emotional distress that will be understood in its

time. People at a given moment in history in need of

expressing their psychological suffering have a limited

number of symptoms to choose from—a “symptom pool,” as

he calls it. When someone unconsciously latches onto a

behavior in the symptom pool, he or she is doing so for a

very specific reason: the person is taking troubling emotions

and internal conflicts that are often indistinct or frustratingly

beyond expression and distilling them into a symptom or

behavior that is a culturally recognized signal of suffering.

“Patients unconsciously endeavor to produce symptoms that

will correspond to the medical diagnostics of the time,”

Shorter told me when I called him in Montreal to speak with

him about Lee’s work. “This sort of cultural molding of the

unconscious happens imperceptibly and follows a large

number of cultural cues that patients simply are not aware


Because the patient is unconsciously striving for

recognition and legitimization of internal distress, his or her

subconscious will be drawn toward those symptoms that will

achieve those ends. Such a dynamic makes the official

public naming of a disease such as anorexia nervosa a

perilous event. It is clear to Shorter that psychiatrists and

physicians themselves have long been key players in

validating which new disorders or behaviors appear in the

symptom pool.

In the late nineteenth century the process of adding a new

symptom to the hysteria symptom pool would go like this:

On the basis of a few new and exciting cases, doctors would

publicly describe and debate and then codify the new

pathological behavior. Popular magazines, newspapers, and

journals would write about the new medical findings.

Women in the general population would unconsciously begin

to manifest the behavior and seek help. Patients and

doctors would then engage in what is called “illness

negotiation,” whereby they would together shape each

other’s perceptions of the behavior. In this negotiation the

doctor would provide scientific validation that the symptom

was indeed indicative of a legitimate disease category, and

new patients would increase the attention focused on the

new symptom in the professional and popular press,

creating a feedback loop that further established the

legitimacy of the new symptom.

So although there may have been a small number of

patients who presented novel behaviors without a cultural

template (like Lee’s atypical anorexics in Hong Kong), the

widespread adoption of a new hysterical symptom such as

anorexia or leg paralysis would follow the official

“discovery” of the symptom or disorder and the

establishment of the cultural feedback loop.

Anorexia was rare in the mid-nineteenth century not

because physicians somehow failed to notice their starving

patients, Shorter believes, but because it hadn’t yet been

widely acknowledged as part of the symptom pool of that

time. Only after it became a culturally agreed-upon

expression of internal distress did it become widespread.

Interestingly, pathological behaviors don’t attain a

permanent place in the symptom pool. It takes a certain

amount of public and professional attention to keep

behaviors like those common to hysteria in play in the

minds of a population. And indeed in the middle part of the

twentieth century many of the most dramatic symptoms

connected to hysteria drifted out of the symptom pool.

When the psychiatrist Hilde Bruch began her study of

anorexia in the 1940s, she reported that it was once again

“so rare . . . that it was practically unknown.” Searching the

admissions records at Presbyterian Hospital in New York

during those middle decades of the twentieth century, she

found on average only one case per year. Like Lee’s

anorexics, the patients Bruch saw during those years often

weren’t aware that their condition had a name, nor did they

know others who suffered similarly. Each one, she recalls,

“was an original inventor of this effort at self-assertion.” The

disorder once again became the topic of intense public and

professional interest after February 4, 1983, when the

popular singer Karen Carpenter collapsed from heart failure

brought on by anorexia nervosa. After that jump in interest,

the number of articles on the topic steadily grew throughout

the decade. By the late 1980s you’d have been hard-

pressed to find a Western teenager, especially among those

girls in the high-achieving, upper-middle-class demographic

group, who did not know about anorexia nervosa. It was

back in the symptom pool, luring another generation of


A Clean Slate

Looking at the rise and fall and rise of anorexia over the

century, Lee was convinced, like Shorter, that eating

disorders were not at all like diseases such as the mumps or

polio; they didn’t have a natural history that could be

separated from the specific time and place in which they

existed. “Mental illnesses, specifically anorexia, do not exist

independent of social and historical context,” Lee

concluded. “There may therefore be no true natural history

of [anorexia nervosa], but rather a social history at a given

time and place, a perspective which questions radically the

biomedical assumption that there is a ‘core problem’ with

[anorexia nervosa].”

Lee began to suspect that his handful of atypical cases in

Hong Kong were akin to the rare cases of self-starvation in

the early nineteenth century, before it had been codified by

the prominent psychiatrists and physicians of the day and

publicized around the Western world. “I began to think that

these atypical patients I was seeing might shed some light

on the early appearance of self-starvation before it became

known as anorexia,” he recalls. “You can’t go back a

hundred or two hundred years to re-interview early anorexic


He came to believe that the reason his patients didn’t

report their self-starvation as coming from a fear of fatness

was because that explanation would have made no sense in

their cultural surroundings. Fear of fatness wasn’t

recognized in the Hong Kong culture as a legitimate reason

for self-starvation; it was therefore unavailable to the

patient both as a private belief and as an explanation she

might give her doctor.

However, there were other explanations at the time that

did make sense. For instance, the Chinese have historically

looked to bodily sensations to indicate psychological

distress. Because of this long history of somaticizing mental

distress, it made sense to Lee that the atypical anorexics he

was seeing often focused on stomach complaints and the

feeling of bloating as the cause of their behavior. Chinese

philosophical thinking avoided making the Cartesian

distinction between the mind and the body. A Chinese girl’s

complaint of stomach pain might carry as much meaning

and impact as a signal of emotional distress as a Western

teenager’s complaint of anxiety or depression. Lee also saw

in his patients echoes of a certain Confucian asceticism—an

almost monk-like self-denial, asexuality, and lack of worry

about their bodily decline or even death. “Their food denial

communicated powerful cultural symbols, private meanings

and interpersonal messages,” Lee concluded. Decoding

these messages required a deep understanding of the

specific cultural forces influencing the self-conception of

these women.

In trying to parse out these meanings, Lee was racing

against time. Even as he was making progress

understanding the particular cultural meanings behind food

refusal in Hong Kong, the Western diagnosis of anorexia was

becoming accepted across the globe. Lee feared that the

DSM diagnosis of anorexia, with its focus on fat phobia and

body image distortion, would obscure more subtle, culturally

specific forms of self-starvation.

Slowly but steadily, in the early 1990s he noticed mental

health providers around him succumbing to a kind of color-

blindness, an inability to see the cultural and individual

differences in the patients they interviewed. As each year

passed, he could see the influence of the Western diagnostic

manual grow, particularly in younger generations of

clinicians. Reviewing other doctors’ notes on new cases of

anorexia referred to him, he would see such sentences as

“The patient still denied having a fear of fatness or dieting.”

For these younger doctors, it couldn’t be a case of anorexia

unless it conformed to the DSM criteria. Lee worried that

these clinicians were adhering to a foreign diagnostic

manual at the expense of understanding both the patient’s

subjective experience and the cultural meaning specific to

Hong Kong at that time. If they became blind to the local

realities of their patients, he feared, they would have little

hope in treating them.

A Death on Wan Chai Road

Although the psychologists and psychiatrists in Hong Kong

began to adopt the DSM description of anorexia, the general

population of Hong Kong remained largely unaware of the

disease. As of the early 1990s, there had yet to be any

outreach campaigns to local high schools. There had been

no Chinese celebrities afflicted with the disorder and little

reported about the condition in newspaper or magazine


Lee speculated that this very lack of public awareness

about anorexia might be key to the rarity of the disorder,

reducing the likelihood that distressed individuals would

choose, as he put it, “anorexia as a convenient form of

illness.” Which is another way of saying that anorexia

remained outside the symptom pool for the majority of the

population. Lee had a fear, though. As he wrote

prophetically in 1989, he worried that somewhere there

might be an “epidemiogenic trigger” for anorexia that, once

tripped, would “exert an explosive effect.” Five years later

that fear was realized.

At 1 p.m. on November 24, 1994, the last day of her life,

14-year-old Charlene Hsu Chi-Ying walked past the trophy

case at Saint Paul Secondary School, underneath the banner

of the Virgin Mary, and out into the Happy Valley district of

Hong Kong. Wearing her school uniform and carrying her

school backpack, she was unsteady on her feet. She had

fainted twice in the previous week. Just the day before, she

had blacked out in front of her school and had to be sent to

the nurse’s office with a cut knee.

Heading home from Happy Valley to her family’s

apartment in the Healthy Gardens high-rise complex, she

walked north through a forest of skyscrapers toward the

central business district of Hong Kong. Having grown up in

the city, she found the cultural mélange she passed through

to be quite normal. She passed the Seventh Day Adventist

Pioneer Memorial Church and a Buddhist temple. She

walked by one McDonald’s and another a few blocks later.

She walked past the Hong Kong Cemetery, the Saint Michael

Catholic Cemetery, and then past the Muslim cemetery. She

also passed by the front doors of the hospital where her

lifeless body would soon be delivered.

Charlene was about to become famous in Hong Kong as

the public face of anorexia nervosa. Her death that day

would introduce the disorder into the public consciousness

and be a critical turning point in the evolution and spread of

the illness. It is therefore important to try to understand—

both intellectually and on a gut level—what it meant to be a

14-year-old in Hong Kong at that particular moment in


The mid-1990s were an uncertain and nervous time for

the population of Hong Kong. The transfer of sovereignty

from Britain to China was just three years away. Even before

the 1989 Tiananmen Square protests, many families had

attempted to emigrate. After the massacre the number of

those trying to get out of Hong Kong doubled; before the

handover more than half a million people would leave.

This caused a great deal of stress on family networks.

Most countries allowed families to immigrate only in

Western-style nuclear groups: a set of parents and a set of

children. But traditional Chinese ties to extended families

remained strong. Indeed in the unforgiving and competitive

business environment of Hong Kong, support from extended

families was an important social safety net. The emigration

of each family unit weakened that safety net for the

relatives left behind.

“Through the early 1990s, each time we returned from

summer holidays, a few more children had disappeared to

Canada, Australia, the United States, Britain,” wrote one of

Charlene’s contemporaries. “For us confused adolescents, it

was a blur of hasty farewells to friends pulled out of school

midterm. . . . All around us, people were panicking about the

future of the British colony, stunned by the bloody crushing

of the student-led protests in Beijing.”

One can get a sense of the confluence of these forces in

the Hong Kong of the 1990s by watching movies about teen

life during the period. One in particular, Autumn Moon,

directed by Clara Law in 1992, tells us a great deal. Along

with those of other so-called second-wave directors in Hong

Kong, Law’s films are moody and strive to communicate the

postmodern disconnect of the time. Autumn Moon is about a

15-year-old Hong Kong girl who strikes up an unlikely

friendship with a bored and nihilistic Japanese tourist named

Tokio. The teenage girl, Hui, is caught between two

countries: her parents have already emigrated to Canada,

leaving her in Hong Kong to wait for the death of her

grandmother. Like Tokio, Hui is disconnected from traditional

culture. She can’t cook and believes that McDonald’s

represents traditional Chinese food. The movie also riffs on

the globalization of teen culture; when Hui worries that in

Canada no one will have heard of Madonna, Tokio reassures

her, “Don’t worry. Madonna is everywhere.”

As the movie suggests, no segment of the world’s

population is more vulnerable to being swept away by the

currents of globalization than adolescents. Teenagers are

often the first to adopt Western dress and slang and identify

with movies, music, and television. But Autumn Moon

reveals that teenagers in Hong Kong were not simply

interested in Western pop cultural tastes in music and food.

What was changing was the very nature of adolescence. The

first scene shows Hui standing in front of her bedroom

mirror; in a voiceover she says, “I am fifteen years old. I’ve

only just found out that the cold weather doesn’t start right

after summer. Autumn is in between.”

Social scientists have coined a shorthand for the Western

view of adolescence, calling it “storm and stress.” Research

in the United States and Europe has consistently shown that

the teenage years bring with them the highest prevalence

of risky behavior, including substance abuse, wild driving,

and unprotected sex. Some researchers have assumed that

what we’ve learned about adolescence in the United States

and Europe is true of teenagers around the world.

Cross-cultural research has shown, however, that the

storm and stress assumptions about adolescence are far

from universal. According to Jeffrey Jensen Arnett, a

professor at Clark University and the author of Adolescence

and Emerging Adulthood: A Cultural Approach, at the heart

of the cross-cultural difference is the importance placed on

achieving independence. Our Western conception of

adulthood places a high value on individual identity and self-

sufficiency, and much of the storm and stress of Western

adolescence comes from the push and pull of this

movement toward separation.

However, in many traditional cultures, particularly in Asia,

personal independence has not been the goal of adulthood.

Instead, inter dependence—reliance on and obedience to

one’s family, clan, and village—has been the goal.

Teenagers on their path to adulthood are not expected to

strain the bonds that tie them to their family. Because

traditional cultures have de-emphasized the notion that

adolescence is the road to personal independence, much of

the storm and stress experienced by Western adolescents

has been absent.

But there were signs that this was changing. “If it is true

that cultural values of individualism lie at the heart of

adolescent storm and stress,” Arnett concludes, “it seems

likely that adolescence in traditional cultures will become

more stormy and stressful . . . as the influence of the West


So not only were governmental and family structures

undergoing rapid change in the mid-1990s in Hong Kong,

but the very nature of adolescence was in flux. Social stress

on the adolescent population was obvious; what had yet to

be determined was how that inchoate psychological charge

would express itself.

Thinner Than a Yellow Flower

It was during this nervous time in the history of Hong Kong

that Charlene Hsu Chi-Ying began to lose weight. Until late

in the summer of 1994 she had been a parent’s dream. Her

grades and test scores consistently put her in the top

percentile of her school. She had a close group of friends

and was active in sports and afterschool activities. Her

mother was never sure why her daughter started to eat less,

as the incident that seemed to spark her food refusal

seemed trivial: her mother had not let her go on a class trip

to mainland China.

Once her weight loss started in August, her personality

quickly changed as well. By October she had become sullen

and uncommunicative. She never mentioned that she was

trying to diet, nor did she mention believing that she was

overweight. Her classmates noticed the change in her

personality. Once a gregarious girl with a group of friends,

by October of that school year she had taken to sitting in

the corner of the lunch room by herself, reading while the

other students ate.

Although the diagnosis of anorexia never came up, both a

school counselor and an outside social worker met with

Charlene to encourage her to eat more and go to a doctor

for a checkup. The last meeting with school personnel took

place the day she fainted in front of the school. The

schoolmistress, Ting Yi, said that the staff had decided not

to tell Charlene’s parents about the incident but to use the

threat as leverage for change. Charlene had one week, they

told her, to improve herself before they would notify her


The next day Charlene took her fateful last walk. After

passing by the graveyards and the hospital, she turned onto

the busy Wan Chai Road. This is where she often hopped a

tram to take her home to Healthy Gardens. Before she

reached the tram stop she became unsteady on her feet. A

shopkeeper from across the street named Chan Suk-kuen

spotted Charlene. She would later tell the inquest board that

Charlene caught her attention because she was so

preternaturally thin. The shopkeeper briefly lost sight of her

when a double-decker tram obscured her from view. When

the tram passed, she saw that Charlene had collapsed onto

the sidewalk. Chan Suk-kuen and half a dozen other people

came to her aid. When she didn’t revive, they called the

police and an ambulance.

The policeman who checked her backpack and found her

school identification card at first couldn’t reconcile the

smiling and healthy young woman in the picture with the

emaciated and ghostly figure being loaded onto a gurney.

The coroner who examined Charlene’s body, Dr. Au Kam-

wah, found that she weighed 75 pounds. Her adrenal gland,

thyroid, kidney, and stomach all showed signs of atrophy.

She had virtually no stores of subcutaneous fat. Her heart

was tiny, weighing just three ounces. The policeman’s

confusion was repeated at the hospital, where several of the

nurses, upon seeing the skeletal body on the stretcher,

initially assumed it was the remains of an elderly woman.

Had Charlene made it home and died in her family’s

apartment in Healthy Gardens, her passing might not have

caught the attention of the media. However, because she

collapsed on a busy shopping street in the heart of Hong

Kong, the story was irresistible. All of Hong Kong’s Chinese

and English papers gave prominent placement to the story

of her death. “School Girl Falls on Ground Dead: Anorexia

Made Her Skin and Bones,” read one headline in a Chinese-

language paper. “Girl Who Died in Street Was a Walking

Skeleton,” reported the English-language South China

Morning Post. “Schoolgirl Falls Dead on Street: Thinner Than

a Yellow Flower,” reported another Chinese-language daily.

The Chinese-language papers used the phrase yan shi

zheng for the disorder. Yan means to loathe or to dislike, shi

means eating, and zheng means disease or disorder. The

literal translation of the term for anorexia in both the

Cantonese and Mandarin dialects would be something along

the lines of “the disorder of loathing to eat” or “the disease

of disliking eating.” This was the first time people in Hong

Kong had read about a local case of anorexia in their daily


Of course all of the articles tried to address the burning

question on everyone’s mind: What was the meaning behind

this strange disease that led a young girl to starve herself to


To answer the question, Chinese reporters looked to

Western sources and experts. One reporter for a Chinese-

language daily was clearly cribbing from the DSM when he

described anorexia this way: “The patients are so afraid of

gaining weight, that even when they are underweight, they

insist that they are fat.” Several papers quoted Western

experts to explain that dieting and the fashion industry were

culpable. “Weight loss became a tragedy!” began one story.

“It was speculated that a 15-year-old girl had been losing

weight with the wrong methods, and her health condition

deteriorated day by day.” Dieting and the beauty industry

were not the only causes cited in the papers. “Besides

weight loss for beauty, other causes of anorexia include

family strife and school pressure,” claimed one article in a

Chinese-language daily. It also noted that the pressure of

being a celebrity sometimes brings on the disorder,

reminding readers that a famous American singer had died

of the disease.

A year later a public inquest was held to determine the

cause of Charlene’s death. Charlene’s mother, schoolmates,

teachers, and counselors all gave testimony. The papers ran

stories emphasizing that anorexia nervosa was a dangerous

disease that threatened young women in Hong Kong.

Headlines read “Call for Vigilance to Prevent Anorexia

Deaths” and “Teen Death Sparks Anorexia Concern.”

There was no evidence at that moment that anorexia was

a widespread disorder among young women in Hong Kong.

Indeed the tone of alarm in the headlines and the leads of

the stories was often contradicted by quotes from local

experts near the bottom of the story. On the stand, the

pathologist Dr. Au Kam-wah testified that he had seen only

one other possible case of anorexia in his ten years of

practice. Nevertheless the jury at the inquest recommended

that schools provide counseling and education on eating

disorders and their consequences. The papers followed suit.

“Teachers, social workers, parents and schoolmates should

make a combined effort to detect anorexia among

secondary school girls before it is too late,” began one

follow-up story in The Standard.

Lies about Beauty

It is difficult to document when a psychosomatic symptom

such as self-starvation worms its way into the unconscious

minds of a population. There is, of course, no single moment

when a behavior enters the symptom pool of a culture.

Looking back over time, however, it is often possible to

identify a tipping point, the period after which the public’s

knowledge and acceptance of a symptom or disorder begins

to grow exponentially. There is little doubt that the year of

Charlene’s death represented that crucial tipping point for

anorexia in Hong Kong.

The day before I visited Dr. Lee during my visit to Hong

Kong, I spent an afternoon flipping through the press

clipping files of the Hong Kong Eating Disorders Association

with the organization’s clinical psychologist, Celia Wu. The

popular press articles that were published about anorexia

after 1994 were remarkable both in their volume and in how

similar they were to Western popular press articles on the

topic. Within a few years of Charlene’s death, there were

several Hong Kong actresses and pop singers telling

harrowing stories of becoming anorexic. In one article

Western celebrity anorexics were compared side-by-side

with their Hong Kong counterparts.

The cultural trends identified as the cause of the disorder

were familiar as well. “Swallowing Lies about Beauty Can

Make You Sick,” read a headline in The Standard in 1995.

“Western influence,” the article claims, “brings with it the

notion of ‘happy go skinny.’ Supermodels on catwalks,

Hollywood stars at the Oscars, and even the slender legs in

beer and automobile adverts all promote the anorexic look

as sexy and glamorous.” “Teenagers Risk Health in Quest for

Beauty: Expert Blames Social Pressures for Eating Disorders

as Patient Numbers Soar,” read another typical headline.

Remarkably, the pieces in both Chinese-language and

English-language papers often relied exclusively on Western

psychologists and psychiatrists to explain the illness. The

Western experts quoted in these popular articles repeated

variations on the common themes that dieting and pop

cultural trends caused anorexia and that fear of being fat

was central to the illness. None suggested that there might

be meaningful distinctions between the manifestation of

anorexia in the West and East.

Quoting Western sources, the media coverage in Hong

Kong repeated several ideas, including the following:

That anorexia was a threat to young women who were

prone to anxiety or depression or facing problems in

school or in their families.

That severe food restriction in young women should be

read as a cry for help.

That a key spark for the disorder lay in shifting cultural

ideas of thinness and beauty.

That fat phobia and a distorted body image defined the


That anorexia usually attacked the most promising

young women.

This conception of anorexia mirrors fairly well the

understanding one would find in the West among educated

people and non–eating disorder specialists in the medical

and mental health fields.* The idea that anorexia is tied to

culturally imposed notions of female beauty has become

conventional wisdom in the West. “In casual conversation

we hear this idea expressed all the time: Anorexia is caused

by the incessant drumbeat of modern dieting, by the erotic

veneration of sylphlike women,” writes Joan Jacobs

Brumberg in her masterpiece Fasting Girls: The History of

Anorexia Nervosa.

The problem was that many of these Western assumptions

had little meaning for most of the anorexics Lee saw in his

practice. Those women were not motivated by ideas of

thinness and beauty. They were not fat phobic, nor did they

have a distorted body image. They were not the “golden

girls” of their schools or workplace. The mental health

experts quoted in the Hong Kong papers and magazines

confidently reported that anorexia in Hong Kong was the

same disorder that appeared in the United States and

Europe. In Lee’s experience, this was simply not the case.

Western assumptions about the disease were spread not

only through the popular press and television. Western

academic researchers also took up the charge. Shirley Geok-

Lin Lim, a professor of English at the University of California,

Santa Barbara and a visiting professor at the University of

Hong Kong, wrote in the journal American Studies

International that the rise in anorexia in Hong Kong was due

to a “globalization of a visual culture in which women’s

bodies and appearances are homogenized and fetishized as

childlike or waif-like, subordinate and vulnerable.”

Although Lee was trained in the West, his frustration at

this lopsided emphasis on Western knowledge when it came

to anorexia sometimes boiled over. “It is sobering to

recognize that although the non-Western cultures are sub-

dominant and ill-prepared to publish, they make up 80% of

the world,” Lee wrote testily in an article published in 1995.

Indeed the unthinking adoption of the DSM diagnosis of

anorexia threatened to turn the very act of disease labeling

into a meaningless abstraction, one that could harm the

doctor-patient relationship by blinding them both to the

more subtle and complex realities of the patient’s history

and her local experience of culture. Lee wrote, “By

intentionally replacing native metaphors with experience-

distancing jargons and by unintentionally demolishing

cultures, the imposition of universalizing biomedical

categories may imperil illness negotiation on the one hand,

and curtail local healing opportunities on the other.”

Lee’s effort to alert the world to the important differences

in local expressions of anorexia in Hong Kong did not go

unheard, at least within the community of those who

seriously study eating disorders. Beginning with his early

research, his papers on the topic appeared in the top

international journals and received wide praise from other

scholars. But in terms of influencing the general

population’s understanding of the meaning of anorexia,

Lee’s work appeared to have little effect.

In the wake of Charlene’s death educational programs

were launched in schools, further spreading news of the

disorder. A youth support organization called Kids

Everywhere Like You (KELY) announced that it was going to

set up special counseling programs to focus on the threat of

eating disorders. They also announced a twenty-four-hour

hotline in both English and Cantonese to provide information

and counseling.

All these avenues for information fed the general public’s

understanding of the disease. Hong Kong teenagers became

increasingly aware that eating disorders were no longer a

Western phenomenon. They now understood that they were

at risk as well.

What happened over the next few years mirrors what

happened in the United States and Europe after the naming

of the disease. As the public became aware that anorexia

was in the symptom pool, local clinicians, including Lee,

noticed an increase in cases of eating disorders. Where Lee

was once seeing two or three anorexic patients a year, he

was now seeing that many new cases each week. The

increase sparked a new series of newspaper, magazine, and

television reports. One typical article noted that eating

disorders were “twice as common as shown in earlier

studies and that the incidence is increasing rapidly.” In the

late 1990s, studies reported that between 3 and 10 percent

of young women in Hong Kong showed disordered eating

behavior. “Children as Young as 10 Starving Themselves as

Eating Ailments Rise,” announced a headline in The

Standard. The lead stated: “A university yesterday produced

figures showing a 25-fold increase in cases of such


Amid all the finger-pointing at diet fads and the influence

of Western fashion and pop culture, few considered the

possibility that the idea of anorexia nervosa itself—

prepackaged in its DSM diagnosis and explained by readily

available Western experts—might have been part of the

reason the disorder caught on so quickly in Hong Kong. This

possibility, however, fits well with Shorter’s theory of how

symptom pools change over time. At another point in

history, the population of troubled teenage girls might be

drawn to a different unconscious behavior to express their

internal distress. But starting in 1994 a new belief became

prominent in the culture of Hong Kong. Each newspaper

article, magazine essay, and television show that depicted

anorexia as a valid and dramatic expression of mental

distress for young women made that conclusion self-

fulfilling. Each repetition of this idea incrementally increased

the gravitational pull of the disorder on the unconscious

minds of the population, making it ever more likely that a

teenager would try food restriction as a method of

communicating her internal distress. The greater the

number of women who experienced the symptom, the more

public concern and media attention was directed toward the


Of course, over time a public interest in disordered eating

might have evolved in Hong Kong without Western ideas.

The critical question is, however, Would the cultural

feedback loop have spun into motion so quickly without the

importation of the Western template for the disease? It

seems unlikely. Beginning with the scattered European

cases in the early nineteenth century, it took more than fifty

years for the disease to be named, categorized, and

popularized by Western mental health professionals. By

contrast, after Charlene fell onto the sidewalk on Wan Chai

Road on November 24, 1994, it was just a matter of hours

before the Hong Kong population learned the name of the

disease, who was at risk, and what it meant. The people of

Hong Kong did not come to these conclusions without help.

Rather, they imported the meaning of anorexia from the

West—no assembly required.

“Me-Too” Anorexics

The increase in cases of the disorder was not the only

remarkable thing that happened after Charlene’s death. At

the same time that Lee was trying to alert the world that

anorexia in Hong Kong had its own distinct expression, the

disease presentation among young women in Hong Kong

began to change.

A survey of adolescent anorexics between 1992 and 1997

showed a clear shift in the anorexic patients’ explanation for

their behavior. Unlike Lee’s earlier patients, by 1997 fat

phobia had become the single most important reason given

for their self-starvation. Eighty percent of these young

eating disordered patients, in fact, said that their key reason

for self-starvation was the fear of becoming fat. By 2007

almost all the anorexics he treated reported fat phobia. New

patients were increasingly conforming their experience of

anorexia to the Western version of the disease.

Were doctors and patients reporting fat phobia and body

image distortion simply to put the condition in line with the

DSM? Lee believes the shifting social understanding of

anorexia actually influenced the expression of the disease

on the deeper level of the patient’s experience. Patients

were not simply reporting fat phobia and body image

distortion but actually experiencing those symptoms.

Aspects of the disease seen in Lee’s early patients, such as

the feeling of fullness or bloating in the stomach, lost their

cultural salience, their ability to communicate internal

distress. The importation of the Western diagnosis was not

only changing the way patients and doctors talked about

the disorder—it was changing the disease experience itself.

Lee came to believe that there are basically two

populations from which eating disordered patients come. A

small percentage begin to self-starve on their own. These

women unconsciously choose self-starvation because of

some set of experiences and unconscious currents that are

unique to their particular lives. (It is likely, he believes, that

there have been a small number of self-styled anorexics

throughout history.) These are the sorts of patients that

Shorter wrote about from the mid-nineteenth century and

Bruch saw in the 1940s.

But at different moments in history there arises another

population of eating disordered patients; they come to the

behavior with a cultural understanding of how it is acted

out, who is at risk, and what attitudes and behaviors result

from the condition. The “holy anorexics” of late medieval

times would fall into this category, as would those women

with hysteria in the late nineteenth century.

Bruch saw the distinction between these two groups

during her research. The rare anorexic patient she met in

1940s New York, she reports, was distinct from the dozens

of young anorexic women she treated starting in the 1970s.

“Those who had developed the illness during the 1970s

often had ‘known’ about the illness, or even knew someone

who had it . . . [or] deliberately ‘tried it out’ after having

watched a TV program,” she wrote in one of her final papers

before her death in 1984. “Instead of the fierce search for

independence [which defined earlier patients] these ‘me-

too’ anorexics compete with or cling to each other.”

The different characteristics of these two groups are

interesting but less important than another fact: the women

attracted to the disorder when there exists a cultural

template for the behavior inevitably far outnumber the

women who come to food restriction on their own. Once an

eating disorder becomes an accepted “pattern of

misconduct,” Richard Gordon writes in Eating Disorders:

Anatomy of a Social Epidemic, “individuals with pre-existing

mood or anxiety disorders, or a whole host of underlying

psychopathologies or developmental vulnerabilities,

histories of sexual abuse or familial concerns with weight

control, may be predisposed to adopting such culturally

sanctioned behaviors as modes of managing unbearable

levels of distress.”

The patients Lee documented in the second half of the

1990s appeared to be mostly of the “me-too” type. Lee

believes that stress from the rapid social changes occurring

in Hong Kong led to a “general loading of psychopathology”

within the population. At such moments there is no

universal way for psychological distress to express itself; the

manifestation of such stress reflects the symptom pool of

the time. Once the idiom of eating disorders became

understood, many of these young women used the behavior

to express their inchoate anxiety and unhappiness. “When

there is a cultural atmosphere in which professionals, the

media, schools, doctors, psychologists all recognize and

endorse and talk about and publicize eating disorders,” Lee

explains, “then people with a certain loading of this general

psychopathology can be triggered to consciously or

unconsciously pick eating disorder pathology as a way to

express that conflict.”

As if to prove the point that eating disorders can act like

contagions that blow across national boundaries on the

cultural currents, the late 1990s saw the rapid rise of

another type of eating disorder. In late 1995 Princess Diana

gave her famous interview confirming the rumors that she

had suffered from bulimia for more than four years. “You

inflict it upon yourself because your self-esteem is at a low

ebb, and you don’t think you’re worthy or valuable,” she

said during the interview, which was carried on Hong Kong

television and widely discussed in the press. “I was crying

out for help.” The newspapers again blared headlines

warning about the new disorder.

Once again an eating disorder symptom had arrived in

Hong Kong’s symptom pool with cultural momentum it had

gained elsewhere. Purging behaviors, including self-induced

vomiting and the use of laxatives and diuretics, quickly

spread among the adolescent population. Patients

themselves often reported to their doctors that the impetus

to try these techniques came from reading or hearing about

others with the disorder. Although dieting was usually the

expressed goal, it was hearing or reading about bulimia

itself that was often the spark for the pathological behavior.

“In line with trends witnessed in Western countries,” Lee

wrote at the time, “bulimia is likely to become an

increasingly ‘fashionable’ mode of coping with distress

among young Chinese women in the coming decade.”

Meeting an Atypical Anorexic

In 1907 Picasso created a painting of five nude women he

titled Les Demoiselles d’Avignon. Now famous for being an

early work of the cubist period that was about to blossom in

Paris, the painting is initially disorienting. Each of the

women’s figures is distorted in some manner: breasts and

elbows are at sharp angles, feet and arms are out of

proportion compared to heads; the faces of two of the

women depicted on the left of the painting look like African

masks. The painting has a strange mismatch of styles, at

once representative, impressionistic, and abstract.

Melanie Katzman, a feminist medical scholar from Cornell

Medical School, and Sing Lee wrote about that painting in a

joint paper they published in 1997. In their view, the image

is a metaphor for the approach that must be taken when

trying to understand women suffering from eating disorders

in general and anorexia nervosa in particular. Just as Picasso

used different artistic styles to depict his subjects, the

meaning behind eating disorders can be understood only

when approached cross-disciplinarily. This would be tragic,

they argued, if researchers failed to see the cross-cultural

differences in anorexic behavior and instead put all such

women in a Western mold. Katzman and Lee were writing

not just of what had happened in Hong Kong. In Tokyo,

Singapore, Cape Town, and Jerusalem the discovery of

eating disorders was quickly followed by the arrival of

American-made knowledge that defined what an eating

disorder was and what it meant.

Katzman and Lee hoped that mental health professionals

would “break through the constraints of current ‘bodily

obsessed analysis’ in which fat phobia and body image

distortion are esteemed as the universal driving force

behind food refusal.” The DSM version of the disorder was

obscuring the indigenous distresses and patterns of

behavior that led young women to adopt self-starvation. If

clinicians around the world could avoid the quick and easy

adoption of Western assumptions about anorexia, they

might be able to hear the complex truths individual women

were trying to communicate. Anorexia and eating disorders

could tell us much about the pressures on women in

different cultures if only their voices weren’t being drowned

out by Western narratives about the power of fashion,

dieting, and pop culture.

Wanting me to understand this point on a personal level,

Lee let me spend an afternoon with one of his long-term

patients whom I’ll call Ling. I knew something about Ling

before I met her; Lee had written about her case

prominently over the years.

During our interview, which was facilitated by a translator,

Ling stayed bundled in an oversized ski jacket with a Pink

Panther logo. Even so, it was clear from her frail hands and

the prominent tendons in her neck that she was seriously

underweight. Throughout our interview she sat almost

perfectly still, with her hands clasped in her lap and her

knees held tightly together. Her expression was sad, and

she often looked at the floor while she talked.

Ling had grown up in an unhappy lower-class family. Her

father, who worked off and on as a glass cutter, was a bad-

tempered alcoholic who violently abused his wife and

children. Ling told me that her father had sexually fondled

her on several occasions when she was 12. Not surprisingly,

she hated him and secretly fantasized about his death. She

had repeated nightmares in which she was weeping and

running away from her father as he “chased her like the


Ling’s troubles with food began at the dinner table, where

her siblings, her mother, and she had to tolerate the angry

and often drunken tirades of her father. To describe the

experience of eating with her father she used the Chinese

saying, “being forced to drink bitter tea.” In hopes of getting

the ordeal over as quickly as possible, she would sometimes

bolt her food, willfully scalding the inside of her mouth. More

often she simply found that she had no appetite when she

sat down at the family table.

The second of four siblings, she had been plagued by

feelings of insecurity and low self-esteem her entire life.

When she was in her late teens and studying for her Hong

Kong Certificate Examination she began to experience

headaches and insomnia. Her menstrual cycle became

irregular and then stopped altogether. She had stomach

pains that were so intense that a doctor removed her

appendix, but to no avail. Not surprisingly, she performed

poorly on the test and had to quit school to take a job in a

factory calculating wages. She cried often during this time

and began to lose interest in everyone and everything

around her, including eating. She made a half-hearted

suicide attempt by drinking detergent. She tried to join a

church but found her fellow worshippers no more kind or

accepting than her coworkers or strangers on the subway.

Ling led a life of utter social disconnection. For months she

would go to work and then straight home, speaking to no


Like many anorexics of that time, she took a circuitous

path to Lee’s door. Her last stop in the medical system

before Lee was to a gynecologist, where she was hoping to

get help restarting her menstrual cycle. She admitted that

this was her mother’s concern more than her own. Her

mother thought her lack of menstruation made her

unsuitable for marriage. Ling herself had no interest in sex,

marriage, or having children.

Lee first met Ling in 1992 when she was 29 years old. At

that time she weighed 70 pounds, far below her ideal body

weight of 101 pounds. He gave her a standard test used in

the West to diagnose disordered eating behavior. From her

answers it was clear that Ling did not fit the Western

conception of anorexia.

When Ling first became aware that there was a disease

category called anorexia, she couldn’t see how it applied to

her. From her perspective, her behavior wasn’t focused on

food. She protested that her problem was that her life

lacked meaning. She didn’t care about food in the same way

she didn’t care about her career or love life or maintaining

social connections. If she didn’t want to live, why would she

be hungry?

While being treated by Lee in the early 1990s, she moved

from her family home to the thirty-second floor of one of

Hong Kong’s many slender apartment high-rises. Even by

Hong Kong standards she lived in a cramped space: less

than 280 square feet. Her tiny bed was shorter than her

height and she slept curled up. The bathtub was just three

feet long. She often bruised herself while laundering clothes

in the cramped bathroom. Living alone, she was something

of a rebel. The tradition at the time for unmarried women in

Hong Kong was to live with family.

In 2000, when her weight again dropped to 70 pounds,

she was briefly hospitalized. By this time there were enough

anorexics in Hong Kong that they had their own hospital

ward. Meeting these other women, she again questioned

her diagnosis. She learned that other anorexics misused

laxatives and diuretics and were intentionally dieting to lose

weight. “These behaviors sounded strange and awful to

me,” Ling told me. “I was not on a diet and I did not have a

tendency of wanting to lose weight. I didn’t have any of

these behaviors, so I thought, ‘I must not have this illness.’”

To this day Ling is still confused about what ails her. After

meeting other anorexics and reading more about the

disorder in the papers, she continues to wonder whether the

disorder describes her condition. This reaction to the

diagnosis, common among his atypical patients, has led Lee

to ask a rather radical question: Is there any therapeutic

value to categorizing patients such as Ling under one

unifying disease label?

“You might want to group patients under a universal

diagnosis if you faced a condition for which a particular drug

had proved effective,” Lee told me. “But there is no

effective drug treatment for anorexia. The only meaningful

components of treatment are understanding the patient’s

life and creating a motivation for the person to change.

Does a medical diagnosis help with these goals? I am not

convinced it does.” A diagnosis such as anorexia,

particularly if that diagnosis comes prepackaged with ideas

and beliefs from a foreign land, can easily obscure the

complex realities of the individual.

Ling, 44 when I interviewed her, expressed deep shame

over a life she feels she has wasted and the burden she has

caused her family. The one bright spot in life, she reported,

was that she has begun to attend church again. “I feel it is

important to have a religion,” she told me. “I feel some

motivation to do things now.”

The Commodification of Anorexia

The rise of eating disorders in Hong Kong reveals an

uncomfortable truth: our cultural fascination with the

meaning of the eating disorders—our natural desire to

understand the lesson behind them and alert the world to

their danger—can become part of the feedback loop by

which the disease goes forward and claims new victims.

That there is a connection between public and professional

attention to such disorders and their spread within a

community is an idea that is only rarely whispered in the

professional literature on the topic. Not surprisingly, popular

book writers, researchers, and mental health educators are

loath to see themselves as a vector transmitting the disease

they hope to eradicate.

Regardless, it is important to look back at the recent

increase in the number of cases of the disorder in the West

and try to trace this effect. To begin with, there is no doubt

that anorexia became iconic, a cause célèbre, within the

feminist movement of the 1970s and 1980s. Whatever else

can be said about the disorder, anorexia packs a wallop of a

metaphoric punch. As the feminist philosopher Susan Bordo

pointed out, anorexia calls attention to “the central ills of

our culture.” The disease has been endlessly employed to

illustrate the social plight of women. In various writings on

the topic, anorexia has been used to decry unrealistic body

image standards, patriarchal family structures, the

subjugation of women by postindustrial capitalism,

unrealistic ideals of perfection, and more.

Unfortunately, in making these arguments writers have

often unintentionally glamorized the disease and elevated

the social role of the sufferer. Law professor Roberta Dresser

argued in the Wisconsin Law Review in 1984 that medical

and parental efforts to forcibly renourish anorexics should

be challenged as a violation of the patient’s civil liberties.

She made the case that anorexics were similar to political

hunger strikers, bravely challenging social injustice. They

should be allowed to starve as a matter of free expression.

Joan Jacobs Brumberg, the feminist author of Fasting Girls:

The History of Anorexia Nervosa, saw such “romanticization

of anorexia” as deeply problematic, as did many of the most

insightful feminist writers on the topic. She worried that the

promotion of anorexia as a “protest against patriarchy”

would overwhelm the more subtle and nonpolitical

psychological realities of the women caught in the throes of

the disease. “As a feminist,” Blumberg writes, “I believe that

the anorexic deserves our sympathy but not necessarily our

veneration.” Although it was seldom acknowledged, the

worry behind such statements seems clear: veneration

encourages imitation.

With the maturing of the feminist movement, this siren

song to potential anorexics has largely died away. No recent

feminist writers that I’m aware of have argued like Dresser

that anorexics should be allowed to starve themselves to

death to prove a political point. Still, anorexia and bulimia

remain in the symptom pool of our time for more subtle and

intractable reasons.

Those who devote their lives to treating disease are in a

conundrum that has rarely gained public attention. At the

same time that they are researching, publishing, and

publicly speaking about these eating disorders, they are

both molding the public’s understanding of the behavior and

keeping it in the symptom pool of our time. The South

African psychologist Lesley Swartz is one of a very few who

have addressed this difficult issue. “Regardless of the

amount of care taken in education about any condition,

professionals are inevitably involved in maintaining and

shaping it,” he writes. “We must allow that an environment

receptive to the understanding of eating disorders may be

one in which they will flourish.”

Sometimes the extent to which researchers avoid this

troubling issue is startling. A recent study by several British

researchers showed a remarkable parallel between the

incidence of bulimia in Britain and Princess Diana’s struggle

with the condition. The incidence rate rose dramatically in

1992, when the rumors were first published, and then again

in 1994, when the speculation became rampant. It rose to

its peak in 1995, when she publicly admitted the behavior.

Reports of bulimia started to decline only after the

princess’s death in 1997. The authors consider several

possible reasons for these changes. It is possible, they

speculate, that Princess Di’s public struggle with an eating

disorder made doctors and mental health providers more

aware of the condition and therefore more likely to ask

about it or recognize it in their patients. They also suggest

that public awareness might have made it more likely for a

young woman to admit her eating behavior. Further, the

apparent decline after 1997 might not indicate a true drop

in the numbers, but only that fewer people weren’t

admitting their condition. These are reasonable hypotheses

and likely explain part of the rise and fall in the numbers of

bulimics. What is remarkable is that the authors of the study

don’t even mention, much less consider, the obvious fourth

possibility: that the revelation that Princess Di used bulimia

as a “call for help” encouraged other young women to

unconsciously mimic the behavior of this beloved celebrity

to call attention to their own private distress.

The fact that these researchers didn’t address this

possibility is emblematic of a pervasive mistaken

assumption in the mental health profession: that mental

illnesses exist apart from and unaffected by professional

and public beliefs and the cultural currents of the time.

Off the podium, some eating disorder experts will admit to

a deep insecurity about the possibility that their work might

be to some degree counterproductive. I asked Michael

Levine, a prominent researcher and eating disorder

educator, whether he ever worries that his work has

potentially spread the very disease he hopes to eradicate.

“In dark periods I worry about it,” he told me. “This disorder

has given me an identity as a professional. I’m a tenured

professor with an endowed chair. Now, am I helping people

or hurting people? I hope I’m helping. But at the same time I

have to acknowledge that anorexia has given me an identity

in the same way it has given one to so many young girls—

sometimes a deadly one.”

The fact that we have not taken full account of how the

professional discourse on eating disorders keeps these

behaviors in the symptom pool is problematic on a number

of levels. As evidenced in Hong Kong, we are engaged in

globalizing our understanding, treatments, and categories of

mental illness. As of now there is no acknowledgment that

in doing this we may be changing the symptom pools by

which people in other cultures find expression for their


What does it take for a symptom such as self-starvation to

exit the symptom pool? Looking back at the history of

hysteria may be instructive. It was in the early part of the

twentieth century that many of the symptoms of hysteria

began to disappear. Hysterical fits and seizures became less

common. Women in large numbers stopped reporting leg

paralysis and temporary blindness and stopped collapsing

while trying to walk across a room. They had fewer facial

tics and involuntary muscle spasms in the arms and legs.

These symptoms didn’t disappear all at once, of course, but

over years. During hysteria’s declining years many of the

symptoms seemed, at first, to lose their vigor, becoming a

kind of pale version of their former selves. In France they

called this la petite hysterie. One French doctor described

women “who content themselves with a few gesticulatory

movements, with a few spasms . . . and the like.” So familiar

were the patient and the doctor with the meaning of

hysteric symptoms that little effort was required to

demonstrate them. It is easy to imagine that once this

milder expression of hysteria became common, it began to

lose its power to communicate deep internal distress.

It may have been the very popularity of hysteria that was

critical in its downfall. If part of the unconscious motivation

for the hysteric was to alert the world to her internal

distress, the symptoms of hysteria would lose power as they

became ubiquitous. “Hysteria during the European fin de

siecle came to mean so many different things that by

around 1900 it ceased to mean anything at all,” Mark Micale

writes in his authoritative book Approaching Hysteria:

Disease and Its Interpretations. The disease was suffering

from “extreme clinical overextension.” By 1930 or so, these

dramatic and unmistakable symptoms began to disappear

from the medical and cultural landscape as they failed to

signal the distress in the unconscious minds of a new

generation of women.

The decline of eating disorders may require a similar

diffusion of the meaning we give them. That is to say, if

anorexia and bulimia lose their ability to effectively

communicate interior distress with a meaningful level of

specificity, they will cease, at least for a time, to be

attractive to the unconscious mind.

Looking back at the history of anorexia, it seems likely

that it will someday fall back to its baseline level. But as we

wait for the epidemic to subside in the West, we may have

unintentionally set in motion cultural currents that will see

the rise of anorexia in culture after culture around the globe.

The Lost Battle

After interviewing Ling I spent the rest of the afternoon

discussing the case with Dr. Lee. He admits that she is far

from cured and that his cultural sensitivity to the meaning

of anorexia in Hong Kong has not led to any surefire

treatments. Indeed he notes that he has lost four patients to

the disease, two by starvation and two by suicide. Although

his insights have not revealed a miracle cure, he believes

that the only hope lies in a deep understanding of each

patient’s subjective experience.

At the end of our time together I asked Lee to sum up the

state of the debate. He had spent the better part of two

decades trying to convince the profession of psychiatry that

Western assumptions about eating disorders were not only

steamrolling local variations but also potentially acting as a

vector, both spreading these illnesses and shaping their

expression. Did he believe he had won the intellectual


“No, I think the battle was lost,” Lee said. “The DSM and

Western categories for disease have gained such

dominance. In the process, microcultures that shape the

illness experiences of individual patients are being

discarded. This is taking place around the world and not just

with anorexia but with other illness categories, such as

depression and ADHD [attention-deficit-hyperactivity

disorder] and psychological trauma. Unfortunately the field

of cross-cultural psychiatry is not doing well in terms of

influencing mainstream psychiatry. I have to admit, we don’t

seem to interest them at all.”

For a few seconds I didn’t ask another question and his

words hung in the air. Then Lee ended the silence. “At some

point in the last ten or fifteen years the current became too

strong,” he said. His tone was not bitter but reflective and

matter-of-fact. “It is, I think, a river of no return.”


The Wave That Brought PTSD

to Sri Lanka

Western mental health discourse introduces core

components of Western culture, including a theory of human

nature, a definition of personhood, a sense of time and

memory, and a source of moral authority. None of this is



Debra Wentz, the executive director of the New Jersey

Association of Mental Health Agencies, arrived in Sri Lanka

on Christmas Day 2004, one day before the tsunami that

would drown more than a quarter-million people. She had

traveled to the shores of the Indian Ocean for a vacation

and to attend a friend’s daughter’s wedding. She was

looking forward to a long-awaited and well-earned vacation.

She spent her first night in a cliff-side room at the Mount

Lavinia Hotel just south of the capital city of Colombo. The

next morning she strolled along the white sand shores below

the hotel. She had planned with another wedding guest to

get up early for a day trip to the historic town of Galle, a

former Dutch fortress. But, tired from the previous day’s

travel, the pair left the hotel an hour later than they had

intended. On the drive south to Galle, they stopped for a

few minutes to buy some bottled water. Many lives turned

on such small choices on that day.

As they were approaching Galle, a smaller wave in

advance of the killer tsunami flooded the road and forced

their driver to turn inland and toward higher ground. As the

driver maneuvered to escape the incoming water, Wentz

could see whole families running for safety. She could tell

that many were in shock. “I don’t think they knew they were

running,” she remembers. She watched helplessly as a bus

struggled through the mud and rising water, unable to

escape the flood. Just a few hundred yards away a train

packed with travelers was swept off the tracks, killing more

than eight hundred people. Wentz remembers briefly

glimpsing a young woman struggling to haul an aged

woman in an antiquated wheelchair away from the incoming

water. The scene seemed unreal. For brief moments she felt

as though she were watching an action sequence from an

epic movie, something like Gone with the Wind. “It was like

you were watching these things from outside yourself,” she

remembers. “I wasn’t really grasping what was going on.”

They were soon inland and out of sight of the water.

Wentz and her companion at first had little comprehension

of the magnitude of what had taken place. It was only when

her driver called relatives in Galle with his cell phone that

they learned that whole sections of the town had been

inundated. Hundreds of people at the local bus stop had

been drowned. When she finally made it back to her hotel,

she took a few deep breaths to process what she had seen

and consider what she could do to help. Between the

rumors and news reports, she gradually became aware of

the extent of the disaster. Hundreds of thousands of people

had died and tens of millions had witnessed the tsunami or

the death and destruction it had wrought. It was then that it

dawned on her how unprepared the region was for the

psychological trauma that was to come.

It was obvious to Wentz that the events of that day would

have a severe, lifelong impact on the mental health of the

survivors—long after their physical needs were met. As

Wentz put it, “staggering acute and long-term mental health

needs would remain.” She had been at the helm of the New

Jersey Association of Mental Health Agencies during the

time of the 9/11 terrorist attacks, and from that experience

she had learned a valuable lesson: the real problems with

grief and post-traumatic stress disorder would come long

after the event. Wentz herself could already feel the

psychological effects of the tragedy she had witnessed. Her

sleep became erratic and she was very emotional about the

horror she had witnessed.

In the ten days she remained in the country, Wentz

worked tirelessly. She moved to a hotel that had computers

she could use to communicate with colleagues in the United

States. Initially she focused on alerting the drug companies

she worked with to the medical needs of the population. She

then turned her efforts to alerting the Sri Lankan population

about the devastating psychological impact that would soon

be felt.

Although not a clinician herself, as head of a statewide

association of 125 nonprofit behavioral health organizations,

she had overseen several public service campaigns with the

goal of lessening the stigma of mental illness and educating

populations unaccustomed to seeking professional help. A

well-connected Sri Lankan friend helped her contact the

office of the prime minister. She informed an official there of

the impending mental health disaster the country was

facing. “I told them that this was going to be unlike anything

they had experienced before,” she recalls. “The

psychological damage in terms of the PTSD and the anxiety

and depression was only going to grow as a problem. I told

them that the impact could be multigenerational.”

She also contacted the Sri Lankan news media. In an

interview that ran repeatedly on Sri Lankan national

television in the days and weeks after the tsunami, Wentz

told the population of how the symptoms of PTSD cluster in

three different categories: avoidance, numbness, and

hyperarousal. She advised everyone to be on the lookout for

this pathological behavior in both adults and children. She

told them that PTSD requires professional attention.

“I knew that the mental health needs after the tsunami

would be unlike anything the world had ever seen,” she

recounted. “But without a sophisticated mental health

system or trained counselors, where were the survivors

going to turn? They had almost no psychiatrists, and most

primary care doctors were not trained in psychiatry or

mental health education. They didn’t have a system in place

to care for these people.” She began to hatch a plan by

which she would collect money in the United States to send

American trauma experts to Sri Lanka to train local

counselors how to spot and treat PTSD.

Looking back on Wentz’s efforts in the hours and days

after the disaster, one has to be impressed with her

selflessness and genuineness of spirit. Her efforts were

clearly motivated by a set of assumptions and beliefs about

the nature of psychological trauma and its appropriate

treatments. Wentz assumed, as do many Western mental

health specialists who focus on trauma, that the

psychological reaction to horrible events is fundamentally

the same around the world. Had she believed otherwise, it is

unlikely that she would have angled to get on Sri Lankan

television to describe the coming impact of widespread

PTSD. From her own recounting of the events, it is also clear

that she believed that the Western world, in particular the

United States, had more and better resources than the

people of Sri Lanka to both understand and respond to the

coming mental health crisis. Wentz’s concern that Sri

Lankans would have to face the psychological impact of the

disaster without a “sophisticated” mental health system or

“trained counselors” was repeated in many quarters during

the days and months after the disaster. In every way Wentz

was acting like a health professional ready to share her

advanced training and knowledge to fight illness—in this

case psychic wounds—in a place that lacked the knowledge

and resources to care for its own.

Although Wentz was in the remarkable position of

communicating directly to the Sri Lankan population in the

immediate aftermath of the disaster, she was far from the

only one sounding the alarm about the impending mental

health epidemic. Mental health professionals around the

world were telling reporters that millions of people would

soon be suffering the debilitating effects of PTSD.

“Traumatized Tsunami Survivors to Take Years to Heal,” read

the headline to a Reuters newswire story filed less than ten

days after the disaster. As many as 15 to 20 percent of

survivors would develop PTSD, said one expert in the

Reuters story. The same expert warned that without

professional counseling, as many as 16 percent of those

PTSD sufferers might commit suicide. Noting that Sri Lanka

already had endured much trauma from its protracted

thirty-year-long civil war, Dr. Sean Scott of St. Vincent’s

Hospital in Sydney told a reporter from Australia’s largest

daily paper that the tsunami would only add to the country’s

psychological burden. “I believe that in the next months,”

Scott said, “the biggest health problem Sri Lanka and all of

the region is going to be faced with is depression and post-

traumatic stress disorder.” Jonathan Davidson, a professor

at Duke University, told a reporter, “Based on prior

experience from other mass disasters, we can expect that

between 50 and 90 percent of the affected population will

experience conditions like post-traumatic stress disorder

and depression which, if untreated, may last for years.”

Although the estimated percentage of people who would

be affected varied widely from expert to expert, there was a

clear consensus among those experts that the need for

psychological treatment services would overwhelm the

available providers in the region. Those experts also

generally agreed that getting to the scene quickly was

critical. “Psychological scarring needs to be dealt with as

quickly as possible,” a psychologist told the Washington

Post in the days after the tsunami. “The longer we wait, the

more damage.” The metaphor of a wave was unavoidable.

Many Western reporters and experts talked about a “second

tsunami” of mental illness that could be avoided only if

proper support and treatment were given. Responding to

the dire warnings, hundreds of nongovernmental

organizations, universities, and private groups quickly

began to gather resources and make plans to send an army

of trauma counselors in teams of various sizes to the coastal

areas of the Indian Ocean.

What happened over the next months in Sri Lanka,

Indonesia, India, and Thailand was likely the largest

international psychological intervention of all time. Trauma

counselors and researchers poured into the region not only

from the United States, but also from Britain, France,

Australia, and New Zealand. As part of its billion-dollar

pledge of assistance, Australia sent multiple teams of

counselors with the intent to bring the mental health

services in the region “into the modern era.” The director of

AusAID, Robin Davies, said that the effort was not intended

to restore or rebuild the mental health care capacity in the

country. “Restore is the wrong word,” Davies was quoted as

saying, “because there was nothing much there before.”

Given the certainty surrounding the need for such an

effort, it is remarkable to remember that we are the first

generation to include psychological first aid with other forms

of assistance after wars and disasters. As late as the mid-

1980s, in fact, the manuals for postdisaster relief focused

exclusively on medicine, food, and shelter and contained no

advice for treating the psychological wounds of a


It’s only been in the past twenty years that the diagnosis

of PTSD has caught the world’s attention. It first gained

critical momentum in the United States and then began

leapfrogging the globe, being put to use after wars,

genocides, and natural disasters. By 2004 PTSD was on the

cusp of becoming the international lingua franca of human

suffering. We were suddenly in a time when, as one

psychiatrist put it, the concern over psychological trauma

had “displaced hunger as the first thing the Western general

public thinks about when a war or other emergency is in the


“We were spreading these ideas around the globe so

effectively that PTSD was becoming the way the entire

world conceived of psychological trauma,” said Allan Young,

a medical anthropologist at McGill University who has

studied the history of PTSD. “The spread of the PTSD

diagnosis to every corner of the world may, in the end, be

the greatest success story of globalization.”

Seldom considered in our rush to help treat the psychic

wounds of traumatized people was the question of whether

PTSD was a diagnosis that could be usefully applied in all

human cultures.

The idea that people from different cultures might have

fundamentally different psychological reactions to a

traumatic event is hard for Americans to grasp. The human

body’s visceral reaction to trauma—adrenaline, fear, and

the fight-or-flight response—is so primal that we assume

that the aftereffects of such events would also be the same

everywhere. The symptoms that make up PTSD, which

include intrusive thoughts and dreams, memory avoidance,

and uncontrollable anxiety and arousal when the victim is

reminded of the event,* seem utterly commonsensical.

But PTSD isn’t just a list of symptoms. Since PTSD was

added to the DSM in 1980, Western mental health

researchers and clinicians have devoted vast amounts of

time and energy researching and treating psychological

trauma. Indeed if you were an ambitious researcher in

psychology or psychiatry during the 1990s, PTSD was where

the action was; by 2004 more than twenty thousand

articles, books, and reports had been indexed in the

National Center for Post-Traumatic Stress Disorder’s

database. Just as hysteria was the archetypal disorder of the

Victorian era, PTSD speaks volumes about how Americans

and the Western world conceive of the self.

Those mental health professionals who formed our

generation’s understanding of PTSD have created an

intricate labyrinth of ideas that includes explicit and implicit

assumptions about what type of event will damage the

human mind and who will be most affected. Within the

literature of this movement are prescriptions for how, as

individuals and as a society, we should react to horrible

events and what types of resources we should devote to the

victims. Farther back in this labyrinth of meaning one

encounters still other ideas: calls for solidarity with the

survivors of violence; incitements to share an enlightened

moral outrage against the atrocities of war and social

injustice; the belief that the study of PTSD has made us

more attuned and sensitive to the world’s suffering. Taken

as a whole, this body of knowledge goes far beyond

describing a disorder with a symptom cluster. It describes a


Western traumatologists have also developed a set of

beliefs about how best to heal from the psychological

effects of trauma. They have proposed that speedy

interventions to counsel survivors within hours or days of

the event are crucial; that retelling or reworking the

memories of the trauma, often in emotionally charged group

settings, promotes mental health; and that truth telling is

better for the mind than stoic silence. Against a growing

body of evidence, traumatologists assume these ideas to be

universally true.

Traumatologists have also advanced the idea that

psychological rehabilitation is best managed by mental

health experts, certified in and sensitized to the Western

understanding of how humans suffer and heal. The post-

tsunami intervention would prove to be a crucible for these

Western certainties.

Kate Chaos

One of the traumatologists who heard the call to help those

suffering in Sri Lanka was Kate Amatruda, a therapist from

northern California. Just days after the tsunami she found a

message in her email in-box from the Association for Play

Therapy seeking volunteers for an urgent mission to the

disaster zone. She immediately faxed her application and

was selected to be part of a team of a dozen play therapists

who would be dispatched to help children suffering mental

trauma in orphanages and local community centers. She

was expected to be on a plane within ten days.

Among the many letters representing her credentials

(MFT, CST-T, DMAT, DSHR-DMH) Amatruda is a BCETS, a

Board Certified Expert in Traumatic Stress. Seen in a broader

context, she is one of thousands of American therapists and

mental health professionals who, in the past twenty-five

years, tied their careers to the remarkable ascendancy of

PTSD in American psychiatry and public consciousness.

Amatruda had become well known in the field. She regularly

gave speeches and taught courses on the subject at local

universities and online, training young therapists to

recognize PTSD. She also taught the techniques for how

best to heal from the disorder, usually through measured

reexposure or retelling of the traumatic event in counseling

with a trained therapist. Amatruda was traveling to Sri

Lanka to apply her knowledge where it was needed most.

Amatruda is a short woman with bubbly energy and a

mane of long, curly, graying blond hair. She self-effacingly

admits that her family often calls her “Kate Chaos,” a

reference to the fact that she is not the most organized

person. In the week before her departure, she worked

frantically to put her professional and personal life on hold.

Preparing for her mission, she bought mosquito repellant,

antacids, antidiarrhea pills, Advil, anti-itch cream, Wet

Wipes, toilet paper, and hand sanitizer—enough supplies,

she said, to “feel like a walking pharmacy.” She also

collected donations of art supplies from several schools in

her town. In one large suitcase she packed sixty-nine

pounds of balloons, scissors, paper and paper punches,

pens, glue, stickers, and “zillions” of children’s Band-Aids.

Through bake sales she also raised two hundred dollars that

she planned to take with her and donate to a worthy local


Like many Western counselors on the way to the scene,

Amatruda believes that trauma forms a kind of psychic

infection in the mind and the best way to drain that

infection is through retelling the story. This is sometimes

difficult because, she explains, in extreme trauma the

human mind often regresses to the point where “we lose our

words.” The purpose of play and art therapy is therefore to

open nonverbal ways of mastering the traumatic memory.

“For children, play is their first language,” she told me.

“They may not have the words for something, but they can

play out their stories with blocks or toys.”

Such techniques, which emphasize retelling or reworking

the trauma verbally or otherwise in the days immediately

after a horror, are in the tradition of what has been called

“psychological first aid,” or sometimes “critical incident

debriefing.” The basic idea, developed and promoted in the

United States throughout the 1990s, is that the earlier a

victim begins to “process” or “master” the memory of the

trauma, the less likely that memory will form the kind of

mental abscess that results in PTSD. Counselors clearly see

themselves as akin to emergency medical professionals

treating wounds at the scene of the accident. Their charge

is to deliver the psychological equivalent of applying clean

dressings to fresh wounds.

In this way of thinking, it seemed to matter very little that

most of the trauma counselors headed to Sri Lanka had no

understanding of the culture they were entering. Like

Amatruda, few could comprehend the local languages, and

for the most part they were unfamiliar with the population’s

religious beliefs, its grieving and burial rituals, or the

country’s long and complicated history of civil war.

In Amatruda’s conception of her job, this lack of

knowledge could even be seen as something of a strength.

In one of the training manuals she authored, she states

emphatically, “One of the requirements of disaster trauma

counseling is to be non-political and non-denominational.

We must not be influenced by religion, ethnicity or political

affiliation.” If you’re doing the mental health equivalent of

applying a compress to someone’s injured head, why would

you need to know his or her religious beliefs, traditions, or

social structures?

Clearly in Denial

The assumption that traumatic reactions exist outside and

unaffected by culture was common among both individual

trauma counselors and the relief organizations sponsoring

them. Dr. Sebastian von Peter, from the Hospital of Neukölln

in Berlin, took the time to read through all the advisory texts

and manuals related to the treatment of trauma after the

tsunami. Mostly written by teams of international mental

health experts to help train relief workers and volunteers,

these texts were produced by CARE, the Red Cross

International, the World Health Organization (WHO), the

Global Development Group, the National Center for Post-

Traumatic Stress Disorder, and the European Society for

Traumatic Event Studies, among others. These organizations

and agencies, he wrote, assume that “at root, people

throughout the world are the same in their emotional

experience and expressions.” Taken together, von Peter

concluded, these manuals imply a universal metaphysic of

emotional experience. In the face of horror, these manuals

assume, all humans are fundamentally the same.

Despite these certainties, there were signs early on after

the tsunami of a cultural disconnect between the ideas

surrounding the Western conception of PTSD and Sri Lankan

beliefs. There was, for instance, a remarkable memo

emailed just days after the disaster by faculty members

from the University of Colombo in Sri Lanka. The professors

acknowledged that “disaster zones attract ‘trauma’ and

‘counseling projects,’” but they pleaded with the arriving

army of counselors not to reduce survivors’ experiences “to

a question of mental trauma” and the survivors themselves

to “psychological casualties.”

They went on to make an argument that fundamentally

undercut the certainty that Western ideas about trauma are

universal. “A victim processes a traumatic event as a

function of what it means,” they wrote. “This meaning is

drawn from their society and culture and this shapes how

they seek help and their expectation of recovery.” Trauma

reactions aren’t automatic physiological reactions inside the

brain, they suggested, but rather cultural communications.

They have nuance and meaning that can be misinterpreted

or overlooked unless observers have a deep understanding

of the culture at hand. What was required before any

organization could offer meaningful help, the professors

wrote, was a deep understanding of “what the affected

people were signaling by this distress.”

In the days after the disaster, reporters and clinicians

arriving from the United States and elsewhere sometimes

seemed confused, even concerned, when the local

population didn’t behave the way they’d expected. One

trauma counselor being interviewed on BBC radio from a

small coastal village expressed his worry that the local

children appeared more interested in returning to school

than discussing their experience of the tsunami. These

children were “clearly in denial,” the expert told the

listening audience. The host of the program concurred,

saying, “Of course, everyone knows that children are the

most vulnerable to trauma such as this.” The expert then

confidently concluded that only later would the children

“experience the full emotional horror of what has happened

to them.” Similarly CNN reporters expressed their

amazement when tens of thousands of Sri Lankans

attempted to abandon their refugee camps just days after

the disaster, preferring to go back to their devastated

villages or depend on friends or family. A New York Times

reporter wrote that it would be only “a matter of time”

before the “wall of determination and denial, which has

enabled so many to cope in the days immediately after the

Dec. 26 tsunami disaster, begins to break down.”

With so many counseling and trauma treatment programs

and PTSD researchers arriving in the country every day, the

situation on the ground soon turned chaotic. Shekhar

Saxena, from the World Health Organization, was disturbed

by the scene he saw in the days and weeks after the

tsunami. “Two weeks after the tsunami there were hundreds

of counselors doing nothing or getting in the way,” he told a

reporter from Reuters. He pointed out that sending mental

health workers who didn’t speak the local language or

understand the culture was as useless as sending the wrong


Dr. Mahesan Ganesan, who was the only psychiatrist in all

of eastern Sri Lanka, desperately tried to keep track of the

various organizations arriving to give psychological aid. For

a few days he managed to keep a tally of the dozens of

groups on a large whiteboard in his office, but he soon lost


Looking back, it’s hard to escape the feeling that these

various efforts had about them the energy and excitement

of a gold rush. The tsunami was one of the most devastating

natural disasters in recorded history, and everyone who

wanted to demonstrate their acumen in healing trauma or

perform large-scale studies of PTSD felt obligated to be on

the scene. If a technique was to be taken seriously as a

treatment for psychological trauma, its adherents had to be

part of the action.

Within days bitter rivalries broke out between counseling

groups over which populations would receive which

services. As one journalist documented, different support

services attempted to “stake their claim to refugee camps.”

The haggling between groups vying to help sometimes

caused confusion and bad feelings among the survivors.

One Sri Lankan health care worker described how children

were lured away from one set of volunteer mental health

care providers by other groups with toys and other

incentives. “Children are torn between these loyalties, and it

can be traumatic,” said T. Gadambanathan, a Sri Lankan

psychiatrist from Trincomalee.

Similarly Ganesan watched with a mixture of horror and

fascination as several organizations offering counseling

services to one camp fought among themselves for the

attention of the children. “It was common for the

[facilitators] to differentiate between ‘our’ children and

‘their’ children,” he reports. “At times children were asked

not to play with children belonging to other groups. This

often led to conflicts . . . and at times brought about

animosity between the children themselves.”

Ganesan noted a key difference between the aid groups

offering medicine, food, and shelter and those offering

trauma counseling. The groups focusing on basic material

needs would immediately meet with local officials and

families to try to assess what the community was lacking.

Was shelter the first priority, or food, or first aid? In contrast,

those setting up PTSD counseling services seldom asked

leaders in the local community what they needed or desired

in terms of help. Thinking back, Ganesan’s considered

several possible reasons for this lack of consultation.

Perhaps these traumatologists felt that the local community

did not understand their own psychological needs, and

therefore “getting their opinion would be a pointless waste

of time.” More likely, he’s concluded, these trauma

counselors shared the “idea that all persons would respond

in a psychologically known manner to trauma and loss, and

a particular universal method existed to help these people

whoever they were and whatever their culture.” Such a

belief would make consultation with the local population


There were other problems. Translators had to be

employed, as nearly none of the trauma counselors arriving

from Western countries spoke the local languages. Given all

the foreign activity in the country, the most proficient

translators were in high demand. This meant that

counselors often relied on those with marginal translation

skills, such as local drivers who plied the tourist trade, to

facilitate their therapy sessions. “At best [these translators]

had very limited capacity to translate the very complicated

and sensitive communication that takes place during a

counseling session,” noted one local health worker.

Despite such difficulties, the pace of counseling often

rivaled the speed of an emergency room. Over two four-day

periods in late January and February, one organization

reported giving “psychotherapy and counseling” to 1,724

people, including 631 children. This was an impressive feat

given that they had only two dozen counselors to do the

work. Another group of Western counselors debriefed

twenty-five traumatized survivors at a time, with the goal of

one hundred treated for each five hours of work.

The drug company Pfizer was quick to get in the mix as

well. In early February 2005, just over a month after the

disaster, the company sponsored a symposium in Bangkok

titled “After the Tsunami: Mental Health Challenges to the

Community for Today and Tomorrow.” Professor Davidson,

quoted earlier predicting pathology rates of 50 to 90

percent, helped organize the conference with an

“unrestricted grant” from the company.

The paper Davidson presented at the conference was

titled “Pharmacologic Treatment of Acute and Chronic Stress

Following Trauma.” He described PTSD as “a severe,

chronic, and disabling condition with major consequences

for the individual and society,” but assured his audience

that antidepressants such as Pfizer’s Zoloft could become

“an effective tool in promoting the long-term psychological

and psychosocial health, and economic recovery, of those in

the region affected by the tsunami.” Zoloft, he reported, had

been shown to reduce anger after the first week of

treatment and lessen “emotional upset” by week six. By the

tenth week of treatment, those who took the drug were less

likely to avoid trauma-related activities. Although Zoloft had

been approved for PTSD only a few years prior, Davidson

described the drug treatment as “currently recommended

as first-line therapy for the treatment of PTSD” in the United


According to World Health Organization observers, fewer

than half of the trauma counseling groups that flooded the

country bothered to register with the government. Fewer

still worked to coordinate their efforts with each other.

“There was no checking,” John Mahoney, the director of the

World Health Organization’s mental health initiative in Sri

Lanka, told a reporter. “We found one organization just

handing out anti-depressants to people.”

A People’s Army of Trauma Therapists

In addition to the assembly-line counseling, Western experts

on the ground in Sri Lanka took to training the locals in the

latest techniques of treating PTSD. Sri Lankans, generally

speaking, have an intense hunger and respect for

education. That these Westerners, with their impressive

credentials, would be offering free training in modern

healing methods seemed a stroke of good fortune.

Thousands of Sri Lankans took advantage of the offer,

packing the training sessions, which were sometimes as

long as two weeks but often as brief as a day.

A team of educators from the University of Pennsylvania

and Swarthmore traveled to the region to train one hundred

master teachers in a child-centered brand of educational

psychology that uses the creation of illustrated storybooks

to give survivors a method to retell their stories. A group of

American therapists and social workers calling itself the

Heart Circle Sangha also arrived to “train Sri Lankan

counselors and leave in Sri Lanka a cadre of skilled

clinicians” who would have “techniques for working with

intense grief and Post-traumatic Stress Disorder.” According

to their literature, the group taught “skills of deep listening,

empathy, the healing power of connection. . . . The project

emphasizes counseling skills that empower clients.” The

Humanitarian Committee of the Association for

Comprehensive Energy Psychology, sometimes called

thought field therapy, sent counselors to Sri Lanka to

provide free treatment and training for the local population.

These energy psychologists tapped on parts of the body

while encouraging the patient to bring up anxious thoughts

and traumatic memories. Practitioners of eye movement

desensitization and reprocessing (EMDR) also offered

training sessions to locals. In EMDR, which is supposed to

resolve symptoms of PTSD, the therapist instructs patients

to follow a moving object from side to side with their eyes

while holding a mental picture of the disturbing life event in

their mind.

The Western experts leading these sessions often reported

frustration at having to school their trainees in the most

basic concepts of Western therapy. Mary Cattan, who was

part of another training effort in Sri Lanka, found the locals

eager but psychologically unsophisticated. They were so

interested in giving practical advice, she recounts, that

“their listening skills were not very good.” More problematic

still was the fact that the local trainees were “not

particularly self-aware.”

Usually, everyone was invited to attend these trainings,

including children. “After a while, most youngsters in

Batticaloa had acquired certificates which indicated that

they had received training in counseling,” noted one Sri

Lankan observer.

The effectiveness of this new people’s army of trauma

counselors concerned some. There simply wasn’t enough

time or resources to provide supervision for these newly

minted counselors or to put in place safeguards should they

run into difficult or dangerous clinical situations. Asked

about these issues, the foreign trainers would wave off the

concern by assuring the questioner that they weren’t, in

fact, training “counselors.” Rather, they said, these were

“befrienders” or “community support officers,” as if the

renaming solved the inherent problem. It’s clear, however,

that these freshly trained locals often believed that they

were now armed with Western-tested knowledge about how

to treat those in distress.

Mixed in among the therapists and counselors was

another large contingent of Western PTSD specialists: the

trauma researchers. Like the counselors, those who

specialized in the scientific study of psychological trauma

couldn’t afford to miss this once-in-a-lifetime disaster. One

of the first research groups on the scene, from the

University of Konstanz in Germany, looked for posttraumatic

stress disorder among children in Sri Lanka starting just

three weeks after the disaster. Studying several locations,

they soon reported finding PTSD rates between 14 and 39


Some of the researchers employed cutting-edge

technology. One team went to various refugee camps

shortly after the disaster collecting blood samples to

measure chemicals indicative of stress reactions. Another

group of researchers used a polygraph machine to record

heart rate, breathing, and skin resistance. Researchers

interested in genetic predispositions for PTSD were

particularly keen about the opportunity the tsunami

presented. They noted that because whole families were

simultaneously exposed to the tsunami, the event provided

a unique opportunity to look at subtle differences in genes

that would lead one family member to develop PTSD and

another family member to psychologically recover in short

order. In one multimillion-dollar study three thousand

tsunami survivors were interviewed and more than six

hundred sufferers of PTSD identified. Researchers then drew

blood from those afflicted as well as their healthy siblings in

hopes of finding gene sequences to explain their differing

psychological reactions.

From the perspective of the locals, there was a good deal

of confusion regarding the trauma researchers, who were

suddenly swarming refugee camps asking deeply personal

questions, requesting samples of their blood, and

sometimes hooking them up to strange machines. To begin

with, the distinction between those who came to treat them

and those who came primarily to study them was often

unclear. The researchers appeared to be just one more tent

of concerned foreigners set up on the periphery of a refugee


In a report to the Sri Lankan Parliament, Dr. Athula

Sumathipala pointed out the ethical problems inherent in

such a situation: “When research is combined with aid, relief

and at times clinical care, there is undue inducement for

participation in this vulnerable population.” Because Sri

Lanka lacked any comprehensive process to review and

approve research involving humans, the country was being

invaded by what he called “parachute researchers.”

Sumathipala pointed out that many Sri Lankans who had

never participated in a research study before didn’t fully

understand that they had the choice not to answer the

questions of the investigators. More disturbing still, locals

sometimes assumed their participation would lead to some

financial assistance or other help. From the perspective of

the victims, it made sense that those gathering such

detailed information about their hardships would be

connected to some form of assistance down the road. Why

else would they be so interested?

One American observer, who asked to remain anonymous,

sat in on a seminar held by a large international

nongovernmental organization that promised to train

teachers how to counsel children with posttraumatic stress

disorder. In reality, the actual focus of the two-day session

was to show the teachers how to complete a PTSD symptom

checklist. Although attendees thought they were learning

new skills in dealing with traumatized children, they were

actually being trained in data collection for a study of the

prevalence of PTSD. Within weeks of the tsunami these

trainees were sent into classrooms to collect data not only

on the children’s reactions to the trauma but also on their

history of domestic violence and sexual abuse.

Further blurring the line between research and assistance

was the fact that dozens of the studies were designed to

assess the validity of one treatment or another. Which is to

say that groups of locals were encouraged to participate in

some style of experimental counseling or therapy for the

purposes of determining that treatment’s efficacy. One

research group, for instance, conducted a study in which

they organized groups of adult and child tsunami survivors

to revisit the exact locations where they experienced the

disaster. The idea was that reexposing them to the scenes

where they witnessed the disaster would help them process

the experience. Afterward the study’s authors reported

somewhat cryptically, “No certain cases of retraumatization

occurred [among the participants].” Nowhere did they make

clear whether the participants understood there was such a


Most of the studies conducted in the weeks and months

after the tsunami were of a simple nature. With local

assistance, Western researchers translated up-to-date PTSD

questionnaires and employed them to assess the mental

health of a given population. These surveys were designed

mostly by researchers in the United States to quickly

determine—usually with fewer than two dozen questions—if

the symptoms of PTSD were present. Children in Phuket and

Krabi, Thailand, were studied with the UCLA PTSD Reaction;

children in the Ranong province of Thailand and others in

Tangalle in the southern province of Sri Lanka were assessed

with the Children’s Impact Events Scale 13, which is referred

to among trauma specialists as the CRIES-13. The

population of northern Sumatra and Aceh, Indonesia, were

assessed using the Post-traumatic Stress Disorder Checklist–

Civilian Version. Adults in Tamil Nadu, India, were given the

Harvard Trauma Questionnaire. The resulting studies

published in peer-reviewed journals universally reported

significant rates of PTSD among the cohorts studied.

For many trauma researchers, these results

unambiguously settle the question of whether PTSD was

present after the tsunami. But there is a more difficult and

telling question here: Did the information gathered from

those PTSD surveys accurately represent the distress being

experienced by these populations?

“When you ask [the] whole checklist, the classical PTSD

criteria would be there, but these are all leading questions,”

one Sri Lankan medical specialist was quoted as observing.

“When you ask ‘do you have intrusive memories?’. . . It is

easier to say ‘intrusive memory’ in English, but [try] to put it

into Sinhala or Tamil. You see, is very difficult and by the

time you have explained all that, they know that they have

to answer in the positive.”

The very act of asking survivors to describe their

psychological response to a horrible experience by choosing

among only a few reactions would seem to unavoidably bias

the outcome. Adding to this problem was the common

misperception on the part of those being studied that

answering such questions “correctly” would result in

assistance for oneself or one’s family.

Further complicating matters was an implicit assumption

imbedded in these PTSD checklists: that the traumatic event

in question was a one-off experience safely in the past and

that life had otherwise gone back to normal. It might indeed

be pathological to be constantly on the watch for danger six

months after an anomalous event, such as witnessing a

violent crime. But for those living with their children in the

squalor and discord of a refugee camp, being vigilant about

safety would certainly have a different meaning.

Unfortunately it was impossible for any of the PTSD surveys

to make a meaningful distinction between the psychological

reaction to the tsunami and the ongoing strains of the social

and economic turmoil caused by that event.

In the end these trauma checklists simply had no ability to

discover what might be culturally unique to the experience

of living through horror in Sri Lanka. These surveys weren’t

designed to discover anything new, but rather to confirm

similarities. Did the population have other reactions to the

trauma not included in the symptom lists? Were the

behaviors on the checklists the reactions that caused the

most concern to the Sri Lankans? Such questions didn’t

seem to occur to the researchers, who appeared to believe

wholeheartedly in the universality of the PTSD construct.

Resilience in Sri Lanka

Dr. Gaithri Fernando, a young assistant professor of

psychology at California State University in Los Angeles, was

with her son in Sri Lanka on high ground when the tsunami

of 2004 rolled ashore. In a bizarre coincidence, she was in

the region preparing a study on the psychological impact of

a 2001 earthquake. After the wave receded, she traveled to

the fishing village of Moratuwa, where she saw people

frozen in disbelief and horror. It was clear that the wave had

inflicted both psychological and physical damage.

Fernando watched with increasing unease as scores of

Western psychologists, counselors, and PTSD researchers

arrived in the disaster zone. A native of Sri Lanka, and a mix

of Tamil and Sinhalese, Fernando moved to the United

States when she was 21 to help her husband, a Tamil,

escape persecution. Since then she has returned often to

conduct research on the psychological impact of the long

civil war. The wave of aid that rolled in on Sri Lanka after the

tsunami, she suspected, had the power to change the

culture of the island country as much as the tsunami itself.

Few understand better than Fernando the Sri Lankan

capacity to live in the face of horror. Her research prior to

the tsunami documents a people with remarkable

psychological resilience. Even through decades of war,

youth uprisings, and poverty, most Sri Lankans have

managed to remain functional and hopeful. This is a

population, she has shown, that seldom needed outside

encouragement or counseling to get back on its feet even

after the most punishing hardships.

Many of the Western counselors and experts who rushed

in after the tsunami assumed that the long and brutal civil

war had made the individuals in the population ever more

psychologically vulnerable and therefore more likely to

experience PTSD after the tsunami. There was, of course, an

alternative possibility: that the Sri Lankans—because of their

intimate familiarity with poverty, hardship, and war—had

evolved a culture better able to integrate and give meaning

to terrible events. In this conception it was the Western

counselors, arriving from communities and enclaves

unfamiliar with the immediate experience of violence and

deprivation, who were uniquely vulnerable.

Fernando knows how Sri Lankans turn to their rich cultural

traditions in times of hardship. Religion is a particularly

important cornerstone in the lives of most. There are

Buddhist traditions for the majority Sinhalese, Hinduism for

the Tamils, Islam for the Moors, and Christianity for the rest.

The notion of karma, central to both Buddhist and Hindu

beliefs, is shared by Sri Lankans across ethnic and religious

lines. Overlapping and weaving together these different

traditions is the shared ethnocultural belief in spirits and the

palpable nearness of the spirit world.

Often closely tied to religious traditions is a wide variety of

healing customs. Health care in Sri Lanka is remarkably

pluralistic. There are Ayurvedic practitioners, doctors,

astrologers, religious leaders, mediums, and faith healers of

various types. The lines between these practices,

delineating, for instance, traditional healing from modern

medicine, are not clearly drawn. A Sri Lankan often consults

two or more of these traditions in search of relief from

illness or psychological distress.

Having watched at close quarters the suffering of children

and their parents caught in the violence of the civil war,

Fernando intimately understands that these cultural

traditions have an impact not only on the ways this

population talks about the psychological aftermath of horror

but on the deeper level of how it is felt and experienced.

She understands, as those Colombo professors said

immediately after the tsunami, that victims process

traumatic events as a product of what they mean.

Indeed Fernando’s earlier work on war trauma in Sri Lanka

had uncovered fascinating connections between religious

beliefs and differences in the ability to recover from the

trauma of war. In one pre-tsunami study she found that

Buddhist and Hindu children who experienced war and

violence were less vulnerable to depression than Christian

children, even though the Buddhist and Hindu kids reported

more personal exposure, witnessing bomb blasts and the

like. She speculated that there might be protective beliefs in

Hindu and Buddhist traditions, such as the active

acceptance of pain and suffering or the beliefs in rebirth and

recompense through reincarnation, that steadied these

children in the wake of terror.

Watching the aftermath of the tsunami, Fernando couldn’t,

of course, predict the psychological consequences. This was

an unprecedented event that could overtax the religious

institutions and healing traditions that the population relied

on. Still, the idea, often repeated by Western experts, that

Sri Lankans had few local resources for psychological

healing (because they lacked trauma counselors) seemed to

simply ignore or discount the cultural traditions, beliefs, and

rituals that Sri Lankans had so long relied on. Similarly the

idea common to many Western traumatologists, that

psychological treatments could be easily divorced from

religion, ethnicity, and the cultural history of the country,

was hard for Fernando to understand.

Most important, Fernando worried that the PTSD symptom

checklists did not reflect the culturally particular ways that

Sri Lankans experience psychological suffering after trauma.

She worried that by using these checklists mental health

professionals from Western countries would be ineffective—

or even do harm—unless they understood that Sri Lankans

had culturally distinct reactions to traumatic events as well

as culturally specific modes of healing. She believed that

unless these local idioms of distress were understood,

appropriate interventions could not be formulated. Without

a deep understanding of the illness, in other words, it would

be impossible to treat the disease.

Fernando took on the task of trying to understand the

local meaning of trauma in post-tsunami Sri Lanka. She

began by gathering a sample of local informants from a

rural area in the southern province of the country. All were

Sinhalese Buddhists, most from poor families. All had

personally witnessed the tsunami, and fifteen of the twenty

had lost family members.

Instead of quizzing these subjects with a predetermined

set of PTSD symptoms, Fernando asked each person to tell

her two open-ended stories in their own language. First she

asked participants to think of someone they knew who had

experienced some type of suffering but was now functioning

well. After that story was finished, the subject was asked to

describe a person who was functioning poorly after a

traumatic event.

Not surprisingly, of the forty stories she collected, thirty-

five were related to the tsunami. With the help of a

researcher and a local community leader, she began to

examine the narratives for similarities in themes and

expressions of wellness and distress. In the end she

collected more than two dozen symptoms and behaviors

that were mentioned by fifteen or more participants. She

then validated the results by conducting a large-scale

survey. She ended up with what she calls the Sri Lankan

Index of Psychosocial Status, a twenty-six-item measure of

the local indicators of distress.

Fernando came to the conclusion that Sri Lankans’

experience of trauma differed from Americans’ in two main

ways. Unlike the PTSD symptomatology, Sri Lankans were

much more likely to experience physical symptoms after

horrible events. Sri Lankans who lost family members or

whose lives were otherwise devastated by the tsunami were

more likely to complain of aches in the joints or muscles or

pain in the chest. Without the mind-body disconnect

common in Western thinking, these Sri Lankans reacted to

the disaster as if they had experienced a physical blow to

the body.

In addition to these somatic symptoms, there was

another, more subtle and pervasive difference. By and large

Sri Lankans didn’t report pathological reactions to trauma in

line with the internal states (anxiety, fear, numbing, and the

like) that make up most of the PTSD symptom checklist.

Rather Sri Lankans tended to see the negative

consequences of an event like the tsunami in terms of the

damage it did to social relationships. Those who continued

to suffer long after a horrible experience, her research

showed, were those who had become isolated from their

social network or who were not fulfilling their role in kinship

groups. In short, they conceived of the damage done by the

tsunami as occurring not inside their mind but outside the

self, in the social environment.

Such social problems are also common in Western

sufferers of PTSD, but Fernando’s research highlighted a

subtle but important distinction. In Western thinking

surrounding PTSD a trauma causes psychological damage

that then results in social problems. A Westerner might, for

instance, assume that depression or anxiety brought on by

PTSD would cause people to fail in their role as a parent. For

a Sri Lankan, this did not appear to be a cause-and-effect

phenomenon. The failure to manage one’s social

responsibilities—to find and fulfill a place in the group—was

identified as the primary symptom of distress and not a

consequence of an internal psychological problem. As she

concluded in her paper on the subject, “The data empirically

support the theory that intra-psychic functioning is not

independent from interpersonal functioning for this

community.” On examination of the interviews, Fernando

realized that every one of the twenty-six symptoms

described by these Sri Lankans was to some extent bound

to this idea that the social trumped the psychological. More

precisely, Sri Lankans interwove the social and the

psychological—to the point where the two could not be

teased apart. Because the Western conception of PTSD

assumes the problem, the breakage, is primarily in the mind

of the individual, it largely overlooks the most salient

symptoms for a Sri Lankan, those that exist not in the

psychological but in the social realm.

This is one of those subtle cultural differences that is hard

to point to at any given time. In trying to describe the

interconnection between the social and the individual sense

of well-being, Fernando told me of interviewing a young boy

in a village that had been the scene of several massacres.

The boy was 8 years old, and his father had been killed

during one of the periods of violence. Fernando was working

with another researcher who didn’t speak the local

language, and so she was translating the questions and

answers so the other professor could understand. At one

point she asked the boy what makes him feel better when

he gets worried about the violence in his community, and

the boy answered that it was the things his mother says to

him. “This boy told me that he feels better when his mother

promises him that if they are attacked and killed that they

would all die together,” Fernando recalls. The answer struck

her so deeply that for several moments she couldn’t

translate the response for the other researcher. The mother

offered no promise of protection or even survival, only

togetherness in the face of violence and death. The boy, for

his part, appeared deeply reassured by his mother’s


This emphasis on the social over the psychological

becomes critical when one considers how one might heal

from tragic events. If depression, anxiety, or hypervigilance

are the primary symptoms (which then lead to social

problems in one’s family or social group), it might make

sense to take time to work though the psychological

symptoms away from one’s social responsibilities. This is a

common pattern of mental health healing in the West: take

a sick leave from the stresses in your life in order to heal. If,

however, the social difficulties are the primary symptom of

distress, taking time away from one’s duties and social roles

to pursue something like individual counseling may actually

exacerbate the problem. In a culture such as Sri Lanka’s, an

emphasis on healing the individual away from the group,

particularly in one-on-one counseling with strangers, is


Kate Chaos, Part II

When I interviewed Kate Amatruda it was several years after

the tsunami. Since that trip she had continued to teach and

visit other disaster zones. Asking her about her experience

at the refugee camps in Sri Lanka, I wanted to know if she

felt any cultural disconnect between her ministrations and

the local ideas of trauma and healing. In response, she

made every effort to assure me of how culturally sensitive

she remained. She recalled that, on arrival, she was given a

full day’s training in Sri Lankan customs and history. Local

officials instructed her to wear her hair up and to eat only

with her right hand. She was also told that she couldn’t ask

children to play a card game called Go Fish because of the

associations with ocean fish eating the bodies of those

washed out to sea; in addition, she was told that all card

games or other activities that might be construed as

gambling were forbidden among Muslims. She tried, she

says, not to refer to the tsunami as “bad” or “mean” for fear

of alienating the Buddhists, who believe in karma.

When I asked her whether she thought that people around

the world differ in their reaction to trauma she told of seeing

striking similarities between the pictures drawn by children

in Sri Lanka and those drawn by children in post-Katrina

New Orleans. “Those pictures are absolutely

indistinguishable,” she said. “You cannot tell the difference.

On some human level, our reaction is probably universal.”

On a personal level, she reports experiencing some

culture shock on her arrival. The normal discomforts of

traveling in a developing nation were heightened in the

aftermath of the disaster. The lack of showers and Western-

style toilets also took some getting used to, and the curry

dishes for breakfast didn’t agree with her stomach. She

remembers being constantly anxious about contracting

head lice from the children in the camps. But overall she has

fond memories of the week she spent leading dances with

children, handing out art supplies, and organizing games.

She is also particularly proud of the training sessions she

helped conduct with local teachers and health care workers.

Despite her obvious enthusiasm for her work, I found it

difficult to get Amatruda to tell me what particular practices

or ideas she brought with her to Sri Lanka. What, I wanted

to know, were the theories behind the activities she

organized during her stay? What information had she

passed on during the time she spent “training the trainers”?

For instance, when I asked her what sort of techniques she

taught to the local health care workers, she told me, “The

trainings were important but not necessarily for what we

taught them as for the fact that we were there for them.

They knew people had flown all across the world to help


I suggested to Amatruda that beyond her admirable desire

to show solidarity with the victims of the tsunami she must

have felt that she had some specific knowledge that she

wanted to impart. She was, after all, leading training

sessions. But each time I tried to turn the conversation to

the question of what that knowledge might be, she

retreated into generalities. “It almost doesn’t matter what

you do,” she insisted. “So much of it is showing up. It

matters that you’re there and that you’re really there and

you’re able to witness the pain and the horror. You’re there

to witness and receive.”

Amatruda wasn’t alone in her reticence. Many counselors

returning from their work in Sri Lanka were loath to be seen

as part of some hegemonic West-to-East, rich-to-poor

transfer of knowledge. Recounting their counseling and

training work after the tsunami, some Western

traumatologists went to almost comic extremes to assure

their readers or questioners that they were sensitive to the

local culture. Dr. John R. Van Eenwyk, the founder and

clinical director of the International Trauma Treatment

Program, curiously insisted that the best role for Western

trauma trainers was to prove that they had nothing to offer

their trainees. The intent of the trainings he conducted in Sri

Lanka was to reveal himself to be as powerless as the

Wizard of Oz. “Our job is to reveal ourselves as ‘the man

behind the curtain,’” he explained. “Then we help them see

that what they seek from us they already possess. Like the

scarecrow, they already have brains. . . . We don’t

indoctrinate. We empower.”

Still hoping to hear the specific techniques she employed

while in Sri Lanka, I asked Amatruda to tell me of a moment

during her trip when she felt her presence there was

effective in helping heal the psychological wounds of the

tsunami. She told me of sitting with a child who used the art

supplies she had lugged across the world to make a

drawing. During this encounter she helped the child “feel

important,” she said. When I asked her how, she said, “The

child felt important because this blonde person had come all

the way across the world to see her.”

One day, not long after her arrival, Amatruda was

counseling a woman named Selvie-amah, who was the

housemother for an orphanage of girls. When Selvie-amah

revealed that she had lost two brothers in the civil war,

Amatruda asked how she managed to keep herself mentally

healthy so that she could care for her girls. The very

question seemed difficult for Selvie-amah to understand.

Amatruda explained that it is important for the healer to

stay healthy herself. She is used to explaining this idea by

employing the metaphor of being on an airplane when the

oxygen masks come down: “If you are sitting with a child or

someone who can’t take care of themselves, put on your

mask first, then take care of them.” Selvie-amah appeared

baffled by this idea. Amatruda’s notion of posttraumatic

stress had led her to a key assumption about the meaning

and impact of trauma that her Sri Lankan counterpart didn’t

share: she assumed that the mental distress experienced by

survivors of horror comes from damage to the individual

psyche and that that damage makes it difficult to help

others. But, as Fernando’s studies showed, Sri Lankans’

sense of well-being emanates from their connection to the

social network around them. For a Sri Lankan, the very

expression and experience of mental health might be

embodied in the act of fulfilling one’s role and helping

others. To repurpose Amatruda’s modern metaphor, putting

the oxygen mask over the mouth of the child in the next

seat would be the very thing that would allow Selvie-amah

to breathe.

Parading Certainties

It is unclear what the Sri Lankans thought of Amatruda, this

energetic Western woman lugging her suitcase full of art

supplies and Band-Aids into refugee camps. Amatruda

reports that she felt welcomed and appreciated. From her

perspective the local population certainly seemed to

recognize the genuine spirit of caring that brought her to

their doorstep in that dark time.

The juxtaposition of these well-meaning Western healers

with the devastated landscape was sometimes

breathtaking. Here, for instance is how Jennifer Baggerly, an

assistant counseling professor at the University of Florida,

recounted arriving in the remote village of Kalladi, where

215 families were living in a refugee camp. “The suffering

here was clear,” she writes. “Rows of white canvas tents in

the sweltering sun face a water tank that has been empty

for a month and a half. Clean water access is a long walk

away so children were thirsty and had unwashed clothes

and hair. Some children had a chronic cough while others

had sores on their bodies.” She then describes her team’s

psychological intervention, providing “temporary relief from

the suffering by conducting our puppet show, helping them

make coping bracelets and magazine collages, playing

active games, teaching them yoga, and passing out candy

and toys to each child.”

Dr. Ganesan, who observed many such Western

interventions, noted that these relief workers, with their

strange behavior, their puppet shows and handcrafts and

interactive games, often did liven the mood of the camps

they visited. “In many instances these sessions, in which

whole communities participated, offered comic relief for the

survivors even though it was probably not intended as

such,” he recalls.

The term “psychosocial aid” has gained great currency

among international trauma counselors who like to believe

that their interventions are sensitive to cultural differences.

In its most promising use, psychosocial aid acknowledges

that helping the culture get back to normal functioning is

the key to maintaining the mental health of the people. The

assumption is that the local people will look to their

churches, mosques, schools, and social networks to find

support and make meaning of what happened to them.

Psychosocial support (again in its most progressive use)

suggests that every effort should be made to put these local

institutions and networks back in working order so that the

people can heal and make meaning in their own way.

In practice, however, it is clear that “psychosocial aid” is

often little more than a buzzword. Although many

interventions talk of psychosocial aid, local religions and

forms of healing are given only lip service or, worse yet, are

used as the proverbial spoonful of sugar that helps the

Western medicine go down. “Trauma victims in disaster

situations may not actively seek mental health services for

various reasons,” wrote David Surface in Social Work Today.

“Some may be in denial or simply not aware of the extent to

which they’ve been traumatized, while others may not seek

out therapy because of social or cultural stigmas. Therefore,

the goal of many disaster mental health workers is to have

therapy be seamless, integrated . . . and, whenever

possible, incorporate familiar community settings and

rituals.” In this way of thinking, it is not the community

traditions or rituals that are seen as healing but the Western

therapy that has been stirred in among local practices.

Some trauma counselors in Sri Lanka all but ignored local

custom and practices and stridently asserted that they knew

better than the locals how to handle the psychological

aftermath of the disaster. William Yule, a child psychologist

from King’s College in London, expressed with particular

certainty that he knew what was best for the population. He

reported with concern that orphaned children were

sometimes coaxed through the experience by relatives who

told them that their parents hadn’t in fact drowned but had

taken jobs that required them to travel to foreign lands. Yule

made it clear that this lack of disclosure would

psychologically damage the children. He writes that he had

to have long discussions with locals “to clarify . . . the need

to be honest with children.”

It’s true that the period after the tsunami was filled with

such hopeful lies and misinformation told not only to

orphaned children but often to desperate parents looking for

missing offspring. Neighbors or relatives would sometimes

tell frantic parents of having seen a missing child or heard

that the child had shown up in a neighboring village.

Following such rumors, one after the next, some parents

traveled hundreds of miles up or down the coast. These

well-meaning lies are certainly heartbreaking and clearly go

against many assumptions of Western mental health

treatment, which values facing and “working through” or

“processing” unhappy experiences. But was Yule’s

insistence that these stories were psychologically damaging

a universal truth or a culturally based assumption?

What Yule didn’t comprehend was that these sorts of

stories are not particular to Sri Lanka or the tsunami.

Anthropologists working in poor or war-torn nations have

documented similar narratives. Based on her work with

Somali refugees, for instance, the anthropologist Christina

Zarowsky wrote that if a person goes missing and is almost

surely dead, it is socially acceptable to lie to family

members to “ease their mind” and say that the missing

person has gone abroad. This is a story born of poverty-

stricken places where people die young or disappear just as

completely through emigration to far-off lands. Dismissing

such stories as psychologically beyond the pale ignores the

tragic social forces from which they spring. In the end all

stories about where parents or children “go” when they die

are, to varying degrees, wishful and culturally bound. How,

one might reasonably ask, is Yule’s insistence on the “need

to be honest” in this sad situation any less culturally

imperialistic than a Christian missionary trying to disabuse

some far-flung population of a local notion of reincarnation?

But regardless of whether trauma counselors tried to be

culturally sensitive or, like Yule, paraded their certainties,

the result was likely the same. Dr. Siddharth Ashvin Shah,

who traveled from his home in the United States to Sri

Lanka after the tsunami to try to help, reports that he

arrived determined to let local healers take the lead. What

he discovered was that the social forces at play made this

approach nearly impossible. “The recipients are driven by a

belief that they lack things, concepts, and behaviors that

the West can supply,” Shah recounts. “The non-West craves

our technology because it anticipates good innovation from

the West. We produce information that verifies its

effectiveness. . . . We are confident that we have something

exceptional to offer and not the other way around.”

Try as he might to be respectful of local beliefs, Shah

found that it was impossible to abdicate the role he was

expected to fill, that of “Western expert” bringing advanced

knowledge. “The attention experts like myself command is

triumphalist,” he wrote, “blinding the relief workers and

myself to the culturally embedded self-concepts and healing

practices.” As much as trauma counselors talked of

“psychosocial approaches” or “cultural competency,” the

obvious preference given to the Western ideas of

psychological suffering often overwhelmed their best


Global Differences in Suffering

A careful look at other cultures and moments in human

history shows that there is little about the human reaction to

trauma that is universal. For instance, the assumption that

each generation of soldiers reacts the same way to combat

is turned on its head by even the briefest look at history.

There is no doubt that soldiers often come back from battle

with psychological as well as physical injuries; the fear and

horror of direct combat can clearly damage the psyche of

men and women. But the medical records of war veterans

kept over the past centuries show that the manifestation of

the injury is always tied up with cultural beliefs

contemporaneous to the time. British soldiers in the Boer

Wars were likely to complain of joint pain and muscle

weakness, a condition their doctors called “debility

syndrome.” In the American Civil War, soldiers often reacted

to the psychological trauma of battle by experiencing an

aching in the left side of the chest and having the feeling of

a weak heartbeat, labeled “Da Costa’s syndrome.” Or they

experienced a withdrawal and lethargy thought to be a type

of pathological nostalgia caused by being far from home. In

the First World War, British and American soldiers commonly

experienced “shell shock,” with symptoms that included

nervous tics, grotesque body movements, and even

paralysis. So although the potential psychic damage of war

is indisputable, the process by which that damage becomes

an outward symptom is a reflection of the cultural beliefs in

a particular time and place. The unconscious mind of a

soldier latches onto culturally current symptoms of distress

(chest pain for the Civil War soldier and muscle spasms for

the World War I soldier) because those symptoms are

recognized as legitimate during a particular time.

It is important to emphasize that even though symptoms

change over time, this is not a matter of faking or play-

acting on the part of those psychologically traumatized.

Rather, soldiers from different times are unconsciously

internalizing cultural expectations and then experiencing

them as unavoidable and real. The simple but mind-bending

truth is that mental illnesses such as PTSD can be both

culturally shaped and utterly real to the sufferer. Therefore,

as the medical anthropologist Allan Young explained to me,

a diagnosis of PTSD “can be real in a particular place and

time, and yet not be true for all places and times.”

What is true across time is also true across cultures.

Researchers studying psychological reactions to trauma in

cultures around the world have found remarkable deviations

from the PTSD symptom list. Salvadoran women refugees

who endured a protracted civil war, for example, often

experience something called calorias, a feeling of intense

heat in their body. Although these women did experience

sleep disturbances, which is one symptom of PTSD, they did

not, for the most part, report increased startle responses or

other physical reactions when reexposed to symbols of the

trauma. For some Cambodian refugees, the most pressing

psychological impact of trauma was being visited by

vengeful spirits and the accompanying feeling of intense

distress that, in escaping from the country, they had not

been able to perform rituals for the dead.

“The meaning of a horrible event has a tremendous

impact on the human psyche, and that meaning differs

across the world,” says psychology professor Ken Miller of

Pomona College. “The meaning matters as much as the

event itself.” Applying the same interviewing techniques

Fernando used in Sri Lanka, Miller has studied psychological

reactions to war trauma in Afghanistan. His analysis yielded

many reactions not on the PTSD symptom list, and several

that had no ready translation in English. There was, for

instance asabi, a type of nervous anger, and fisha-e-bala,

the sensation of internal stress or pressure. The only way for

aid providers to be effective, Miller believes, is for them to

understand the local idioms of distress—the particular ways

psychological trauma is understood, experienced, and

expressed in specific cultural contexts.

Duncan Pedersen from McGill University found unique

expressions of psychological trauma among the Quechua

natives in the southern central Peruvian Andes who were

caught up in the brutality of the Maoist guerrilla movement

the Shining Path and the Peruvian army. The estimated

death toll during the period topped sixty-nine thousand,

with more than half a million internally displaced. The horror

they suffered was remarkable both for its severity and its

unrelenting nature. As Pedersen notes, this was the

“destruction of ways of life—targeting and attempting to

eliminate entire ethnic groups, eradicating cultures and

social systems, thus undermining the critical means

whereby people can endure and recover from suffering and

loss.” The Shining Path even enforced strict rules for how

victims of the conflict were to be mourned, deeming the

traditional public tears of women to be “a sign of


Pedersen and his fellow researchers discovered that the

people of the Ayacucho highlands have two distinct

semantic categories to describe their suffering. Nakary

conveys the notion of collective suffering, often described

with the metaphor “it’s like carrying the cross on the

shoulders of everyone,” and includes the notion that this

suffering is a punishment for wrongdoings in the past. Llaki,

on the other hand, refers to the individual experience of

sorrow and distress. In its extreme form, llaki is seen as an

illness with symptoms that include a variety of physical

pains, such as headaches, stomach pains, and body aches.

Critically, neither llaki nor nakary is thought to be related

to specific experiences of trauma or discrete periods of

upheaval. These are experiences of distress indicative of the

long-term nature of the conflict. Because PTSD connects

symptoms to specific moments of trauma, the diagnosis

does not take account of the indirect and ongoing

consequences of violence that were most troubling to this

population: the destruction of important social networks and

their webs of reciprocity, the impact on the local economy,

the malnutrition, and the spread of disease.

The researchers concluded that the diagnosis of PTSD

could not effectively communicate this type of shared

cultural suffering, “given the multiplicity of ways peoples

and societies live through massive trauma, express their

distress and suffering, and assign meaning to the human

experience.” Insisting on employing Western assumptions

about trauma, the researchers wrote, potentially

“undermined indigenous health systems and largely

discredited the power of local healing practices, as well as

resiliency, coping and survival strategies.” In short, using

the PTSD diagnosis and foreign notions of trauma

counseling in this situation had the potential to continue, in

a new form, the very cultural demolition that had caused

the population its greatest distress.

The argument that the insertion of Western PTSD beliefs

might actually undercut and disempower the local culture

has been made by other researchers as well. In East Timor

two researchers, Kathleen Kostelny and Michael Wessells,

visited the war-torn area around the capital of Dili and saw a

population pushed to the breaking point by war and the

increased sexual violence and poverty that came with it.

Most distressingly, the Indonesian militias often destroyed

or ransacked sacred structures where families and clan

members performed rituals and kept their sacred objects.

This amounted to a “spiritual calamity,” according to

Kostelny and Wessells. The insertion of trauma counseling

and PTSD didn’t ameliorate this problem; it heightened it.

“In a situation of desperation, local people often silence

their own cultural practices, cling to Western approaches

that have the imprimatur of science, or ‘play along’ by

giving the appearance of accepting outside approaches in

hopes of getting food or money from powerful outsiders,”

Kostelny and Wessells conclude. They note that this

undermining of local pathways to recovery can happen so

subtly as to escape the notice of both the caregivers and

those being provided for. “Tacitly, a damaging message sent

is that local views and practices are inferior. In the authors’

field experience, this message can strengthen a colonially

implanted sense of inferiority and weaken local people’s

belief that they have the capacity to build their own positive


Education or Indoctrination?

Such concerns about the use of PTSD and Western beliefs

surrounding trauma have done little to stem the efforts of

Western traumatologists to intervene in other cultures after

times of crisis. Why, one might reasonably ask, are we so

certain that the rest of the world needs our help in this


A look at the one of the first cross-cultural applications of

PTSD—in response to the 1995 earthquake in Kobe, Japan—

sheds some light on this question. It was only a matter of

days after the disaster when a team of PTSD experts from

Harvard University arrived in the city to collect data on the

psychological damage caused by the quake. As with other

international PTSD research that was to come, it was clear

from the start that this was far from a dry exercise in

epidemiology. The survey and the results were overtly

intended to advocate for a dramatic shift in thinking on the

part of the Japanese mental health system. The fact that the

report was as much a call to arms as an academic document

could be seen in its title: “The Invisible Human Crisis.”

“The PTSD concept was used to point to the reality of a

field of suffering recognized by the more psychologically

advanced culture of the United States but ignored in Japan,”

reported the anthropologist Joshua Breslau, who studied the

aftermath of the Kobe quake. Behind this effort to influence

the Japanese response to the disaster was a deep certainty

commonly shared by traumatologists that the rest of the

world doesn’t pay nearly enough attention to mental health

and that other cultures lack crucial knowledge that

Americans possess.

Although undertaken as humanitarian outreach, these

efforts often look more like massive attempts at

indoctrination. To accept the ideas of PTSD, other cultures

first had to be “educated” in the appropriate symptoms of

PTSD and modern modes of healing. After the genocidal

killings in Rwanda one nongovernmental organization (NGO)

quickly produced seventy-five thousand copies of a brochure

on the signs and symptoms of traumatic stress. Foreign

trauma counselors gave interviews to local journalists on

the psychological sequelae of trauma, and public health

campaigns were undertaken to educate the benighted

population in the symptoms of PTSD. Within two years of the

killings more than six thousand “trauma advisors” had been

trained in the country. Less than two years later, they

reported that more than 144,000 children had been


Similarly, within hours of the bombing of the U.S. Embassy

in Nairobi, Kenya, in 1998, a trauma counseling program

called Operation Recovery was put into motion. “Mental

health experts used local and national radio and television

broadcasts to discuss the symptoms of acute stress

reactions, and these broadcasts continued for 2 weeks after

the bombing,” wrote two psychiatrists of the project. More

than seven hundred counselor-trainees were given a two-

day seminar on PTSD within a week of the bombings.

An equally impressive intervention came the next year,

when trauma counselors went to the mountainous area on

the northern coast of Venezuela after a massive flood and

landslide claimed more than fifty thousand lives. A radio,

TV, and newspaper ad campaign was launched to make the

population aware of what psychological consequences to

expect, and posters of the PTSD symptom list were placed in

schools, community buildings, police stations, churches, and

grocery stores.

Often these campaigns seemed to imply that the

psychological consequences of trauma were similar to a

newly discovered disease, and that local populations were

utterly unaware of what happens to the human mind after

terrible events. That implicit assumption often left

anthropologists shaking their heads in disbelief. It takes a

willful blindness to believe that other cultures lack a

meaningful framework for understanding the human

response to trauma.

“Most of the disasters in the world happen outside of the

West,” says Arthur Kleinman, a medical anthropologist from

Harvard University. “Yet we come in and we pathologize

their reactions. We say: ‘You don’t know how to live with this

situation.’ We take their cultural narratives away from them

and impose ours. It’s a terrible example of dehumanizing


Once one comprehends the cultural differences in

psychological reactions to trauma, the efforts of the Western

traumatologists who rush into disaster zones on a few days’

notice begin to look somewhat absurd. To drive this point

home, Miller asked me to consider the scenario reversed.

“Imagine our reaction,” he said, “if Mozambicans flew over

after 9/11 and began telling survivors that they needed to

engage in a certain set of rituals in order to sever their

relationships with their deceased family members. How

would that sit with us? Would that make sense?”

The Rise of Fearlessness

The mistake in applying Western notions of trauma without

consideration for local beliefs goes beyond just being

ineffective: there is real danger of doing harm. This lesson

should have been learned long before the tsunami in, of all

places, Sri Lanka.

For over a year and a half starting in 1996, Alex Argenti-

Pillen, now an anthropology professor at University College

London, spent time in a poor Sri Lankan village trying to

make sense of the local modes of psychological suffering

while at the same time documenting the impact of the rising

influx of Western ideas about trauma.

In response to the ongoing civil war, organizations such as

the UN High Commission for Refugees, UNICEF, Oxfam, and

the International Rehabilitation Council for Victims of Torture

organized workshops and training seminars in the country,

and international trauma specialists spoke about PTSD and

Western-style trauma counseling. It was commonly asserted

at the time that helping war-torn populations heal from

PTSD could slow or stop the cycles of violence. Researching

the effects of these efforts in small villages, Argenti-Pillen

came to the opposite conclusion. She became concerned

that these Western ideas of trauma and healing had the

potential to destabilize fragile local truces that existed

among families, clans, and ethnic groups.

The social and economic situation in the Sinhalese

Buddhist village she studied was indeed dismal. There was

desperate poverty, and many local men and boys had been

drawn into the civil war between the Sri Lankan government

and the separatist Liberation Tigers of Tamil. Many of those

drafted into the Sri Lankan army deserted from military

service, forcing them to lead itinerant lives to avoid arrest.

In addition to the civil war, a violent youth revolt by the

Janatha Vimukthi Peramuna between 1988 and 1991

brought on a harsh crackdown by the government. Villagers

had been brutalized by literally all sides in these conflicts.

Neighbors often informed on each other, leading to

kidnapping, torture, and murder.

But as bad as the situation was, Argenti-Pillen was

interested in what kept the violence from spinning even

further out of control. What were the factors that kept

villages from undergoing a conflagration of revenge and

ethnic violence such as that seen in Rwanda and Bosnia? In

the village she studied, there remained boundaries on the

violence. Although many men had been killed, their wives

and children were usually left physically unharmed. In the

aftermath of the violence, perpetrators were clearly

disassociated from their families and revenge killings didn’t

target relatives. In many cases, the family of the killer and

the family of the victim (or the informant and the informed

upon) remained living side by side.

Argenti-Pillen documented the villagers’ remarkably

complex way of talking and thinking about the experience of

violence that, in several key respects, contradicted

assumptions about PTSD. In the cosmology of these

villagers, humans are vulnerable to what they call the “gaze

of the wild,” the experience of being looked in the eye by a

wild spirit, which can take the form of a human being intent

on violence. According to this belief it is not witnessing

violence that is destructive. Rather, the moments of terror

that come from violence leave one vulnerable to being

afflicted by the gaze. Struck by such a gaze, one enters an

altered state of consciousness and can become violent

oneself, behave lasciviously, become physically

immobilized, or in other ways step outside of normal modes

of social behavior. Somatic symptoms, including chronic

headaches, stomach aches, and loss of bodily strength, are

also common. Someone in this sort of semitrance may

speak in the voice of the spirit or alternate between the

perspective of the wild spirit and a human state called inna

barikama, which roughly translates as “can’t stay here.”

Often those experiencing inna barikama will yell for hours

variations on “I can’t stay,” “can’t live,” “can’t be,” or they

will simply repeatedly moan “Can’t.”

Those afflicted by the gaze of the wild might also express

their distress by “becoming closed off” or having “a terrified

heart,” which can lead to any number of somatic symptoms,

including vomiting and physical aches and pain. These

semitrance states are treated in the village with a long and

arduous cleansing ritual. Such ceremonies often last up to

thirty hours, during which the afflicted person is encouraged

to dance, tremble, and speak in tongues at specific times

during the ceremony. The rituals themselves are designed to

elicit fear. Healers elaborately disguised as wild spirits visit

the sick, often in the early hours of the morning, in order to

frighten the subject as severely as possible. Often those

who complete these cleansings show dramatic recoveries.

Interestingly, it doesn’t necessarily require a violent event

to spark a terrified heart. Simply speaking directly about a

recent act of violence, with words that graphically or

emotionally evoke the experience, is also considered

potentially pathological. Because most villagers hid in their

houses during the periods of intense violence, their

experience of terror was largely through what they heard.

The shouts of the attackers and the cries of the wounded

and tortured were the soundscape of the wild spirits and

could bring on the fear-related illness of “a terrified heart.”

“Just as the soundscapes of violence and civil war affect

people, so do the words used to represent this reality,”

Argenti-Pillen concluded. “In other words, discourses about

the wild act as agents of the wild.”

Stories or even words describing the violence were

considered literally dangerous. Because of this, the

community had established a complex set of rules for how

villagers are allowed to talk about or remember the

violence. Argenti-Pillen had to learn a complex dialect of

“cautious words” that allow someone to reference a

horrifying event without explicitly bringing it to mind. On

examining these local euphemisms, she began to see that

they were intentionally replacing words or phrases that

might invoke fear or moral anger with those that connote

safety and trust. Torture, for example, was evoked with a

word that also means a child’s mischief.

Unraveling this secret code, Argenti-Pillen filled her

notebooks with these euphemisms. “Those and these”

meant quarrels and fights. “The confusion and mistakes of

people who hurry too much” referred to the brutal civil war.

A “place that takes sacrifices” indicated a location where

many people died. “Funny nonsense” was a way of invoking

the disorientation and confusion of the terrified. To “bother”

could mean anything from child abuse to bombing. “Rowdy

sons” were the perpetrators of violence.

Argenti-Pillen also noticed that women in the village who

had suffered from terrified hearts often took it upon

themselves to be the enforcers of such indirect speech.

While this use of indirect language could easily be filed

under the rubric of “psychological avoidance” in the style of

the PTSD diagnosis, that would miss the fact that this local

custom had a specific purpose. Only gradually did Argenti-

Pillen come to understand that the prohibitions on speech

were a kind of “acoustic cleansing” by which people

protected themselves and others from spreading the gaze of

the wild and avoiding a potentially exponential rise in

revenge violence. These people weren’t avoiding talking

about what had happened to them because they were

psychologically blocked or traumatized; rather, they were

attempting, as best they could, to keep the violence under


There was another local reaction to horrible events that

ran counter to the idea of the terrified heart. Some women

believed that the atrocities they had witnessed or endured

had made them become “fearless.” Usually “fearlessness”

applied to men who acted violently or yaka-like (like an evil

spirit), but over the years of the civil war women were

increasingly embodying the trait as well. These fearless

women attested that they were no longer susceptible to

having a terrified heart and that they no longer needed the

domestic cleansing rituals. It was these fearless women who

often violated the rules of cautious speech. They were said

to speak with “sharp tongues” and carelessly. Such women

often found themselves socially marginalized by those in the

village, seen as akin to wild spirits themselves. Fearless

women were likely to intentionally raise their children to be

fearless as well. Often sons of such mothers were the boys

who became yaka-like, prone to violence and terrifying the


Into this delicate and intricate social and psychological

landscape began to flow Western ideas about trauma and

healing. This transmission of knowledge was not as direct as

it was in the aftermath of the tsunami. No Western

counselors set up tents on the outskirts of Argenti-Pillen’s

village. Rather, these ideas trickled down from training

programs sponsored by NGOs in Colombo. Western trauma

specialists would train regional health care workers; that

knowledge would then flow down to rural health care

workers, who then treated and sometimes trained local

villagers in these methods.

The problem was that the central tenet of Western trauma

counseling—that traumatic experiences must be retold and

mastered—ran counter to the local customs regarding the

use of euphemistic speech. Rural health care workers were

suddenly insisting that experiences of trauma be spoken

about directly. One Sri Lankan health care provider told

Argenti-Pillen that she had learned from Western experts

that it was important not to allow the traumatized individual

to keep secrets or talk around traumatic events. “There is a

method of talking,” she said, “talking with our eyes, our

face, with our whole posture, we must tie them to us. . . .

We take the information out of the clients. . . . We put them

in a position in which they can’t keep any secrets.”

The Western-trained counselors saw it as their job to

reorient the population’s beliefs about trauma and healing.

Many counselors expressed certainty that their new

counseling methods proved that the traditional local rituals

were ineffective. “A terrified heart cannot be cured by

means of domestic cleansing rituals,” one Western-trained

counselor told Argenti-Pillen. “The illness that has hit the

mind can sometimes not be cured even if you danced a

thousand cleansing rituals, let alone one. So, if you don’t

give counseling . . . in the correct way, that person will stay

in the same condition.”

However, it was rarely the women with terrified hearts

who were first in line for this new method of counseling.

After all, it was their job in the community to ensure that

people were circumspect in telling stories of violence.

Rather, it was the fearless women, with their penchant for

telling unambiguous stories of the violence, who embraced

the new healing methods. Whereas from the villagers’

perspective fearless women were potentially dangerous,

from the perspective of the Western-trained counselors they

were “empowered.” Not only were fearless women often the

first to accept trauma counseling; they were also the first to

accept training as counselors themselves.

“While the majority of the community consider

fearlessness an aberration . . . the NGO activities now

provide an outside legitimization for fearlessness,” Argenti-

Pillen writes. “The NGOs now support fearlessness as a

viable form of sociability.”

By encouraging fearlessness and pathologizing the local

custom of using ambiguous speech, this intervention was

tampering with a delicate social balance. Argenti-Pillen’s

concern was that Western-style trauma counseling was

undermining a fragile social stopgap that kept violence in

these tight communities from spiraling out of control. These

counselors were playing with fire. “Tales of ‘traumatized

survivors’ fail to provide a much-needed framework in which

local techniques for containing violence can be

safeguarded,” she concludes. “They also fail to assess the

potential risks of the introduction of the discourse on trauma

to such local techniques.” Trauma counseling services had

the potential to have the exact opposite effect intended.

Instead of ending the social cycles of violence, they were

potentially removing the brakes. The risk, she concluded, is

that “trauma counseling services will further destabilize a

local cycle of containment of major outbreaks of violence.”

The American Way to Suffer

It would be hard to overstate the certainty that most

Americans currently place in the diagnosis of PTSD.

Although it has been officially recognized for only twenty-

five years, it is reflexively evoked after school shootings,

natural disasters, and terrorist attacks. It has become part

of our common parlance and conventional wisdom. With so

many soldiers serving in the long-term conflicts in Iraq and

Afghanistan, PTSD has become a national touchstone in the

debate regarding the costs of war. PTSD is as real in our

time as fisha-e-bala is to an Afghani, as calorias is to a

Salvadoran, and as terrified heart is to a Sri Lankan.

It is real, that is, but not timeless.

Looking back at the brief history of the disorder, it is

remarkable to see how much it has changed even within a

generation. A soldier given the diagnosis today would be

hard-pressed to recognize it as the same one that was first

formulated in the 1970s for soldiers coming home from


The movement to recognize PTSD began as a political as

much as a psychiatric movement. Originally called post-

Vietnam syndrome, the idea came out of the hothouse of

rap sessions held by Vietnam Veterans Against the War and

supervised by antiwar psychoanalysts. Dr. Chaim Shatan,

who was codirector of the postdoctoral psychoanalytic

training clinic at New York University, was one of the first to

help find the professional volunteers to sit in on the rap

sessions. In a memo he circulated to colleagues his politics

were clear: “This is an opportunity to apply our professional

expertise and anti-war sentiments to help some of those

Americans who have suffered most from the war.”

These psychoanalysts and veterans had no intention of

carving out a diagnosis that could be applied to all victims

of terrifying events, or even all soldiers who experience

battle. The original idea was to show that being a soldier in

the Vietnam War was an experience utterly distinct from

that of being a soldier in any other military conflict. Listen to

one of the first descriptions of post-Vietnam syndrome,

written by Shatan and published in the New York Times in

the spring of 1972. According to Shatan, these veterans felt

upset because they had been “deceived, used and

betrayed” by both the military and society at large.

Although Shatan did mention that these veterans

experienced “rage,” he did not link this or any psychological

reaction to particular traumatic battlefield experiences.

Instead the rage, as Shatan described it, “follows naturally

from the awareness of being duped and manipulated” by

the military and the U.S. government. It was the moral

ambiguity of the Vietnam War and the deceitfulness of the

U.S. government and military, not the trauma of battle, that

damaged the psyche of the soldier.

In their push to gain official diagnostic status in the DSM,

the advocates for recognition of post-Vietnam syndrome

found it necessary to cede some ground. Despite the early

arguments intent on carving out a disorder specific to the

experience of Vietnam veterans, it proved politically

expedient to make alliances with other researchers and

clinicians who wanted to extend the concept to include

those who suffered psychologically after surviving other

horrors, including fires, natural disasters, and accidents. The

earlier argument that the psychological trauma suffered by

Vietnam veterans was utterly specific to soldiers in that

conflict was put aside and then forgotten.

As PTSD expanded in influence, more and more advocates

were making the argument that the disorder had an

immutable objective existence independent of culture, time,

or place. This left the obvious question: If it was so timeless,

why had it only recently been recognized?

In a history of the International Society for Traumatic

Stress Studies, written by one of the group’s former

presidents, Dr. Sandra Bloom, the early advocates of the

disorder are portrayed as the first to bravely overcome the

social pressure to ignore the psychological reaction to

trauma. Forces in our society, Bloom writes, have a stake in

“denying the profound and long-term effects of trauma. . . .

The larger society will continue to deny the magnitude of

the problem not only because of the emotional arousal

exposure causes, but because it is becoming increasingly

clear that fixing the problems and actually preventing

trauma, will cost a great deal.” PTSD has always been with

us, the argument went, but we were just now raising our

consciousness to the point that we could face its


As the diagnosis expanded in the West, encompassing

more and more experiences, there grew a market for those

claiming to have the latest techniques for treating the

condition. These techniques, in turn, began to shape our

cultural expectations and understanding of how trauma

affects the mind. Few were more influential in creating the

American style of PTSD than a former paramedic named

Jeffrey T. Mitchell, who created a seven-step regimen called

Critical Incident Debriefing. Mitchell’s debriefings were

intended to be performed in the first hours or days after a

threatening event. Led by a trained facilitator, groups of

survivors would be first informed of the common reactions

to traumatic stress. Each participant was then encouraged

to describe his or her perspective on the trauma in order to

“make the whole incident come to life again in the room.”

The metaphor of trauma creating a “psychic wound” was

taken quite literally. It just made sense that the quicker

debriefers got to the scene, the more they could do for the

victims. Beginning in the late 1980s counselors armed with

this new knowledge were rushed to the scenes of school

shootings, train wrecks, fires, maritime disasters, and all

manner of other calamity. In 1989 Mitchell founded an

organization called the International Critical Incident Stress

Foundation to teach debriefing as a method of heading off

PTSD. The foundation grew quickly and was soon training

tens of thousands of debriefers each year.

The fall of 1989 proved to be a watershed moment for the

American public’s awareness of trauma counseling and the

ideas behind critical incidence debriefing. In September of

that year Hurricane Hugo made landfall on the coast of

South Carolina, pushing a twenty-foot wall of water over

coastal communities. Disaster counseling and critical

incident debriefers were included in the response to the

devastation, to the fascination of the journalists and public

who followed the events.

Just a month later, on the other side of the country, the

Loma Prieta earthquake struck the San Francisco Bay Area.

Occurring during the pregame warm-up to the third game of

the World Series, the quake was broadcast live to the

nation. The first pictures of the collapsed section of the Bay

Bridge were sent from the Goodyear Blimp, which had been

hovering over Candlestick Park to cover the game. Many

mental health workers who had been providing debriefing

and trauma counseling in the coastal towns of South

Carolina got on planes and flew directly to San Francisco to

set up counseling services for quake victims. Again,

reporters and TV crews focused a great deal of attention on

these efforts.

By the time Hurricane Andrew sliced through the southern

tip of Florida and crashed into the south central portion of

Louisiana three years later, the public’s respect for the PTSD

diagnosis and the need for trauma counseling had solidified.

That new certainty could be heard in a Knight Ridder/Tribune

news service story filed in Miami: “Hurricane Andrew’s

biggest impact wasn’t its physical destruction. That was

only $20 billion. What it wrought in South Floridians’ minds

is incalculable.” By this point Mitchell’s International Critical

Incident Stress Foundation was training upwards of thirty

thousand debriefers each year.

Despite the public and professional certainty that

counselors and debriefers should rush in after disasters to

treat traumatized populations, there was one problem: there

was little evidence that such efforts helped. In fact study

after study published during the 1990s, the heyday of

trauma counseling, showed that early interventions were

either ineffective or actually caused harm. One study

followed several hundred car accident victims over a three-

year period. At random, some of the victims were debriefed

or given no immediate psychological treatment. Interviewed

three years later, victims displayed a remarkable difference:

the people who were debriefed were more likely to be

anxious and depressed and harbor a nagging fear of riding

in cars. The study, which was published in the British

Medical Journal in 1996, concluded, “Psychological

debriefing is ineffective and has adverse long-term effects.

It is not an appropriate treatment for trauma victims.”

Another study of burn victims showed a similar effect:

measured after a year, those who had been debriefed were

much more likely to qualify for the diagnosis of PTSD and to

express hostility, feel depressed and anxious, and report a

lower quality of life than those who received no help. The

conclusion was that the early interventions were actually

impeding the mind’s natural healing process.

Early interventions sometimes appeared to be priming

victims to experience certain symptoms. “When dealing

with people after an accident we need to remember that

emotionally aroused people are suggestible,” David Brown,

a psychologist from Australia, wrote later in the British

Medical Journal. “If we suggest they might feel angry, it is

likely to come true.”

Others have noticed the same phenomenon. “Sometimes

when we put people in a group and debriefed them, we

gave them memories that they didn’t have,” Malachy

Corrigan, the director of the Counseling Service Unit of the

New York City Fire Department, told the New Yorker. “We

didn’t push them to psychosis or anything, but, because

these guys were so close and they were all at the fire, they

eventually convinced themselves that they did see

something or did smell something when in fact they didn’t.”

Looking back, it is remarkable that so little attention was

paid to the danger that debriefing might be shaping and

suggesting reactions in the minds of distressed individuals.

Social psychology has a rich literature on group belief-

building and social contagion that could have been well

employed here. If you take a group of disoriented and

unsettled victims mere hours or days after a life-altering

tragedy, put them in a highly charged encounter where they

are told to expect certain psychological symptoms, and then

they share their experiences, you are creating the perfect

setting by which emotions are likely to spread and intensify.

Why didn’t these practices cease in the face of the

evidence that they might actually be harming those they

intended to treat? Dr. Richard Gist of the Kansas City Fire

Department, who researched the impact of debriefing,

noted that the evidence for and against trauma counseling

was beside the point because debriefing was, he told a

journalist, “more of a social movement.” Indeed the

evolution of the ideas behind PTSD and the promotion of

modern ideas of trauma counseling have been social

movements from the beginning. This fact, however, is

seldom acknowledged by the evangelical trauma counselors

who travel the world to inform other populations about the

modern treatments for PTSD.

It is a psychological truism that those who display dead

certainty in their convictions are often hiding or covering up

for deep insecurities. Professor Vanessa Pupavac, writing

from the School of Politics at the University of Nottingham,

links the rise in our international trauma interventions—our

confident assertions that we must teach the world how to

respond to horrible events—with a period of time when we

in the West had become increasingly uncertain about how to

help the developing world.

The 1990s was a period when our efforts to help other

countries with money and aid began to seem impossibly

complex and fraught. Book after book took to task

humanitarian efforts for bureaucratic waste, having

shortsighted goals, and encouraging dependence. This crisis

of confidence in the humanitarian community was, Pupavac

argues, a reflection of a deep post–cold war uncertainty at

home. We had become, she writes, “bereft of convictions

and disposed to introspection. . . . The erosion of previous

political or communal affiliations [had] not resulted in a

vigorous individualism, but anxious insecure individuals.”

When we looked out at the violence and hardship in the

rest of the world and knew that our psychological assistance

was desperately needed, we may have been simply

projecting our own postmodern insecurities.

Trauma Stripped of Meaning

In reading the best anthropological writing on the “idioms of

distress” in other cultures, one is often struck by the

richness of these psychological and social landscapes. The

experience of horror or violence in these places is

interwoven into religions, social networks, traditions, and

rituals of burial and grieving. When one comes back home

to PTSD, the starkness and thinness of the idea become

glaringly apparent. In the modern Western world, the idea of

PTSD is that of a broken spring in a clockwork brain.

PTSD researchers would certainly object to this

characterization. They would point to the tens of thousands

of research papers, monographs and books on the topic.

How could so much research be characterized as “thin”? But

I’m not talking about the research, but rather the

experience of the PTSD sufferer. By isolating trauma as a

malfunction of the mind that can be connected to discrete

symptoms and targeted with new and specialized

treatments, we have removed the experience of trauma

from other cultural narratives and beliefs that might

otherwise give meaning to suffering. Being value-neutral to

cultural beliefs is problematic given that these beliefs—be it

God’s plan for someone who’s lost a child or patriotism for

the soldier crippled in battle—are the very places where we

once found solace and psychological strength.

Think back to the ideas surrounding post-Vietnam

syndrome. The original intent of that designation was to

create a social narrative to prove that being a soldier in the

Vietnam War was different from being a soldier in other wars

at other times. Proponents were searching for meaning and

coming up with stories of government betrayal and the

destruction of social trust. Beliefs that had sustained many

of their fathers in World War II were suddenly insufficient

and meaningless to these soldiers. They replaced those

beliefs with another, angrier set of ideas that might give

meaning to their experience. But as it evolved into its

modern clinical form, PTSD left behind such quests for social

meaning in tragedy. In doing so, it has set adrift those

struggling in the aftermath of trauma. In contrast to those

angry but socially engaged Vietnam War veterans, the

personal accounts of current-day soldiers returning from

Afghanistan and Iraq often seem pigeonholed into a PTSD

diagnosis that is tied to a particularly modern style of lonely


Here’s one soldier blogging on a popular website devoted

to PTSD:

I constantly doubt how I feel. I don’t know if it’s real or if I’m making it up. . .

. I feel guilty. When I was in the service, the Air Force therapist said that it

was PTSD . . . but I don’t know if he was right. I worry that I’m trying to fool

everyone, even myself. I didn’t do anything. I never fired a weapon in

combat. I missed everything, I feel guilty about it, and I feel ashamed that I

even consider that PTSD might be the problem. I feel like I don’t deserve to

think this is what is wrong with me. I can’t bring myself to read up on PTSD

on the internet, because I’m worried that the more I know about it, the more

likely I am to make it be the problem subconsciously. . . . I feel like I’ve

fooled myself into playing a character and I don’t know how to just put it


PTSD is clearly too narrow a category to give meaning to

this soldier’s experience, but he worries it like a bone

because he doesn’t appear to have other options; the

frustration, anger, and unhappiness of modern soldiers have

been moved from the social (where one might find moral

anger, nationalistic justification, or religious meaning to

justify the sacrifice) to the biopsychomedical. Because PTSD

largely focuses on internal states and chemical imbalances

within the individual brain, this explanation for psychological

problems often leaves the soldier, to borrow a recent

military marketing slogan, feeling like “an army of one.”

Looking at ourselves through the eyes of those living in

places where human tragedy is still embedded in complex

religious and cultural narratives, we get a glimpse of our

modern selves as a deeply insecure and fearful people. We

are investing our great wealth in researching and treating

this disorder because we have rather suddenly lost other

belief systems that once gave meaning and context to our


Patrick Bracken, a senior research fellow at Bradford

University’s Department of Health Studies, argues that the

emergence of PTSD is a symptom of a troubled postmodern

world. “In most Western societies there has been a move

away from religious and other belief systems which offered

individuals stable pathways through life, and meaningful

frameworks with which to encounter suffering and death,”

Bracken writes. “The meaningful connections of the social

world are rendered fragile.” Although we might be able to

ignore the absence of these belief systems during our

normal day-to-day lives, truly traumatic events have the

power to startle us into awareness of a heart-stopping

emptiness. The diagnosis of PTSD can categorize some of

our reactions to trauma, but in the end it is cold comfort. It

cannot replace what we’ve lost.

Without social mechanisms to cope, we’ve become

increasingly vulnerable and fearful. Indeed many have

pointed out that we are now a culture that has a suspicion

of resilience and emotional reserve. “In a momentous shift,

contemporary Western culture now emphasizes not

resilience but vulnerability,” says Derek Summerfield, of

Kings College, who has worked extensively with victims of

war and genocide. “We’ve invited people to see a widening

range of experiences as liable to make them ill. This

becomes a problem because we are globalizing our culture.

We are presenting just one version of human nature—one

set of ideas about pain and suffering—as being definitive. In

truth, there is no one psychology.”

The Civil War Reignites

Seven months after the tsunami, Lakshman Kadirgamar, the

Sri Lankan foreign minister, was murdered in his home by a

sniper. The precarious cease-fire between the government

and the separatist rebels began to destabilize. By the end of

that year the guerrillas in the north of the country were

again fighting the government both on land and at sea. The

conflicts escalated until, in January 2008, the government

officially withdrew from the cease-fire agreement. The battle

in the next year would not go well for the Tamil Tigers. By

the end of spring 2009 the government forces had routed

the Tamil rebels from their last stronghold.

The reality for the civilian population caught in the

fighting on the ground became so grim that Gaithri

Fernando found that for the first time she had to avoid all

news of her home country. She had heard too many stories

of mothers digging shallow graves for their children and

families trying to escape the fighting by fleeing deep into

the jungle, only to lose family members to animal predators.

In the uneasy peace after the fighting, there was again

much interest in psychological healing and the damage of

PTSD. Having alerted the Sri Lankan Parliament of the

abuses of parachute researchers after the tsunami, Dr.

Athula Sumathipala published a series of articles in the

Island newspaper asking again for restraint on the part of

globe-trotting trauma counselors. “Undue emphasis on

counseling or medicalizing the psychological, sociological

and political implications of the displaced population should

not be promoted,” he wrote. “What [the displaced

populations] need is not ‘therapy’ but provision of basic

needs, care with dignity, respect, reassurance to avoid

uncertainty and move them to accommodation as soon as

possible so that they will have some privacy and also the

opportunity to reintegrate to ‘normal’ life. The best therapy

will be a sound social policy.”

Whether his voice will be heard is not yet clear. Thanks to

the many training seminars set up after the tsunami, there

are now thousands of Sri Lankans who believe they are

trained in trauma counseling and the Western ideas behind

PTSD. In addition, there will undoubtedly be new efforts by

international aid agencies to provide psychological therapy.

Whether these efforts will heal these communities or, as

Argenti-Pillen fears, unintentionally destabilize them

remains to be seen. It would be tragic and ironic if Western-

style trauma counseling ends up sparking violence between

ethnic groups and clans that already have reason to hate

each other. Intending to break cycles of violence, Western

beliefs about trauma and healing may be poised to spin

them back into motion.


The Shifting Mask of Schizophrenia

in Zanzibar

What we say about mental illness reveals what we value and

what we fear.


On my first night in Zanzibar I was awakened by the distant

sound of a telephone ringing. I came to consciousness

fitfully, puzzling out where I was. I was bone-tired from two

days of red-eye plane travel and a rough ferry crossing to

the island from mainland Tanzania, disoriented by the ten-

hour time change and, possibly, by the side effects of the

prophylactic malaria medication I had begun taking a few

days before. I checked the bedside clock: 3 a.m. I could hear

my hosts, Juli McGruder and her partner, Ahmed Kassim, in

the upstairs room of the house as one of them answered the

phone. As in most houses in Zanzibar, there was no glass in

the windows—better to let the steady trade winds sweep

out the stuffy air during the night—and I could hear their

voices talking low and intently in Kiswahili. I stood at the

window, listening and looking out into the night. It was a full

moon and there was a racket of premorning birdsong

coming from the thick, low brush beyond the cinderblock

wall that surrounded the house. After a few minutes Kassim

came downstairs, walked across the sandy driveway, and

drove off in his rattletrap Toyota van. I got back in bed,

retucked the mosquito netting, and lay awake wondering

what might have occasioned the call. I was new to the local

customs, but I suspected that Americans and Zanzibaris

shared at least this cultural truism in common: no good

news comes in a phone call at 3 a.m.

I had come to Zanzibar, a sixty-mile long coral island off

the Swahili coast of East Africa, to spend some time with

McGruder. She had recently retired from her teaching

position at the University of Puget Sound in Washington and

had opened a guesthouse at the very northern tip of the

island with Kassim, a younger local man who was both her

romantic and her business partner. She had been a

professor of occupational therapy, and late in her career she

had received a PhD in anthropology from the University of

Washington. Her field research focused on three families

struggling with schizophrenia in Zanzibar, where she went

to figure out a puzzle that has baffled cross-cultural

researchers in mental illness for twenty years: Why did

people diagnosed with schizophrenia in developing nations

have a better prognosis over time than those living in the

most industrialized countries in the world?

In the morning I met McGruder in the kitchen, where she

was brewing a pot of strong cowboy coffee, boiling the

grounds directly in a pot of water. “I need the real thing this

morning,” she said by way of greeting. “Instant is not going

to do it.” She told me the news before I could ask. The early

morning phone call had been for Kassim. His 10-year-old

daughter, Latifa, a child from an early marriage, had died

suddenly in the night. The family had known that the girl

had an enlarged heart, but she had recently been healthy

and happy. Just that day she had been to Koran school,

played with her friends, and eaten well. But that night she

woke up vomiting blood. The family had rushed her to the

hospital, where she died shortly after being admitted.

Kassim had gone south to assist with the burial, which,

according to Muslim custom, would happen that day.

After a moment I asked how Kassim was holding up.

McGruder shrugged as she stirred the coffee. “It’s hard to

say,” she said. “Swahili men tend not to show a lot of

emotion when things like this happen.”

When I saw Kassim late the next day, I shook his hand and

told him how sorry I was to hear about his daughter. He

smiled weakly and said only, “That is life.” Later at dinner

he told McGruder and me how the women cried during the

day. He described how the crying would reach a crescendo

and then die down, only to be started again when a new

woman showed up and saw the body.

Kassim’s own demeanor remained a mystery to me. At

first I assumed that he was just in shock and would be

overcome with emotion when he had time to reflect on the

event. It would be unfortunate, I also found myself thinking,

if some notion of local machismo made him push his true

feelings aside. He would certainly pay a steep psychological

price for such repressing of his feelings.

Although I had traveled here with the intention of learning

about the different ways people in Swahili culture express

emotion in the face of mental illness and other difficult life

challenges, I couldn’t let go of my assumption that the

healthy reaction to the loss of a child would be abject

displays of grief. I believed the natural—the truly human—

reaction to such an event was the way I imagined I would

have reacted if the 3 a.m. phone call had carried tragic

news about my own daughter back in San Francisco. I was

as unable to understand what Kassim was feeling from his

outward affect as I was to understand the meaning of his

words when he spoke Kiswahili; he was expressing himself

in an emotional language that I did not comprehend.

Even anthropologists, who diligently train themselves to

be nonjudgmental observers of cultural differences, have

trouble when it comes to recognizing and allowing for

cultural differences in emotions. Because our emotions

come into our consciousness unbidden and often surprise us

with their intensity, we often assume that they are not

influenced by cultural cues or social scripts. But with careful

study, anthropologists have learned that emotions are not

like muscle reflexes; rather, they are communications with

deep and sometimes obscure meanings. Cultures differ not

only in their response to specific events (as we’ve seen with

reactions to trauma) but also in more global ways.

Describing and understanding these differences has in

fact been central to McGruder’s research on Zanzibari

families who struggle with schizophrenia. During her

research she began to suspect that the emotional tenor of

families dealing with mental illness in Zanzibar was

qualitatively different from that of families in the

industrialized world. Subtle differences in this emotional

temperature of households, she theorized, might go a long

way to explaining why a schizophrenic patient in Zanzibar

will often do better than someone diagnosed with the

disease in the United States.

From the Clouds to the Equatorial Sun

McGruder is of a type common among the faculty of West

Coast colleges. Her politics are liberal and she is prone to

antiestablishment and contrarian thinking. She is short with

spiked blond hair and a friendly but no-nonsense demeanor.

As a child she was smart and rebellious, a difficult

combination for a Catholic schoolgirl growing up in northern

Indiana in the 1950s. When she was a teenager she dated

African American men despite her parents’ strenuous

objections. One of her first encounters with the mental

health profession was when her parents forced her to see a

psychologist to cure her of her “pathological” romantic

behavior. At one point she was even threatened with

incarceration in a mental hospital.

Despite her parents’ efforts, she got married at age 18 to

an African American man. This was just one year after the

Supreme Court’s 1967 ruling Loving v. Virginia, which

effectively ended race-based restrictions on marriage in the

United States. McGruder’s first job after college was in the

mid-1970s at the Hudson River Psychiatric Center in

Poughkeepsie, where she witnessed what passed for mental

health treatment at the time. As she remembers, the

doctors relied heavily on sedating antipsychotics such as

Thorazine, Stelazine, and Haldol and some early tricyclic

antidepressants. She couldn’t help but notice the way some

of the drugs knocked the patients for a loop. “These drugs

worked like big hammers,” she told me. “They just snowed

people. They would make the patients shake and drool and

feel miserable.”

After that she went back to school for a degree in science

education and became a teacher, eventually finding a post

teaching occupational therapy at the University of Puget

Sound. On the side she worked as a private therapist and

guardian with elderly and institutionalized schizophrenic

clients. After a decade of teaching and making her way up

the university’s academic ladder, she got bored with the

routine and found herself reading feminist philosophical

tracts on science and gender. With a sabbatical coming up,

she sent out dozens of letters to international aid agencies

offering her services. For months she heard nothing. Then

came a lone reply from a Danish international development

organization that had an office in Dar es Salaam, Tanzania.

They offered her a year-long post at the Kidongo Chekundu

Mental Hospital on the island of Zanzibar with a salary of

forty-two dollars a month. She jumped at the chance and

immersed herself in learning Kiswahili. Once she got to

Zanzibar, she helped establish an occupational center at the

hospital where patients could learn carpentry skills and

practice art therapy.

The Western-trained doctors she met at the hospital in

Zanzibar had access to the basic arsenal of Western

antipsychotic drugs. However, the idea that diseases such

as schizophrenia spring from chemical imbalances or brain

abnormalities had not yet been accepted by most of the

population of Zanzibar. Much more salient were beliefs in

spirit possession and the permeability of the human

consciousness by magical forces.

McGruder became fascinated by the ways these beliefs in

spirits shaped the experience of mental illness both for the

families and the patients themselves. She was also

interested in how these local ideas were beginning to

intermingle and sometimes compete with the imported

Western idea that mental illnesses were caused by

biological brain malfunctions. At the end of her sabbatical,

she decided to pursue a doctoral degree in anthropology so

she could dive further into these questions. After finishing

her course work in anthropology at the University of

Washington, she couldn’t wait to escape the dreary Pacific

Northwest and get back to the island.

Zanzibar lies at the midpoint of the Swahili Coast, a 1,800-

mile stretch of coastline straddling the Equator from Kenya

to Mozambique. For millennia it was to this coastline that all

of Central Africa brought its goods in order to trade them

with the world. The predictable monsoon trade winds were

key to its culture. From November to March those winds

blew steadily down the coast, bringing merchants and

traders from India and the Persian Gulf. From July to

September they shifted northward, sending the traders

home. On the northbound winds small lateen-sailed boats

called dhows traveled up the coast with sturdy mangrove

wood, aromatic tree resins, gold, ivory, clove, and the fine,

multipurpose fibers of the raffia palm. On the southbound

winds they brought back manufactured goods from Arabia,

India, and China in the form of carpets, incense, glassware,

and cloth. The months between the shifts in the trade winds

gave merchants from the Middle East time to sell their

goods and buy their new cargo. It also gave them time to

share their ideas and religious beliefs and to infuse Swahili

with Arabic words. The months in foreign harbors also

allowed for merchants and sailors to take wives and

otherwise leave their genetic mark on the population.

The resulting cultural texture of Zanzibar was endlessly

interesting to McGruder. She enjoyed the smell and the

sound of the place, the way the echoing calls to prayer

broke up the day, and the constant commotion of children at

play. She even liked the way the names of things felt on her

tongue. The place-names Kisimkazi, Manzi Moja, and

Kakunduchi felt good to say. She particularly liked saying the

name of the local public transport along one of the main

roads: the Bububu daladala.

Not that life there was a tropical paradise. Although her

memory of that first year has sweetened, her field notes

attest to the frustrations of living in a developing country.

There were outbreaks of cholera, and the dust whipped up

by the constant trade winds during the dry season often

contained enough bacteria to cause epidemics of

conjunctivitis. Raw sewage sometimes fouled the white

beaches and the baby-blueness of the ocean. Fishermen had

recently taken to using sticks of dynamite to fish the reefs,

and the joy of speaking the words Bububu daladala was

offset by the sheer terror she felt while actually riding these

speeding minibuses.

In the end, however, her desire to return and study mental

illness in Zanzibar came not simply out of an abstract

pursuit of knowledge or the social good that might come of

her findings, but because she felt a deep affinity for the

people and the place.

Incidental Content versus Essential Form

McGruder was well aware that the cutting-edge research on

schizophrenia was not coming out of the field of

anthropology. 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.

Although far from the limelight, there were scholars and

researchers looking at the disease from other perspectives

as well. McGruder found perplexing data and fascinating

theories in cross-cultural studies of the disease. Although

something approximating schizophrenia could be found in

populations at every corner of the globe, there were enough

variations to suggest that the disease was shaped by

something besides the purely genetic or biological.

The most obvious differences between cultures were in

the delusions and hallucinations experienced by those with

schizophrenia. These harrowing visions and disembodied

voices were often distorted reflections of the phobias and

fascinations of specific cultures. No one, after all, endures

the psychotic delusion that the CIA is beaming microwave

signals into his or her fillings unless that person is culturally

acquainted with the CIA, modern dentistry, and the

disquieting idea that our bodies are constantly permeated

by unseen electromagnetic waves.

Those who have studied these differences have noted,

among other things, that delusional guilt is most often

associated with Judeo-Christian cultures, as are religious

hallucinations such as hearing the voice of God. Such

hallucinations are rarer in Islamic, Hindu, and Buddhist

populations. Schizophrenic patients from Pakistan are more

likely to have visual hallucinations of ghosts and spirits than

are British schizophrenics, who are more prone to hearing

persecuting voices. In traditional Southeast Asian villages,

where it is often frowned upon to strive willfully for personal

status, delusions of grandeur are rare. In the United States,

where celebrity, wealth, and power are popular fetishes,

people with schizophrenia commonly believe that they are

famous or all-powerful.

It is also clear that delusional content in any particular

culture can change over time. In Austria, to take one

example, cases of delusions of grandeur, hearing the voice

of God, and feeling persecuted have been steadily

increasing over the past fifty years, while delusional guilt

and psychotic hypochondria are on the decline.

Researchers who focused on the biomedical or genetic

linchpins of the disorder often dismissed these differences.

The fact that the “delusions of schizophrenics in

industrialized societies will concern television sets and x-

rays rather than ghosts and spirits . . . [is] often considered

to be of secondary importance,” writes Rutgers professor of

psychology Louis Sass. “They are presumed to have little to

do with the illness’s genesis or essential form.”

Does it really matter that a person with schizophrenia in

one culture talks with a dead relative, while someone in

another culture believes he is receiving communications

from an extraterrestrial? The distinction that often gets

made in this debate is between pathoplastic aspects of the

disease, which vary from person to person, and the

pathogenic cause, which is assumed to be the root cause of

the disorder. Pathoplastic symptoms are often dismissed for

describing only the coloring and content of an illness but not

its fundamental nature. The true prize—the quest of the

brain researchers—was to get past the cultural noise and

discover the pathogenic factors that are the universal cause

of the illness. They wanted to weed out the “incidental

content” and get to the “essential form.”

But McGruder kept coming across research suggesting

that culture and social setting play a more complicated role

in the disease than simply influencing the content of the

delusions. Studies showed, for instance, that prevalence

rates vary from place to place. Those living in urban settings

in the United States and Europe appear to suffer more often

from the disease than those living in the country or the

suburbs. These curious spikes in the disorder remain even

when researchers took migration, drug use, and poverty out

of the equation. Men living in the most densely populated

areas of Sweden, for instance, are at a 68 percent higher

risk of being admitted for psychosis—often the first sign of

schizophrenia—than those who live in the countryside. For

women the risk is 77 percent higher. Something about city

living seems to spark the harrowing delusions,

hallucinations, and disorganized thinking characteristic of a

schizophrenic break. Stranger still, some neighborhoods in

cities produce more schizophrenics, to such a degree that

scientists have wondered about the environmental

pathogens that might exist in one place and not another.

The more McGruder read of the cross-cultural research on

the disorder, the more it appeared to shape-shift from place

to place, and no one seemed to have a clear explanation for

this. Janis Hunter Jenkins and Robert John Barrett, two of the

premier researchers in the field, describe the general state

of affairs.

In sum, what we know about culture and schizophrenia is . . . [that] culture

is critical in nearly every aspect of schizophrenic illness experience: the

identification, definition and meaning of the illness during the primordial,

acute, and residual phases; the timing and type of onset; symptom

formation in terms of content, form, and constellation; clinical diagnosis;

gender and ethnic differences; the personal experience of schizophrenic

illness; social response, support, and stigma; and perhaps most important,

the course and outcome with respect to symptomatology, work, and social


By “course and outcome,” Jenkins and Barrett are referring

to that most perplexing finding in the epidemiology on the

disease: people with schizophrenia in developing countries

appear to do better over time than those living in

industrialized nations.

McGruder read with fascination the startling results of two

huge international studies carried out by the World Health

Organization over the course of twenty-five years starting in

the late 1960s. These two studies, which had follow-up

periods of two and five years, took place in a dozen sites

around the world, taking into account ten countries and

following more than a thousand patients from both rural and

urban settings. What they found was that those diagnosed

with schizophrenia living in India, Nigeria, and Columbia

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 over

time to be “severely impaired,” only 24 percent of patients

in the poorer countries ended up similarly disabled.

That result, which is perhaps the most famous finding in

the field of cross-cultural psychiatry, was widely discussed

and debated in part because of its obvious irony: the regions

of the world with the most resources to devote to the illness

—the best technology, the cutting-edge medicines, and the

best financed academic and private research institutions—

had the most troubled and socially marginalized patients.

McGruder found it remarkable that even in the face of

these cross-cultural differences in outcome, some

researchers still seemed uninterested. As with the

differences in the content of the delusion, these variations

in course and outcome were considered in some quarters to

be beside the point. Ignoring the WHO studies might make

sense to a brain scientist or geneticist looking for the first

trigger for schizophrenia, but for someone like McGruder,

who had worked closely with and cared for schizophrenic

patients, there was nothing—save a miracle cure—more

important than the question of the disease’s course and


As McGruder read more about the WHO studies she

became fascinated by the debate within psychiatry over the

possible reasons for these differences. Some researchers

suggested that the demands placed on a person in a poorer

nation to be productively employed were lighter and easier

to meet. Perhaps there were more opportunities to feel

productive by engaging in work with one’s family, such as

gardening and child care. Others put forward the idea that

the expectations for appropriate behavior were clearer and

simpler in nonindustrialized, traditional, or premodern

cultures. The rules of behavior for living in the modern world

simply overwhelmed schizophrenics, causing them

increasing distress. Perhaps, suggested others, it was

traditional beliefs in supernatural agents and spirit

possession that removed the weight of blame and guilt from

both the person experiencing psychosis and the family. Still

another set of scholars thought that families in certain

cultures might express less highly charged attention and

criticism toward the ill family member. This research into

what was called “expressed emotion” suggested that

schizophrenics often got worse when surrounded by family

members who were constantly critical of their behavior or

showed intense and intrusive concern about their condition.

Given all the different theories that attempted to explain

the WHO studies, McGruder could immediately see one

truth: no one had yet found a convincing explanation for the

cross-cultural differences. Indeed the researchers who

conducted the WHO studies admitted as much. Although a

“strong case can be made for a real pervasive influence of a

powerful factor which can be referred to as ‘culture,’” one of

the WHO researchers concluded, none of the WHO studies

was designed to “penetrate in sufficient depth” to

understand what might be happening. This left researchers

guessing which cultural factors might be ameliorating this

devastating disease.

The fact that researchers couldn’t offer meaningful or

specific conclusions about the effect of different cultures on

schizophrenia didn’t surprise McGruder. Culture, as she was

learning to understand it as an anthropologist, did not exist

in large data sets. The word can be defined in broad terms

as, say, the “the intellectual, moral, and aesthetic standards

prevalent in a community” or as the “shared symbols and

meanings that people create in the process of social

interaction.” Yet anthropologists firmly hold that culture can

be truly understood only in the particular. Culture, especially

as it shapes and informs the consciousness of a mentally ill

person, is a local phenomenon.

Again and again in the debate surrounding the WHO study

McGruder saw researchers pleading for anthropologists to

pick up the ball and run. “More ethnography is needed,”

concluded one well-known researcher, “if only to elucidate

those aspects of everyday practice that remain obscure.” All

the way back in 1987 the Harvard medical anthropologist

Arthur Kleinman wrote with obvious frustration about the

lack of anthropological attention to the WHO data on

schizophrenia: “For over ten years this finding has been the

most provocative to emerge in cross-cultural psychiatry . . .

[Yet] the most important finding of cultural difference—

arguably the single most important finding in the study—

receives scant attention.”

McGruder saw the window of opportunity presented by the

WHO study. What was clearly missing was an on-the-ground

examination of the ways patients in a developing country

are treated by their families and caregivers. What ideas and

beliefs do family members in developing nations use to

understand the delusional behavior of a loved one? How do

they talk about this behavior—what specific words and ideas

do they employ? And, critically, how does the local

understanding of the illness impact the beliefs, behaviors,

and self-conception of the ill family member?

Given the importance of the questions posed by the WHO

studies, it was surprising that droves of young

anthropologists hadn’t heeded the call. Then again,

considering the scope of the challenge, this reticence is

perhaps understandable. Even observable public aspects of

culture are difficult to understand and describe in depth;

elucidating the cultural currents that affect the functioning

of a mentally ill person would be much more difficult. The

challenge of McGruder’s research went beyond describing

what people did. She had to explain, on a nearly existential

level, who they were. A younger PhD candidate would have

been well advised to pick a topic that had firmer boundaries.

Fortunately McGruder was not at the beginning of her career

but closer to its end, and so she had no need for a safe

research topic. She brought to her research the particular

type of passion that comes when one picks a topic that is

the confluence of one’s life interests.

Revolution and Madness

On my fourth day in Zanzibar, McGruder walked me through

a maze of narrow alleys in Stone Town to the house of one

of the three families she studied. It was a low white building

facing a small public square, in the center of which stood a

large shade tree. The house was not much to look at: a

single-story cement structure with four square columns

supporting the roof over a small porch. The windows were

shuttered behind steel bars. The family had moved a few

years ago and the house was empty. A message in red spray

paint read in Kiswahili, “This house is not for sale.” This,

McGruder told me, was where Hemed and his daughter

Kimwana, both diagnosed with schizophrenia, had lived with

their family.* The head of the household was Amina,

Hemed’s ex-wife and Kimwana’s mother.

As with most Zanzibari families, these three did not live as

a nuclear family unit. During the year McGruder spent

visiting the family, the household included Amina’s mother;

her two married daughters and their children; one

unmarried daughter, who was sometimes away at college;

one unmarried son, who was studying at the local Islamic

teacher’s college; Hemed’s half-brother, who was a deaf-

mute; plus his adopted sister and her children. At night the

600-square-foot, eight-room structure slept as many as ten

adults and ten children.

As we sat on a low brick wall at the edge of the square

nearest the house, I asked McGruder if her memory of the

place was of rooms constantly packed with people. “No, my

impression of the place was of traffic; constant streams

coming and going,” she told me. She described how women

would converse and do chores indoors or in the small walled

courtyard. Men and children would be outside on the

covered baraza, the cement bench that ran along the front

of the house. The kitchen would be in constant use, as

household members cared for and fed each other in a bustle

of steady activity. One of McGruder’s favorite words in

Kiswahili is onomatopoeic for such managed chaos:


The sheer number of people in the household posed a

challenge to her research. She had hoped to tell the history

and take the emotional temperature of the family, but even

a rough sketch of the family tree of this pulsing kinship

group proved complicated. Amina, the mother, seemed the

obvious focal point for her study. The swirl of activity in the

household revolved around her. She was the rock.

Like many Zanzibaris, Amina was of mixed Swahili and

Arab descent. She was married at 18 in an arranged union

to Hemed, the older son of the plantation owner for whom

her father worked. Like many Arab families who had

immigrated from the Middle East over the centuries,

Hemed’s father owned a clove plantation and traded in the

spice business. During their courtship in 1960 and the

months after their marriage that year, Amina remembered,

Hemed was lighthearted and charming. Sadly, it was less

than a year after their marriage that he experienced his first

psychotic episode.

The period in which Hemed began to experience

symptoms of schizophrenia was, not coincidentally, a time

of political upheaval on the island. 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.

As Amina remembered, Hemed loved to talk politics, and

he would often come back from political meetings so wound

up that he couldn’t sleep. He would talk all night about the

various faction leaders and the ever-changing alliances.

Over the months, these ramblings became tinged with fear

of political persecution. His worries were not mere paranoia,

given the ethnic and political killings that were to come.

Soon Hemed’s political monologues transformed into

fretful discussions with unseen interlocutors. He began to

frighten his new wife with his unpredictable behavior.

Such an onset of schizophrenia can be explained by the

stress-diathesis model, the theory that biological factors

make one vulnerable to schizophrenia, but stress in one’s

environment may set off the illness. Stress may come from

any number of sources, but researchers have paid particular

attention to conflict within a person’s social world. 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.

At the end of the year Hemed broke down. Soon after his

first son was born, in September, he was admitted to the

local mental hospital after beating his great-aunt during a

delusional episode. Early the next year he was certified as a

person of unsound mind. His medical charts reported that

he had a “shallowness of emotion, visual hallucinations and

aggressiveness, tend[ed] to lose temper, ha[d] delusions.”

The New Year brought no relief from the political turmoil.

Violent riots followed the elections, prompting the British to

send in soldiers from the mainland and declare a state of

emergency. Dozens of foreign-born Arabs were murdered

and more than a thousand people were arrested. During this

time Hemed returned to the mental hospital and stayed

there for six months. He was released around the time his

daughter Kimwana was born.

Over the next two decades Hemed was hospitalized eight

times for various periods and twice given electroconvulsive

treatments. As McGruder examined his hospital records, it

became clear that the dates of his worst episodes were

during or right after periods of political strife or family


In 1970, when Hemed was hospitalized for nearly an

entire year, Amina divorced him, employing an Islamic law

that allows divorce for reasons of nonsupport. Still, Hemed

eventually came back to live with the family, and he and

Amina even had a sixth child together. Later he suffered a

stroke that paralyzed one side of his body. In the end Amina

saw Hemed’s stroke as something of a blessing. Although it

made him an invalid, she told McGruder, “it has broken the

strength of his anger, his wanting to beat people.”

Kimwana, their daughter, showed no signs of the illness

during childhood. Amina remembers her daughter’s early

years with the compliment that she was “not a heavy load.”

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.

One Saturday night, just a few months after starting her

new job, Kimwana was restless and couldn’t sleep. Late in

the evening she wandered outside the house and in a loud

voice began asking for forgiveness. “Forgive me!” she

yelled. “Oh God, what have I done wrong!” When the family

couldn’t calm her, they assumed it was a case of spirit

possession. The family debated two theories. Perhaps, they

thought, she had been possessed by a spirit from a

deceased ancestor who had not been acknowledged for

watching over Kimwana, had not been shown the proper

gratitude for all the success she had experienced up to that

point. The other possibility was that a jealous coworker had

sent the spirit with the use of witchcraft.

At 1 a.m. Kimwana’s ranting hadn’t yet subsided, and the

family took her to the local hospital. Amina remembers that

she was examined, given antimalaria pills, and admitted for

four days.* At the end of the week, Amina recalls, Kimwana

came back home, slept well, and was able to go to work

again on Sunday.

She worked that week, but the following Monday again

became upset and refused to go to work. This time Amina

employed a traditional remedy. She burned a mixture of

leaves, flowers, grasses, and seaweed, whose strong odor is

believed to repel many types of weak spirits. Amina

remembers taking her daughter to the hospital, where she

again “became herself.” But even with periods of remission,

the delusions of hearing disembodied voices came back on

a regular basis.

He Sees Me up to My Heart

Fifteen years later, when McGruder began to spend time

with the family, her goal was not to show that Kimwana’s or

Hemed’s mental illness would have had a different course in

a different cultural setting; that would be impossible to

prove as there are no control groups in ethnographic

scholarship. Rather, she set about trying to record how

cultural beliefs and practices contributed to the family’s

understanding of the illness and to their treatment of

Kimwana and Hemed.

McGruder first wanted to get an idea of what the

experience of madness felt like. Hemed was so disabled by

his schizophrenia and the stroke that it was not possible to

get a sense of what was happening in his mind. Kimwana,

however, had periods of relatively high functioning and

could tell McGruder her impressions.

Kimwana told McGruder that the voices she heard in her

head were usually male, and they spoke to her as if they

could “see to my very soul.” These voices told her variations

on the theme of what a bad person she was. Sometimes she

heard two or more men gossiping that she was a disloyal

and disrespectful daughter and sister. The chorus could be

relentless: “She doesn’t love her mother,” one voice would

say to the other. “She doesn’t love her brothers and sisters.

She is not a person of God, just a useless person.”

Sometimes they would curse her in riddles or make negative

but oblique statements such as “Abhorrent badness even to

the soul.”

Although Kimwana understood that her thoughts were

unstable and disorganized, she often insisted the voices

were of real people and not delusional. And although she

sometimes believed that the voices came from outside the

window, her subjective experience was that the person

speaking was seeing into her thoughts and feelings. “I don’t

see him but he does [see me],” she told McGruder. “He

really sees me a lot. Actually he sees me up to my heart, up

to my mind. He has the ability to speak to me because he is

able to see me because whatever I think about he sees it.”

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 if 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 for her to do

this out loud.

This sense of decorum also made Kimwana reluctant at

first to name her tormentors, for it turned out that she

recognized the voices. They were, she admitted to

McGruder, the voices of the bicycle repairmen who worked

in front of the house. This bit of reality left McGruder in a

quandary over Kimwana’s perceptions. For most of the day

and often into the evening the voices of the bicycle

repairmen could be heard quite clearly in the house. It was

often difficult to tell to what extent Kimwana’s delusions

were jumping off of actual conversations drifting through

the window and to what extent they existed exclusively in

her mind.

That Kimwana’s delusions would come in the form of

intrusive auditory hallucinations made sense given the

location of the household. The roiling, pulsing sound that

filled the square during the day was remarkable for its

volume, texture, and complexity. Across the square from the

house was the Bakathrir Muslim School for Girls, and directly

to the right of the house was the Al Nour Islamic School for

Boys. At any given moment the undulating, overlapping

choruses of hundreds of children chanting in Arabic could be

heard.* The noise that emanated from the schools created a

kind of hypnotic background sound, like breaking surf.

On top of that sound could be heard the single voices of

individual children teasing and playing with each other or

calling out to people in the courtyard. Then there were the

voices and footsteps of adults heading across the square on

their errands and the constant squawk of crows in the shade

tree. In that cacophony of sounds reverberating and echoing

off tin roofs and cement surfaces, the only discernable

individual voices were those of the bicycle repairmen

chatting among themselves or with their customers as they

did their work.

Considering the additional commotion of the comings and

goings of the members of the household, the noise must

have been unrelenting. The many small children, though

well behaved in the manner of most Zanzibari children,

created a racket. Hemed, even though he could not walk or

even bathe himself, could yell and often did for long

stretches without ceasing. Several of the family members

shared with McGruder their belief that the noise itself was

exacerbating Kimwana’s illness. Bimkubwa, the most

Westernized of the siblings, told McGruder that Europeans

have much smaller families and that their houses were

much quieter. “There are too many of us and this place is

too noisy,” she said emphatically.

Kimwana often asserted that she felt better when she was

alone. But given her auditory hallucinations and the general

noisiness of her surroundings it was clear that she was

talking not just about a desire for physical solitude but also

for quiet. “I do like being on my own,” she once told

McGruder. “Being with people I feel like I am tangled with

them. I feel like calming myself, just silently. Just quiet and

silent.” Unfortunately time alone was a scarce commodity in

the packed household. And silence was all but unavailable.

The Emotional Temperature of the Household

It didn’t take long for McGruder to sense that Amina’s family

displayed an amazing tolerance for the difficulties of having

two severely mentally ill people (not to mention a deaf-

mute) in their household. It was a testament to the strength

of this family unit that Hemed, even after the divorce for

nonsupport and the years of violent psychotic episodes, was

still taken care of by Amina and the family.

McGruder noted that the family took a remarkably relaxed

stance toward Kimwana’s illness in particular. When asked

about Kimwana’s symptoms, Amina gave matter-of-fact

answers. When McGruder wanted to know what Amina

thought of Kimwana’s central delusion, all she could elicit

was the simple declaration that her daughter felt that the

“bicycle repairmen concern themselves with her affairs.”

Amina told McGruder that she did not share her daughter’s

belief, but there was no judgment or frustration attached to

the delusions. To many questions Amina would only answer,

“I am unable to know” or “I take it as one of God’s mercies,

one of God’s wishes.”

To try to give me a sense of the emotional tone in this

house, McGruder recounted a day in late September after a

particularly difficult few months for the household. Kimwana

was recovering after taking an overdose of her medication,

and a bad cold had sickened nearly everyone in the family.

Amina had admitted to McGruder that they were too poor

even to buy aspirin. Although each family member had

mostly recovered from the illness, the family unit was still

trying to regain its normal rhythm.

When McGruder arrived in midmorning she went right to

work in the kitchen. She had found that participating in the

daily chores was a much less intrusive way to observe the

goings-on in the household than sitting in a corner with a

notebook. Over the course of the morning she watched

Amina prepare food for a dozen hungry mouths, negotiate

the payment of school fees with a local official, send family

members on a variety of errands, and deal with minor

setbacks, including a large pot of ginger tea that had

unexpectedly curdled. On top of this she did her best to

keep the children (and McGruder) from disturbing Hemed or

Kimwana, both of whom were more upset that morning than


In her notebook McGruder listed the stressors Amina dealt

with that day. There were the relentless financial worries,

three family members who needed constant care, over a

dozen mouths to feed, and a small pack of children to be

protected and cared for. McGruder crossed off one theory

that might account for the differences in outcome of

schizophrenia between developing and industrialized

nations: the idea that life was simpler and less stressful for

poor people living in more traditional cultures. McGruder

suspects that this theory springs from a fantasy on the part

of Westerners, who are soul-weary from lives of commuting,

competing, and trying to find time for family. We want there

to be a place in the world where our life might distill to a

simple combination of satisfying work and close human

interaction. In reality, a stress-free life was as elusive in

Zanzibar as anywhere else in the world.

Despite the zogozogo and the hardships, however,

Kimwana’s behavior and her deficits were tolerated with

remarkable equanimity. While Kimwana’s activities and

social interactions were often reported to McGruder as a

gauge of her wellness, McGruder rarely witnessed Amina or

anyone else in the family pressure Kimwana into displaying

normal behaviors. During periods when Kimwana was

feeling well, for instance, Amina would report that she had

washed the dishes or swept the house. But Amina didn’t

assume a cause and an effect between productivity and

wellness. This goes against some basic tenets of Western

occupational therapy, which suggests that the path to

mental health can be found in productivity and participation

in group activity. Although the family viewed her

participation in household chores as a sign of health, they

didn’t pressure her to perform chores with the assumption

that they were curative. Indeed, when Kimwana was doing

poorly, the family allowed and even encouraged her to

withdraw from activity and to rest. Often, when she tried to

help out during such times, her family cautioned her not to

overextend herself.

For the most part, however, Kimwana was allowed to drift

back and forth from illness to relative health without much

monitoring or comment by the rest of the family. Periods of

troubled behavior were not greeted with expressions of

concern or alarm, and neither were times of wellness

celebrated. As such, Kimwana felt little pressure to self-

identify as someone with a permanent mental illness. This

stood in contrast with the diagnosis of schizophrenia as

McGruder knew it was used in the West. There the diagnosis

carries the assumption of a chronic condition, one that often

comes to define a person.

The prizing of rest over work and passive acceptance of

abnormal behavior versus active encouragement or

criticism were representative of an overall calm emotional

tone in the household. Even on difficult days there was an

air of tolerance when dealing with Hemed’s and Kimwana’s

disturbed behavior. McGruder believed that this tone

emanated not simply from the personalities in this particular

family but from cultural cues in Zanzibar, and she took it as

her mission to find the sources that created this emotionally

even atmosphere.

Emotional Expression and Schizophrenia

The early research into the relationship between the

emotional temperature within families and the long-term

course of schizophrenia took place in England in the 1950s.

Clinicians had anecdotally observed that some patients with

schizophrenia released from hospital care came back within

a short period of time, whereas other patients managed to

stay out of inpatient care for longer periods. A team of

researchers led by the psychiatrist George Brown decided to

try to figure out what factors might distinguish the two

groups. They conducted lengthy open-ended interviews

designed to encourage first-person stories from family

members. There were no right or wrong answers;

researchers attempted only to elicit rich descriptions of daily

life with the mentally ill family member. After categorizing

all the emotional reactions they could identify, they tracked

the patients over time, noting their rates of relapse and

general levels of functioning.

Initially they looked at the families of the patients who

fared better, but they could find no behavior that had

significant predictive value. Studying the families of the

high-relapse patients, however, they did find factors that

appeared to predict outcomes. Three emotional reactions

from family members showed a relationship with the

patients with higher relapse rates. Collectively referred to as

“high expressed emotion” they were criticism, hostility, and

emotional overinvolvement. In particular, high-relapse

patients tended to live in an environment where at least one

relative routinely criticized and attempted to control the

patient’s behavior.*

Criticism and hostility are relatively self-explanatory.

“Emotional overinvolvement,” however, is a term of art that

requires a little explanation. It describes a range of

behaviors that may include dramatic expressions of self-

sacrifice, extreme devotion, overprotectiveness, or

intrusiveness in the patient’s life. One mother, for instance,

was rated as emotionally overinvolved when she reported

that she was so concerned with her son’s condition that she

had dropped all other interests from her life. Her sole

activity, she reported, was to take care of him and protect

him, “like a pearl or a diamond.” This same mother said that

she often became so distraught over her son’s plight that

she considered committing suicide by shooting herself,

running out into traffic, and throwing herself down the

family staircase.

Researchers have found a connection with high expressed

emotion (EE) and poorer outcomes with some other mental

illnesses, but nowhere is it as pronounced as with

schizophrenia. Why is there such a strong connection?

Researchers believe that the experience of being criticized

or constantly observed and judged parallels the experience

of the disease itself. It is not coincidence, in other words,

that one of the central symptoms of schizophrenia is

hearing demanding, critical, or disparaging voices. Social

stress is a known trigger for psychotic episodes, and a

number of studies testing diastolic blood pressure, skin

conductance, and electrodermal reactivity all pointed to the

connection between high-expressed-emotion relatives and

increased feelings of stress in a patient. When confronted

with relatives known for their high levels of expressed

emotion, researchers could watch as dials measuring bodily

stress rose in the patient.

This connection between high-expressed-emotion

households and relapse rates proved true across cultures.

Over the course of the 1970s and 1980s dozens of studies

were conducted on populations in Denmark, Italy, Germany,

Spain, France, North America (including both Anglos and

Mexican Americans), China, Taiwan, India, North Africa, and

Australia. In a paper that aggregated the data from a dozen

studies, researchers noted that the relapse rates were three

to seven times greater for patients from high-expressed-

emotion families. The connection remained even when the

severity of the initial symptoms and drug compliance were

taken into account. In another paper that brought together

the data from twenty-five studies, researchers found that

the relapse rate was 50 percent for high-expressed-emotion

families and 21 percent for low-expressed-emotion families.

God’s Blessings

McGruder could sense that Amina’s household had a low

level of expressed emotion when it came to dealing with

Hemed and Kimwana, but it took her quite a while to

understand the cultural sources of that tone. She spent a

good deal of her time trying to tease out the local religious

beliefs that wove themselves around the ideas of madness

in Zanzibar. Like 90 percent of Zanzibaris, Amina’s family

belonged to the Sunni Shafi’ites sect. This is an Islamic sect

that believes in adhering faithfully to the teachings of the

Koran and the stories collected by Al-Bukhari that recount

the life of the Prophet Mohammed. It is from these stories,

collectively called a hadith, that many Zanzibaris draw

wisdom to manage the everyday challenges of life.

Both the Koran and Al-Bukhari’s hadith recount ideas

about suffering and hardship that McGruder could see had

deeply informed the family’s treatment of Kimwana and

Hemed. Amina and other family members often repeated

the belief that Allah would never put more burdens on a

person than he or she could bear. “In our family we have

this challenge but this is just life,” Amina would tell

McGruder when talking about Kimwana and Hemed. “Other

people have other problems. Maybe their house has burned

down. Everyone knows their own burden best.”

McGruder came to understand that these were not just

bromides. In the family’s Muslim belief, managing hardships

provided a way to pay the debt of sinfulness. Illness or bad

turns of fortune were seen as neither arbitrary nor a

punishment. Rather, they believed that God’s grace awaited

those who not only endured suffering but were grateful for

the opportunity to prove their ability to endure it. In this way

Amina’s remarkable ability to stay steady and resolute in

the presence of sick and disabled family members was an

expression of her religious belief.

McGruder had heard similar “God willed it” sentiments

repeated among Christians in the United States, but the

embrace of hardships in Zanzibar was qualitatively different.

Although American Christians might believe that God had

sent a challenge or a misfortune, they were also likely to

believe that God had given them the strength not just to

embrace the difficulty but to overcome it or learn a valuable

lesson. 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 burdens was a continuous act of penance.

“Religion as I understood it as a child had more to do with

what you believed than what you did during your day,”

McGruder told me. “Here in Zanzibar religion has much

more to do with what you do. You can see it in how people

live their lives, how they pray five times a day and fast

during Ramadan.” In McGruder’s view, the steady care

given to Kimwana and especially Hemed seemed to come

out of the family’s religious desire to prove worthy of the

burden God had given them.

Sometimes it seemed that their acceptance of burdens

bordered on the fatalistic. “Fatalism” is not a word McGruder

would employ, given that its negative connotations violate

the anthropologist’s credo to remain judgment-neutral. Still,

McGruder found herself using such phrases as

“acquiescence in the face of adversity” and “embracing

difficulties as a natural part of life” almost as euphemisms.

She remembers times when she tried not to let her jaw drop

at the family’s lack of upset. One such moment came when

Kimwana took an overdose of her medication and ended up

in the hospital. “There was no noisy woe-is-me talk or

dramatic wringing of hands. They seemed to take it in stride

like everything else,” McGruder recalls. “When I asked what

I could do, Amina told me that I could take a carton of milk

to Kimwana in the hospital. So I took the milk.” For

McGruder, a fighter and problem solver by nature, it took

some time to recognize the benefits of such acceptance of

life’s difficulties.

The Creatures in Our Heads

The other religious belief that was central to the family’s

conception of the illness was spirit possession. It would be

easy for a Westerner to assume that belief in spirit

possession would almost certainly increase the stigma for a

mentally ill person. McGruder remembered the horror

stories of spirit possession she learned as a child in the

United States. Those beliefs were informed more by pop

cultural representations (such as the movie The Exorcist)

than by what she heard in church. Nevertheless her cultural

understanding of these devil-focused narratives about spirit

possession included dramatic suffering and ostracism for

the person believed to be possessed. In the Christian

context, possession is nearly always thought of as a

profoundly disturbing experience, usually requiring dramatic

and sometimes violent interventions. Given the choice

between the biomedical understanding of schizophrenia and

the spirit possession narrative, most Westerners assume the

drier science-bound explanation for the disease would

certainly inflame less emotion and stigma. As McGruder

came to understand the spirit possession beliefs of families

like Amina’s, however, she found them to be very different

from Christian beliefs in the West. To begin with, spirit

possession in Zanzibar was not an uncommon or necessarily

an extreme experience. As Amina explained to McGruder,

we all have “creatures in our heads.”

The beliefs surrounding spirit possession in Zanzibar arose

from the complex combination of traditional Swahili culture

and Arabic beliefs about jinns. These spirits that often

inhabit living individuals aren’t uniformly good or bad but

can cause problems if they are not dealt with in appropriate

ways. A spirit handed down from one’s ancestor is generally

thought to have a protective effect for the person who

carries it. Such an entity will cause difficulties only if it is

ignored or not properly appeased. These spirits can have an

ethnicity, gender, and religious affiliation of their own. A

spirit might be picked up accidentally or through witchcraft.

Sorcerers are said to raise and feed spirits, which they use

to harm their enemies.

The main difference between the character of spirits and

of humans, McGruder learned, is that spirits are often

autonomous, rude, selfish, and not given to concealing their

emotions. (In this way they are sometimes compared to

tourists who intrude but do not greet.) When a spirit

possesses someone, he or she often violates the social

norms. A sister momentarily influenced by a spirit may

strike a brother who is harassing or threatening her, for


Because nearly everyone on the island believed in spirit

possession and had a personal experience with it, the

application of the belief to mental illness had the

counterintuitive effect of lessening the stigma attached to

the behavior of the mentally ill person. It made bizarre or

disruptive behavior more understandable and forgivable.

Like the sister who has a ready explanation for hitting her

brother, mentally ill persons and their family can evoke the

narrative of spirit possession to explain unusual or antisocial


Belief in spirit possession also gives the family a sense of

agency in that it allows for a variety of socially accepted

interventions. “Spirits causing problems are not exorcised in

the Christian sense of casting out demons,” McGruder

explains. “Rather they are coaxed with food and goods,

feted with song, dance. They are placated, settled, reduced

in malfeasance.” It was common, for instance, to write

phrases from the Koran on the inside edges of a teacup with

saffron paste and then to dissolve the writing so that the ill

person could literally imbibe the holy words. Similarly the

Koran might be read over water before it was used for

bathing. Pagan spirits would be driven away by such acts,

and Muslim spirits would become subdued. Kimwana found

such activities calming. She especially enjoyed it when

family members read to her the short verses from the Koran

that children learn to read and memorize early in school. “If

someone reads and I listen, then my mind clears,” Kimwana

said. “It tells us to become compliant and wait patiently. I

listen to the Koran and then I rest.”

For McGruder the point was not that these practices were

effective in combating the biological causes of

schizophrenia. Rather, they were simple examples of how

the spirit possession narratives kept the sick person within

the social group. Importantly, the idea that spirits could

come and go allowed the person with schizophrenia a

cleaner bill of health when the illness went into remission.

An ill individual enjoying a time of relative health could

employ the spirit possession story to, at least temporarily,

retake his or her responsibilities in the kinship group.

In all these ways the belief in spirit possession could

decrease the sense of blame or shame carried by the family

or the ill individual. The blessings and burdens of God and

the mysteries of the spirit world were, after all, beyond the

ability of the individual or family to effectively control. As

McGruder observed, “When humans do not assume they

have rather complete control of their experience, they do

not so deeply fear those who appear to have lost it.”

In some ways the low expressed emotional atmosphere in

the family stood in contrast to McGruder’s work as a

Western anthropologist trying diligently to understand it. At

times she had to remind herself to turn off her analytical

gaze, her desire to document and categorize the behavior

she was there to witness.

She remembers one day when Kimwana invited her to sit

with her on the steps of the family’s interior courtyard.

McGruder could tell from the liveliness in her eyes that

Kimwana was more fully present than she had been

recently. Kimwana sat, barefoot, with her back against the

door frame, and talked of how enjoyable it was to feel the

breeze. McGruder asked her what she had been doing prior

to her arrival that day and Kimwana told her that she had

been resting but not sleeping.

“When you rest, do you think a lot?” McGruder asked.

“Yes, I think so much,” Kimwana admitted.

“What do you think about?”

“For example,” Kimwana answered, “just now I was

thinking if I would get better.”

It was a promising opening. McGruder sensed that it

would be a good time to ask her more questions about her

disease experience. But then she found she could not bring

herself to risk breaking the peacefulness of the moment.

Making the ill individual aware that his or her behavior and

cognition are being monitored and judged was, she knew, a

sign of emotional overinvolvement. So as much as she

wanted to question Kimwana more, McGruder turned the

conversation back to the quality of the breeze and how cool

it was to sit in the shade of the house, trying, as best she

could, not to document the low emotional intensity of the

household but instead to manifest it.

Emotion across Cultures

McGruder’s intent in describing Amina and her family was

not to make them into heroes. Indeed what made them

remarkable in her eyes was just how unremarkable they

considered their sacrifice. Amina never suggested that the

care she gave her crippled and mentally ill ex-husband was

praiseworthy or particularly out of the ordinary. Because

many other families subscribed to similar religious and

cultural beliefs about the need to accept God’s burdens,

Amina’s family’s unemotional self-sacrifice was the norm in


Because different cultures around the world view mental

illness in different cultural contexts, the intensity of emotion

attached to these experiences often varies. Researchers

have found different average levels of expressed emotion

not just among families but also among cultures and even

among different subcultures in the same city. “To be

specific,” Janis Hunter Jenkins writes, “a culture provides its

members with an available repertoire of affective and

behavioral responses to the human condition, including

illness. . . . It offers models of how people should or might

feel and act in response to the serious illness of a loved

one.” Individuals in a given place and time will react to

illness similarly, in other words, because they share the

same limited repertoire of cultural scripts for how to play

their part.

The different ways that cultures communicate

expectations for behavior are often quite subtle. Seemingly

small differences, such as the disease’s name, can make a

difference. Jenkins noticed, for instance, that Mexican

American families in southern California, who had lower

expressed emotion scores than Anglo-American families

tended to use the term nervios to describe the illness of the

relative with schizophrenia. This seemed at first an

inappropriate word; nervios is a folk term often used as a

generic way to describe any one of a whole range of

symptoms, including headaches, dizziness, sleeping

disorders, aggressive or grumpy behavior as well as feelings

of anxiety, insecurity, or fear. Nervios is a catchall diagnosis

for feelings of disquiet or distress. The use of the term

appeared to be a kind of culturally inspired, willful blindness

for these family members. Calling schizophrenia nervios was

the equivalent of telling someone with cancer that he is just

feeling under the weather.

On closer examination, though, there appeared to be a

subtle purpose behind the misnomer. Jenkins saw that the

use of the word was part of a strategy by which the family

jointly downplayed the gravity of the illness. Nervios carried

little of the dire connotations an Anglo-American would

associate with schizophrenia. Nervios, like spirit possession,

is thought of as a transitory state. This allowed relatives and

the ill family member to regard periods of remission in a

more favorable light.

This hopeful naming also fostered feelings of empathy.

Many of the Mexican American family members in one of

Jenkins’s studies told her that they too had suffered from

nervios, in a milder form, and so could empathize with the

relative’s distress. “In this way,” Jenkins concluded,

“conception of the illness as nervios enables the

maintenance of close identification of family members by

fostering the view that the relative is ‘just like us only more

so.’” The label and its connotations allowed family members

to keep the relative within the fold.

That the very naming of the disease could have an impact

on its outcome again highlights the distinction between a

medical illness and a mental illness. The course of a

metastasizing cancer is unlikely to be changed by how we

talk about it. With schizophrenia, however, symptoms are

largely expressed within the person’s complex interactions

with those around them. The key to the emotional tenor of

those interactions lies to some extent in the words and

cultural beliefs that surround the disease.

Because these words and narratives are shared by

cultures, it is not surprising that the average level of

expressed emotion varies from place to place. Comparing

different groups around the world, it turns out that urban

Anglo-Americans have the highest level of expressed

emotion on average. In one study over 67 percent of Anglo-

American families with a schizophrenic family member were

rated as “high-EE.” Of the other groups studied:

Among British families 48 percent were high EE

Among Chinese families 42 percent

Among American families of Mexican descent 41 percent

Among British Sikh families 30 percent

Among Indian families 23 percent

What does it mean that European American families have

the highest average levels of expressed emotion? Is this an

indication that white Americans lack the sympathy or the

kindness to care for their mentally ill?

Professor Jill Hooley of Harvard University conducted a

study to understand what distinguishes high-EE relatives

from their less emotionally intense counterparts. She gave

both high- and low-EE relatives a simple test that measures

what psychologists call “locus of control.” Basically she

wanted to know to what extent these relatives believed they

had individual control over their own lives. To determine this

she asked them whether they agreed or disagreed with

statements such as the following:

When I make plans, I am almost certain that I can make

them work.

I believe a person really can be a master of his fate.

I can control my own problems only if I have outside


A great deal of what happens to me is probably a matter

of luck.

Those who tended to agree with statements such as the first

two were thought to have an internal locus of control. They

were the type of people who thought of themselves as

captains of their own destiny, able to shape their future

through force of will. Those who agreed with statements

similar to the second two were thought to have an external

locus of control, meaning they believed that the course of

their lives was largely influenced by factors outside


Hooley found that relatives who were highly critical of the

mentally ill family members were those with an internal

locus of control. Their critical comments to the mentally ill

person didn’t mean that they were cruel or uncaring; they

were simply applying to their relative the same assumptions

about human nature that they applied to themselves. “An

internal based locus of control reflects an approach to the

world that is active, resourceful, and that emphasizes

personal accountability,” concluded Hooley. “Thus, far from

high criticism reflecting something negative about the

family members of patients with schizophrenia, high

criticism (and hence high EE) was associated with a

characteristic that is widely regarded as positive.”

Widely regarded as positive, that is, in the United States.

It has long been noted that countries and cultures differ in

their shared beliefs about locus of control and related

measures such as scales of individualism versus collectivism

or egocentric versus sociocentric conceptions of self. In

many cross-cultural studies, the cliché that Americans are

more individualistic proves to be true. In a masterful meta-

analysis of dozens of cross-cultural studies performed over

the past fifty years, professor of psychology Daphna

Oyserman and colleagues from the University of Michigan

concluded that, compared with other groups around the

world, European Americans are indeed “more individualistic

—valuing personal independence more. . . . To

contemporary Americans, being an individualist is not only a

good thing; it is a quintessentially American thing.”

Viewed in the most positive light, these highly emotionally

involved relatives were more hopeful about the disease

because they remained convinced that the ill family

member should be able to overcome the symptoms with an

application of personal will. “It is plausible to speculate,”

Hooley and a colleague in another paper on the topic

concluded, “that certain cultural values (e.g., fatalism) in

traditional groups might engender more benign and less

blaming attributions toward those with mental illnesses. In

contrast, cultural values that emphasize individuality,

achievement, and personal accountability might be

expected to facilitate more attributions of responsibility and

control in the context of disturbed behavior.”

In his book Crazy: A Father’s Search through America’s

Mental Health Madness, Pete Earley vividly documents a

common response among Western parents when faced with

the onset of a severe mental illness in their child. One

typical father described his reaction to the schizophrenic

break of his son: “I went to the library and began reading

books about mental illness. . . . I thought: ‘No, I’m going to

fix this.’ That is your first instinct as a parent. You’re going

to fix it. I thought, ‘I can get him help. I can get him cured.’”

This intense can-do spirit is admirable and often

heartbreaking. Because there is no silver bullet cure for

schizophrenia, families who attack the problem looking to fix

it are often frustrated by the results. That intense focus,

even when it springs from a hopeful engagement of the

problem, might be the very thing that exacerbates the


“Mental illness is feared and has such a stigma because it

represents a reversal of what Western humans have come

to value as the essence of human nature,” McGruder

believes. “Because our culture so highly values self-control

and control of circumstances, we become abject when

contemplating mentation that seems more changeable, less

restrained and less controllable, more open to outside

influence, than we imagine our own to be.”

When the Biomedical Narrative Comes to Town

All of the patients with schizophrenia that McGruder

interviewed in Zanzibar received at least some treatment

from doctors trained in other countries. During the country’s

communist years, foreign doctors came from East Germany

and China. More recently they hail from the United States

and Britain. Over that time chronically mentally ill patients

in Zanzibar were prescribed a wide range of the

psychopharmacological drugs that are now ubiquitous

around the world.

During the years that McGruder studied mental illness in

Zanzibar, she watched as traditional beliefs began to mix

with biomedical explanations of mental illness. For some

families, such as Amina’s, those two understandings didn’t

necessarily compete with each other. The idea that spirit

possession was causing bizarre behavior coexisted with the

notion that the pills from the doctors might help her

daughter’s quality of life. One does not have to believe the

“brain disease” explanation, after all, to take a pill.

In some families that McGruder studied, however, the

introduction of Western ideas about schizophrenia had a

more complicated and problematic effect.

Shazrin al-Mitende was 43 when McGruder began visiting

her family. She lived with five adult relatives and ten

children, one of whom was developmentally disabled.

Shazrin’s half-brother, Abdulridha, was her main caretaker,

devoting much of his life to the task. The male nurse who

suggested Shazrin and her family for inclusion in

McGruder’s study thought of Abdulridha as an excellent


Abdulridha himself certainly agreed with this assessment.

In their first meeting he listed for McGruder all the ways that

he had taken charge of his sister’s life. “It is necessary that I

give up my own activities so much in order to care for her,”

he said. At another point he told McGruder, “I am like her

slave now. She says ‘bring me some water.’ I go and fetch it.

It is she who should be bringing me water.”

As McGruder got to know the family, she learned Shazrin’s

history. Trouble began in 1968, when Shazrin was just 13, on

the night of the new moon that signals the end of Ramadan.

Shazrin was sitting with a group of women relatives applying

henna designs to each other’s hands. This group

beautification was in preparation for the feasting and

gathering of relatives that followed the end of the month-

long daylight fast. As she sat with the other women, the

sight of a black cat walking through the room startled her.

During the feasting the next day, she told her family that

she felt unwell and overheated. When her mother told her to

lie down and tried to help her out of her new dress, Shazrin

began to scream uncontrollably. She was inconsolable for

several days.

Because her behavior could be traced to the sighting of

the black cat, it was at first agreed that spirit possession

was behind her strange and disruptive behavior. Shazrin’s

grandfather had been a spirit cult practitioner, who, it was

said, conjured spirits in the family courtyard. Some family

members and neighbors assumed that one of those spirits,

set free of the grandfather’s control at his death, had

alighted on the soul of Shazrin.

Shazrin’s family took her to see several traditional

doctors. They traveled up and down the Swahili Coast

consulting with healers in Dar es Salaam, Bagamoyo, and

Tanga in Tanzania and traveling as far away as Mombasa in

Kenya. In one instance her hair was shaved and small cuts

were made in her scalp into which herbal medicines were

rubbed. Other healers used techniques intended to call forth

the spirit so it could be negotiated with and placated.

Another healer was skilled in diagnosing ailments by

drawing pictures of the patient. Despite these efforts,

Shazrin improved little.

As it happened, a young neighbor had recently become a

doctor at the local mental hospital. He persuaded the family

that Shazrin should be taken to Kidongo Chekundu Mental

Hospital the next time her behavior became difficult to

control. And so, when Shazrin became disturbed a few

weeks later, the family called the police, who took her to be

admitted. She was still only 13 years old, a frightened girl in

a locked ward for adults with severe mental illnesses. In

those first hospital records, the staff noted that she was

restless and preoccupied but mostly rational.

It was during this time that she briefly came under the

care of an American psychiatrist named Charles Swift, who

was having a dramatic impact on Tanzania’s evolving

treatment of the mentally ill. He had come to the newly

formed country in 1966 intending to stay only two years but

ended up staying eight, working mostly in hospitals on the

mainland. From the perspective of Tanzania’s Ministry of

Health, Swift was a godsend. When he arrived he was the

only trained psychiatrist in the country.

Once a month Swift would fly from Dar es Salaam to

Zanzibar and visit the mental hospital, where the medical

director put him to work diagnosing difficult cases. One of

those patients was the young Shazrin. She remembers

being frightened in the presence of this American. “He was

very fierce,” she says. It was Swift who first diagnosed her

condition as schizophrenia.

Shazrin’s assessment of Swift as “fierce” stands in sharp

contrast to the caring and rather humble man he presents

to the reader in Dar Days, his memoir of his time in

Tanzania. He reports having disdained the superior attitude

of the former British colonialists he met in the country. But

while it is clear that Swift took pains to be culturally

sensitive, he also had a great certainty in the value of the

expertise he brought to the country. He clearly saw his

service as parallel to medical doctors who brought state-of-

the-art practices and medication to places where local

clinicians had little knowledge or resources to battle


Humble as he may have been, he did not turn down the

status he was granted as a mental health professional from

the Western world. Looking back at Swift’s tenure in

Tanzania, it is not surprising that he extended his stay by six

years. Back in New Jersey he worked for a medium-size child

development center, but in Tanzania he was a central player

in establishing the mental health system for the entire

country. His advice was sought in every aspect of the

country’s approach to mental illness, and he dined regularly

with politicians and dignitaries.

In his memoir Swift makes it clear that the pervasive

beliefs in spirits and witchcraft were a problem for the

population. Replacing such native beliefs with clear and

unemotional Western diagnoses seemed to him an obvious

improvement. It was Swift’s hope that by providing Western

knowledge he could help erase these myths that he

believed brought stigma to the mentally ill. For Shazrin, his

diagnosis would have long-lasting effects.

For the next two decades Shazrin was in and out of the

mental hospital dozens of times, for both long and short

stays. Overall she spent nearly one-fifth of her young

adulthood at Chekundu. Her records show that she took a

variety of medications during that period, including, for a

time, a large fifty-milligram dose of the antipsychotic

fluphenazine every two weeks. During another period the

doctors prescribed her a nightly dose of the barbiturate

sodium amytal. In the late 1970s she also underwent a

series of electroconvulsive treatments. Some of the

medication brought on epileptic-like fits and made her lips

and hands tremble uncontrollably.

Shazrin’s treatment at the hospital wasn’t the only way

that Western medicine affected her life. Over the course of

her illness her half-brother, Abdulridha, increasingly

distanced himself from the beliefs of traditional healers and

aligned himself more and more with Western notions and

treatments of his sister’s condition. He associated Western

medicine and Western beliefs about mental illness with his

self-conception of being a modern and educated man.

Abdulridha acquired his knowledge about Western

understandings of mental illness from a variety of sources.

He learned much from the doctors at the hospital. Of all the

family members McGruder interviewed, Abdulridha was the

only one who understood the distinction between the

symptoms of schizophrenia and the side effects, including

tremors and weight gain, of the antipsychotic medication.

He was also the only one to understand that some of

Shazrim’s medications were taken to control the side effects

of other drugs.

He picked up information from other sources as well. For

instance, from a Voice of America program about drugs that

treat depression he came to the conclusion that Western

doctors had a medicine that would cure his sister’s

uncontrollable bouts of crying. As understood by Abdulridha,

the biomedical approach implied that his sister’s mind was

broken but fixable through medication.

McGruder began to think that she was watching a classic

display of emotional overinvolvement as she observed

Abdulridha attempt to manage every aspect of his sister’s

existence. What particularly intrigued McGruder was how

Abdulridha used his biomedical orientation toward the

disease to justify his control over Shazrin. Aligning himself

with the Western doctors, he allowed himself to express

intense frustration at his sister for her apparently stubborn

refusal to get better. Shazrin’s lack of recovery despite his

efforts and those of the doctors appeared to embarrass and

infuriate him. “I tell her, ‘I do everything for you,’” he

recounted to McGruder. “ ‘You should stop all those

behaviors in order to give me some encouragement.’”

McGruder had a front-row seat in witnessing how the

biomedical explanation affected Abdulridha’s treatment of

his sister. She was even, at times, recruited against her will

into the dynamic. For Abdulridha, McGruder was a

representative of modern Western knowledge and authority,

and he attempted to co-opt her presence in the life of the

family to prove that his opinions and actions were backed

up by doctors and educated people.

When McGruder came to visit, Abdulridha took pride in

reciting for her every detail of Shazrin’s daily activities. He

was particularly forthcoming about his knowledge of her

menstrual cycle, detailing the precise dates menses began

and ended. He would then tell her of any recent bad

behavior. “She has finished bleeding some three days ago

now, but her condition is still bad,” he said in one typical

encounter. That he openly talked about such aspects of

Shazrin’s life startled McGruder. A brother talking about

such things was a clear violation of the rules of modesty she

had observed elsewhere in Zanzibar. Abdulridha’s

biomedical conception of his sister’s illness appeared to

invalidate normal rules of conduct. Similarly he would often

talk about Shazrin as if she could not hear him. At these

times she would go blank and stare at the floor, refusing to

respond to anyone. “This is the problem,” Abdulridha said at

one point when his sister’s affect went flat. “She is not here

at all now; she has been completely covered. I told you you

would see it.”

Needless to say, being forced into an alliance that

excluded Shazrin was uncomfortable for McGruder; she

worried that her presence was actually helping Abdulridha

stigmatize his sister. In her field notes she wrote, “I am

finding it progressively harder to write about this family and

harder still to visit them. The events . . . have convinced me

that family interactions definitely increase Shazrin’s

suffering and I am now included against my will in that


In the end Abdulridha’s increasing alliance with Western

medicine had the effect of stripping away the local beliefs

held by other families McGruder had studied in Zanzibar.

Unlike Kimwana’s family, there was no safe harbor in the

belief that God had sent the illness as a blessing, a burden

to be embraced. Those beliefs were replaced by a set of

ideas that appeared to allow Abdulridha to dehumanize his

sister and justify his harsh control over her life.

The Rise of the Biomedical Narrative in the West

Over the past two generations, Western psychologists and

psychiatrists have promoted the biomedical approach to

mental illness around the world with the argument that

adopting this way of thinking would lessen the stigma

surrounding these conditions. Even patient and family

advocacy groups such as the National Alliance for the

Mentally Ill in the United States and SANE in the United

Kingdom have consistently promoted the idea that mental

illnesses should be viewed as medical illnesses, as

“diseases of the brain.”

Western mental health professionals coined the term

“mental health literacy” to describe the set of ideas they’ve

promoted around the world. Populations are considered

more “literate” if they adopt Western biomedical

conceptions of these diseases. A study from the World

Psychiatric Association, for instance, identified respondents

as “knowledgeable” and “sophisticated” when they

identified schizophrenia as a “debilitating disease.” Another

study portrayed those who endorsed the statement that

“mental illness is an illness like any other” as having a

“knowledgeable, benevolent, supportive orientation towards

the mentally ill.”

The logic seemed unassailable: once people believed that

the symptoms of mental illnesses such as schizophrenia

were not the choice of the individual and did not spring from

supernatural forces, the sufferer would be protected from

blame. The brain disease narrative would make it less likely

that the public would attribute the onset of mental illness to

an individual’s life choices or a weakness of character. In

addition, people would be less likely to connect the difficulty

of recovery to a patient’s lack of personal will or motivation.

By pushing the blame onto the functioning of genes or

broken biochemistry in the brain, the individual could

escape stigma.

Studies show that over the past fifty years the world has

steadily adopted this medical model of mental illness.

Although these changes have happened most dramatically

in the United States and Europe, similar shifts have been

documented around the world. When asked to name the

sources of mental illness, people from every country studied

are increasingly likely to mention “chemical imbalance” or

“brain disease” or “genetics” as part of the cause of mental

illness. These global changes in belief represent a hard-won

victory on the part of mental health care providers, drug

companies, and advocacy organizations.

Unfortunately, as mental health professionals and

advocates for the mentally ill have been winning this

rhetorical and conceptual battle, they’ve been

simultaneously losing the war against stigma. Studies of

attitudes in the United States between the 1950s and 1996

have demonstrated that the perception of dangerousness

surrounding the mentally ill has steadily increased over this

time. Similarly a study in Germany found that the public’s

desire to maintain distance from those diagnosed with

schizophrenia increased between 1990 and 2001.

Researchers hoping to figure out what was causing this

rise in stigma found a startling connection. It turns out that

those who adopted the biomedical and genetic beliefs about

mental illness were most often those who wanted less

contact with the mentally ill or thought of them as

dangerous and unpredictable. This unfortunate cause-and-

effect relationship has held up in numerous studies around

the world. In a study conducted in Turkey, for example,

those who labeled schizophrenic behavior as akil hastaligi

(illness of the brain or reasoning abilities) were more

inclined to assert that schizophrenics were aggressive and

should not live free in the community than those who saw

the disorder as ruhsal hastagi (a disorder of the spiritual or

inner self). Another study, which looked at populations in

Germany, Russia, and Mongolia, found that “irrespective of

place . . . endorsing biological factors as the cause of

schizophrenia was associated with a greater desire for social

distance.” The authors of that study concluded that

“promulgating biological concepts among the public might

not contribute to a desired reduction in social distance

towards people with mental disorders.”

The problem, it appears, is that the biomedical or genetic

narrative about an illness such as schizophrenia carries with

it the subtle assumption that a brain made ill through

biomedical or genetic abnormalities is more thoroughly

broken and permanently abnormal compared to one made

ill though life events. “Genetic arguments may work in an

asymmetric fashion,” wrote researcher Jason Schnittker

from the University of Pennsylvania. “They encourage the

view that mental illness is impersonal and uncontrollable in

its development, but more stable and unyielding in its

course. By the same token genetic arguments inflate

perception of dangerousness in so far as [they imply that]

the mentally ill are always at risk for violence even when

treated. . . . Genetic arguments make the person appear

even more ‘at risk’ and threatening.”

In a dramatic experiment, Professor Sheila Mehta from

Auburn University in Montgomery, Alabama, effectively

answered the question of how these beliefs about mental

illness can translate into behaviors between people. In her

study, subjects were led to understand that they were

participating in a simple learning task with a partner, who

was actually a confederate in the study. Before the

experiment started, the two partners exchanged some

biographical data, during which the confederate told the

test subject that he suffered from a mental illness.

Confederates then stated either “[The illness occurred due

to] some things that happened to me as a kid” (the

psychosocial explanation) or “I had a disease just like any

other which affected my biochemistry” (the disease

explanation). The learning experiment called for the test

subject to supposedly teach the confederate a certain

pattern of button presses. The only feedback the test

subject could give to incorrect button pushes was a mild to

“somewhat painful” electrical shock.

Analyzing the data, Mehta found a dramatic difference

between the group of subjects given the psychosocial

explanation for their partner’s mental illness history and

those given the brain disease explanation. Those who

believed that their partner suffered an “illness like any

other” increased the severity of the shocks at a faster rate

than those who believed they were partnered with someone

who had a mental disorder caused by childhood events.

Mehta concluded, “The result of the study suggests that we

may actually treat people more harshly when their problem

is described in disease terms. . . . We say we are being kind

but our actions suggest otherwise. . . . The disease view

engenders a less favorable estimation of the mentally

disordered than the psychosocial view.” She added,

“Viewing those with mental disorders as diseased sets them

apart and may lead to our perceiving them as physically

distinct. Biochemical aberrations make them almost a

different species.”

Indeed it was just this dynamic that McGruder witnessed

between Shazrin and her brother. Remarkably, despite more

than forty years of evidence suggesting that the biomedical

or brain disease belief increases stigma, the Western mental

health professionals continue to promote these ideas with


Just Chemistry

One afternoon McGruder took me to the Kidongo Chekundu

Mental Hospital, a few miles from downtown Stone Town.

The compound was made up of several single-story white

stucco structures with tiled roofs surrounding a large

courtyard. There was an intake area where patients and

their families sat on benches waiting to be seen, a

documents room, and an area where meals were prepared

over a wood fire. McGruder showed me the occupational

therapy room she had helped establish many years ago.

Hundreds of paintings and drawings by former patients

hung on the wall.

The facility for housing the patients was separated into an

open ward for patients considered to be of no danger to

themselves or others and two locked areas for the women

and men who were more seriously disturbed. In the

courtyard I talked with a young man who was lighting a

small cooking fire to boil water for tea. His English was

perfect, with an American accent. I assumed he was a

doctor or a caretaker until he told me he had come from the

mainland for a long stay at the hospital while the doctors

attempted to find the right balance of medication for his

manic depression. He was excited to talk to me. He had

gone to college in Arizona and had fond memories of the


Later two guards led me to the entryway of the locked

area of the men’s compound. For a few minutes several

men on the other side of a barred window talked animatedly

at me in Kiswahili. Behind them I could see a half dozen

other men in the open area. Some were sleeping, and others

rocked restlessly.

Given my cultural background, I was incapable of

believing that these men were possessed by spirits. Indeed I

find it difficult to think of the biological explanation for

mental illness as fungible cultural “belief” or “narrative.” I

assume, in short, that it is the scientific truth. But as I later

thought of my brief visit to the locked ward at Kidongo

Chekundu I began to wonder about the meaning behind

these certainties.

If you ask me what it means that schizophrenia is related

to genes, for instance, I will say that people with a family

history of schizophrenia are at greater risk. Although this

appears to be statistically true, that is pretty much the

extent of my actual knowledge on the topic of the genetic

precursors to schizophrenia. My scientific understanding of

abnormalities in brain chemistry related to the disease is

similarly limited. So although I deeply believe that the

biomedical explanation for mental illness is likely true, that

certainty does not come with a degree in biochemistry or


If these beliefs have so little weight, why do I continue to

hold to them so tightly? Beliefs about mental illness—and

this is as true in the United States as it is in Zanzibar—are

first and foremost testaments to group membership. By

attesting to my biomedical orientation, I am placing myself

in that group of people who I believe have a “sophisticated”

and “knowledgeable” orientation to the mentally ill. I am

placing myself in the group of doctors, biomedical

researchers, clinicians, and scientists. Note that, unlike the

spirit possession belief common in Zanzibar, the group I’m

affiliating myself with does not include the mentally ill


Aside from their objective truth or falsehood, one

meaningful way to compare cultural beliefs about mental

illness is to ask this simple question: Which cultural beliefs

tend to exclude the sufferer from the social group and which

allow the ill individual to remain part of the group?

Accounts written by patients themselves and their loved

ones make it clear just how stigmatizing the biomedical

explanation can be. Here, for example, is D. A. Granger

writing of his experiences years after being diagnosed with

schizophrenia in his first year of Harvard Medical School:

I have spent years . . . clinging to the understanding that I was a defective

biological unit. . . . This may truly be a valuable perspective for those who

observe mental illness, but for me, as a subject, this tree bore only dry and

tasteless fruit. . . .

I have a chemical imbalance; I really didn’t feel those things.

I have a chemical imbalance; I didn’t really experience those things.

I have a chemical imbalance; I didn’t really think those things . . .

Here is an insight! The entire human drama of love, suffering, ecstasy, and

joy, just chemistry.

Jay Neugeboren, writing about his schizophrenic brother,

similarly asked, “[If he] . . . doesn’t hold onto his illness and

its history as a legitimate, real and unique part of his

ongoing self—what of him, at fifty-two years old, will be


We ask people diagnosed with schizophrenia and those

who love and care for them to adopt the brain chemistry

narrative without consideration of the cost: the devaluing of

the perceptions that make up the ill individual’s very sense

of self. Indeed, as Granger suggests, the fact that healthy

people do not dwell on the “brain chemistry” story as an

explanation for their own moods and feelings should be an

indication of how unappealing and dehumanizing the idea

is. When we fall in love, get jealous, feel the joy of playing

with a child, or experience religious ecstasy we do not

describe the experience to friends as a fortunate or

unfortunate confluence of brain chemicals. Yet we continue

to suggest that the narrative of brain chemistry will be

useful in lessening the stigma associated with a mentally ill

person. What could be more stigmatizing than to reduce a

person’s perceptions and beliefs to the notion that they are

“just chemistry”? It is a narrative that often pushes the ill

individual outside the group, allowing those who remain in

the social circle to, as Mehta observed, view the ill person as

“almost a different species.”

What We Can and Can’t Learn

I asked McGruder on several occasions what we might learn

from her research on schizophrenia in Zanzibar. She offered

various possible lessons, the most obvious being a

cautionary one. Simply put, we might reconsider our

interventions in the parts of the world that appear to have

better outcomes than we can manage in the industrialized


But coming away with only that warning was unsatisfying.

It is part of my American character that I’m not much

interested in being told what not to do. Like those highly

emotionally involved caretakers, I’m interested in how to fix

the problem. I wanted a positive take-away message, some

recommendation for action or change. So I kept pestering

McGruder, trying to get her to be prescriptive. What had she

learned from her Zanzibari research that we might be able

to use in the United States to help the mentally ill?

One late afternoon, a week into my visit to Zanzibar,

McGruder and I were sitting in her small apartment in Stone

Town waiting for Kassim to get back from the final day of

mourning his daughter. McGruder was folding laundry. By

this point in the trip we had an easy rapport, although I was

feeling like a houseguest who had overstayed. I turned on

my tape recorder and again quizzed her on what we might

learn from the way the locals address and deal with serious

mental illness. Instead of answering the question on a

theoretical level, this time she told me a story.

After she and her former husband, an African American

whom I’ll call Ed, returned from her year of research in

Zanzibar they had difficulty settling back into their American

lives. McGruder was back teaching and trying to bang out

her dissertation. Their marriage was in a rough patch and

they fought about money.

Ed, McGruder told me, had been discontent since

returning from Africa. He tried out a couple of different

businesses but struggled to get them off the ground. At

some point he got hooked up with an aggressive multilevel

financial marketing group. He went to seminars that were

like revival meetings, where motivational speakers told the

attendees that they could achieve financial success by

selling the company’s life insurance and recruiting others

into the business. McGruder sensed it was a shady outfit—

their promises were too good to be true—but she deeply

wanted her husband to find success and happiness. At the

same time Ed started a janitorial business. With McGruder’s

help he bought a van and cleaning supplies and he landed

some contracts with area restaurants. “He was running full

speed, night and day,” McGruder told me. “At the same time

we were going ever further into debt because we were

throwing money at the startup costs of the businesses.”

Around this time McGruder went to a conference in

Philadelphia. While she was away she had trouble getting Ed

on the phone, which was unusual. When she landed at Sea-

Tac, he came to the airport to pick her up and they went out

to dinner. Ed didn’t say much at dinner and seemed to be in

an unusually somber mood. When they got home McGruder

came down with something like food poisoning. Looking

back, she wonders whether her body was picking up on

something her mind couldn’t yet accept.

The next morning Ed told her that he was going out. She

said she was going to stay in bed and try to get some rest.

Hours went by and he didn’t return. At one that afternoon

the police called and informed her that her husband’s car

had been abandoned on a local street with the motor

running and doors opened.

Fearing that he had been the victim of a robbery,

McGruder immediately got on the phone and called some

friends for help. After retrieving the car, she called the

hospitals and police stations, asking if there were any

reports of injured people. It was more than twenty-four

hours before they discovered that Ed had been arrested and

had spent the night in the Pierce County Jail howling

incoherently and ripping his clothes to shreds.

McGruder later pieced together the missing hours. After

abandoning the car, Ed had jogged down the middle of a

busy street. After that he switched to the railroad tracks,

walking more than ten miles to the nearby town of

Lakewood. Once there he entered someone’s backyard,

climbed into the bed of a pickup, and started throwing the

contents all over the lawn. “These are the kinds of things

people do when they have mania of psychotic proportions,”

McGruder told me. “They just don’t make any sense and

they can’t explain to you why it seemed like a good idea at

the time.”

It took a full day to find Ed in the legal system because he

had thrown away his identification and when asked his

name would only say, “They call me Mr. Edwards.”

McGruder immediately understood this. “Mr. Edwards” was

the name he was called by friends and neighbors during

their stay in Zanzibar.

Once she found him, McGruder spent the rest of the day

figuring out how to get him out on bail. After finishing the

paperwork, she was told to go home and wait for a phone

call, which she did. Late that afternoon her husband showed

up at the door. He had been released, but no one had called

her to pick him up. He had walked miles in freezing rain in

nothing but a jail-issued jumpsuit.

She put him in a warm bath, where he rocked back and

forth alternately crying and laughing. She tried to calm him

and get him to sleep but he was restless and confused. She

stayed up with him as late as she could but finally fell

asleep herself. She woke to find Ed on a rampage. He had

pulled out several saplings in the backyard and was in the

middle of knocking everything off shelves in the kitchen and

living room.

She called friends to come over and help calm Ed down

and keep him from tearing apart the rest of the house. They

tried to convince him that he needed to see a doctor, but he

didn’t seem to comprehend what they were saying. At times

he would go blank; at other times he would howl and make

animal noises. Finally the friends distracted Ed while

McGruder called for help.

Having taught many classes on mental health and the

law, McGruder believed she knew the system she was

entering. She understood, for instance, that in order for Ed

to be put in the hospital against his will she had to attest

that he posed a danger to people or property. That part of

the process turned out to be easy, and Ed was admitted into

Puget Sound Hospital. Knowing what to say to get him out

proved to be the hard part.

The next day McGruder went to the hospital. It was a

rundown place. (It would soon be shut down by the Health

Department for multiple violations, including chronic

overcrowding, sexual assault in the mental wards, and dead

bugs and mouse droppings in a supposedly sterile supply

room.) Like many acute psychotic manias, Ed’s suddenly

ebbed. He was now calm and spoke rationally, telling

McGruder that he was afraid to stay in the hospital. He said

he was ready to go home and start seeing a doctor for his

illness. McGruder was certain he had a better chance of

regaining his balance if she could manage his behavior

outside the hospital. She thought, “Okay, let’s get him out of

this place.”

But the system she had triggered was not ready to let him

go. Over the next two weeks she struggled with doctors,

lawyers, and judges. The first doctor she met with wanted to

start Ed on five different psychiatric medications at once.

McGruder knew that he could be helped by medication but

argued for a more conservative approach. She was

particularly put off by the judge at the commitment hearing,

who appeared to be making assumptions based on Ed’s

race. “Has a toxicology screen been done on this man?” he

asked repeatedly, even though there was no indication that

the mania had been drug-induced.

Her reaction to the crisis couldn’t have been more distinct

from Amina’s passive acceptance. McGruder was a

passionate advocate for her husband at every turn. She

could tell that she annoyed many of the doctors, lawyers,

nurses, and clerks she interacted with. “They treated me

like a nuisance for the most part,” she remembers. “They

treated me like I was emotionally overinvolved.”

In the end, the insights she had gained while studying

mental illness in Zanzibar were of little help. She was back

in her own culture, and many of the Zanzibari beliefs and

practices she had witnessed and so carefully documented

simply didn’t apply. This was true down to the level of

simple logistics. McGruder and her husband lived alone and

had no close kinship groups on which they could rely. They

had devoted friends, but those friends all had jobs and other

commitments and most lived dozens of miles away; they

couldn’t be counted on to care for or watch over Ed for

significant periods of time. McGruder and her husband were,

for the most part, alone with their burden.

McGruder did try one gambit. Ed had once been a

religious man, and he began to believe that his psychotic

break might have been part of God’s plan. Perhaps, he

suggested, God had caused the psychotic break because He

wanted McGruder to better understand mental illness. “I

thought that that was a little egocentric to believe that God

up in heaven decided, ‘She needs a little more insight,’”

McGruder recalled. “But I said okay, if Ed thinks it’s helpful

for us to consider this possibility, I’m cool with that. That is

useful. My experience in Zanzibar helped me avoid saying

‘That’s a crock of shit.’”

She offered to start going to church with Ed, but the

religious narrative she tried to help create was an

ineffective balm. Religion is a difficult palliative to employ

on an as-needed basis. It either exists in one’s life and

surrounding culture, shaping one’s conception of the self, or

it does not. For Amina and her family, religion and spiritual

belief permeated their lives in the same way the Koranic

chants of the schoolchildren washed over their household.

McGruder and her husband had no such ambient, pervasive

faith to rely on, and, not surprisingly, the Christian beliefs

McGruder and her husband belatedly tried to adopt proved

to be of little comfort.

Try as she might, McGruder couldn’t mimic the calm

acquiescence Amina managed. Instead she found herself

constantly monitoring Ed’s behavior for signs of his mental

illness. When he left the cap off the toothpaste, she found

herself wondering, “Is he unable to put the cap back on

because his mind is running too fast?” She began to

reconsider their whole life together. She second-guessed her

fond memories from their first years of dating. Had he been

so charming and fun to be with because he was prone to

mania? In the end the marriage failed under the pressure of

Ed’s illness. “Once you start looking at a loved one through

the lens of a Western psychiatric diagnosis,” McGruder said,

“it is really hard to stop.”

When McGruder finished telling me this story she was

sitting on the daybed in the living room in complete

darkness. The sun sets fast near the Equator, and the

electricity had been out on the entire island for over a week.

The air was hot and still. We sat for a time listening to the

sound of footsteps echo up from the stone alleyways

outside the apartment window.

“The Hallmark movie ending would be that I had learned

something about mental illness in Zanzibar that I was able

to use in my own time of crisis,” McGruder said. “But stories

of mental illness don’t often have Hallmark endings.”

The Transliteration

After traveling back to the United States, I kept in touch with

McGruder by email. Every so often I would ask after her

partner, Kassim, to see how he was dealing with the loss of

his daughter. McGruder admitted in this correspondence

that she herself was still trying to figure out what was going

on inside his head. Despite everything she knew about

different emotional expressions between cultures, she

couldn’t help but be concerned about his emotional flatness

in the days after his daughter’s death.

McGruder told me that a few days after the funeral she

overheard a phone call Kassim received from a relative who

had just heard about the death and wanted to travel from

mainland Tanzania to offer her condolences. McGruder

listened as he told the relative “Tumeshapao,” meaning “We

have already cooled down” or “We have healed, we are

okay.” When he hung up the phone, McGruder felt

compelled to ask him if he really had already healed. Unable

to read his outward emotions, she wanted to know whether

he felt he was still grieving. She had not witnessed him

weep over his daughter’s death.

He explained that in the phone call he was only trying to

save the relative the cost and trouble of traveling to the

island. He told McGruder that he thought of his daughter

often but was comforted by the fact that he had performed

all of the religiously required rituals after her passing. Her

body had been properly wrapped in a winding cloth and

sewn into a flexible reed mat. He had carried her to the

cemetery and had gotten down into the grave and arranged

her body so that she was lying on her side, facing Mecca.

Later, in a different conversation, he told McGruder that

since his daughter’s death he had been unaccountably

waking in the middle of the night, at about the time he got

the telephone call, and had trouble getting back to sleep.

When he finally did sleep again he was assaulted with vivid

and disturbing dreams.

McGruder wondered whether his unexpressed grief was

souring into depression. Kassim had a different explanation.

He believed he had picked up some troubling spirits while at

the graveyard burying his daughter. A few days later he

went to a Koran school and paid a small fee to have a group

of boys sing some Arabic prayers to the soul of his daughter.

The teacher at the Koran school gave him a transliteration

of the prayers so that he could pronounce the Arabic words

in Kiswahili. After that, every night he recited the prayer in

words he could not understand and slept soundly.


The Mega-Marketing of Depression

in Japan

One of the chilling things about these events, whether a

puzzle or a scandal, is how a very few people in key

positions can determine the course of events and shape the

consciousness of a generation.


I went to visit Dr. Laurence Kirmayer in his book-lined office

at McGill University in Montreal because he had a

particularly good story to tell. I’d heard that a few years

ago, Kirmayer had a personal brush with the pharmaceutical

giant GlaxoSmithKline and the remarkable resources that

the company employed to create a market for their

antidepressant pill Paxil in Japan.

In person Kirmayer is the picture of a tweedy academic.

He speaks in complete paragraphs in a deep authoritative

voice. He has a large head and a broad face that is covered

nearly to the cheekbones in a thick light-gray beard. His

slightly wandering left eye suits his demeanor. If you look at

the left side of his face his expression is attentive and

focused on the conversation. If you look at the right side of

his face he appears to be looking past you into the middle

distance, as if searching for a word or pondering a thought.

In telling his story of being feted by GlaxoSmithKline,

Kirmayer likes to point out that he is unaccustomed to the

trappings of great wealth. Not that he’s doing badly. As the

director of the Division of Social and Transcultural Psychiatry

at McGill, he makes a respectable living and adds to his

income with a private psychiatric practice. As editor in chief

of the journal Transcultural Psychiatry, he is well known in

certain circles and can draw a crowd of admiring grad

students and colleagues at an anthropology or mental

health conference. But to get to those conferences he flies


It was in the fall of 2000, as he tells it, that he came to

understand just how un spectacularly rich he was. That was

when he accepted an invitation from something called the

International Consensus Group on Depression and Anxiety

to attend two all-expenses-paid conferences, the first in

Kyoto and the second a few months later on the shores of


Accepting the invitation didn’t at first seem like a difficult

decision. Although he knew that the conference was

sponsored by an educational grant from the drug maker

GlaxoSmithKline,* such industry funding wasn’t unusual for

academic conferences in the field of psychiatry. When he

checked out the list of other invitees, he recognized all the

names. It was an extremely exclusive group of highly

influential clinicians and researchers from France, the United

States, and Japan, among other countries. The topic,

“Transcultural Issues in Depression and Anxiety,” was right

up his alley. Even better, he had an eager young graduate

student named Junko Kitanaka who was in Japan finishing

her dissertation on the history of depression in the country;

such a gathering of luminaries would be a boon to her

research. In addition to those incentives, attendees would

be given the chance to publish their presentations in a

supplement of the prestigious Journal of Clinical Psychiatry.

“I wouldn’t say it was a no-brainer, but it wasn’t very hard

for me to say yes,” Kirmayer remembers. “How much

trouble could I get in?”

His first inkling that this wasn’t a run-of-the-mill academic

conference came when the airline ticket arrived in the mail.

This ticket was for a seat in the front of the plane and cost

nearly $10,000. The next hint came when one of the

conference organizers told him in no uncertain terms that

these would be closed-door meetings. His grad student,

Kitanaka, would not be allowed to attend. There would be no

uninvited colleagues and no press.

On arrival in Kyoto in early October 2000 he found the

luxury of the accommodations to be beyond anything he

had personally experienced. He was ushered into an

exclusive part of the hotel, where he was given a drink while

an attractive woman filled out the hotel forms. His room was

a palatial suite. The bath was drawn and strewn with rose

petals and dosed with frangipani oil. There was a platter on

the credenza filled with fruits so exotic that he could identify

only the mangosteens.

“This was Gordon Gekko treatment—the most deluxe

circumstances I have ever experienced in my life,” Kirmayer

says, smiling at the memory. This was how the other half

lived, he realized—or, rather, how the other .01 percent

lived. “The luxury was so far beyond anything that I could

personally afford, it was a little scary. It didn’t take me long

to think that something strange was going on here. I

wondered: What did I do to deserve this?”

Kirmayer was well aware that drug companies routinely

sponsor professional conferences and educational seminars

and that these events do double duty as marketing

seminars. It was also common knowledge that drug makers

use enticements to encourage both researchers and

practitioners to attend. A prescribing doctor might be

treated to a round of golf or a fancy dinner in exchange for

attending an hour-long seminar about the effectiveness of

some new drug. These practices are the medical equivalent

of what real estate agents do to sell vacation timeshares.

But it was clear from the start that the gatherings of the

International Consensus Group on Depression and Anxiety

were different from the normal drug company dog and pony

show, and not simply because the enticements being

offered were so dear. Once the group of academics actually

gathered in a plush conference room and began their

discussions, Kirmayer realized quickly that the

GlaxoSmithKline representatives in attendance had no

interest in touting their products to the group. Indeed there

was little mention of the company’s antidepressant drug

Paxil, which was just a few months away from hitting the

market in Japan. Instead they seemed much more interested

in hearing from the assembled group. They were there to

learn. “The focus was not on medications,” Kirmayer

remembers. “They were not trying to sell their drugs to us.

They were interested in what we knew about how cultures

shape the illness experience.”

As Kirmayer got to know them during the conference, he

realized that the drug company representatives weren’t

from the ranks of the advertising or marketing departments

or the peppy salespeople. As best he could tell, these were

highly paid private scholars who could hold their own in the

most sophisticated discussion of postcolonial theory or the

impact of globalization on the human mind. “These guys all

had PhDs and were versed in the literature,” Kirmayer said.

“They were clearly soaking up what we had to say to each

other on these topics.”

The intense interest the GlaxoSmithKline brain trust

showed in the topic of how culture shapes the illness

experience made sense given the timing of the meeting.

The class of antidepressant drugs known as selective

serotonin reuptake inhibitors (SSRIs) had become the

wonder drug of the 1990s, at least in terms of the profits

they’d garnered for the drug companies. That year alone, in

the leading regions for SSRIs, sales grew by 18 percent and

totaled over thirteen billion dollars. Most of those sales were

still in the United States, but there was wide agreement that

lucrative international markets had yet to be tapped.

Indeed it was somewhat remarkable that none of the best-

selling SSRIs had been launched in Japan. This was more

than twelve years after Prozac became available for

prescription in the United States. What caused this

uncharacteristic timidity on the part of these

pharmaceutical giants? It certainly wasn’t that the Japanese

eschewed Western drugs. To the contrary, U.S.-based

companies at the time were exporting upwards of fifty

billion dollars in medications to the country each year. It was

said that Japanese patients felt underserved if they didn’t

come away from a doctor’s visit with at least a couple of


But Eli Lilly, then the out-front world leader in the SSRI

horse race with Prozac, had decided in the early 1990s not

to pursue the Japanese market because executives in the

company believed that the Japanese people wouldn’t accept

the drug. More precisely, they wouldn’t want to accept the

disease. “The people’s attitude toward depression was very

negative,” explained a spokeswoman for Eli Lilly to the Wall

Street Journal. She was referring to the fact that the

Japanese had a fundamentally different conception of

depression than in the West, one that made it unlikely that a

significant number of people in Japan would want to take a

drug associated with the disease.

Most other SSRI manufacturers followed Eli Lilly’s lead and

held off as well. Getting drugs approved in Japan was a

costly gamble. The rules at the time required that drugs

already on the market in Western countries had to be

retested in large-scale human trials using an exclusively

Japanese population. That meant years of effort and millions

of dollars spent, with the distinct possibility that the drug

might fail the trial. No company wanted to make such an

investment if no market existed for the drug.

The Japanese pharmaceutical company Meiji Seika was

the first to break from the pack, working through the decade

to run Japanese trials on the SSRI Luvox, which it had

licensed from the Swedish company Solvay. After reading

Peter Kramer’s 1993 book Listening to Prozac, Meiji’s

president, Ichiro Kitasato, sensed an unexplored opportunity

in the Japanese marketplace. “People in the company said

there are too few patients in Japan,” he told a reporter in

1996. “But I looked at the U.S. and Europe and thought this

is sure to be a big market.”

GlaxoSmithKline was the next to get in the race. In the

years prior to the 2000 conference in Kyoto, the company

had spent an immense amount of money and resources

jumping through the regulatory and bureaucratic hoops to

get the green light to put Paxil on the market in the country.

Having watched Prozac dominate the American market in

the late 1980s, drug company executives knew the

advantages of early market share, and GlaxoSmithKline

didn’t want Luvox to be the only SSRI in Japan.

But both companies faced the same problem: there was

no guarantee that Japanese doctors would prescribe the

drug or that the population would be interested in taking it.

The problem was that the profession of psychiatry in Japan,

unlike in the West, seldom ministered to the walking

worried; rather they focused almost exclusively on the

severely mentally ill. Consequently, talk therapy was all but

nonexistent in the country. For the small percentage of the

population diagnosed with a debilitating mental illness, long

hospital stays were the norm. The average stay in a mental

hospital in Japan was over a year, versus just ten days in the

United States. So although there was a psychiatric term for

depression in Japan, utsubyô, what it described was a

mental illness that was as chronic and devastating as

schizophrenia. Utsubyô was the sort of illness that would

make it impossible to hold down a job or have a semblance

of a normal life. Worse yet, at least for the sales prospects

of Paxil in Japan, utsubyô was considered a rare disorder.

At the Kyoto meeting Kirmayer began to understand the

company’s intense interest in the question of how cultures

shape the illness experience. To make Paxil a hit in Japan, it

would not be enough to corner the small market of those

diagnosed with utsubyô. The objective was to influence, at

the most fundamental level, the Japanese understanding of

sadness and depression. In short, they were learning how to

market a disease.

To have the best chance of shifting the Japanese public’s

perception about the meaning of depression,

GlaxoSmithKline needed a deep and sophisticated

understanding of how those beliefs had taken shape. This

was why, Kirmayer came to realize, the company had

invited him and his colleagues and treated them like royalty.

GlaxoSmithKline needed help solving a cultural puzzle that

might be worth billions of dollars.

Judging from the records of the conference, it’s clear that

the company got its money’s worth. During the meetings

eminent scholars and researchers gave insightful

presentations on subjects ranging from the history of

psychiatry in Japan to the Japanese public’s changing

attitudes about mental illness. The prominent Japanese

psychiatrists in attendance were particularly helpful in

framing the state of the public’s current beliefs about

depression and anxiety disorders.

Osamu Tajima, a professor at the Department of Mental

Health at Kyorin University and a leading Tokyo psychiatrist,

told the assembled group of a rising public concern about

the high suicide rates in Japan. He described how dozens of

middle-aged men each year hike deep into the so-called

suicide forests in the foothills of Mt. Fuji with lengths of rope

to hang themselves. He described how service along the

Central Line Railway in Tokyo was routinely disrupted by

office workers leaping in front of commuter trains.

Tajima also gave a detailed description of how psychiatric

services were structured within the overall health care

apparatus of Japan. Services were in the midst of a critical

change, he reported. There was a burgeoning concern in the

population about mood disorders and the need for social

attention to suicide rates and depression. He also

documented how the Western definition and symptom

checklist for depression—thanks to the influence of the DSM

in the profession—was steadily gaining ground among

younger psychiatrists and doctors in Japan. “Japanese

psychiatry is undergoing a period of important change,” he

concluded, which was certainly good news for

GlaxoSmithKline. He was upbeat about the changes

heralded by the standardization of psychiatry around the

world. “Adoption of internationally standardized diagnostic

criteria and terminology in psychiatry will provide additional

advances in assessing prevalence and facilitating accurate

diagnosis.” He was also clearly impressed with the scientific

advances in drug treatments that were soon to come to his

country. “New and effective treatment options,” he said,

“most notably the SSRIs, will contribute to reducing the

burden of depression and anxiety disorders in Japanese


After lunch on the second day of the conference, it was

Kirmayer’s turn to speak. He had written many papers in his

career documenting the differing expressions of depression

around the world and the meaning hidden in those

differences. He had found that every culture has a type of

experience that is in some ways parallel to the Western

conception of depression: a mental state and set of

behaviors that relate to a loss of connectedness to others or

a decline in social status or personal motivation. But he had

also found that cultures have unique expressions,

descriptions, and understandings for these states of being.

He told the assembled scholars and drug company

representatives of how a Nigerian man might experience a

culturally distinct form of depression by describing a

peppery feeling in his head. A rural Chinese farmer might

speak only of shoulder or stomachaches. A man in India

might talk of semen loss or a sinking heart or feeling hot. A

Korean might tell you of “fire illness,” which is experienced

as a burning in the gut. Someone from Iran might talk of

tightness in the chest, and an American Indian might

describe the experience of depression as something akin to


Kirmayer had observed that cultures often differ in what

he called “explanatory models” for depression-like states.

These cultural beliefs and stories have the effect of directing

the attention of individuals to certain feelings and

symptoms and away from others. In one culture someone

feeling an inchoate distress might be prompted to search for

feelings of unease in his gut or in muscle pain; in another

place or time, a different type of symptom would be

accepted as legitimate. This interplay between the

expectations of the culture and the experience of the

individual leads to a cycle of symptom amplification. In

short, beliefs about the cause, symptomatology, and course

of an illness such as depression tended to be self-fulfilling.

Explanatory models created the culturally expected

experience of the disease in the mind of the sufferer. Such

differences, Kirmayer warned the group, tended to be

overlooked when clinicians or researchers employed the

symptom checklists relating to the DSM diagnosis of


Understanding these differences is critical, however,

because culturally distinct symptoms often hold precious

clues about the causes of the distress. The American Indian

symptom of feeling lonely, for instance, likely reflects a

sense of social marginalization. A Korean who feels the

epigastric pain of fire illness is expressing distress over an

interpersonal conflict or a collective experience of injustice.

The wide variety of symptoms wasn’t the only difference.

Critically, not everyone in the world agreed that thinking of

such experiences as an illness made sense. Kirmayer

documented how feelings and symptoms that an American

doctor might categorize as depression are often viewed in

other cultures as something of a “moral compass,”

prompting both the individual and the group to search for

the source of the social, spiritual, or moral discord. By

applying a one-size-fits-all notion of depression around the

world, Kirmayer argued, we run the risk of obscuring the

social meaning and response the experience might be


Indeed, around the world, it is the Western conception of

depression, in particular the American version of the

disease, that is the most culturally distinctive. Kirmayer told

the group that Americans are unique both in being willing to

openly express distressful emotions and feelings to

strangers and in our penchant for viewing psychological

suffering as a health care issue. Because people in other

cultures find social and moral meaning in such internal

distress, they often seek relief exclusively from family

members or community elders or local spiritual leaders. The

idea of seeking help from a doctor or mental health

professional outside one’s social circle has traditionally

made little sense.

The drug company representatives listened closely to

Kirmayer’s presentation and thanked him heartily afterward.

To this day, he’s not entirely sure what they took away from

his presentation. In the end Kirmayer’s comments could

have been taken in two ways. On the one hand, they could

be seen as a warning to respect and protect the cultural

diversity of human suffering. In this way, he was like a

botanist presenting a lecture to a lumber company on the

complex ecology of the forest. On the other hand, he might

have told the GlaxoSmithKline representatives exactly what

they wanted to hear: that cultural conceptions surrounding

illnesses such as depression could be influenced and shifted

over time. He made that point clearly in the conclusion of

the paper he wrote based on his presentation:

The clinical presentation of depression and anxiety is a function not only of

patients’ ethnocultural backgrounds, but of the structure of the health care

system they find themselves in and the diagnostic categories and concepts

they encounter in mass media and in dialogue with family, friends and


In the globalizing world, he reported, these conceptions are

in constant transaction and transformation across boundaries of race,

culture, class, and nation. In this context, it is important to recognize that

psychiatry itself is part of an international subculture that imposes certain

categories on the world that may not fit equally well everywhere and that

never completely captures the illness experience and concerns of patients.

In other words, cultural beliefs about depression and the self

are malleable and responsive to messages that can be

exported from one culture to another. One culture can

reshape how a population in another culture categorizes a

given set of symptoms, replace their explanatory model,

and redraw the line demarcating normal behaviors and

internal states from those considered pathological.

Kirmayer’s appreciation of the irony of his brief encounter

with GlaxoSmithKline has only grown over the years since

he gave that presentation. “People like me got into cultural

psychiatry because we were interested in differences

between cultures—even treasured those differences in the

same way a biologist treasures ecological diversity,”

Kirmayer told me. “So it’s certainly ironic that cultural

psychiatrists sometimes end up being handmaidens to

these global marketing machines that are intent on

manipulating cultural differences . . . in order to capitalize

on those changes.”

I asked Kirmayer how clear it was to him that

GlaxoSmithKline was interested in changing notions of

depression in Japan. “It was very explicit. What I was

witnessing was a multinational pharmaceutical corporation

working hard to redefine narratives about mental health,”

he said. “These changes have far-reaching effects, informing

the cultural conceptions of personhood and how people

conduct their everyday lives. And this is happening on a

global scale. These companies are upending long-held

cultural beliefs about the meaning of illness and healing.”

The consensus paper produced to summarize the Kyoto

conference provided both an action plan and a marketing

piece for GlaxoSmithKline. In that paper the International

Consensus Group on Depression and Anxiety warned that

depression was vastly underestimated in Japan but that

Western scientific advances would soon be on hand to help.

“Clinical evidence supports the use of SSRIs as first-line

therapy for depression and anxiety disorders,” the paper


Looking back, Kirmayer can now see how the company

used the conference as the beginning of its broader

marketing strategy; its representatives identified the

cultural challenges and fleshed out the resonant cultural

notes the company would attempt to play in the critical

coming months and years. Among those themes were that

suicide in Japan was an indicator of undertreated

depression; that Western SSRIs represented proven

scientific advances in treatment; that primary care

physicians should use simple three-minute surveys to help

diagnose mental illness; that patients not meeting the

criteria for depression should still be considered sick; and

that the Japanese should be helped to reconceive social

stress related to work and industrialization as signs of

depression that should be treated with SSRIs. These

confident conclusions would prove the foundation on which

GlaxoSmithKline would begin to change the culture of Japan.

Psychiatry in the Time of Cholera

The rapid rise of the depression narrative in Japan, which

took place over the next few years, is remarkable in many

respects. The marketing campaign of GlaxoSmithKline and

other SSRI makers set off a seismic shift in the culture, the

aftershocks of which are still being felt. And just as

earthquakes are the expression of tectonic pressures that

build slowly over decades, there were unseen forces in the

cultural history of Japan that laid the groundwork for Glaxo-

SmithKline’s remarkable success.

To understand how GlaxoSmithKline was so successful in

selling depression in Japan at the beginning of this

millennium, it’s important to spend some time with a guide

who knows the historical lay of the land. Ironically the

person who best understands the cultural history of

depression in Japan turns out to be none other than Junko

Kitanaka, the grad student who was barred from the

conference in 2000. In the years since, she finished her

award-winning dissertation, “Society in Distress: The

Psychiatric Prod-uction of Depression in Contemporary

Japan,” and has taken up an associate professorship at Keio

University, often called “the Harvard of Japan.”

A visitor to the university will quickly notice that Keio’s

architects were intent on giving the place an Oxford–Ivy

League flavor. At the Mita campus where Kitanaka works,

campus gates are set in arches in red brick buildings and

paths run into open courtyards filled with huge ginkgo trees

that turn a luminescent yellow in the fall. As the style of the

architecture suggests, Western influence on Japanese

academia, particularly science and medicine, is hardly new.

When I asked Kitanaka how far back in time it was

necessary to go to begin tracking the Western influence on

mental health trends in Japan, she suggested that a good

starting point was the mid-nineteenth century. This was

when ideas of German neuropsychiatry and notions of

neurasthenia—the disease of frayed nerves—first began to

filter into Japanese professional and popular culture.

Cultures are most susceptible to outside ideas about the

nature of the human mind at times of social change and

upheaval, and the second half of the nineteenth century

was just such a time in Japan. The Edo era—the rule of the

shogun warlords—was at an end. For the previous 250 years

Japan had stayed relatively isolated from many cultural

trends and forces in the West, including those in science and

medicine. During the long Edo era the population of Japan

had thought of health mostly in terms of yojo, a set of

concepts imported from China sometime between the

seventh and tenth centuries. Yojo connected health with

diet, mental control, exercise, and sexual restraint. It

focused less on the control of disease or longevity and more

on issues of social health, including morality, culture, and


During this time the concept that most closely tracked

modern notions of depression would have been utsushô,

which described the stagnation of vital energy, or qi. This

stagnation or blockage could come from a combination of

emotions, social conflict, loss, or the changing physiology of

the body. Critically, however, utsushô was not thought of as

an illness. As portrayed in plays and popular books of the

time, utsushô described a nonpathological—indeed, a

respected—way of being. The person affected by utsushô

was not considered sick and did not necessarily seek a cure

for his symptoms; rather it was expected that those affected

would have to look for the social or moral meaning in their


As the rule of the shoguns was replaced with that of the

emperor, Japan began to open up to ideas from Europe and

the United States. The Japanese public’s acceptance of

psychiatry as a legitimate field of science and mental health

largely paralleled the growing influence of Western


It was the cholera epidemics, which began in 1859 and

plagued the nation for the rest of the century, that were

critical in breaking the hold of the yojo beliefs regarding

health. These deadly epidemics terrified the population.

Thousands died. The sick and those thought to be infected

were hauled away to hospitals under police guard. Whole

neighborhoods were sealed off and quarantined. According

to Kitanaka, the state used the outbreaks to justify the

creation of an imposing network of local government

controls that claimed authority from Western advances in

medicine. Improvements in sanitary conditions and public

hygiene did appear to limit the cholera epidemics, and the

success was taken as proof that European and Western

knowledge about health and illness had validity. Traditional

beliefs surrounding yojo were increasingly replaced by

newer ideas of eisei, which encouraged the population to

think of health as something that must be actively and

carefully cultivated by following scientifically approved

hygienic practices.

In choosing which Western public health models to follow,

health ministers in the Japanese government were

particularly taken with the German model, which promoted

the idea that the individual and the society were best

thought of as a single organism, each dependent on the

health of the other. As more and more Japanese doctors and

public health officials studied advances in German medical

practices, the burgeoning science of neuropsychiatry was

bound to follow. It wasn’t long before many of Japan’s most

promising psychiatrists were making pilgrimages to

Germany to find mentors among the ranks of the famous

neuropsychiatrists of the day.

Those German doctors were focusing their attention on

the severely mentally ill, especially patients with psychotic

symptoms related to schizophrenia or manic depression. For

the most part they believed that such dramatic mental

illnesses were caused by malfunctions somewhere in the

brain or nervous system and were likely the result of

inherited predispositions. Following these interests, the first

psychiatrists in Japan also focused their ministrations on

those with severe psychotic symptoms.

As the cholera epidemic introduced the Japanese public to

Western notions of medicine, Western psychiatry was

carried into public consciousness through crisis. That crisis

was the combination of rapid social changes at the end of

the nineteenth century that included urbanization, the

Industrial Revolution, and three wars within thirty years.

Government officials and social commentators expressed

increasing concern during this time over rising social

problems such as increased juvenile delinquency and the

disappearance of traditional practices and values. The

government produced reports on rising suicide rates and the

discontent of the working class. And just as Western-

oriented medical doctors consulted with government

officials to control the outbreaks of cholera, psychiatrists

gave advice on the social discontent of the time. Newly

minted psychiatrists in Japan, trained in German

neuropsychiatry, suddenly found that they had a voice in

these public debates.

In popular lectures and newspaper and magazine articles,

these psychiatrists began to introduce new ideas into the

popular culture. The people learned about hysteria in

women, mental hygiene, and antisocial personalities. Given

the uneasiness about the new realities of industrialization

and urban living, there was intense interest and debate on

these topics. One prominent intellectual wrote in the early

part of the twentieth century that the new medical

knowledge had brought to light many ailments that the

people had never heard of and that had previously gone

unnoticed. The people, he said, were now “constantly

worried over the slightest changes in their health” and had

consequently become “more vulnerable to illness.”

Japan’s First Mental Health Epidemic

Of the many ideas being imported from those Western

advances in psychiatric thinking, one in particular struck a

chord with the Japanese population. Riding on its recent

popularity in the United States and Europe, neurasthenia

was introduced to the Japanese public as an illness of


Writing in professional and popular forums, Japanese

psychiatrists and others knowledgeable about Western

illness categories carefully explained to the public that

neurasthenia (translated as shinkeisuijaku) was a disease of

the nerves. The idea that the body had nerve pathways,

often described as tiny electrical cables, was a new one for

the Japanese, but the notion quickly became conventional

wisdom. The metaphor often employed to describe this new

condition was that of electric streetcars. Just as a trolley

would fail to function if its electric cables became worn or

broken, so too could human wiring fray and malfunction

from overuse.

What made neurasthenia different from other psychiatric

illnesses studied by Japanese psychiatrists at the time was

that it was not a disorder of the severely mentally ill but of

the common man. “The rise of neurasthenia,” Kitanaka

says, “was the first instance of the broad-scale

medicalization of everyday distress in Japan.” She found

remarkable parallels between the rise of neurasthenia at the

beginning of the twentieth century and the introduction of

the Western conception of depression at the beginning of

the twenty-first.

Neurasthenia, she believes, became a compelling social

narrative in Japan because it distilled and gave a name to

the inchoate anxiety of the times. Commentators connected

the disease with all manner of troubling trends, including

increased marketplace competition, excessive studying,

smoking, drug abuse, labor inequities, rising crime rates,

and juvenile delinquency.

The excitement surrounding the diagnosis of neurasthenia

came not only from the mental health professionals of the

time but from popular culture as well. Articles, pamphlets,

and books provided guides to self-diagnosis, symptom lists,

and suggestions for which specific groups should be

considered particularly vulnerable. People were told to be on

the lookout for symptoms: insomnia, ringing in the ears, lack

of concentration, stomach pains, eye fatigue, and the

feeling that a heavy pot covered one’s head. A brisk market

in pills and potions to cure the illnesses soon sprang up.

Unlike other mental illnesses being discussed in popular

culture at the time, this one carried little social stigma.

Indeed, because neurasthenia was at first considered an

illness of the elites, the diagnosis became somewhat trendy.

An article in an intellectual magazine circa 1902 was

headlined “Neurasthenia: Operators, Writers, Government

Officials, and Students, Read This.” The assumption was

that those employed in positions requiring strenuous

intellectual labor were dangerously taxing their nerves. “The

media initially depicted it as an inevitable outcome for

people on the forefront of the process of modernization, for

whom exhausted nerves even became a mark of

distinction,” Kitanaka explains. “An unprecedented number

of cases of neurasthenia among elites, including

government officials, company executives, university

professors and artists began to be reported.”

The belief that neurasthenia was a disease of the elites

and intellectuals no doubt helped with the wide acceptance

of the illness in Japan. By the early years of the twentieth

century, however, it was not only the elites on the front

lines of cultural change who were claiming this disease of

modernity. In 1902 an article reported that fully one-third of

patients visiting hospitals for consultations were suffering

from this new disease. Large and diverse segments of the

population were also reporting or being diagnosed as having

frayed nerves. Neurasthenia was suddenly being referred to

as Japan’s “national disease.”

But although the Japanese people seemed willing to

accept, even idolize, this disease when it was only in an

elite population, they were less sanguine when large

numbers of regular citizens also invoked the diagnosis. With

tens of thousands claiming the illness, the country was

poised for a backlash.

An early sign of that change could be heard in the debate

surrounding a single suicide that caught the public’s

attention. In 1903 a young student named Misao Fujimura

carved a poem in a tree near Nikko, a popular scenic area

north of Tokyo. The message in the brief verse was that life

was “incomprehensible.” When he finished, he walked to a

local waterfall renowned for its beauty and leaped to his


Those who wrote about his suicide in the years afterward

fell into two broad categories. There were many artists and

intellectuals who saw such suicides as having great social

and philosophical meaning. Fueling the rise of the

neurasthenia diagnosis was a popular idea that some

Japanese were too pure of heart to live with the conflicts,

compromises, and demands of modern life. Misao’s suicide

was a brave act, some prominent thinkers suggested,

committed by a young man freeing himself from the mental

torture of modernity. This understanding of his actions was

in line with a long Japanese tradition of viewing suicide as

an act of personal resolve. Just as neurasthenia was

considered a mark of distinction among certain elite groups,

suicides among similar groups were often excused or even

admired as expressions of the purity of the Japanese


But as the diagnosis of neurasthenia began to rise

exponentially, some prominent doctors and officials stepped

forward to challenge the social status given individuals like

poor Misao. In a speech to psychiatrists reprinted in a 1906

issue of the Journal of Neurology, the statesman Shigenobu

Okuma took a harder line:

These days, young students talk about such stuff as the “philosophy of life”

[applause from the floor]. They confront important and profound problems

of life, are defeated, and develop neurasthenia. Those who jump off of a

waterfall or throw themselves in front of a train are weak-minded. They do

not have a strong mental constitution and develop mental illness, dying in

the end. How useless they are! Such weak-minded people would only cause

harm even if they remained alive [applause].

Prominent psychiatrists also began to question the

diagnosis. In a book on mental illness published in 1912 a

professor at Kyushu University wrote that those who

suffered from neurasthenia were “born with an inherent

weakness in the brain” and had only “half the mental

capacity of a normal person.” Not everyone who had a

mentally taxing job, other psychiatrists pointed out,

developed the disease; thus there must be something

fundamentally wrong with the affected individuals to make

them vulnerable.

Psychiatrists began to offer up new categories and

formulations. They began to talk of the difference between

the few who had “true neurasthenia” and a larger number

of people who were burdened with a type of nervous

disposition. This sort of disposition was not caused by the

overwork and mental stress that came with high-profile elite

jobs but came from an inherited abnormal personality that

made the sufferer incapable of withstanding the everyday

challenges of a normal life.

Looking back on the debate, it seems as if acceptance of

neurasthenia had been so successful that psychiatrists felt

obligated to restigmatize this mental disorder in hopes of

limiting its adoption. By the end of World War II the

diagnosis had almost completely gone out of style among

both psychiatrists and the population at large. A new

generation of psychiatrists wrote papers and gave

presentations dismissing neurasthenia by suggesting that

the thousands of patients who had claimed to suffer from

the illness had either been misdiagnosed by uninformed

doctors or were malingerers trying to get time off work.

The Culture of Sadness

During the early part of the twentieth century the concept of

depression remained attached to the diagnosis of severe

manic depression imported from those German

neuropsychiatrists. It wasn’t until after World War II that

depression became a disease category of its own. There was

nothing mild about this conception of depression. This so-

called endogenous depression was a crippling type of

psychosis believed to be caused by a genetic abnormality.

Professors of psychiatry at the time often explained

endogenous depression using the metaphor of an internal

alarm clock. “According to this model, the depressed person

is like someone carrying a psychotic time bomb, for whom

depression begins when the internal clock goes off and ends

after it runs its course,” Kitanaka explains. Endogenous

depression expressed itself only in individuals with that

ticking alarm clock and wasn’t connected to external


At the same time another idea was gaining ground in

Japan’s mental health community. The personality typus

melancholicus was introduced in the early 1960s by a

professor of clinical psychopathology from Heidelberg

named Hubert Tellenbach. This idea never caught on in the

United States and rather quickly became dated in Germany,

but it influenced psychiatric thinking in Japan. As Tellenbach

first described it, someone with a melancholic personality

possessed a highly developed sense of orderliness as well

as “exceptionally high demands regarding one’s own

achievements.” Typus melancholicus mirrored a particularly

respected personality style in Japan: those who were

serious, diligent, and thoughtful and expressed great

concern for the welfare of other individuals and the society

as a whole. Such people, the theory went, were prone to

feeling overwhelming sadness when cultural upheaval

disordered their lives and threatened the welfare of others.

Neither endogenous depression nor the melancholic

personality type were of great concern to the general public

at the time. Because endogenous depression was thought of

as a psychotic state, akin to schizophrenia in severity, it

carried a severe stigma and was considered rare. As for the

melancholic personality type, 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.

This absence of a category parallel with the modern

Western-style depression persisted for many years. When

the DSM-III was first translated into Japanese in 1982, the

diagnosis of depression, with its two-week threshold for low

mood, was widely criticized among Japanese psychiatrists as

far too expansive and vague to be of any use. Prominent

psychiatrists believed, in short, that the description did not

amount to a meaningful mental illness.

Indeed, as Kirmayer has pointed out, in the late twentieth

century no word in Japanese had the same connotations as

the word “depression” in English. Consider the various

words and phrases that have often been translated into

English as “depression.” Utsubyô describes a severe, rare,

and debilitating condition that usually required inpatient

care and thus was not much of a match for the common

English word “depression.” Yuutsu, which describes grief as

well as a general gloominess of the body and spirit, was in

common use. There was also ki ga fusagu, which refers to

blockages in vital energy. Similarly, ki ga meiru is the

leakage or loss of such energy. Although each of these

words and phrases had overlaps with the English word

“depression,” there were also critical differences. The

experiences these words describe do not exist only in the

thoughts and emotions but encompass full-body sadness. As

such, the Japanese person who felt yuutsu or ki ga fusagu

was likely to describe it in terms of bodily sensations, such

as having headaches or chest pains or feeling heavy in the


Not only did Japanese ideas of sadness include both the

body and the mind but, metaphorically at least, they

sometimes existed beyond the self. The experience of

yuutsu in particular contained connotations of the physical

world and the weather. A young Japanese researcher named

Junko Tanaka-Matsumi, studying at the University of Hawaii

in the mid-1970s, conducted a simple word-association test

on a group of Japanese college students and compared the

results to Caucasian American college students. The

American students were asked to respond with three words

that they connected with “depression.” The Japanese

students were asked to do the same with yuutsu.

The top ten word associations for the native Japanese


1. Rain

2. Dark

3. Worries

4. Gray

5. Suicide

6. Solitude

7. Exams

8. Depressing

9. Disease

10. Tiredness

For the Caucasian Americans, the top ten word associations


1. Sad or sadness

2. Lonely or loneliness

3. Down

4. Unhappy

5. Moody

6. Low

7. Gloom

8. Failure

9. Upset

10. Anxious

Comparing these answers, Tanaka-Matsumi saw a notable

difference. In the responses given by the Japanese natives,

only a few of the words (such as “worries” and “solitude”)

were related to internal emotional states. On the other

hand, the majority of the word associations supplied by the

American students related to internal moods. The Japanese,

in short, were looking outward to describe yuutsu, and the

Americans were looking inward to describe depression.

Tanaka-Matsumi believed that these were not simply

linguistic differences but cultural “variations in the

subjective meanings and experience of depression.”

The Japanese and Americans weren’t just talking about

depression and sadness differently, she believed; they were

feeling these states differently as well. What she saw

reflected in the language was a difference between how

Japanese and Americans conceived of the nature of the self.

The word associations suggested that Americans experience

the self as isolated within the individual mind. The Japanese,

on the other hand, conceive of a self that is less

individuated and more interconnected and dependent on

social and environmental contexts. Feelings that Americans

associate with depression have, in Japan, been wrapped up

in a variety of cultural narratives that altered their meaning

and the subjective experience for the individual.

Even as the DSM diagnosis of depression became more

widely employed around the world during the 1980s, the

experience of deep sadness and distress in Japan retained

the characteristics of the premodern conception of both

utsushô and the mid-twentieth-century idealization typus

melancholicus, the idea that overwhelming sadness was

natural, quintessentially Japanese, and, in some ways, an

enlightened state.

As Kirmayer has documented, this was a culture that often

idealized and prized states of melancholy. Feelings of

overwhelming sadness were often venerated in television

shows, movies, and popular songs. Kirmayer noted that

yuutsu and other states of melancholy and sadness have

been thought of as jibyo, that is, personal hardships that

build character. Feelings that we might pathologize as

depressive were often thought of in Japan as a source of

moral meaning and self-understanding. He and others have

connected this reverence to the Buddhist belief that

suffering is more enduring and more definitive of the human

experience than transient happiness.

Other cross-cultural scholars have also noticed this

Japanese affinity for states of sadness. Studying menopause

in Japan, McGill Social Studies of Medicine professor

Margaret Lock wrote:

Feeling sad and reacting sensitively to losses, particularly of loved ones, is

an idea that has a 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 among the living, and to reaffirm group


This cultural embrace of sadness, Lock believes, might have

been motivated by society’s discouragement of other

emotional states.

Unlike anger and irritability, which both disrupt harmony and threaten the

social order, sadness, grief, and melancholy are accepted as an inevitable

part of human life and even welcomed at times for their symbolic value, as

a reminder of the ephemeral nature of this world. An association between

melancholy and the weather reinforces sad feelings as natural and

unavoidable and hence as states not induced solely through human


Given these cultural currents, it makes sense that the first

popular psychopharmacological medications adopted in the

1960s and 1970s were sedatives, whereas amphetamines

and early mood enhancers were viewed with suspicion. As

Lock implies, culturally designated pathological states are

often the flipside of states a culture values. Along with the

sedating drugs, Japanese quickly adopted disease

categories describing social anxiety or aggression but

resisted viewing deep and extended periods of sadness as a

mental illness.

When the first SSRIs came online in the West,

consequently, Japanese considered them harsh medications

that exaggerated types of personality valued in the United

States. A leading Japanese psychopharmacologist described

how classes of drugs matched or ran afoul of different

cultural narratives: “The Japanese system is much more

modest and co-operative—people work together more.

Against this background, amphetamines are much more of a

problem than are the benzodiazepines; we are much more

sensitive to the changes, the exaggeration of behavior,

produced by the amphetamines. Sedative agents are seen

as much less of a problem in Japan. . . . There is something

of a preference for an agent that will be sedative rather than

arousing, like, perhaps, Prozac.”

“One society’s enhancement of personality can be

another’s pathology or provocation,” remarks Kirmayer.

“Something like this may occur with Prozac, where the

extraversion, gregariousness and pushiness that typify the

life of a salesman in the USA may be associated with

inappropriately brash and insensitive social behavior in


Given all these cultural forces, it is not surprising that

major drug companies at first saw no market for SSRIs in

Japan at the beginning of the 1990s. The psychiatric

category of depression was not a widespread public

concern, and the capacity to experience great sadness was

considered not a burden but a mark of strength and

distinction. That belief, combined with a suspicion of drugs

that heightened moods or extraverted personality traits,

made the market for SSRIs unpromising. Those public

perceptions, however, were soon to change.

In the Lost Decade a Young Man Joins an Ad Firm

In the spring of 1990, 24-year-old Oshima Ichiro joined the

Dentsu advertising agency, the largest company of its kind

in the world. When he first showed up at Dentsu, Oshima

was healthy and athletic. His fellow employees described

him as honest, happy, and committed. Like many unmarried

men, he lived with his mother, father, and brother. He had a

girlfriend but no immediate plans to get married;

establishing his career would come first. At Dentsu he was

assigned the daunting task of handling public relations for

more than forty corporate clients.

Because Oshima would come to symbolize a new

understanding of depression among corporate workers in

Japan, it is worth pausing to note the timing of his hiring in

relation to the trajectory of the economy of Japan.

It was on the last trading day of 1989, just three months

before Oshima started his new job, that the Japanese Nikkei

index hit an all-time high. That index had nearly quadrupled

in value over the previous five years. At the end of those go-

go days, choice apartments in the Ginza district of Tokyo

were going for nearly $100,000 per square foot. The

Japanese economy was the envy of the world. It was a time

when it seemed that any business could secure a loan and

everyone with the willingness to work hard could ride the

wave of prosperity.

But when stock traders got back to their posts at the

beginning of January 1990, something had shifted. In the

next days and weeks stocks began to slide, and then free-

fall. By the time Oshima started his job in April there was

something approaching panic in the financial markets.

As was true of many new hires, the sudden economic

downturn steeled Oshima’s resolve to prove his worth. He

showed right away that he was willing to roll up his sleeves

and dig into his considerable workload. He often spent the

first eight hours of his workday just trying to juggle

meetings and field phone calls. Staying at work after hours

was the only way he could write the press releases and

proposals his clients required. Just a few months into his job,

he was coming home past midnight on most nights. On

some mornings, when his colleagues showed up for work, it

was clear that the hard-driving Oshima had been at his desk

the entire night. He took no days off.

In November 1990 his mother and father began to worry

about his health. Oshima’s eyes looked unfocused and he

sometimes fell asleep while sitting with them at the kitchen

table. In his contract, Oshima was promised ten days of

vacation each year, and his parents suggested that he

schedule some days to rest. But he refused. He felt that any

days off would only increase the burden he would face when

he got back to work. Anyway, he told them, he didn’t think

his boss would allow him the time off. Not knowing what

else to do, his mother made him nutritious breakfasts in the

morning and drove him to the train station to ease the

burden of his hour-long commute.

After months at this sprinter’s pace, cracks began to show

in his behavior. At work small setbacks and mistakes

brought on waves of self-loathing. “I’m no good as a human

being,” coworkers sometimes heard him saying out loud to

himself. “I’m of no use.”

The New Year brought no relief from the economic bad

news or from Oshima’s burdens. From its high in 1989, the

Nikkei had lost nearly half of its value. Home prices were

plummeting just as precipitously. The normally hardworking

life in corporate Japan became even more intense. The

frustration of Dentsu executives at their declining profits

rolled down the chain of command, putting ever more

pressure on the rank and file. At one late-night drinking

binge at the office, Oshima’s boss poured beer into his own

shoe and demanded that Oshima drink it down. When he

momentarily refused the request, his boss beat him.

By the summer of that year Oshima’s workload had only

gotten worse. On top of his regular duties, he was put in

charge of a four-day conference for a client to be held in

August. If he got home at all that summer, his parents

remember, it was often simply to clean himself up before

getting back on the train to the office. On the night before

the beginning of the conference he managed to get home at

6 a.m. He was back at work less than four hours later to

drive his boss to the site of the conference.

As they drove, his boss couldn’t help but notice that

Oshima seemed troubled. He drifted and swerved erratically

from lane to lane. He mumbled incoherently, something

about being possessed by spirits.

After a grueling four days at the conference, Oshima

finally made his way back home at 6 a.m. on August 26. He

looked so drawn and haggard that he promised his brother

that he would go to the hospital that day. He called the

office at 9 a.m. to tell them that he was sick and would not

be in that day. Less than an hour later, his family found him

dead. He had hanged himself in the bathroom.

When Oshima’s parents’ lawsuit against Dentsu came to

court a few years after his death, newspaper editors and

television producers featured the story prominently. It was

an easy pick, given that the story had a clear antecedent. In

the boom years of the 1980s hardworking Japanese

businessmen sometimes collapsed and died at their desks

after putting in weeks or months of overtime. In the press

this was called karoshi, death from overwork, and reports on

the trend had become popular. In the early 1990s suicides

topped thirty thousand a year. This was between three and

four times the number of Japanese killed in car accidents.

The suicide trend became a concern to the general public

and there was much debate over who or what was

responsible. When Oshima’s suicide came to light,

journalists and editors immediately saw the story’s

potential. Headlines announced the new trend: karojisatsu,

suicide from overwork. Because the Oshima family’s lawsuit

sought to assign blame for his death, it was tailor-made to

become the focus of this public debate.

The lawyers for Oshima’s parents argued that the stress of

his job and his long hours brought on a depression that

caused his death. This form of depression was different from

the endogenous depression in the Japanese psychological

literature because it hadn’t resulted from an inherited

defect in Oshima’s brain; rather it was brought on by the

circumstances of his life. This was a type of depression that

could strike anyone.

The newspapers followed each revelation of the case.

There was, for instance, the mystery of just how many

overtime hours young Oshima worked during his time at

Dentsu. According to the time sheets he submitted to the

company, his overtime ranged between twelve and twenty

hours each week. Lawyers for the company pointed out that

that level of commitment was hardly unusual in hardworking

Japan, and it was certainly not the sort of workload that

you’d expect would drive a healthy and ambitious young

man to hang himself in the bathroom. To prove that he had

worked much longer than he claimed, the lawyers for his

parents relied on the records of the office night guards, who

were required to make frequent checks of each floor of the

building, noting the names of the employees at their desks.

Based on that evidence, it was clear that Oshima was

clocking a much more problematic average of forty-seven

overtime hours per week.

Oshima’s parents won their case. As the Dentsu lawyers

appealed the verdict through the courts they continued to

argue that the company should not be held liable because

Oshima’s depression was a result of a preexisting mental

weakness. They were, in effect, arguing for a pre–DSM-III

version of endogenous depression: Oshima wouldn’t have

become sick had he not had that alarm clock ticking inside

his brain.

The different rulings of the higher courts rather neatly

reflect a culture in the process of changing its collective

mind. The Tokyo High Court first reduced the amount of the

compensation, concluding that Oshima’s inborn mental

stamina was at least part of the cause in his death. “Not

everyone becomes depressed from being overworked or

being in a stressful situation,” the verdict read. “It cannot be

denied that his . . . premorbid personality resulted in

increasing the amount of his own work.” Here the court held

onto earlier notions prominent in Japanese psychiatry: that

inborn pathological characteristics were the psychiatric

equivalent of fate. The Supreme Court, however, rejected

that lower court’s ruling and argued that individual

character—as long as it is within a normal spectrum—should

not be considered in such a case. The ruling suggested that

anyone, put under enough stress, could succumb to


Thanks partly to the debate over Oshima’s suicide, the

shift in public opinion during this period couldn’t have been

more dramatic. “When people first heard about the

litigation, they would ask if it was the company, not the

family, that was suing for the damage caused by the

employee’s suicide,” said Kitanaka, who studied the case

closely. “When Japanese heard in the media of the plaintiff’s

victory, many came to hear, probably for the first time, that

suicide could be caused by a mental illness called


That Oshima’s lawsuit might be the first time many

Japanese connected suicide with depression is hard for a

Westerner to comprehend. Most Americans would certainly

assume that suicidal acts are nearly always caused by

mental illness, most commonly depression. Indeed the

Western SSRI manufacturers who were eyeing the Japanese

market in the 1990s routinely invoked the high suicide rate

as proof positive of an epidemic of depression in Japan.

Yet the Japanese public remained split as to whether

suicide was an intentional act with moral or philosophical

meaning or a desperate act of a mentally ill person. In many

ways the public debate regarding why Oshima hanged

himself picked up the public dialogue that took place almost

a hundred years before, when Misao Fujimura jumped off

the waterfall. Although many Japanese agreed that the high

rate of suicide was a legitimate public health concern, there

was not yet a consensus that the epidemic, or the act of

suicide itself, was the result of mental illness. In Japanese

history, literature, and movies there were many stories of

the noble suicide, such as when Samurai warriors

committed seppuku and World War II soldiers killed

themselves to avoid capture. Psychiatrist Masao Miyamoto

was not alone when he remarked in 1998 that he didn’t see

much of a connection between the rise of suicide and

depression. Most of the reasons Japanese people kill

themselves have nothing to do with depression, he argued.

“A peculiarity of the Japanese is that they often die for the

sake of the group,” he said. “They die for shame.” Wataru

Tsurumi’s Complete Manual of Suicide, published in 1993,

was the modern embodiment of the Japanese public’s

intense interest in suicide. The book, written in flat,

unemotional tones, is a guide to the ten most popular

methods of suicide, including hanging, drowning,

electrocution, and jumping from heights. The author awards

a number of skulls to rate each method in categories such

as painfulness, how much a nuisance you’ll cause others,

how much effort is required, and the likelihood of success.*

The remarkable sales of the book speak to a uniquely

Japanese fascination. During the 1990s the book sold more

than 1.2 million copies. If we can believe the author, the

book was written not for shock value but from a deeply

philosophical belief that suicide is a legitimate—and

perfectly sane—act of personal will.

The story of young Oshima and several other prominent

suicides from overwork put faces and personal stories on

the growing public concern that Japan had ignored the

mental health consequences of overwork. As was true at the

turn of the nineteenth century, the end of the twentieth

century was a disconcerting time for the people of Japan.

Shameful bankruptcies were common and divorce and

unemployment were on the rise. Just as at the end of the

Edo era a hundred years before, the public was on the hunt

to explain the distress being felt during these uncertain


The Japanese public’s impression that the country was

behind the times in addressing mental health got a boost

after the devastating earthquake in the city of Kobe in

January 1995.* The government response to the disaster

was criticized by Western mental health experts for being

lackluster on many fronts. Researchers from the United

States were soon on the scene and garnered much press

attention by suggesting that the population needed not just

food and shelter but more attention paid to their emotional

and mental health.

Several prominent Japanese psychiatrists and mental

health advocates used the authority of the visiting mental

health experts to make a broad argument that Japanese

culture discouraged talking about emotionally loaded issues.

“The comparison, quite unfavorable to Japan, was often

made to the United States, where the emphasis on

psychological issues is generally believed to be culturally

strong and given proper priority,” the anthropologist Joshua

Breslau reported. “One well-known newspaper critic noted

that his friend told him how nearly everyone in U.S. cities

has a psychological counselor.”

A critical turning point came just three months after the

Kobe quake. A TV producer named Kenichiro Takiguchi was

browsing through the English-language section of a Tokyo

bookstore and started to flip through a paperback copy of

Peter Kramer’s American best seller Listening to Prozac.

Always on the lookout for good ideas for programs, he took

the book to his bosses at Japan’s largest television network

and persuaded them to let him produce a fifty-minute

special. The message of the special was similar to the

beliefs made popular after the Kobe earthquake, namely,

that Americans were far advanced in their recognition and

treatment of emotional disorders such as depression and

anxiety. The show hit a nerve. Millions watched and more

than two thousand viewers called in afterward to praise the

network for running the program.

Japanese psychiatrists were largely taken by surprise at

this turn in public interest. Up to that point the public had

eschewed the intrusion of psychiatry into daily life. As the

small population of psychiatrists had mostly limited their

practice to the severely mentally ill, the call to address

common unhappiness and anxiety that came with bad

economic times caught them off-guard. Like many people in

the country up to that point, they had not considered

unhappiness (or divorce or suicide) a mental health issue.

They were in need of a new and compelling explanation for

what was going on. Fortunately for them, GlaxoSmithKline

and several other major psychopharmaceutical companies

were just then preparing to throw them a lifeline.

Junk Science and First World Medicine

Kalman Applbaum, a professor at the University of

Wisconsin in Milwaukee, is an anthropologist, but he doesn’t

study little-known tribes in far-off lands. His interest is closer

at hand: the rituals and practices of international

corporations. His specialty, the anthropology of the

boardroom, has led to teaching posts both in anthropology

departments and at business schools, including Harvard and

Kellogg. He is also fluent in Japanese and often consults with

companies interested in the Asian markets. When he heard

in the late 1990s that major players in the pharmaceutical

industry were attempting to introduce SSRIs to Japan, he

knew he had the topic for his next set of research papers.

At the beginning of the new millennium, Applbaum went

out of his way to visit the headquarters of GlaxoSmithKline,

Lilly, and Pfizer, the major international players who were at

various stages of trying to get their drugs into Japan. At the

time both Pfizer and Lilly were playing catch-up to

GlaxoSmithKline, which was just then launching Paxil in the

country. Although he had to sign nondisclosure agreements

promising that he wouldn’t identify the executives by name

or company affiliation, Applbaum managed to get

remarkable access to the inner workings of these

companies. Several of his former MBA students who were

then working in these firms helped make key introductions,

but in the end these executives proved more than willing to

talk. When I asked Applbaum why they were so forthcoming,

he told me it was simple: because of his business school

credentials and his extensive experience in the Japanese

market, they thought he might be able to give them some

free advice.

Applbaum discovered that the companies intent on

entering the SSRI market in Japan were not battling each

other like Coke and Pepsi for market share—or at least not

at the beginning. Instead he found wide acknowledgment

within the ranks of drug company executives that the best

way for companies to create a market was for competing

companies to join forces.

A critical player in this joint effort was the trade

organization Pharmaceutical Manufacturers of America, or

PhRMA, which functions as the national and international

lobby and public relations organization for a coalition of

major drug companies. In the late 1990s Applbaum found

PhRMA working on a number of levels in Japan to influence

what they considered to be a backward and bureaucratic

drug approval process. As one PhRMA executive based in

Chiyoda-Ku, Tokyo, told Applbaum, their job was to create “a

market based upon competitive, customer choice and a

transparent pricing structure that supports innovation.” The

lobby wanted drugs such as Paxil to be able to enter new

markets based on “global, objective, scientific standards.”

The more Applbaum talked to drug company insiders, the

more righteous frustration he found. When he visited the

offices of a leading SSRI manufacturer in November 2001,

he discovered a wellspring of anger directed at what they

perceived as Japanese resistance to pharmaceutical

progress. These executives criticized scientific standards for

clinical testing in Japan as “quite poor” and asserted that

there was no “good clinical practice” in the country. Why,

they asked Applbaum rhetorically, should their company be

forced to retest these drugs in exclusively Japanese

populations? The assumption was that the science behind

the American human trials was unassailable—certainly

better than anything the Japanese would attempt.

No doubt that annoyance at having to retest drugs was so

intense because a couple of recent large-scale human trials

of SSRIs in Japan had failed to show any positive effects.

Drugs such as Pfizer’s Zoloft, which were widely prescribed

in the United States, had at least one large-scale human

trial failure in Japan in the 1990s. Instead of considering the

meaning of such results, the drug company executives

railed at Japanese testing practices, calling them second

rate. “There is no sense of urgency about patient need in

Japan,” one executive complained to Applbaum.

The Mega-Marketing of Depression

Although drug company executives clearly would have

preferred to avoid the expensive and time-consuming

process of retesting their SSRIs in Japan, they ultimately

found a way to put those trials to good use as the first step

in their marketing campaign. The drug makers often bought

full-page ads in newspapers in the guise of recruiting test

subjects. Applbaum believes that this was one of several

savvy methods the drug companies employed to sidestep

the prohibitions in Japan on marketing prescription drugs

directly to the consumer. These advertisements, supposedly

designed only to recruit people for the trials, were well

worth the cost, as they both featured the brand name of the

drug and promoted the idea of depression as a common

ailment. One company scored even more public attention

when it recruited a well-known actress to take part in the


But getting the drug approved for market was only the

first step. Talking with these executives, it became clear to

Applbaum that they were intent on implementing a complex

and multifaceted plan to, as he put it, “alter the total

environment in which these drugs are or may be used.”

Applbaum took to calling this a “mega-marketing” campaign

—an effort to shape the very consciousness of the Japanese


The major problem GlaxoSmithKline faced was that

Japanese psychiatrists and mental health professionals still

translated the diagnosis of “depression” as utsubyô, and in

the mind of many Japanese that word retained its

association with an incurable and inborn depression of

psychotic proportions. In hopes of softening the

connotations of the word, the marketers hit upon a

metaphor that proved remarkably effective. Depression,

they repeated in advertising and promotional material, was

kokoro no kaze, like “a cold of the soul.” It is not clear who

first came up with the phrase. It is possible that it originated

from Kenichiro Takiguchi’s prime-time special on depression.

In that show, it was said that Americans took anti-

depressants the way other cultures took cold medicine.

Whatever its origin, the line kokoro no kaze appealed to

the drug marketers, as it effectively shouldered three

messages at the same time. First, it implied that utsubyô

was not the severe condition it was once thought to be and

therefore should carry no social stigma. Who would think

less of someone for having a cold? Second, it suggested

that the choice of taking a medication for depression should

be as simple and worry-free as buying a cough syrup or an

antihistamine. Third, the phrase communicated that, like

common colds, depression was ubiquitous. Everyone, after

all, from time to time suffers from a cold.

Although advertising couldn’t mention particular drugs,

companies could run spots in the guise of public service

announcements encouraging people to seek professional

help for depression. In these ads SSRI makers attempted to

distance depression further from the endogenous

depression as it was understood by Japanese psychiatrists

for most of the century. One GlaxoSmithKline television

advertisement showed an attractive young woman standing

in a green field, asking, “How long has it been? How long

has it been since you began to worry that it might be

depression?” The scene then shows a woman on an

escalator and then a middle-aged office worker staring out a

bus window. The voiceover then recommends that if you’ve

been feeling down for a month, “do not endure it. Go see a


The subtext of the ad is clear to Kitanaka. It presents

depression as “intentionally ambiguous and ill-defined,

applicable to the widest possible population and to the

widest possible range of discomforts. . . . The only feature

that distinguishes depression as a ‘disease’ from an ordinary

depressed mood seems to be the length of time (one

month) that the person has experienced these ‘symptoms.’”

Depression was so broadly defined by the marketers that

it clearly encompassed classic emotions and behaviors

formerly attributed to the melancholic personality type. The

label of depression then took on some laudable

characteristics, such as being highly sensitive to the welfare

of others and to discord within the family or group. Being

depressed in this way became a testament to one’s deeply

empathic nature.

To get these messages out to the Japanese public, the

SSRI makers employed a variety of techniques and avenues.

Company marketers quickly reproduced and widely

disseminated articles in newspapers and magazines

mentioning the rise of depression, particularly if those

pieces touted the benefits of SSRIs. The companies also

sponsored the translation of several best-selling books first

published in the United States on depression and the use of


Given all the ways that GlaxoSmithKline and the other

SSRI makers managed to make the average Japanese aware

of their drugs, the official ban on direct-to-consumer

marketing became almost meaningless. If there was any

doubt about this, one only had to look at how these

companies used the Internet. “The best way to reach

patients today is not via advertising but the Web,” one

Tokyo-based marketing manager told Applbaum. “The Web

basically circumvents [direct-to-consumer advertising] rules,

so there is no need to be concerned over these. People go to

the company website and take a quiz to see whether they

might have depression. If yes, then they go to the doctor

and ask for medication.”

The mega-marketing campaign often came in disguised

forms, such as patient advocacy groups that were actually

created by the drug companies themselves. The website, which appeared to be a coalition of depressed

patients and their advocates, was funded by

GlaxoSmithKline, although visitors to the site would have

had no clue of the connection. What they would have found

was a series of articles on depression driving home the key

points of the campaign, including the idea that it was a

common illness and that antidepressants bring the brain’s

natural chemistry back into balance.

The public interest in the new diagnosis brought a

remarkable amount of media attention. Often in back-to-

back months, the major magazines Toyo Keizai and DaCapo

ran pieces on depression and the new drugs. In 2002 a

leading Japanese business magazine ran a twenty-six-page

cover story encouraging businesspeople to seek

professional help for depression. The article rather perfectly

mirrored the key points of the SSRI makers’ mega-marketing

campaign and in many ways reflected the early conceptions

of neurasthenia a century before. The article suggested that

it was the more talented and hard-charging workers who

were the most susceptible to depression. Estimates of how

many Japanese secretly suffered from depression, which

ranged from 3 to 17 percent of the population, seemed to

increase every month.

The distress caused by the long-ailing economy also

proved to be a useful selling point. GlaxoSmithKline

promoted the idea that there was an enormous economic

cost for untreated depression, which could be counted in

lost man-hours and decreased productivity. In this way, the

lure of the drug, especially to the younger generation, was

tied to ideas about competition in the global marketplace.

One Japanese psychiatrist was quoted in a local newspaper

describing SSRIs as “drugs that can transform minus

thinking into plus thinking” and that “can help a person live

tough,” like financially successful Americans.

The SSRI makers made much of one public relations

windfall in particular. It was rumored for years (and finally

confirmed by the Imperial Household Agency) that Crown

Princess Masako suffered from depression. Soon it was

revealed that she was taking antidepressants as part of her

treatment. This was a huge boost for the profile of

depression and SSRIs in the country. Princess Masako’s

personal psychiatrist was none other than Yutaka Ono, one

of the field’s leaders that GlaxoSmithKline had feted at the

Kyoto conference in 2001.

As a marketing line, there was one problem with the

phrase kokoro no kaze: the metaphor lacked a sense of

urgency about the condition. After all, one rarely rushes to

the doctor with a cold. Worse yet, medicating a cold was

always optional, as the illness goes away rather quickly on

its own.

To counter this aspect of the metaphor, the drug

companies leveraged the population’s growing concern over

the high suicide rates. The medical anthropologist Emiko

Namihira reported that SSRI makers were funding studies to

prove the link between depression and suicide. Those

studies that showed a connection were reprinted in

pamphlet form and reported to national media outlets as

breaking news. Studies that failed to show a connection

could simply be ignored. The founder of the Mood Disorders

Association of Japan claimed in the Japan Times that “90

percent of those who commit suicide are considered to

suffer from one kind of mental illness or another, and 70

percent of suicides are attributable to depression.” Without

medical attention, the message went, this “cold of the soul”

could kill you.

When taken together, the messages advanced by

GlaxoSmith-Kline during their rollout of Paxil don’t always

make sense. Previous notions of endogenous depression

were employed only sparingly in order to evoke the

seriousness of the disorder. On the other hand, they were

happy to associate this new conception of depression with

the Japanese veneration of the melancholic personality,

even though that didn’t particularly jibe with the parallel

message that this was an illness caused by an imbalance of

serotonin. Neither did the message that overwork could

spark depression mesh with the idea that individuals should

counter such social distress by taking a medication that

changed their brain chemistry. If it was unrealistic social

demands that were the cause of distress in the population,

why should the individual be taking the pills? In the end,

however, the coherence of these various messages took

second place to their effectiveness.

Speeding the Evolution

After the Kobe earthquake in Japan there was growing

consensus in the country that the West, and the United

States in particular, had a deeper scientific understanding of

pathological emotional states such as PTSD and depression.

Responding to this insecurity, the advertisements, websites,

waiting room brochures, and other materials produced by

the drug companies played up the idea that SSRIs

represented the cutting edge of medical science. These

drugs, which were said to rebalance the natural chemicals in

the brain, would bring Japan up to date.

GlaxoSmithKline worked very hard to win over the most

prominent medical researchers and psychiatrists in the

country and keep them on message. Their inclusion at lavish

conferences such as the one Kirmayer attended was just a

taste of the incentives offered. Drug companies offered

grants to sponsor research on their drugs; those researchers

who produced results favorable to the drugs found

themselves with new offers of research funding. Research

that showed the drug in question to be both safe and

effective was trumpeted by the company and the

researchers often paid as consultants. In addition,

researchers were given honoraria for speaking about their

findings at drug company–sponsored professional

conferences. Influence over the prominent scientists and

researchers in Japan was so pervasive that Applbaum

concluded that these scientists and doctors had been

basically “commandeered into a kind of market research by

pharmaceutical companies. The research simultaneously

serves as publicity for the essentially predetermined

consumer need.”

It is important to note that the drug company executives

whom Applbaum interviewed didn’t present themselves as

people driven only by profits. Rather these men and women

saw themselves as acting with the best of intentions,

motivated by the belief that their drugs represented the

proud march of scientific progress across the world. They

styled themselves as people fighting depression, anxiety,

and social phobia—diseases that remained cruelly untreated

in Japan and elsewhere. Applbaum could see that this

mixture of moral certainty and the lure of billions of dollars

in potential profits was a potent force.

“These executives seemed to believe that they are

straightforwardly trying to heal the world,” said Applbaum.

When he was meeting them in 2000 and 2001 he had no

reason to doubt these self-assessments. “They seemed to

believe their products were effective and they were baffled

that anyone should question their value. The

pharmaceutical industry, more than other industries, can

link its marketing activities to ethical objectives. The result

is a marriage of the profit-seeking scheme in which disease

is regarded as ‘an opportunity’ to the ethical view that

mankind’s health hangs in the balance. This helps even the

most aggressive marketers trust that they are performing a

public service.”

Bolstering their certainty was their faith in the science

behind these drugs. The fact that these SSRIs had proven

clinically effective made it morally imperative that they be

introduced into other cultures. The drug companies were

replacing what one executive referred to as “junk science”

in Japan with “first world medicine.”

During his talks with the executives, consultants, and

marketers for the drug companies, Applbaum heard a

repeated theme. These men and women kept talking about

different cultures as if they were at different stages of a

predetermined evolution. The American market, with its the

brand recognition, high rates of prescriptions (by specialists

and nonspecialists alike), and free market pricing, was seen

as the most modern and advanced of markets. Japan was

fifteen years behind the United States, executives would

say. Or China was five years behind Japan. The lucrative U.S.

market, Applbaum could see, was the standard against

which all others were measured. We were the most

“evolved” culture and, as one executive said to Applbaum,

their job was to “speed the evolution along,” that is, to

move other countries along the path to be like us.

This talk of evolutionary process wasn’t idle chatter, for it

was often the same executives and marketing specialists

who went from country to country waiting for the right

moment to make their push. “Pharmaceutical manufacturers

. . . circulate internal instructional materials regarding

experiences with the same product in what they consider

similar markets,” Applbaum said. “Managers fly about the

world to training conferences where such archetypes are

hardened. And old advertisements and communications

strategies from the earlier stage of more ‘advanced’

markets are imported.” With each new implementation of

the mega-marketing campaign, these drug companies

learned new maneuvers and strategies. They got better at

helping along the evolution.

The reasons these executives were so open about this

endeavor goes back to their shared belief that the evolution

in question was toward higher quality science. Westerners

may have lost their sense of moral authority in many areas

of human endeavor, but we can still get our blood up

defending our science. We lead the world in scientific

discovery and medical breakthroughs, so why shouldn’t the

citizens of Japan and other countries around the world have

access to the newest brand-name antidepressants? These

molecules were created using the latest advances in science

and technology. They had been reviewed by the leading

researchers at the world’s most famous universities and

found effective in studies published in the most prestigious

scientific journals. The latest antidepressants, in this moral

logic, were akin to antiretrovirals, polio vaccine, and

penicillin. Everyone in the world deserved access to the

fruits of our scientific discoveries as a human right.

It is not an argument without merit, but it depends rather

critically on the accuracy and validity of the science behind

the medical advance being touted. If the science is

overblown, skewed, or downright wrong, then the moral

certainty that fuels the charge into other cultures becomes


Blinding Them with Science

Of all the luxuries provided him during that Glaxo-sponsored

Kyoto conference in 2001, Kirmayer remembers one evening

with particular relish. On the second night of the conference

he was instructed to dress in a “smart suit” and was taken

to the Tsuruya restaurant, one of the most exclusive and

expensive restaurants in Japan. At the restaurant he was

shown the guest book, where Henry Kissinger and other

world leaders had left their compliments. During dinner a

personal geisha sat at his arm smiling and pouring his tea

and sake. After trying to make small talk with this young

woman in his limited Japanese, he turned to James Ballenger

to bring up a question that had been on his mind.

Ballenger was the head of the International Consensus

Group on Depression. For three years he and a group of

other academic researchers hosted seven meetings at

various luxury resorts and hotels around the world. At these

conferences, funded by GlaxoSmithKline, Ballenger

gathered prominent scholars and researchers to consider

the best treatments for PTSD, panic disorder, and

generalized anxiety disorder. In the end these supposedly

independent scholars, with their affiliations to some of the

world’s finest universities, recommended that SSRIs be

prescribed for all of these conditions. Tellingly, the only SSRI

mentioned by name in the Consensus Group’s summation

paper was paroxetine, aka Paxil.

Kirmayer was curious about the relationship between the

drug companies and academics like Ballenger who

published the papers recommending these drugs. Wanting

to be polite, he thanked Ballenger for the remarkable

accommodations and treatment he was receiving. Kirmayer

was, of course, in no position to take the moral high road, as

he was at that very moment enjoying the splendor and

luxury for which GlaxoSmithKline was picking up the tab.

Nevertheless he felt compelled to ask Ballenger, as nicely as

he could: Isn’t this something of a conflict of interest?

Although he can’t remember what Ballenger said word for

word, he remembers the gist.* “He told me, ‘Look, I’ve

made my peace with this a long time ago. The drug

companies are going to do this anyway—they are going to

market drugs and produce guidelines, so they can either do

it with input of good people who are knowledgeable and

scientifically sophisticated and evenhanded or not,’”

Kirmayer remembers.

“In their heart of hearts,” Kirmayer said, “I think

academics who have consulted with drug companies think

that they are doing good and that they deserve the

consulting fees and perks.” In short, no one seemed to be

losing any sleep over the ethics of such a luxurious meeting

being sponsored by a drug company. No doubt the thread

count in the sheets helped in this regard.

At the time Ballenger’s response did not seem

unreasonable to Kirmayer. This was before it was revealed

that many of the most influential studies on SSRIs,

supposedly written by prominent academics, were in fact

ghostwritten by private firms hired by drug companies. This

was before it was widely known that many academics had

taken hundreds of thousands of dollars (sometimes millions)

in consulting and speaking fees while at the same time

helping to hide or disguise negative data on the very drugs

they were supposedly evaluating.

It has been only in the past few years, in fact, that these

issues have become a public scandal prompting ongoing

litigation and an investigation in the U.S. Senate. Many

drugs and companies have been implicated in this recent

upheaval, but one company and one drug have been at the

very heart of the scandal: GlaxoSmithKline and Paxil.

Under even the mildest scrutiny, the confident marketing

messages proclaiming the scientific validity of SSRIs begin

to break down. Take for instance the idea, often repeated in

the ads and promotional material surrounding the launch of

SSRIs in Japan, that a depletion of serotonin is the root

cause of depression and that SSRIs reestablish the

“balance” of the “natural” chemicals in the brain.

Pharmaceutical companies have been repeating this idea

ever since SSRIs came on the market twenty years ago. On

their website the makers of the SSRI Lexapro are still telling

the story: “The naturally occurring chemical serotonin is

sent from one nerve cell to the next. . . . In people with

depression and anxiety, there is an imbalance of serotonin—

too much serotonin is reabsorbed by the first nerve cell, so

the next cell does not have enough; as in a conversation,

one person might do all the talking and the other person

does not get to comment, leading to a communication


Here’s how GlaxoSmithKline describes the same idea on

its website advertising Paxil CR: “Normally, a chemical

neurotransmitter in your brain, called serotonin, helps send

messages from one brain cell to another. This is how the

cells in your brain communicate. Serotonin works to keep

the messages moving smoothly. However, if serotonin levels

become unbalanced, communication may become disrupted

and lead to depression. . . . Paxil CR helps maintain a

balance of serotonin levels.”

As often repeated as this story is, it turns out that there is

currently no scientific consensus that depression is linked to

serotonin deficiency or that SSRIs restore the brain’s normal

“balance” of this neurotransmitter. The idea that depression

is due to deficits of serotonin was first proposed by George

Ashcroft in the 1950s, when he thought he detected low

levels in the brains of suicide victims and in the spinal fluid

of depressed patients. Later studies, however, performed

with more sensitive equipment and measures, showed no

lower levels of serotonin in these populations. By 1970

Ashcroft had publicly given up on the serotonin-depression

connections. To date, no lower levels of serotonin or

“imbalance” of the neurotransmitter have been

demonstrated in depressed patients. The American

Psychiatric Press Textbook of Clinical Psychiatry states

simply, “Additional experience has not confirmed the

monoamine [of which serotonin is a subgroup] depletion


SSRIs don’t bring a patient’s brain chemistry back into

balance, but rather broadly alter brain chemistry. Although

that change may sometimes help a depressed patient, the

idea that SSRIs restore a natural balance of serotonin is a

theory without evidence. Put another way, this idea is more

of a culturally shared story than a scientific fact, in the exact

same way neurasthenia’s invocation of “frayed nerves” was

a story.

What made this story so popular was that it turned out to

be an effective marketing line, first employed in the United

States and Europe and then around the world. SSRIs came

on the heels of the public scandal about the overprescribing

of benzodiazepines. These drugs, including Valium and

Librium, were initially embraced by the medical

establishment until they were revealed to be highly

addictive. As SSRIs came to market, the public was

understandably wary of psychopharmacological agents. The

story that SSRIs only helped balance natural chemicals in

the brain, therefore, was just what the public needed to

hear. This marketing line was useful in a similar way in

Japan, where many considered Western psychiatric

medicines to be harsh and unnatural.

In the end, to judge the value of a drug, its benefits must

be considered in light of its risks. Unfortunately, in judging

the benefit-risk balance of SSRIs one immediately runs into

an even more complicated and thorny question: To what

extent can the Western scientific literature describing the

risks and benefits of these drugs be trusted? What worries

many researchers is that the makers of pharmaceutical

drugs such as SSRIs have gained remarkable control over

the creation and presentation of the scientific data that

purport to show that these drugs are safe and effective.

No man has fought harder to expose the process by which

pharmaceutical makers control the knowledge pipeline

behind their drugs than David Healy, a psychiatrist in the

North Wales Department of Psychological Medicine and a

professor at the University of Cardiff. Healy’s particular

crusade is not against SSRIs or the use of any drug in

particular, but for the full and unbiased accounting of the

data.* Because GlaxoSmithKline and other drug companies

have control over the creation of the science, Healy argues,

“there is almost no possibility of discrepant data emerging

to trigger a thought that might be unwelcome to the

marketing department of a pharmaceutical company.”

This skewing and shaping of the data becomes more

confounding as the information gets transmitted across

cultures and languages by the marketers intent on selling

the medication.

According to Healy, drug companies first started

ghostwriting scientific papers for university researchers in

the 1950s. Back then it was seen as a marginally

disreputable practice, and these papers usually appeared

only in obscure journals with little prestige or influence. But

by the 1970s the drug companies had taken control of

funding the major randomized control studies, and by the

mid-1990s, Healy estimates, over half of the studies in the

most prestigious journals were being drafted not by the

university researchers supposedly heading the studies but

by medical writing companies paid by the drug companies.

Once this became an accepted practice, the drug

companies found that they not only had control over what

information made it into print but they also had remarkable

power over which university researchers rose to become

stars in their field. “In effect,” writes Nassir Ghaemi, director

of the Mood Disorders and Psychopharmacology Programs

at Tufts Medical Center, “ghost authorship is the steroid

problem of academia; some of our experts get their fame

artificially, their achievements appearing greater than they

really are.” Those who take the high ground and refuse to

be part of this process run the risk of falling behind their

colleagues who are, so to speak, on the juice.

In the scientific and public discussion that surrounds these

drugs, it is usually only the published results that influence

opinion. Unfortunately, negative results almost never see

print and therefore rarely become part of the debate. A

recent review of seventy-four studies of antidepressants

found that nearly all (thirty-seven out of thirty-eight) of the

positive studies were published in professional journals. Of

the thirty-six negative studies, only three managed to make

it to print. The other thirty-three negative studies either

went unpublished or were reported in a form that claimed a

positive outcome different from the one the study intended

to examine.*

When the raw data from the published and unpublished

studies are examined together, the SSRIs begin to look

nothing like the miracle drug being promoted in Japan and

elsewhere. An analysis of the clinical trial data submitted to

the U.S. Food and Drug Administration shows that about five

out of ten test subjects given an SSRI improve over a couple

of weeks on the depression rating scale. This at first seems

like a fantastic outcome, until one considers the placebo

group, those people in the trial who were given a sugar pill.

On average, four out of ten patients taking a fake pill

improve. Indeed, in many of the unpublished studies, SSRIs

have failed to outperform placebos.

This means that only one in ten test subjects shows a

positive response that can be attributed to the effect of the

SSRI. This is hardly impressive, especially when one

considers the fact that “improvement” doesn’t mean that

the depression goes away but often only indicates a change

on a symptom rating scale. A person who is still depressed

but sleeping better, for instance, might be seen as

improved. Indeed with enough test subjects, even minor

changes in one or two of the checklist items can appear to

be significant.

This rather anemic level of effectiveness would certainly

surprise many Japanese who have been subject to the

mega-marketing campaign promoting SSRIs as a cure for

depression. Negative data get weeded out or spun, while

even small beneficial results zoom through the supposedly

scientific gatekeepers (the academics “authoring” the

studies and the journal editors) to the salespeople, the

marketers, and the public relations firms and out of the

mouths of credulous journalists. Each stage of the process

by which this information is manufactured distances the

doctor and the depressed patient from the actual benefits

and risks of the drug. When this information pipeline crosses

cultural boundaries under the auspices of a mega-marketing

campaign funded by the drug maker, the relation between

the consumer’s perception of the product and the science

behind the drug becomes all but illusory.

In judging just how honest drug companies are being with

the data, one example stands out. In July 2001, just as

GlaxoSmithKline’s marketing campaign in Japan was

ramping up, a paper titled “Efficacy of Paroxetine [Paxil] in

the Treatment of Adolescent Major Depression: A

Randomized, Controlled Trial” was published in the Journal

of the American Academy of Child and Adolescent

Psychiatry, the most influential journal in the field. Among

the half dozen authors were many prominent names,

including lead author Dr. Martin Keller, the chairman of

psychiatry at Brown University. The study had been

conducted between 1994 and 1997 and included almost

three hundred depressed adolescents. It was a double-blind

study—the gold standard—meaning that neither the patient

nor the doctor giving the pills knew which of the subjects

were getting the drug being tested rather than the placebo.

In the paper the authors gave their hearty approval, writing

that Paxil was “generally well tolerated and effective for

major depression in adolescents.”

Within a month of the publication of the study, the

company sales reps were alerted to the good news. A memo

dated August 2001 from Paxil Product Management to “all

sales representatives selling Paxil” trumpeted “this ‘cutting

edge,’ landmark study” as having “demonstrated remarkable

Efficacy and Safety in the treatment of adolescent


Internal company documents that have come to light

through lawsuits and government investigations report

remarkably different results. Those internal memos suggest

that the study had in fact failed to show a significant

difference between Paxil and the placebo on any of the

eight measures the study had set out to use. A company

memo reported that the results had proven “insufficiently

robust” and recommended that the company “effectively

manage the dissemination of these data in order to

minimize any potential commercial impact.” The memo

went on: “It would be commercially unacceptable to include

a statement that efficacy had not been demonstrated, as

this would undermine the profile of paroxetine (aka Paxil).”

Needless to say, this in-house assessment by

GlaxoSmithKline staff stands in remarkable contrast to the

published conclusion that Paxil was “well tolerated and

effective for major depression in adolescents.” But more

disturbing still is that the published study apparently

downplayed or hid the drug’s side effects. Early drafts of the

study, which came to light during lawsuits, show that

serious side effects (including hospitalizations and suicide

attempts) were more than five times more likely in the teens

taking Paxil than in those taking the placebo. In addition,

severe and often incapacitating problems with the nervous

system were four times more likely for those on the drug.

Nevertheless, in the first version of the study submitted for

publication there was no mention of any serious adverse

side effects. In a subsequent version there was a sentence

suggesting that “worsening depression, emotional lability,

headache, and hostility” were possible side effects. Even

that acknowledgment was left out of the final published

version of the paper that reports the side effects as only one


So here is an example of the knowledge pipeline created

by Glaxo-SmithKline. From the company’s own internal

documents we see that the study data that entered the

pipeline showed that the effect of the drug on depression in

teens was “insufficiently robust” and that some of those

teens on the drug showed dramatic increases in

hospitalizations and suicide attempts over those given the

placebo. At the other end of the pipeline comes the

marketing claim that the study “demonstrated remarkable

Efficacy and Safety.”

The story of this study, and the problem that it highlights,

is not isolated. After two decades of working at the

esteemed New England Journal of Medicine, Dr. Marcia

Angell became convinced that the system by which these

drugs gain scientific status is broken. “It is simply no longer

possible to believe much of the clinical research that is

published, or to rely on the judgment of trusted physicians

or authoritative medical guidelines,” she wrote in 2009 in

the New York Review of Books. The problems of ghostwriting

and payments to researchers from the drug companies

have, she said, reached their most florid form in the field of

psychiatry and the studies of SSRIs.* The science behind

SSRIs used to justify their sale in other cultures has proven

to be suspect at best.

Suicides and SSRIs

The question of whether these drugs can, in some patients,

increase thoughts of suicide has become a contentious

public debate. Given that GlaxoSmithKline was leveraging

the suicide-depression connection to sell Paxil in Japan, this

question becomes even more salient. Healy estimates that

SSRI trials, when taken together, show that about one in

twenty patients become extremely agitated on these drugs.

For some, that agitation will be so disquieting that it will

spark suicidal thoughts or behavior. The likelihood is that

these drugs are ineffective in most patients, work well for a

small percentage of patients, and spark suicidal thoughts or

behaviors in another small segment. Two well-designed

studies conducted fifteen years apart both point to this

conclusion. In 1993 three researchers from the Department

of Psychiatry at Harvard concluded that antidepressants,

including the SSRI Prozac, likely lessened the chances of

suicide in some patients while raising it in others. “These

observations suggest that antidepressants may redistribute

the risk, attenuating risk in some patients who respond well,

while possibly enhancing risk in others who respond more


Fully fifteen years later another set of researchers, these

from the College of Physicians and Surgeons of Columbia

University, came to a similar but more refined conclusion.

This study looked closely at two years’ worth of patient data

and found that in adults there was no significant difference

between the group that got the drug and the group that

didn’t. In teenagers and children, however, those who took

the drug were significantly more likely than those who didn’t

to attempt suicide within four months after being started on

the drug. Looking at the data further, researchers found one

group in which the drug had a protective effect against

suicidal behavior: adult men. The redistribution of the risk,

in this case, appeared to be away from adult males and

toward teenagers and children.

In the end it is possible that both the critics of SSRIs and

their promoters might have legitimate points on the suicide

question. The agitation and aggression sometimes noted in

association with these drugs are most pronounced early in

the treatment, the very period often focused on in clinical

trials. In real-world use such negative reactions to the drug

may lessen or disappear after this early period. In addition,

attentive doctors may quickly take a patient off the drug, so

that only patients who respond well (or at least don’t spiral

into suicidal behavior) continue taking the drug. Thus it is

possible that these drugs increase suicidality in test subjects

in short-term clinical trials, as critics have contended, and

yet, when judged over years, reduce suicide in the overall


Even if it proves to be true that SSRIs reduce suicidality in

large populations, the drug companies and the researchers

who helped them distort or underreport negative data might

still be culpable. Had those early treatment risks been

accurately reported in the published research on these

drugs, doctors would have had a chance to change the way

they monitored their patients and been better prepared to

spot a patient having a bad reaction. Because suicidal

behavior has been demonstrated even in healthy subjects

(those taking the drug with no symptoms of depression),

doctors almost certainly would have second-guessed

prescribing this medication to those with only mild

symptoms of depression.

The timing of who knew what and when regarding the

risks associated with Paxil is a critical issue because Japan

was so late in adopting the drug. Was GlaxoSmithKline

hiding or downplaying side-effect risks at the same time it

was rolling out its mega-marketing campaign in Japan?

Internal company documents that surfaced in a recent

lawsuit appear to answer that question quite clearly. Data

originally submitted to the U.S. Food and Drug

Administration back in the late 1980s and early 1990s, but

never published, appear to have been presented to

intentionally hide results that test subjects on the drug had

an eightfold increase in the risk of suicidality. “It looks like

GlaxoSmithKline bamboozled the FDA,” Senator Charles

Grassley said in a speech on the floor of the Senate after he

examined the evidence. “We cannot live in a nation where

drug companies are less than candid, hide information and

attempt to mislead the FDA and the public.”

The extent to which the SSRI makers have manufactured

and systematically controlled the creation, flow, and

international distribution of the science is hard to overstate.

Take a step back and look at the system as a whole, and you

can suddenly see it in a different light, as a massive

interconnected marketing system. Applbaum, the

anthropologist who documented the SSRI invasion of Japan,

puts it this way:

Actors traditionally found outside the “distribution channel” of the market

are now incorporated into it as active proponents of exchange. Physicians,

academic opinion leaders, patient advocacy groups and other grass roots

movements, nongovernmental organizations, public health bodies, and

even ethics overseers, through one means or another, have one by one

been enlisted as vehicles in the distribution chain. . . .

In our pursuit of the near-utopian promisea of perfect health, we have,

without realizing it, given corporate marketers free rein to take control of

the true instruments of our freedom: objectivity in science, ethics and

fairness in health care, and the privilege to endow medicine with the

autonomy to fulfill its oath to work for the benefit of the sick.

Even the patient, often now referred to as the

“consumer,” has been enlisted in the distribution chain. In

marketing directly to the consumer through the Internet and

various other avenues, drug companies can claim to be

treating patients as informed consumers. Such informed

consumers can be enlisted to petition their doctors and drug

review boards for access to the drugs. This has been

heralded as a positive change: no longer is the patient a

passive recipient of the doctor’s privileged knowledge.

Unfortunately, the patients, particularly those living outside

the United States, are often the last to know that the

knowledge they are acquiring may have been manipulated

to create specific beliefs and desires.

Early Adopters Have Second Thoughts

There is no doubt that the efforts of GlaxoSmithKline in

Japan proved profitable. In just the first year on the market

Paxil sales brought in over 100 million dollars. At the end of

2002 the company reported, “Sales of Seroxat/Paxil, GSK’s

leading product for depression and anxiety disorders, was

the driver of growth in the CNS (Central Nervous System)

therapy area, with sales of 3.1 billion, up 15% globally and

18% in the USA. International Sales of Paxil Grew 27% to

$401 million led by continued strong growth in Japan, where

the product was launched only two years ago.” By 2008

sales of Paxil were over one billion dollars per year in Japan.

Kitanaka has been stunned to see how fast things have

changed in Japan since SSRIs were introduced. “The whole

culture surrounding psychiatry has changed drastically,” she

told me. “From a stigmatizing notion that no one talked

about, depression has become one of the top concerns of

people. It has become a legitimate disease at so many

different levels and at the same time these changes have

transformed the nature of depression as an experience


Some Japanese psychiatrists, even Ono and Tajima, whom

the company feted in 2000, felt they were not leading this

new trend but reacting to it. Ono reports that starting in

2001 he suddenly had a rush of patients showing up at his

office with either a magazine article or an advertisement in

hand and wanting to talk about their depression. It was

clear to him that the mild symptoms these patients

described would not previously have been considered an

illness. As more and more Japanese began to identify

themselves as depressed and as the risks of SSRIs came to

his attention, he has wondered if there were ways to reverse

the trend.

“The marketing campaign has been in many ways too

successful. The slogan, depression is like a ‘cold of the soul,’

has convinced far too many people to seek medical

treatment for something that is often not an illness,” Ono

told me. “Perhaps we could start saying that depression is

like a ‘cancer of the soul.’ That would be more accurate and

perhaps not so many people would be willing to adopt that


Dr. Tajima has come even further in his thinking. Tajima is

the prominent psychiatrist who made such encouraging

remarks in Kyoto in 2000 about the adoption of international

diagnostic standards that would “facilitate accurate

diagnosis.” At the time he welcomed the introduction of

SSRIs, saying that they would “contribute to reducing the

burden of depression and anxiety disorders in Japanese

society.” For several years after the conference, Tajima was

a central figure in the company’s attempt to win over other

psychiatrists in Japan. He was paid well by GlaxoSmithKline

to give speeches and appear at conferences. The paper

based on his talk at the Kyoto conference was widely used

in the company’s educational material.

But in the past few years he has become concerned as

he’s watched just how many of his countrymen have been

diagnosed with depression and started on Paxil. Revelations

made public by David Healy and others have caused him to

become skeptical as to whether GlaxoSmithKline has

accurately reported the scientific data regarding the drug’s

effectiveness and risks. He has taken it upon himself to

translate one of Healy’s books into Japanese and now jokes

that he is going to become “the David Healy of Japan.”

In discussing the remarkable changes that he’s seen in

Japan over the past ten years, Tajima does not come off as a

man who is angry with GlaxoSmithKline. Indeed, in

recounting his own participation in these changes, he often

laughs heartily, like a man telling the story of how he was

thoroughly fooled by a talented magician or card shark. His

laughter communicates “I have only myself to blame.”

He maintains that Paxil is helpful for some anxiety

disorders and can be used in serious cases of depression so

long as the patient is monitored closely through the early

days of treatment. However, he has come to believe that

the drug is massively overprescribed and that it can

sometimes spark suicidal thoughts in patients. “After the

Ministry of Health in Japan issued a warning of a suicide risk

with this drug for patients under twenty-five, many doctors

and patients are now aware of this risk,” says Tajima. What

he can’t understand, however, is why the drug remains so

widely prescribed for patients with depressive symptoms

that are transient and relatively mild. The warning about the

risk of suicide seemed not to have had much effect against

the forces of the mega-marketing campaign sponsored by

GlaxoSmithKline in the years since 2000.

Tajima has also come to mistrust the confident science

presented by the pharmaceutical manufacturers. Although

he is aware that the drug companies don’t take kindly to

criticism, he is committed to fighting the good fight and

getting the best information to the Japanese people any way

he can.

Did he have any hope, I asked him, of challenging the

imported ideas that helped popularize depression in Japan?

“The force of this tide is still very strong,” Tajima said. He

did point to some signs that might indicate a lessening of

the momentum. The marginal effectiveness of the drug has

not gone unnoticed. “There are so many patients in Japan

who have not improved and not recovered,” he told me.

“Many ordinary people now have questions about these so-

called magic drugs.”

As journalists often do, I saved the most uncomfortable

question for the very end of my interview with Dr. Tajima. I

told him that I did not want to pry too far into his personal

finances, but I wanted to know how he felt about the money

he had taken from GlaxoSmithKline over the years. “Yes,” he

said, laughing again. “This is a very important question.

Some people say that this relationship between the

researchers and the drug companies is a kind of

prostitution. I agree. But I am not a puritan. I am a very

realistic man. This is very problematic. We have to change

the current situation not only in Japan but also in the United

States and other countries. The strong force of the

pharmaceutical industry threatens to turn medicine into a

pseudoscience in the same way they have made opinion

leaders in the field of Japanese psychiatry into a type of


Then he paused, laughed again, and added, “We were

very cheap prostitutes.”


The Global Economic Crisis

and the Future of Mental Illness

Cultures become particularly vulnerable to new beliefs

about the mind and madness during times of social anxiety

or discord. It is no surprise that the Western form of

anorexia was able to worm its way into the unconscious

minds of young Hong Kong women in the uneasy years

between the Tiananmen Square massacre and the British

handover of the province to China. As demonstrated in Sri

Lanka, the Western notion of PTSD often gains a hold

because it is deployed in populations that are disoriented

and reeling from wars or natural disasters. It is also no

coincidence that the GlaxoSmithKline version of depression

caught hold in Japan during that country’s lengthy and

painful recession. Ongoing economic upheaval can be

particularly unsettling because the unrelenting threat to

one’s status, security, and future seems to come from

everywhere and nowhere at the same time.

In early 2009, as I was researching the chapter on

depression and Japan, the world economy went into a

tailspin. What happened to the Nikkei in 1990 appeared to

be happening to every major stock index, from the S&P 500

to the OMX Copenhagen 20. The globalization of the world

economy, which had wrought a great many disorienting

changes, had now brought us something new: a truly global

economic crisis. The social upheaval that made Japan

vulnerable to GlaxoSmithKline’s mega-marketing campaigns

was now prevalent in pretty much every country in the


As the crisis grew I listened for the first mental health

experts to step forward with warnings about the

psychological consequences of the crisis. Quick on their

heels, I was sure, would come the promise of new medicines

and perhaps even a new category of mental illness to

explain our distress.

I didn’t have to wait long.

In early February articles about the downturn’s effect on

mental health began to appear in major publications.

“Suicides: Watching for a Recession Spike” was one headline

at Time magazine. “Suicide experts say there is a strong

correlation between acute financial strains and depression,”

the article reported. Near the same time, USA Today

reported, “Signs abound that the battered economy is

causing serious damage to mental health. . . . Nearly half of

Americans said they were more stressed than a year ago,

and about one third rated their stress level as ‘extreme’ in

surveys conducted by the American Psychological


The New York Times soon had its own front-page story:

“Recession Anxiety Seeps into Everyday Lives.” Quoting

experts and individuals, the article listed over two dozen

mental health problems caused by economic worries. These

symptoms ranged from the mundane (sleeplessness,

anxiety, constant worrying) to the severe and sometimes

bizarre (struggling to breathe, rapid heartbeat, chills,

choking sensation, numbness and tingling in the fingers,

and arthritis). Such a wide-ranging list of potential

symptoms suggested that we were in the midst of creating

the symptom pool for the current economic crisis. We were

publicly debating, as a culture, which symptoms and

pathologies we would jointly recognize as legitimate

expressions of economic anxiety.

Many of these articles pointed out that our national

mental health was already poor and was now certain to get

worse. The National Institute of Mental Health announced

that one in every four Americans age 18 and older suffers

from a diagnosable mental disorder each year. Among

young adults mental illnesses had become the leading

cause of disability. There were other troubling signs: a study

came out suggesting that the mental disorders sparked by

Hurricane Katrina were proving strangely resistant to both

treatment and the healing effect of time; fully three years

after the fact, the incidence of mood disorders and PTSD

linked to the disaster was still rising in Louisiana.

To counter such bad news, Senior Vice President Ken

Johnson of the pharmaceutical advocacy group PhRMA

announced that no fewer than 301 new medicines were in

development to treat mental illnesses, including sixty-six for

depression and fifty-four for anxiety disorders. It was

important, given the worrisome trends, that the public knew

that new medications were on the way to help people “live

longer, happier, healthier lives.”*

Of course, just what types of disorders those 301 new

drugs will be tasked to treat depends largely on the

American Psychiatric Association, which will soon publish a

new edition of its influential diagnostic manual, the DSM-V.

The research journals have been filled with suggestions for

changes and additions and APA work groups are currently in

the process of hashing out which disorders will be included,

changed, or cut.

As if to demonstrate the point that the creation of mental

illness categories remains as much a social and cultural

endeavor as a scientific process, the APA is soliciting input

from the public. As of this writing there is still a “Make a

Suggestion” link on the association’s website describing the

DSM-V project. Click on that link and you are presented with

a number of options, including “Submit suggestions for

deletion of an existing disorder” and “Submit suggestions

for a new disorder to be considered for addition to DSM-V.”

All suggestions, the public is promised, will be routed to the

proper DSM-V work group for debate.

If I had to lay a bet on which new disorder recently

discussed in the psychiatric literature has the most

promising future, it would be “post-traumatic embitterment

disorder.” PTED describes the reaction to an exceptionally

negative but not life-threatening event, such as conflict in

the workplace, sudden unemployment, the loss of social

status, and separation from one’s social group. Symptoms

include embitterment, feelings of injustice, and


If PTED can get enough allies on the right DSM-V work

groups and a multinational drug company with a new drug

targeting the condition, this disorder has the chance to be

the next PTSD, for it seems well suited to describe many of

the reactions to the precipitous cultural changes during this

time of globalization and economic crisis. Indeed the

disorder was first “discovered” among East Germans who

had become unmoored, unemployed, and insecure in the

social upheaval following the fall of the Berlin Wall.

Whatever new disorders end up in the DSM-V and

whatever new drugs and treatments are declared

scientifically proven to be effective for treating them, there

is no doubt that the American public will show intense

interest. We are a psychologically oriented people. Experts

will appear on talk shows and provide quotes and

commentary for journalists. Over time these new

discoveries will become cultural certainties, conventional

wisdom. In this process these new disorders will further

shape our conscious and unconscious senses of self.

Then the Western mental health profession will take the

show on the road. At international conferences in exotic

locales professionals will train foreign healers in these new

disease categories. Drug companies lured by potential

profits will engage in ever more sophisticated mega-

marketing campaigns. In cultures made vulnerable by the

global financial crisis and the speed of social change, the

seeds of these ideas will no doubt find fertile ground.

If the irony isn’t already obvious, let me make it clear:

offering the latest Western mental health theories in an

attempt to ameliorate the psychological stress caused by

globalization is not a solution; it is a part of the problem. By

undermining both local beliefs about healing and culturally

created conceptions of the self, we are speeding along the

disorienting changes that are at the very heart of much of

the world’s mental distress. It is the psychiatric equivalent

of handing out blankets to sick natives without considering

the pathogens that hide deep in the fabric.

While I was in Zanzibar researching how Swahili beliefs were

mixing with Western biomedical notions of mental illness,

my wife, who is a psychiatrist, sent me a text message from

our home in San Francisco. The brief note told of a tough

day. A patient in her private practice had suffered a

psychotic break and had to be admitted to a psychiatric


The note reminded me of a point my wife had made often:

while I was traveling the world documenting how Western-

born cultural currents are altering beliefs about the mind,

mental health professionals in the United States and

elsewhere had little choice but to do the best they could

with the knowledge and technology they had at hand. She

worried, you see, that this book would unfairly disparage the

mental health profession, a group of people, including

herself, who are doing their best to heal troubled minds.

Keeping that concern in mind, I have tried to avoid making

the clichéd argument that other, more traditional cultures

necessarily have it right when it comes to treating mental

illness. All cultures struggle with these intractable diseases

with varying degrees of compassion and cruelty, equanimity

and fear. My point is not that they necessarily have it right—

only that they have it different.

It is not surprising that we want to believe everyone is just

like us. As with any generation in human history, we have

little awareness of how our culture shapes our mental life

because it so envelops us, informing both our conscious and

our unconscious thinking. We are like swimmers out of sight

of land: it is difficult to gauge the direction and strength of

the cultural current that carries us along. Difficult, certainly,

but not impossible. As this book suggests, deep explorations

into the beliefs of other cultures can reveal our own cultural

biases in startling ways.

So what does a cross-cultural perspective reveal about our

conception of the mind?

The ideas we export to other cultures often have at their

heart a particularly American brand of hyperintrospection

and hyperindividualism. These beliefs remain deeply

influenced by the Cartesian split between the mind and the

body, the Freudian duality between the conscious and

unconscious, as well as teeming numbers of self-help

philosophies and schools of therapy that have encouraged

us to separate the health of the individual from the health of

the group. Even the fascinating biomedical scientific

research into the workings of the brain has, on a cultural

level, further removed our understanding of the mind from

the social and natural world it navigates. On its website

advertising its antidepressant, one drug company illustrates

how far this reductive thinking has gone: “Just as a cake

recipe requires you to use flour, sugar, and baking powder

in the right amounts, your brain needs a fine chemical

balance in order to perform at its best.” The Western mind,

endlessly parsed by generations of philosophers, theorists,

and researchers, has now been reduced to a batter of

chemicals we carry around in the mixing bowl of our skulls.

What is certain is that in other places in the world, cultural

conceptions of the mind remain more intertwined with a

variety of religious and cultural beliefs as well as the

ecological and social world. They have not yet separated the

mind from the body, nor have they disconnected individual

mental health from that of the group.

With little appreciation of these differences, we continue

our efforts to convince the rest of the world to think like us.

Given the level of contentment and psychological health our

cultural beliefs about the mind have brought us, perhaps it’s

time that we rethink our generosity.



American Psychiatric Association. (1994). DSM-IV: Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition.

Hacking, I. (2002). Mad Travelers: Reflections on the Reality of Transient Mental

Illnesses. Harvard University Press.

Okasha, A. (1999). Mental Health in the Middle East: An Egyptian Perspective.

Clinical Psychology Review, 19 (8), 917–933.

Chapter 1

The Rise of Anorexia in Hong Kong

This chapter relied heavily on the work and generosity of Sing Lee and his

assistant, Jenny Ng. Lee’s willingness to arrange interviews with his patients and

his introduction to other experts in Hong Kong and elsewhere were beyond the

call of duty. I am grateful also for the honesty and openness of the patients who

spoke with me. For those interested in diving into this subject further I highly

recommend the Lee papers listed below. They are remarkably readable and

deeply philosophical contemplations on the connection between culture and

mental illness. They should some day be collected under one cover. Edward

Shorter’s historical work on anorexia, hysteria, and the nature of psychosomatic

illnesses informed both this chapter and some key ideas that play out through

the book.

Here is a list of the papers and books that also were helpful:

Aderibigbe, Y. A., & Pandurangi, A. K. (1995). The Neglect of Culture in

Psychiatric Nosology: The Case of Culture Bound Syndromes. International

Journal of Social Psychiatry, 41(4), 235.

American Psychiatric Association. (2000). DSM-IV-TR: Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition (Text Revision) (p. 943).

Andepson-Fye, E. P. (2003). Never Leave Yourself: Ethnopsychology as Mediator

of Psychological Globalization among Belizean Schoolgirls. Ethos, 31(1), 59–


Arnett, J. J. (1999). Adolescent Storm and Stress, Reconsidered. American

Psychologist, 54(5), 317–326.

———. (2002). The Psychology of Globalization. American Psychologist, 57(10),


———. (2003). Adolescence and Emerging Adulthood: A Cultural Approach.

Prentice Hall.

Baer, M. (1992). Theatre and Disorder in Late Georgian London. Clarendon Press.

Banks, C. G. (1992). “Culture” in Culture-Bound Syndromes: The Case of

Anorexia Nervosa. Social Science & Medicine, 34(8), 867.

———. (1996). “There Is No Fat in Heaven”: Religious Asceticism and the

Meaning of Anorexia Nervosa. Ethos, 24(1), 107–135.

Becker, A. E. (2004a). New Global Perspectives on Eating Disorders. Culture,

Medicine and Psychiatry, 28(4), 433–437.

———. (2004b). Television, Disordered Eating, and Young Women in Fiji:

Negotiating Body Image and Identity During Rapid Social Change. Culture,

Medicine and Psychiatry, 28(4), 533–559.

———. (2007). Culture and Eating Disorders Classification. International Journal

of Eating Disorders, 40(53), 5111–5116.

Bishop, K. (1994, December 20). KELY to Tackle Eating Disorders. South China

Morning Post.

Bordo, S. (1996). Anorexia Nervosa: Psychopathology as the Crystallization of

Culture. In A. Garry & M. Pearsall, eds., Women, Knowledge, and Reality.

Explorations in Feminist Philosophy, Routledge.

Bordo, S., & Heywood, L. (2003). Unbearable Weight: Feminism, Western

Culture, and the Body. University of California Press.

Bruch, H. (1985). Four Decades of Eating Disorders. In D. M. Gardener & P. E.

Garfinkel, eds., Handbook of Psychotherapy for Anorexia Nervosa and Bulimia

(pp. 7–18).

———. (2001). The Golden Cage: The Enigma of Anorexia Nervosa. Harvard

University Press.

Brumberg, J. J. (1988). Fasting Girls: The Emergence of Anorexia Nervosa as a

Modern Disease. Harvard University Press.

———. (2000). Fasting Girls: The History of Anorexia Nervosa. Vintage Books.

———. (1998). The Body Project: An Intimate History of American Girls. Vintage


Chan, H., & Lee, R. P. L. (1995). Hong Kong Families: At the Crossroads of

Modernism and Traditionalism. Journal of Comparative Family Studies, 26(1).

Chan, Z., & Ma, J. (2002). Anorexic Eating: Two Case Studies in Hong Kong.

Qualitative Report, 7, 1–14.

Chan, Z., & Ma. J. (2003). Anorexic Body: A Qualitative Study. Forum Qualitative

Sozialforschung/Forum: Qualitative Social Research, 4(1), Art 1.

Cheung, D. (1994, December 4). Dieting Dangers. South China Morning Post.

Cohen, G. L., & Prinstein, M. J. (2006). Peer Contagion of Aggression and Health

Risk Behavior among Adolescent Males: An Experimental Investigation of

Effects on Public Conduct and Private Attitudes. Child Development, 77(4),


Cummins, L. H., Simmons, A. M., & Zane, N. W. S. (2005). Eating Disorders in

Asian Populations: A Critique of Current Approaches to the Study of Culture,

Ethnicity, and Eating Disorders. American Journal of Orthopsychiatry, 75(4),


Dennis, C. (2004). Mental Health: Asia’s Tigers Get the Blues. Nature, 429(6993),


Dinicola, V. F. (1990). Anorexia Multiforme: Self-Starvation in Historical and

Cultural Context, Part I: Self-Starvation as a Historical Chameleon.

Transcultural Psychiatry, 27(3), 165.

Dishion, T. J., & Dodge, K. A. (2005). Peer Contagion in Interventions for Children

and Adolescents: Moving towards an Understanding of the Ecology and

Dynamics of Change. Journal of Abnormal Child Psychology, 33(3), 395–400.

Dolan, B. (1991). Cross-Cultural Aspects of Anorexia Nervosa and Bulimia: A

Review. International Journal of Eating Disorders, 10(1), 67–79.

Dresser, R. (1984). Cited in J. J. Brumberg, Fasting Girls: The History of Anorexia


Garner, D. M., & Garfinkel, P. E. (1985). Handbook of Psychotherapy for Anorexia

Nervosa and Bulimia. Guilford Press.

The Girl Who Wants to Die. (1996, November 30). South China Morning Post.

Gordon, R. A. (2000). Eating Disorders: Anatomy of a Social Epidemic. Blackwell.

Gremillion, H. (1992). Psychiatry as Social Ordering: Anorexia Nervosa, a

Paradigm. Social Science & Medicine, 35(1), 57–71.

———. (2003). Feeding Anorexia: Gender and Power at a Treatment Center. Duke

University Press.

Habermas, T. (1989). The Psychiatric History of Anorexia Nervosa and Bulimia

Nervosa: Weight Concerns and Bulimic Symptoms in Early Case Reports.

International Journal of Eating Disorders, 8(3), 351–359.

———. (1996). In Defense of Weight Phobia as the Central Organizing Motive in

Anorexia Nervosa: Historical and Cultural Arguments for a Culture-Sensitive

Psychological Conception. International Journal of Eating Disorders, 19(4),


Hermans, H. J., & Dimaggio, G. (2007). Self, Identity, and Globalization in Times

of Uncertainty: A Dialogical Analysis. Review of General Psychology, 11(1),


Higginbotham, N., & Connor, L. (1989). Professional Ideology and the

Construction of Western Psychiatry in Southeast Asia. International Journal of

Health Services: Planning, Administration, Evaluation, 19(1), 63.

Hoshmand, L. T. (2003). Moral Implications of Globalization and Identity.

American Psychologist, 58(10), 814–815.

Hsu, L. K., & Lee, S. (1993). Is Weight Phobia Always Necessary for a Diagnosis

of Anorexia Nervosa? American Journal of Psychiatry, 150(10), 1466.

Jensen, L. A. (2003). Coming of Age in a Multicultural World: Globalization and

Adolescent Cultural Identity Formation. Applied Developmental Science, 7(3),


Katzman, M. A., & Lee, S. (1997). Beyond Body Image: The Integration of

Feminist and Transcultural Theories in the Understanding of Self Starvation.

International Journal of Eating Disorders, 22(4), 385–394.

Khandelwal, S. K., Sharan, P., & Saxena, S. (1995). Eating Disorders: An Indian

Perspective. International Journal of Social Psychiatry, 41(2), 132.

Kim, U., & Park, Y. S. (2005). Integrated Analysis of Indigenous Psychologies:

Comments and Extensions of Ideas Presented by Shams, Jackson, Hwang and

Kashima. Asian Journal of Social Psychology, 8(1), 75–95.

Kleinman, A. (1999). The Moral Economy of Depression and Neurasthenia in

China: A Few Comments on Sing Lee’s “Diagnosis Postponed: Shenjing

Shuairuo and the Transformation of Psychiatry in Post-Mao China,” by Sing

Lee. Culture, Medicine and Psychiatry, 23(3), 389–392.

Lai, K. Y. C. (2000). Anorexia Nervosa in Chinese Adolescents: Does Culture Make

a Difference? Journal of Adolescence, 23(5), 561–568.

Lai, K. Y. C., Pang, A. H. T., & Wong, C. K. (1995). Case Study: Early-Onset

Anorexia Nervosa in a Chinese Boy. Journal of the American Academy of Child

and Adolescent Psychiatry, 34(3), 383–386.

Law, N. (2001, April 4). Eating Disorders Spread among Youth. South China

Morning Post.

Lee, S. (1989). Anorexia Nervosa in Hong Kong. Why Not More in Chinese?

British Journal of Psychiatry, 154(5), 683–688.

———. (1991). Anorexia Nervosa in Hong Kong: A Chinese Perspective.

Psychological Medicine, 21(3), 703–711.

———. (1991a). Anorexia Nervosa across Cultures. British Journal of Psychiatry,

158, 284–285.

———. (1991b). Eating Disorder in Asian Women. British Journal of Psychiatry,

158(1), 131b.

———. (1992). Bulimia Nervosa in Hong Kong Chinese Patients. British Journal of

Psychiatry, 161(4), 545–551.

———. (1993). Response to Sing Lee’s Review of “Transcultural Aspects of Eating

Disorders”: Reply. Transcultural Psychiatric Research Review, 30, 296.

———. (1994a). The Diagnostic Interview Schedule and Anorexia Nervosa in

Hong Kong. Archives of General Psychiatry, 51(3), 251–252.

———. (1994b). The Definition of Anorexia Nervosa. British Journal of Psychiatry,

165(6), 841.

———. (1995). Self-Starvation in Context: Towards a Culturally Sensitive

Understanding of Anorexia Nervosa. Social Science & Medicine, 41(1), 25–36.

———. (1996). Reconsidering the Status of Anorexia Nervosa as a Western

Culture-Bound Syndrome. Social Science & Medicine, 42(1), 21–34.

———. (1997). How Lay Is Lay? Chinese Students’ Perceptions of Anorexia

Nervosa in Hong Kong. Social Science & Medicine, 44(4), 491–502.

———. (1998a). Global Modernity and Eating Disorders in Asia. European Eating

Disorders Review, 6(3), 151–153.

———. (1998b). Estranged Bodies, Simulated Harmony, and Misplaced Cultures:

Neurasthenia in Contemporary Chinese Society. Psychosomatic Medicine,

60(4), 448–457.

———. (1999a). Fat, Fatigue and the Feminine: The Changing Cultural

Experience of Women in Hong Kong. Culture, Medicine and Psychiatry, 23(1),


———. (1999b). Diagnosis Postponed: Shenjing Shuairuo and the Transformation

of Psychiatry in Post-Mao China. Culture, Medicine and Psychiatry, 23(3), 349–


———. (2001a). From Diversity to Unity: The Classification of Mental Disorders in

21st-Century China. Psychiatric Clinics of North America, 24(3), 421–431.

———. (2001b). Fat Phobia in Anorexia Nervosa: Whose Obsession Is It? In M.

Nasser, M. Katzman, & R. A. Gordon, eds., Eating Disorders and Cultures in

Transitions, (pp. 40–54).

———. (2002). Socio-Cultural and Global Health Perspectives for the

Development of Future Psychiatric Diagnostic Systems. Psychopathology,

35(2–3), 152–157.

———. (2004). Engaging Culture: An Overdue Task for Eating Disorders

Research. Culture, Medicine and Psychiatry, 28(4), 617–621.

Lee, S., Chan, Y. Y. L., & Hsu, L. K. G. (2003). The Intermediate-Term Outcome of

Chinese Patients with Anorexia Nervosa in Hong Kong. American Journal of

Psychiatry, 160(5), 967–972.

Lee, S., Chan, Y. Y., Kwok, K., & Hsu, L. K. (2005). Relationship between Control

and the Intermediate Term Outcome of Anorexia Nervosa in Hong Kong.

Australian & New Zealand Journal of Psychiatry, 39(3), 141.

Lee, S., Ho, T. P., & Hsu, L. K. G. (1993). Fat Phobic and Non–Fat Phobic Anorexia

Nervosa: A Comparative Study of 70 Chinese Patients in Hong Kong.

Psychological Medicine, 23(4), 999–1017.

Lee, S., & Kleinman, A. (2007). Are Somatoform Disorders Changing with Time?

The Case of Neurasthenia in China. Psychosomatic Medicine, 69(9), 846.

Lee, S., Kwok, K., Liau, C., & Leung, T. (2002). Screening Chinese Patients with

Eating Disorders Using the Eating Attitudes Test in Hong Kong. International

Journal of Eating Disorders, 32(1), 91–97.

Lee, S., & Kwok, K. (2005). Cross-Cultural Perspectives on Anorexia Nervosa

without Fat Phobia. In C. Norring & R. Palmer, eds., EDNOS, Eating Disorders

Not Otherwise Specified: Scientific and Clinical Perspectives on the Other

Eating Disorders (p. 204), Routledge.

Lee, S., & Lee, A. M. (2000). Disordered Eating in Three Communities of China: A

Comparative Study of Female High School Students in Hong Kong, Shenzhen,

and Rural Hunan. International Journal of Eating Disorders, 27, 317–327.

Lee, S., Lee, A. M., Ngai, E., Lee, D. T. S., & Wing, Y. K. (2001). Rationales for

Food Refusal in Chinese Patients with Anorexia Nervosa. International Journal

of Eating Disorders, 29(2), 224–229.

Lee, S., Ng, K. L., Kwok, K. P. S., & Tsang, A. (2009). Prevalence and Correlates of

Social Fears in Hong Kong. Journal of Anxiety Disorders, 23(3), 327–332.

Lee, S., & Tsang, A. (2009). A Population-Based Study of Depression and Three

Kinds of Frequent Pain Conditions and Depression in Hong Kong. Pain

Medicine, 10(1), 155–163.

Lee, S., Tsang, A., Li, X., Phillips, M. R., & Kleinman, A. (2007). Attitudes toward

Suicide among Chinese People in Hong Kong. Suicide & Life-Threatening

Behavior, 37(5), 565–575.

Lee, S., Tsang, A., Zhang, M., Huang, Y., He, Y., Liu, Z., et al. (2007). Lifetime

Prevalence and Inter-Cohort Variation in DSM-IV Disorders in Metropolitan

China. Psychological Medicine, 37(1), 61–71.

Lee, S. W., Stewart, S. M., Striegel-Moore, R. H., Lee, S., Ho, S., Lee, P. W. H., et

al. (2007). Validation of the Eating Disorder Diagnostic Scale for Use with

Hong Kong Adolescents. International Journal of Eating Disorders, 40(6), 569–


Leung, S. K., & Lee, S. (1997). The Variable Presentation and Early Recognition of

Anorexia Nervosa in Hong Kong. Hong Kong Medical Journal, 3, 433–435.

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Feminism. American Studies International, 38(8).

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———. (2004). Commentary: Globalization, Culture, Body Image, and Eating

Disorders. Culture, Medicine and Psychiatry, 28(4), 597–602.

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Suffering from Anorexia Nervosa: A Case Study. Family Journal, 13(1), 19.

———. (2007). Living in Poverty: A Qualitative Inquiry of Emaciated Adolescents

and Young Women Coming from Low-Income Families in a Chinese Context.

Family Social Work, 12(2), 152–160.

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Patients Suffering from Anorexia Nervosa: Implications for Clinical Social Work

Practice. Social Work in Mental Health, 2(1), 47–70.

Ma, J. L. C., Chow, M. Y. M., Lee, S., & Lai, K. (2002). Family Meaning of Self-

Starvation: Themes Discerned in Family Treatment in Hong Kong. Journal of

Family Therapy, 24(1), 57.

Micale, M. (1993). On the “Disappearance” of Hysteria: A Study in the Clinical

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———. (1994). Approaching Hysteria: Disease and Its Interpretations. Princeton

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and Cross-Cultural Review. Psychiatry: Interpersonal & Biological Processes,

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Chapter 2

The Wave That Brought PTSD to Sri Lanka

I owe a great many debts on this chapter, and they go back many years. In

particular I’ve relied on the work of Allan Young and his trenchant book Harmony

of Illusions: Inventing Post-Traumatic Stress Disorder. Two up-and-coming

scholars were particularly giving of their time: Gaithri Fernando and Alex

Argenti-Pillen. It was through the analyses of these two researchers that I saw

the most complex and compelling picture of the mental landscape of the Sri

Lankan people. Many of my ideas about the impact of culture on conceptions of

psychological trauma came from my years chronicling the recovered memory

wars. My former coauthor, Richard Ofshe, as well as Paul McHugh, and Fred

Crews, were excellent guides in this regard.

Here is a more extensive list of the sources:

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from the Past: Venezuela Floods and Nairobi Bombing. Journal of Clinical

Psychiatry, 67, 56.

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Community for Today and Tomorrow. Journal of Clinical Psychiatry, 67 Suppl.

2, 3–8.

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from N.J. Aids Sri Lanka. The Record. (New Jersey).

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Buddhist Perspective. International Review of Psychiatry, 18(3), 281–287.

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Defining a Concept, Controversies and Guidelines for Intervention. Australian

Psychologist, 38(2), 144–150.

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Incident Stress Debriefing/Management (CISD/M). Australian Psychologist,

39(1), 35–40.

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Psychological Debriefing and Therapeutic Interventions: In the Work Place

and after Disasters. Review of General Psychology, 10(4), 318.

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Health. Reuters.

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Framework for Comparative Analysis. Culture, Medicine and Psychiatry, 8(3),


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Counseling with Caution. Press Release. University of Colombo, Sri Lanka.

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The Role of the Clinical Psychologist. Intervention: International Journal of

Mental Health, Psychosocial Work and Counselling in Areas of Armed Conflict,

2(2), 108–117.

———. (2005). Interventions for Survivors of the Tsunami Disaster: Report from

Sri Lanka. Journal of Traumatic Stress, 18(3), 267–268.

———. (2008). Assessing Mental Health and Psychosocial Status in Communities

Exposed to Traumatic Events: Sri Lanka as an Example. American Journal of

Orthopsychiatry, 78(2), 229.

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Unexplained Illness Attributed to Persian Gulf War Military Service.

Psychosomatic Medicine, 63(5), 842–849.

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Chapter 3

The Shifting Mask of Schizophrenia in Zanzibar

It perhaps goes without saying that the work of Juli McGruder has been central

to my thinking on schizophrenia. Her dissertation brought me to Zanzibar; her

hospitality when I visited her was very gracious. A small group of researchers—

Kim Hopper, Janis Hunter Jenkins, Robert John Barret, Byron Good, Sue Esteroff,

Louis Sass, and Nancy Scheper-Hughes—formed the intellectual foundation on

which McGruder built. All of these scholars, save the last, contributed to a

remarkable book of papers entitled Schizophrenia, Culture, and Subjectivity: The

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Chapter 4

The Mega-Marketing of Depression in Japan

The scholars at McGill University are overrepresented in this book because that

university is a hotbed for the study of cross-cultural psychiatry. That fact, I

believe, has much to do with Larry Kirmayer, whose work and leadership in the

field informs not just this chapter but this entire book. Junko Kitanaka,

Kirmayer’s former graduate student, was as generous as her mentor with her

time and guidance. Her book on the history of depression in Japan will be out

within a year or two, and I will be first in line at the bookstore to snap it up.

David Healy was an inspiration both for his research on the science behind SSRIs

and for his dogged courage.

Other resources include the following:

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49(3), 192.

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Antidepressants to Women. Women and Health Protection, 1–27.

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———. (2004b). Shaping the Intimate: Influences on the Experience of Everyday

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———. (2001). Cultural Variations in the Clinical Presentation of Depression and

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———. (2002). Psychopharmacology in a Globalizing World: The Use of

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———. (2005). Culture, Context and Experience in Psychiatric Diagnosis.

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———. (2006a). Beyond the “New Cross-Cultural Psychiatry”: Cultural Biology,

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Psychiatry, 43(1), 126.

———. (2006b). Culture and Psychotherapy in a Creolizing World. Transcultural

Psychiatry, 43(2), 163.

———. (2007). Psychotherapy and the Cultural Concept of the Person.

Transcultural Psychiatry, 44(2), 232.

Kirmayer, L. J., & Groleau, D. (2001). Affective Disorders in Cultural Context.

Psychiatric Clinics of North America, 24(3), 465–478.

Kirmayer, L. J., & Looper, K. J. (2006). Abnormal Illness Behaviour: Physiological,

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in Psychiatry, 19(1), 54.

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Epidemiological, and Ethnographic Perspectives. Psychosomatic Medicine, 60,


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in Contemporary Japan. PhD dissertation, Department of Anthropology, McGill


———. (2008). Diagnosing Suicides of Resolve: Psychiatric Practice in

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Kleinman, A. (2001). A Psychiatric Perspective on Global Change. Harvard

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——— (2004). Culture and Depression. New England Journal of Medicine, 351,


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———. (2007). The Right Patients for the Drug: Managing the Placebo Effect in

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the Global Health Debate. PLoS Medicine, 5(5), e106.

Olfson, M., & Marcus, S. C. (2008). A Case-Control Study of Antidepressants and

Attempted Suicide during Early Phase Treatment of Major Depressive

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Existential Suffering in Japan. Culture, Medicine and Psychiatry, 32(4), 516–


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Markets, Practices. Duke University Press.

Read, J., Haslam, N., Sayce, L., & Davies, E. (2006). Prejudice and Schizophrenia:

A Review of the “Mental Illness Is an Illness Like Any Other” Approach. Acta

Psychiatrica Scandinavica, 114(5), 303–318.

Rihmer, Z., & Akiskal, H. (2006). Do Antidepressants T(h)reat(en) Depressives?

Toward a Clinically Judicious Formulation of the Antidepressant-Suicidality

FDA Advisory in Light of Declining National Suicide Statistics from Many

Countries. Journal of Affective Disorders, 94(1–3), 3–13.

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Times Magazine.

Stotland, N. (2009, February 26). Drug Companies and Doctors: An Exchange.

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the Royal Society of Medicine, 99, 161–162.

Tajima, O., et al. (2001). Mental Health Care in Japan: Recognition and Treatment

of Depression and Anxiety Disorders. Journal of Clinical Psychiatry, Suppl.,

62(13), 39–46.

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Preoccupation during Fluoxetine Treatment. American Journal of Psychiatry.

147, 207–210.

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Challenging the Globalisation of Biomedical Psychiatry. Journal of Public

Mental Health, 4(3), 23–32.

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Drugs and Mental Health. Psychoanalytic Psychology, 18(1), 184–187.

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Course of Illness in Neurasthenia and Chronic Fatigue Syndrome.

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Medicine, 338, 1475–1476.

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E. (2004). Selective Serotonin Reuptake Inhibitors in Childhood Depression:

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Psychiatry (Vol. 4). American Psychiatric Publishing.


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York Times.

Chisholm, D., Flisher, A. J., Lund, C., Patel, V., Saxena, S., Thornicroft, G., et al.

(2007). Scale Up Services for Mental Disorders: A Call for Action. Lancet,

370(9594), 1241–1252.

More Than 300 New Medicines Being Developed for Mental Illnesses. (n.d.).

PhRMA: New Medicine, New Hope. Retrieved from


Seligman, R., & Kirmayer, L. J. (2008). Dissociative Experience and Cultural

Neuroscience: Narrative, Metaphor and Mechanism. Culture, Medicine and

Psychiatry, 32(1), 31–64.

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I had several insightful readers at critical stages of this

project. Po Bronson, Charis Conn, Rob Riddell, and my wife,

Rebecca Watters, assisted me with everything from word

choice to finding my way out of the conceptual labyrinths

that these long chapters sometimes created. Others read

portions as needed, including Alan Burdick, Laura Fraser,

Michal Story, Todd Oppenheimer, and Eleanor Wendell. I’m

indebted to my agent, Chris Calhoun, a champion for this

project from the very beginning. At Free Press I’ve been

pleased to work with Dominick Anfuso, who gave this book

his thoughtful attention during a challenging year. Leah

Miller was critically important in the creation of this book.

My thanks also go to copyeditor Judith Hoover. Michal Story

transcribed many of the interviews and gave me moral

support as well. Kasie Cheung provided Chinese translation.

Joelle Jaffe worked as my researcher on the anorexia and

schizophrenia chapters and helped me think through the

approach for the rest of the book. Encouragement from my

mother, Mary Pulliam Watters, and my brother, Aaron

Watters, was essential. This book was written at the San

Francisco Writers’ Grotto.


Adolescence and Emerging Adulthood: A Cultural Approach (Arnett), 40


SSRI use in, 239–41, 242–43

storm and stress view of, 39–41

Afghanistan, 102, 114, 121


eating disorders in, 24

schizophrenia in, 153

“After the Tsunami” (symposium), 80

Akil hastaligi, 173

Amatruda, Kate, 73–75, 93–97

American Indians, 195

American Psychiatric Association, 3, 251–52

American Psychiatric Press, 235

American Psychological Association, 250

American Studies International, 47

Amina (family caretaker), 141, 142–43, 144, 145, 148–50, 154–55, 156, 157,

160, 165, 182, 183

Amok, 2, 5

Amphetamines, 212, 213

Angell, Marcia, 241

Anorexia, 3, 6, 9–63. See also Hong Kong changing presentation of, 13, 50–53

Chinese language translation, 43

commodification of, 57–62

debate on reasons for spread, 24–26

educational programs on, 48

feedback loop in, 33, 48–49, 58

feminist perspective on, 58–59

formal recognition of, 30–31

historically low rate (Hong Kong), 14–15

historical perspective on, 26–31

increase in (Hong Kong), 48–49

increase in (nineteenth century), 31–32, 33

inverse relationship with acculturation, 25

media on, 42–47, 48

“me-too,” 50–53

natural vs. social history of, 34–35

physiological experience of, 22–24

research on, 47

social stress and, 38–41, 249

somatic symptoms, 27, 35–36

symptomology (Hong Kong), 12–13, 15–19, 27, 35–36

symptomology (Western), 11, 17, 36–37, 45–47

in the symptom pool, 31–34, 48, 49, 59, 61–62

trigger/tipping point for, 37, 44

two patient populations identified, 50–51

“Anorexia Nervosa in Hong Kong: Why Not More in Chinese?” (Lee), 14

Antidepressants. See Selective serotonin reuptake inhibitors

Applbaum, Kalman, 222–24, 226, 230–31, 244

Approaching Hysteria: Disease and Its Interpretations (Micale), 62

Argenti-Pillen, Alex, 108–14, 125

Arnett, Jeffrey Jensen, 40

Asabi, 102

Ashcroft, George, 235

Association for Play Therapy, 73

Astasia-abasia, 28

Auburn University, 173–74

Au Kam-wah, 42, 44

AusAID, 70

Australia, 70, 153

Austria, 135

Autumn Moon (film), 39

Ayurvedic medicine, 89

Baggerly, Jennifer, 97

Ballenger, James, 232–34

Barrett, Robert John, 136–37

BBC, 77

Beauty industry, 9–10

Benzodiazepines, 236

Berlin Wall, fall of, 252

Biomedical narrative of schizophrenia, 4, 5, 176–78

case history, 165–71

rise of, 171–75

Bloom, Sandra, 116

Boer Wars, 101

Bordo, Susan, 58

Bosnia, 109

Bracken, Patrick, 122–23

Bradford University, 122–23

Breslau, Joshua, 105, 221

British Journal of Psychiatry, 15

British Medical Journal, 118

Brown, David, 118–19

Brown, George, 151

Brown University, 239

Bruch, Hilde, 18, 34, 51

Brumberg, Joan Jacobs, 46, 58–59

Buddhism, 88, 89, 94, 135, 211

Al-Bukhari, 154

Bulimia, 11, 52–53, 59–60, 62

California State University in Los Angeles, 87

Calorias, 102, 114

Cambodian refugees, 102

CARE, 76

Carpenter, Karen, 34

Case histories

of anorexia (see Hsu Chi-Ying, Charlene; Jiao [anorexic woman]; Ling [anorexic

woman]) of depression, 214–21

of schizophrenia (see Al-Mitende, Shazrin [schizophrenic woman]; Zanzibar,

schizophrenic family) Catalepsy, 28

Cattan, Mary, 82

Celebrities and eating disorders, 10–11, 14, 43, 45

Chan Suk-kuen, 42

Charcot, Jean-Martin, 28, 29

Chen, Bobo, 10

Cheung Pak-chi, Cecilia, 10

Children. See also Adolescents

PTSD and, 73–75, 77, 78–79, 82, 83, 84–86, 89, 94, 99, 106

SSRI use in, 242–43

Children’s Impact Events Scale 13 (CRIES-13), 85–86

China, 1, 9, 200

anorexia in, 14

depression in, 195

expressed emotion in, 162

Hong Kong sovereignty transfer, 38–39, 249

schizophrenia in, 153

Cholera epidemic, 201, 202

Christianity, 88, 89, 155, 156

Chung, Gillian, 10, 11

Civil wars

American, 101

Salvadoran, 102

Sri Lankan, 69, 87, 88, 89, 96, 108–14, 123–25

Clark University, 40

CNN, 77

Colombia, 137

Columbia University, 242

Complete Manual of Suicide (Tsurumi), 219–20

Cornell Medical School, 53

Corrigan, Malachy, 119

Crazy: A Father’s Search through America’s Mental Health Madness (Earley), 164

Critical incident debriefing, 75, 116–19

Culture of sadness, 207–13

DaCapo (magazine), 227

Da Costa’s syndrome, 101

Dar Days (Swift), 167–68

Data torturing, 238n

Davidson, Jonathan, 69, 80–81

Davies, Robin, 70

Debility syndrome, 101

Debriefing. See Critical incident debriefing

Demoiselles d’Avignon, Les (Picasso), 53

Denmark, 137, 153

Dentsu advertising agency, 214–19

Depression, 2, 3, 6, 32, 187–248, 249, 250. See also Japan; Selective serotonin

reuptake inhibitors diversity of cultural expression, 193–98

endogenous, 207, 208, 218, 225

explanatory models of, 195, 197

Japanese view of, 192–93, 208–11

media on, 221, 227

mega-marketing of, 224–29

moral compass for, 196

social and moral meaning of, 196, 201

somatic symptoms, 209

stigma of, 208, 225

Western view of, 194, 209–11

Dhows, 132

Diagnostic and Statistical Manual of Mental Disorders (DSM), 3

anorexia in, 17, 19, 36, 37, 43, 47, 48, 50, 54, 63

Culture-Bound Syndromes, 5

depression in, 194, 195, 208, 211

Japanese translation, 208

new edition, 251–52

PTSD in, 71–72n, 115

Diana, Princess, 52, 59–60

Dresser, Roberta, 58, 59

Drug companies, 4. See also specific companies ghostwritten studies of, 234,

237–38, 241

marketing enticements used by, 189–90

motivations given by, 230

researchers paid by, 234, 241, 248

research sponsored by, 229–30

DSM. See Diagnostic and Statistical Manual of Mental Disorders

Duke University, 69

Earley, Pete, 164


in Japan (Kobe), 105–6, 220–21, 229

Loma Prieta, 117

in Sri Lanka, 87

Eastern Europe, 13

East Germany, 252

East Timor, 104–5

Eating disorders. See Anorexia; Bulimia

Eating Disorders: Anatomy of a Social Epidemic (Gordon), 51–52

Economic crises

global, 249–53

Japanese, 214–15, 227–28, 249

Edo era (Japan), 200, 220

Eisei, 201

Eli Lilly, 191, 222

Emotional expression. See Expressed emotion

Empathy, 161

Endogenous depression, 207, 208, 218, 225

European Society for Traumatic Event Studies, 76

Explanatory models of depression, 195, 197

Expressed emotion, 138–39, 151–54, 160–65

Eye movement desensitization and reprocessing (EMDR), 82

False memories, 119

Fasting Girls: The History of Anorexia Nervosa (Brumberg), 46, 58–59

Fatalism, 155–56, 164


admiration for, 14

fear of, 11, 13, 17, 18, 35, 36, 46, 50

Fernando, Gaithri, 87–93, 96, 102, 124

Fertile Crescent (Middle East), 2

Fire illness, 195, 196

Fisha-e-bala, 102, 114

Fluphenazine, 145n, 168

Food and Drug Administration (FDA), U.S., 238, 243–44

France, 70, 153

Fujimura, Misao, 205–6, 219

Gadambanathan, T., 79

Ganesan, Mahesan, 78, 79, 97

Gaze of the wild, 109–11

Geok-Lin Lim, Shirley, 47

Germany, 208

East, 252

neuropsychiatry in, 200, 201–2, 207

schizophrenia in, 153, 172, 173

Ghaemi, Nassir, 237–38

Gist, Richard, 119

GlaxoSmithKline (GSK), 187, 192, 221, 222, 224–36, 239–44, 245–48, 249, 250

conferences hosted by, 188–90, 193–99, 229, 232–34, 246

marketing campaign of, 224–29

U.S. market for products, 188n

Global Development Group, 76

Golden Cage, The (Bruch), 18

Gordon, Richard, 51–52

Granger, D. A., 177

Grassley, Charles, 244

Great Britain

bulimia in, 59–60

expressed emotion in, 162

schizophrenia in, 135

trauma counselors from, 70

Hacking, Ian, 3

Hadith, 154

Haldol, 131

Harvard Medical School, 177

Harvard Trauma Questionnaire, 86

Harvard University, 107, 139, 162, 222, 242

Healing, indigenous. See Indigenous healing techniques

Healy, David, 187, 236–37, 247

Heart Circle Sangha, 81–82

Hemed (schizophrenic man), 141–46, 148, 149, 150, 151, 154, 155

Hinduism, 88, 89, 135

Holy anorexics, 51

Hong Kong, 1, 6, 9–26, 33, 34–57, 61, 62–63. See also Anorexia beauty industry

in, 9–10

bulimia in, 11, 52–53

celebrity culture and, 10–11, 14, 43, 45

educational programs in, 48

media of, 42–47, 48

social stress in, 38–41, 249

sovereignty transfer, 38–39, 249

Hong Kong Eating Disorders Association, 44

Hooley, Jill, 162–63, 164

Hospital of Neukölln, 76

Hsu Chi-Ying, Charlene, 6, 37–38, 41–45, 48, 49, 50

Hudson River Psychiatric Center, 131

Humanitarian Committee of the Association for Comprehensive Energy

Psychology, 82

Hurricane Andrew, 117–18

Hurricane Hugo, 117

Hurricane Katrina, 94, 251

Hysteria, 3, 5, 6, 27–31, 33, 51, 61–62, 202

debate on meaning and cause of, 29–30

PTSD compared with, 72

symptoms of, 28

waning of, 34

Ichiro, Oshima, 214–21

Idioms of distress, 120

Illness negotiation, 33


depression in, 195

eating disorders in, 24

expressed emotion in, 162

PTSD in, 70

schizophrenia in, 137, 153

Indigenous healing techniques, 3

in Japan, 20

in Sri Lanka, 88–89

in Zanzibar, 145

Individualism, 163–64

Indonesia, 2, 70

Inna barikama, 109

International Consensus Group on Depression and Anxiety, 188, 190, 198, 233

International Critical Incident Stress Foundation, 117, 118

International Rehabilitation Council for Victims of Torture, 108

International Society for Traumatic Stress Studies, 116

International Trauma Treatment Program, 95

Internet marketing, 226–27

“Invisible Human Crisis, The” (report), 105

Iran, 195

Iraq, 114, 121

Islam, 88, 94, 129, 135, 146–47, 154–55, 158

Island (newspaper), 124

Italy, 153

Japan, 6, 32, 187–248, 250. See also Depression anorexia in, 14, 24

cholera epidemic in, 201, 202

cultural history of, 199–203

culture of sadness in, 207–13

drug approval process in, 191–92, 223–24

drug imports, 191

earthquake in, 105–6, 220–21, 229

economic crisis in, 214–15, 227–28, 249

Japan, contd.

“evolution” analogy and, 231–32

first mental health epidemic in, 203–7

media of, 221, 227

menopause in, 211–12

psychiatric profession and services in, 192–93, 194, 201

PTSD counseling in, 105–6

sedative use in, 212–13

suicide in, 193–94, 198, 202, 205–6, 216–20, 228

workload in, 214–20, 229

Japan Times, 228

Jenkins, Janis Hunter, 136–37, 160–61

Jiao (anorexic woman), 15–22

Jibyo, 211

Jinns, 157

Johnson, Ken, 251

Journal of Clinical Psychiatry, 189

Journal of Neurology, 206

Journal of the American Academy of Child and Adolescent Psychiatry, 239

Judeo-Christian cultures, 135

Kadirgamar, Lakshman, 123

Kansas City Fire Department, 119

Karma, 88, 94

Karojisatsu, 217

Karoshi, 216

Kassim, Ahmed, 127–29, 178, 184–85

Kassim, Latifa, 128–29

Katzman, Melanie, 53–54

Keio University, 199

Keller, Martin, 239

Kellogg School of Management, 222

Kenya, U.S. embassy bombing in, 106

Kidongo Chekundu Mental Hospital, 131, 167, 168, 175–76

Kids Everywhere Like You (KELY), 48

Ki ga fusagu, 209

Ki ga meiru, 209

Kimwana (schizophrenic woman), 141, 144–51, 154, 155, 156, 158, 159, 171

King’s College, 98, 123

Kirmayer, Laurence, 187–90, 193, 194–98, 208, 211, 213, 229, 232–34

Kissinger, Henry, 232

Kitanaka, Junko, 188–89, 199–200, 201, 203, 204, 207, 218, 226, 245

Kitasato, Ichiro, 192

Kleinman, Arthur, 107, 139–40

Knight Ridder/Tribune news service, 117–18

Koda, Kumi, 10

Kokoro no kaze, 225, 228

Koran, 154, 158


anorexia in, 14

depression in, 195–96

Koro, 2, 5

Kose Corp., 10

Kostelny, Kathleen, 104–5

Kramer, Peter, 192, 221

Kyorin University, 193

Kyushu University, 206

Lancet, 28

Laségue, Charles, 28, 29, 30

Law, Clara, 39

Lee, Sing, 9, 11–24, 26–27, 32, 33, 34–37, 44, 46–58, 62–63

anorexic behavior mimicked by, 22–24

anorexic populations identified by, 50–51

early research of, 13–15

patient deaths from anorexia, 22, 62

scholarly output of, 12

Levine, Michael, 60–61

Lexapro, 234

Liberation Tigers of Tamil, 108, 124

Librium, 236

Ling (anorexic woman), 54–57

Listening to Prozac (Kramer), 192, 221

Llaki, 103

Lock, Margaret, 211–12

Locus of control, 162–63

Loving v. Virginia, 131

Luvox, 192

Mad Travelers (Hacking), 3

Mahoney, John, 81

Malaysia, 24

Manic depression, 175, 202, 207

Marce, Louis-Victor, 29

Masako, Crown Princess of Japan, 228

McGill University, 71, 103, 187, 188, 211

McGruder, Juli, 127–34, 136–42, 144–51, 154–60, 175, 178–85

background, 128, 130–31

biomedical narrative and, 165–66, 169–71, 174

ex-husband’s breakdown, 179–83

love of Zanzibar culture, 133


on anorexia, 42–47, 48

on depression, 221, 227

on PTSD, 67–68, 69, 77, 117–18

Medications, 3–4

for depression (see Selective serotonin reuptake inhibitors)

for PTSD, 80–81

for schizophrenia, 131, 145n, 165, 168–69

Mehta, Sheila, 173–74, 178

Meiji Seika, 192

Melancholic personality (typus melancholicus), 208, 211, 229

Menopause, 211–12

Mental health literacy, 171

“Me-too” anorexics, 50–53

Mexican Americans, 160–61, 162

Micale, Mark, 62

Middle East, 2, 24

Miller, Ken, 102, 107

Mitchell, Jeffrey T., 116–17, 118

Al-Mitende, Shazrin (schizophrenic woman), 165–71, 174

Miyamoto, Masao, 219

Mohammed (prophet), 154

Mongolia, 173

Monoamine depletion hypothesis, 234–36

Mood Disorders Association of Japan, 228

Moral compass, 196

Moss, Kate, 11

Multiple personality disorder, 5, 32

Nakary, 103

Namihira, Emiko, 228

National Alliance for the Mentally Ill, 171

National Center for Post-Traumatic Stress Disorder, 72, 76

National Institute of Mental Health, 251

Nervios, 160–61

Neugeboren, Jay, 177

Neurasthenia, 200, 203–7, 227, 236

Neuropsychiatry, 200, 201–2, 207

New England Journal of Medicine, 28, 241

New Jersey Association of Mental Health Agencies, 65, 67

New York City Fire Department, 119

New Yorker, 119

New York Review of Books, 241

New York Times, 77, 115, 250

New York University, 114

New Zealand, 70

Next (magazine), 10


depression in, 195

eating disorders in, 24

schizophrenia in, 137

Nikkei index, 214, 215, 249

North Africa, 153

North Wales Department of Psychological Medicine, 236

Okuma, Shigenobu, 206

Ono, Yutaka, 228, 246

Operation Recovery, 106

Oppenheim, Janet, 28

Oxfam, 108

Oyserman, Daphna, 163–64

Pakistan, 135

Pantoliano, Joe, 251n

Parachute researchers, 84, 124

Paxil, 6, 187, 190, 192, 193, 222, 223, 229, 233, 239–41. See also Selective

serotonin reuptake inhibitors double-blind study of, 239–41

ghostwritten studies of, 234

manufacturer description, 235

sales revenue, 245

second thoughts on, 245–48

side effects of, 240–41

suicide and, 240, 242–44, 247

Pedersen, Duncan, 103

Peramuna, Janatha Vimukthi, 108

Petite hysterie, la, 61

Pfizer, 80, 222, 223

Pharmaceutical Manufacturers of America (PhRMA), 223, 251

“Pharmacologic Treatment of Acute and Chronic Stress Following Trauma”

(Davidson), 80

Picasso, Pablo, 53

Play therapy, 73–75

Pomona College, 102

Post-traumatic embitterment disorder (PTED), 252

Post-traumatic stress disorder (PTSD), 1–2, 3, 6–7, 32, 65–125, 220n, 249, 251,

252. See also Sri Lanka critical incident debriefing for, 75, 116–19

“denial” of, 77, 98

education vs. indoctrination on, 105–7

global differences in, 100–105

history of, 70–71, 114–18

hopeful lies and, 99–100

literature on, 72

meaning stripped from, 120–23

media on, 67–68, 69, 77, 117–18

medication for, 80–81

play therapy for, 73–75

somatic symptoms, 91, 103

symptom checklists, 84–86, 90

symptomology (Sri Lanka), 91–93

symptomology (Western), 68, 71

treatment risks, 107–14, 118–19

wave metaphor, 70

worldview described by, 73

Post-traumatic Stress Disorder Checklist—Civilian Version, 86

Post-Vietnam syndrome, 114–15, 121

Presbyterian Hospital (New York City), 34

Prince of Wales Hospital, 9, 12, 13, 14, 21

Prozac, 191, 192, 213, 242

Psychological first aid, 4, 75

Psychosocial aid, 97–98

PTSD. See Post-traumatic stress disorder

Pupavac, Vanessa, 119–20

Qi, 20, 200

Qigong, 20

Quechua natives, 103–4

Red Cross International, 76

Religion. See also Spirit possession; specific religions

schizophrenic hallucinations and, 135

in Sri Lanka, 88, 89, 94

in Zanzibar, 146–47, 154–59

Reuters newswire service, 69, 70, 78

Ruhsal hastagi, 173

Russia, 13, 173

Rutgers University, 135

Rwanda, 106, 109

Salvadoran refugees, 102, 114

Samurai warriors, 219

SANE, 171

Sass, Louis, 135

Saxena, Shekhar, 78

Schizophrenia, 6, 127–85. See also Zanzibar culture and content of, 134–36

culture and naming of, 160–61

culture and prognosis, 128, 130, 137–40

expressed emotion and, 138–39, 151–54, 160–65

medication for, 131, 145n, 165, 168–69

neuropsychiatric view of, 202

pathoplastic vs. pathogenic aspects, 135–36

prevalence rates, 136

scientific explanations of, 134

social stress and, 153

stigma of, 172–75, 176–78

stress-diathesis model of, 143

Schnittker, Jason, 173

Scientology, 237n

Scott, Sean, 69

Sedatives, 212–13

Selective serotonin reuptake inhibitors (SSRIs), 191–92, 194, 198–99, 218, 222–

48. See also Lexapro; Luvox; Paxil; Prozac; Zoloft benefit-risk balance, 236–38

clinical trial results, 223–24

cooperation among manufacturers, 222–23

early Japanese view of, 213

effectiveness level of, 238–39

ghostwritten studies of, 234, 237–38, 241

marketing of, 224–29

monoamine depletion hypothesis, 234–36

negative results withheld, 238

placebo compared with, 238, 240

sales growth, 191

scientific data, 230–41

side effects of, 240–41

suicide and, 240, 242–44, 247

Selvie-amah (Sri Lankan woman), 96

Seppuku, 219

September 11 terrorist attacks, 67, 107

Serotonin depletion hypothesis. See Monoamine depletion hypothesis

Shah, Siddharth Ashvin, 100

Shatan, Chaim, 114–15

Shell shock, 101

Shining Path, 103

Shinkeisuijaku, 203

Shorter, Edward, 26–27, 29–31, 32–33, 34, 49, 51

Sikhs, 162

Singapore, 24

Social Work Today, 98

“Society in Distress” (Kitanaka), 199

Sodium amytal, 168

Soldiers, reactions to combat trauma in, 101, 114–15, 121–22

Solvay, 192

Somali refugees, 99

Somatic symptoms

of anorexia, 27, 35–36

of depression, 209

of PTSD, 91, 103

South China Morning Post, 42–43

Southeastern Asians, 2

South Korea, 14

Spain, 153

Spears, Britney, 10

Spirit possession

in the Middle East, 2

in Zanzibar, 6, 132, 145, 156–59, 165, 166–67

Sri Lanka, 6–7, 32, 65–100, 102, 249. See also Post-traumatic stress disorder

certainty of trauma workers in, 97–100

civil war in, 69, 87, 88, 89, 96, 108–14, 123–25

cultural/language deficiencies of therapists, 75, 78, 79–80

earthquake in, 87

extent of psychological intervention in, 70

“gaze of the wild” in, 109–11

media of, 67–68, 69, 77

pace of counseling in, 80

religious beliefs in, 88, 89, 94

resilience in, 87–93

rise of fearlessness in, 107–14

rivalries among counseling groups, 78–79

social relationships in, 91–93, 96

trauma researchers in, 83–87, 124

trauma training for locals, 81–83, 95, 124

Sri Lankan Index of Psychosocial Status, 91

SSRIs. See Selective serotonin reuptake inhibitors

St. Vincent’s Hospital (Sydney, Australia), 69

Standard, The (Hong Kong newspaper), 10, 44, 45, 48

Stelazine, 131

Stiebel, Salomon, 27


of depression, 208, 225

of neurasthenia, 204, 207

of schizophrenia, 172–75, 176–78

Stotland, Nada, 241n

Stress-diathesis model of schizophrenia, 143


economic conditions and, 250

in Japan, 193–94, 198, 202, 205–6, 216–20, 228

serotonin levels and, 235

SSRIs and, 240, 242–44, 247

Suicide forests, 193–94

Sumathipala, Athula, 84, 124

Summerfield, Derek, 65, 123

Sunni Shafi’ites sect, 154

Surface, David, 98

Swartz, Lesley, 59

Sweden, 136

Swift, Charles, 167–68


anorexia in, 24

schizophrenia in, 137, 153

Tajima, Osamu, 193–94, 246–48

Takiguchi, Kenichiro, 221, 225

Tanaka-Matsumi, Junko, 209–11

Tanzania, 167

Tellenbach, Hubert, 208

Textbook of Clinical Psychiatry, 235

Thailand, 70

Thorazine, 131

Thought field therapy, 82

Tiananmen Square protests, 38, 249

Time (magazine), 250

Ting Yi, 41

Tong, John, 10–11

Toyo Keizai (magazine), 227

Transcultural Psychiatry (journal), 188

Tsunami, 6

description of, 65–66

as metaphor for PTSD, 70

Tsurumi, Wataru, 219–20

Tufts Medical Center, 237

Turkey, 173

Typus melancholicus. See Melancholic personality

UCLA PTSD Reaction, 85


United Nations High Commission for Refugees, 108

United States Embassy bombing (Kenya), 106

University College London, 108

University of California, Santa Barbara, 47

University of Cardiff, 236

University of Colombo, 76–77, 89

University of Florida, 97

University of Hawaii, 209

University of Hong Kong, 47

University of Konstanz, 83

University of Michigan, 163

University of Nottingham, 119–20

University of Pennsylvania, 81, 173

University of Puget Sound, 128, 131

University of Washington, 128, 132

University of Wisconsin, 222

USA Today, 250

Utsubyô, 193, 209, 225

Utsushô, 200–201, 211, 227

Valium, 236

Van Eenwyk, John R., 95

Venezuela, 106–7

Victorian era, 3, 5, 28–29, 72

Vietnam Veterans Against the War, 114

Vietnam War, 114–15, 121

Vomiting epidemic, 29

Von Peter, Sebastian, 76

Wall Street Journal, 191

Washington Post, 70

Wentz, Debra, 65–69

Wessells, Michael, 104–5

Wisconsin Law Review, 58

World Health Organization (WHO), 76, 78, 81, 137–40

World Psychiatric Association, 171

World War I, 101

World War II, 121, 207, 219

Wu, Celia, 44

Yaka, 111, 112

Yan shi zheng, 43

Yin-yang balance, 20

Yojo, 200, 201

Young, Allan, 71, 102

Yule, William, 98–100

Yuutsu, 209–11

Zanzibar, 6, 127–51, 154–60, 165–71, 178–85. See also Schizophrenia author’s

stay in, 127–29, 141, 175–76, 178–79, 253

lessons learned from research, 178–84

monsoon effect on culture, 132–33

Zanzibar, contd.

schizophrenic family, 141–51, 154–60, 171, 182, 183

social upheaval in, 142–44

Zar, 2, 6

Zarowsky, Christina, 99

Zogozogo, 142, 150

Zoloft, 80–81, 223–24

* Not that an eating disorder specialist would necessarily disagree with these

items. I mean to point out only that the Western research literature on anorexia

goes far beyond these baseline assumptions in both complexity and diversity of

opinion. What was being transmitted to Hong Kong in the mid-1990s, in other

words, was a lay Westerner’s view of anorexia, the sort of information you’d

glean if you read about anorexia in a weekly news magazine.

* As the DSM-IV describes PTSD: “The essential feature of Post-traumatic Stress

Disorder is the development of characteristic symptoms following exposure to

an extreme traumatic stressor involving direct personal experience of an event

that involves actual or threatened death or serious injury, or other threat to

one’s physical integrity; or witnessing an event that involves death, injury, or a

threat to the physical integrity of another person; or learning about unexpected

or violent death, serious harm, or threat of death or injury experienced by a

family member or other close associate (Criterion A1). The person’s response to

the event must involve intense fear, helplessness, or horror (or in children, the

response must involve disorganized or agitated behavior) (Criterion A2). The

characteristic symptoms resulting from the exposure to the extreme trauma

include persistent reexperiencing of the traumatic event (Criterion B), persistent

avoidance of stimuli associated with the trauma and numbing of general

responsiveness (Criterion C), and persistent symptoms of increased arousal

(Criterion D). The full symptom picture must be present for more than 1 month

(Criterion E), and the disturbance must cause clinically significant distress or

impairment in social, occupational, or other important areas of functioning

(Criterion F).”

* For some critics, this very first study became emblematic of the rush to

diagnose PTSD. How could PTSD have been diagnosed starting at three weeks,

some wondered, when the definition of the disorder requires the symptoms to

last for longer than one month?

* All the names of the African families mentioned in this chapter are


* When McGruder compared Amina’s memory to the records in the hospital,

there were considerable differences. The pills she had been given were not,

according to the chart, antimalaria medication but an antispasm drug called

trihexyphenidyl hydrochloride, used to counter facial muscle spasms that can be

a side effect of a powerful antipsychotic called fluphenazine that had been given

to Kimwana in an injection.

* I’ve placed an audio recording of the sound of the square on www.crazy if you’d like to listen to the soundscape Kimwana lived in.

* Expressed emotion researchers have been careful to point out that they were

not tying emotional temperatures in families to the onset of schizophrenia. High

emotion was not a cause of the disease, but rather appeared to be a factor that

greatly influenced its course and outcome. While there is a significant difference

between families with high emotional temperatures and those with low, this is

not true in every case. Many high-expressed-emotion families care for

schizophrenics with low incidence of relapse, and vice versa. It should also be

noted that it is not only relatives who have been studied. Similar results have

come from research into high and low emotionality expressed by caretakers in

group homes and mental institutions.

* Although headquartered in the UK, GlaxoSmithKline has much of its operations

in the United States, where its consumer products division is based. The United

States is the single largest market for GSK drugs.

* The instructions are given in great detail. For potential jumpers, for example,

the book recommends the Takashimadaira housing project and provides a map

to help the reader find the place. The chapter on throwing oneself in front of a

train recommends precisely where to stand on the platform and which express

trains will do the quickest work. To combat these instructions, the transit

authority has placed mirrors at strategic spots, following the theory that seeing

one’s reflection may dissuade one from jumping.

* As discussed in chapter 2 this disaster also played a key role in the

international spread of the PTSD diagnosis.

* Ballenger did not return phone calls requesting an interview for this book.

* In the debate over the risks and benefits of SSRIs there are few people in the

middle ground and a wealth of easily accessible information designed to appear

evenhanded that is, in fact, secretly produced by the drug companies or the

most extreme critics. For instance, both the drug companies and Scientologists

(who believe psychiatric drugs are basically poison) sponsor websites that

appear to the reader to be created by patient advocates or impartial experts in

mental health. Although the SSRI makers have actively tried to portray Healy as

a man of radical opinions, the facts of Healy’s professional life speak for

themselves. Not only was he the former secretary of the British Association of

Psychopharmacology and a professor in psychological medicine at Cardiff

University, but in his medical practice he continues to use antidepressants with

patients who he believes can benefit from the drugs.

* Searching for some secondary positive aspect in otherwise negative data is

referred to as “data torturing” and is often criticized as being the statistical

equivalent of placing the target after throwing the darts.

* In defending her members against Angell’s charges, Dr. Nada Stotland,

president of the American Psychiatric Association, replied to Angell’s criticism,

“It is unfair to suggest physicians are ‘corrupt’ for activities that were virtually

universal when they occurred.’ ” Such a sentence can stop one cold. Is the

president of the APA really falling back on that old chestnut of an excuse for bad

behavior, “Everyone was doing it”? And what definition of corruption is she

relying on that ensures that those in the majority cannot be at fault?

* In the same release, PhRMA announced that it had helped launch a new

consumer advocacy site featuring the well-known actor from The Sopranos, Joe

Pantoliano, who had publicly admitted to struggling with depression. “The goal,”

according to the No Kidding, Me Too website, was to “make brain dis-ease cool

and sexy.”

  • Cover Page
  • Title Page
  • Copyright Page
  • Dedication
  • Contents
  • Introduction
  • 1 The Rise of Anorexia in Hong Kong
  • 2 The Wave That Brought PTSD to Sri Lanka
  • 3 The Shifting Mask of Schizophrenia in Zanzibar
  • 4 The Mega-Marketing of Depression in Japan
  • Conclusion The Global Economic Crisis and the Future of Mental Illness
  • Sources
  • Acknowledgments
  • Index
  • Footnotes
    • Page 46
    • Page 71
    • Page 83
    • Page 141
    • Page 145
    • Page 147
    • Page 152
    • Page 188
    • Page 219
    • Page 220
    • Page 233
    • Page 236
    • Page 238
    • Page 241
    • Page 251