ArticlePDF Available

Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: Interview-based study

Authors:

Abstract

Background: We still know little about whether and how the auditory hallucinations associated with serious psychotic disorder shift across cultural boundaries. Aims: To compare auditory hallucinations across three different cultures, by means of an interview-based study. Method: An anthropologist and several psychiatrists interviewed participants from the USA, India and Ghana, each sample comprising 20 persons who heard voices and met the inclusion criteria of schizophrenia, about their experience of voices. Results: Participants in the U.S.A. were more likely to use diagnostic labels and to report violent commands than those in India and Ghana, who were more likely than the Americans to report rich relationships with their voices and less likely to describe the voices as the sign of a violated mind. Conclusions: These observations suggest that the voice-hearing experiences of people with serious psychotic disorder are shaped by local culture. These differences may have clinical implications.
e British Journal of psychiatry
(2015)
206, 41-44.
doi:
10.1192/bjp.bp.113.139048
Results
Participants in the
USA
w~rf? rnQr~ lik(illy to U$~ ~ig~no~tic
labels and to report violent c\'lmmfJnd~ th1JnthQ1le in Inlii€!
and Ghana, who were more Iik~ly th€!n
the
Amllrj(j€!m; to
report rich relationships with the.ir voices and
less
likely to
describe the voices as the Sign Of
i;l
viol§lted mino, .
Conclusions
These observations suggest that the VQice,heiilrinl:!
experiences of people with serious psychotic oiggrd&f af~
shaped by local culture. These differences may haVe clinical
implications. .
Declaration of interest
None.
fferences
in voice-hearing
experiences
people with psychosis in the USA, India
nd Ghana: interview-based study
. Luhrmann, R. Padmavati, H. Tharoor and A. Osei
ound
·n
know little about whether and how the auditory
. ations associated with serious psychotic disorder shift
cultural boundaries.
pare auditory hallucinations across three different
es, by means of an interview-based study.
od
ropologist and several psychiatrists interviewed
:cbants from the
USA,
India and Ghana, each sample
. ing 20 persons who heard voices and met the
criteria of schizophrenia, about their experience
oces.
whether the phenomenology of hearing voices by
serious psychotic disorder may be shaped by local
- report here on the first structured interview-based
.;;;:;;:sa:. of hearing voices in three different cultures, comparing
"~':l::O
adults each living respectively in or around San Mateo,
L"SA;Accra, Ghana; and Chennai, India. The experience
- '"{licesis complex and varies from person to person.' A
.!::::::s:-ion
of cultural variations in the kinds of relationships
rt with their voices may offer a natural experiment
of recent research suggesting that the voice-hearing
is mutable.
Method
met our inclusion criteria if different sources (interview,
- brief psychosis screen from the Structured Clinical
_ •.••• ~:iJr••.
DSM-IV Axis I Disorders," and, if available, medical
_""', •....-. clinicians' reports) together provided evidence that
aad experienced at least two positive symptoms (such
"'~~1i·,ons and delusions) and had been ill for at least
prior signs of illness for at least 6 months (in most
.cipants had been ill for years) to the degree that
been seriously disrupted. These are the inclusion
schizophrenia.' However, we did not rule out individuals
symptoms in addition to their psychosis. Many of
"CJ:=;l2nts were diagnosed at some point with schizo affective
••• 0:::;. .•••.• 111
some - particularly those in Accra - carried chart
both bipolar disorder and schizophrenia. We also
_c.. ~~
out people who reported using cannabis and other
.iu:ring the course of their illness; doing so would have
our American and African participant pooL
_ included only those who heard voices in the absence
ceo
Yateo participants were recruited primarily through
at the San Mateo County Psychiatric Hospital and
'Y
T.1., an anthropologist with extensive experience
among people with serious psychotic disorder. They were almost
all supported by disability stipend and lived in supported housing.
All had been ill for years. There were 10 men and 10 women; their
average age was 43 years. In Chennai participants were recruited
from the Schizophrenia Research Foundation (SCARF), where
they were either receiving out-patient treatment or in long-term
residential care. All had been ill for many years. They were
interviewed by R.P. and H.T., senior research psychiatrists,
primarily in TamiL There were 9 women and 11 men; their average
age was 41 years. In Accra participants were in-patients at the
Accra General Psychiatric Hospital. They were recruited by staff
following the direction of A.O., its medical director and chief
psychiatrist. All were interviewed by T.1. in English, although in
two cases the bulk of the interview was conducted in Twi by
T.1.'s research assistant. There were 12 women and 8 men; their
average age was 34 years. This group was thus younger and more
seriously ill than people in the Chennai and San Mateo samples.
Interview
The interview protocol (see online Appendix DSl) began by
asking the participants about the phenomenology of their
hallucination experience: how many voices they heard, how often,
and whether they experienced hallucinations in other sensory
modalities. The interview was loosely based on the Maastricht
interview developed by Romme
&
Escher:" we also consulted a
series of other established interviews about voice-hearing, such
as the Leudar-Thomas Voices Pragmatics Assessment Interview,"
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. We asked what caused the voices and what caused their
illness. Not all participants completed the full interview protocol,
but all spoke about their experience in detail. All interviews were
digitally recorded, transcribed and if necessary translated by a
41
LUhrmannet al
42
-------
professional, and checked for word-for-word accuracy by a
researcher competent in both English and the speaker's native
language.
In all cases participants gave informed consent for the interview
and the research was approved by the Stanford University
institutional review board, the SCARF ethics committee and the
medical director of the Accra General Psychiatric Hospital.
Results
Broadly speaking the voice-hearing experience was similar in all
three settings. Many of those interviewed reported good and
bad voices; many reported conversations with their voices, and
many reported whispering, hissing or voices they could not quite
hear. In all settings there were people who reported that God had
spoken to them and in all settings there were people who hated
their voices and experienced them as an assault. Nevertheless,
there were striking differences in the quality of the voice-hearing
experience, and particularly in the quality of relationship with
the speaker of the voice. Many participants in the Chennai and
Accra samples insisted that their predominant or even only
experience of the voices was positive - a report supported by chart
review and clinical observation. Not one American did so. Many
in the Chennai and Accra samples seemed to experience their
voices as people: the voice was that of a human the participant
knew, such as a brother or a neighbour, or a human-like spirit
whom the participant also knew. These respondents seemed to
have real human relationships with the voices - sometimes even
when they did not like them. This was less typical of the San
Mateo sample, whose reported experiences were markedly more
violent, harsher and more hated.
San Mateo
In general the American sample experienced voices as bombard-
ment and as symptoms of a brain disease caused by genes or
trauma. They used diagnostic labels readily: all but three
spontaneously described themselves as diagnosed with 'schizo-
phrenia' or 'schizo affective disorder' and every single person used
diagnostic categories in conversation. Fourteen described voices
that told them to hurt other people or themselves, sometimes in
disturbing detail: for example,
'usually.it'sliketorturingpeople,totaketheireye outwitha fork,or cutsorneone's
headand drinktheirblood,reallynastystuft.'
Five people even described their voice-hearing experience as a
battle or war, as in 'the warfare of everyone just yelling'. Finally,
the Americans talked about their voices as unreal thoughts in
which there is a disrupted relationship between their thoughts
and their mind. They said things such as,
'I
don't thinkthere's anythingthere or anything.
1
thinkit's justthe way mymind
works.'
None of the San Mateo sample reported predominantly positive
experiences, although half reported some positive dimensions to
the voice-hearing. These participants tended to do so as throw-
away remarks. One man described his voice as mean and insulting
but said, when asked if there were any voices that liked him, 'Yeah
... that's what I live for'. Then he returned to describing the voices
he did not like. Five reported hearing God speak audibly, although
15 were clearly religious. Only two reported that they heard family
members on a regular basis, and both these were women molested
by their father (or stepfather) who heard their (negative)
molester's voice. Only one person reported that she heard
primarily people she knew: 'my therapist, my best friend, a friend
from high school and this horrible guy'. Eight people said that they
did not know who their voices were. Even when they said they
knew them, the names they sometimes gave them suggested that
they did not consider their voices to be human, as in 'their name
is M' or 'Demon and Entity'. Few described personal relationships
with their voices. The participant with the most positive experience
described voices that seemed sometimes magical and sometimes
horrific: For her, sounds seemed to resolve themselves into voices,
so she heard voices all the time - 'I think I have friends in the
wind' - but she could not really communicate with them because
they spoke a language she did not know. She talked with God -
'he's very nice' - but her only account of their interaction was this:
'Sometimesitseemsthe Lordgivesmethe thoughtand
gives
methe light,
gives
rre
the say-soas to
have
myownthoughtsand
have
myownmind,andthensometimes
he'llerase it whenhe wantsto
give
itto someoneelse.'
Meanwhile, she emphasised the bad voices: 'Someone is like
yelling loudly in my ear'.
Chennai
More than half of the Chennai sample
(n
=
11) heard voices of kin,
such as parents, mother-in-law, sister-in-law or sisters. Another
two experienced a voice as husband or wife, and yet another
reported that the voice said he should listen to his father. These
voices behaved as relatives do: they gave guidance, but they also
scolded. They often gave commands to do domestic tasks.
Although people did not always like them, they spoke about them
as relationships. One man explained, 'They talk as if elder people
advising younger people'. A woman heard seven or eight of her
female relatives scold her constantly. They told her that she should
die; but they also told her to bathe, to shop, and to go into the
kitchen and prepare food. Another woman explained that her
voice took on the form of different family members - it 'talks like
all the familiar persons in my house'. Although the voice
frightened her and sometimes, she clamed, even beat her, she
insisted that the voice was good: 'It teaches me what I don't know:
Only four persons in the Chennai sample said that they did not
know who spoke to them. These voices did not even seem
particularly disembodied. At least nine Chennai participants
described their voices as if the voice itself acted physically or
had physical experience. For example, one man described his
voices as souls in hell who needed him to ease their suffering. They
complained that he dragged them along with him when he went
out and that it hurt them. He said that the voices vomited when
he had sex. Another man used this vivid metaphor:
'I
wentto Bangaloreand
1
couldhearthe
voices
thereaswell,canbe heardlikeithas
beensoakedand
stuck
to mybody.'
Only four of the Chennai sample used the term 'schizophrenia';
indeed, the lesser use of diagnostic labels by patients and their
families in South Asia has previously been described in the
ethnographic literature." Only three - and occasionally a fourth
- described their voices as commanding them to hurt other people
or themselves (although more people than that heard voices with
threatening content). Instead, what more participants (at least 13)
reported as distressing about their voices was that their voices
spoke about sex. Nine persons understood their voices as spirits
or magical (although only six had heard a god speak audibly).
Nine described voices that were significantly good, even though
we judged only five to have had voice-hearing experiences that
were predominantly good, They made comments that suggested
that these voices were both social relationships and entertainment:
'I like my mother's voice'; later, this woman added 'I have a
companion to talk [to] ... [laughs] I need not go out to speak.
I can talk within myself!' A man who in general found his voices
difficult still said that they were interesting: 'I will play with my
mind'. Another man, who heard two or three women he thought
were wives, said, 'Voices, I like it. It will keep talking which is
enjoyable.' In fact, several Indian participants seemed to
experience their main voice as playful - true for none of the San
Mateo or Accra group to any notable degree, One woman spoke
exe
cell
he,
'He
of
jt
pea
Shl
wa
giv
bee
thE
Shl
AC
All
aU!
wo
car
USE
vo:
no
vie
to
to
he:
f01
eXI
WE
eXI
tlu
po
ha
vo
'rh
de,
It
ba
sir
('l
ad
he
hi
ba
'th
vo
sp
vii
WI
to
hi
hi
hi
to
m
he
de
as
sa:
se<
'II'
tw
he
m
sh
as
excitedly about her voices as if she was living in the pages of a
celebrity gossip magazine. When another woman first fell ill, she
heard Hanuman, the Hindu god represented as part monkey:
'Heishalfmonkey.halfman;he isa godandhe wearsa reddhotiandhe wearsa lot
ofjewellery.Andhe carriesa bigstickwitha bigroundthingbecausehe protects
peoplefromwickedpeople.'
She was very clear that in the beginning he was not ni~ to her and
was always trying to punish her. 'Such horrible orders he used to
give me' - for example, to drink water from the toilet. Then he
became fun. She described him as her baby brother. She said that
they have parties and throw pillows and she pinches his bottom.
She still heard him speak audibly.
Accra
Although many of the Accra participants understood that hearing
audible voices could be a sign of psychiatric illness, their social
world accepts that there are human-like non-embodied spirits that
can talk. 'Voices [are] spirits: one man explained. Only two people
used diagnostic labels (schizophrenia). Only two described their
voices as asking them to kill or to fight, although six who did
not were admitted to the hospital because they had committed
violent acts. Only four said that they did not know who spoke
to them. When people talked about their voices they were likely
to emphasise the positive. Fully 16 of the sample of 20 reported
hearing God (or another divinity) speak audibly; the remaining
four were the only interviewees who reported no positive
experiences. (Because many Christians speak of 'hearing' God,
we were careful to establish in the interview whether this
experience was actually audible.) Fully half of the 20 described
their current voice-hearing experience as entirely or primarily
positive. A man admitted with terrible burns because a 'bad' voice
had told him to grab a live electrical wire said that, 'Mostly, the
voices are good'. A man admitted for the first time in 2007 said:
'Theyjust tellmeto do the rightthing.IfIhadn't hadthese voices
I
wouldhavebeen
deadlongago.'
It sometimes took time for participants to admit that they heard
bad voices as well as good ones. One man, in and out of hospital
since 1987, heard many voices speaking to him, among them God
('he's saving my life'), and they gave him helpful and protective
advice. Partway through the interview it became dear that he also
heard horrible voices as he walked across the ward - but God told
him to ignore them, he said, so he did. 'I don't pay attention to the
bad voices when they speak.' Indeed, people often insisted that
their good voice (usually God) was more powerful than any bad
voice. Another man had a special relationship with four river
spirits who gave him authority over the domestic animals in the
village, which he proceeded to kill and eat if they did not stay
within certain bounds (it was this that led his village headman
to send him to hospital). He heard bad voices as well, which gave
him commands he did not want to follow. God, he explained, gave
him the ability to call the good spirits to him, and they protected
him from the bad: 'They can never come back again'. A woman
told us that when God's voice became audible to her about nine
months earlier, she also began to hear demons whispering behind
her back every day. 'They try to tell you to do bad things.' The
demons spoke more loudly than God did (other patients said this
as well). But God's voice came first, and she followed him, she
said. Even when the voices were bad, people often described what
seems like a social relationship with them. Another woman heard
'many, many voices'. She heard God speak, but she dwelt on the
two bad voices she heard more often: her husband's brother and
her manager. They said, 'I like you. I want to kill you. I want to
marry you. I want to kill you.' She disliked them intensely. But
she held ordinary conversations with them. She talked about them
as people, not as intrusive noise: 'I know them'.
voice-hearing experiences in three cultures
Discussion
One of the most robust observations in cultural psychology and
psychological anthropology is that Europeans and Americans
imagine themselves as individuals; as Clifford Geertz put it:
A bounded,unique,moreor less integratedmotivationaland cognitiveuniverse;a
dynamiccenterof awareness,emotionand judgmentorganizedinto a distinctive
wholeandset contrastivelyagainstothersuch
wnoles?
This is a claim about how people conceive of themselves as
persons, not about psychological mechanism, and its point is that
outside Western culture people are more likely to imagine mind
and self as interwoven with others. These are, of course, social
expectations, or cultural 'invitations' - ways in which other people
expect people like themselves to behave. Actual people do not
always follow social norms. 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 many times in many places -
among them India and Africa.
8,9
For instance, the anthropologist
McKim Marriott wanted to be so dear about how much Hindus
conceive themselves to be made through relationships, compared
with Westerners, that he called the Hindu person a 'dividual,.lo
His observations have been supported by other ethnographers of
South Asia and certainly in south India,
!l,12
and his term
'dividual' was picked up to describe other forms of non-Western
personhood.
13
The psychologist Glenn Adams has shown
experimentally that Ghanaians understand themselves as
intrinsically connected through relationships.Y'P The African
philosopher John Mbiti remarks: 'only in terms of other people
does the [African] individual become conscious of his own being;"
Cultural orientations
These examples do not add up to a single proposition, nor are
they presumed to do so in the anthropological or psychological
literature. Instead, the point this research makes is that relationships
with others are far more salient to the ways non-Westerners
(certainly South Asians and Africans) interpret their experience
than they are to Westerners. We believe that these social expectations
about minds and persons may shape the voice-hearing experience
of those with serious psychotic disorder. Our participants in San
Mateo were more likely to experience their voices as an assault.
The voices were felt to be intrusions into their private world,
and the sense that they could not be controlled upset them deeply.
Our participants in Chennai and Accra were not as troubled by the
presence of voices they could not control; they interpreted them,
in effect, as people - who cannot be controlled. The voices seemed
to make more sense to them, and they were more likely to say that
they liked them. There were, of course, many differences between
the voice-hearing experiences of those in Accra and those in
Chennai - the Chennai voice-hearing experience included more
playfulness and more emphasis on sex, for example, whereas the
Accra voice-hearing experience was more likely to involve the
dominant voice of God - but our most striking finding was that
hearing voices in the two non-Western settings seemed less harsh
and more relational than in San Mateo. Although our work
seems to be the first interview-based structured comparison
of the phenomenology of voice-hearing among people with
serious psychotic disorder in three different cultures, previous
anthropological and psychiatric work has also observed that the
voice-hearing experience outside the West may be less harsh.17-20
These differences in experience cannot be ascribed to a difference
in religiosity. Most of the Americans were religious, and the five
Americans who heard God's voice did not, in general, like their
voices. Many of the more pleasurable voice-hearing experiences
43
44
Luhrmann et al
in Chennai were not experiences of hearing God (although they
were in Accra). Nor can the difference be ascribed to differences
in urban living: almost all those interviewed were city-dwellers,
and Accra and Chennai are noisier and more chaotic than San
Mateo. Instead, the difference seems to be that the Chennai and
Accra participants were more comfortable interpreting-their voices
as relationships and not as the sign of a violated mind. We suspect
that the American cultural emphasis on individual autonomy
shapes not only a clinical culture in which patients have the right
to know, and should know, their diagnosis, but a more general
cognitive bias that unusual auditory events are symptoms, rather
than people or spirits.
Many years ago, in a famous paper, Jane Murphy demonstrated
that serious psychotic disorder was recognised by the same
behaviours in many different societies.f ' Altering the social
context of the illness might alter the content of hallucinations
and delusions, she argued, but little else. We believe, however, that
the cultural shaping may be more profound. It seems from our
evidence that auditory hallucinations are not only construed
differently in different cultural settings, but that their affective
tone actually shifts. This is in accord with the new cognitive-
developmental model of psychotic hallucinations, which argues
that cognitive bias, as well as cognitive deficit, shapes the rate,
content and phenomenology of psychotic hallucination.22,23 We
suggest that everyday expectations determine (to some extent)
the way people attend to the messy array of auditory events that
occur for most people with serious psychotic disorder and, in
consequence, alter those auditory phenomena; that everyday,
socially shaped expectations alter not only how what is heard is
interpreted, but what is actually heard.
Implications
These findings may be clinically significant. Researchers have
found that what the hallucinatory voices say affects how well the
person hearing them does?4,2S They have also discovered that
specific therapies may alter what patients hear their voices say.26,27
A new, primarily consumer-driven movement (the Hearing Voices
Network) claims that it is possible to improve a person's relationship
with their voices by teaching them to name their voices, to respect
their voices and to interact with them, and that doing so reduces
the voice's caustic quality.28 There is evidence that schizophrenia
has a more variable outcome than once was thought and that
social environment affects not only the severity but also the rate
of illness?9 The finding that schizophrenia has a more benign
course and outcome outside the West (in India, specifically)
remains robust despite further follow-up and fresh analysis.
30
Our work adds yet another hypothesis (to the many that now
exist) to explain this gentler trajectory, which is that more benign
voices may contribute to more benign course and outcome.
There is clearly more work to be done. Our study is limited by
its small numbers, which are characteristic of qualitative work.
Nevertheless, it suggests that the harsh, violent voices so common
in the West may not be an inevitable feature of schizophrenia,
T. M. Luhrmann, PhD, Stanford university, Stanford, California, USA;R. Padmavati.
MD, H. Tharoor, DNB, MNAMS,SchizophreniaResearch Foundation, Chennai, India;
A.
Osei, MB ChB, FWACP,Accra General Psychiatric Hospital, Accra, Ghana
Correspondence: T. M. Luhrmann, Stanford University, 441 Gerona Road,
Stanford, CA 94305, USA. Email: luhrmann@stanford.edu
First received 19 Sep 2013, final revision Feb 2014, accepted 3 Apr 2014
References
1 Tuttle G. Hallucinations and illusions. Am
J
Psychiatry 1902; 58: 443-67.
2 First M, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for
DSM-IV-TR Axis I Disorders, Research version, Patient Edition With Psychotic
Screen (SCID-IIP WIPSY SCREEN). Biometrics Research, New York State
Psychiatric Institute, 2002.
3 American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders (4th edn, Text Rev) (DSM-IV-TR). APA, 2000.
4 Romme M, Escher S. Making Sense of voices. Mind, 2004.
5 Leudar, I, Thomas P. The Verbal Hallucinations Pragmatics Assessment
Schedule. Department of Psychology, university of Manchester, 1995.
6 Sousa A. Pragmatic Ethics, Sensible Care: Psychiatry and Schizophrenia in
North India. PhD dissertation, University of Chicago, 2011.
7 Geert2 C. From the 'native's point of view': on the nature of anthropological
understanding. Bull Am Acad Arts Sci 1974; 28: 26-45.
8 Markus H, Mullally PR, Kitayama S. Selfways: diversity in modes of cultural
participation. In The Conceptual Self in Context (U Neisser, D Jopling, eds):
13-74. CUP, 1997.
9 Nisbett R. The Geography of Thought. Free Press, 2004.
10 Marriott M. Hindu transactions. In Transaction and Meaning: Directions in the
Anthropology of Exchange and Symbolic Behavior: 109-42. Philadelphia
Institute for the Study of Human Issues, 1976.
11 Miller J. Cultural psychology of moral development. In Handbook of Cultural
psychology (S Kitayama, D Cohen, eds). Guilford, 2006.
12 Trawick M. Notes on Love in a Tamil Culture. University of California Press,
1992.
13 Strathern M. The Gender of the Gift. university of California Press, 1988.
14 Adams G. The cultural grounding of personal relationship: enemyship in
North American and West African worlds.
J
Person Soc psychol 2005; 88:
948-68.
15 Ma C, Schoeneman TJ. Individualism vs. collectivism: a comparison of Kenyan
and American self-concepts. Basic Appl Soc Psych 1997; 19: 261-73.
16 Mbiti J. African Religions and Philosophy. Heinemann, 1969.
17 Fortes M, Mayer D. Psychosis and social change among the Tallensi of
Northern Ghana. Cah Etud Afr 1966; 6: 5-40.
18 Scott EHM. A study of the content of delusions and hallucinations in 1000
African female patients. S Afr Med
J
1967; 4: 853-6.
19 Okulate GT, Jones OBE. Auditory hallucinations in schizophrenia and affective
disorder in Nigerian patients. Transcult Psychiatry 2003; 40: 531-41.
20 Suhail K, Cochrane R. Effect of culture and environment on the
phenomenology of delusions and hallucinations. Int
J
Soc Psychiatry 2002;
48: 126-38.
21 Murphy J. Psychiatric labeling in cross-cultural perspective. Science 1976;
191: 1019-28.
22 Bentall R, Fernyhough C, Morrison A, Lewis S, Corcoran R. Prospects for a
cognitive-developmental account of psychotic experiences. Br
J
Clin Psychol
2007; 46: 155-73.
23 Bell V. A community of one: social cognition and auditory verbal
hallucinations. PLoS Biology 2013; 11: e1001723.
24 Connor C, Birchwood M. Power and perceived expressed emotion
of voices: their impact on depression and suicidal thinking in those who
hear voices. Clin
rsycro!
Psychother 2013; 20: 199-205.
25 Connor C, Birchwood M. Through the looking glass: self-reassuring
meta-cognitive capacity and its relationship with the thematic content
of voices. Front Hum Neurosci 2013; 7: 213.
26 Jenner JA, van de Willige G, Wiersma D. Effectiveness of cognitive therapy
with coping training for persistent auditory hallucinations: a retrospective
study of attenders of a psychiatric out-patient department. Acta Psychiatr
Scand 1998: 98: 384-9.
27 Leff J, Williams G, Huckvale M, Arbuthnot M, Leff P.Avatar therapy for
persecutory auditory hallucinations: what is it and how does it work?
Psychosis 2013; doi:10.1080/17522439.2013.773457.
28 Romme M, Escher S. Accepting voices. Mind, 1993.
29 Morgan C, McKenzie K, Fearon P. Society and Psychosis. CUP, 2008.
30 Hopper K, Harrison G, Janca A, Sartorius N, eds. Recovery From
Schizophrenia. OUP, 2007.
0
EXTRA
_g~~11EENT
... In addition, some symptoms of psychosis are more frequently viewed as both positive and deeply meaningful in many cultures from the Global South, as they often indicate a special relationship with a deity, the dead, or some other spiritual force. For example, Luhrmann et al. (2015) observed that samples from India and Ghana treated their hallucinations as more benign than American samples, did not use diagnostic labels to explain them, and were more likely to believe that they came from God or family members rather than due to an illness; as a result, hallucinations were viewed as less harmful and more comforting relative to participants from the United States. Such interpretations are important to delineate in a culturally sensitive way as they can affect treatment seeking, treatment progress, and development of treatment goals. ...
... Such interpretations are important to delineate in a culturally sensitive way as they can affect treatment seeking, treatment progress, and development of treatment goals. For example, given that the experiences of voices for individuals from India and Ghana were deemed to be more "benign" (Luhrmann et al., 2015), treatment goals for individuals from these cultures could focus less on alleviating distress with the voices and potentially more on helping an individual disengage from interacting with their voices, in situations where they may distract them from other responsibilities (e.g., work, household chores, engaging with their family). ...
Article
Full-text available
Cognitive behavioral therapy for psychosis is an effective treatment for psychosis. However, psychosis presents differentially according to an individual’s cultural context, and it is currently unclear which methods have been used to formulate culturally adapted cognitive behavioral therapy for psychosis (CaCBTp). The current systematic review examines the approaches to CaCBTp that have been evaluated to date and comments on preliminary evidence for the efficacy of CaCBTp. Key features of CaCBTp interventions are discussed in reference to broader cultural adaptations of psychosocial interventions for psychosis and culturally adapted cognitive behavioral therapy for other disorders. Overall, our results identified 12 studies and highlighted five overarching themes of cultural adaptation that clinicians should integrate into the design of future CaCBTp interventions, including family members in treatment, targeting stigma, relying on spiritual leaders, using multifaceted models of mental health, and ensuring adequate language match. The results of this review also highlight the paucity of literature in global CaCBTp interventions, as only 10 studies examining CaCBTp interventions were found.
... Could this give us access to some 'islands of stability' (Pickering, 2017) other than those provided by psychiatry so far? Perhaps Luhrmann's work, which suggests that a non-self-contained understanding of the mind may be an advantage in living with voice-hearing, and that traditional training in becoming a spiritual healer seems beneficial to voice-hearing, lends some additional credibility to just that (Luhrmann et al, 2015;Luhrmann, Dulin & Dzokoto, 2023) 3 . ...
Article
Full-text available
This paper summarizes experience and knowledge from a co-research project in collaboration with several voice-hearers between 2017 and 2023. This includes a preliminary characterization of the apparent personhood of voices and how best to interact with them as such, including suggestions for practice. The final part of the paper considers how the apparent subjectivity or personhood of voices might be understood in relation to recent developments in anthropology concerning animism.
... However, the room has small details 12 In this paper, I chose not to focus on Luhrmann's vast work on voice-hearing with people with mental illness (see for example . Nonetheless, we can observe that the kind of voices Jerome heard (hostile and impersonal, etc.) are similar to those that she found in other Western contexts (Lebovitz, et al., 2021;Luhrmann, et al., 2015aLuhrmann, et al., , 2015b, in contrast to other cultural contexts in which the voices' content ranges more widely and includes benevolent voices (Ng et al., 2023). 13 See A. K. Shah (1994), as well as Campbell and Nicole (2007) on the safety requirements of interview rooms. ...
Article
Full-text available
Through a longstanding collaboration, psychiatrists and anthropologists have assessed the impact of sociocultural context on mental health and elaborated the concept of culture in psychiatry. However, recent developments in ecological anthropology may have untapped potential for cultural psychiatry. This paper aims to uncover how “ecologies” inform patients’ and clinicians’ experiences, as well as their intersubjective relationships. Drawing on my ethnography with Jerome, a carriage driver who became my patient in a shelter-based psychiatric clinic, and on anthropological work about how psychic life is shaped ecologically, I describe how more-than-human relationality and the affordances of various places—a clinic and a stable—influenced both Jerome’s well-being and my perceptions as a clinician. I also explore how these ecologies shaped our different roles, including my dual roles as psychiatrist and ethnographer. In the discussion, I define ecological factors, describe their implications for clinical practice, and suggest how they could be integrated into DSM’s cultural formulation.
... Furthermore, we did not examine data on the basis of study design and publication type, which may have resulted in comparisons between nonhomogeneous data, contributing to concerns about outcome reliability. Finally, the included studies were from White-dominant Western countries, especially the United States, raising concerns about generalizability to nations or communities with differing sociopolitical cultures, mental health systems, and civil cultures and differences in how people respond to and understand mental health concerns (95,96). Finally, we note a project-specific limitation related to the planned collaboration with a LEO in this research. ...
Article
Full-text available
Objective: Mental health lived experience organizations (LEOs) and their lived experience workforce are increasingly recognized as invaluable. However, a deeper understanding of the elements that enhance or inhibit LEOs' efficacy is required to learn how to sustain LEOs and support their workforce. Rapid international expansion has resulted in significant LEO growth and change, challenging many LEOs to adapt. With this rapid expansion, the field is evolving faster than many LEOs can keep pace with. This review, codesigned and coproduced in partnership with a LEO to draw on both lived experience and academic perspectives, aims for a deeper understanding of which elements within a LEO enhance or inhibit its efficacy, growth, and support for its lived experience workforce. Methods: A systematic search of peer-reviewed and non-peer-reviewed literature, following the PRISMA-ScR guidelines and JBI methodology, identified 60 records published in English between 2000 and 2022. Results: The results indicate general agreement regarding which LEO elements are important (e.g., culture, leadership, board composition, organizational structure, financial arrangements, and professionalization). However, considerable disagreements exist regarding the relative influence of several of these elements, especially funding arrangements, in which funder and LEO values often diverge; training for increased lived experience professionalization; and partnerships with medical model-focused mental health services. Conclusions: Organizational disagreements relate to managing future LEO growth and advancing the lived experience workforce while preserving LEOs' unique characteristics that make them valued mental health services. Further research should examine community differences among LEOs, including hybrid LEOs within services and non-LEO mental health organizations.
... While patients in North America are more likely to report digestive problems as expressions of stress or anxiety, in India many experience burning sensations (Escobar & Gureje, 2007;Kirmayer, 2001). Likewise, patients with schizophrenia in India are more likely to report hearing positive or playful voices; whereas patients in the U.S. or Canada usually report voices that are menacing or threatening (Luhrmann et al., 2014). Culture-bound syndromes are perhaps the most salient examples of the strong influence culture has. ...
Conference Paper
Over the past decade, findings from cultural neuroscience have demonstrated that functional neural processes vary significantly across populations. These findings add a new dimension to the well-established literature describing cultural differences in human behavior. Although these findings are informative for understanding complex relationships between social and neurobiological processes, they also have significant implications for psychiatric research. Neuropsychiatry already co-considers the relationship between brain and social world; however, its research findings notoriously underrepresent diverse cultural, ethnic, and gender groups. Considering that psychiatric patients across cultures exhibit different behavioral presentations and symptom distributions, they may exhibit equally different functional neural processes as well. Increasing representation of diverse patient groups in neuropsychiatric research would allow potential differences to be investigated and understood. Although cross-cultural comparisons may be the most direct means of accomplishing this goal, such studies must be carefully constructed to avoid reinforcing stigmas or stereotypes when working with sensitive patient populations. For example, hypotheses and inclusion criteria must avoid reliance on stereotypes or conflation of geographic boundaries with cultural boundaries. These pitfalls point to deeper problems with current approaches to culture-brain research, which lack operational definitions of ‘culture’ more generally. After outlining these issues, solutions to these methodological problems will be presented and an operational definition of culture for neuropsychiatry will be proposed.
Article
Purpose The purpose of this survivor-researcher-led study is to explore the agency of voice-hearers who are migrants and/or from black and minority ethnic backgrounds in actively negotiating the gaps between their understanding of hearing voices, and those of their family, their society or the medical establishment. Design/methodology/approach This study draws four case studies of voice-hearers, who are migrants and/or from black and minority ethnic backgrounds. Data were thematically analysed. Findings This study shows how bilingual voice-hearers related emotionally to voices in one or two languages. Originality/value This study is original in that it shows that bilingual voice-hearers may hear their voice/s in either their native language or second language, but that in both cases voices may embody strong positive or negative emotions.
Article
After years of armed conflict in northern Uganda, many local people have turned to Evangelical churches for help with healing and recovery. We observe that the healing practices in these churches encourage particular notions of what the mind is, how the mind works and whether it is bounded or porous to the outside world. In the traditional cultural setting in which these people grew to adulthood, many accept that vengeance can attack supernaturally from without. Based on ethnographic research conducted in the region between 2015 and 2025, this article argues that these new ideas about mind (broadly conceived) may help some community members recover (to some extent) from traumatic experiences arising from the armed conflict by modeling trauma as not supernatural, and modeling the mind as protected by God from attack. Learning a new way of understanding the mind and its boundaries with the outside world—e.g., as more closed and bounded—and learning to practice a certain amount of control over this boundary, may have a significant effect on the experiences of mental distress This argument contributes to debates on anthropology of mind, and on the way local theories of mind may shape mental experience.
Article
Over the past century, the “right to health” has been recognized by medical organizations and governments across the globe. This essay calls for recognition of a parallel “right to be sick” intended to reframe physician attitudes toward patient autonomy and the right to refuse care. Rather than seeking to discourage allopathic medicine or to question laws requiring involuntary treatment when indicated by the collective welfare, the goal is to have the medical and public health communities reconceptualize their attitudes toward individuals who reject unsought guidance and care.
Article
Although there is considerable evidence showing that the prevention of mental illnesses and adverse outcomes and mental health promotion can help people lead better and more functional lives, public mental health is overlooked in the broader contexts of psychiatry and public health. Likewise, in undergraduate and postgraduate medical curricula, prevention and mental health promotion have often been ignored. However, there has been a recent increase in interest in public mental health, including an emphasis on the prevention of psychiatric disorders and improving individual and community wellbeing to support life trajectories, from childhood through to adulthood and into older age. These lifespan approaches have significant potential to reduce the onset of mental illnesses and the related burdens for the individual and communities, as well as mitigating social, economic, and political costs. Informed by principles of social justice and respect for human rights, this may be especially important for addressing salient problems in communities with distinct vulnerabilities, where prominent disadvantages and barriers for care delivery exist. Therefore, this Commission aims to address these topics, providing a narrative review of relevant literature and suggesting ways forward. Additionally, proposals for improving mental health and preventing mental illnesses and adverse outcomes are presented, particularly amongst at-risk populations.
Article
Full-text available
We have developed a novel therapy based on a computer program, which enables the patient to create an avatar of the entity, human or non-human, which they believe is persecuting them. The therapist encourages the patient to enter into a dialogue with their avatar, and is able to use the program to change the avatar so that it comes under the patient's control over the course of six 30-min sessions and alters from being abusive to becoming friendly and supportive. The therapy was evaluated in a randomised controlled trial with a partial crossover design. One group went straight into the therapy arm: "immediate therapy". The other continued with standard clinical care for 7 weeks then crossed over into Avatar therapy: "delayed therapy". There was a significant reduction in the frequency and intensity of the voices and in their omnipotence and malevolence. Several individuals had a dramatic response, their voices ceasing completely after a few sessions of the therapy. The average effect size of the therapy was 0.8. We discuss the possible psychological mechanisms for the success of Avatar therapy and the implications for the origins of persecutory voices. © 2013 Copyright Taylor and Francis Group, LLC.
Article
Full-text available
We have developed a novel therapy based on a computer program, which enables the patient to create an avatar of the entity, human or non-human, which they believe is persecuting them. The therapist encourages the patient to enter into a dialogue with their avatar, and is able to use the program to change the avatar so that it comes under the patient's control over the course of six 30-min sessions and alters from being abusive to becoming friendly and supportive. The therapy was evaluated in a randomised controlled trial with a partial crossover design. One group went straight into the therapy arm: "immediate therapy". The other continued with standard clinical care for 7 weeks then crossed over into Avatar therapy: "delayed therapy". There was a significant reduction in the frequency and intensity of the voices and in their omnipotence and malevolence. Several individuals had a dramatic response, their voices ceasing completely after a few sessions of the therapy. The average effect size of the therapy was 0.8. We discuss the possible psychological mechanisms for the success of Avatar therapy and the implications for the origins of persecutory voices.
Article
Full-text available
Auditory verbal hallucinations have attracted a great deal of scientific interest, but despite the fact that they are fundamentally a social experience-in essence, a form of hallucinated communication-current theories remain firmly rooted in an individualistic account and have largely avoided engagement with social cognition. Nevertheless, there is mounting evidence for the role of social cognitive and social neurocognitive processes in auditory verbal hallucinations, and, consequently, it is proposed that problems with the internalisation of social models may be key to the experience.
Article
This book is a report of the findings of the International Study of Schizophrenia (ISoS), Focusing on variations in the course and outcome of schizophrenic disorders, the investigation covers 14 countries in both the developed and developing world. The bulk of the volume consists of portraits of individual field research centres in each country and reports on the outcomes of these centres’ schizophrenic patients. The “portrait chapters” are flanked by introductory and synoptic chapters laying out both the genealogy and design of ISoS and synthesising its major findings. Of these, the most significant conclusions: that while recovery from schizophrenia is a struggle for many patients, it is possible to achieve in terms of improved daily function and quality of life and that, with appropriate and sustained treatment, schizophrenia is largely an episodic disorder that has a favourable outcome for a significant portion of those afflicted with it. The book also includes extensive tables that present the research data, permitting further independent analysis. Recovery from Schizophrenia is unique - there is virtually nothing like it in the contemporary field of cross-cultural psychiatric epidemiology, and the massive, multinational investigations upon which it is based are not likely to be replicated any time soon in the area of mental illness. As such, this book will be a unique resource for mental health professionals, practitioners, and researchers worldwide, providing an empirically based reason for hope in the long run for persons living with schizophrenia.
Book
Psychiatry is in the process of rediscovering its roots. It seemed as if the long history of interest in the impact of society on the rates and course of serious mental illness had been forgotten, overtaken by the advances of neuroscience and genetics. However, as our knowledge of physiological and genetic processes improves, it becomes increasingly clear that social conditions and experiences over the life course are crucial to achieving a full understanding. Old controversies are giving way to genuinely integrated models in which social, psychological and biological factors interact over time, culminating in the onset of psychosis. This book reviews these issues from an international perspective, laying the foundations for a new understanding of the psychotic disorders, with profound implications for health policy and clinical practice. It will be of interest to academics, researchers, clinicians and all those who work with people with a serious mental illness.