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The places where 'hearing voices' is seen as a good thing

Western medicine typically views anyone who admits to being told what to do quante carte ci sono in un mazzo di pokerby disembodied voices as suffering from psychosis. But that is not the case everywhere – so what can we learn from those who treat these hallucinations differently?

Hearing voices is more common than you might think. Studies through the decades have shown that a surprising number of people without any previously diagnosed mental health condition – often more than three quarters of those taking part – experience voices speaking to them from an unknown source.

In Western psychiatry, however, these auditory hallucinations are one of the principal symptoms of psychotic disorders. And the resulting stigma surrounding these mental health conditions means that few people will publicly admit to hearing voices in their head.

But in some cultures these hallucinations are not only widely accepted but actively celebrated. They are seen as offering guidance or as helping to keep people safe. What can we learn about mental health from other cultures? And can we see people who experience hearing voices in a different light?

Local expectations shaped by the culture, environment and people we grow up with affect whether those who experience hallucinations are judged to be ill, or not, says Tanya Luhrmann, a professor of anthropology from Stanford University in the US, and co-author of the book Our Most Troubling Madness.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is the standard reference for diagnosing mental disorders in the US, lists hearing voices as a primary feature of schizophrenia and psychosis. Yet in Western countries some hallucinations are more accepted than others – as many as 80% of bereaved Americans and Europeans report seeing, hearing or feeling a close relative who has passed away. The Achuar tribes of Ecuador, by comparison, prohibit mourning the loss of family members because they consider visions or dreams of the deceased as threatening to the souls of the living.

Even drug-induced hallucinations of voices vary depending on cultural differences. In the Amazon, the Siona tribe believe that such hallucinations are an experience of an alternative reality, while the Schuar tribe believe that everyday life is an illusion, and reality is what is seen during a hallucination.

People's personal responses to hearing a voice in their head can also be shaped by culture. A comparison between US, Ghanaian and southern Indian psychosis patients found that Americans were more likely to hate their internal voice, and usually did not know the identity of the speaker. Patients in Chennai in India and Accra in Ghana, by comparison, associated their internal voices with God or family members, and did not always dislike hearing them, according to the study conducted by Luhrmann.

More than half of the people from Chennai in the study said that they heard the voices of specific family members, such as their parents, mother-in-law or sisters. These voices offered practical advice, instructions for daily tasks, and were also there to give a telling off. The voices told the interviewees to go to the shops, to prepare food and to bathe. "They talk as older people advising younger people," said one interviewee. "It teaches me what I don't know," said another.

For the participants in Chennai, the voices seemingly had a more realistic quality, and only a small number of interviewees said that they did not recognise the voice that spoke to them. Some of the interviewees from Accra went further and said that their voices were positive influences. One man told Luhrmann, "They just tell me to do the right thing. If I hadn't had these voices I would have been dead long ago". However, Americans were more likely to describe their voices as imaginary. "I don't think there's anything there or anything. I think it's just the way my mind works," one US participant said to Luhrmann.

Some of the Chennai interviewees spoke of feeling frightened of their voices, and many said they disliked being told off. But the voices could also be playful, which is something that no-one from the US or Ghana mentioned.

Luhrmann says that non-Western people are more likely to say that their minds are interwoven with others. Ghanaians, for example, understand that they are connected to others by their relationships. And while many of the study participants from Accra accepted that hearing voices was a symptom of a psychiatric disorder, it was more socially acceptable to them to hear those voices, though Luhrmann adds that people in Ghana might be hesitant to reveal that they have heard critical or violent voices because of local stigmas around witchcraft.

Some cultures accept, and even celebrate, people who hallucinate rather than pathologising them says Luhrmann, giving the example of the people from Ghana whose voices were seen as contact from God. "In different parts of the world, people are expected to see the dead, to talk to spirits, to interact with fairies," says Luhrmann.

As Western psychiatrists in the 20th Century tried to agree on how they would define and diagnose various mental illnesses, anthropologists such as Ruth Benedict and Jane Murphy were recording how people with similar symptoms were treated with acceptance and even honour in non-Western cultures.

Murphy lived with Egba Yoruba people, for example, a subgroup of Yoruba-speakers from western Nigeria, whom she observed hearing voices and trying to show other people where they were coming from – though the source could not be seen by anyone other than the hearer. She noted that this seemed to be a fairly common occurrence within the Egba Yoruba people and troubled neither the person hearing the voices or the people who couldn’t.

Most cultures, says Luhrmann, have words for thoughts that can pass from one mind to another. In English we might say "telepathy", "witchcraft" or "divine inspiration".

Humans generally feel as though their thoughts are private, says Luhrmann. But most of us have probably had experiences that go against this. "Sometimes a powerful dream feels as if it's conveying information from outside," she says. "Sometimes, if you get really mad at somebody who is not in the room with you, and you curse at them, it feels like it could get through to them."

Two personality traits called porosity and absorption seem to describe why some people are more accepting of external voices and other phenomena. Porosity is a readiness to accept that external thoughts can enter our minds.

Absorption, meanwhile, allows us to leave our present world and enter the world of our imagination, blurring the boundary between our inner and outer mental experience. People with a lot of absorption are unlikely to immediately question whether an experience is real, but are more willing to wonder what the experience might teach them.

A readiness to accept and engage with voices might explain cultural differences in recovery from mental illness. In a study comparing the experiences of Nigerian and British schizophrenia patients, the latter were more likely to hear abusive and aggressive voices. And in other research focusing on Pakistani and British schizophrenia patients, the latter were more likely to hear orders to kill themselves.

That some people experience their voices as extremely negative has clinical consequences. This is where hearing a voice may become more serious, and undeniably pathological. Across several studies, Americans were much more likely to say that the voices they heard had violent intentions. Some interviewees told Luhrmann their voices asked them to torture people and drink their blood, while others described voices calling them into battle.

Luhrmann suggests that societal factors could explain this to some extent. The US has a much higher rate of gun violence compared to other high-income countries. People with mental illnesses are also more likely to be homeless in the US and to experience violence directed towards them.

While working in an area of Chicago that has the densest population of people with schizophrenia in the state of Illinois, outside of prisons, Luhrmann became curious about how culture shapes people's experiences of psychosis. Some people with psychosis can have a nomadic life moving between institutions and services like jail, the hospital, the street and housing shelters – referred to as the "institutional circuit". "They hear voices saying that people are watching them," says Luhrmann. "And there's some people around the institutional circuits who do actually pursue them, make fun of them, mock them."

Critical or violent voices are the biggest predictor of whether someone will be given a clinical diagnosis of a psychotic disorder. Cultural differences may also affect how people recover from illness. In another study of patients who heard voices from Chennai and a group from Montreal in Canada, who were monitored over a five-year period, Indian patients emerged as more likely to have chosen to stop their medication after one year. Indian patients also had fewer negative symptoms and a better ability to function in society, regardless of whether they were on or off their medication.

Ashok Malla, a professor of psychiatry at McGill University in Montreal, notes that "function in society" might have a broader definition in India than in Canada, as looking after the household or looking after elderly parents is as important, or more important, a role for women as being in paid employment. In the West, he says, not being in paid employment can carry more stigma.

The treatments were almost identical in terms of medications, case management and cognitive behavior therapy. Malla explains that while antipsychotic medications are effective, they only go some way to addressing symptoms of disease. "Antipsychotic medication really only works for positive symptoms, which are things that should not be there, like illusions or hallucinations," says Malla. Negative symptoms are the absence of things that should be there, such as emotional expression, ability to generate thoughts and ability to relate socially to people. The reverse of which would be social withdrawal, a lack of experience, feelings and so on. "Medications have very little, if any, impact on these," says Malla. Generally, negative symptoms, like low mood, respond poorly to drugs.

Malla suggests that the social differences between India and Canada go some way to explain the difference in the success of treatments. Homelessness is less common among people with schizophrenia in Chennai, for example. Malla puts this down to families wanting to keep mental illness within the household so that any stigma associated with having a family member with schizophrenia can be "kept under wraps". He says that marriage is a key concern for families, and anything that might affect an offspring's marriageability will be dealt with as a family.

Malla points out that families in Canada are as interested in taking care of their sons and daughters, brothers and sisters, as they are in India. But he says that the sophisticated legalisation of contact and confidentiality with patients can be a problem. A young adult in North America can more easily leave home and cut off contact if they wish, he says. But this could lead to worse outcomes.

Family interventions have been shown to be effective in improving recovery from psychosis. "In Chennai, a patient hardly ever comes to the clinic without a family member. We hypothesised that it would result in a better outcome on negative symptoms," says Malla. "And that's exactly what we found."

Much like the difference between how Western countries and the Achuar tribe in Ecuador define contact with the deceased, what is considered a "normal" experience is greatly influenced by our culture. When you look at how some around the world celebrate those who hear voices, perhaps it can be more normal than we think.

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