Mental(izing) Health
Newsletter, #34
What keeps you up at night? My sleepless night ranged wildly across the political, the personal, and the professional: from thinking about the election that could augur the end of democracy, to the two positive COVID tests in my son’s class last week, onto the career plans of my daughter to join the field, and then swerving to ponder my (and other family members) health concerns, before finally dwelling on the troubling reality that legions of people are struggling, who really need our help, but whom we are failing to help. This is, to some extent, a numbers problem: we need to train more mental health professionals in the next generation, and we need to continue to protest vigorously against mental health stigma. However, the problem is deeper: many people who might benefit from our help choose not to seek it, and sadly, some people who have sought help do not find what they are looking for. Under the sway of social media, people are drawn to seek out treatments that might not be optimal for them.[i]
It is also the case that mental health professionals can be poorly equipped to be able to help and, thereby, unintentionally alienate people. Failing to help people who are seeking our services is particularly concerning, and in this newsletter, I shall try to put aside my own woes, large and small, at least temporarily, and zero in on this phenomenon. My aim is to encourage clinicians to engage and strive to understand, rather than ignore our failures. It would be dishonest, though, not to realize that the election, one week away, could prove to be such a disaster that all decent human beings will need to be prepared to join the fight against authoritarianism.
A good starting place is to acknowledge that psychotherapy began at a certain time and place. While many cultures have ways of treating human suffering, psychotherapy differs in creating a private space for individuals to focus on themselves. No doubt, the appeal of this is produced by the conditions of modernity: people living too closely in proximity, amongst strangers, in cities, where life keeps unfolding at a faster pace, harboring both the alluring promise of success and the dread of abject failure. There is more to say about the origins of psychotherapy, as Freud’s identity as a Jew was a factor in his courage to create a new approach to mental health, given that full acceptance in the Austro-Hungarian empire was limited and variable for minorities. Psychotherapy has evolved over the century and a quarter in which it has existed. Psychoanalysis is at the source, regardless of whether one is comfortable with feeling connected to this past, or one holds the belief that we have entered a threshold of science that transcends Freud’s innovation.
In order to deepen our understanding of where and why we fail, I propose that we pay greater attention to the realm of emotions, and how they are impacted by culture. All psychotherapeutic orientations concern themselves with emotions, and patients typically come to therapy because of trouble with their emotions: that they are overwhelmed, or that they are distanced from, or that they struggle to make sense of their emotions. Fortuitously, there is a recently published book, Between Us: How Cultures Create Emotions, by Batja Mesquita, a Dutch born social and cultural psychologist, who lived and worked in the US, but now is teaching at the University of Leuven, Belgium., that can jumpstart our investigation of emotions and psychotherapy. [ii] The book offers a powerful challenge to assumptions about emotions as universal that are, in truth, a product of the beliefs of WEIRD people.[iii] Mesquita understands emotions as interruptions that are constructed by the language of the culture in which one lives. Following the psychologist Lisa Feldman Barrett, the Darwinian-Ekman paradigm of “basic emotions” does not go far enough in acknowledging cultural differences.[iv] Thus, we ought to be more cautious about regarding emotions as universal based upon facial expressions, given the evidence that currently exits. Moreover, it is likely that we will profit from greater curiosity about the impact of culture on the experience of emotions.
Although Mesquita’s argument mentions the WEIRD construct, she introduces her own distinction that plays the major role in the book: understanding emotions as MINE or OURS. The logic of MINE is that emotions are “Mental, Inside the person, and Essentialist, whereas the logic of OURS is that emotions are OUtside, Relational and Situational. This distinction coincides to a large extent between Western versus East Asian culture, although Mesquita does not aspire to be comprehensive geographically. Her interests developed from research, where she interviewed Dutch people and immigrants to the Netherlands from Surinam and Turkey concerning various emotional situations: the Dutch subjects exhibited MINE beliefs about their own subjective states, whereas the Surinamese and Turkish subjects exhibited OURS beliefs, emphasizing social concerns.
Mesquita’s book provides a wealth of evidence from social psychology studies that support the fundamental difference between these two emotional universes. For example, she cites a study by Uchida that asks American and Japanese students to say which condition showed more emotion, one with a single winning athlete or one with a winning athlete accompanied by three teammates.[v] The American subjects thought the single athlete showed more emotion, while the Japanese subjects thought the athlete in a group did. In another study with Masuda, Mesquita asked American and Japanese subjects to compare the specific facial emotions of a figure in the foreground with four people in the background. The American subjects judged only by looking at the target figure, whereas the Japanese subjects looked at the others’ expressions as well.[vi]
The OURS versus MINE paradigms can be traced back to childhood and parenting styles. The MINE style invites attention to internal states, and parents “help their children figure out how their emotions related to what they want or think” (p. 38). In contrast, the OURS style dwells on social consequences. The MINE style welcomes praise as conducive to the emergence of a sense of self; the OURS style relies more on shame (although we need to be careful about assuming shame is the same emotion across cultures). Mesquita argues, for instance, that in Japanese culture, shame has to do with acknowledging the expectations of parents but does not presume the humiliation that the MINE view does. It can be salutary, according to OURS logic, to acknowledge shame. She reports a fascinating study, of which she was a part, where Japanese subjects were more comfortable talking about shame than American subjects.[vii] Mesquita’s intellectual journey had led her to confront how acculturation in MINE contributed to her being insufficiently aware of the OURS paradigm.
Some of Mesquita’s work has strong implications for clinical work. She documents the difference between the kind of positive emotions most highly valued in OURS as calmness, in contrast to excitement in MINE. There is, in fact, research that Mesquita does not cite that suggests that positive emotions are coded negatively in East Asian cultures, as they signal hubris and potentially undermine social harmony.[viii] Mesquita explores the issue of expressing emotions, beginning with Freud who proposed that expressing feelings facilitates our ability to overcome loss. Indeed, an experience in my own research lab is relevant here. My research team created a measure, the Mentalized Affectivity Scale, that distinguishes among identifying, processing and expressing emotions.[ix] Our findings to date have been mixed about expressing, I suspect, because we began with the (MINE) assumption that expressing emotions is a good thing, which may not be true for some subjects. Just think about how mistaken it might be to encourage expression in sitting with patients who come from OURS backgrounds. Just imagine how many patients have had disappointing therapeutic experiences because of this cultural misunderstanding.
My assessment of Mesquita’s distinction is that it is fruitful in reigning in Western ethnocentrism., but that the distinction itself is not fully convincing. It is far from clear that all cultures must fall into one of the two categories. Mesquita never seems to consider the possibility of hybrid forms. Also, she does not grapple with gender: are women discouraged from being angry across the two categories (she emphasizes that women are not allowed to be angry in specific cases from OURS cultures)? Most importantly, rendering the main distinction in terms of “inside or outside” bypasses a distinction that strikes me as crucial: the MINE paradigm rests on mind/body dualism in contrast to the OURS paradigm that has its source in mind/body unity. Contrary to what Mesquita suggests, the OURS paradigm encourages attention to the body, while the MINE paradigm ultimately values the mind over the body (a legacy of Christianity).
The main distinction might be questioned in that there are subtle ways that the MINE point of view is rooted in social interaction (Western toddlers mentalize if they have someone who is mentalizing about them), and the OURS point of view requires people to recognize their own mental states (otherwise there would be no such thing as family conflict). Mesquita’s distinction risks being overgeneralization, and its strongest plausibility is as a historical postulate. Although Mesquita mentions globalization, she does not engage in much speculation about its implications. Will one of the two win out? Might it be possible to take elements of each and combine them? What would such an integration look like?
In centering the focus on the between group difference, Mesquita inevitably underestimates within group differences. She does offer personal reflections about moving to the US: and becoming aware of how her tendency to be authentically honest, which the Dutch cherish, could be experienced as being blunt and verging on rudeness. She also reports on being struck by the perky and cheerful style that Americans take for granted. Mesquite does not venture to consider, though, whether such differences might force us to question the coherence of the MINE paradigm. Might MINE people misunderstand each other as much as they do with OURS people?
Mesquita’s discussion of within group differences highlights the experience of immigrants, but it does not linger on issues concerning the dominant group versus minority groups. She cites research that suggests that it takes three generations for immigrants to assimilate into the emotional world of their new culture. But think about how poorly race in the US fits with this schema. In my admittedly psychoanalytic view, we need to take greater account of conflict, both in within group and between group comparisons.
Clinicians can learn from Mesquita’s book. In a recent interview about her work, she stresses that therapists ought not be so attentive to individual concerns that relationship to others (and systems) are deemed as irrelevant.[x] In the book, Mesquita wisely affirming the value of cultural humility, that we need to give space for patients to inform us from their point of view, remaining mindful of how our own point of view, if different, can interfere with understanding others. Dealing with this would not simply be a matter of MINE clinicians doing a better job of tuning into OURS patients. As I stated in the beginning, we certainly need more therapists; but it is especially important to train more therapists who come from OURS backgrounds. I imagine that most people might agree with this in principle; so then, the question naturally arises: how can we make this goal a reality?
[i] https://www.nytimes.com/2022/10/29/well/mind/tiktok-mental-illness-diagnosis.html
[ii] B. Mesquita (2022). Between Us: How Cultures Create Emotions (New York: Norton).
[iii] J. Henrich, S.Heine, & A. Norenzayan (2010). The Weirdest People in the world? Behavioral and Brain Sciences, 33(2-3), 61-83. doi:10.1017/S0140525X0999152X. WEIRD stands for “western, educated, industrial, rich, and democratic.” It is certainly the case that too much research in psychology relies on US college students as subjects. However, there is good reason to be skeptical about the WEIRD construct, given several points: the diminished quality of our education, information replacing the industrial revolution, and, of course, that our democracy is imperiled. In addition, in failing to distinguish between dominant and minority members of WEIRD, we risk overlooking what Miranda Fricker refers to as the “epistemic injustice” that defines the experience of minorities.
[iv] L. Feldman-Barrett (2017). How Emotions Are Made: The Secret Life of the Brain. Boston: Mariner.
[v] Y. Uchida, S. Townsend, H. Markus, and H. Bergsieker (2009). Emotions as Within or Between People? Cultural Variations in Lay Theories of Emotion Expression and Inference. Personality and Social Psychology Bulletin, Vol 35(11), 1427-1439.
[vi]T. Matsuda, P. Ellsworth., B. Mesquita, J. Leu, T. Janxin, S. Tanida, and E. Van de Veerdonk (2008). Placing the Face in Context: Cultural Differences in the Perception of Facial Emotion. Journal of Personality and Social Psychology, 94(3): 365-281.
[vii]S. Kitayama, B. Mesquita, M.Karasawa (2006). Cultural affordances and emotional experience: Socially engaging and disengaging emotions in Japan and the United States. Journal of Personality and Social Psychology. 2006;91(5):890-903. doi:10.1037/0022-3514.91.5.890
[viii]X. Ma, M. Tamir,. & Y. Miyamoto, Y. (2018). A Socio-cultural Instrumental Approach to Emotion Regulation: Culture and the Regulation of Positive Emotions. Emotion, 18(1), 138–152. https://doi.org/10.1037/emo0000315
[ix] D. Greenberg, J. Kolasi, C., Hegsted, Y. Berkowitz, Y., & E. Jurist. (2017). Mentalized Affectivity: A New Model and Assessment of Emotion Regulation. PloS one, 12(10), e0185264.