The NURJ

Examining Mainstream Perspectives on Mental Health:  A Conversation with Medical Anthropologist Dr. Rebecca Seligman

As we have entered an era dubbed by many as a mental health crisis, questions have swirled around our conceptions of mental health, its diagnosis, and its treatment. I sat down with Rebecca Seligman, medical and psychological anthropologist and associate professor at Northwestern University, to talk about how our understanding of mental health, a matter more complex than we realize, is often incomplete. 

This interview has been edited and condensed for clarity. 

A lot of your work has to do with culture and mental health. Where do those two intersect, and how do they interact?

I think this is something that people don’t think about all that often, because there’s a  presumption that mental illness is something that’s universal and biologically driven. And this is the Western psychological/psychiatric model of what mental health and illness are about. There’s this presumption that it’s going to be the same wherever you go and that there might be some cultural differences that are superficial, but at the most basic level mental illnesses are these kinds of universal entities independent of all of the social and cultural phenomena that surround the individual. This is a super Western perspective because it’s also tied to a Euro-American model of people as discrete individuals who have private interiors, where things like emotions, thoughts, and therefore psychological distress live. Tied to that view of mental illness is the idea that we should treat or address mental illness by working directly on an individual at the individual level. And even when there are social causes or factors, it’s still at that individual level, so the responsibility, the cause, the location of treatment, all of those are at the individual level.

We then muster these kinds of resources and mental health treatment models that work at that individual level, which is the Western model. It has become increasingly widespread and has been exported from Euro-American contexts all over the world. Anthropologists have been researching and documenting for many years that the Euro-American model is very culturally specific and doesn’t necessarily apply everywhere. And the way that people’s mental health and their mental illness or distress manifests is really different in different places and might not adhere to that particular model at all.

But the message here is also not that this is how mental health and illness work in the U.S. and Western Europe, and it’s just different in “other” places, which is often sort of the take away that people have from cross cultural research. To me, the insight here is that the model that everything’s at the individual level, biologically-driven, and can be treated and dealt with at the individual level, actually doesn’t really apply anywhere. It is a problematic model that doesn’t take into account cultural and social factors in the U.S. or anywhere else. 

What gets defined as illness or disorder is always very much tied to a particular social and cultural context, and the norms and values that are dominant within the context. It’s a little simplistic, but helpful in the sense that it’s easy to understand, to say “what’s pathological in one context, what looks like a disorder — problematic behavior, emotional experience, or symptoms — might not be defined, perceived, or experienced that way in another context.”

I’ll just give you one example that I’ve worked on a lot. What used to be called multiple personality disorder is now called dissociative identity disorder; where people lose time, they do things they’re not aware of doing, maybe there’s a different self who’s in control at times, and they don’t feel like themselves. That’s understood to be quite pathological in the Euro-American context. It’s very distressing for people when they have experiences where they don’t feel like they’re in control of themselves, and they feel like they don’t have access to all of their memories and that kind of thing. That’s partly because in the Euro-American context there’s a high priority on having a very integrated, unitary autonomous self. We think of this as a unique self and that you have this control over awareness of yourself at all times — that’s the sort of norm within Euro-American contexts. 

I’ve done a lot of research in the northeastern part of Brazil, where there’s the potential for similar kinds of experiences to be understood entirely differently: not as this terrifying pathological loss of self control, but as a signal that one is having a spiritual calling, within a particular religious context. There are a number of Afro-Brazilian Spirit Possession religions in which trance and possession, or dissociative experiences, are embraced. And actually, there are lots of other places in the world as well, where people participate in and are devoted to religions that have a spirit possession element, and those same experiences of what we would call dissociation are not pathologized and in fact, can be really beneficial and are embraced by people because they have spiritual meanings and  practices that are associated with them. So you can’t take a single set of experiences and definitively say, in a non-relativistic way, that this is an illness, a problematic experience that is by definition universally pathological. And that applies to all of the things that we define as mental disorders in the Euro-American context, in the DSM, including something like schizophrenia, which seems like wherever it happens it would be a terrible set of symptoms. That’s true to some extent, that there are people who suffer from schizophrenia all over the world, and it can be really damaging to people. On the other hand, there’s a continuum of those symptoms, right? What we would automatically label as psychotic and problematic in the U.S., like having a hallucination, doesn’t necessarily translate into a terrifying pathological experience everywhere. Hearing voices or having hallucinations in other contexts may have different kinds of meanings and applications for people. And lots of people actually hear voices and have hallucinations in ways that are not distressing to them, and they can remain functional. 

So the other thing I think is really important to keep in mind is that there’s always a continuum of these kinds of phenomena that we call symptoms, and sometimes they count as symptoms sometimes they don’t. There are still really big and important differences, even in something like a florid psychosis [an acute phase of schizophrenia], in terms of how that unfolds in different cultural contexts. In some contexts, it’s understood to be chronic and devastating. And recovery is something that’s really challenging and doesn’t have very high success. But there’s a lot of research now that shows that in different cultural contexts, chronicity is really variable and that actually, schizophrenia isn’t a life sentence. Again, that has been tied to the way that the social world makes meaning of those symptoms. So when there’s a lot more social support and a lot less [of a] negative response to somebody who’s [suffering from] psychosis, [then] people are able to remain functional, [and] the prognosis looks a lot better. So when we just say, “Oh, my gosh, that person is severely mentally ill, and we just have to isolate them and treat them,” that doesn’t actually seem to work out as well as in contexts where there’s a different kind of response.

How does our model work and what would you consider an alternative to our Euro-American model of mental illness?

Well, I think it’s sometimes misleading or a bit problematic to continue to refer to it as mental illness. I often just say mental health or mental wellness, to try to point to the fact that mental illness signals [certain things] to people who are accustomed to the Euro-American understanding of mental health. 

So something that we would call depression might just be perceived as an understandable response to a distressing social context, such as living in poverty, or you have been the victim of domestic violence, or you have experienced an enormous amount of loss, or you live in a place where there’s a ton of political violence — all of those things that cause people to be distressed. The Euro-American/Western approach to that would be to label that distress as a particular disorder, and then treat it accordingly. So we might say, “That’s depression,” or “That’s PTSD.” And then we have these ways of dealing with that. 

There are lots of social contexts in which it is not the automatic interpretation; having a response to loss or to grief doesn’t necessarily mean that we should label you as having major depression and put you on an antidepressant. It might be that we need to deal with the loss that you’ve experienced, and support you socially. If you will, a better model is to [think] about the social and structural causes of people’s distress, and addressing things at broader levels, more collectively.. 

There are cultural contexts in which that’s sort of automatically what people do, or at least what they did before we really exported the DSM model to people. There would be a social response; people would come out and support you if you’ve had a loss that’s a material loss. Like, we rebuild your house, we rebuild your life, right? We offer you ways to be functional, job opportunities, safe housing and those kinds of things, as opposed to saying, “Oh, you’re depressed, so let’s give you some psychotherapy and some medications.” And I’m not saying that those things are not ever the right response, or that in conjunction when people are really distressed that those things might not be really helpful. But if that’s where we stop, then that’s a problem. People who are living in marginalized social circumstances who are victims of continuous structural violence, if we stop at just offering them some psychotherapy, or  mindfulness practices, or Prozac, and we don’t treat the structural factors, — the things that are driving the distress in the first place — then we’re really doing a disservice to people. Unfortunately I think that’s basically how we’re approaching things in the contemporary US for the most part. 

When thinking about mental illness, how is it not purely biological? For example, something like depression?

I don’t want to imply that I don’t think that there’s a biological component to depression, or schizophrenia, or any of these other disorders. I think there is, and sometimes that makes people more vulnerable to becoming distressed as a result of the kinds of lived experiences they have. And there’s a feedback between those things: if you have some vulnerability, then you have some very stressful experiences, and you start to become depressed, that can kind of kindle this biological response and enhance it. It then makes it much harder to deal with the social and experiential things that are happening and you get more depressed, and you withdraw from your activities and from your social world. And then that makes you much more depressed. And that amplifies the biological components, right? So those things are all wrapped up together and interrelated, and I don’t think we can think about them independently, and sort of isolate them or reduce just to one or the other. 

I’m focused more on thinking about the social aspects because that’s the part that actually tends to get much more neglected in mainstream approaches to mental health. But I don’t want to give the impression that I don’t think that there’s a biological aspect. I also don’t think that that’s necessarily the driver, or the primary thing that causes something like depression in most people. I think it’s a part of it but I don’t think we can say that’s the “true” cause in every case.  

Is depression always tied to an event? Oftentimes you hear that people don’t have a particular reason to be depressed etc., but they just are.

I don’t think depression is always tied to an event, but I think that it’s almost always tied to somebody’s social context. So if you’re thinking about a middle class, white American teenager, lots of them get depressed, and in fact there is kind of a crisis going on right now with teen mental health.  Even for a person who is relatively privileged, looking at the social context, and by that I don’t just mean their immediate everyday world, the peers that they’re hanging out with, or what’s happening at home in their family. I mean the broader social and cultural context that sends a lot of messages to individuals about what’s valued and what’s valuable and what’s important. And if they feel like they aren’t achieving those things, then that can be something that’s highly distressing. 

I also think that the explosion of psychiatric diagnoses in the U.S. is something that we need to think about. Is it just that the world is far more distressing now, so everybody’s distressed? The rates of depression in the U.S. or people who will in their lifetime be diagnosed with major depression is something like 20%. 

You’re also seeing higher levels of diagnosis of things like ADD, ADHD, and so on and so forth. Is it that those disorders are just much more prevalent now? Or is there also something going on about what we identify as disorder and push into the medical context? You might be struggling as an adolescent and need extra social support and feeling really vulnerable and really anxious and so forth. But we might or might not say that that’s necessarily a diagnosable disorder, right? And in the contemporary U.S., more and more, we’re looking for solutions to those experiences within the medical realm. I guess I’m throwing out there the possibility that some of the time, there are other kinds of solutions that would work as well, if not better, than to medicalize. I’m not saying that the diagnoses that people are getting now are not real, and people should just deal with it. That’s not at all what I’m saying. But I do think that having been bullied on social media or something — that’s really distressing. And that’s happening to a lot of kids. Do we necessarily need to send them to a psychiatrist and put them on medication for that? I’m not sure, I think we need to deal with some of the other stuff, helping them resist being sucked into that world, giving kids a sense of their own sort of power, and helping them be resilient in ways that therapists, but also parents and teachers, can help them with. And there are potentially other ways that we can access that resilience and empowerment.  One of the big ways is through social support but also structural changes and new policies that get at the root causes of distress, like some of the awesome things that are burgeoning in some parts of the U.S. currently, including restorative justice practices.

Could you expand on that? What other factors could contribute to the reasons why mental health is such a prevalent issue these days?

Well, I also do think that some of these drivers of distress – like marginalization, oppression, dispossession, racism, discrimination, and poverty — those things also have increased. We’ve seen a rise in authoritarianism, we’ve seen there’s massive numbers of displaced people, right? So those things are real causes of real distress. And if we’re going to label that distress as mental illness, then yes, we’re going to see a rise in the rates of mental illness globally, and not just in the U.S. But, if we want to say those are totally predictable, normative responses to extraordinarily distressful experiences that are becoming more and more prevalent in the world, then that’s a little bit of a different way of thinking about it. And that’s the way I would emphasize more: it’s not just that somehow there is an increase in mental illness, but that there are these sets of circumstances that unfortunately are increasingly prevalent around the world that are distress-inducing, and we’re labeling a lot of that distress as mental illness.

What research are you working on currently?

I have two research projects going on right now. I was just funded by the National Science Foundation to do a research project with my postdoc, Maddalena Canna. The project that we’re doing is on mind-body illnesses in functional neurological disorder, a very poorly understood disorder in which people often have severely debilitating symptoms that look like neurological symptoms. In fact, they look very similar to specific neurological disorders like Parkinson’s disease or Epilepsy. But when they are examined, the typical underlying neurological signatures that would be associated with disorders like Parkinson’s or Epilepsy are absent. This disorder, I think, actually can be traced directly back to what used to be known as hysteria. And it’s also still commonly known as conversion disorder, the idea being that people are having emotional problems that are “converted” into physical symptoms. But the mechanisms through which that conversion would take place are really poorly understood. What’s not taken into consideration is people’s lived context, their social contexts and the kinds of meanings that they absorb and internalize that contribute to the way that they perceive and experience their own bodily sensations and symptoms. Our study takes an anthropological approach and is trying to fill in some of that information. And one of the other really interesting things about this disorder is that it is disproportionately experienced or diagnosed in women: it’s 80% women. So we really want to dig into the social components of that gender bias. So that’s one project we are very excited about, which we’ll be getting up and rolling this summer. And then the other project that I’m working on is with Professor Peter Locke in the Global Health Studies program and Professor Dave Tolchinsky who’s in the School of Communications in TV and Film. We’ve been working on a project that recently got funding from the Buffet Institute and has to do with media representations of mental illness globally. It’s not just a research study;  the aim of that project is to critically examine the way mental health is represented in mass media — in particular TV and film, but also in plays, podcasts, and other media arts creative forms — and how they tie into dominant models and narratives of what mental health is, who’s responsible, how we treat it, and how those representations reflect and reinforce dominant narratives. The other part of the project is to scaffold the creation of new media that produces different kinds of narratives of mental health, ones that don’t buy into the problematic aspects of those dominant narratives, and that represent people’s experiences in ways that are destigmatizing and really represent that continuum of experience that we discussed. We’re super excited about that project, and in the next year we’ll be doing some preliminary research and launching more fully after that.