Medical anthropology has a long history and we can gain invaluable insights into the human condition and its ills from studying this tradition. Viktor von Weizsäcker (highly regarded by Finnish psychiatrist-psychoanalyst Martti Siirala), a physician, medical anthropologist and existential psychiatrist, made important contributions to the field of psychosomatic medicine and was very influenced by Martin Buber. Von Weizsäcker emphasized the self isolation of the person with psychosis, there is little Thou for its I. The result of this absence is the installation of this double, for the state of this aloneness is unbearable (see the work of HS Sullivan, Frieda Fromm-Reichmann and Melanie Klein on loneliness). The split in the I reflects on the felt unattainable relation of I to Thou. Von Weizsäcker, in his medical anthropology, recognizes the difference between an objective understanding of something and the ‘transjective’ understanding of someone. The patient is a subject, like the physician, who cannot become an object without a loss of vital contact.The most important aspect of ‘inclusive’ therapy, according to von Weizsäcker, is that the physician allows her/himself to be changed by the patient (see Searles ‘patient as therapist’ as well as the work of Gaetano Benedetti), this contact brings the I and Thou closer together. Contemporary medical anthropologists, such a Sue Estroff (at the University of North Carolina, Chapel Hill), Kim Hopper (at the Nathan Klein Psychiatric Research Center in NY), H. Fabrega (see his “Origins of Psychopathology: The Phylogenetic and Cultural Basis of Mental Illness” published in 2002 by Rutgers University Press), Arthur Kleinman (chair of the Department of Anthropology at Harvard University and author of “Writing at the Margin: Discourse Between Anthropology and Medicine” published in 1995 by Berkeley, University of California Press), and Meredith Small (Cornell University) have much to offer us in terms of a deeper understanding of how culture impacts on the expression and course of the mental disorders.

Meredith F. Small (2006), a professor of anthropology at Cornell University, in her recently published volume “The Culture of Our Discontent: Beyond the Medical Model of Mental Illness,” offers us a thoughtful critique of the Western medical model of mental disorders from a sociological-anthropological perspective. I will summarize some of her main points, which I find are a necessary corrective to the genocentric and biology- apart- from- environment- culture or person approach highlighted in Western psychiatry. In her volume, Small interviews Arthur Kleinman, psychiatrist and chair of the Department of Anthropology at Harvard University, She describes his critique of what is missing in current Western psychiatry as follows:

“...an understanding of how the human mind is entwined with the whole experience of being an individual embedded in a family, a culture, and a society. Mind and body cannot be separated, and both are affected by everything else in life. He believes quite strongly that all human experiences are social, and that to understand someone’s mental state you must know everything about that person’s relationships” (p. 149).

Kleinman thinks what is absent from good health care today is an anthropological approach-being a careful observer and a good listener, particularly being interested in the details of the patient’s relationships. Kleinman noted: “Suffering gives a sense of what are some of the deeper and more significant aspects of social experience” (p. 149).

Small points out that how we are socialized,how our cultures and economies change, how we internalize loss and fear according to the norms of the culture, are all important, and when mental health clinicians turn a blind eye to the very personal aspects of illness, they do not see how deeply we all are affected by forces other than genes, biochemistry, viruses, etc.  Javier Escobar pointed out that the social, not only defines how a mental illness is expressed, but also guides thinking on the prognosis. In the US we accept that the rates for depression are higher in women than men. We attribute this to a host of biological factors. However, the gender difference in depression is found primarily in the US. Indeed, it has been reported that depression is very rare in certain other countries, e.g., Iceland.Kleinman notes:

“What we take a symptom to be is a cultural matter, as is the assumption that a symptom mirrors a single deficit in physiological process. That assumption is not only cultural but naive.”

Small remarks that, so far, there is no data showing that the Western medical model of mental illness is better than other cultural models. In fact, the WHO studies demonstrate the reverse (this is one interpretation of the data showing significantly better recoveries in the developing countries over the Western countries).Perhaps, we have something valuable to learn from these cultures in how best to treat persons with a severe mental illness. Embedded in the move towards a biomedical model is the assumption that biology is both the cause and cure of mental illness.

Cultural factors strongly influence medication use. It is very difficult to track prescription statistics in this country in the private sector, however, psychiatrist Randolph Nesses discovered that prescriptions in the US for mental disorders increased from 131 million in 1988 to 233 million in 1998. I am sure this number is much higher now. It is easier to track medication prescriptions in countries with a nationalized health care system. In Great Britain, physicians wrote 8 million more prescriptions for agents which relieve anxiety and depression in 2003 than in 1998, a five year difference. In Canada, prescriptions for antidepressants increased 64% between 1996 and 2000.

In terms of psychopharmacological efficacy for depression, in one analysis of 19 placebo-controlled clinical trials of antidepressants, Irving Kirch and Guy Sapirstein (2003-”Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication, Prevention and Treatment 1: 1-14) found that only 25% of the increase in mood could be attributed to the active agent, while 50% was due to the placebo effect. In other words, expectancies make for very powerful real changes in brain biochemistry and mood regulation. In 2005, GlaxoSmithKlein had suppressed results of clinical trials on adolescent use of the antidepressant Paxil.

Antipsychotic agents are now being prescribed for a variety of conditions and at younger ages. Contrary to public opinion, no one really knows how the agents work, when they do work. In addition, no one knows what price the culture will pay , for relying on pharmaceuticals as first-line treatment for an ever growing list of mental disorders. To the questions:
Are we losing our minds? Our souls? I would add, are we losing valuable opportunities to make cultural changes in our health care system, in our very ways of treating and understanding each other? Are we depriving patients, and physicians, of potentially valuable learning opportunities, e.g., of the powerful effects of what neuroscientists call ‘top-down processing,’ of how one and one’s cultural surround can help in mood regulation. A case in point: one of my patients diagnosed with paranoid schizophrenia and placed on mandated medication treatment (he was placed on AOT-a program in NY which was originally designed for violent, to self or other, patients who resisted treatment, ie, medications) never took the medications yet was afraid to tell his team in fear of being sent back to hospital. His delusions cleared up in psychotherapy, and he has been symptom free for over a year now. His team congratulates him on taking the medications and that they led to his becoming non-psychotic. I realize that this is one case and that many patients can potentially be helped by the judicious use of medications, however, it is good to keep in mind that the standard view of medicating ‘axis I’ disorders and giving psychotherapy to ‘axis II’ disorders may be an artificial dichotomy. Both can impact significantly on gene expression and neurochemistry.

Small concludes her interesting and informative volume with these words:

“What other cultures and other models of mental illness-the evolutionary model, the nutritional model, the idea that genes and environment interact...teach us that there are all sorts of ways to conceive of human behavior, and all have validity for treatment. These models show that the human mind is universally known to be quite fragile. The mind apparently needs social connections, a stable culture, and a psychological way to cope with life’s uncertainties. That stability might be provided by a belief in witchcraft, or psychoanalysis, or psychotropic drugs; each has its advantages and disadvantages...

The panoply of models and belief systems to explain human mental states is most of all, I think, a testament of hope. Mental illness is human misery; the opposite of misery is not happiness, but hope” (p. 157).

Small, M. F. (2006). The Culture of Our Discontent: Beyond the Medical Model of Mental Illness. Washington, DC: Joseph Henry Press.

The Culture of our Discontent
Brian Koehler PhD
New York University
brian_koehler@psychoanalysis.net