Within the field of medical sociology, there has been debate about whether biomedical diagnoses legitimate or stigmatize patient groups. Some argue that biomedically recognized diagnoses for ‘contested illnesses,’ such as Chronic Fatigue Syndrome (CFS), provide patients with a sense of relief – that their problems do not exist only in their heads (psychosomatically), but is medically recognized in their bodies. This is important insofar as it legitimizes and lends weight their experiences, which can be tested and subsequently treated in certain ways. Physicians, as well as employers, insurance companies, and family members, begin to take them seriously by socially recognizing their condition as ‘real.’
With other conditions, biomedical recognition works the other way around. For example, in eating disorders, patient groups have successfully advocated for a more holistic approach to treatment, arguing that the illness exists not only in their bodies (with regards to diagnostic criteria such as weight loss and amenorrhea), but also in their minds (i.e., obsessive thoughts, body dysmorphia, anxiety), which must be treated with psychotherapy.* For decades, eating disorder treatment consisted primarily of re-feeding and weight stabilization in psychiatric hospitals. Once patients reached a certain weight, they were released and presumed to have been “healed” of their illness. Patient advocacy groups and patients themselves, outraged over high relapse rates, pushed for longer treatment programs that incorporated in-depth psychotherapy and holistic modalities (such as art therapy). They successfully argued that eating disorders involve, at their root, deep and systemic disturbances in cognition and behavior patterns that can’t be fixed quickly. Tired of being told they should just “get over it,” or that eating disorders are just “a phase,” patients groups pushed to get their condition biomedically (and thus, socially) legitimized as a serious mental illness – not just something they can “turn off” with enough willpower. In many ways, this has led to better social acceptance and empathy for people struggling with disordered eating.
But what about biomedical explanations for mental health conditions that do not lead to social acceptance?
Take schizophrenia, for example. In the West, a schizophrenia diagnosis can push someone into social alienation and ostracization almost overnight. But as Ethan Watters (2011) argues in Crazy Like Us: The Globalization of the American Psyche, it’s not that way in every society. How we treat people with schizophrenia is highly dependent upon the culture in which we live.
Watters describes research in medical anthropology that demonstrates how people with schizophrenia in developing countries tend to be treated better than those in developed countries. A large study by the World Health Organization (WHO 1973) found that, “Whereas 40 percent of schizophrenics in industrialized nations were judged over time to be ‘severely impaired,’ only 24 percent of patients in the poorer countries ended up similarly disabled” (Watters 2011:137).
In light these findings, researchers in cross-cultural psychiatry put forward several possible explanations. Perhaps demands placed on workers in poorer countries are lighter and easier to meet, or perhaps it is more acceptable to be productively employed within one’s family through practices like child care or gardening. Others suggested that rules about appropriate behavior and social expectations are clearer and simpler in non-industrialized nations. Still others suggested that, perhaps, the rules of behavior for living in industrialized societies are simply overwhelming to schizophrenics, exacerbating symptoms (such as hallucinations and paranoia), thus increasing rates of disability and social isolation.
Janis Hunter Jenkins, a medical anthropologist specializing in cross-cultural presentations of schizophrenia, poignantly points out the following about the schizophrenia-culture connection:
In sum, what we know about culture and schizophrenia at the outset of the twenty-first century is the following: Culture is critical in nearly every aspect of schizophrenic illness experience: the identification, definition and meaning of the illness during the primordial, acute, and residual phases; the timing and type of onset; symptom formation in terms of content, form, and constellation; clinical diagnosis; gender and ethnic differences; the personal experience of schizophrenic illness; social response, support, and stigma; and perhaps most important, the course and outcome with respect to symptomatology, work, and social functioning.” (Jenkins 1998:357, emphasis mine)
All this is to say that not only does symptomatology vary by culture, but so too do levels of social acceptance and functioning. In developing countries, the mental states of schizophrenics do not disrupt their connections to family and society as much as they do in developed, industrialized countries.
Whether there is disruption to social functions has everything to do with the type of etiological explanation employed by the culture in question.
In the West, schizophrenia is described biomedically as a severe brain disorder in which a person suffers from a disconnection with reality. Genetics, early environment, and neurobiology are all described as important contributory factors in developing schizophrenia. But most crucial to our cross-cultural discussion of the phenomenon here is that it is viewed as a discrete, static condition – that is, one either has or is schizophrenic, or one does not – and one is schizophrenic for their entire lifetime.
Contrast this with Zanzibar. In Zanzibar, schizophrenia is viewed partly as an intense inhabitation of spirits. This means that Zanzibaris often view people with schizophrenia as experiencing a passing phenomena. Psychotic episodes are socially tolerated as unfortunate but endurable, and most importantly, impermanent. This stands in contrast with biomedical explanations in the West, which defines schizophrenia as a brain disorder “[carrying] the assumption of a chronic condition, one that often comes to define a person” (Watters 2011:151).
This has everything to do with how a person with schizophrenia is treated socially – particularly in light of current gun control debates going in America. Some political groups have suggested creating a national database of the mentally ill, singling out people who suffer from mental illness as potential social menaces and would-be mass killers. Schizophrenics in particular are pointed out as troublesome, citing the fear that they may engage in homicidal behavior during psychotic episodes.
To bring this discussion about biomedical explanations, social ostracization, and cultural differences full circle, I’d like to argue the following:
In the case of schizophrenia, biomedical explanations about the nature of the condition make it possible for society to simultaneously ‘other’ schizophrenics as permanently unstable and label them as an always-potentially dangerous group. A biomedically-charged diagnosis in developed countries carries a heavier burden than in developing countries, where schizophrenia is viewed more as a temporary trouble than a permanent label. And in the wake of current gun control debates, a biomedical diagnosis can potentially lead to increased social control through the creation of a national database for the mental ill and potential social restrictions on those who might be registered in such a database. In short, biomedical diagnoses can potentially lead to increased social control.
In conclusion, I wish to say that it is important as medical sociologists that we consider the varying contexts of diagnoses and what they symbolize socially as well as medically in different cultures. In the case of schizophrenia, a biomedical diagnosis serves to stigmatize patients and isolate them socially. The potential for diagnoses to lead to increased social control – an argument made best, perhaps, by Ivan Illich in 1975 – is as timely today as ever. We must tread carefully during gun control debates to avoid trashing the civil liberties and social dignity of those with a mental health diagnosis in the interest assuaging our fears, lest we jeopardize not only our democratic ideals, but also our empathy.
Jenkins JH. (1998). Diagnostic criteria for schizophrenia and related psychotic disorders: Integration and suppression of cultural evidence in DSM-IV. Transcultural Psychiatry. 1998;35:359–378.
Watters, Ethan. (2011). Crazy Like Us: The Globalization of the American Psyche.
WHO. (1973). “Report of the International Pilot Study of Schizophrenia.”
Metzl, Jonathan. (2010). The Protest Diagnosis: How Schizophrenia Became a Black Disease.
Illich, Ivan. (1975). Medical Nemesis.
* Please note, this has not been a complete victory. Many patients have struggled to get their mental health services covered by insurance, though the Mental Health Parity and Addiction Equity Act of 2008 has helped in the United States. Eating disorders are, by and large, still viewed and treated biomedically by MDs, who may be not be well attuned to their patients’ mental health needs.