How Culture Influences Voice Hearing: An Interview with Stanford Anthropologist Tanya Luhrmann

This interview was originally published on Mad in America on November 13, 2020 here.

Tanya Luhrmann is a Watkins University Professor in the Anthropology Department at Stanford. Her work explores how cultural contexts shape the experience of mental distress, particularly voice-hearing and the symptoms associated with psychosis. She also turns the lens on the practice of Western psychiatry itself, investigating how the field represents the mind and how these representations influence our collective understanding of reality.

Luhrmann’s book When God Talks Back was New York Times’ Notable Book of the Year, and she has written numerous articles on psychosis, medical anthropology, and spiritual experiences. Recently, Our Most Troubling Madness: Schizophrenia and Culture was published by the University of California Press. Her newest book, How God Becomes Real: Kindling the Presence of Invisible Others, was published by Princeton in 2020.

Luhrmann describes herself as someone who is interested in different types of “realnesses.” Given that she grew up surrounded by different worldviews, it is not surprising that her work reflects this diversity of interests. It spreads across academic fields and geographical terrain – from anthropology to psychiatry on one side and Chicago to Chennai on the other. Throughout these writings, she has challenged many assertions of mainstream psychiatry, often to the annoyance of leading figures in the field.

In this interview, she talks about the damaging effects of a diagnostic identity and the often-unseen challenges that peer counselors can face. She also takes on big questions: What does it mean when a person with high scores on psychosis scales is functional in one culture but not in another? Are auditory hallucinations shaped by cultural experiences? Are they always a source of distress?

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Ayurdhi Dhar: Your work crosses both disciplinary and geographical boundaries. How is the relationship between psychiatric diagnosis and social identity in the US and different from other places, like India?

Tanya Luhrmann: People I came to know in the United States, mostly in California and Chicago, are often exceptionally aware of the nature of diagnosis and the terms. I gave this young woman a psychosis scale to see if she would meet a schizophrenia diagnosis. I remember she said, “Oh, I meet all these criteria. I’m so used to these questions.” I was really quite struck by that.

I had done work in Ghana in West Africa and Accra, another large city, and then Chennai in South India, an enormous, chaotic city. These were very sophisticated, modern, urban places, but people who appeared to meet the criteria for schizophrenia simply did not use diagnostic categories. They did not seem to think in terms of diagnostic categories. I think this may be an advantage for the folks in Chennai and in Accra and Cape Coast.

I think these diagnostic categories, particularly for psychotic disorders, carry a quality of the diagnosis of death. In our country, they evoke a sense that one is crazy, that the craziness is permanent and involves a broken brain — something central to our understanding of selfhood and identity in the United States. That was just a lot less salient abroad.

Dhar: You have written about how cultures and contexts shape the experience, content, and the consequences of voice-hearing. Could you give us some examples and tell us more about this phenomenon?

Luhrmann: My colleagues and I did a study where we talked in some detail with people who met the criteria for schizophrenia in this country. The first group was outpatients in supported housing, around 20 of them. I did the interviews in the States, and two colleagues did them at the Schizophrenia Research Foundation (SCARF) in Chennai, India — a very well-respected place. They also interviewed 20 people similar in age and length of diagnosis.

Then I interviewed 20 folks in hospitals in Accra; these were younger patients who were more ill. I went into the wards with a Ghanaian research assistant, and I had her go back to do more interviews after I left. I was worried about what people might tell me because I had white skin and I am a foreigner, and so different from them.

We found that the Americans uniformly hated their voices. This is probably not true for everybody, but it was pretty striking for the sample I interviewed — they didn’t know who was speaking. They hadn’t met in the flesh the person whose disembodied voice they heard. There was a lot of violent content, and these violent commands and negative experience really captured their experience. There was this alien, unhuman voice saying terrible things to them, and it was highly distressing.

It was different in Chennai and Accra. I do not want to give the impression that it is just fine to have schizophrenia in these parts of the world — the similarities of the illness were much more striking than the differences. But it was pretty striking that in Chennai, people heard commands which were more everyday ordinary things — “get dressed,” “don’t smoke,” “clean up.”

Dhar: Sounds like a parent…

Luhrmann: Exactly. That is exactly how they were interpreting their voices.

Over half of them heard kin speaking negative voices, but the negative voices were much more sexual. Even Americans heard sexual voices — there was this one guy who would hear a voice say, “give me the booty.” The content of his experience was all about sex.

The experience of these voices is often multisensory — they feel sexual. Americans, when they talked about these sexual experiences, felt that there was some fun in that too — they are complicated, whereas, in Chennai, twice as many people talked about sex. There was some enjoyment, but the voices were much more likely to be shaming. There was a mixture of experience — some physical, some quasi-hallucinated.

For one man, his voice was his mother-in-law, who was going to tell everybody — she was the hallucinated voice. She would say out aloud what he was doing, and he would be humiliated.

Then in Accra and Cape coast, those threads were still there, but I was so struck by this insistence that the voice was good and that the voice was God or the gods. People would say things like, “If I didn’t hear God, I would be dead because God is helping me with this problem that I’m having.” That was different.

Dhar: When I researched people hearing voices in the rural mountains of Northern India, I was struck by how functional they were. Some voices were good, like a woman dancing with a baraat (wedding procession) she visually hallucinated, others not. Often even with bad voices, they took care of their families and worked on farms. Could you tell me if you noticed a difference between how functional people were in the different places you did your research?

Luhrmann: I am running this large team, ‘The Mind and Spirit Project,’ and we are interested in the way people think about their minds and their experience of spirit — cool, weird, anomalous, unusual, and sometimes common experiences in which people interact with invisible beings.

For this project, in Ghana, there’s a group of people we interviewed who are called Okomfu — people who talked to the local gods. There is a cultural model — a common set of ideas that, at some point, the human is called by the Gods, and the human will resist this call. The call is often an auditory experience mixed with dissociative stuff — they are able to dissociate.

So, you are called, and when you resist this call, other people think you are crazy. This will last for a couple of years, and if you accept the call, you go off for training, which is pretty tough and involves listening to the gods identified as good, even though you might be afraid of them, and not listening to the demons.

I was intrigued about whether there might be people considered psychotic who were functionally effective in these roles. I found 18 people, about half of them were these traditional healers and half were Christians. There were people who would make a clinician wonder about psychosis because they described are a lot of auditory and demonic experiences.

When they talked about being called by the gods, they told a story about how distressed other people thought they were. For example, one man said, “my aunt came and told my mother to take me to the psychiatric hospital, but she didn’t want to do that, so she took me for training.” There were other groups of people, like those who loved going into a trance. There were those who said they heard voices, but I am not really sure that that was the experience from the way that they were talking about it.

I am tempted to think that it’s easier for somebody whose body is vulnerable to displaying and expressing the kinds of symptoms that we associate with psychosis to kind of wrap those symptoms in a culturally appropriate model — this causes the severity of the symptoms to abate to some extent.

Dhar: Does this relate to WHO’s findings of many developing nations showing better prognosis rates for psychosis, especially for hearing voices?

Luhrmann: I think so. The data are most robust for India and not just rural India. It is in Chandigarh and Chennai, which is not where you go for rural tranquility. Many times, people have tried to probe those observations that they have found in India. They look at somebody when they first fall ill and go to healing shrines, to hospitals, and do the same in the States, in Denmark, in the UK, and other settings. When you look at those people two years later, they look about 50% better in India. I am pretty persuaded by this data.

I think the caustic nature of the hearing voices experience might play a role. In our culture, for a whole set of reasons, people who are psychotic often end up on the streets. It is hard to know the exact figures, but they suggest that this is a pretty common experience. It is a terrible way to treat psychosis; this happens less in India. It happens, but it happens less.

I think a lot of it is because the person with psychosis in our country learns the word schizophrenia. It’s an identity. It’s who you are. I was really struck in India. One of my colleagues introduced me to one of her patients. If you gave this woman a standard psychiatric evaluation of the severity of her illness, like the PANSS — the positive and negative symptom scale — she would look pretty ill, but she was really functional.

I talked to her and her husband, I talked to her and her father, nobody used a psychiatric diagnosis. Voice hearing was only a problem when it interfered with her life. When she “followed the God out of the house and got lost,” that was a problem. But what really mattered to her husband was that she cared for the kids. She was in charge of the kitchen. There was a servant, but she had a job and a set of expectations as a wife. As long as she more or less fulfilled those expectations, that was okay.

Dhar: In your book Our Most Troubling Madness, you write about the place of families and their responsibilities in caring for someone with mental health issues. At both faith healing sites and hospitals in India, I noticed that families were always present. They would stick around. In the Psychology literature, families are often seen as a source of distress and dysfunction. How do these cultural differences in the role of families in caring for people affect patients?

Luhrmann: In America, because we have the social safety net, and because we have this model of independence because people are expected to value their freedom, kids leave their families by the age of 18. They do not always return. This is one reason why such a high percentage of people who have symptoms that meet the criteria for schizophrenia, I think half of them, end up on the street for some period of time.

In India, I went into villages with people from SCARF, and families would assemble with their ill family member in the hospitals. The families are always present. The families always go to medical appointments with the patient.

Social support is critical to humans. It can also drive some of us crazy. I remember my first encounter with an Orthodox Jewish community; there is such an intense communal life — all of these generations living together, praying together, poking their nose into everybody’s personal business. I know that it can drive ordinary folks crazy, but I think it is, on average, great for the person with psychosis.

For a person with psychosis, the family knows whether they are at risk of unpredictable behavior or violence. They are often taking measures to manage their access to things that could hurt them or others. Then the person with psychosis lives in a much more predictable world.

I spent a bunch of time on streets in Chicago, and this neighborhood with one of the densest per capita population of persons with psychosis, next maybe only to jail in the entire state of Illinois. People would leave the hospital, have a nomadic lifestyle, move between the homeless shelter, supported housing, jail, and then back to the hospital.

I saw that women, in particular, had this freedom, they were able to choose what they would do, and they were raped and beaten. That was really complicated. If you read Foucault, for example, there is a sort of romance in madness, and the madman is truly free, and we want to believe that. But you know, for a woman with psychosis on the streets — her body is so vulnerable. That happens less in India for psychotics. It absolutely happens, but less.

Dhar: Your work was covered by the New York Times, and then it inspired a harsh, and one might say an extreme reaction from the former APA president, Jeffery Lieberman. Why do you think that was the case, and how would you respond to his accusation that no other science will be asked to explain itself to Anthropology?

Luhrmann: I think that is ridiculous. Fields walk into each other’s fields all the time.

I had written this piece where I talked about this manual called ‘Understanding Psychosis‘ published by the British Psychological Society. It made these radical claims and said that if you’re somebody who seems to be ill, maybe it matters to you to name this illness, maybe it doesn’t, maybe you want to take medication, maybe you don’t, maybe you want to think about these symptoms religiously, maybe you don’t. That book, you could say, is a pretty anti-psychiatry book. That would be too strong an interpretation, but I think that is the interpretation he placed on it.

It can feel difficult. It’s like saying, “Oh, psychiatrists, don’t know what they’re talking about.” I wasn’t saying that. There is a temptation in this country that when clinicians are taught about hearing voices, they encourage their patients to ignore those experiences because they are irrational. This cultural data and this new movement that is coming out of Europe suggest that for some people, if you treat the voice like a person, then it behaves better.

My own suspicion is that if you put the voice into a social relationship, then the person who is hearing the voice finds that they have to experience that voice as a social relationship.

Dhar: Some of the biggest criticisms of mainstream psychiatry have come from prominent psychiatrists. From Robin Murray on schizophrenia to DSM-IV chair Allen Frances critiquing the diagnostic inflation in DSM-5. Your book Of Two Minds talks about psychiatrists’ training and how they are asked to make really difficult choices. Could you speak more about this training and how these difficulties eventually influence patient care?

Luhrmann: I was looking at psychiatry in the early and mid-nineties, and it was still a battlefield between the psychodynamic approach, where people see conflicting emotions causing symptoms, versus people who think about psychiatric illness is caused by something wrong in the brain that medication will fix.

I was struck that, for many psychiatrists, there is so little time, particularly these days. The pressure came from managed care, where there is a completely understandable concern to reduce the cost of medical care. Psychiatrists, in particular, sometimes have 15 minutes to spend with the patients. Then it becomes a symptom checklist, an examination, the medication, and how the medication is working — so the encounter with a patient becomes a kind of sorting exercise.

I was aware of this diagnostic nosology, a list of categories. Somebody once explained the DSM to me as a combination of the Bible and the telephone directory. The psychiatrists knew that these categories did not capture the experience of their patients, but at the same time, they were schooled in sorting patients — try this medication, that medication. It was just easy for the person to be lost. Even in mainstream medicine, we know that having a doctor who cares about you as a person is helpful to your care.

Dhar: This is what you have called the crisis of managed care that focuses on stabilization. I have heard from people working at psychiatric hospitals that there is a revolving door. You see the same patients over and over, you stabilize them, and lose faith in anything being a real treatment. You write about peer counselors and the challenges they can face. Peer counselors have expertise about a certain condition, like hearing voices, because they have experienced it first-hand and can provide great help to other people. But like you’ve written about John Hood, there can be complications and repercussions with that work. Could you tell us more?

Luhrmann: I was really struck by John. When I met him, he was the mental health person of the year in San Diego — everybody was proud of him. He was funny, bright, articulate, so well put together. He was serving as a peer counselor.

But because of the way that mental illness, and schizophrenia, in particular, are understood in America — something that produces brokenness and is the product of a broken brain — he had this incentive to drop out of the system and adopt the anti-psychiatry model that you should be artistically and rebelliously resisting ‘the man’ or the authority.

Then he became a peer counselor. Suddenly, in his experience, he was ‘the man.’ What really symbolized this for him was that he had keys. He had been hospitalized like umpteen times and hated being behind locked doors. Now he was given the keys to those doors, and it was a source of great pride, but it was also a source of great conflict.

He had also internalized that he was, by definition, not good. There was this quality that when he became a counselor, he was being asked to have a false self that was not his true self. That was really, really, hard for him.

He decided to go off medications, and many people around him wanted to attribute it to the pressure of being a peer counselor. Then he became homeless, and then he disappeared into the anonymous world of the homeless. I think it can be hard because, particularly in this culture, there is so much anger among persons who meet the criteria for schizophrenia in treatment centers in this country. There is a sense of being kicked out of the social world, and then entering back in becomes complicated.

Dhar: My last two questions are: how did you become interested in studying psychosis across cultures? And what is the most interesting and important thing happening in medical anthropology right now?

Luhrmann: I think that medical anthropology is newly aware of the importance of working with clinicians. There was a period of critical medical anthropology where our job was to criticize clinicians. Now there is more of an engagement in medical anthropology where people have a sense that their knowledge really has something to contribute.

Clinicians realize that anthropologists and people who study cultures and historical contexts of these experiences have something to contribute to the understanding of illnesses themselves.

I have always been interested in how things become real to people. I first became interested in religion, and my dad is a psychiatrist. So, I grew up with stories about people in different worlds, in different kinds of realnesses.

I grew up as Shabbos goy. My mother’s father was a Baptist pastor, and my cousins are very conservative Christians. My father’s father was a Christian Scientist. My father went to medical school (that doesn’t usually happen) and became a psychiatrist. So, it was really striking to me when I was young that there were people, these good people who had very different understandings of ultimate reality, and that was something we sort of bracketed. Then there were these other people who had experiences of ultimate reality, who were really very ill.

I lived in that soup thinking about the nature of human connection with the real. That has always driven me.

MIA Research News Team: Ayurdhi Dhar is assistant professor of psychology at Mount Mary University. She is the author of Madness and Subjectivity: A Cross-Cultural Examination of Psychosis in the West and India (to be released in September 2019). Her research interests include the relation between schizophrenia and immigration, discursive practices sustaining the concept of mental illness, and critiques of acontextual and ahistorical forms of knowledge.

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