Understanding Culture To Understand Mental Health

Mental illness is extremely common across the world, but attempts to achieve a universal understanding of such disorders are flawed. Unpacking the complex sociological phenomenon of the practice of diagnosis reveals that culturally insensitive methods are a strong cause of our societal shortcomings in accurately understanding mental illness. Socially constructed cultural disparities are widespread, and, as a society, we must confront them through the creation of culturally attuned mental health practices.

An apt example of such cultural disparities is that of anorexia in Hong Kong and the United States in the late 1980s and early 1990s. Experiences with anorexia were once considered to be differentiable between Eastern and Western societies because the causes and symptoms were said to differ. In Hong Kong, anorexia was highly uncommon, and its causes were rarely attributed to the common “Western” causes: “Fat phobia” and intentional dieting. Dr. Sing Lee, who studied anorexia in Hong Kong, commonly received patients suffering from the disorder, though they most often attributed their self-starving behavior to chronically “bloated stomachs” instead. The prevalence of, and societal attitudes towards, anorexia in Hong Kong changed dramatically with the abrupt death of an anorexic adolescent female, Charlene Hsu Chi-Ying, in 1994. Western media publications covered the news, providing their own culturally-influenced medical explanations for Charlene’s death and noting the causes of anorexia. The Western media’s medical understanding and portrayal of anorexia was influential. “In the wake of Charlene’s death,” reporter Ethan Watters writes, “the transfer of knowledge about the nature of anorexia (including how and why it was manifested and who was at risk) went only one way: from West to East. The changes in societal perceptions of anorexia were salient to Dr. Lee. “Lee once saw two or three anorexic patients a year; by the end of the 1990s he was seeing that many new cases each month. […] In contrast to Lee’s earlier patients, these women most often cited fat phobia as the single most important reason for their self-starvation. By 2007 about 90 percent of the anorexics Lee treated reported fat phobia.”

Disorders can occur in various manners and degrees of intensity; in fact, the influence of one culture upon another can lead to conforming and societal shifts. In this case, the influence of Western media led to a re-evaluation of the definition of anorexia in the eyes of Hong Kong’s residents. Ideas of mental illness—in this case, the perception and diagnosis of anorexia in Hong Kong—are social constructs vulnerable to change. Our instincts, in defining mental illness as in many other facets of life, are subconsciously ingrained in us through the norms of our cultures and societies, thereby obstructing the ability to determine an objective and global definition of mental illness. The fact that a society’s perceptions of anorexia could change so quickly due to the ideas purveyed by Western media exposes how fragile and almost arbitrary our societal norms can be.

Indeed, it seems that cultural landscapes can shift quite erratically, and shifts such as Hong Kong’s call into question the legitimacy of others around the world. Research by Watters exposes just how fluid our cultural norms truly are. In his book Crazy Like Us: The Globalization of the American Psyche, he explains that in the 1990s, depression in Japan was understood to be a rare disorder only experienced by handful of individuals. Those who did suffer from “classic” symptoms of depression, such as consistent feelings of sadness and hopelessness, were often told that they were not suffering from depression and that the causes of their feelings were merely physical. Depression was not viewed as commonplace or something that afflicted “normal”, everyday individuals. The only treatment for this type of suffering—feelings of sadness, worthlessness, et cetera—was getting some physical rest.

"While, of course, it is not always possible to predict or halt a cultural shift, there are preemptive conscious efforts we can take to promote culturally attuned practices from the grassroots level up."

The view of depression as being a treatable, complex interaction of biological, psychological and genetic factors has been primarily a Western view. The Japanese acceptance of their country’s norm, on the other hand, could be attributed to a combination of strong cultural stigmas against outward displays of suffering, traditional norms discouraging the understanding of one’s emotions, and historical, collectivist factors related to order and a disinclination to challenge the status quo. In the late 1990s, the contrasting Western view of depression suddenly and surprisingly permeated Japan thanks to the marketing campaign of a pharmaceutical company, GlaxoSmithKline, that wished to increase sales of their antidepressant, Paxil. The company described depression with the universally catchy phrase kokoro no kaze: a cold of the soul”.  As a result, “word was spread about depression, […] it could happen to anyone, and medication could treat it.” This repainting of depression as a no-longer rare and completely treatable illness led to drastic shifts in social attitudes towards the disorder in Japan. Soon, sales of antidepressants, as well as tracked incidences of diagnoses of this disorder, increased massively. This example shows the effect of ingrained societal factors when it comes to each culture’s unique views towards mental illness. Savvy marketing was key in the redefining of depression in Japan. In just a few short years, depression was refashioned and marketed in a manner which led to an immense cultural shift in Japan towards Western values.

In these examples, massive cultural shifts occurred due to the influence of Western media and a pharmaceutical company’s marketing campaign. These cultural shifts, which had huge effects on individuals, were brought about by almost haphazard causes. Although in the case of antidepressants in Japan, the shift towards destigmatization of mental illness and increased accessibility of antidepressants seemed for the better, our societies should still regard culturally insensitive approaches with caution. The implications of imprinting a cultural norm onto another culture, or taking a “bird’s-eye” approach to mental illness treatment, can be perilous. In the example of anorexia, it seems that the spread of norms though Western media increased prevalence massively. The conforming to and establishment of Western perspectives in Hong Kong, created detrimental effects—the society’s original anorexia problem was very different from its more grave successor that followed the mass coverage of Chi-Ying’s death.

Desultory influences such as the “mega-marketing of depression” are careless measures which disregard the need to recognize each culture’s individual history, norms, and mannerisms before pushing for massive societal changes. While, of course, it is not always possible to predict or halt a cultural shift, there are preemptive conscious efforts we can take to promote culturally attuned practices from the grassroots level up. For one, Western diagnostic manuals—notably, the DSM-IV—should not be used in a vacuum by healthcare providers, as they are typically biased towards the experiences of those in the West. Rather, more emic approaches such as “a perspective focus on the intrinsic cultural distinctions that are meaningful to the members of a given society” are important, since it is not possible to accurately and effectively institute standardized methods of diagnosis and treatment indiscriminately. For example, prior to the cultural shift regarding anorexia in Hong Kong, Dr. Lee’s original study of anorexia involved such an approach by taking into account the incredibly unique experiences of the young women—even going as far as hypothesizing that a special, “indigenous” form of anorexia existed only local to that region. Rather than applying a Westernized approach to his studies, or assuming a general, uniform diagnosis of anorexia, he focused on culturally specific details and differences.

Additionally, it is essential for health care providers to be cognizant of their own cultural biases, and cultural differences existing between themselves and the patient. Interestingly, even within the US, miscommunications attributed to lack of cultural sensitivity by healthcare providers is an issue, resulting from the nation’s vast multiculturalism. For example, research has shown that certain African-Americans have not found medical or healthcare professionals to be culturally sensitive towards or conscious of unique experiences of marginalized groups. The medical anthropological approach to treatment—which examines cultural, historical, biological, religious, moral, spiritual, socioeconomic, and a multitude of other societal aspects—is extremely comprehensive and should be more integrated into health care systems worldwide.

The promotion of more culturally sensitive practices on the grassroots level would increase knowledge and understanding of our own culture’s experience of mental illness. Consequently, a better and more confident understanding could help prevent arbitrary influence by other cultures with differing experiences, and eventually lead to the creation of more culturally sound and culturally specific infrastructures across societies.

Photo: “Pills 3”

About the Author

Madeline Noh '22 is a Staff Writer for the Culture Section of the Brown Political Review. Madeline can be reached at madeline_noh@brown.edu