Lorin Kleinman   Reading, writing, and occasionally eating.

A woman tries to walk across a room, but collapses. Another suddenly goes blind, for no obvious physical reason. Victorian hysteria, clearly a product of a time when women lived highly constricted, repressed lives. A veteran suffering from PTSD, on the other hand: doubtless a real disease, immutable, applicable in all situations and cultures. Not so, says Ethan Watters, who convincingly argues that all mental illnesses are circumscribed and molded by the cultures in which they occur. A person who is distressed will express it by drawing from whatever pool of symptoms is available in his culture–which may well be entirely different from what is available in my culture.

In Crazy Like Us: The Globalization of the American Psyche, Ethan Watters, a veteran journalist who presented a scathing indictment of the recovered memory movement in Making Monsters, examines four illnesses in four parts of the world: anorexia in Hong Kong, PTSD in Sri Lanka, schizophrenia in Zanzibar, and depression in Japan.

These four illnesses (and cultures) are quite different from each other, but share something important: none of them looked like the accepted Western clinical definition of the disease. Anorexics in Hong Kong did not believe that they were fat, trauma sufferers in Sri Lanka tended to describe physical symptoms and damage to family relationships rather than psychological problems, schizophrenics in Zanzibar were believed to be possessed by spirits, and in Japan, milder forms of depression were not viewed as an illness that required treatment.

Watters describes a world far from the definitive-sounding edicts of  the DSM (the diagnostical and statistical manual of psychological disorders, the handbook of Western psychology); one in which distress is signaled in an enormous variety of ways. “The simple but mind-bending truth,” the anthropologist Allan Young explains, “is that mental illnesses such as PTSD can be both culturally shaped and utterly real to the sufferer.” This world collides unhappily with the immutable-disease view of much of the Western mental health establishment.  (Anne Fadiman’s The Spirit Catches You and You Fall Down makes a good companion read.)

Western health professionals increasingly treat patients throughout the world, and Watters suggests that they are often far less helpful than they believe. A DSM-trained therapist, unwilling to consider that a Hong Kong anorexic does not believe herself fat, is unable to hear what the patient is actually saying. This is one problem with the globalization of the DSM. An even larger concern is that in the course of describing an illness, particularly if the description is dispersed widely throughout a culture, therapists may actually create an illness where it did not exist before. The local expressions of mental illness begin to disappear, and the clues that could have been gleaned from them are lost.

Crazy Like Us is not a polemic against Western mental health care: it is clear that competent Western therapists can be very helpful, under the right circumstances. It is equally clear, though, that they can be distinctly unhelpful under the wrong circumstances, when they fail to understand that their definitions are not universal.

This is especially clear in Sri Lanka, as American therapists rush to the scene of the tsunami, insisting that the local population has no understanding of trauma, and no idea how to treat victims. The psychology professor Ken Miller suggests that we consider the opposite scenario, with Mozambicans telling 9/11 survivors which rituals they need to engage in to sever their relationships with deceased family members. That the therapists earnestly believe themselves to be doing good makes these scenes no less disturbing. They explain that large segments of the population will fall victim to PTSD, and that it is not necessary to understand Sri Lankan culture to make this prediction. (There is an obvious connection to Watters’ previous work, with echoes of the victim mentality that characterized the recovered memory movement in these PTSD predictions, as well as in the medicalization of very minor depression in Japan. Human beings occupy a large spectrum, from fragility to resilience, and it’s not clear why fragility should be the default option.) These therapists are, of course, wrong: Sri Lankan history is sadly full of tragedy, and Sri Lankans have developed specific and effective methods of coping with it.

In all of these cultures, a shift is underway to a more Western view of the mind. Watters believes that a society is most susceptible to this influence when it is under a great deal of strain: the Chinese takeover in Hong Kong, for instance, or the tsunami in Sri Lanka. These changes do not happen on their own, but tend to be encouraged by outside agencies. The most striking instance that Watters describes of Western intervention is a successful attempt by a consortium of pharmaceutical companies to change the definition of depression in Japan, through an enormous and society-wide campaign. The high regard in which U.S. knowledge is held in much of the world makes such attempts to influence local mental health practices particularly effective–and dangerous.

From the U.S. point of view, the culture-blind promotion of Western ideas on the mind could appear to be a good thing. Shift your vantage point a bit, though, and these efforts look misguided and even harmful. This is a brilliant and genuinely paradigm-shattering book.