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So while the bio-psycho-social model exists theoretically, in practice it is far from being realized. This is borne out by the fact that pill treatments are up, long-term psychotherapy is on the decline, and that psychiatrists rarely make social interventions. In short, bio-psychiatry advocates do not necessarily advance their negative model of suffering by way of their theoretical pronouncements, but by way of their clinical practices—something implied by the fact that biological treatments are generally preferred.

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The growing dominance of the bio-psychiatric myth of suffering raises many new and serious questions. Does this domination lead increasing numbers of us to view our suffering in entirely negative terms as something to be erased or anaesthetized at all costs? After all, as diagnostic thresholds lower and as the number of disorders increase, more and more realms of emotional distress have been medicalized. We are replacing traditional philosophical and religious ways of managing and understanding distress, which once allowed people to find meaning and opportunity in many forms of suffering,
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with a starker technological view that sidesteps the bigger humanistic questions: Cannot suffering often be a necessary call to change (and therefore a message to be understood rather than anaesthetized), or the organism's protest against harmful social conditions (therefore requiring a social or psychological rather than a chemical response), or a natural accompaniment of our psychological development (therefore having vital lessons to teach if managed responsibly and productively)?
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The rise of the biological, negative view of suffering shores up a wider cultural ideology particular to our times, one in which emotional anesthetics—pills, alcohol, retail therapy, escapist activities—have become the preferred vehicles for managing distress. In what way, therefore, has the idea that we can consume our way out of depression become a myth that is convenient not only for psychiatry and Big Pharma but for the wider capitalist system in which we live?

Psychiatry is not an island. Its ideas and preferences shape, reflect, and respond to the dominant cultural shifts of our time. But psychiatry's cultural embeddedness is not just pertinent for the regions in which it was developed. This is because, in recent years, Western psychiatry has aggressively expanded into new lucrative markets—China, India, Indonesia, South America, Eastern Europe—rapidly converting whole new parts of the globe to our culturally specific modes of misery management. What happens, then, when a system made in the United States or the UK is exported to communities that have never before embraced our medicalized view of emotional suffering? By exporting our remedies, can we therefore be confident that we are really helping heal the world?

Before you begin to formulate an answer, I ask you to first consider the bizarre series of facts that I'm now about to reveal to you, facts that require us to take a journey to a series of destinations somewhat farther afield than the United States.

PSYCHIATRIC IMPERIALISM

O
n a sunny afternoon in 1994, a fourteen-year-old schoolgirl called Charlene Hsu Chi-Ying collapsed and died on a busy Hong Kong street. Nothing untoward appeared to have precipitated her death. She had just been walking home from school as usual.

A coroner was called in to investigate Charlene's body. He was immediately disturbed by what he found. She only weighed seventy-five pounds. Worse still, her heart was tiny—weighing a shocking three ounces, half the usual size for a girl her age. In fact, her body looked so emaciated that nurses at the local hospital actually mistook her corpse for that of a woman in her nineties.

A public inquest was immediately undertaken to work out what had happened. What it revealed seemed shocking: Charlene had done something then practically unheard of in Hong Kong—she had starved herself to death.

After Charlene's death, a chilling series of events started to unfold in the city. Young women suddenly seemed to begin copying Charlene's self-starving. First it was one or two, but very quickly the numbers began to rise dramatically. What was initially considered an isolated event now appeared to turn into a citywide minor epidemic, and nobody could understand why. What was going on in Hong Kong?

That question led one of America's foremost investigative writers, Ethan Watters, to fly to the city in the hope of unraveling the mystery. He had undertaken his preliminary research, so he knew exactly where to start his investigation—with one of Hong Kong's leading eating disorder specialists, a physician called Dr. Sing Lee. Lee had made a career of working with patients suffering from eating disorders and was extensively knowledgeable about the events preceding and following Charlene's death. As Watters's conversations with Lee took place, the key facts surrounding Charlene's death began to become clear. Here is what Watters found.
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After Charlene's death, there was uproar in the Hong Kong media. A young schoolgirl dying in such a public way, under such odd circumstances, was bound to be irresistible for news corporations. “Girl Who Died in the Street was a Walking Skeleton,” one headline rang out; and another, “Schoolgirl Falls Dead on Street: Thinner Than a Yellow Flower.” As reporter after reporter presented the facts, most also asked the same burning question: What was the meaning of this strange disease that led a bright young local girl to starve herself to death?

As the question was turned over again and again in Hong Kong's media circles, the phrase anorexia nervosa began to be heard. Until this time anorexia was a little-known condition in the city, only being readily diagnosed by a few Western-trained psychiatrists working in Hong Kong. But because the public wanted to know more, anyone who knew about the condition was in great demand. Psychiatrists were recruited in discussions that started appearing in women's magazines and daily papers. Educational programs were soon set up in schools to increase awareness of the disorder. A youth support program was initiated called Kids Everywhere Like You, which included a 24-hour helpline for children struggling with eating irregularities. As these forces gained momentum in Hong Kong, the disorder was slowly put on the map. The word was getting out that anorexia nervosa was not just a Western disease—the youth of Hong Kong were susceptible as well.

As public awareness of anorexia grew in Hong Kong, so did the number of anorexia cases reported. For instance, psychiatrists like Lee, who before Charlene's death had only seen about one case of self-staving a year, were now seeing many cases each week. As the author of one typical article noted, eating disorders were now “twice as common as shown in earlier studies and the incidence is increasing rapidly.” And as a headline in Hong Kong's
Standard
also echoed when a reporter described a study of this rise: “A university yesterday produced figures showing a twenty-five-fold increase in cases of such disorders.”
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Watters was desperate to know why a disorder like anorexia, once practically unknown in Hong Kong, could suddenly become a local epidemic. The first answer he considered was that the growing media attention had brought to public attention a widespread problem that had always been there but carefully hidden, making it easier for doctors to recognize and diagnose this disorder. Perhaps until that time people had not felt permitted to report their anorexic experiences; perhaps the new discourse had given a voice to a disorder long kept underground. But as compelling as this explanation initially seemed, for Watters it didn't appear to fit the facts.

In the first place, if there had always been many cases of anorexia in the non-clinical population, then schools, parents, psychiatrists, and pediatricians would surely have spotted it. After all, anorexia is not something that sufferers can easily hide, given its very obvious symptomatic signs. As it therefore appeared unlikely that the rise in anorexia was solely due to increased public attention, Watters considered another explanation: Perhaps as Western ideas of female beauty became dominant in the media, the accepted ideal of female beauty had begun to transmute. As women encountered more images of slim paragons alleged of perfection, they simply felt pressured to make their bodies conform.

But again, the evidence did not support this. After all, Western depictions of featherweight beauty did not rise hand in hand with anorexia cases. These depictions were widespread long before the anorexia epidemic broke out and so could not account for the sudden explosion of cases. Watters was therefore convinced that something else was going on, something less obvious, something perhaps even more disturbing. The question that continued to plague him was what could this “something” be?

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Before we pursue that question further, let us first journey a few thousand miles from Hong Kong and a little way back in time to investigate another odd series of events occurring in Britain that I had been independently researching. The time period I was focusing on was the late 1980s, when another strange psychiatric contagion seemed to be spreading.

During this time, increasing numbers of young women started arriving in clinics up and down the country displaying severe and disturbing wounds. Some had gashes on their arms and legs, others had marks from scalding, burning, hitting, and scratching, or were missing clumps of hair. What linked all these puzzling cases was that other people weren't inflicting these wounds. No, the young women were inflicting these wounds upon themselves.

As the 1990s and 2000s unfolded, cases of such “self-harming” behavior continued to increase dramatically. A study on the mental health of college students found empirical evidence that at one university, the rate of self-injury doubled from 1997 to 2007.
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And when the BBC reported on self-harm in 2004, it bemoaned the escalating rates in Britain: “One in ten teenagers deliberately hurts themselves and 24,000 are admitted to hospital each year.”
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A later BBC investigation also revealed that the number of young people being admitted to hospital for self-harm was up 50 percent in five years (2005–2010).
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What began as a tiny number of cases in the late 1980s had suddenly exploded beyond most people's comprehension. The urgent question there too, was how could this be?

By the mid-2000s, many conventional explanations had been advanced to provide an answer. Dr. Andrew McCulloch, chief executive of the Mental Health Foundation, put one as follows: “The increase in self-harm … may be visible evidence of growing problems facing our young people, or of a growing inability to respond to those problems.” Susan Elizabeth, director of the Camelot Foundation, similarly pointed out: “It seems the more stresses that young people have in their lives, the more they are turning to self-harm as a way of dealing with those stresses.” Professor Keith Hawton, a psychiatrist at Oxford University, also joined in the fray: Self-harm was rising because “pressures have increased and there's much more expected of young people.”
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Statements like these by members of the mental health establishment boiled down to the simple idea that self-harming was on the increase because teenage life-satisfaction was down. But today, with the benefit of hindsight, this explanation appears unsatisfactory. First, it is not so clear whether teenage life in the late 1980s was so much easier than it was in the late 1990s, the period during which self-harming really began to rise. On the contrary, there is strong evidence that the social conditions for teenagers during the 1990s, if not significantly improving, at least did not decline.

For instance, sociologists at Dartmouth and Warwick Universities showed that overall, general well-being in Britain actually flatlined rather than plummeted during the 1970s, 1980s, and 1990s.
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And an independent study conducted at the University of York (commissioned by Save the Children) concluded that: “While overall the UK can claim that life is getting better for children, child wellbeing continues to be mixed: The list of improving indicators is more or less equal in length to the list of deteriorating/no-change indicators.”
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So the situation was not ideal, but at the same time neither did it seem to be declining in the 1990s and 2000s, a fact somewhat undermining establishment claims about why self-harm was on the rise. Perhaps there was something else at play that had escaped mainstream attention.

To explore some possible alternatives, I called Professor Janis Whitlock, a specialist in self-harm behavior at Cornell University. Whitlock has dedicated much research to trying to work out what makes this particular behavior attractive to young people at a particular time. “In some of our early work we found evidence of self-harming back in the early twentieth century,” said Whitlock, “but all amongst severely traumatized people like war veterans. How it shows up among otherwise normally functioning kids in the 1990s I think says a lot about our culture, what is going on in that time and place.”

The aspect of culture Whitlock focused on was how popular depictions of self-harm grew exponentially during the 1990s and 2000s. In a recent study, her team focused on representations of self-harm in the media, in popular songs, and in movies from the 1970s until 2005.
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What they found was that between 1976 and 1980, there was only one movie depicting self-harm behavior, while there were no references to it in popular songs. But between 2001 and 2005, depictions and references rose sharply, appearing in twenty-three movies and thirty-eight songs. Furthermore, when charting the rise of news articles on the issue, between 1976 and 1980 they only found eleven articles featuring self-harming, while between 2001 and 2005 this figure had soared to a whopping 1,750 articles. Was the growth of popular references to self-harm simply reflecting a growing epidemic? Or were these references actually helping spread self-harming behavior?

I put this question to Whitlock. “My educated guess was that it was the latter. In the late eighties, I don't think self-harm was out there as an idea, so mostly the average kid's response was ‘Eww, why would you do that?' But when you hear people like Christina Ricci and Johnny Depp and Angelina Jolie talking about their experiences of it, the idea can become normalized. And once an idea becomes part of the repertoire of possibilities, it can easily gain traction.”

This is especially true when behavior like self-harm gains authoritative recognition from institutions like psychiatry, something that was also occurring during the 1990s. For instance, in 1994 self-harm was for the first time given prominence in the
DSM
as a symptom of Border Personality Disorder. This meant that a kind of behavior once peripheral to psychiatric discourse was now part of the psychiatric canon, potentially making media conversations about the behavior somewhat easier to facilitate because there was now a legion of qualified experts who could explain the behavior to a concerned public.

Was it mere coincidence that after self-harm entered the
DSM
in 1994 the number of popular articles on self-harm literally trebled, increasing from 485 articles in the four-year period before its inclusion to 1,441 in the four-year period after?
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“In many of the media articles we assessed,” said Whitlock, “sure, there was just plain sensationalism, you know, ‘Look at what is going on!' But in others there was now a serious attempt to understand what was happening, and of course people turned first to the clinical world to do that.”

Whitlock gave me an example of how popular news channels like NPR recruited psychiatrists to discuss self-harming. “These would have been classic venues for exporting a psychiatric framework and language of self-harm,” said Whitlock, “and may have helped it enter public consciousness too.”

Since the rise of media reporting and psychiatric recognition of self-harm appeared to coincide with its escalating rates, one question seemed to me inevitable: Was psychiatry, by giving prominence to self-harm in the
DSM
, helping endorse the idea that self-harm was a legitimate way through which young people could express distress? And was this endorsement, coupled with the increasing media reports on self-harm, somehow contributing to its higher prevalence?

This was the very question plaguing Ethan Watters as he attempted to understand why anorexia soared in Hong Kong after Charlene's death. Was there something about psychiatric recognition of the behavior, coupled with growing media attention, which was partly responsible for self-harm's escalation? What Watters soon realized was that in order to answer this question, another matter needed settling first: If psychiatric and media publicity of a disorder could actually increase its occurrence, how did this process work? What were the mechanisms by which growing cultural awareness of a condition could lead to its proliferation?