Schizophrenia is a severe mental disorder characterized by symptoms such as hallucinations, delusions, and disorganized thinking. Among these, auditory hallucinations such as hearing voices are a defining feature of schizophrenia. However, according to a new Stanford report, the nature of these voices varies significantly depending on the person’s cultural context.
In the United States, people with schizophrenia often hear hostile, threatening voices, while in India and Africa, the voices tend to be kinder, more familiar, and sometimes even comforting. Hearing voices affects each patient differently and often reflects their unique social and cultural background. These factors can significantly influence how they respond to treatment.
Cultural Differences in Voice-Hearing Experiences
A study led by Stanford anthropologist Tanya Luhrmann and published in the British Journal of Psychiatry compared the voice-hearing experiences of 60 adults diagnosed with schizophrenia across 3 countries. These 3 countries were the United States, India, and Ghana (20 participants from each country). All participants reported hearing voices, but not a single participant from the U.S. study hearing positive voices.
In the U.S., the majority of participants described their voices as hostile, commanding, and intrusive. 14 out of 20 U.S. participants heard voices instructing them to harm themselves or others, and 5 described their experience as being in a battle or war. None reported predominantly positive or comforting voices. These voices were often perceived as symptoms of a brain disease, reflecting the dominant medical model of schizophrenia in Western medicine.
In contrast, 13 Indian participants reported often hearing voices of family members or spouses offering guidance, advice, or commands related to everyday tasks. These voices were generally thought of as good or helpful, even when demanding or scary. Only a minority reported voices commanding them to do harm.
Similarly, in Ghana, 16 participants reported hearing voices of God or other deities, which were mostly positive and protective. The participants said that even when negative voices appeared, good voices often outweighed their power. In Indian and African communities, people often prioritize relational harmony and spiritual beliefs over individual diagnoses.
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The Role of Cultural Models of Mind and Self
Luhrmann and colleagues propose that these differences arise from culturally learned expectations about the mind, self, and social relationships. Western cultures tend to emphasize a culture of individuality and view the mind as a private, unbreachable stronghold. This framework causes American patients to experience hearing voices as an intrusion and a violation of personal boundaries, which might explain why they focus on the most antagonistic and hostile voices.
By contrast, Indian and African cultures emphasize close relationships and a sense of self defined through connections with others. In these societies, people understand the mind as interconnected with others and the spiritual world. They often interpret hearing voices as communication with ancestors, spirits, or deities and integrate these experiences into their social and religious life. This relational model allows patients to experience voices as familiar, meaningful, and sometimes supportive rather than alien and threatening.
How Culture Influences Schizophrenia’s Course and Outcome
The cultural shaping of voice-hearing experiences may, in part, explain why schizophrenia tends to have a more severe and negative outcome in Western countries compared to India and some African nations. Studies have consistently found better social functioning and recovery rates among Indian patients, which may be due to the less hostile and more relational nature of their hallucinations.
Luhrmann’s research suggests that the hostile voices common in the U.S. may exacerbate distress and disability, while more benign voices in India and Ghana might facilitate coping and social integration. This insight supports therapeutic approaches like the Hearing Voices movement, which encourages patients to engage with and build relationships with their voices rather than suppress them. Such interventions may help reduce the harmful impact of hostile hallucinations and improve therapeutic outcomes.
Rethinking Treatment Across Cultures
The study challenges the dominant medical model that treats hallucinated voices solely as pathologies to be silenced. Instead, the study focuses on the importance of cultural context in shaping patients’ experiences and responses to their voices.
Clinicians working with diverse populations should consider patients’ cultural backgrounds and beliefs about voice-hearing. Integrating cultural understandings into treatment can enhance engagement, reduce stigma, and tailor interventions to improve patients’ lived experiences with schizophrenia and hearing voices.
Conclusion
The voices heard by people with schizophrenia differ significantly across cultures. In the U.S., people mostly report harsh and threatening voices, reflecting how the dominant medical model views schizophrenia as a brain disease. In India and Africa, voices are often kinder, familiar, and integrated into spiritual and social relationships. These cultural differences influence the experience, course, and treatment of schizophrenia. As research advances, embracing cultural perspectives will be essential to supporting people with compassionate and effective care for schizophrenia globally.
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