It's official: America's mental-health professionals are getting more culturally sensitive

You may not have heard of koro --  a mental syndrome in which a person has an overwhelming belief that his or her genitals are disappearing -- or zar-- a condition that generates dissociative episodes characterized by intense laughter and singing -- but that doesn't mean these are any less universal than, say, anorexia.  At least that was the theme of a fascinating article by journalist Ethan Watters about "the Americanization of mental illness," published in the New York Times Magazine in 2010.  

One of the primary points Watters makes is that the Western mental-health practitioners behind the Diagnostic and Statistical Manual of Mental Disorders (DSM-4) problematically placed "culture-bound" disorders -- like those mentioned above --in their own section at the back of psychiatry's most definitive diagnostic guide, implying that these syndromes are somehow affected by culture in a way that predominantly Western illnesses are not:

Western mental-health practitioners often prefer to believe that the 844 pages of the DSM-IV prior to the inclusion of culture-bound syndromes describe real disorders of the mind, illnesses with symptomatology and outcomes relatively unaffected by shifting cultural beliefs. And, it logically follows, if these disorders are unaffected by culture, then they are surely universal to humans everywhere. In this view, the DSM is a field guide to the world's psyche, and applying it around the world represents simply the brave march of scientific knowledge.

But Watters disagrees with that approach. "In the end," he concludes, "what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations.... [M]ental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions - the idiosyncratic cultural trappings - of the mind that is its host."

The American Psychiatric Association (APA), it seems, is heeding that advice. The organization is unveiling DSM-5, the long-anticipated (14 years, to be exact) new edition of its manual, over the weekend during its annual meeting in San Francisco. And based on preliminary information, the task force that wrote it appears to have been more sensitive to the nuances of patient care across countries.

"Rather than a simple list of culture-bound syndromes," reads one statement on the APA's methodology, "DSM-5 updates criteria to reflect cross-cultural variations in presentations, gives more detailed and structured information about cultural concepts of distress, and includes a clinical interview tool to facilitate comprehensive, person-centered assessments."

What exactly will this look like? Instead of relegating cultural expressions of mental disorders to the back of the book, the manual will incorporate these throughout the text. The example the APA provides is for social anxiety disorder. In the new manual, "fear of 'offending others'" will be included in order to reflect "the Japanese concept in which avoiding harm to others is emphasized rather than harm to oneself."

Another example: A preliminary version of the DSM-5, which the APA released for feedback last year, updated the criteria for dissociative identity disorders so that professionals won't need to diagnose practices like shamanism as a mental illness. In the new manual, practitioners are told that if the so-called "disturbance" is actually "a normal part of a broadly accepted cultural or religious practice," then it does not technically constitute dissociative identity disorder.

Changes such as these are definitely a start. But all the medical anthropologists out there need not worry. With ambiguous words like "broadly accepted" and "normal" peppered in the DSM-5, there's certainly still room for criticism.



Things Donald Rumsfeld actually said this week

Donald Rumsfeld has never had a reputation for being particularly tactful or articulate (let's all take a moment to remember how Saturday Night Live portrayed him, even before the invasion of Iraq), but he's demonstrated a habit of owning his mistakes -- in his own way. The former defense secretary took his infamous, convoluted, "There are known knowns" comment, made in a press conference in 2002, and appropriated it as the title of his 2011 memoir, Known and Unknown. And now he's doing it again as he promotes his new book, Rumsfeld's Rules: Leadership Lessons in Business, Politics, War, and Life, a collection of aphorisms and rules to live by -- if only Donald Rumsfeld took his own advice.

"You go to war with the Army you have" may have been a gaffe when Rumsfeld said it to a National Guard soldier asking about jerry-rigged armor on Humvees, but in Rumsfeld's Rules, it's a pearl of wisdom. And when he's not rehabilitating his own troublesome turns of phrase, he often cites the advice of others with little self-awareness. All of this has made for an incredibly awkward book tour.

There was the time, for instance, when Rumsfeld cited one of his rules at a book party in Washington on Tuesday: "Every government looking at the actions of another government and trying to explain them always exaggerates rationality and conspiracy and underestimates incompetence and fortuity," he observed. "I learned that from watching you!" Circuit Court Judge Laurence Silberman, who coined the rule, reportedly called out.

And when Rumsfeld spoke to Politico's Patrick Gavin, he wasted no time contradicting himself: "If you have rules, never have more than 10," he joked of his 380-rule book. Then again, he added, "All generalizations are wrong, even this one."

It's complicated, you see.

For example, when Rumsfeld said, "It's easier to get into something than it is to get out," he's not talking about the invasions of Afghanistan and Iraq. In a conversation with Kai Ryssdal, the host of American Public Media's Marketplace, Rumsfeld clarified that he was thinking of a much smaller deployment of U.S. forces 20 years earlier:

I thought of that when I was President Reagan's Middle East envoy and we had 241 Marines killed at Beirut, at the airport. And I concluded then that the United States has to be careful about putting ground forces in because we're such a big target.

"I sorta can't believe these words are coming out of your mouth," an incredulous Ryssdal interjects. When Ryssdal asks if he's ever considered apologizing, Rumsfeld replies, "Well, my goodness, you know, as Napoleon said, 'I've been mistaken so many times I don't even blush for it anymore.' Sure, you see things that don't turn out the way you hope. You look at intelligence -- and of course, if intelligence were a fact, it wouldn't be intelligence."

Incidentally, "If intelligence were a fact, it wouldn't be intelligence" is not one of Rumsfeld's rules.

You can listen to Ryssdal's whole, cringe-inducing interview below. And if you're wondering how Rumsfeld is doing, he'd like you to know, he's "happy as a clam."