Globalization of the Medicalized's Effect on Western Notions of Mental Health

This essay will discuss how, in contemporary society, a person’s state of being can become classed as a medical illness through the process of medicalization in western society and then how those ideas become transported to other parts of the world through globalisation. This essay will first discuss what medicalization is with reference to the foundational work of Peter Conrad with two ways he believes society encourages medicalization. Then, how medicalised western notions of mental health conditions are becoming a universal truth around the world due to globalization, the effect that has on the society taking on those western ideas and the overall negative effects of homogenising mental illness will be examined. This will relate to three examples, outlined in Ethan Watters book surrounding how western notions of mental illness are spread including western notions of Anorexia Nervosa being taken over to Hong Kong, depression to Japan and post-traumatic stress disorder to Sri Lanka. This will relate sociologically as the examples will focus on what societal factors cause and allow for the globalisation of the western ideas to occur and impact on the society in which has western ideas imposed upon them. Prior to the examples, however, the work of Edward Shorter and Laurence Kirmayer will be touched on as their work may provide an explanation for how and why cultures differ in how they experience and understand mental illness.

Medicalization is the name given to the process by which behaviours that were previously thought to be non-medical, though they may be seen as deviant or abnormal in some cases, become redefined as a medical condition thus allowing the medical field to intervene with diagnosis, prevention and treatment. This phenomenon ties into the sociological concept known as social construction. When something is socially constructed, there is a shared, accepted idea of how something should be within society created by the people in that society. This ties into medicalization as a society and the medical field have socially constructed illnesses out of behaviours that were previously not a medical issue. Society has accepted the ideas that certain behaviours are medical conditions so therefore medical conditions have a socially constructed nature. This does not mean however that symptoms and conditions are not real, it simply means that the medical diagnosis given to a set of symptoms or behaviours is created by people in society and is therefore socially constructed.

Conrad suggests there are particular social factors that encourage medicalization. One example Conrad gives is the changing organization and structure of the medical profession. The medical profession has power and jurisdiction over all thing’s health-related. Over time, the medical profession has encouraged medicalization as the more behaviours that are considered medical problems, the more power the profession has with the increasing number of areas it has jurisdiction over, suggests the medical field monopolizes, gains power and profits over previously non-medical behaviours becoming labelled as medical conditions. Pawluch and Halpern hypothesise differing ways that medicalization is caused by the medical profession.

Pawluch’s market hypothesis suggests that the medical profession adapts to maintain their power and relevancy. An example used is paediatricians who specialise in children's health. Previously they were needed to treat illnesses that have now been reduced and prevented by vaccination. In order to maintain relevance with the decrease in cases of sick children, children’s problem behaviours became medicalised so that paediatricians had something to treat such as hyperactive behaviour becoming Attention deficit hyperactivity disorder (ADHD). This allowed paediatricians to enhance their medical dominance by expanding their territory over which they have jurisdiction over. Halpern’s routinization hypothesis however suggests that medicalization occurs due to the fact that because of increased routine inpatient care which is tedious and uninteresting, new medical conditions have been created so that doctors can become specialised in new illnesses and then continue to work in academics, teaching about those new illnesses to medical students which is seen as more stimulating. High up physicians in the medical field can become managers of medicine while others perform the routine work. 

Another example Conrad suggests is that secularization, the decrease in importance that religion plays within society, may increase medicalization as religion is replaced by medicine and science. This largely occurred during the 18th century enlightenment period where rationalism was introduced, the medical model started, and the growth of modern science began. Conrad used the example of anorexia nervosa and said that the condition was used by individuals to reach their own new non-religious idea of perfection relating to their body image whereas previously with religion being a more influential and important part of society, perfection would have been gained by achieving inner spirituality. Anorexia, the medicalized term for starvation behaviour, is an example of medicalization which has occurred due to societal factors, in this case, the lack of a religious presence. Both aspects mentioned in a society that encourages medicalization to appear to correlate with a western society which could suggest why western societies have many examples of medicalization including the three examples in the following paragraphs. For example, the Office of National Statistics shows a decrease in religious influence in Western society stating that in England and Wales, the predominant religion Christianity, dropped from 72% to 59% of the population reporting to be Christian from 2001 to 2011, 4.1 million fewer people. Also, 6.4 million more people were reported to be non-religious in the same time frame, increasing from 15% of the population to 25%. Although unfortunately, these statistics do not cover all western society, these two countries are integral parts of western society. Surís, Holliday and North studied the American Diagnostic and Statistical Manual (DSM) throughout time, a manual about mental disorders used by health professionals to diagnose mental illnesses and used in America as well as other areas of western society, and found that there was an increase in the number of clinical diagnoses from 106 diagnoses in the first edition published in 1952 to 265 in the third published in 1980. This provides evidence for medicalization occurring, showing the increasing number of behaviours being redefined as medical conditions.

In order to move on to how western medicalized ideas of mental illnesses become globalised and impact others, we first must understand how and why cultures have differences in response and beliefs about mental illness by looking at how society affects the unconscious mind. Edward Shorter and Laurence Kirmayer’s work can help to explain this. Shorter coined the term symptom pool which is essentially a limited number of symptoms/behaviours (ways of presenting illness) in a society that is considered as a signal for suffering. The symptom pool is a collective belief within a society but different between societies. He believed that when an individual faces an internal feeling that is difficult to express, they latch onto a symptom from this symptom pool as a means of expression. There is a difference between cultures in terms of what is expressed/ what symptoms are chosen because different symptoms in different cultures are recognised as signals of suffering. Shorter gave the example that Anorexia Nervosa in America is thought to be unconsciously chosen by an individual experiencing psychic distress in American/western society, to express what they are feeling as starvation in western society is a recognised signal for suffering. Shorter explains that people adopt certain behaviours over others as a means of expression because of the culture in which that individual life signals to them the appropriateness of the behaviour/symptom in the society. Society sends more signals to individuals if the behaviour/symptoms associated with an illness are considered legitimate. Legitimacy is increased by medical professionals having an increased interest in an illness and behaviours/symptoms associated with the illness, the medical field providing individuals with information about which symptoms are considered serious and the acknowledgement that certain behaviours show symptoms of legitimate illnesses such as starvation being a legitimate behaviour for Anorexia. The more signals of legitimacy sent by society to individuals the increased likelihood of that behaviour being chosen to express inner turmoil. Because of the legitimacy of anorexia in western society due to the aforementioned factors, this could explain why cases of anorexia have increased over time. Individuals are increasingly likely to unconsciously choose symptoms of Anorexia such as starvation behaviours to express their internal feelings as they know that society will consider them as having legitimate suffering as they are performing symptoms of a legitimate mental illness. This also shows how culture is shaping the unconscious mind to create behaviours that correspond to medical diagnoses in society so that they can express themselves. Kirmayer’s cycle of symptom amplification ties into Shorter’s symptom pool. Cultures have different ways of explaining various mental states such as depression. Cultures have different ways of explanation due to them having different beliefs about how the mind and the body function together and these beliefs direct individuals in that society towards/away from certain feelings/experiences of mental illness. This is the cycle of symptom amplification, the unconscious way in which individuals latch onto a symptom in the symptom pool that society directs them towards.

The globalization of western ideas regarding mental illness has a large impact on how the rest of the world views and experiences mental illness, an overall homogenising mental illness which can have negative consequences. Three examples of the globalization of western notions of mental illness from Watters will be examined with an interest in what societal factors allowed for globalisation to occur. The first example of the globalisation of western medicalized ideas of mental illness is the spread of Anorexia Nervosa to Hong Kong. The turning point that led to the sudden rise of the westernized version of the illness was the public death of 14-year-old Charlene Hsu Chi-Ying in 1994. She had collapsed on the very busy public Wan Chai Road and subsequently died because she had been starving herself. Due to the public nature of her death, it sparked the attention of the media but because this starving behaviour and subsequent death were so uncommon in Hong Kong previously, the media attempted to explain to the population what this behaviour was and why she partook in such behaviours. To do this, reporters turned to western society as they were experts in that area because we had already medicalized a term for the behaviour and researched the behaviour. Because western society provided Chinese journalists with their ideas about what Anorexia was, that pushed Western ideas onto Chinese society, so the population started to have the same beliefs about Anorexia as the West did. Chinese interest in fashion also increased during this time, increasing the interest in body image which also allowed starvation behaviour to become part of the symptom pool for society in Hong Kong. This could explain why there was an increase in the number of cases of Anorexia in Hong Kong after 1994, because now starvation behaviours were in the unconscious minds of the population, so members of the population were increasingly likely to choose starvation behaviours to express inner turmoil. This was a nervous time for Chinese society anyway as Charlene’s death was just after the Tiananmen Square protests in 1989 where thousands of people were killed while demonstrating for more liberal rights. Charlene's death was also just before Hong Kong was handed over from British to Chinese rule in 1997. Both factors, among many more could explain why there was an increase in cases of anorexia because starvation behaviours were used to express feelings of nervousness during a difficult time in Chinese and Hong Kong’s history.

The second example is the globalization of westernized depression to Japan. Watters describes the events of Laurence Kirmayer, a social psychiatry expert, being invited to a conference held by the pharmaceutical company GlaxoSmithKline. GlaxoSmithKline was trying to sell their antidepressant drug ‘Paxil' in Japan. To Kirmayer, it appeared that GlaxoSmithKline was not interested in a discussion about their drug itself but in information regarding cultural differences in the beliefs and experiences of depression and whether those beliefs about depression in Japan could be changed in order to better sell their drug. Although Japan does have a clinical definition for depression, termed Yuutsu, it is seen as much more severe and rare than in western society, often leading to hospitalisation as opposed to western ideas where depression can be related to a feeling of sadness as well as a serious clinical disorder. Tanaka-Matsumi and Marsella provide evidence for the differing ways in which Japanese and American (Western) cultures understand and experience depression. They conducted an experiment on Japanese and American university students where Japanese students were asked to say three words associated with Yuutsu and American students were asked to do the same with depression (the western term). Japanese were shown to look externally to explain Yuutsu such as the weather being grey or raining, or situations like exams that could cause a depressive-like state. Americans, however, explained depression as something to do with an individual's internal emotional state such as sadness or loneliness. Japan also has a culture of sadness, where sadness is embraced and dealt with in drama, song, and spirituality amongst other things. Sadness is also culturally respected in Japanese society as it is used as a moral compass by many to guide people to make correct life decisions and find meaning in life. For GlaxoSmithKline to sell more Paxil in Japan, they first need to understand and then change the way Japan thinks about depression. This means westernizing the Yuutsu definition, to the belief that even though depression can be clinically serious, it can also be less serious such as the feeling of sadness being defined as Yuutsu. It also means changing the Yuustu definition to become more internalised. Because internal states associated with the western idea of depression are more common such as sadness, especially in Japanese culture which embraces sadness, if GlaxoSmithKline could market their drug to individuals in Japan with emotional feelings such as this then they could sell to a large majority of the population as opposed to selling purely to individuals with a serious clinical mood disorder that requires hospitalization. This overall shows an example of how a western pharmaceutical company is trying to globalise and homogenise western notions of mental illness, in this case, depression, to profit from an increased number of drug sales, expanding the jurisdiction of medicine.

Lastly is the effect that western notions of PTSD, the medicalization of disorderly behaviours following the experience of a traumatic event, on Sri Lankan culture. Following the tsunami that hit Sri Lanka after an earthquake in the Indian ocean on the 26th of December 2004, trauma councillors came in from the west to help. The councillors believed that the survivors in Sri Lanka would be suffering from PTSD resulting from the event that they had endured so they went in with preconceived notions of what PTSD looked like, how to help PTSD sufferers etc, ideas that they had taken from the western medicalized notions of PTSD. The councillors did this without prior knowledge and understanding of how Sri Lankan culture might deal with a situation like this differently from how this would be dealt with in western society. After a traumatic event, western societies tend to believe that the trauma negatively affects the mind causing PTSD to manifest. In Sri Lankan culture, however, they see the experience as negatively affecting their social world, their role in society and their family and friendships, not a break in their brain but a break in their social setting. Due to these differences, both cultures have different ways of coping and healing. When western councillors went in with their notions of how to heal, although they had the best intentions, they altered the way in which people deal with situations, detaching cultures from their traditional ways to heal, cope and understand emotions. The medical anthropologists, Kleinman and Becker state how ignorant it is of the west to assume that all beliefs and experiences of mental illness are the same and that emotional traumas are dealt with in the same way all over the world, a westernized way. They also say that it is extremely arrogant to impose the way we think onto other cultures without first understanding the way in which they think. Overall, western notions of how trauma is dealt with have spread to Sri Lankan culture due to the society being weak after the 2004 tsunami. The west willingness to help without first understanding cultural differences has negatively affected how individuals in that culture deal with trauma, dethatching Sri Lankans from their traditional ways of healing.

Globalization of western ideas of medicalized mental illness, causing a homogenising effect of mental illness around the world, has negative consequences. It changes the expression of mental illnesses in different parts of the world. If we change the way people express and understand the illness, then we are unifying the human psyche around the world without first understanding the ways that they think so we are missing out on what we can learn about coping and understanding/expressing emotions from different cultural perspectives. We are detaching cultures from their traditional ways to heal, cope, understand emotions and thinking about the mind. Taking western notions of anorexia to Hong Kong has increased the number of people with the illness as it has become a larger part of the symptom pool. GlaxoSmithKline trying to westernize the notions of depression in Japan removes their cultural respect for sadness and replaces it with a mental illness that needs to be treated by medication. And although western councillors had the best intentions, rushing over to Sri Lanka after the tsunami in 2004 negatively impacted the way in which survivors dealt with the trauma. They were told that they were to deal with the breakage in their mind and treat their PTSD when the people from Sri Lanka never saw that breakage in the first place. Western society appears to believe that because the west is advanced and technological, that the ideas in western culture about mental illness are factually correct all over the world however, they are not, they are socially constructed through medicalization and encouraged through societal factors just like in other parts of the world. The popularization of medicalized western mental illness to other parts of the world has been shown through these examples to be detrimental to those cultures taking on the western definitions.

This essay has shown what medicalization is and what societal factors encourage medicalization through the use of the work by Peter Conrad which may possibly explain why western societies have medicalized so many behaviours previously thought of as non-medical. The work of Edward Shorter and Laurence Kirmayer were used to show how and why different cultures have varying beliefs, expectations and cases of individuals with mental illnesses, which provides evidence for the socially constructed nature of health and illness. And lastly, this has shown three examples of cultural forces spreading the notions of the western interpretation of mental illness and the negative effect that that has, the consequences of the globalization of western medicalised terms and the forces that allowed for globalization and medicalization to occur. As a takeaway from this, we must learn to appreciate the cultural differences in the understanding and expression of mental illness, and we must understand that we have an impact on those understandings, so we must be careful to not impose our western ideas to cause a negative impact on other societies.

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