Schizophrenia in Developing Countries, or How the Self-Esteem Researchers Screwed Us All.

Fun facts:  Prognosis for schizophrenia is better in the developing world than it is in the West. (We will come back to this).

First, I want to make a point.  We in psychology are idealists.  When we get an idea, and it seems semi-supported by research, we like to tell people we have found the cure to life’s struggles and implement broad social changes to improve things.  A few decades ago, somebody noted that people with higher self-esteem seemed happier and more successful.  So they decided that if EVERYBODY had high self-esteem, they would be happier and more successful.  Note the mistaken assumption of causality here.  (And we wonder why the physicists won’t look at us!)

Here’s the reality, in case the self-esteem researchers got to you too: we are not all awesome at doing everything all the time.  And having people lie to us and tell us we are, though it might make us feel better on the spot, interferes with our reality testing in the long run. 

Here’s why.  In order to make sense of the ambiguous realities of everyday life, we need some kind of social consensus (Asch, 1951; Sherif, 1931).  Some researchers go so far as to argue that we have a need to compare ourselves to others (Festinger, 1954) because we are looking to make sense of reality (Sherif, 1931). 

The world is complicated.  People’s behaviour doesn’t always make sense.  If someone is brusque to you, you have to make a decision.  Are they being rude, are they in a bad mood, did you do something wrong, or is it a culture or personality disconnect?  On a day to day basis, these are the kinds of questions that we need answered.  And sometimes we just don’t know so we ask other people.  We use social consensus to decide whether someone was rude, whether an outfit is fashionable, whether we are rich or poor, and for just about any other question, big or small, that does not have an observable physical reality - and even then (see Asch, 1951, where 30% of people said an obviously longer line was shorter because everybody else in the room said it was. If you don't believe me, here's a link). 

That’s how important it is to know that the people around you - who you depend on for these answers - are being honest.

A child who wants to know if he is good at baseball or a teenager who wants to know if she is a good driver are looking primarily for the right answer.  The truthful answer.  Not the nicest answer.  We need to know that we perceive as right or wrong, everybody else perceives as right or wrong.  There’s something calming about that - and that's very nice.

Here’s the problem with telling a kid who doesn’t have an athletic bone in his body that he’s good at baseball:

HE’S GOING TO BELIEVE YOU!!!

Now back to the schizophrenics.

Schizophrenia is one of those scary mental disorders that baffles the medical community.  Oh we have a few ideas, but really, prognosis is pretty bad.  But somehow, in less developed parts of the world, it’s better (Isaac, Chand, & Murthy, 2007)

This should blow everybody’s mind. Quality of life is higher here. Medical care is better. People are nicer. There’s less war, disease, death. There doesn’t seem to be any reason diseased individuals should do better elsewhere. (To be fair, some have argued schizophrenics do not always do better in the developing world. Cohen et al 2008).

Unless the problem is that these people are hypersensitive to things that we do not do well here.  Like maintaining relationships with our families and reality testing.  We North Americans are good at many things, but we are not good at telling people when they are making us angry, when they are being rude, or when they suck at baseball.  We are also a highly individualistic culture that allows people to live most of their adult lives separated from their families (maybe not always a bad thing, but very isolating). 

Developing countries don’t have time for that nonsense.  Half of my family is of Algerian heritage (so I feel like I have the right to generalize my experience to the entire developing world).  And my experience is this: people are not concerned with your self-esteem, and families stick together just because.  (I actually think families stick together there because there is very little other form of social infrastructure - but that’s beside the point.) Families are more direct and, though not necessarily less dysfunctional, less afraid of their dysfunctionality.  And I think there is enormous therapeutic value there.

I think that in daily life we underestimate the therapeutic value of looking life’s ugly in the face and knowing we are not alone.  I think that a lack of acknowledgment of certain undesirable realities, even if it’s because we want to make people we love feel better, ultimately leads to problems in our basic understanding of the world and of our place in it.  And I think these problems can have graver consequences than just producing the occasional obnoxious individual with an inflated sense of self.