Crazy Like Us

1. The Global Export of the American Psyche

Our golden arches do not represent our most troubling impact on other cultures; rather, it is how we are flattening the landscape of the human psyche itself.

Homogenizing the mind. The book argues that American culture's most profound and disturbing global influence isn't just through consumerism like McDonald's, but through the widespread export of its understanding of the human mind and mental illness. This "Americanization" of the psyche is flattening the diversity of human suffering, replacing unique cultural expressions with Western diagnostic categories and treatment approaches. This process, often driven by good intentions, has unforeseen and significant consequences for global mental health.

Unintended consequences. Over the past three decades, American ideas about mental illness, including definitions and treatments, have become international standards. This has led to a global homogenization of how people experience and interpret mental distress. The book highlights how this influence is evident in the changing manifestations of mental illnesses worldwide, such as the rise of eating disorders in Hong Kong, the widespread adoption of PTSD after disasters, and a particularly Americanized version of depression spreading globally.

The virus is us. The core premise is that the "virus" spreading these mental illness manifestations is American culture itself. By teaching the world to think like us about the mind, we are inadvertently homogenizing the ways people "go mad." This raises critical questions about the universality of mental illness constructs and the impact of Western scientific and cultural assumptions on diverse human experiences of suffering.

2. Mental Illnesses are Culturally Constructed

In the end, all mental illnesses, including such seemingly obvious categories such as depression, PTSD, and even schizophrenia, are every bit as shaped and influenced by cultural beliefs and expectations as hysterical leg paralysis, or the vapors, or zar, or any other mental illness ever experienced in the history of human madness.

Diversity of suffering. Mental illnesses are not uniformly distributed or expressed across the globe; they appear in endlessly complex and unique forms shaped by local cultures and historical contexts. Examples include:

• Amok in Indonesian men: Brooding followed by murderous rage.
• Koro in Southeast Asian males: Debilitating certainty of genital retraction.
• Zar in the Middle East: Spirit possession leading to dissociative episodes of crying, laughing, shouting, and singing.
  These "culture-bound syndromes" highlight how deeply intertwined mental distress is with specific cultural narratives and beliefs.

Historical fluidity. The forms of madness also change across time within the same culture. Ian Hacking's "Mad Travelers" documented a fleeting fugue state in Victorian Europe where young men would walk for hundreds of miles in a trance. Similarly, the epidemic of hysterical leg paralysis among upper-class women in the mid-19th century reflected societal restrictions on women's roles. These examples demonstrate that symptoms are "lightning in the zeitgeist," products of specific times and places, not immutable biological facts.

Beyond biomedical. Western mental health often assumes a biomedical, scientific understanding of mental illness transcends cultural influence. However, cross-cultural research reveals that people invariably rely on cultural beliefs and stories—whether of spirit possession or serotonin depletion—to understand their suffering. These narratives profoundly shape the experience, course, and outcome of the illness, challenging the notion of universal, culture-independent disorders.

3. The "Symptom Pool" Effect: How Awareness Shapes Disease

Patients unconsciously endeavor to produce symptoms that will correspond to the medical diagnostics of the time.

Unconscious adoption. People experiencing psychological suffering often draw from a "symptom pool" of culturally recognized expressions of distress. When a new illness category is officially named, described, and popularized by medical professionals and the media, it enters this pool, making it a more likely unconscious choice for individuals seeking to articulate their internal turmoil. This dynamic creates a feedback loop where public and professional attention can inadvertently increase the incidence of a disorder.

Historical precedent. Edward Shorter's work on hysteria and anorexia in Victorian Europe illustrates this. Before anorexia nervosa was formally recognized in 1873, self-starvation was a rare, inchoate symptom. Once named and debated by prominent doctors like Laségue, it became a codified "template" for suffering, leading to a dramatic increase in cases. The medical establishment, by validating the symptom, inadvertently disseminated a model for how patients would behave and doctors would respond.

Modern parallels. The phenomenon is not confined to history. The sudden rise of multiple personality disorder (now dissociative identity disorder) in the late 20th century, or the dramatic increase in anorexia after Karen Carpenter's death, show how public and professional attention can bring a disorder into prominence. This suggests that mental health professionals, by researching and publicizing disorders, are inevitably involved in maintaining and shaping them, even if unintentionally.

4. Anorexia's Shifting Face: From Somatic Distress to Fat Phobia

Most, for instance, did not display the classic fear of fatness common among Western anorexics, nor did they misperceive the frail state of their body by believing they were overweight.

Atypical presentation. Before Western influence, anorexia in Hong Kong presented differently. Dr. Sing Lee's early patients often denied fear of fatness or desire to lose weight for attractiveness. Instead, they attributed food refusal to physical causes like abdominal fullness, bloating, or digestive issues, reflecting a historical Chinese tendency to somaticize psychological distress. They were not the "golden girls" of Western literature, often coming from poorer families and lacking the moral superiority sometimes observed in Western anorexics.

Historical echoes. Lee found striking similarities between his "atypical" Hong Kong patients and early self-starvers in 19th-century Europe, before anorexia nervosa was a recognized diagnosis. These historical cases also reported somatic complaints (lumps in the throat, painful digestion) rather than fat phobia, suggesting a pre-codified form of the illness. This led Lee to believe he was witnessing a rare, pre-20th-century expression of self-starvation, uninfluenced by Western cultural beliefs about body image.

The tipping point. The death of 14-year-old Charlene Hsu Chi-Ying in 1994, widely publicized in Hong Kong media, served as the "epidemiogenic trigger." News reports, drawing on Western experts and the DSM, introduced the "Western template" of anorexia, emphasizing fat phobia and distorted body image. Subsequently, the presentation of anorexia in Hong Kong rapidly shifted, with patients increasingly reporting fear of fatness as their primary motivation, demonstrating how the imported diagnostic framework reshaped the disease experience itself.

5. PTSD's Western Lens: Overlooking Local Resilience and Causing Harm

A victim processes a traumatic event as a function of what it means. This meaning is drawn from their society and culture and this shapes how they seek help and their expectation of recovery.

Universalizing trauma. Following the 2004 tsunami, Western mental health professionals rushed to Sri Lanka, predicting a "second tsunami" of PTSD and advocating for immediate psychological interventions. They assumed a universal psychological reaction to trauma and that Western methods were superior, often dismissing local coping mechanisms as "denial." This led to a chaotic influx of foreign counselors, many lacking cultural or linguistic understanding, and the widespread use of PTSD checklists that failed to capture local idioms of distress.

Cultural disconnect. Sri Lankan academics warned against reducing survivors' experiences to "mental trauma," emphasizing that the meaning of a traumatic event is culturally derived. Dr. Gaithri Fernando's research revealed that Sri Lankans often experience trauma somatically (aches, pains) and primarily in terms of damage to social relationships, rather than internal psychological states like anxiety or numbing. Their sense of well-being is deeply intertwined with fulfilling social roles and community connection, making individualistic Western counseling potentially counterproductive.

Undermining resilience. Western interventions, such as insisting on direct "truth-telling" about violence, often clashed with local customs like "cautious words" in Sri Lanka, which were designed to contain violence and prevent escalation. Anthropologist Alex Argenti-Pillen found that promoting "fearlessness" and pathologizing ambiguous speech could destabilize fragile social balances, inadvertently removing brakes on violence. This highlights how imposing Western trauma narratives can disempower local healing practices and inadvertently cause harm by disrupting culturally evolved coping strategies.

6. Schizophrenia's Better Prognosis: The Power of Cultural Acceptance

What we say about mental illness reveals what we value and what we fear.

The outcome paradox. Cross-cultural studies, particularly two large WHO studies, revealed a perplexing finding: people diagnosed with schizophrenia in developing nations (e.g., India, Nigeria) often have a better long-term prognosis, with less severe symptoms and higher social functioning, than those in industrialized countries (e.g., US, Denmark). This challenges the purely biomedical view, suggesting that cultural and social factors play a significant role in the disease's course and outcome.

Low expressed emotion. One key factor identified is "expressed emotion" (EE) within families, which includes criticism, hostility, and emotional overinvolvement. Families in developing nations tend to exhibit lower EE, fostering a more accepting and less critical environment for the patient. In Zanzibar, Juli McGruder observed families like Amina's displaying remarkable tolerance and equanimity towards schizophrenic relatives, viewing their illness as "God's wishes" or a burden to be embraced, rather than a personal failing to be criticized or "fixed."

Spirit possession as a buffer. Traditional beliefs, such as spirit possession in Zanzibar, paradoxically reduce stigma. Instead of blaming the individual, bizarre behavior is attributed to external spirits (jinns), making it more understandable and forgivable. These beliefs also offer socially accepted interventions (rituals, prayers) that keep the sick person integrated into the social group and allow for a "cleaner bill of health" during remission. This contrasts sharply with Western views that often isolate and stigmatize the mentally ill.

7. The Stigma Paradox: Biomedical Explanations Can Increase Social Distance

The result of the study suggests that we may actually treat people more harshly when their problem is described in disease terms.

Unintended consequences. Western mental health professionals and advocacy groups have vigorously promoted the "brain disease" or biomedical model of mental illness, arguing it would reduce stigma by shifting blame from the individual to biological factors. However, studies show the opposite: as belief in biological causes has increased globally, so has the perception of dangerousness and the desire for social distance from the mentally ill. This "stigma paradox" is evident in countries like Germany and Turkey, where endorsing biological causes correlates with a greater desire for social separation.

Dehumanizing effect. The biomedical narrative, while seemingly compassionate, subtly implies that a brain made ill by genetic or biochemical abnormalities is more fundamentally and permanently broken than one affected by life events. This can lead to viewing the mentally ill as "almost a different species," as demonstrated in a study where subjects delivered harsher electrical shocks to partners whose mental illness was described in "disease terms" versus "psychosocial terms." This dehumanizing effect can justify increased control and criticism, as seen in Abdulridha's treatment of his sister Shazrin in Zanzibar.

"Just chemistry." The reduction of complex human experiences—love, suffering, joy—to "just chemistry" can be deeply stigmatizing and devaluing for individuals with mental illness. It strips away the personal meaning and identity associated with their struggles, leaving them feeling like "defective biological units." This narrative, while embraced by many healthy individuals as a scientific truth, is rarely applied to their own emotions, highlighting its unappealing and isolating nature when applied to mental distress.

8. Mega-Marketing a Disease: How Pharma Reshaped Depression in Japan

To make Paxil a hit in Japan, it would not be enough to corner the small market of those diagnosed with utsubyô. The objective was to influence, at the most fundamental level, the Japanese understanding of sadness and depression.

Creating a market. In the early 2000s, pharmaceutical giant GlaxoSmithKline (GSK) faced a challenge in Japan: the market for antidepressants was tiny because "depression" (utsubyô) was understood as a rare, severe, psychotic illness with high stigma. GSK embarked on a "mega-marketing" campaign, not just to sell a drug, but to fundamentally reshape the Japanese public's perception of sadness and depression, transforming it into a common, treatable medical condition. This involved a sophisticated understanding of cultural nuances, gleaned from experts like Laurence Kirmayer.

Historical resistance. Japan had a long history of different understandings of distress:

• Utsushô (Edo era): Stagnation of vital energy, not an illness, but a respected state requiring social or moral meaning.
• Neurasthenia (early 20th century): "Frayed nerves" as a disease of modernity, initially elite, then widespread, eventually restigmatized.
• Endogenous depression (post-WWII): Severe, genetic psychosis.
• Typus melancholicus (mid-20th century): Valued sadness, associated with diligence and empathy.
  Japanese language for sadness (yuutsu, ki ga fusagu) often included somatic symptoms and reflected a less individuated self, with melancholy often seen as character-building.

The "Lost Decade" opportunity. The economic downturn of the 1990s ("Lost Decade") and high suicide rates created social anxiety. Prominent cases like Oshima Ichiro's "karojisatsu" (suicide from overwork) litigation linked suicide to depression, shifting public perception. The Kobe earthquake further highlighted perceived Japanese deficiencies in mental health response compared to the West. This fertile ground, combined with a TV special on Peter Kramer's "Listening to Prozac," primed the Japanese public for a new understanding of depression.

9. "A Cold of the Soul": The Strategic Normalization of Depression

The slogan, depression is like a ‘cold of the soul,’ has convinced far too many people to seek medical treatment for something that is often not an illness.

The "kokoro no kaze" metaphor. GlaxoSmithKline's marketing campaign ingeniously employed the metaphor "kokoro no kaze" ("a cold of the soul") to normalize depression in Japan. This phrase simultaneously conveyed three key messages:

• Depression was not the severe, stigmatizing condition of utsubyô, but a common ailment.
• Taking medication for depression was as simple and worry-free as taking cold medicine.
• Like colds, depression was ubiquitous, affecting everyone from time to time.
  This metaphor effectively softened the connotations of depression and made it more palatable to the Japanese public.

Multi-channel influence. GSK utilized a multifaceted approach to disseminate these messages, circumventing direct-to-consumer advertising bans:

• Recruitment ads for clinical trials doubled as brand promotion.
• Public service announcements broadly defined depression and encouraged seeking help.
• Internet marketing (e.g., utu-net.com, a GSK-funded "patient advocacy" site) offered self-diagnosis quizzes.
• Media saturation with articles on rising depression, often touting SSRI benefits.
• Leveraging public figures like Crown Princess Masako, whose antidepressant use boosted the drug's profile.
• Economic framing that linked untreated depression to lost productivity, appealing to a nation grappling with recession.

Contradictory but effective. The marketing messages were often inconsistent, blending notions of severe endogenous depression with the valued melancholic personality, and linking overwork to a brain chemistry imbalance. However, their coherence was secondary to their effectiveness in shifting cultural perceptions. The campaign successfully transformed depression into a legitimate, widespread concern, leading to a dramatic increase in diagnoses and Paxil sales, despite initial Japanese resistance to mood-altering drugs.

10. Compromised Science: The Illusion of Efficacy and Safety

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.

The serotonin myth. A cornerstone of SSRI marketing, including in Japan, was the claim that depression is caused by a "chemical imbalance" or serotonin deficiency, and that SSRIs restore this balance. However, this "serotonin depletion hypothesis" was publicly abandoned by its proponent in 1970 and has never been scientifically confirmed. The idea that SSRIs restore a natural balance is a marketing story, not a scientific fact, broadly altering brain chemistry rather than correcting a specific deficit.

Ghostwriting and data manipulation. David Healy's research exposed how pharmaceutical companies systematically control the scientific knowledge pipeline. By funding major studies, hiring medical writing companies to ghostwrite papers for prominent academics, and selectively publishing positive results while suppressing or spinning negative ones, drug makers create a distorted picture of drug efficacy and safety. This practice has become a public scandal, particularly concerning GSK and Paxil.

Paxil's hidden risks. A landmark 2001 study on Paxil in adolescents, led by a prominent Brown University psychiatrist, was published as "generally well tolerated and effective." However, internal GSK documents revealed the study actually showed "insufficiently robust" efficacy and a more than fivefold increase in serious side effects, including hospitalizations and suicide attempts, compared to placebo. This deliberate misrepresentation of data highlights how scientific integrity is compromised, misleading doctors and patients about the true benefit-risk balance of these drugs.

11. The Peril of "Helping": Undermining Global Mental Health Diversity

Offering the latest Western mental health theories in an attempt to ameliorate the psychological stress caused by globalization is not a solution; it is a part of the problem.

A global crisis of meaning. The global economic crisis of 2009, like past social upheavals, created fertile ground for new mental illness categories and treatments. The proposed "post-traumatic embitterment disorder" (PTED), for instance, reflects a Western tendency to pathologize reactions to social and economic distress. This continuous creation and export of new disorders, often accompanied by pharmaceutical marketing, risks further homogenizing human suffering and undermining diverse cultural ways of making meaning from hardship.

The "blanket" analogy. Exporting Western mental health models without appreciating cultural differences is akin to "handing out blankets to sick natives without considering the pathogens that hide deep in the fabric." These interventions, while well-intentioned, can inadvertently exacerbate distress by:

• Undermining local beliefs about healing.
• Discrediting culturally created conceptions of the self.
• Imposing a hyper-individualistic and hyper-introspective view of the mind.

Rethinking generosity. The Western mind, shaped by Cartesian dualism, Freudian psychology, and self-help philosophies, often reduces the mind to a "batter of chemicals" in the skull, disconnected from the social and natural world. Other cultures, however, maintain more intertwined conceptions of mind, body, and community. The book urges a critical re-evaluation of this "generosity," suggesting that our confident assertions of universal mental health solutions may be driven by our own cultural biases and insecurities, ultimately eroding the invaluable diversity of human understanding and resilience.

Last updated: January 1, 2026