The Changing Voices in Our Heads: Society’s Impact on Psychosis
Zoya Qureshi
Illustrations by: Claire Iannetta
“I know you don’t want to, but it’s okay. Go bathe, then go to the shop. When you come back, you can go into the kitchen and prepare food for your family.” “You’re a waste, give up now.” The first quote is a description of a voice heard by a woman with schizophrenia in Chennai, India [1]. The second quote is one of many voices heard by a man with schizophrenia in Lee’s Summit, Missouri [2]. The first voice, though it nags, mainly addresses the patient like her relatives do, giving guidance and the occasional scolding. The other voice is violent; it is impatient, unforgiving, and harsh, and it taunts the man whose head it lives in. But why are these two voices different? Can it be that people living with schizophrenia in different parts of the world experience the disorder differently due to distinct cultural norms?
Schizophrenia: What it is and Why We Should Care
Schizophrenia is an often persistent mental disorder that can be severe and disabling [4]. The most common symptoms of schizophrenia are categorized into positive (behaviors not present in a neurotypical individual) and negative (lack of neurotypical behaviors) symptoms [4, 5]. The positive symptoms of schizophrenia include hallucinations (hearing voices or seeing things that are not there) and delusions (fixed, false beliefs), while the negative symptoms include reduced emotional expression, difficulty in social relationships and in finding motivation to accomplish goals, and both cognitive and motor impairments. Thought disorder (in which one experiences unusual and disorganized thinking, such as an unintelligible mixture of seemingly random words) is another prevalent symptom of schizophrenia but is not usually categorized as either positive or negative [5].
Schizophrenia is one of the top 15 leading causes of disability globally and affects 20 million people worldwide [4,6]. People with this illness are 2-3 times more likely to die early compared to the general population; they are also more likely to face stigma, discrimination, and human rights violations [6]. Additionally, individuals with schizophrenia are more likely to be enrolled in criminal justice programs or social services due to failings in our system, thus increasing the impact of this disorder on the economy [7,8]. Many people with schizophrenia have a higher risk of arrest and incarceration compared with the general population, not because of unlawful behavior on their part, but often due to unfair victimization: not only are individuals with schizophrenia frequently the victim of a crime themselves, but they may be accused of a crime that they have not actually committed simply because their disorder makes for an easy scapegoat. Those who do commit crimes often do so when they are not adhering to antipsychotic medication -- sometimes due to a lack of access-- that can be necessary to keep the disorder under control [8]. A 2010 study attempted to break down the prevalence of encounters with the criminal justice system experienced by individuals with schizophrenia, as well as the costs attributable to this disorder [8]. The numbers were astounding. Individuals with schizophrenia were left to pay heightened costs, often due to factors beyond their control. These findings have a larger economic impact as well: the ineffective funneling of patients into governmental systems ultimately increases taxes for everyone. While you may not be aware of it, this disorder affects you too.
How is Schizophrenia Experienced Differently Around the World?
Although early studies focused mainly on Western society, researchers have been discussing the impact of society and culture on mental disorders for decades [9]. Recent studies looking at schizophrenia, and specifically at auditory hallucinations (the most commonly reported schizophrenia symptom across cultures) are being conducted on a global scale [10]. A compelling study conducted in 2002 aimed to compare the influence of culture and immediate environment on the auditory hallucinations in three groups of patients with schizophrenia: white people living in Britain, Pakistanis living in Britain, and Pakistanis living in Pakistan [10]. By distinguishing between these three groups, the researchers could separate the effects of differences in cultural thinking (due to distinct environments) from ethnic differences. Interestingly, scientists found that both sets of patients living in Britain experienced significantly more auditory hallucinations in their day-to-day than patients living in Pakistan, implying that one’s immediate environment plays a greater role than ethnicity. The researchers also found that the content of auditory hallucinations differed significantly between the British groups and the group in Pakistan: while both British groups experienced violent negative hallucinations (voices cursing and telling patients to kill themselves), patients living in Pakistan (though they did experience negative/unpleasant hallucinations) had markedly fewer voices encouraging suicide or other forms of violence [10].
A study conducted soon after looked at patients with schizophrenia in Nigeria and compared their auditory hallucinations to those of patients in the U.K. [11]. Researchers found that the number of British patients experiencing unfriendly and unfamiliar voices was higher than in the Nigerian group; meanwhile, patients in the Nigerian group heard voices that were less aggressive and usually familiar, in comparison to their British counterparts [11]. These two studies taken together suggest that auditory hallucinations may differ in patients living in distinct parts of the world. But the most compelling evidence was yet to come.
Patients in the U.S. Hear Harsher Voices Than Patients in India or Africa
A 2014 study spearheaded by Stanford anthropologist Tanya Luhrmann suggested that people with schizophrenia in certain countries don’t hear the same harsh, violent voices that many Americans do [1]. In her study, she and her colleagues, many of whom were psychiatrists, interviewed 60 adults diagnosed with schizophrenia: 20 each in San Mateo, California; Accra, Ghana; and Chennai, India. Respondents were asked to describe how many voices they heard, how often they heard them, and what the voices were like. Individuals in all cultures described hearing a mixture of good and bad voices. Strikingly, while many of the African and Indian subjects reported predominantly positive experiences with their voices, not one American did. Instead, the U.S. subjects were more likely to report experiences as violent and hateful [1,3].
One American patient described his voices being consistently violent, “like torturing people, to take their eye out with a fork… really nasty stuff,” while one participant from Ghana said “mostly, the voices are good [2].” More than half of the Chennai sample heard familial voices (including those of parents, in-laws, and siblings) who spoke as though they were elders advising younger people. They would sometimes scold the patients, but usually the voices were helpful and taught the patients skills, such as domestic tasks. When speaking of their experiences with negative voices, the majority of patients in Accra insisted that their good voices were more powerful than any bad voice; oftentimes, their good voice was the voice of God, providing guidance. Patients in both Chennai and Accra described negative voices as the voices of people they knew or the voices of spirits but never described them as disembodied or intrusive. Meanwhile, the latter description illustrates how patients in California spoke of their auditory hallucinations [1,3].
Breaking Down the Difference: Individualism vs. Collectivism
Luhrmann and her team attributed the differences in how the voices were perceived to distinct societal values[1,3]. Americans view themselves as individuals and place an overarching cultural emphasis on independence, so the voices experienced due to schizophrenia were perceived as an intrusion into the patient’s distinct, self-made mind. Meanwhile, Indian and Ghanan cultures emphasize collectivism and relationships within a community, so additional voices were likely to be interpreted as more people in an already extensive social network. The widely accepted presence of supernatural elements in both these cultures (partially attributed to religion) also meant that people in Chennai and Accra were already used to the idea of beings beyond their comprehension; therefore, they were not as troubled by the presence of voices outside of their control. In the future, Luhrmann is hopeful that she can use these societally distinct ways of thinking to her advantage [1,3]. Although there is no cure for schizophrenia, encouraging patients to develop relationships with their hallucinated voices and negotiating with them as though they are people, and not disembodied things, may hold therapeutic value.
REFERENCES
1. Luhrmann, T. M., Padmavati, R., Tharoor, H., & Osei, A. (2015). Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: interview-based study. The British Journal of Psychiatry, 206(1), 41-44. doi:10.1192/bjp.bp.113.139048.
2. Carey, B. (2011, August). Learning to cope with a mind’s taunting voices. The New York Times. Retrieved from https://www.nytimes.com/2011/08/07/health/07lives.html?pagewanted=all&_r=0
3. Parker, C. (2014, July). Hallucinatory ‘voices’ shaped by local culture, Stanford anthropologist says. Stanford News. Retrieved from https://news.stanford.edu/2014/07/16/voices-culture-luhrmann-071614/
4. National Institute of Mental Health (2018). Schizophrenia. Retrieved Oct 5, 2020, from https://www.nimh.nih.gov/health/statistics/schizophrenia.shtml
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6. World Health Organization. (2019, October 4). Schizophrenia: Key Facts. Retrieved Oct 5, 2020, from https://www.who.int/news-room/fact-sheets/detail/schizophrenia
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