The Western Mind

For centuries, psychology has been shaped by the Western perspective. Western researchers and participants, Western scientific methodologies, Western philosophical assumptions about the human mind. This has created a framework of psychological theory and practice that, when applied on a global level, or even to the increased diversity in modern cities, is fundamentally lacking. While we readily accept the powerful interaction between mind and environment on a more general level, why do we then neglect its vital importance in how psychological distress is experienced and expressed?

For example, take the biomedical approach that is currently front-and-centre in Western psychological treatment. This is rooted in empirically validated data, stresses the biological roots of mental illness, and tends to prioritise pharmacological treatment. Think of the serotonin hypothesis for depression. Depression results from a neurochemical imbalance, a lack of serotonin – it must therefore be treated by rebalancing neurochemistry. Hence SSRIs.

Intuitively, this is appealing. Scientific objectivity has produced remarkable breakthroughs in physical medicine and it’s our most reliable system for establishing knowledge. However, this strict adherence to scientific objectivity falters when handling the vast subjectivity of the mind. All our cosmic ignorance regarding the nature of consciousness, deeply enmeshed with personal and cultural nuance, is not able to be captured through current methods of scientific objectivity.

The biomedical model’s fundamental flaw lies in its oversimplification of mental experiences, which are far messier, more subjective, and inextricable from socio-cultural environment. It is however, the easier way to empirically validate results. Much easier to compare rates of recovery with 0mg, 25mg, and 50mg control groups than by trying to quantify and measure the impact of community dynamics, cultural beliefs and rituals, or social connectedness. Yet by failing to consider these subjective, qualitative factors, we neglect such a dramatic portion of one’s subjective experience of mental illness.

Western psychological paradigms often fail to address this complexity. The dualistic orientation to mind and body also fails to holistically understand mental illness, arguing that mental illness lies in faulty biology. This aligns with biomedical priorities, but disregards the intricate interplay of mind, body, and environment, if one even considers those as distinct entities.

Cognitive Behavioural Therapy (CBT), the holy grail of psychological intervention in the NHS, exemplifies this limitation. While effective for many, CBT is inherently individualistic, requiring that the individual engages in a quest of introspection and cognitive restructuring, with no consideration for the fundamental importance of social and community dynamics in most people’s wellbeing, particularly in non-Western cultures.

The bible of this Western biomedical reductionism is the DSM. This titan of a book categorises mental illnesses into neat classifications of symptoms and diagnoses, e.g., 5 or more symptoms in the DSM classification of depression, and you have depression. These are all based on the latest empirical research alongside extensive debate and review by the American Psychiatric Association (APA). This book loosely implies that there are universal patterns of mental illness, and only increased scientific precision can get to the bottom of them.

Almost laughably, more abstract mental illnesses in other cultures are termed under the heading ‘Culture-Bound Syndromes’, as if there are some syndromes that are culture bound and some that aren’t. For example, Indonesian men experience amok, in which a minor social insult leads to extended brooding followed by murderous rage. In the Middle East, there is zar, related to spiritual possession that brings about dissociative bouts of crying, laughing, shouting, and singing. The idea that these are strange, defective manifestations of ‘normal’ mental illness is undoubtedly tied to notions of civility, and that diagnoses within the Western-bound DSM are the ‘normal’ way to experience psychological strain.

All these ideas are pointing to the idea there exist self-imposed confines of Western practice that impede our ability to map the mind. Mental health is deeply tied to cultural, social, and environmental contexts of which non-western traditions and holistic approaches are often more equipped to navigate.

This critique is not a rejection of Western science but an invitation to broaden its horizons. Despite its many strengths, its emphasis on the biomedical nature of mental illness stems from an overconfidence in the ability of the scientific method when grappling with illnesses that reside in the hazy waters of consciousness.

Anorexia in China/Hong Kong

Watters first explores how anorexia manifests differently in Western and Eastern contexts, highlighting how cultural factors influence mental illnesses. Anorexia is generally understood to be caused by intense fears of fatness and/or body dysmorphia, predominantly affecting young, high-achieving women from relatively affluent backgrounds. It’s an illness that has been extensively studied, neatly codified in the DSM, and heavily publicised in Western culture.

Watters recounts the case of Jiao, who presented with some typical anorexia symptoms: skipping meals, social withdrawal, abdominal discomforts, rapid loss of weight, low mood. However, contrary to western presentations of anorexia, Jiao had no such fears of being overweight. This is likely because historically, fatness in Chinese culture has more positive attributions – of wealth, fortune, good health – and so wouldn’t have made sense as a means to communicate distress. Instead, she described ‘an impossible lump in her throat’ that left her unable to eat, a physiological symptom far removed from typical Western presentations. 

Moreover, Jiao’s background didn’t fit the typical Western demographic for anorexia. Rather than being predominant amongst well-off, popular and promising young women as is the case in the West, anorexic girls in China were often from poor families and were lower achievers in school. 

This points to a broader truth about psychosomatic illnesses: contrary to the efforts of the DSM, they are only broadly categorisable, with symptoms being influenced by prevailing cultural narratives. Doctors and patients reinforce one another’s understanding of what an illness should look like, creating a shared framework that lends legitimacy to certain patterns of distress. In this way, the prevailing cultural script of a particular illness guides how individuals express their distress, consciously or unconsciously, in order to fit what is understood and recognised within a particular cultural context.

Jiao’s experience made sense within her cultural context, where body image concerns weren’t a dominant narrative. The bidirectionality of how manifestations of mental illness and understandings of mental illness shape each other is visible in how, from the 1990s, as Western diagnostic frameworks and mental-health paradigms grew in global influence, anorexia in the East began to mirror Western presentations.  Following the death of Charlene Hsu Chi-Yung, a girl who starved herself in order to be thin, anorexia went from being a tiny minority of cases to a full-blown epidemic. In effect, as the notion that psychological distress could be expressed via anorexia became mainstream through the propagation of Western culture, people became more and more anorexic, and in increasingly Western fashion. As the reported cases increase, so does the publicity, so does medical concern, and then so increases the pertinence of this particular method of communicating distress.

In other words, in an unconscious effort to make their suffering legible to others, patients align their symptoms within the dominant narratives of their culture.* The reason why Jiao’s anorexia didn’t align with the usual fears of fatness is because that wouldn’t have made sense in her cultural surroundings. As the awareness of anorexia became increasingly Westernised, fears of fatness made more sense as a means to communicate psychological distress, so the very experience of the illness began to change. 

This raises an important question: if the manifestation of mental illness is shaped by a combination of environmental triggers, personal disposition, and culturally bound understandings of the illness, how useful can a universal diagnostic framework be, when two of these factors are culturally specific?

I feel this is where more dynamic, individually attuned approaches to psychological treatment may be more effective, rather than attempting to force patient’s experiences into rigid universalised diagnostic criteria. A doctor applying the DSM-guided approach to Jiao’s case would assume a certain nature of the illness, without fully exploring its cultural nuances.

*A fascinating exploration of this idea regarding FND is Suzanne O’Sullivan’s The Sleeping Beauties’

PTSD in Sri Lanka

The 2004 Sri Lankan Tsunami of 2004 brought swathes of Western mental health professionals to the island. Despite good intentions, many came with the assumed superiority of Western scientific understandings of mental illness. Under the guidance of the DSM, they presumed the universality of trauma and expected Western treatments to be the most effective at handling the local manifestations of psychological distress.

This perception meant these professionals, often unfamiliar with the local language and culture, rarely consulted local leaders and healers, believing their methods would be insufficient at addressing such trauma. Psychopharmacological interventions dominated, antidepressants flooded the island. In one anecdote, it was reported that a mental health organisation was literally handing out packages of SSRIs to whoever wanted them.

Interestingly, while these Western aid workers assumed Sri Lankans, shaped by years of hardship and civil war, would be more psychologically vulnerable, the opposite was found to be true. Sri Lankan culture had evolved pluralistic methods of coping with suffering, involving local healers, religious leaders, and community tradition. Hindu and Buddhist traditions that emphasise the active acceptance of pain and suffering, as well as the meaningfulness of pain, offered powerful protective frameworks from psychological distress.

There was also a remarkably social orientation to trauma-healing. Western PTSD assumes the problem resides in the mind of the individual, but Sri Lankans’ trauma largely resides in the social realm. One mother, consoling her son about the violence in the community, didn’t offer the promise of protection or survival, but rather the togetherness in suffering: ‘If we die, we will all die together’. The Western ‘put on your oxygen mask first’ analogy for mental health didn’t apply; there was no separation between personal and communal healing.

This psychological paternalism, reinforced by Western funding, actually disrupted local healing practices. Many local practitioners, with extensive knowledge in local healing traditions, abandoned their expertise to gain the extra resources/funding of western aid organisation. Worse still, many Sri Lankans were forced to reinterpret their distress through foreign constructs like the DSM understanding of PTSD, undermining their personal and culturally rooted understandings of their distress.

Ultimately, the lesson is clear: effective mental health aid requires a deep acknowledgement and incorporation of local cultural frameworks and idioms of distress.*

*The question regarding the extent of the universality of suffering is unclear, but very interesting. In a dream study, I’d have a massive, longitudinal, cross-cultural neuroimaging and qualitative study of the various manifestation of suffering.

Schizophrenia in Zanzibar

Schizophrenia is a particularly interesting example of cultural influences on mental illness due to the presence of delusions and hallucinations. The abstract and individually oriented nature of these provides even more explicit demonstrations of how social/cultural values become intertwined with the manifestations of mental distress.

In the West/Judeo-Christian-centric cultures, schizophrenia is characterised by either paranoia, that they are being watched, spoken to, or tracked by some negative force, or delusions of grandiosity, believe they hear, and sometimes are, God.

In contrast, non-western hallucinations more commonly report visual delusions of ghosts and spirits, and delusions of grandeur are rare (a distinction perhaps tied to the more individualistic orientation of western culture).

A distinction is made between pathoplastic aspects of a disease, which vary from person to person, and pathogenic aspects, which is assumed to be the root cause of the disease.  Western biomedical approach to psychology often focusses solely on the pathogenic, assuming this to be the fundamental nature of the illness, and dismisses the pathoplastic as incidental content.

However, the importance of pathoplastic elements of mental illness is clear in how the context of schizophrenia may profoundly affect recovery rates: patients in developing countries fare better than those in industrialised countries, patients in rural settings fare better than those in urban settings. Assumptions of a universal form of schizophrenia overlook these differences.

The West also tends to pathologise mental illness as a negative aspect of someone’s identity – someone is a schizophrenic. In many non-western cultures, antisocial, mentally dysfunctional behaviours are seen as temporary, just part of life’s natural ebb and flow. This reduces the stigma surrounding the symptoms, allowing families and communities to empathise and support individuals without labelling them as ‘ill’, and thus out-grouping them. In Zanzibar, for example, spirit possession, though alien to Western psychology, serves as a culturally meaningful explanation for erratic behaviour, relieving individuals of the accountability that is usually accompanied by shame and self-hatred. Bad mental health, no different to bad physical health, is like a natural disaster; unavoidable, uncontrollable, the best cure being support and love in the community. The problem is not the individual, as implied in Western contexts, but the inexorability of fate. In conjunction with religious beliefs emphasising acceptance and the meaningfulness of inevitable suffering, one can see the benefits of such an environment in the healing of illness. Studies show these cultures tend to have more forgiving and less blame-oriented responses to mental illness.

‘Certain cultural values (e.g., fatalism) in traditional groups might engender more benign and less blaming attributions towards 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 behaviour’.

Our individual nature in the west stresses accountability and individual senses of accomplishment and control. Thus, the loss of internal control generally assumed upon those with mental illness is, in effect, a form of social deviancy.

Viewing those with mental disorders as diseased sets them apart and leads us to perceive them as physically distinct. This impedes relatability, community, and social connection, which are fundamental to proper healing.

One anecdote illustrates the power of these culturally rooted approaches to healing. Since his daughter’s death Kassim had been waking up in the night, at about the same time he received the phone call, and upon falling back asleep was assailed by vivid and disturbing dreams. Rather than considering he had some genetically predetermined, neurochemical imbalance, he believed he had picked up some troubling spirits while at the graveyard burying his daughter. A teacher at a local Koran school gave him a transliteration of some prayers so he could pronounce them in his native Kiswahili. He recited the prayer each night in words he could not understand, and through this was able to sleep soundly.

Depression in Japan

The most nefarious aspect of Western psychological understanding lies not in the neglect of how cultural contexts shape mental distress, but how the psychopharmacological industry, wielding western scientific research, has exploited these understandings to turn mental illness into a mass profit industry. Watters describes in detail how GlaxoSmithKline (GSK), seeking to expand the market for their SSRI, Paxil, invested immensely in shifting the dominant narratives of depression in Japan to one in which their cure was the most effective.

Before the 1990s, depression in Japan was understood as Utsubyô, a rare chronic depressive state that would affect one’s ability to live as much as severe schizophrenia. In word-association studies, depression was largely associated with external factors, like bad weather, disease or exams, while in the West, usually associated with internal factors, moodiness, loss of motivation, etc. The traditional approach to suffering, rooted in Buddhist practices of acceptance and gratitude, doesn’t see mental states like melancholia, sensitivity, or fragility as negative, but as natural aspects of the human experience that offer opportunities for personal growth, self-awareness, and deeper understanding. In the West, they are pathological, and must be cured with whatever scientific approach has been deemed most valid.

Likely due to the immutability of prevailing cultural narratives regarding depression, SSRIs failed repeated testing amongst Japanese populations, and failed to outperform placebos in many unpublished studies. GSK’s attempts to market SSRIs in Japan were looking to be a failure.

However, through an extensive advertising campaign, publication of favourable research/stifling of unfavourable research, and the ethically dubious co-opting of medical professionals, GSK redefined depression to ‘a mental state/set of behaviours that relate to a loss of connectedness to others/a decline in social status/personal motivation’. Shifting what was previously considered an external problem to an internal one. They shifted the understanding of a mental illness while at the same time marketing the cure. Genius. They also had the moral safety net that they were saving the Japanese people just didn’t know they had yet.

These efforts increased the potential market of Paxil from a few rare cases to the vast majority of slightly unhappy people. Doctors could now prescribe them for anyone reporting relatively minor symptoms. Like in the earlier case of anorexia in China, as this new understanding of depression gained mainstream attention, along with the aid of medical professionals, it then shaped how people would communicate their distress, creating a feedback loop that would uphold the GSK notion of depression.

This proved hugely profitable, and by 2008 Paxil was earning GSK over a billion dollars per year in Japan.

This is not to say that depression was not an issue in Japan. In fact, suicide has been a major social concern in Japan, with rates more than twice those of the US. It’s also not to say that Paxil could do nothing to aid the troubled mental states that result in suicide. What’s concerning is how Western conceptualisations of the illness bulldozed local traditions and belief systems with the goal of profit, as well as the insidious nature of how it was achieved.

Final Thoughts

Conscious thought is inherently subjective, rooted in the individual nuances of one’s genetics, personal experiences, and environment. Psychological distress is fundamentally shaped by this subjectivity. Therefore, objective measures and classifications are inherently reductive. While useful in a clinical context, ie. treating the most patients in the most methodical way, it is vital to recognise where they fall short in understanding and engaging with mental illness. Western psychological models would improve their ability to navigate the mind with an open and thoughtful integration of local understandings and healing traditions. As diversity in populations increases, this becomes increasingly important – the more tied to local frameworks an individual is, the less effective these Western-bound frameworks will be. The most pragmatic and effective strategy to healing lies in combining the knowledge and efficacy of Western psychological practice with a sincere engagement with the individual’s unique socio-cultural context and its influence their psychological distress.