Apparently every rationalist-adjacent blogger read this book at the same time.
I just finished reading The Geography of Madness: Penis Thieves, Voodoo Death, and the Search for Meaning in the World’s Strangest Syndromes, by Frank Bures, and it was… reasonably fun. Probably the best part was getting to tell people I was reading a book about penis theft. Second best was the fun facts in the book, which were infrequent but very entertaining. For example, I learned that Chinese poet Su Dongpo was exiled from mainland China to the island of Hainan, in part for writing verses like:
Families when a child is born
Hope it will turn out intelligent.
I, through intelligence
Having wrecked my whole life,
Only hope that the baby will prove
Ignorant and stupid.
Then he’ll be happy all his days
And grow into a cabinet Minister
Excellent.
The penis theft the book refers to, if you were wondering, isn’t literally happening. Instead, Bures is writing about a particular mental illness (commonly called koro) in which the sufferer believes that his penis is being or has been stolen. I don’t want to make fun of people who are clearly suffering too much, but this is also funny. One of my favorite stories in the book is about a man who insists that his penis has been stolen and is brought to a hospital. When the doctor checks and points out that everything seems to be where it belongs, the man looks down, shocked, and says that the witch who stole it must have put it back just now. I’ll do my best in the rest of the review to take koro seriously, which is probably what Bures would want.
A lot of the rest of the book isn’t so great. Did you know that the placebo effect is real? Did you know that believing a certain health outcome will happen makes it much more likely to happen? If so, you can save yourself some time and skip a few chapters of this book. But I’m not writing about the book because it’s bad (even though I do think it’s not great) - I’m writing because it has a cool idea that it doesn’t explore enough.
Like Scott Alexander, I’m interested in Bures’ analysis of mental illness. Bures suggests that most mental illnesses are culturally conditioned, meaning that they’re so strongly filtered through perceptual lenses we absorb from our cultures that they might appear to be totally different in different cultures, or might even be nonexistent in some cultures. Unfortunately, Bures chooses the particularly bad example of PMS for this part of the book, suggesting that PMS is mostly or entirely culturally conditioned and in some sense (my words, not his) unreal. He also tries to do some political jiu-jitsu so that instead of ignoring or invalidating the lived experience of women, he’s instead taking on the partriarchy for making the sexist(?) assumption that women’s hormones can dramatically affect their moods and/or decision-making. The political/signaling aspect of this isn’t interesting to me, but it raises an interesting question: to what extent should we reify mental illness?
Imagine that you, a person who has never heard of mental illness, start feeling unmotivated and uninterested in life. The things you used to enjoy don’t interest you as much anymore and you stop maintaining your personal relationships. After a couple of weeks, a friend tells you that everyone feels bad every now and then, and this is getting out of hand. Your problems are nothing special, they tell you, you just happen to not be dealing well with this one. They point out that it will only get harder, both mentally and logistically, to engage with things that make you feel alive. Your friend points out that the best way to deal with vicious cycles is to intervene early, sometimes by radically altering your daily routine. They offer to let you sleep on their couch for a couple of weeks, and persistently push you to get out of your comfort zone, exercise regularly, etc.
Now imagine that your friend instead takes your mental illness very seriously. You have depression, they explain to you, and it’s not your fault. Depression is a serious mental illness that impacts a huge and growing proportion of the US population. Your friend doesn’t want to blame you, the victim, so they instead point out that this could very possibly have something to do with an imbalance in your brain chemistry, or current events. After all, the climate disaster is looming, Republicans* are destroying democracy, etc. They tell you that you might need drugs or therapy and push you to make an appointment with a psychiatrist.
This example is a little extreme, but it’s just supposed to illustrate a point. In the first case, your friend doesn’t make any reference to mental illness at all and uses the framing of “you’re not dealing with your problems well.” In modern society this might be considered borderline gaslighting, but the upside of victim-blaming is that it gives the victim all the agency. In being sort of brutal towards you, your friend is also attributing agency to you and giving you concrete options towards recovery. In the second case, your friend is being much nicer and more sensitive to you and staying on your side, but their framing also implicitly suggests that there’s very little you can do about your problems. Altering your brain chemistry would maybe be helpful, but it’s too vague and abstract to be actionable. Meanwhile, altering the trajectory of world events is too hard and unlikely to succeed. Making an appointment with a psychiatrist is by far the best idea your friend has in the second case (as the only actionable item), but it’s high-variance. The psychiatrist might write you a subscription for an SSRI and send you on your way, or they might even decide there’s actually nothing wrong.
That’s the case for not reifying mental illness. On the other hand, what if you actually have BPD and this is a depressive episode? BPD is difficult and dangerous to address purely through lifestyle interventions, you should definitely not try to do that without a doctor’s supervision.
My point, then, isn’t that you should never reify mental illness! Instead, I’m bringing this up here because I think Bures fails to take seriously a point that he himself makes: the fact that a mental illness is culturally contingent doesn’t mean that it isn’t real. On the other hand, the fact that something is a real problem doesn’t make “mental illness” any less of a completely imaginary category that we’ve stuffed a huge variety of phenomena into. The common thread of interacting successfully with mental illness seems to be understanding specifically what is happening - which includes noticing how it interacts with cultural elements - and treating the actual thing that’s happening. One example of this can be found in Johann Harl’s TED talk on depression - I’ve paraphrased here:
An American doctor named David Sommerfield went to Cambodia to promote the antidepressant drug Paxil, but when he got there the Cambodian doctors explained that they didn’t need it because they already had a treatment for depression. Dr. Sommerfield was intrigued by the possibility of a new, herbal treatment for depression. Instead, locals told him about a rice paddy farmer who had lost his leg to an undetonated American land mine left over from the Vietnam war. Working in a rice paddy with the prosthetic leg was painful, and the patient had PTSD and was terrified of losing his other leg in another explosion. His situation became so bad that he stayed in bed crying with depressive symptoms. This sounded like a difficult case to treat, so Dr. Sommerfield asked the doctors how they treated the patient’s depressive symptoms. The Cambodian doctors explained that they simply bought the patient a cow. The man couldn’t be a rice paddy farmer anymore, so his community pooled their money and bought him a dairy cow, which presumably acted as a combination service animal and source of income. The man, according to the Cambodian doctors, recovered within a month.
What’s missing from the above story is a diagnosis of depression. The farmer’s mental condition wasn’t taken as a category of thing that was happening purely in his brain, it was taken as a unique product of circumstance and response. In this case, it was harder to treat the farmer’s PTSD and (very reasonable) fear of losing another leg “in his head” (though talk therapy, medication, or similar) than it was to get him a cow, so they went with the cow option and it worked! This doesn’t mean that cows are good for treating mental illness (or depression), it means that it’s important to recognize how the concept of mental illness (or depression) itself can be limiting.
And so, to return to my original question of how much mental illness should be reified, my cowardly answer is that it should be reified as much as is appropriate given the context. Some things really are brain chemistry, as far as I can tell, and need very finely-balanced medication to resolve in the short-to-medium term. A lot of other things aren’t, and maybe framing those things in ways that deprive people of agency is doing more harm than good.
* Replace bad guy of your choice if you want, but my new hot take is that even if there’s very little to be done about it and it makes more sense to critique liberal policies than to essentially scream into the void by critiquing conservatives, maybe it’s good from a purely discourse-shaping perspective to bring up the fact that Republicans want to destroy democracy every now and then