Tanya Luhrmann, professor of anthropology, studies how culture affects the experiences of people who experience auditory hallucinations, specifically in India, Ghana and the United States.
Stanford anthropologist Tanya Luhrmann found that voice-hearing experiences of people with serious psychotic disorders are shaped by local culture – in the United States, the voices are harsh and threatening; in Africa and India, they are more benign and playful. This may have clinical implications for how to treat people with schizophrenia, she suggests.
People suffering from schizophrenia may hear "voices" – auditory hallucinations – differently depending on their cultural context, according to new Stanford research.
In the United States, the voices are harsher, and in Africa and India, more benign, said Tanya Luhrmann, a Stanford professor of anthropology and first author of the article in the British Journal of Psychiatry.
The experience of hearing voices is complex and varies from person to person, according to Luhrmann. The new research suggests that the voice-hearing experiences are influenced by one's particular social and cultural environment – and this may have consequences for treatment.
In an interview, Luhrmann said that American clinicians "sometimes treat the voices heard by people with psychosis as if they are the uninteresting neurological byproducts of disease which should be ignored. Our work found that people with serious psychotic disorder in different cultures have different voice-hearing experiences. That suggests that the way people pay attention to their voices alters what they hear their voices say. That may have clinical implications."
Positive and negative voices
Luhrmann said the role of culture in understanding psychiatric illnesses in depth has been overlooked.
"The work by anthropologists who work on psychiatric illness teaches us that these illnesses shift in small but important ways in different social worlds. Psychiatric scientists tend not to look at cultural variation. Someone should, because it's important, and it can teach us something about psychiatric illness," said Luhrmann, an anthropologist trained in psychology. She is the Watkins University Professor at Stanford.
For the research, Luhrmann and her colleagues interviewed 60 adults diagnosed with schizophrenia – 20 each in San Mateo, California; Accra, Ghana; and Chennai, India. Overall, there were 31 women and 29 men with an average age of 34. They were asked how many voices they heard, how often, what they thought caused the auditory hallucinations, and what their voices were like.
"We then asked the participants whether they knew who was speaking, whether they had conversations with the voices, and what the voices said. We asked people what they found most distressing about the voices, whether they had any positive experiences of voices and whether the voice spoke about sex or God," she said.
The findings revealed that hearing voices was broadly similar across all three cultures, according to Luhrmann. Many of those interviewed reported both good and bad voices, and conversations with those voices, as well as whispering and hissing that they could not quite place physically. Some spoke of hearing from God while others said they felt like their voices were an "assault" upon them.
'Voices as bombardment'
The striking difference was that while many of the African and Indian subjects registered predominantly positive experiences with their voices, not one American did. Rather, the U.S. subjects were more likely to report experiences as violent and hateful – and evidence of a sick condition.
The Americans experienced voices as bombardment and as symptoms of a brain disease caused by genes or trauma.
One participant described the voices as "like torturing people, to take their eye out with a fork, or cut someone's head and drink their blood, really nasty stuff." Other Americans (five of them) even spoke of their voices as a call to battle or war – "'the warfare of everyone just yelling.'"
Moreover, the Americans mostly did not report that they knew who spoke to them and they seemed to have less personal relationships with their voices, according to Luhrmann.
Among the Indians in Chennai, more than half (11) heard voices of kin or family members commanding them to do tasks. "They talk as if elder people advising younger people," one subject said. That contrasts to the Americans, only two of whom heard family members. Also, the Indians heard fewer threatening voices than the Americans – several heard the voices as playful, as manifesting spirits or magic, and even as entertaining. Finally, not as many of them described the voices in terms of a medical or psychiatric problem, as all of the Americans did.
In Accra, Ghana, where the culture accepts that disembodied spirits can talk, few subjects described voices in brain disease terms. When people talked about their voices, 10 of them called the experience predominantly positive; 16 of them reported hearing God audibly. "'Mostly, the voices are good,'" one participant remarked.
Individual self vs. the collective
Why the difference? Luhrmann offered an explanation: Europeans and Americans tend to see themselves as individuals motivated by a sense of self identity, whereas outside the West, people imagine the mind and self interwoven with others and defined through relationships.
"Actual people do not always follow social norms," the scholars noted. "Nonetheless, the more independent emphasis of what we typically call the 'West' and the more interdependent emphasis of other societies has been demonstrated ethnographically and experimentally in many places."
As a result, hearing voices in a specific context may differ significantly for the person involved, they wrote. In America, the voices were an intrusion and a threat to one's private world – the voices could not be controlled.
However, in India and Africa, the subjects were not as troubled by the voices – they seemed on one level to make sense in a more relational world. Still, differences existed between the participants in India and Africa; the former's voice-hearing experience emphasized playfulness and sex, whereas the latter more often involved the voice of God.
The religiosity or urban nature of the culture did not seem to be a factor in how the voices were viewed, Luhrmann said.
"Instead, the difference seems to be that the Chennai (India) and Accra (Ghana) participants were more comfortable interpreting their voices as relationships and not as the sign of a violated mind," the researchers wrote.
Relationship with voices
The research, Luhrmann observed, suggests that the "harsh, violent voices so common in the West may not be an inevitable feature of schizophrenia." Cultural shaping of schizophrenia behavior may be even more profound than previously thought.
The findings may be clinically significant, according to the researchers. Prior research showed that specific therapies may alter what patients hear their voices say. One new approach claims it is possible to improve individuals' relationships with their voices by teaching them to name their voices and to build relationships with them, and that doing so diminishes their caustic qualities. "More benign voices may contribute to more benign course and outcome," they wrote.
Co-authors for the article included R. Padmavati and Hema Tharoor from the Schizophrenia Research Foundation in Chennai, India, and Akwasi Osei from the Accra General Psychiatric Hospital in Accra, Ghana.
What's next in line for Luhrmann and her colleagues?
"Our hunch is that the way people think about thinking changes the way they pay attention to the unusual experiences associated with sleep and awareness, and that as a result, people will have different spiritual experiences, as well as different patterns of psychiatric experience," she said, noting a plan to conduct a larger, systematic comparison of spiritual, psychiatric and thought process experiences in five countries.
In the United States, the voices are harsher, and in Africa and India, more benign, said Tanya Luhrmann, a Stanford professor of anthropology and first author of the article in the British Journal of Psychiatry.
The experience of hearing voices is complex and varies from person to person, according to Luhrmann. The new research suggests that the voice-hearing experiences are influenced by one's particular social and cultural environment – and this may have consequences for treatment.
In an interview, Luhrmann said that American clinicians "sometimes treat the voices heard by people with psychosis as if they are the uninteresting neurological byproducts of disease which should be ignored. Our work found that people with serious psychotic disorder in different cultures have different voice-hearing experiences. That suggests that the way people pay attention to their voices alters what they hear their voices say. That may have clinical implications."
Positive and negative voices
Luhrmann said the role of culture in understanding psychiatric illnesses in depth has been overlooked.
"The work by anthropologists who work on psychiatric illness teaches us that these illnesses shift in small but important ways in different social worlds. Psychiatric scientists tend not to look at cultural variation. Someone should, because it's important, and it can teach us something about psychiatric illness," said Luhrmann, an anthropologist trained in psychology. She is the Watkins University Professor at Stanford.
For the research, Luhrmann and her colleagues interviewed 60 adults diagnosed with schizophrenia – 20 each in San Mateo, California; Accra, Ghana; and Chennai, India. Overall, there were 31 women and 29 men with an average age of 34. They were asked how many voices they heard, how often, what they thought caused the auditory hallucinations, and what their voices were like.
"We then asked the participants whether they knew who was speaking, whether they had conversations with the voices, and what the voices said. We asked people what they found most distressing about the voices, whether they had any positive experiences of voices and whether the voice spoke about sex or God," she said.
The findings revealed that hearing voices was broadly similar across all three cultures, according to Luhrmann. Many of those interviewed reported both good and bad voices, and conversations with those voices, as well as whispering and hissing that they could not quite place physically. Some spoke of hearing from God while others said they felt like their voices were an "assault" upon them.
'Voices as bombardment'
The striking difference was that while many of the African and Indian subjects registered predominantly positive experiences with their voices, not one American did. Rather, the U.S. subjects were more likely to report experiences as violent and hateful – and evidence of a sick condition.
The Americans experienced voices as bombardment and as symptoms of a brain disease caused by genes or trauma.
One participant described the voices as "like torturing people, to take their eye out with a fork, or cut someone's head and drink their blood, really nasty stuff." Other Americans (five of them) even spoke of their voices as a call to battle or war – "'the warfare of everyone just yelling.'"
Moreover, the Americans mostly did not report that they knew who spoke to them and they seemed to have less personal relationships with their voices, according to Luhrmann.
Among the Indians in Chennai, more than half (11) heard voices of kin or family members commanding them to do tasks. "They talk as if elder people advising younger people," one subject said. That contrasts to the Americans, only two of whom heard family members. Also, the Indians heard fewer threatening voices than the Americans – several heard the voices as playful, as manifesting spirits or magic, and even as entertaining. Finally, not as many of them described the voices in terms of a medical or psychiatric problem, as all of the Americans did.
In Accra, Ghana, where the culture accepts that disembodied spirits can talk, few subjects described voices in brain disease terms. When people talked about their voices, 10 of them called the experience predominantly positive; 16 of them reported hearing God audibly. "'Mostly, the voices are good,'" one participant remarked.
Individual self vs. the collective
Why the difference? Luhrmann offered an explanation: Europeans and Americans tend to see themselves as individuals motivated by a sense of self identity, whereas outside the West, people imagine the mind and self interwoven with others and defined through relationships.
"Actual people do not always follow social norms," the scholars noted. "Nonetheless, the more independent emphasis of what we typically call the 'West' and the more interdependent emphasis of other societies has been demonstrated ethnographically and experimentally in many places."
As a result, hearing voices in a specific context may differ significantly for the person involved, they wrote. In America, the voices were an intrusion and a threat to one's private world – the voices could not be controlled.
However, in India and Africa, the subjects were not as troubled by the voices – they seemed on one level to make sense in a more relational world. Still, differences existed between the participants in India and Africa; the former's voice-hearing experience emphasized playfulness and sex, whereas the latter more often involved the voice of God.
The religiosity or urban nature of the culture did not seem to be a factor in how the voices were viewed, Luhrmann said.
"Instead, the difference seems to be that the Chennai (India) and Accra (Ghana) participants were more comfortable interpreting their voices as relationships and not as the sign of a violated mind," the researchers wrote.
Relationship with voices
The research, Luhrmann observed, suggests that the "harsh, violent voices so common in the West may not be an inevitable feature of schizophrenia." Cultural shaping of schizophrenia behavior may be even more profound than previously thought.
The findings may be clinically significant, according to the researchers. Prior research showed that specific therapies may alter what patients hear their voices say. One new approach claims it is possible to improve individuals' relationships with their voices by teaching them to name their voices and to build relationships with them, and that doing so diminishes their caustic qualities. "More benign voices may contribute to more benign course and outcome," they wrote.
Co-authors for the article included R. Padmavati and Hema Tharoor from the Schizophrenia Research Foundation in Chennai, India, and Akwasi Osei from the Accra General Psychiatric Hospital in Accra, Ghana.
What's next in line for Luhrmann and her colleagues?
"Our hunch is that the way people think about thinking changes the way they pay attention to the unusual experiences associated with sleep and awareness, and that as a result, people will have different spiritual experiences, as well as different patterns of psychiatric experience," she said, noting a plan to conduct a larger, systematic comparison of spiritual, psychiatric and thought process experiences in five countries.
BY CLIFTON B. PARKER