This just in from the Library Journal which reviews books in advance of their publication:

The United States has long been known as the country that sent fast food and hip-hop music to other parts of the world. Watters (Urban Tribes) asserts that America is pushing more than just its culture: American trauma counselors and mental health workers are convincing the world to adopt their definition of mental illnesses occurring in times of crisis. Through case studies, Watters shows how the symptoms and causes of anorexia, PTSD, schizophrenia, and depression have become more prevalent in Eastern countries owing to American influence. Watters urges readers to set aside cultural expectations of the causes of mental illnesses by illustrating the idiosyncrasies and so-called treatments of these diseases by Western clinicians in foreign nations. He deftly outlines the implications of American influence and the need to treat mental illness in a culturally appropriate context.

Verdict Watters commands attention with his repartee and conversational manner while drawing much-needed attention to the consequences of Western intrusion. This fascinating book deserves attention from mental health workers and Americans interested in the reach of their culture’s psyche across the globe.—Melissa Mallon, Univ. of Pittsburgh Johnstown

Here's the first version of the book cover that Free Press came up with. The foreign words, which all mean crazy in different languages, are supposed to form the image of a globe. The problem is that the readers -- unless they are exceptionally multilingual -- are not going to get the joke. Still, it was exciting for me to see a visual manifestation of the ideas in the book.



In the next version the designer at Free Press had the idea to replace country names with disease names. This left the question of what do do with the space over America. I suggested putting a phrenology head over the U.S. I was hoping that it would suggest both that the ideas came from us and that they had an element of pseudoscience.



This version made me more nervous than anything else. The fine people at Free Press seemed excited but I was worried that there was something else out there that we hadn't thought of. Authors are notorious complainers so I endeavored to continue the dialogue about the cover design with Free Press without sounding like I was just hard to please. I'd watched my friend Po Bronson engage in epic cover-discussions with his publishers. His tactic was to get involved, not just with criticism but with ideas and solutions. So I enlisted the help of JD Beltran, a friend and a talented artist and designer, to help me keep the conversation going.

In a matter of a day or so she came up with some startling ideas. Including:



and



and


I posted all the versions in the kitchen at the San Francisco Writers Grotto where I work and asked the 33 writers there to rate the cover concepts from- 10. Interestingly, JD's images tended to get 1s or 2s or 9s or 10s. Which is to say that people either really liked them or found them profoundly disturbing. In the end, I decided that I couldn't risk turning off a large chunk of my potential audience.

The map cover concept rated solid 7s and 8s. No one was thrilled but people thought it suggested a smart and interesting book. In the end the process gave me confidence in the designers at Free Press. All that was left to do was to figure out was something else to do with the space over America and also to suggest causation.  The solutions we came up with are unsubtle (nothing suggests causation better than arrows!) but get they point across.

Writers I've met over the years have some pretty harrowing stories about book cover negotiations -- tales where they get steamrolled by by the sensationalist or lowbrow proclivities of the publishing house. I'm sure editors and publishers share their own stories about writers who complain bitterly and endlessly about their covers. Less often told are the stories where everyone acts in good faith to keep the conversation alive until a reasonably good solution presents itself.

Here's the final version:

In my chapter about cultural differences in the expression of schizophrenia I traveled to Zanzibar to spend some time with anthropologist Juli McGruder who studied families on the island who lived with the disease. The chapter addresses the ways families in different cultures conceive of the disease and how those beliefs effect the experience of the ill person.

The auditory landscape of a place often becomes central to the experience of a schizophrenic. I've placed an audio clip of the sound of a public square in Zanzibar on the front page of this site because this is the soundscape in which a Hemed and his daughter Kimwana lived while they struggled with their disease. Sitting with anthropologist Juli McGruder and listening to the sounds of that square was a memorable moment for me in reporting this book.

 Kimwana's central delusion was that the bicycle repairman outside here house could see into her thoughts and feelings. That her 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 theday 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 West-
ernized 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.

    It is well known that American culture is a dominant force at home and abroad; our exportation of everything from our movies to our junk food is a well documented phenomenon. But is it possible America’s most troubling impact on the globalizing world has yet to be accounted for? In Crazy Like Us, Ethan Watters reveals the most devastating consequence of the spread of American culture has not been our golden arches or our bomb craters but our bulldozing of the human psyche itself: We are in the process of homogenizing the way the world goes mad.
    America has been the world leader in generating new mental health treatments and modern theories of the human psyche. We export our psychopharmaceuticals packaged with the certainty that our bio-medical knowledge will relieve the suffering and stigma of mental illness. We categorize disorders, defining mental illness and health, and then parade these seemingly scientific certainties in front of the world.  The blowback from these efforts is just now coming to light: It turns out that we have not only been changing the way the world talks about and treats mental illness – we have been changing the mental illnesses themselves.
    Local beliefs in different cultures have for millennia shaped the experience of mental illness into endless varieties. Crazy Like Us documents how American interventions have discounted and worked to change those indigenous beliefs, often with dizzying speed. Over the last decades, mental illnesses popularized in America have been spreading across the globe with the speed of contagious diseases. Watters travels from China to Tanzania to bring home the unsettling conclusion that the virus is us; as we introduce Americanized ways of treating mental illnesses, we are in fact spreading the diseases themselves.  
    In post-tsunami Sri Lanka, he reports on the western trauma counselors who, in their rush to help, inadvertently trampled local expressions of grief, suffering and healing. In Hong Kong he retraces the last steps of the teenager whose death sparked an epidemic of the American version of anorexia. He reveals the truth about a multi-million dollar campaign by one of the world’s biggest drug companies to change the Japanese experience of depression – literally marketing the disease along with the drug.
    But this book is not just about the damage we’ve caused in far away places. Looking at our impact on the psyches of people in other cultures is a gut check – a way of forcing ourselves to take a fresh look at our own beliefs about mental health and healing. Examining our own assumptions from a farther shore, we can begin to understand how our own culture constantly shapes and sometimes creates the mental illnesses of our time. If we can set aside our role as the world’s therapist, we may come to accept that we have as much to learn from other cultures’ beliefs about the mind as we have to teach.

In my chapter on the marketing of antidepressants in Japan I make the case that drug companies endeavored to sell both the American conception of depression along with the drugs purporting to cure that illness. Near the end of the chapter I take on what has to be one of the most polarizing issues in psychopharmacology today, namely: Whether SSRIs can sometime spark violent and/or suicidal behavior.

Unfortunately for me, I came to a conclusion that will no doubt anger both sides of a highly contentious debate.

Experts who have looked closely at the human trial data for SSRIs estimates that these antidepressants show a positive effect for about one in ten test subjects but that they can spark extreme agitation in about one in twenty patients. For some, that agitation, called akathisia, 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 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 poorly.”

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. This is because these two groups tend to use two different data sets to bolster their main point. The critics point to the human trials which chart patients’ first few weeks on the drugs. While the SSRI advocates tend to use larger population data sets which often show an overall decrease in suicides in populations that have access to these drugs.

Here’s why they could both come to legitimate – but opposite conclusions:

The agitation and aggression sometimes noted as a reaction to 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. More likely, attentive doctors may quickly take a patient off a drug if they note a severely negative response. (Which is to say that patients who respond well are more likely to stay on the drug for the long-term.)  

Thus it is possible that these drugs can 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 population.

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 in clinical trials might still be culpable. (More on this aspect of the debate in the book.) 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. Doctors almost certainly would have second-guessed prescribing this medication to those with only minor symptoms of depression.

    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, Tan-
zania. We shake our heads at the sight of a Mcdonald’s on Tianan-
men 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 cul-
tures; 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. . . .

Interesting article in the NY Times on new mental toughness training programs being tested on soldiers. What struck me was how experimental it was. No evidence that this works but they are trying it out anyway. This from the article:

But outside experts cautioned that the Army program was more an experiment than a proven solution. “It’s
important to be clear that there’s no evidence that any program makes
soldiers more resilient,” said George A. Bonanno, a psychologist at Columbia University. But he and others said the program could settle one of the ...<< MORE >>

The latest version of the American Psychiatric Association's influential diagnostic manual won't be out for a year or two. As if to prove the point that the designation of these illnesses remains as much a cultural and political project as it is a scientific one, the APA is soliciting input from the public.

As of this writing you can still make a suggestion. You can go here to register. And then you can:

Submit comments that serve to alert us about problems, limitations, or shortcomings
with DSM-IV-TR (without specific suggestions about how to fix ...<< MORE >>