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Culture and Hallucinations: Overview and Future Directions

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Abstract

A number of studies have explored hallucinations as complex experiences involving interactions between psychological, biological, and environmental factors and mechanisms. Nevertheless, relatively little attention has focused on the role of culture in shaping hallucinations. This article reviews the published research, drawing on the expertise of both anthropologists and psychologists. We argue that the extant body of work suggests that culture does indeed have a significant impact on the experience, understanding, and labeling of hallucinations and that there may be important theoretical and clinical consequences of that observation. We find that culture can affect what is identified as a hallucination, that there are different patterns of hallucination among the clinical and nonclinical populations, that hallucinations are often culturally meaningful, that hallucinations occur at different rates in different settings; that culture affects the meaning and characteristics of hallucinations associated with psychosis, and that the cultural variations of psychotic hallucinations may have implications for the clinical outcome of those who struggle with psychosis. We conclude that a clinician should never assume that the mere report of what seems to be a hallucination is necessarily a symptom of pathology and that the patient's cultural background needs to be taken into account when assessing and treating hallucinations.
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Schizophrenia Bulletin vol. 40 suppl. no. 4 pp. S213–S220, 2014
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Culture and Hallucinations: Overview and Future Directions
FrankLarøi1,, Tanya MarieLuhrmann*,2,, VaughanBell3, William A.Christian Jr4, SmitaDeshpande5,
CharlesFernyhough6, JanisJenkins7, and AngelaWoods8
1Department of Psychology, University of Liège, Liège, Belgium; 2Department of Anthropology, Stanford University, Stanford, CA;
3King’s College London, Institute of Psychiatry, London, UK; 4Department of Social Anthropology, Autonomous University of
Barcelona, Bellaterra, Spain; 5Department of Psychiatry and Addiction Services, Dr Ram Manohar Lohia Hospital, New Delhi, India;
6Department of Psychology, Durham University, Durham, UK; 7Department of Anthropology, University of California San Diego, San
Diego, CA; 8Centre for Medical Humanities, Durham University, Durham, UK
*To whom correspondence should be addressed; Department of Anthropology, Stanford University, Stanford CA 94305, US;
tel:1-650-723-3421, fax: 1-650-725-0605, e-mail: luhrmann@stanford.edu
These authors equally contributed to this paper and are willing to share the rst authorship.
A number of studies have explored hallucinations as com-
plex experiences involving interactions between psychologi-
cal, biological, and environmental factors and mechanisms.
Nevertheless, relatively little attention has focused on the role
of culture in shaping hallucinations. This article reviews the
published research, drawing on the expertise of both anthro-
pologists and psychologists. We argue that the extant body
of work suggests that culture does indeed have a signicant
impact on the experience, understanding, and labeling of
hallucinations and that there may be important theoretical
and clinical consequences of that observation. We nd that
culture can affect what is identied as a hallucination, that
there are different patterns of hallucination among the clini-
cal and nonclinical populations, that hallucinations are often
culturally meaningful, that hallucinations occur at different
rates in different settings; that culture affects the meaning
and characteristics of hallucinations associated with psycho-
sis, and that the cultural variations of psychotic hallucina-
tions may have implications for the clinical outcome of those
who struggle with psychosis. We conclude that a clinician
should never assume that the mere report of what seems to
be a hallucination is necessarily a symptom of pathology and
that the patient’s cultural background needs to be taken into
account when assessing and treating hallucinations.
Key words: hallucination/culture/ethnography/
psychosis/religion
What Is Culture?
Anthropologists commonly use the term “culture” to
describe shared patterns of meaning that are learned
within a particular social world—“that complex whole
which includes knowledge, belief, art, law, morals, custom,
and any other capabilities and habits acquired by man as
a member of society”1 or “patterns, explicit and implicit,
of and for behaviour acquired and transmitted by sym-
bols.”2 By the term, anthropologists draw attention to
the fact that humans are meaning-making animals and
that, over time, different groups of humans develop dif-
ferent habits in interpreting even the most basic features
of their experience. The research reported here suggests
that cultural expectations shape the way people pay atten-
tion to their sensory experience. These different patterns
of attention may be responsible for differing experiences
of hallucinations.
Culture Can Affect What Is Identied as a
Hallucination
One of the most signicant factors in how culture affects
the recognition of the experience of hallucination rests
on the understanding of reality in the culture in question.
Although there are many denitions used in the academic
literature, many describe hallucinations as “false” percep-
tions. This denition can seem to depend on a specic
understanding of reality alien to most humans, who
accept some degree of supernatural reality.3
An ethnographic approach to hallucinations there-
fore becomes essential in understanding how members
of particular societies identify and understand sensory
events that would be recognized by secular observ-
ers as hallucinations and how they distinguish between
unusual sensory events they regard as appropriate and
those they identify as signs of illness. The richness of the
ethnographic method captures meaning that experimen-
tal approaches will miss. For example, the Cashinahua,
Siona, and Schuar peoples of the Upper Amazon all use
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F. Larøi etal
the hallucinogenic brew ayahuasca as a spiritual guide.
However, the Cashinahua consider the experiences as
hallucinations that provide guidance,4 the Siona believe
that ayahuasca provides access to an alternate reality,5
and the Schuar hold that all normal human experience is
a hallucination and ayahuasca provides access to veridi-
cal reality.6 This is an important point because research
on hallucinations usually involves asking people about
experiences that are not explainable, have no obvious
source or are not shared by others.7 Differing views of
what constitutes veridical reality may affect how these
experiences are reported. At the least, these cultural
issues should shape the way researchers frame both their
assessment methods and their research questions. More
empirically, the fact that different cultural models of
reality may lead to differing levels of reporting means
that the kinds and rates of hallucinatory experience may
vary between cultures in epidemiological studies due to
different theories of the world and not just differing lev-
els of experience.
Different Patterns of Hallucinations
Both the ethnographic and clinical literatures agree that
hallucinations are common in the nonclinical popula-
tion.8,9 The form of hallucination in the clinical and non-
clinical population are, however, relatively distinct, and
there seem to be, broadly speaking, 3 dominant patterns.10
Persons with psychosis often hallucinate many times
each day. These hallucinations may be unpleasant, even
horric. In the schizophrenia spectrum, hallucinations
are primarily auditory, and they are often accompanied
by strange, xed beliefs (delusions) not shared by other
people. It is also true that the voice-hearing experience of
persons with psychosis is varied; Jenkins11 describes such
a woman who did not consider hearing voices as “discon-
tinuous with the self” but rather as “part of herself ” and
a struggle over moral goodness and “the right to be in
the world.” It has been clear for many decades that seri-
ous psychotic disorder is recognized across cultures with
a similar pattern of symptoms, despite increasing aware-
ness that culture may shape the content, meaning, and
possibly the severity of the symptoms.12,13
By contrast, hallucinations experienced in the gen-
eral population are likely to be brief, not unpleasant and
not experienced frequently.14 Depending on the way the
question is asked, 10%–15% or more of the population
report them.15 They are even more common among the
bereaved. As many as 80% of those who have lost loved
ones report seeing, hearing, or feeling the touch of the
dead person even among Euro-American populations, in
which speaking to the dead is not normative.16 Those with
longer and happier marriages are more likely to report
these sensory experiences, and for the most part, the expe-
riences are comforting.17 An older study found an even
higher rate (90%) among the Japanese,18 who at the time
often maintained ties with the deceased through religious
rituals. However, there are clearly cultural variations.
The Achuar people of Ecuador prohibit remembrance
practices and consider any form of reexperiencing of a
specic person, including thoughts, visions, or dreams, as
a threat to the soul of the experiencer. They do, however,
seek sensory encounters with a dead person whose iden-
tity is obscure to them.19
Finally, there are also some people who have unusual sen-
sory experiences as often as people who can be diagnosed
with schizophrenia, yet without the intense distress psycho-
sis carries in its wake, or any of its other symptoms—delu-
sions, cognitive difculties, or emotional atness. Religious
experts around the world also sometimes behave as if, and
speak as if, they have frequent and ongoing hallucinatory
experiences. We return to these expertsbelow.
In addition, hallucinations may also arise as the
result of the deliberate use of psychotropic agents such
as ayahuasca or peyote. Religions incorporating such
agents have been particularly common in the indigenous
Americas, where shamans and other religious experts
have sought visions and voices they take to be guidance
from the spirit world.
Hallucinations Are Often Culturally Meaningful
There is robust evidence that unusual sensory experi-
ences have been given great importance as foundational
spiritual experiences throughout the world—Moses
and his burning bush, Paul on the road to Damascus,
Arjuna’s vision of Krishna, Buddha beneath the Bo
tree. Bourguignon20 examined data collected from the
Human Relations Area File (HRAF) from 488 societies
worldwide. In 62% of the cultures studied, hallucinations
played a role in ordinary ritual practices. These halluci-
nations were positively valued, could be understood in
the context of local beliefs and practices, and the pres-
ence of hallucinations was not usually associated with
intake of psychoactive chemicals. Bourguignon thought
that her rate was relatively low because the material in
the HRAF was incomplete and the absence of a record
of hallucinations in the archive did not imply the absence
of the phenomenon from the society.
Typically, such sensory experiences of the immaterial
are understood as contacts with gods, spirits, or the dead.
While many such experiences never enter the historical
record, others take on broad public meaning. Lourdes21
became a major healing shrine because a young girl,
Bernadette Soubirous, reported that she saw the Virgin
Mary there, and many people came to believe that indeed
she had. The shrines of Fatima and Medjugore similarly
draw millions of worshippers who believe that the Virgin
appeared to specic individuals so that they saw her with
their eyes and who come to worship and request favor
from the Virgin at a place where her immaterial body was
perceived with the physical human senses.
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Culture and Hallucinations
To become available as plausible experiences of the
divine, such hallucinations must conform to local cul-
tural expectations.22 The local population at Lourdes,
expected Mary to act like a benign mother; had
Bernadette reported seeing the blindingly powerful g-
ure Mary was understood to be toward the end of the
Middle Ages, the 19th-century French population would
probably not have believed that she had seen the Virgin.
At the same time, in each vision locale, a kind of uid
and evolving microculture develops, in which some fea-
tures partake of a broader pattern—known through lit-
erature, visual media, and shared pilgrims—but others
are idiosyncratic and innovative. At Lourdes, Bernadette
behaved oddly, scratching up the earth to nd the spring
that would later become the focal point of pilgrimage.
Tave s 23 similarly demonstrates that as the 19th century
progressed, the capacity to hear God or the dead speak
became more acceptable for ordinary Christians as
spiritualism became a popular movement and began to
change the way people thought about the human psyche.
The same holds true in the way people become identi-
ed as religious experts. For example, the shaman-to-be
usually must report certain kinds of phenomena that are
understood by his or her broader social world to be the
appropriate signs of the spirit. For example, among an
Amazonian people called the Bororo, the novice shaman
is identied when he has a dream of soaring high above
the earth, like a vulture, and seeing the ery cloud of
smoke that indicates an attacking illness.24 Then, he must
see a stone or anthill move, and he must hear a voice,
when alone in the forest, that asks him where he is going.
In a social setting where hallucinations are taken as
evidence of the supernatural or divine, people typically
take considerable care to distinguish explicitly between
the hallucinations of madness and hallucinations that
indicate contact with the spiritual world. When some-
one’s experience matches cultural expectations, this is
often taken to demonstrate that the unusual sensory
experience is of the spirit world and not madness. At the
same time, adding personal vivid detail demonstrates
that the experience is authentic and not repeated as a
cultural script. This pattern is common in these ethno-
graphic and historical accounts of hallucinations.
So is the frank identication of their nonpathological
character. Dein and Littlewood25 interviewed 25 members
of a Pentecostal church in London who said that they had
heard God speak audibly. In such churches, congregants
talk of “discerning” whether such a voice comes from
God by asking whether the voice is in accord with scrip-
ture, gives one peace, and so forth. The anthropologists
described 1 man with bipolar disorder who distinguished
between God’s voice and his own experience of psychosis
this way: “God says something and doesn’t force you, so
you can do what you like with it … [the psychotic voices]
you can’t refuse to do something when you hear them.
They are very pushy.”
In such settings, people also often distinguish between
unusual sensory experiences from God and those from
demons. The Christian church has been intensely inter-
ested in this question, particularly during its medieval
periods of great visionary activity (eg, Caciola26) and also
throughout its history. Tracts like “The Appearance of a
Spirit”27 describe an apparent hallucination reported to
a woman in 1628 and the efforts of clerics to determine
the spirit’s true nature. “Huguette [the woman who saw
the spirit] is told to pay attention to its hands and its feet
and its head, if may be she did not see any nails that were
too long, like the talons of some bird of prey … a demon
would not be able to appear for long in the guise of a man
without mixing into it some wild, clawed, beaked, tailed,
or horned beast.”27
Such culturally acceptable hallucinations are some-
times experienced by many and sometimes only by a
few. Apolito28 identies the former as “weak” visionar-
ies, such as the “dancing sun” phenomenon in Europe, in
which many people report that the sun behaves in pecu-
liar, hallucination-like ways and that these apparitions
indicate that Mary is at hand. An example of “stronger”
visionaries are Amazonian shamans who are sometimes
described by their ethnographers as reporting that they
see spiritual jaguars who come and go over long peri-
ods of time and with whom they have complex conver-
sations.29 Such experts are generally more practiced and
sometimes describe a process of entrainment whereby
over time their perceptions become more precise, more
senses become involved, and the visions can occur on
demand, as in the Basque visions at Ezquioga.30
When people report speaking with God or other super-
natural agents frequently and repeatedly, anthropologists
and historians have suggested that the underlying psy-
chological mechanism is dissociation (eg, Taves23). They
presume that the subjects have trained their attention in
culturally prescribed ways, so that the shaman or pos-
sessed person who regularly hears spirits talking is best
understood as going into frequent trance.
Thus, we can speak of the “cultural conditioning” of
hallucination experience. Organized religions are them-
selves cultural systems that provide an evolving set of
expectations. In Roman Catholicism, as we have seen,
unusual sensory experiences have specied the location
of healing shrines, established devotional practices and
religious orders, and conrmed or questioned Church
dogma. The embodied nature of the visions—whether
the seers enter into a dissociated state, or not, and what
kind of dissociation (abstraction, insensibility to physi-
cal stimuli, some kind of in-between state, catalepsy, or
ts)—has varied greatly from site to site and among seers
at the same site. What visionaries see and hear, when they
do so, and how the experience impacts their bodies, espe-
cially when onlookers are present, all evolve over time, an
indication that the visions are quite vulnerable to expec-
tations and suggestion.
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It is only in the 20th century, as Leudar and Thomas31
point out, that hallucinations have been described as
exclusively the sign of an illness. As a result, the term
“hallucination” can carry stigma. Nonetheless, events
that appear technically to be hallucinations and that con-
form to popular expectations of the presence of God are
still often reported as religious events in popular Western
media.
Hallucinations Occur at Different Rates in Different
Cultural Settings
Al-Issa32 has suggested that Euro-American culture itself
dampens the rate of hallucinations because the shared
culture strives to clarify and distinguish whether a given
experience is real or imaginary, and when individuals
seem not to be able to make such a distinction by report-
ing something that seems to be a hallucination, they are
likely to be labeled as out of contact with reality and
therefore pathological. In contrast, he argued, many non-
Western societies do not make such a rigid distinction
between reality and fantasy. One might expect, then, that
hallucinations would be more readily reported outside of
the Western setting.
Epidemiological studies seem to support this infer-
ence. Johns et al33 demonstrated that reports of hallu-
cinations in the general population varied signicantly
across different ethnic groups living in the United
Kingdom. In this study, 5196 participants from ethnic
minorities (Caribbean, Indian, African, Asian, Pakistani,
Bangladeshi, and Chinese) and 2867 White UK respon-
dents were screened for mental health problems and
asked about hallucinations. Reports of hallucinations
were around 2.5 times higher in the Caribbean sample
(9.8%) compared with the white sample (4%). Compared
with the white sample, the experience was only half as
common in the South Asian sample (4% vs2.3%).
Anthropological work certainly also demonstrates
that hallucinations may suddenly increase in a social
group at a particular time. For example, after the death
of Menachem Schneerson—a Hasidic Rebbe believed by
many of his followers to be the messiah and thus a man
who would not die in an ordinary way—many followers
reported seeing him.34 The pattern of their reports resem-
bles the reports of seeing Jesus after his death described
in the Bible: they are rare; brief; and, often, surprising
mundane. Jesus appears as a gardener: the Rebbe shows
up in the kitchen.
Culture Affects the Meaning and Characteristics of
Hallucinations Associated With Psychosis
Both anthropology and psychology/psychiatry have con-
cluded that to some extent, the hallucinations associated
with serious psychotic disorder are “pathoplastic,” mean-
ing that they are shaped by local expectation and mean-
ing. Certainly the content of hallucinations is inuenced
by local culture. Rural Africans are more likely to hallu-
cinate about ancestor worship; Christians are more likely
to hallucinate about Christ, Mary, and Satan. But cul-
ture seems to affect the form of hallucinations as well.
Mitchell and Vierkant35 compared hallucinations in
patients admitted in an East Texas hospital during the
1930s with those reported in patients in the same hos-
pital in the 1980s (patients were matched for age, race,
and gender distribution). They found that the hallucina-
tions of the 1930s reected the intense desire for mate-
rial goods associated with the Great Depression, and
those of the 1980s reected the new technological tools
of the 1980s. More strikingly, the command hallucina-
tions of the 1930s were primarily benign and religious
(“live right”, “lean on the Lord”), but those of the 1980s
were negative and destructive (“kill yourself”, “kill your
mother”). The authors suggested that the more negative
commands of the later period reected a more negative
and hostile environment.
Indeed, command hallucinations seem to vary consid-
erably. Suhail and Cochrane36 used case notes to com-
pare the modalities and themes of hallucinations in 3
different groups of psychotic patients: (a) white British
patients, (b) Pakistani patients living in Britain (who lived
an average of 17years in the United Kingdom), and (c)
Pakistani patients living in Pakistan. They found that the
most dissimilar pair was the white British patients and
the Pakistani patients living in Pakistan. In particular,
the British patients were more likely (compared to the
Pakistani patients) to hear, for instance, voices comment-
ing on behavior, personality, and actions; commands
to kill self or others; and voices calling bad names. On
the other hand, the Pakistani participants more often
heard criticising, threatening, or insulting voices. Kent
and Wahass37 compared the auditory hallucinations
of patients with schizophrenia in Saudi Arabia and the
United Kingdom and found that the Saudi Arabian
patients were more likely to describe hallucinations with
religious content, while the British were more likely to
report a running commentary. Similarly, Okulate and
Jones38 reported that the frequency of auditory halluci-
nations that were commanding, abusive, cursing, arguing,
and frightening was generally lower among their Nigerian
patients with schizophrenia than among patients in the
United Kingdom, on the basis of ndings by Nayani and
David.39 Furthermore, in this study, voices discussing the
patient in the third person were not as frequent among
the Nigerian schizophrenic patients as in the UK study.
It is, however, important to underline that evaluations of
the 2 groups of patients were not carried out by the same
team of researchers.
It also appears to be true that the rate of hallucina-
tion varies considerably in different settings. Bauer
et al,40 using identical inclusion/exclusion criteria and
identical assessment procedures, compared persons with
schizophrenia in 7 different countries (Austria, Poland,
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Culture and Hallucinations
Lithuania, Georgia, Pakistan, Nigeria, and Ghana). In
all settings, patients were more likely to report auditory
than visual hallucinations, but the 1-year prevalence rates
ranged considrably: auditory hallucinations from 67%
(Austria) to 91% (Ghana) and visual from 4% (Pakistan)
to 54% (Ghana). Thomas et al,41 using identical inclu-
sion/exclusion criteria and identical assessment proce-
dures and comparing US patients and Indian patients,
found similar results. Stompe et al42 examined groups
of patients diagnosed with schizophrenia in the same
data set later used by Bauer et al.40 Using discriminant
analysis, they argued that between 15% and 30% of the
psychotic symptomatology examined in their study was
culture dependent, 16% for hallucinations specically.
Meanwhile, Barrett43 found that his attempt to trans-
late the Present State Examination from English into the
Iban language failed when it came to rendering thought
insertion and withdrawal. In the Iban culture, thinking
arises from the heart-liver region. It is not contained in
the mind, which is somehow contained in the brain—a
more Western conception. Fabrega44 had already made
this criticism of the Schneiderian rst-rank symptoms:
“These symptoms imply to a large extent persons are
independent beings whose bodies and minds as separated
from each other and function autonomously.” Barrett
found that the process of making thought insertion/with-
drawal questions intelligible to the Iban meant that they
lost their core Schneiderian meaning.
More recently, Luhrmann et al (in press)45 have com-
pared the experience of hearing voices among people
with schizophrenia in San Mateo, California; Accra,
Ghana; and Chennai, South India. In each setting, they
interviewed 20 people with schizophrenia who were asked
in detail about the phenomenology of their hallucinatory
experiences, their relationships with their voices, and
their experiences of their voices. They found that their
American sample hated their voices, readily used the diag-
nostic label of schizophrenia, and could even sometimes
recite diagnostic criteria. For them, the primary meaning
of an external voice was being “crazy.” In general, the
American sample did not treat their voices as persons, and
their accounts of voice-hearing were lled with violence.
Patients in Chennai and Accra, by contrast, did not use a
diagnostic label, and they did not experience voice-hear-
ing as necessarily bad. They were more likely to identify
voices as people they know and more likely to describe
conversational relationships with their voices. Yet, there
were differences between the 2 settings. In Accra, half of
the patients reported that their dominant external voice
was God, that hearing God was a good experience, and
(usually) that God told them to ignore the mean (or
demonic) voices. In Chennai, patients were more likely to
hear their kin. They often did not like the voices, but the
voices usually did not tell them to kill themselves, the way
the voices of the Americans often; the voices told them
to get dressed, clean up, and do chores. These ndings
suggest that hallucinations associated with schizophrenia
or serious psychotic disorder may be less caustic, on aver-
age, for persons in the non-West, compared to those in
the West.
Anthropologists and psychologists have also demon-
strated that kin respond to the voices heard by psychotic
relatives in varying ways. Jenkins46 found that Mexican-
Americans relatives were more likely to express tolerance
and sympathy to relatives with distressing voices, while
Euro-American families were more liable to generate crit-
ical or hostile responses. South Asian families too seem
to respond with less “expressed emotion” than Euro-
Americans.47 Corin and colleagues48 observed that, in
South Asia, persons with psychosis often exhibit “positive
withdrawal.” In detailed interviews of patients recently
diagnosed with schizophrenia, they demonstrated that
not only were patient narratives often inscribed within a
religious frame but also the patients would use this reli-
gious frame of reference to support a calm inner detach-
ment. As 1 subject remarked: “I sit patiently, quietly, and
wait.” Corin etal argue that this positive withdrawal is
particularly salient in Hinduism, but they found that ref-
erences to it were also to be found in narratives of people
interviewed by Corin in Montreal.
In sum, the evidence suggests that the voice-hearing
experience is deeply shaped by local patterns of under-
standing the self, the mind, and the fundamental nature
of reality. Jenkins11 captures this richness in arguing that
the subjective experience of psychosis and schizophrenia
provides a “paradigm case for understanding fundamen-
tal human processes” and that “hearing voices” is undeni-
ably a fundamental self-process that is thoroughly infused
with cultural meaning.
Do the Cultural Variations of Psychotic Hallucinations
Have Implications for Clinical Outcome for Those Who
Struggle With Psychosis?
Studies have shown that a number of mechanisms and
factors play a key role in the transition between subclini-
cal hallucinatory experiences and clinical psychosis (see
Johns etal9). In a population-based, longitudinal study,
Krabbendam et al49 found that those with subclinical
hallucinatory experiences at baseline who developed a
depressed mood at year 1 were at increased risk of tran-
sitioning to psychotic disorder at year 3 follow-up. The
authors interpret these ndings in light of work show-
ing that attributions of hallucinations as coming from a
threatening, powerful, and omnipotent force will lead to
feelings of helplessness and depression.50 If persons with
psychosis experience more benign hallucinations in some
cultural settings than in others, it may well be the case
that the voice-hearing experience will be less clinically
harmful. Indeed, both Corin and Luhrmann et al place
their observations in the context of the more benign tra-
jectory of schizophrenia in India and elsewhere outside of
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F. Larøi etal
the West.51 Research with a consumer-driven movement
(the Hearing Voices Movement) has found that training
people who hear distressing voices to interact with their
voices leads to reduced distress.52
It is worth bearing in mind, however, that “functional
impairment” and “clinical outcome” can itself only be fully
dened with regard to the cultural context. For example,
the disability caused by hallucinated voices may depend
a great deal on the cultural organization of work and the
norms of collective toil: people who live in cultures where
there is less exibility with regard to work schedules may
nd themselves perhaps more impaired than those where
the home-work divide is more uid. Furthermore, there
are cultural criteria for who is considered to be in need
of clinical attention. In earlier decades, Schooler and
Caudill53 found that Japanese people with schizophrenia
were more likely to be identied and brought to the atten-
tion of clinical services through aggression, while British
people are more likely to be identied as in need of care
by the presence of hallucinations.
Conclusion
The present review demonstrates that culture shapes
hallucinations in all dimensions of the phenomena: in
identication, in experience, in content, in frequency, in
meaning, in the distress they elicit, and in the way in which
others respond. Further, culture shapes hallucinations in
both their pathological and nonpathologicalforms.
In a recent review of research strategies and future
directions in cultural psychiatry, Kirmayer and Ben54
warn against the danger of reifying culture and of relying
exclusively on population-level categories of nationality
or ethnicity in understanding its relationship to mental
ill health. We also insist that culture cannot be reduced
to national or even ethnic differences and that there are
complex and signicant variations within cultures—reli-
gious, regional, and political. The global Hearing Voices
Movement constitutes an international subculture in
which hallucinatory experience is positively valued and
through which individuals have been able to embrace a
public identity as “voice-hearers,”55,56 in turn changing
the ways in which they understand, relate to, and experi-
ence their voices.
Culture belongs not only to the patient but also to
the professional; it plays a structural role in shaping the
meaning of hallucinatory experience within a clinical set-
ting, but no less of an important role in the context of
research. Hallucinations research, like most experimental
work in psychology and neuroscience, is WEIRD.57 That
is, a majority of participants and subjects in mainstream
studies live in Western, Educated, Industrialized, Rich,
Democratic societies, as do the researchers who study
them. This limits what is known scientically and clinically
about the ways in which hallucinations are experienced,
interpreted and valued across cultures, and places renewed
emphasis on the importance of ethnographic and interdis-
ciplinary58 approaches, as well as on increasing the number
of countries and cultural groups involved in research.
A number of issues need to be addressed in future stud-
ies. For instance, the issue of cross-cultural hallucination
prevalence rates in the general (nonclinical) population has
not been examined in a direct and in-depth manner. In a
recent review of studies examining auditory hallucination
prevalence in the general population,10 no such studies are
reported. Further, in a worldwide cross-national (52 coun-
tries) study,59 highly varying prevalence rates for halluci-
nations among persons with psychosis across countries
(0.8% in Vietnam to 31.4% in Nepal) were reported and
no further analyses were carried out in order to underline
any potential cross-cultural patterns. We are in need of
better epidemiological work on hallucinations in both the
non-clinical and the clinical populations.
There is also an important implication for epidemio-
logical or cross-cultural assessments of the presence of
hallucinations. As with the study of Nuevo et al,59 that
used the same denition to assess for the presence of hal-
lucination across a large number of countries, it is not
clear to what extent the huge difference in prevalence is
due to genuine difference in the experience of “false per-
ception” and to what extent the difference is due to differ-
ing cultural labeling of what is relevant when discussing,
“an experience of seeing visions or hearing voices that
others could not see or hear.”
Table1. Key Points for Future Directions
Several important questions emerge from this overview:
1. We still know relatively little about hallucinations
cross-culturally, including prevalence rates within the
nonclinical population in different cultures and within
clinical populations.
2. We also know little about cultural inuences on the
development of hallucinations within the life span,
particularly in childhood and adolescence, for both
clinical and nonclinical populations.
3. The work reported here suggests that positively
valuing psychotic hallucinations improves the patient’s
experience; more work is needed to determine whether
this also improves clinical outcome.
4. The work reported here also suggests that experiencing
psychotic hallucinations as a person-to-person
relationship may improve the patient’s experience; again,
we need more work to explore whether this improves
clinical outcome.
5. The observation that culture affects the meaning and
characteristics of hallucinations suggests that clinicians
might develop these observations for clinical use. Much
more work remains to explore whether and how this
might be done.
6. It needs to be recognized that a clinician is also part of
a culture and that the factors that affect the clinician’s
interpretation of hallucinatory experiences need to be
understood in making clinical judgments. More work is
needed to understand this process.
by guest on September 23, 2014http://schizophreniabulletin.oxfordjournals.org/Downloaded from
S219
Culture and Hallucinations
Finally, ndings presented in this review also have
clinical implications. First, clinicians should never
assume that the mere report of what seems to be a hal-
lucination is necessarily a symptom of pathology (see
Johns et al9). Indeed, patients who are newly bereaved
may need a clinician to reassure them that hallucinations
of the lost loved one are normative. Second, clinicians
should take seriously the new ndings, supported by this
review, that hallucinatory experiences respond to cultural
shaping. Thus, the clinician, in addition to providing a
detailed account of the hallucinations, must also take
into account a person’s cultural background when assess-
ing and treating hallucinations. As Bentall60 has pointed
out, failure to appreciate the cultural context may prevent
clinicians from responding appropriately to the distress
experienced by their patients. On the other hand, where
hallucinatory experiences are culturally accepted reac-
tions to various life events (and therefore might be quite
common), the clinician may consider not intervening at
all. Thus, awareness of people’s attitudes toward hallu-
cinations (based on cultural background) may help the
clinician distinguish between pathological and culturally
sanctioned hallucinations.
Funding
Wellcome Trust (098455/Z/12/Z to C.F.and A.W.).
Acknowledgments
The ndings included in this paper were, in part, pre-
sented at the Second Meeting of the International
Consortium on Hallucination Research, Durham, UK,
12–13 September 2013.61 The authors have declared that
there are no conicts of interest in relation to the subject
of this study.
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... Such large differences are hard to interpret, as culture shapes the meaning and expression of PEs [22]. A review on the relationships between culture and hallucinations, [22] demonstrated how culture affected what was identi ed as a hallucination, how hallucinations could be culturally determined and interpreted, and moreover whether hallucinations were perceived as negative or positive. ...
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... Voice Club educated us in each other's work on voicehearing by, for example, introducing the cognitive neuroscientists to the most celebrated texts in medieval mysticism, deepening the literary scholars' understanding of contemporary theorization of voice sub-typing, and bringing the full range of disciplinary perspectives to bear on the analysis of new psychotherapeutic approaches to distressing voices. More profoundly, the meetings enabled and encouraged reciprocal influence to develop into novel and interdisciplinary approaches to the study of hearing voices (Bernini and Woods, 2014). ...
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The interviews collected with psychiatric service users during the Voices in Psychosis (VIP) study offer an opportunity to compare hallucinatory experience as perceived by two Western groups experiencing hallucinations in very different contexts. Looking at the data collected in the VIP study, it is striking to see that, while in shamanic centres, voices are voluntarily sought out and frequently valued as therapeutic, in the psychotic experience, voices are perceived spontaneously, involuntarily, and most often as disruptive and negative. How are the voices perceived by users of psychiatric services similar to, and different from, those perceived by shamanic tourism clients? What can this comparison tell us about the attribution of a pathological dimension to voice-hearing phenomena? How do the institutionalized practices of hallucinations, in the indigenous cultures of the Americas and more recently in the West, invite us to take a fresh look at voices in psychosis?It is to these questions that I will propose some answers. Comparing the data collected in the Peruvian Amazon with the VIP interviews, I will show that the ability to control voices is the main distinguishing criterion between these two groups, and will explore the implications of this difference for a better understanding and treatment of ‘voices’ in psychosis.
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Despite the clinical and theoretical importance of the negative content in auditory verbal hallucinations (AVHs), little research has been conducted on the topic. A handful of studies suggest that trauma or adverse life events contribute to negative content. The findings are somewhat inconsistent, however, possibly due to methodological limitations. Moreover, only trauma occurring in childhood has been investigated so far. In the present study, we studied the effect of abuse, experienced in either child- or adulthood, and clinical status on negative content of AVHs in four groups of participants that were assessed as part of a large, previously published online survey: Individuals with a psychotic disorder and AVHs (total n = 33), who had experienced abuse (n = 21) or not (n = 12) as well as a group of healthy individuals with AVHs (total n = 53), who had experienced abuse (n = 31) or not (n = 22). We hypothesized that having experienced abuse was associated with a higher degree of negative content. The clinical group collectively reported significantly higher degrees of negative AVHs content compared to the healthy group, but there was no effect of abuse on the degree of negative AVHs content. The presence of AVHs was more common amongst individuals who reported a history of abuse compared to individuals with no history of abuse, both in clinical and healthy participants with AVHs. This implies that at group level, being subjected to traumatic events increases an individual's vulnerability to experiencing AVHs. However, it does not necessarily account for negative content in AVHs.
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Chapter
Re-Visioning Psychiatry explores new theories and models from cultural psychiatry and psychology, philosophy, neuroscience and anthropology that clarify how mental health problems emerge in specific contexts and points toward future integration of these perspectives. Taken together, the contributions point to the need for fundamental shifts in psychiatric theory and practice: • Restoring phenomenology to its rightful place in research and practice • Advancing the social and cultural neuroscience of brain-person-environment systems over time and across social contexts • Understanding how self-awareness, interpersonal interactions, and larger social processes give rise to vicious circles that constitute mental health problems • Locating efforts to help and heal within the local and global social, economic, and political contexts that influence how we frame problems and imagine solutions. In advancing ecosystemic models of mental disorders, contributors challenge reductionistic models and culture-bound perspectives and highlight possibilities for a more transdisciplinary, integrated approach to research, mental health policy, and clinical practice.
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Article
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Background and aims Psychotic-like experiences (PLEs) are hallucinatory or delusional experiences that fall below the threshold of a diagnosable psychotic disorder. Although PLEs are common across the spectrum of psychiatric disorders, they also have been commonly reported in the general population. In this study, we aimed to describe the types of PLEs experienced by university students in Qatar. Furthermore, we aimed to examine how students frame, explain, and deal with these experiences as well as understand how culture and religion may shape the way students attribute and respond to these experiences. Method This study used a qualitative phenomenological approach. For collecting the data, we conducted semi-structured interviews using the Questionnaire for Psychotic Experiences (QPE). The QPE is a valid and reliable tool to assess the phenomenology of psychotic-like experiences. The questionnaire was translated into Arabic and tested and validated in Qatar (a fast-developing Muslim country in the Arabian Peninsula). We conducted interviews in Arabic with 12 undergraduate female students at Qatar University (the only national university in Qatar). The interviewees were of different Arab nationalities. Interviews were transcribed verbatim and two authors conducted the content-thematic analysis separately, as a strategy to validate the findings. The study was part of a larger nationally funded project that was approved by the Qatar University Institutional Review Board. The approvals were granted before any interview was conducted. Results The PLEs were prevalent in our non-clinical sample. The content-thematic analysis revealed the following main themes about these experiences: type, impact on daily function, frequency, immediate reaction, attribution style, assumptions about the root cause of these experiences, other associations, and religious links to experiences. The results also highlighted that religion and culture play a role in shaping the types of hallucinations and some delusions. Conclusion Our findings support the importance of culture and religion in relation to the types and explanations that students provided when describing PLEs. Notably, it was common among those who reported having these experiences to normalize and link PLEs to real-life events. This may be a defense mechanism to protect the self against the stigma of mental illness and from being labeled as “abnormal”.
Chapter
Acceptability of acceptance and commitment therapy for psychosis (ACTp) is a notable example of third-wave cognitive behavior therapy for psychosis. Research has demonstrated the safety, feasibility, and acceptability of ACTp with significant improvements in psychotic symptoms, depression, and functioning, along with reducing rehospitalization rates compared with treatment as usual. ACTp has been used in inpatient and outpatient settings, in group and individual formats, in chronic and acute psychosis, and in emerging mHealth formats. However, it is important to note that clinical effects vary based on the outcome measure used and the sample characteristics. Symptom reduction may be more variable given ACTp’s lack of specific focus on this goal and encouragement of a more honest open reporting of experiences by individuals with psychosis. Larger and more rigorously controlled clinical trials of ACTp are needed to further clarify the treatment’s clinical effects. Furthermore, at this time, it is unclear whether ACTp is more or less effective compared with other empirically-supported first or second wave approaches, or whether it works through similar or different mechanisms to achieve its outcomes, because direct tests have not been conducted in randomized controlled trials. Given its treatment model, ACTp may be most appropriate for those with chronic or acute psychosis, where reducing ineffective struggle with symptoms can help to decrease functional impairment. In sum, ACTp should be considered as a treatment option for patients who have failed other first/second wave treatments or whose clinical problems fit the ACTp model, taking into account patient preference and therapist competency.KeywordsThird wave behavior therapyThird wave cognitive behavior therapy for psychosisAcceptance and commitment therapy for psychosis
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This volume brings together a number of the foremost scholars - anthropologists, psychiatrists, psychologists, and historians - studying schizophrenia, its subjective dimensions, and the cultural processes through which these are experienced. Based on research undertaken in Australia, Bangladesh, Borneo, Canada, Colombia, India, Indonesia, Nigeria, the United States and Zanzibar, it also incorporates a critical analysis of World Health Organization cross-cultural findings. Contributors share an interest in subjective and interpretive aspects of illness, but all work with a concept of schizophrenia that addresses its biological dimensions. The volume is of interest to scholars in the social and human sciences for the theoretical attention given to the relationship between culture and subjectivity. Multidisciplinary in design, it is written in a style accessible to a diverse readership, including undergraduate students. It is of practical relevance not only to psychiatrists, but also to all mental health professionals.
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This volume brings together a number of the foremost scholars - anthropologists, psychiatrists, psychologists, and historians - studying schizophrenia, its subjective dimensions, and the cultural processes through which these are experienced. Based on research undertaken in Australia, Bangladesh, Borneo, Canada, Colombia, India, Indonesia, Nigeria, the United States and Zanzibar, it also incorporates a critical analysis of World Health Organization cross-cultural findings. Contributors share an interest in subjective and interpretive aspects of illness, but all work with a concept of schizophrenia that addresses its biological dimensions. The volume is of interest to scholars in the social and human sciences for the theoretical attention given to the relationship between culture and subjectivity. Multidisciplinary in design, it is written in a style accessible to a diverse readership, including undergraduate students. It is of practical relevance not only to psychiatrists, but also to all mental health professionals.
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Ten years ago, in a paper written for a psychiatric audience, the anthropologist A. F. C. Wallace spoke of hallucination as “one of the most ancient and widely distributed modes of human experience” [9]. This broad claim is facilitated by his definition of hallucination as “pseudo-perception”, which includes dreams and hypnagogic imagery. While I do not wish to make my definition quite so broad, I must recognize the considerable difficulty which exists in distinguishing waking hallucinations from the two other types of pseudo-perceptions in the self-reporting of ethnographic informants. For example, in many North American Indian societies, young men went out in quest of a vision, to obtain the help of a guardian spirit. From their reports, usually narrated many years after the event, it is often impossible to tell whether the “vision” they experienced was, in fact, a waking hallucination, a sleeping dream or hypnagogic imagery and, for the purposes for which they sought the vision, this distinction is, in fact, quite immaterial.
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This book is started with the main question, how come some people in the USA believe in an invisible being, that is God. How has belief in God come to influence people’s lives? How has God come to be really present in human life? Almost 100 percent people in the US, believe in God according to a Gallup Poll (Luhrmann, 2012: xi). In addition, religious enthusiasm for American has grown increasingly rapidly. Throughout the 20th century, American churches and congregations have developed remarkably (Luhrmann, 14). Even Luhrmann gives an example about the paradoxical things. Many people thought that the hippie vision would bring radical revolutionaries movement that threated the right wing. As a contrary, Christian Hippies play significant roles in making religion to be able publicly accepted (even though there were on drugs) (Luhrmann 16-17)
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Excerpt from “Conclusion,” from Fits, Trances, and Visions: Experiencing Religion and Explaining Experience from Wesley to James A professor of American religion and Catholic studies at the University of California, Santa Barbara, Ann Taves's areas of expertise include the study of Catholicism, “tradition” as a category of analysis, and psychological and experiential models of religion, among others. As a scholar also concerned with methodological and theoretical issues in the study of religion, Taves has written and lectured extensively on historical understandings of religious experience and its resultant impact on Christian theology, the relationship between cognitive science and the study of religion, and theorizing involuntary experiences (such as spirit possession). Her book publications include Religious Experience Reconsidered (2009), The Household of Faith: Roman Catholic Devotions in Mid-Nineteenth Century America (1986) and Fits, Trances and Visions: Experiencing Religion and Explaining Experience from Wesley to James (1999), from which the following essay is excerpted. Fits, Trances, and Visions is a historical study of some of the most dramatic and controversial ecstatic experiences in America throughout the eighteenth and nineteenth centuries, including trances, mesmerism, tongue-speaking, and faith-healing, among others. Understanding the significance that the term “experience” carries within the study of religion, Taves argues that one cannot understand religious experience-or any experience, for that matter-outside of the context in which that experience takes place. She privileges William James's view that attempting to view a phenomenon outside of its context is a lost analysis, for the extracted phenomenon is rendered dead inasmuch as it is robbed of the very components that made it socially meaningful. © Craig Martin, Russell T. McCutcheon, and Leslie Dorrough Smith 2012 Essays