Meredith F. Small examines the western medical model of mental illness from the perspective of an anthropologist.  Her book journeys across various approaches which attempt to shed light on some of the evolutionary perspectives and cultural differences surrounding mental illness.  Much of her consideration is in respect to the emotional expression evident in many disorders and how cultural contaminants shape them.  The thrust of her argument is that psychiatric disorders should not be analyzed in isolation, with the individual as the singular focus, but to take a more multi-dimensional approach that accepts the influence of environmental pressures in the expression of disorders.  Such a process, in her estimation, would not only offer a better understanding of the actuality of psychiatric illness but it may reduce the over reliance in the belief in medical models, which have become the main concern of western psychiatry. 

 The book proceeds in an engaging enough manner and Small provides empathic writing on the subject, adding some personal accounts on mental illness, including her own.  The first few chapters flow nicely from the questioning of mental illness from evolutionary models; then to what primate studies may have to offer; followed by examination of nutrition.  These chapters compliment each other and provide a backdrop to add the culture related perspectives of the subsequent chapters.  

The evolutionary approach, through Darwinian psychiatry, postulate reasons for these mental states based on selective pressures, rather than defining pathology, this approach attempts to understand functionality and whether some adaptive value was involved.  Offering some of the hypotheses along these evolutionary lines, the examination is mainly in respect to human emotionality.  Small considers primate studies as complimenting an evolutionary perspective of human behavior and accepts that experimentations to induce mental trauma may appear cruel, she believes, the results have also yielded scientific value.  Some may find this questionable.    

Nutrition also has major implications for mental health and brain development.  The chapter entitled The Happy Fat takes the changes in diet as having a significant impact in western mental health and, in particular, how the western diet has moved from a diet containing healthy fats which were a main staple in human brain development, such as Omega 3, towards one which has adverse effects on mental health and behavior.  She points out that eating is a part of culture as are the many expressions of mental illness.  Indeed even many of the mental illness that relate to diet, such as anorexia and bulimia, are specific to the western culture.

Following this, the book then examines the cultural relations with mental illness.  Some of the individual cases of culture bound syndromes which are examined are provocative.  I found the collective personality of the Doubuan particularly amusing.  Small writes "In Dobuan Society, where life was rough and no one trusted anyone, a person with an optimistic and happy personality was considered crazy" (p.107).  Although she gives such anecdotes her examination of mental illness and the magico-religious practices of other cultures, overall her approach is very limited and reveals nothing new.

Throughout the book she questions the western medical model; the over reliance on drugs; the questionable validity of many disorders; the incomplete nature of biological explanations and the culture bound specificity of many disorders. The problematic surrounding society and mental illness are brought together in a way that covers the broad conceptual issues and retains some nuanced argumentations.  Some of these argumentations deserved greater detail and the book does suffer from covering too much ground at pace, neglecting topics that deserve closer scrutiny.  Maybe Small didn't set out to wholly critique the western medical model and, while she does temper her argument with fruitful lines of inquiry that do go some measure beyond the model, there is a neglect in her narrative of the history of psychiatric critiques and current trends, even from within the western establishment itself.  She does concede some positive aspects to the medical model but one would think, from the story she outlines, that the western medical model is generally uncritically accepted, yet this is far from the case.  At times, through her personalized and novelese style, it feels as if Meredith Small is an investigative journalist uncovering a story.  Unfortunately her hurried investigation passes over vital evidence.  Much of her writing is based on interviews and the book is not as reliant on research as the subject matter would seem to warrant.  No topic is really covered with sufficient depth to make this a satisfying or fulfilling read.   

For example, the chapter on nutrition was limited to a discussion of Omega3 and fatty acids that seemed a little dated and restrictive.  Her argument could have easily have included other identifiable nutritional factors rather than congealing it in the happy fat. The importance of Omega3 has currently led to it being incorporated into a wide range of consumer products, revealing popular recognition on a scale of influencing a marketable and viable economic demand.  Artificial additives have also been associated negatively with the behavior of children and recent studies have confirmed this.  Many of these negative behavioral symptoms have been attributed to contentious psychiatric disorders, such as Attention Deficit Hyperactivity Disorder and Conduct Disorder.  Even the absence of certain trace elements can have a severe impact on cognitive functioning.  One could even argue that the nutritional model itself is part of the medical model.

A severe limitation of this book is in respect to the conceptualization of mental illness in general.  Small's emphasis is on the emotional dimensions that can lead to mental illness.  Emotionality is undoubtedly of major factor in many disorders, however psychiatric disorders or illnesses are not limited to affective disorders but often reflect fundamental problems of cognition or information processing, often leading to behavioral and emotional problems.  On the subject of gender and mental illness she asserts, in a paragraph in passing in the concluding chapter, that "the gender difference for depression is found primarily in the United States."(p.154)  This does not seem to be the case nor are gender issues reducible to depression.  Distribution along lines of gender is evident throughout many disorders and has raises concerns.  Some studies have noted that same symptoms may even lead to different diagnoses depending on the gender exhibiting the symptoms.

These are issues that could have aided her discussion.  Her attempt to go beyond the medical model is a very tentative one and suffers from a lack of detail and systematic analysis.  To promote different perspectives on mental illness is surely worthwhile but to frame the issues with such brevity and sweeping abstraction leaves the reader more likely to raise questions about the book rather than the western medical model of psychiatry and this is certainly not an achievement.  These criticisms might not be substantial enough to deter a general reader, one coming fresh to the subject matter, who may even enjoy the pace and style.

© 2007 Edmund O'Toole

Edmund O'Toole is a Philosophy PhD student at the National University of Ireland in Galway.

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Categories: Philosophical