Cultural Influences
“Culture is the bedrock, the final wall, against which one leans one’s back in a godforsaken chaos.” – J.C. Powys
In Stanford anthropology professor Dr. Tanya Luhrmann’s groundbreaking study, “Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: Interview-based study” (2018), Luhrmann invited people from three different countries who either had been diagnosed with a psychotic disorder, or would qualify for one, to talk about the various experiences and relationships they had with their voices. The results were staggering (see graph). Why might people in their respective countries interpret their experiences so differently from each other even when eligible for the same diagnosis?
Individualism vs Collectivism
One theory suggests that the differences between individualist and collectivist countries influence the validation, acceptability, and level of support given towards an individual’s presentations.
Individualistic societies, such as the United States, value a person’s individual sense of responsibility, self-reliance, and self-sufficiency over that of the collective group1. Many people who experience unusual beliefs/experiences are often isolated, discriminated against, and stigmatized due to their perceived inability to control or handle oneself.
Many people who are homeless in America also live with unusual beliefs and experiences – the lack of communal responsibility and support from their society perpetuates a discriminatory stigma that people who are homeless or mentally ill wound up that way because of personal failures, and are thus not worthy of help nor support from others.
Collectivist societies, such as Ghana and India, value the importance of mutual/group responsibility and looking out for each other. If someone is around family or friends who know what concerning things to look out for, they will live in a more predictable and supportive world.
People who live in collectivist societies also have an easier time externalizing their voices as separate from themselves; this enables them the ability to foster a healthier relationship between themselves and their voices.
Differences in meaning between subjects in San Mateo, Accra, and Chennai5
US Results
(San Mateo, CA)
Ghanian Results (Accra, Ghana)
Indian Results (Chennai, India)
Diagnostic labels and diagnostic criteria used readily to describe their experiences
Almost no diagnosis talk in reference to their experiences
Almost no diagnosis talk in reference to their experiences
“Hearing voices” means being “crazy”
Hearing voices has a spiritual meaning as well as a psychiatric one
Voices are often different relatives talking to them
Hate their voices
Emphasis on the moral quality and purpose of the voice
Voices can be given spiritual interpretation
Hear and report violent content and commands
Voices are often reported as positive
Voices can be physical (affect them physically)
Voices are experienced as a disrupted relationship between thought and the mind
Voices can be physical (they can affect one physically)
Voices are often positive and can be playful
Hearing voices is an act of violating the privacy of their minds
“The mind should be positive”
Voice offer guidance: they teach people to “come to know”
Many people remain isolated from friends and family due to stigma
Voices are often gods/God; talking to gods is a part of their culture and is an honorable experience
Voices are often neutral commands (e.g. "get dressed")
Family members often attend doctors appointments
Diagnostic influences
One major difference between the United States, Ghana, and India, is the fact that only one of these countries devotedly ascribes to diagnostic labeling. The latter cultures often do not diagnose, and instead only focus on addressing behaviors if they interfere with the individual’s ability to fully participate in their lives.
“I think these diagnostic categories, particularly for psychotic disorders, carry a quality of the diagnosis of death.”6
When exporting diagnostic categories from one culture to another, category fallacies may occur since the foreign diagnostic categories may not apply to the people and problems specific to that place. This colonizing action may cause diagnostic errors and inappropriate interpretations of the real problems, as every experience seen will be viewed though that limiting lens2.
The looping effect, where “categorizing people in certain ways (especially when done by powerful cultural actors like doctors) leads to a change in peoples’ experiences of themselves and their symptoms”3. This can look like someone relabeling experiences that they initially referred to as “life problems” to “depression”. This invalidation of personal understanding not only shifts their experiences to those in which they feel helpless against; they also may start to internalize the diagnosis and start to experience symptoms outlined by the diagnosis – even if those symptoms weren’t present before being assigned the label. Diagnostic categories can become self-reinforcing in this way.
The social kindling hypothesis
Originally coined by Emil Kraepelin (1921), the social kindling hypothesis states that “people who fall ill with serious psychotic disorder pay selective attention to a constant stream of many different auditory and quasi-auditory events … because of different “cultural invitations” — variations in ways of thinking about minds, persons, spirits, and so forth. We think that as people pay attention in culturally varied ways, there are small but important cognitive biases in the way that they identify, respond to, and remember auditory experiences.”4