Crazy Like Us


Some of the most thoughtful dialogue regarding Crazy Like Us has come in the form of blogs. Here's one I particularly enjoyed. Remarkably she made the connection between my arguments in Crazy Like Us and the rise and fall of the recovered memory movement in the 90s. That is exactly where many of my ideas came from. I avoided making the connection in the book so as not to be seen as retracing my own tracks.


I'm not exactly sure who Hayton and Associates are (their website says that they are billing service for the behavioral health industry) but I enjoyed the headline of their cautionary article regarding my book. I also liked the idea that physicians and therapists are going to have to read the book. Excellent.

The Ethan Watters Phenomenon

by dhayton on February 14th, 2010

Physicians and therapists are going to have to read Ethan Watters’s new book Crazy Like Us, if only to respond to friends and patients who have read it.

Watters is attracting attention across the press spectrum, from NY Times to Psychology Today, as well as international press stories. We have already pointed to some of this press in two earlier posts: Exporting Mental Illness and Is the U.S. Exporting Mental Illness?.

The rest here:

Review Just in from Dubai

I've been pleased to see how many foreign papers have shown interest in the book. Here's a review from The National a newspaper in Dubai.

It’s a sad, sad world

Eli Lilly, the manufacturers of Prozac, assumed that anti-depressants couldn’t sell in Japan. GlaxoSmithKline got rich proving them wrong. AP Photo / Matt Dtrich

Wesley Yang follows the western psychiatric establishment around the world, watching its representatives sometimes hurt the very people they try to help.

Crazy Like Us: The Globalization of the American Psyche
Ethan Watters
Free Press

The history of western intervention abroad – well-meaning, overconfident, oblivious to cultural context, and therefore doomed to magnify and multiply the problems it has come to solve – gets a powerful new chapter in Ethan Watters’s Crazy Like Us: The Globalization of the American Psyche. The book is a critical account of four western psychiatric interventions around the globe, and its heroes are a loose collection of researchers and anthropologists who dissent from the mental health orthodoxy that has spread from the United States to the rest of the planet.

The other doctors, aid workers, experts and executives Watters meets, by contrast, do not understand the cultures they have decided to educate and to heal – and they do not think they have to. As a result, they do not help the people they have come to help. Sometimes they hurt them.

The westerners parachuting into foreign lands to promote various forms of “mental health literacy”, as they call it, believe machines that can watch blood flow through the brain and drugs that can change the brain’s chemistry have elevated modern psychiatry above the primitive diagnoses of the discipline’s long infancy, when “culturally contrived manifestations of mental illness” ran riot.

During this age of blind empirical groping, doctors first identified symptoms like convulsive fits, paralysis and linguistic impediments as indicators of mental illness. But each time new diagnoses emerged in the medical literature, and in public discourse, doctors found that the incidence of these same symptoms skyrocketed. This shifting of the “symptom pool”, as the medical historian Edward Shorter calls it, was a constant embarrassment to psychiatry’s claim to provide timeless and objective descriptions of a hard reality.

But today, the new orthodoxy insists, western psychiatry is at last rooted in an objectively “biomedical” account of how the brain works and fails. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Illness is, on this view, a universally valid guidebook that describes “illnesses with a symptomatology and outcomes relatively unaffected by shifting cultural beliefs.”

Not so, insists Watters. “All mental illnesses,” he writes, “ including such seemingly obvious categories such as depression, post-traumatic stress disorder, and even schizophrenia, are every bit as shaped and influenced by cultural beliefs and expectations as hysterical leg paralysis, or the vapours, or zar, or any other mental illness ever experienced in the history of human madness.” All mental illnesses are cultural for the simple reason that all forms of expression are irreducibly cultural. The modern western individual for whom American psychiatric diagnoses were conceived is itself a cultural artefact – a radical break from conceptions of the self obtaining in the many non-western cultures where the individual is regarded “as inseparable from your role in your kinship group, intertwined the story of your ancestry and permeable to the spirit world”. Thus any account of mental illness that uses a uniquely western template for all minds everywhere will inevitably “blind local clinicians to the unique realities of patients in different cultures”.

Each of the four case studies that Watters examines poke holes in a different aspect of the western mental health orthodoxy. In Hong Kong, China’s leading researcher of eating disorders finds that shifting cultural beliefs can radically alter the nature and distribution of a mental illness. In 1994, the highly publicised starvation death of a 14-year old schoolgirl – and the subsequent profileration of news reports containing the western definitions of an anorexia nervosa – led to a dramatic rise in the awareness, and the incidence, of the disease.

In Sri Lanka, thousands of Western-trained “trauma counsellors” marvelled at the obstinate cheerfulness and resilience of the natives in the wake of the 2004 tsunami that ravaged the island. They concluded that the Sri Lankans were “in denial” and needed to be forced to confront the trauma they have just experienced – lest the unprocessed terror seep into their unconscious to fester and manifest itself as post-traumatic stress disorder. Toward that end they employed a “debriefing” technique that, in 1996, the British Medical Journal had concluded was “ineffective and has adverse long term effects” – namely the instigation of the very symptoms it is intended to avert.

The first western psychiatrist in Tanzania was keen on weaning the natives away from superstitious beliefs in spirit possession that stigmatise the mentally ill. Here, as elsewhere, western psychiatry acted as a tireless promoter of the view that mentally ill people are afflicted by an illness like any other. The view is meant to reduce the stigma experienced by the mentally ill. But everywhere the idea has been accepted, the effect has been to increase public aversion to the sick, further isolating them from their communities.

By contrast, Tanzanian beliefs in spirit possession have the effect of keeping the schizophrenic within the social group. A western anthropologist marvels at the “amazing tolerance” and “passive acceptance of abnormal behaviour” that one Tanzanian family shows toward the mentally ill in their midst. In the West, where the allegedly enlightened and humane biomedical view dominates, schizophrenics experience fewer periods of remission and lower levels of functioning than they do in cultures that believe in ghosts.

Not even a disease as seemingly straightforward as depression is exempt from a remarkable degree of cultural determination. Japanese people have traditionally considered profound sadness to be a poetic ennobling emotion, not a disease to be banished with the aid of doctors and pills. For this reason Eli Lilly, the makers of Prozac, declined to enter the Japanese market. “Executives in the company believed that the Japanese people wouldn’t want to accept the drug,” observes Watters, “More precisely, they wouldn’t want to accept the disease.” Glaxo SmithKline, the makers of Paxil, did not give up so easily. A “mega-marketing campaign” successfully altered the traditional Japanese view of sadness and depression. By 2009, sales of Paxil in the country had reached $1 billion.

The researchers that Watters lionises correctly note that the importation of western psychiatric process smuggles in cultural assumptions that threaten to upset social balance. For example, therapists working in Sri Lanka after the tsunami urged reflection and “individual quests of introspection” onto Sri Lankans – who conceived of themselves as tightly woven into kinship networks in which the well-being of the individual is contingent on the well-being of the group, and the well-being of the group as contingent on collective avoidance of unconstrained speech.

In doing so, they “largely discredited the power of local healing practices, as well as resiliency, coping and survival strategies” in a way that “had the potential to continue, in a new form, the very cultural demolition that had caused the population its greatest distress.”

In the end, Watters concludes, “offering the latest western mental health theories in an attempt to ameliorate the psychological stress caused by globalization is not a solution; it is part of the problem.”

Wesley Yang writes for Tablet Magazine and n+1.

BOSTON GLOBE: Crazy Like Us is both groundbreaking and shocking

Making the rest of the world crazy

Americans are a generous people. We donate riches to needy countries. We send our troops abroad. We have exported some of history’s most influential cultural, scientific, and social inventions: democracy, fast food, and Britney Spears.

Whether that generosity is helpful to other nations is another question. And so it goes with mental health. According to Ethan Watters in “Crazy Like Us: The Globalization of the American Psyche,’’ the American way of perceiving and treating mental illness has quickly and ruthlessly become the worldwide way.

What is lost are local customs, beliefs, and practices that worked fine before the invention of antidepressants and antipsychotics. For example, people who suffer from schizophrenia in some developing nations tend to cope better than those in industrialized nations armed with “Diagnostic and Statistical Manual of Mental Disorders’’ diagnoses. Why? In East Africa, for example, traditional beliefs in spirit possession help families accept schizophrenia and reduce social stigma. But Western ideas have “the effect of stripping away the local beliefs’’ that in practice can make people feel better.

Watters, who wrote “Urban Tribes,’’ an examination of the “never-married’’ generation, and “Making Monsters,’’ an indictment of the false memory movement, blends scholarship, journalism, and travel reportage to unearth this hidden story of good intentions in the mental health profession gone awry.

“Crazy Like Us’’ is both groundbreaking and shocking. By focusing on four countries and four disorders - anorexia in Hong Kong; post traumatic stress disorder in post-tsunami Sri Lanka; schizophrenia in Zanzibar, Tanzania; and depression in Japan - Watters shows how American mental health professionals and pharmaceutical companies, sometimes accidentally, sometimes insidiously, have actually hastened the spread of some Western disorders.

The opening section on anorexia is the most eye-opening and establishes the book’s thesis. Watters focuses on Dr. Sing Lee, a researcher bent on discovering why in the 1990s, increasing numbers of women in Hong Kong began unconsciously expressing their “mental distress’’ as anorexia nervosa. Sensational media stories and the swift spread of Western diagnoses, Watters argues, were “not only changing the way patients and doctors talked about the disorder - [they were] changing the disease experience itself.’’ Watters astutely draws parallels to the rise of hysteria among Victoria era women plagued by internal strife. Like the fits, paralysis, and blindness exhibited by the sufferers of hysteria, for troubled modern Chinese women, starving themselves began entering the “symptom pool’’ of the disorder. Thus began “the feedback loop by which the disease goes forward and claims new victims.’’

As an aside, Watters notes that cases of hysteria fell as knowledge of the symptoms and the symptoms themselves became more commonplace, thereby losing some power to communicate the emotional pain of the sufferer. He suggests that eating disorders may someday similarly decline if we can find a way to diffuse “the meaning we give to them.’’ The ways America has colonized the foreign mind can be more deliberate. Or worse: driven by greed, as in the example of GlaxoSmithKline and other drug makers, which fund and influence favorable medical studies, wine and dine experts, and attempt to shape attitudes about depression in order to sell treatments in the lucrative Japanese market. GlaxoSmithKline, for instance, has succeeded wildly: From effectively zero market share in 2000, sales of the firm’s Paxil in Japan topped $1 billion in 2008.

For mental heath volunteers who rushed to Sri Lanka to counsel victims after the 2004 tsunami, it was case of big hearts colliding with naivety. Cultural differences were ignored; workers assumed that Sri Lankans would automatically express checklist symptoms for PTSD like New Yorkers after 9/11. The blunder resulted in often pathetic outcomes, such as bands of counselors competing for the affections of traumatized children.

Watters writes skillfully. His tone is measured, but you can see Watters struggling for a consistent voice and style. Is this lay scholarship (the nearly three dozen pages of sources are impressive) or first person travelogue? The “I’’ wavers in and out. Zanzibar is the most personal section. Sri Lanka feels the most distant, seemingly reported largely from library research and phone conversations; the section could have benefited from in-country reporting and more follow-up now that five years have passed since the tsunami. One could criticize the inconsistent methodology, or see the various approaches as creative tacks into a tricky subject matter.

Watters never fully unleashes his indignation, either. One might wish for a little more passion, particularly in the Sri Lanka and Japan chapters. But “Crazy Like Us’’ isn’t outright investigative journalism; the book is thoughtful, contextualized reportage of a disturbing if not entirely surprising trend.

The situation presented in “Crazy Like Us’’ is akin to the disappearing Amazon. “The remarkable diversity once seen among different cultures’ conceptions of madness,’’ Watters writes, “is rapidly disappearing.’’ Whether Watters’ book will be sand in the engines of the bulldozers remains to be seen. At least it proves the West, despite its best intentions, does not possess all the answers.

Ethan Gilsdorf, author of “Fantasy Freaks and Gaming Geeks: An Epic Quest for Reality Among Role Players, Online Gamers, and Other Dwellers of Imaginary Realms,’’ can be reached at ethan@ethangilsdorf .com.  


1) Don't expect any warm up. Jon Stewart comes into the green room before the show and chats with you for about 3 minutes. The conversation in my case focused exclusively on the contents of my Daily Show gift bag.

2) You'll have about an hour to hang out and get nervous before you go on. A staff member on the show is there to distract you. In my case she told me the story of one former interviewee who sweated so profusely that he nearly shorted out the lavalier microphone. (To be fair to the staffer, the context of the story was -- "that rarely happens.")

3) You will only see the set 30 seconds before you walk on. When they need you, a production assistant will lead you down a series of grim hallways past groups of hipsters (writers perhaps?) hanging out in the break room. You'll be thinking, "this is not very glamorous." Your eyes will be drawn to all "Exit" signs.

4) Do not look at the audience as you walk out onto the set. Look only at the familiar face of Jon Stewart. Know that he will get you through this. Trust in him.

5) Do not think any of the following thoughts: "Everyone I know is watching this." "Whatever happens in the next 5 minutes will live forever on the web." "Better not screw this up."

6) Don't try to be funny unless you ARE funny. If you are not sure if you are funny, assume that you are not and if you try to be in this situation you will look like an incredible jackass because you are sitting next to someone who is preternaturally, almost freakishly,  hilarious.

7) When you start to speak -- large images of your face will appear on monitors around the set. If you look at these images of yourself your mind will freeze up and then explode. Look only at Jon. You'll only have to say a sentence and a half before he jumps in with a zinger.

8) Do not laugh too hard at his zingers. They are for people watching at home. If you start giggling the interview is going to grind to a halt.

9) Bask in the post interview handshake. This is the moment when they are cutting away to commercial and the host leans in to shake your hand and say something just between the two of you. I can't tell you what Jon said to me during those five seconds except to say that it was of a highly personal nature.

10) Try not to open the copious amounts of liqueur in the gift bag* until you are out of the building and safely in the Town Car on your way back to your hotel.


*What is in that Daily Show gift bag? Glad you asked:

-Monopoly Board game.
-One huge bottle of Cherry Flavored Vodka -- in case you want to go get some high school kids hammered after the show.
-One bottle of 1800 Tequila
-A package of those Nespresso packets but no machine by which to actually make an espresso
-One Daily Show Hat
-One Daily Show T-shirt
-One gift certificate to get a professional photographic portrait of your pet -- in case you are ever traveling through NY with your dog.



Sure CSPAN Book Talk is not as sexy as the Daily Show.Still I'm happy to have this record of the first reading for Crazy LikeUs at The Booksmith. The co-owner of the store Praveen Madan has been asupporter both of this book and the San Francisco Writers' Grotto.

Time Magazine Thumbs Up

I knew this one was coming and I have to say that I was nervous. The three possible ratings they give books this column are:


Needless to say there's only one of those categories you'd want your book to land in. It seemed to take my Iphone about 3 minutes to download the Time Magazine webpage to get the verdict. Thank you AT&T for those long moment of anxiety. -Ethan

Monday, Jan. 11, 2010

The Skimmer

Crazy Like Us: The Globalization of the American Psyche

By Ethan Watters

Free Press; 306 pages

The U.S. exports plenty of things that much of the world would gladly send back: the Golden Arches, Jerry Bruckheimer movies and Baywatch, to name a few. But in addition to the cultural flotsam that drives the rest of the world crazy, America is literally exporting its mental illnesses. "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," writes journalist Ethan Watters. He traces how conditions first widely diagnosed in the U.S., such as anorexia and PTSD, have spread abroad "with the speed of contagious diseases." The growth of Big Pharma and the widespread adoption of U.S. health standards have made the ailing American psyche the primary diagnostic model. By 2008, for example, GlaxoSmithKline was selling over $1 billion worth of Paxil a year to the Japanese, who didn't know they had a problem with depression until drug marketers informed them. Though Watters' indignation can be wearying at times, he is on to something worth pondering.





BTW. Anyone who knows me will tell you that my indignation is anything but wearying. - e.

Review from BookPage

One of the things about writing a book is that for the rest of your life you'll regret the things you didn't say and ideas you didn't include. Often times those regrets are sparked by thoughtful reviews like the one below by a professor of journalism from Loyola. -Ethan

Crazy Like Us By Ethan Watters A new global phenomenon

Review by John T. Slania
Save for our popular culture and our fast food, there is little that the United States exports anymore. But move over Miley, Madonna and McDonald’s: America’s newest export is madness. At least, that’s the thesis of Ethan Watters’ Crazy Like Us
Watters argues that Americans are as overbearing and influential in their treatment of mental health as they are with their other major exports. “In teaching the rest of the world to think like us,” he writes, “we have been, for better and worse, homogenizing the way the world goes mad.” More specifically, American-born psychoses like depression, post-traumatic stress disorder and anorexia are being taught to people in foreign countries. And because American drug companies stand to make billions from treating these worldwide maladies, they are encouraging this behavior.
Watters argues that because of cultural, religious and other historical differences, a one-size-fits-all approach to mental health treatment doesn’t work: “Cross-cultural researchers and anthropologists . . . have shown that the experience of mental illness cannot be separated from culture.” He supports his position with detailed case studies in which Western doctors failed in their treatment of mental health disorders in foreign countries. And from his research, he makes some eyebrow-raising allegations, such as that in Hong Kong, teenagers began suffering from anorexia after Western experts started raising awareness of the disorder. He also posits that when Western crisis counselors swooped in to treat the PTSD they expected after a tsunami devastated a portion of Sri Lanka, in some cases they actually caused local communities more distress.
The major defect of Crazy Like Usis that it doesn’t spend enough time acknowledging that perhaps in some cases, the lessons Americans are teaching foreign nations about mental health treatment might actually be worthwhile. For instance, do Third World countries with no concept of mental disorders benefit in any way when Western doctors provide treatment? Still, the provocative thesis and the exhaustive research behind Watters’ examples makes Crazy Like Usworthy of consideration as we grapple to understand the impact of globalization—even if it is just a state of mind. 
John T. Slania is a journalism professor at Loyola University in Chicago.


Bookseller Insider Review

This is from Shelf Awareness a daily bookseller newsletter. When I get a new review I often quickly scan the text for key phrases so I know what I'm in for. In this case my eyes instantly landed on the words "well intentioned failure" and my heart sank. Next time I think I'll just start from the top. -Ethan.

Crazy Like Us: The Globalization of the American Psyche by Ethan Watters (Free Press, $26, 9781416587088/141658708X, January 12, 2010)

Ethan Watters stirs up one controversy after another in this provocative study of mental illness diagnosis and treatment in cultures other than our own. In the best investigative reporting tradition, he examines the incidence and current treatment regimens for anorexia in Hong Kong, schizophrenia in Zanzibar, depression in Japan and post-traumatic stress disorder (PTSD) in Thailand, Sri Lanka and Indonesia following the tsunami of 2004.

Watters argues that we have effectively spread worldwide an idea that "mental illnesses exist apart from and unaffected by professional and public beliefs and the cultural currents of the time." This has occurred through the prevailing use of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders as a basic reference tool; training of other countries' mental health professionals in the West; and drug companies' marketing campaigns that emphasize predominantly Western perspectives. In interviews, he hears again and again that mental health professionals, by ignoring important cross-cultural factors, may be doing more harm than good in many circumstances.

Watters's report on mental health practitioners arriving in Sri Lanka after the 2004 tsunami with very little understanding of the country and culture is particularly disturbing. The generally accepted Western course for effective healing from PTSD is to process the trauma experience with the help of a trained therapist. Watters views the wholesale application of Western treatments in Sri Lanka (without taking account of the culture and recent brutal 30-year-long civil war) as having been a monumental waste of energy and resources.

That well-intentioned failure is still not as disconcerting as the story Watters has to tell about GlaxoSmithKline (manufacturers of Paxil) in Japan. "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," Watters writes of Japanese beliefs before 2000. Despite Japanese thinking to the contrary, GlaxoSmithKline saw a huge potential market for Paxil and mounted a massive marketing campaign that combined savvy marketing and questionable scientific research. That campaign eventually bulldozered cultural resistance and long-held beliefs--by 2008, GlaxoSmithKline was selling $1 billion of Paxil annually in Japan.

"The ideas we export to other cultures often have at their heart a particularly American brand of hyperintrospection and hyperindividuality... [reflecting] the Cartesian split between the mind and the body, the Freudian duality between the conscious and the unconscious," Watters notes as he implores all to carefully consider cross-cultural factors at play when storming in to treat mental illness in other countries.--John McFarland

Shelf Talker:
A provocative study of American mental illness treatments that often harm, not help, people in other countries.


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