When a patient with schizophrenia hears voices in their head, is the experience shaped by the culture they live in? Tanya Luhrmann and her colleagues investigated by interviewing twenty people diagnosed with schizophrenia living in San Mateo, California; twenty in Accra, Ghana; and twenty others in Chennai India. There were similarities across cultures, including descriptions of good and bad voices, but also striking differences.
In San Mateo the interviewees talked about their condition as a brain disease, they used psychiatric diagnostic terms to describe themselves, and their experiences were almost overwhelmingly negative. Fourteen described hearing voices that told them to hurt others or themselves. Eight people didn't know the identity of their voices and few described having a personal relationship with their voices.
By contrast, in Chennai, the interviewees frequently spoke of their relationships with their voices - that is, they heard the voices of relatives or friends, giving them advice or scolding them. These patients rarely used diagnostic terms, and rarely talked of voices instructing them to commit violence. Instead, distress, when it occurred, usually arose from their voices talking about sex. Nine interviewees described voices that were significantly good - in terms of being playful or entertaining.
In Accra, yet another picture emerged. Most of the interviewees here mentioned hearing God. This isn't simply a case of this sample being more religious - the interview groups in all three locations were predominantly religious. Half the interviewees in Accra reported that their voice hearing was mostly or entirely positive. Others frequently emphasised the positive. Use of diagnostic labels was rare, as were incitements to violence by voices.
Luhrmann and her team said their most striking finding was that the experiences of voice hearing in the two non-Western samples were less harsh and more "relational" - that is, patients perceived their voices as other people, who could not be controlled. The researchers believe this difference is likely due to Western cultures emphasising independence and individuality - in which case heard voices are experienced as a violation - whereas African and Asian cultures emphasise how each person's mind is interwoven with others. "We believe that these social expectations about minds and persons may shape the voice-hearing experience of those with serious psychotic disorder," the researchers said.
These results need to be replicated with larger samples matched more precisely for illness severity, and with more tightly controlled measures (the current study was deliberately qualitative and exploratory). If replicated, the findings would imply the experience of hearing voices in schizophrenia is to some extent malleable, which could have exciting therapeutic implications. Indeed, it's notable that the outcomes for patients with schizophrenia outside the West, especially in India, are known to be more positive - perhaps because of the way patients relate to their voices. "The harsh violent voices so common in the West may not be an inevitable feature of schizophrenia," the researchers said.
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Luhrmann, T., Padmavati, R., Tharoor, H., & Osei, A. (2014). Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: interview-based study The British Journal of Psychiatry DOI: 10.1192/bjp.bp.113.139048
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