Culture and Psychosis


[Dr. Lauren Fordyce] Hi everyone, thanks for
joining us to today. My name is Lauren Fordyce. I’m an American Association for the Advancement
of Science Technology Policy Fellow in the Office of Behavioral and Social Science Research.
This is our monthly OBSSR Lecture Series. This month we’re actually doing a webinar
so please excuse our figuring things out. Today, we’re going to be joined by Dr. Tanya
Luhrmann who is the Watkins University professor in the Anthropology Department at Stanford
University. Dr. Luhrmann studied social anthropology at Cambridge University, and her most recent
book was entitled “When God Talks Back: Understanding the Evangelical Relationship with God.” She’s
also a continuing opinion-writer for the New York Times. Her most recent work is a project
funded by the National Institute of Mental Health which examines how life on the streets,
both chronically or periodically homeless, contributes to the experience and morbidity
of schizophrenia. Today she is going to talk about culture and psychosis. And I just wanted
to let you know that we will be collecting questions through the chat box. We’re going
to be muting everyone so you can’t ask questions over the vocal part. We’ll mute everyone.
Then if you can type in questions in the chat box, we will ask her some of the questions
at the end. So, I’m going to mute myself so Dr. Lurmann can begin. Thanks.
[Dr. Tanya Luhrmann] Hi well it’s a pleasure to be here. Thank you for joining us. This
is the first…whoops….sorry [had a moment of technical difficulty]. Here we go. This
is the first in a series of illustrations of psychosis by people with psychosis. I’m
going to talk today on the role of culture in psychosis, and I’m going to talk about
two issues. First, the culture within the world of persons with psychosis, and second,
the role of culture in shaping the symptoms of psychosis. So, let me begin with the first,
let’s talk about the first. I began with a practical problem which is that people who
can be diagnosed with serious psychotic disorder often refuse the help that is offered to them
by mental health providers. So, they’ll refuse housing. They’ll refuse medication.
They’ll come to the mental health service center to use the telephone but refuse to
talk to somebody. And this apparent willingness to sabotage care can be extremely frustrating
to care providers, and it seems to contribute to this fundamentally nomadic life in which
people move between supported housing and jail and hospital and the street. Kim Hopper
talks about this as the “institutional circuit.” So, the clinician’s temptation is to say
that people who could become, who become homeless when they could get housing are suffering
from a lack of insight. My work suggests that the story is more complicated, that the refusals
are not only from a lack of insight, but that they’re cultural expressions. That they
are communications to actors within a particular social world and that they have meaning within
the shared culture of the street. So, the method in my field is participant observation
or ethnography. It involves spending a lot of time in the world that you’re seeking
to understand, and what you’re trying to do to some limited extent, and of course this
is impossible, is trying to kind of go native, to use that term, in this world. Trying to
figure out what it would take to be a member of this community. I think that this method
is kind of the best method to understand culture which I take to be these complex more or less
shared, often partially articulated cognitive schemas that people use to understand their
daily life and to communicate to others. So, the basic question of my work in this
domain was, is there a culture on the street? And in particular, in those portions of the
street where the people who live these nomadic lives can be found. This is the street corner
at the center of my work [referring to photo projected] in uptown in Chicago. And I should
say that I did this work about 10 years ago stretched over a 3 or 4 year period. The neighborhood
has changed I think. I now live in California. I believe that the kinds of patterns that
I see may resonate with other communities, like the one that I’m going to describe,
around the country. My students and I did about 1000 hours of participant observation.
I did much of the field work, but, this is one of my field subjects that I’m pictured
with. I was joined by five students who did terrific work, and I had them do kind of an
afternoon of work in the neighborhood for about once a week for 20 weeks. Then I had
them do more structured interviews. And all of them had at least limited clinical training.
I trained them in the use of the SKID, and they had taken some courses on psychiatric
diagnosis and mental illness. We worked in what’s commonly described as
a “service ghetto.” So, this is a neighborhood in Chicago, often described as uptown, often
said to have the largest density of persons with serious psychotic disorder in the entire
state of Illinois outside of the jails. There are about 60 service agencies, a variety of
sorts, in this neighborhood. It’s kind of a cool area. It’s a mixture of gracious
mansions and tree-lined streets and urban squalor. It was built as the theater district
in the 1920s, and traces of that era still remain in this beautiful architecture that
you still see around. There are old theaters, and there’s a swing-dance lounge once frequented
by Al Capone and his men. This is a neighborhood that’s filled with big, old hotels. They
were built for the entertainers, and they began to empty out in the ‘40s when the
entertainment business left to go out West or downtown. And uptown was then the last
stop on the train to go down to the loop, and the hotels began to be filled by these
white collar workers. Around the ‘50s and ‘60s, they fled to the suburbs, and the
hotels emptied out. The architecture decayed, and this was just in time for deinstitutionalization.
So, as patients were released into the streets, they tended to end up in these large hotels.
This became a scandal in the ‘70s. There were suicides, people, some people leapt out
of the windows. The hotels were in terrible shape. The city’s response was to pour more
money into maintaining the hotels but basically left the patient population, or the ex-patient
population, where it was. And certainly at the time when I was visiting, the place was
packed with halfway houses and drop in centers and addiction treatment centers and missionary
outreach settings, state services, food pantries, and supported housing. So these are these
old hotels. When I was there you could stand on this street corner and see a thousand psychiatric
beds. So, the basic aim of our research was to understand
the refusal of services. Many people would wander around this area and eat and sleep
in the shelters but refuse care. So we based our work in a drop in center in the middle
of the neighborhood. And basically, this is a drop in center that required no diagnostic
label to entry. It was for women only. As long as you were a woman, you could come in,
have a meal, use the shower, kind of hang out, talk to people. What we did was to do
primarily participant observation. So, I would hang out in Sarah’s Circle and I would go
to the local coffee shops and spend time in the park and spend time in the shelter. We
also had the students do a formal representative sample of 60 subjects in our, in the drop
in center. And at the end of the process, I sent a student back to do follow up interviews
with women I hadn’t met to evaluate kind of the inferences that I was drawing from
the field work. So let me share with you some of the data.
So, what we found from the formal subjects was that indeed these were women in the institutional
circuit. 40% of them had been homeless for more than 6 months. Over 55% had a history
of psychiatric hospitalization. Over 55% had a history of arrest. 43% of them were currently
living in shelters and 29% in single room hotels, in sets of rows in these big hotels.
11% were sleeping on the street or in a local shelters, well no actually sleeping on the
street. About a third of them were white, 45% African American. 28% said spontaneously
that they had a diagnosis of schizophrenia or bipolar disorder, but in a formal sample,
you could infer from 78% a history of psychosis either by looking at what they said or looking
at their disability status or from the way that they comported themselves in the interview.
So many, many people in this drop in center and indeed in the neighborhood were evidently
psychotic. So, this is the first in a series of portraits
of women at the drop in center done by a different graduate student. The first thing to say is
we really saw people refusing services. It was not uncommon to see a woman walk into
the drop in center and say publically, vocally in a way that was kind of theatrically present
for other people in the room, that she wasn’t crazy. “I’m not going to go to the Sommerset
House. That’s for crazy people.” People were very clear that you could get housing
if you were crazy. People would say things like this, and these quotations I should say
don’t match the portraits. They were said by women that I spent time with. “You can
get housing if you’re crazy, addicted, or you got a job.” It was pretty well-know
that if you had a psychiatric diagnosis that you could get housing.
What I inferred as a result of this work is that the word “crazy” had a meaning on
the street, or in this institutional circuit, that it did not have in the middle class world,
at the university, and really service providers. And what I thought the word meant, I thought
it had 3 features. It evoked a kind of or at least when people were using the word,
it was consistent with these 3 features. That there was a social cause. People would say
that the street will drive you crazy that being on the street was sufficient to make
somebody psychotic. That the condition was permanent. It’s something that can’t be
fixed. And that not everybody on the street would become crazy. People would talk about
“she’s crazy now because you gave up,” that people became crazy because they were
weak or because they gave up. Let me give you a feel for the way that people through some of these quotations. Sometimes people
would say, they would point to someone with flagrant psychosis, and they would kind of
twirl their finger around their heads to indicate someone was crazy and say “she’s been
on the street too long.” For permanence, being crazy is something you absolutely cannot
control, and a lot of them don’t even take medication. They have retardation, and there’s
nothing you can do about it. Alcoholism you can do something about. You can stop drinking.
You can do those things and reverse your situation, but somebody who appears mentally ill can’t
do that. And again, many of these women struggle with psychosis themselves. They’re talking
about other people, and of course, psychosis is a continuum. In a neighborhood like this,
there’s always somebody who’s more flagrantly ill than you are. Only the weak fall ill.
“There’s a couple of girls come up here that talk to themselves. That’s because
they let the streets take over them…a lot of women have been raped by the men here and
[those girls] just can’t deal with it, so that just made them go haywire.” Only those
who give up get sick. “The street will drive you to the brink of–it goes back to being
mentally strong…I’m not going to let that happen to me. It happens because there are
women in the shelter, when they gave up.” In the follow up interviews, we asked 21 whether,
what other women in the neighborhood meant by the word “crazy,” and 5 of them gave
answers that were recognizable in the psychiatric idiom. But fully 16 of the 21 women gave answers
that were, gave us their own opinion, a kind of dynamic model of psychosis in which the
social experience of being on the street caused psychosis in those who were weak or gave up.
The richness and redundancy of these comments suggest that this kind of cognitive schema,
this cultural model is easily accessible in this social world. And so in this setting
when women say that they’re not crazy, they mean that they’re not weak, and they have
not been defeated. So, this is stigmatizing, but it’s also important to recognize that
it comes out of a particular social world. This is a world in which violence is common.
All the follow up interviews spontaneously mentioned violence. A third of them spontaneously
mentioned domestic violence or childhood sexual assault. The staff said that somebody came
in beaten up once a week or more often. I thought I often saw the signs of violence
on women’s bodies. So the women adopt a kind of aggressive style to get other people
to back down. There was a freely verbalized kind of need for aggression. “If you’re
going to survive, you have to smack somebody down.” This was also a profoundly isolated
world. A world without a lot of perceived social support.
So, these are our focal interviews. Of these 60 women, over 40% of them said that they
didn’t feel connected to the women at Sarah’s Circle, which is the name of this drop in
center. Two thirds of them couldn’t name a single person that they regarded as a friend.
When asked to describe their day, 40% reported no face-to-face interactions. This is quite
stunning because these are people who are with other people all the time. They’re
often sleeping in rooms with 15 other women. They’re on the street, they’re standing
in lines to get their food, they’re sitting in Sarah’s Circle for 5 hours. There’s
a lot of face-to-face interaction. 40% of them reported none of it. When we asked them
who they could turn to, 30% said no one. Meanwhile there’s a kind of tension between
the toughness required of being on the street and the compliance required to get care. So,
service centers, shelters often have long lists of rules. One of the shelters in the
neighborhood actually asks women to recite the rules out loud before they go to sleep.
So you’re there late in the evening, and the rules are things like “don’t wash
below your neck at the sink.” And all these women are able to recite it together, this
long list of rules. Michael Hartman is asking for access to my
shared applications. Do I approve this or decline it? I’m going to decline it.
[Technician] Decline it. Don’t share anything that you have. They have all the access they
need. [Dr. Luhrmann] Okay. Excellent. Alright. So,
we’re back to the shelter, and I would say that the women themselves verbally articulate
the conflict between the code of the street, the code of “street people” they sometimes
call it, and the code of, what they would call, “decent people.” And that tension,
managing that tension contributes to the importance of what they would call “being strong.”
So, this is somebody that said to me “If [homelessness] ever happens to them they better
have a strong heart and a strong mind because when they see everything they’re gonna need
a strong heart and a strong mind. If you’re not strong hearted you can’t take it out
here.” So strong had a set of meanings. One of them was just being tough. Being strong
is like “I ain’t getting hurt.” It was also about inner toughness. “One time I
got raped, and I had nowhere to go. I had to get right back on the street and make some
money so I could have a room for the night. I couldn’t call the police. I called my
mom in Minneapolis, I said Momma, I’m gonna do something I don’t want to do, she said
what’s that, I said prostitution, she said, God bless you, be careful. I’ll pray for
you. That’s what my momma told me. A few minutes later I had to wash up, so I washed
up and I had to get right back out there and make some money. That’s part of being strong
too.” So, these twin themes of physical and mental
toughness run throughout the interviews. The other clear meaning to being strong is that,
if you’re strong, you’re not crazy. “I didn’t think anything was wrong with his
head because he was a strong man. I just thought he was this strong many, that that wouldn’t
ever happen to him, you know, he would never be crazy, he would never be actually crazy
because he was a strong minded person, strongminded man, strong, so it wouldn’t happen to him.
But I was wrong because it did.” What she’s describing is an afternoon back at her house,
when she had a house in Texas when her husband came into the room, sat down on the sofa and
said “honey I love you,” pulled out a revolver and shot his brains out. So what
these women infer is that in order to survive, you’ve got to be strong and not weak. Assume
nobody wants to be crazy. People don’t always refuse services, but
there is this powerful, cultural interpretation that says that if you admit to being crazy,
you’re saying that you’re weak and you’re vulnerable and you can be attacked. If you
say you are not crazy, you’re asserting that you’re tough, and you’re strong,
and you’re going to survive to get off the street. And it’s important to note that
these are plausible inferences to draw from a social setting. Again, there’s always
somebody in these settings who is flagrantly psychotic and more crazy than the person who
is talking about being crazy. And they are right. They are surviving in way that the
other person is not. Paradoxically, what it means to be crazy in
this setting comes to mean being beyond help which is exactly the opposite of what most
treatment providers and mental health workers would mean to imply. So, this has treatment
implications. The implications are that, at least in these settings, you should avoid
diagnosis talk with clients. You should avoid requiring clients to engage in diagnosis talk
in order to receive services. Examples of programs that I think are effective are these
Housing First programs in which often supported housing asks people to participate in an explicit
diagnosis. There’s a stepwise progression so that you only get guaranteed housing when
you agree to participate in psychiatric care and give up your substances. Housing First
just gives people housing, and there have been recent randomized controlled trials that
suggest that people stay housed for longer and are behaviorally more effective. And this
work would suggest some reasons why that might be true.
One way of using ethnography is to look at the way people understand, interpret and understand
illness. Another way is to ask whether the illness experience is shaped by culture. This
is a man praying for somebody that’s in uptown [referring to the projected picture].
I want to now move on to the second part of my talk rather more quickly than I thought
that I’d be moving on. In the background here is the relationship between illness and
disease. With disease, when anthropologists use this contrast, we’re thinking of disease
as the organic malfunction, and illness as the experience of the disease. What I want
to suggest is that culture can shape the way people pay attention to their symptoms and
change the experience of the symptoms themselves. So, now I want to present a study that I did
with colleagues among persons with psychosis who hear voices. This is an interview-driven
study with 20 adults in San Mateo, California, Accra, Ghana, and Chennai, India, and everybody,
all the subjects meet criteria for schizophrenia, schizoaffective disorder. They’re all voice
hearers. They’re all recruited through psychiatric hospital care. So everyone around them knows
that they’re ill. I don’t want to suggest that I’m telling a romantic story here.
I’m going to give evidence that the voice hearing experience may be somewhat more benign
in Ghana and India, at least with this sample. But I want to be really clear that schizophrenia
is a struggle no matter where you are. Everybody in this sample recognizes that they have a
problem and is perceived by other people to have a problem as well.
Let me just say as a background, folks in San Mateo and Chennai were pretty similar.
They’d both been 20 years into the hell of their diagnosis for many, many years, and
they were all either in supported housing or they were in day treatment if they lived
with their families. The subjects in Ghana were a little less—they were in a hospital.
They were in-patients, and so they were a little younger and they were a little more
ill. Many, many of those patients had been in a hospital for a long time. They had many
visits to the hospital. And I should say that we took as much care as we could to make sure
that we were not, that we were getting as representative of a description as we could.
So, I did all the interviews in San Mateo. I’ve now talked to another, with this entry,
I’ve now talked to another 40 people in the United States. I did the initial set of
20 interviews in Accra with a Ghanaian research assistant. I then sent her in without me,
and she did another 19 interviews. And we’ve talked to another 30 people in Accra. My Tumal-speaking
colleagues did the first interviews in Chennai. I came back, talked to 5 of their subjects,
talked then to another 20 subjects and we’ve since then talked to another 30 or 40 subjects.
So I feel reasonably confident of the data that we are reporting.
This is what the interview was about. Interviews took roughly 30 to 60 minutes, and we asked
about what people heard, what they saw, what their experience was. We wanted to know whether
they knew the person whose disembodied voice they could hear, whether they knew in the
flesh the voice that they were hearing. We asked about their experience of control over
the voices, what was most distressing, whether they’d had any positive experiences, whether
they’d ever heard God speaking. We talked to them about whether other people could hear
these voices when they spoke and what would cause the experience. And I’ll only talk
about a few features of these experiences today.
So this is a caricature, and I emphasize this is a caricature of the differences that we
saw. That Americans hear horrible voices telling them that they are worthless and should die.
That Africans hear an audible God who tells them to ignore evil voices, and that South
Asians hear annoying relatives who tell them to get dressed and clean up. And I should
say that we presented these findings to a group of South Asian psychiatrists, and their
experience was that, the psychiatrists said, “my goodness what is wrong with those Americans.”
Ok so let me share in more detail what we actually found in the interviews.
Americans are very comfortable with diagnostic labels. They say things like “I fit the
textbook on schizophrenia,” “That’s just their job, to give us labels and then
give us medication,” “I have schizophrenia from my grandfather. It’s a hereditary illness
of the brain,” “They know I’m a schizophrenic.” And so 17 out of the 20 spontaneously described
themselves as diagnosed with schizophrenia. Every person used diagnostic labels. Many
of them were comfortable with the idea of the symptom checklist. I was actually doing
sort of this psychosis SKID to confirm the diagnosis because we didn’t have access
to their records. And people would say things like “Ugh yeah I’ve done all of those.
Don’t worry about.” This is my favorite comment “I went into the hospital with a
little depression, and I must have caught all that other stuff on the way out.” To
Americans, hearing a voice means that you’re crazy. That is the predominant meaning, is
something people said again and again. “I didn’t tell them I’m hearing voices. I
was afraid I might be called crazy,” “You tell people out there that you have voices,
they treat you differently.” I would say “Do you talk about hearing voices to your
family?” [they would answer] “No…we’re not supposed to have mental illness.” I
should say with these slides, these are all different people, comments from different
people. In American, the voices are often unknown.
Only 3 people reported knowing, in the flesh, the people whose disembodied voice that they
heard. In American, the voices are often violent. This is quite striking. “Usually it’s
like torturing people to take somebody’s eye out with a fork, or cut someone’s head
and drink their blood, really nasty stuff,” “They want to take me to war with them,”
“You’re gonna die,” “You’re going to hell,” “My suicide voice,” “Why
don’t you end your life.” Not one American said that their dominant voice hearing experience
was positive. I’ve since talked to Americans who have said that, but I would say much more
representative is the comment from somebody I was talking to in the San Francisco General
Hospital a couple weeks ago who said “Positive voices? I’m sure I’ve had them. I just
don’t pay attention to them.” Americans, when I spoke to them, wanted to dwell on the
difficult, hard voices. Accra. This is a world in which hearing voices
does not mean that you are crazy. This is a world with a highly salient idea of, about
witchcraft. In which, even if you don’t believe in witchcraft, you know that there
are other people in your social world who believe that there are, who believe some people
can have negative thoughts, and those thoughts and feelings that can go out into the world
and hurt somebody’s body. There’s this highly salient idea that people are in a war
between good and evil. And the idea of spiritual attack is an experience of that war. And so,
people, that’s how we would actually ask about the voice hearing experience. We’d
start asking about the spiritual attach and move on to hearing voices. Among this world
or group of 20 people, there were more known voices than in the American sample, a nurse,
a boyfriend, a husband’s brother, a manager, relatives, neighbors, mother, siblings, boss.
But what was really striking about this sample was that half, fully half the sample, so that
means that half the sample did not report this, but half the sample insisted that their
predominant experience or only experience was positive, and mostly it was the Christian
God. In one or 2 cases, it was a non-Christian spirit. People would say things like, “Mostly
the voices are good,” “They just tell me to do the right thing. If I hadn’t had
these voices I would have been dead long ago,” “That’s what has kept me alive til now,
the voices, the voice of God I hear.” It was actually pretty difficult to get people
to feel comfortable talking to me about negative voice hearing experience. It would often take
a little while into the interview. Some people just refused. People would say sometimes that
God told them not to pay attention to these experiences. Sometimes I would have to, I
would say, if somebody was insisting that only their experiences, their experiences
were only good and then I would say “Well if you walk across the unit, do you find that
a lot of people are muttering mean things to you?” [they would reply] “Ah yes. God
tells me not to pay attention.” So, that was a striking feature of the way that people
wanted to talk to me about their voice hearing experience.
Here’s an example. This is a woman whose experience was that she was cursed and raped
by the people she stayed with. She began to see this snake that sort of hissed at her
[hissing noises] hissed at her and tormented her, gave her command hallucinations. She
was sort of in league with this merwoman who’s this folkloric [unintelligible] type figure
and went on for months. Then this angel shows up, slices off the heads of the snake and
merwoman. Now this woman tells me that she only hears angels. They stand in the corner
of her room. They fight with each other. They can be kind of noisy but they’re angels
and they’re good. She likes having them around. There’s a quality in these interviews
where it really felt there was more of a quality of a relationship with the voices even if
they, well in these two cases, people knew in the flesh whose voices they were hearing.
In one case, there’s a woman who developed this very elaborate relationship with her
boss. He gave her good advice, talked to her a lot. She had a constant, ongoing relationship
with him. She was very happy with it. In this other case, a woman heard her husband’s
brother and also her manager, and they would say these contradictory things [such as] “I
love you,” “I want to kill you” which she insisted on describing these experiences
as conversations. She referred to them as people, and she spoke about them as if they
were relationships, not as assaults which is a much more common quality, I thought,
in the American transcripts, in the American interviews.
Chennai. Over half the sample hears kin. Some don’t. Some hear God. Some hear distressing,
negative voices without content, but over half the sample heard kin and most of the
kin they knew in person. Some people heard dead relatives, but typically they had, typically
they also heard living relatives or relatives who they had known. Kin did what kin do. They
command a patient to do domestic tasks, to go into the kitchen to prepare food. They
also insist on good behavior. They tell people not to smoke, not to drink. That can be very
annoying, but people would acknowledge that this was kind of good advice. At least 8 people
had positive voices. So, they would hear relatives, ancestors, famous people. People would say
things like “I like my mother’s voice,” “Voices, yes, I like it. It will keep talking
which is enjoyable,” “I have derived happiness by thinking about him.” I was struck by
this. Many, many people talked about sex and masturbation, and for at least 8 of the 20,
it was a major theme. So, the voice would say out loud, “You’re a thug. You’re
a goonda if you have masturbation.” Some would get onto a bus, and they would hear
somebody saying, that they were telling everybody that he was masturbating. A woman said that
she heard a “Male voice, very vulgar, words and raw. I would cry…All vulgar words.”
It seemed to me, or at least the invitation here, is to say that the Chennai voices were
not devoid of violence, but the violence was such a striking theme in the American voice
hearing experience. It seemed to me that the negative experiences in Chennai were more
likely to be shaming somebody sexually in public. That was the experience of hearing
these voices. One of the qualities in the Chennai voices
that I didn’t see in the Accra voices or the American voices was a kind of playfulness
where people were enjoying this as a kind of ongoing story or a film or an opportunity
to hear the latest gossip. The example I present here is a woman who heard Hanuman who is the
avatar who is represented as a monkey. And when she first heard Hanuman, he would give
terrible commands like to drink out of a toilet bowl, and now she has, plays with him. He
has, Hanuman has a child avatar and an adult and she kind of spends a lot of time with
a baby Hanuman. She pinches his bottom. They throw streamers at each other. She is very
clear that her illness is a problem and wishes she did not have this problem. But when she
sits on the bus to come to the day treatment hospital, the staff say that she is talking
out loud, probably with Hanuman, and she seems to be having a great time.
Why these differences? What I want to do is play you about 45 seconds of a track by Pat
Deacon. And this is, of course, we think that voice hearing is variable. People have a lot
of different experiences, but people are very different from each other. But I think that
we know that people may have more varied experience than they report. So, Pat Deacon and her colleagues
made this track to represent the voice hearing experience. She herself hears voices. It’s
about 45 seconds. [plays recording with various noises and voices, largely saying unintelligible
things] Ok. So, the reason to play that is to illustrate that there may be a very, a
broad array of phenomena that other people are experiencing. Good voices, bad voices,
commands, probably inside experiences and outside experiences, thought-like experiences
and more auditory experiences, probably a wash of auditory and quasi-auditory stuff.
And I think that there’s a process of selective attention that may shape the way people attend
to these experiences and habituate their voice hearing patterns. I think that particularly
there are theories about mind and self which direct the way people pay attention. In some
broad sense, you could say that in South Asia and Africa compared to the United States really
privilege more interdependent social worlds. Americans value the sense of being different,
being individuals. That is less socially salient outside of the United States, and I would
say that in other parts of the world the supernatural is more socially available. All of the Americans
I was speaking to, or almost all of them were religious, but they didn’t particularly
talk about God speaking to them whereas the supernatural is more kind of salient as an
interpretation of these experiences outside of the United States. In fact if you look
at the ethnographic literature, you would see striking differences in the ways that
people represent mental action and mental events. I think that you could argue that
in the United States, the mind is, the culture invites you to imagine the mind as a thing
that’s private. Nobody else comes into your mind, that your thoughts are really important,
but that they’re not real. They’re fundamentally different than the material world. And I think
that the experience of a mind being broken or that thoughts being, somehow, someone’s
thoughts being outside the mind is deeply distressing to folks in America. In Ghana,
again there’s this idea of witchcraft and even if you yourself as a Ghanaian don’t
believe in witchcraft, there’s this highly salient invitation to understand that some
people think that some people have thoughts that can leave the mind and affect the world
in a bad way. I think this may be playing a role and this intense hesitancy to acknowledge
negative experiences and attend to the positive experiences.
In India, the ethnographic records are very clear that there’s this highly elaborated
idea of the mind as a social process, that individuals make each other up. In fact, one
scholar describes not as individuals but DE-viduals, that somehow, that the substance, that you
use each other’s substance to make who it is that you are. It’s also this invitation
to see the mind has a spiritual part and human part, and somehow the mind connects to the
spiritual world directly. I think the process that I see, I would call
kindling. So, this is a phrase that comes out of psychiatry. Kraepelin was the first
to observe that people who became depressed probably needed less of a body blow in life
to become depressed a second time. In think that in effect the depressive response becomes
kindled, that people have a habituated response to stress that becomes depression. In the
psychiatric literature, what you see is that there’s this deep–cultural invitations
shape the way symptoms are expressed so that when people are depressed, typically they
feel sad, and their body also hurts. One of the things that Arthur Kleinman pointed out
was that in China, well so in the United States, it’s perfectly acceptable to go to a doctor
with sadness as a presenting problem and to use sadness to generate care from other people
and to stay home from work. That was unacceptable in China before the 1980s, particularly agricultural
workers, what legitimized care, what motivated care, justified staying home from work, took
you to a psychiatrist, was bodily illness. And Kleinman was able to demonstrate that
people who presented with a diagnosis of neurasthenia, which really tended to describe the attenuated
nerves and headaches and problems with the body, could also be diagnosed as depression
in that part of the world. I want to suggest that what we’re seeing
in psychosis is a story of cultural kindling, that there are, what you might call, “affordances”
of the psychotic mind. June Gibson uses the word “affordances” to describe the things
that the world affords us to see, that we don’t always see and attend to. I think
that there are many different kinds of experiences, quasi-auditory experiences that people encounter
during psychosis and that practices of selective attention shaped by the mind, shaped by local
ideas about the mind, alter how those experiences are identified and may shape the way that
they’re experienced and may become a habituated interpretation of the experience.
I wanted to take, I’m going to take 3 minutes and just say a little bit about the evangelical,
charismatic Christians who are not psychotic but to give you a sense of how powerful this
American sensibility about disliking voices in the mind, or voices from the mind, in the
world can be. This is a world in which God is a person and He’s mighty, He’s beyond.
This is a theology where people expect God to talk back in their mind. So, when you come
to a church like this, you’re invited to experience the mind, not as private, but that
thoughts, images, and sensations you might have understood as self-generated are actually
God speaking. Here’s an example, somebody’s explaining, she says “When people were praying
over me and I’m just receiving it [meaning the prayer] and all of a sudden I hear ‘go
to Kansas’” which is where her parents live “because I was debating whether to
go to Kansas, but I hadn’t been thinking about it within a 24 hour period. It makes
you want to say ‘where did that come from?’” Recently I’ve been comparing charismatic,
Christian churches in the Bay Area but also in Chennai and Accra, quite similar churches
in many ways. They aspire to be modern and to teach people to be modern, and they share
a similar theology that God will speak back in their mind. And I’ve been struck by the
difference in the way that Americans talk about this experience. They are very clear,
even in a church where they are meant to experience God in the mind, they repeatedly talk about
this as weird and crazy. “This is crazy, but I’m getting an image of something,”
“You don’t need to call the white coats for me,” “It blew my mind,” “You know
‘those people are tripping’ you might say,” “You’d go ‘she’s crazy.’”
They talk, they do what I call a double epistemological register. They will have a thought, and they
will be ambivalent about whether this thought is from God or whether it’s just a thought,
you’re not quite sure. It’s kind of unreliable. You don’t find either of those 2 features
in the way the Chennai congregants, the way the Chennai congregants talk about their experience.
There’s something really striking in this sharp, clear sense of a mind as a mind with
unreliable thoughts in which voices in the mind, or even a little outside of the mind,
mean that you’re crazy. So I think that reinforces the sense that there really is
something different about the American experience. Why do we care about this? I think I have
3 more slides. Why do we care about this? Well, we know that the course of schizophrenia
is more benign elsewhere. The best data come from India. We know that the harshness of
voices contributes to poor outcome. I that this kind of work suggests that there are
treatment implications. That I think it suggests that the voice content may respond to learning,
and I think many American mental health providers tend to imagine voices as irrational. You
shouldn’t attend to them. You shouldn’t encourage people to pay attention to their
voices. There are a series of new treatments that invite people to engage with their voices,
respond to their voices, think about their voices, talk about their voices. They’re
very different kinds of treatments, but they all share an emphasis in acknowledging voice
meaning and respecting and engaging with the voices. I think this work invites us to take
these new treatments seriously and explore them as important tools to use with people
with psychosis. In conclusion, let me just say that culture
matters in psychosis–it can shape the social context of lived experience. It can shape
symptom content. It may have treatment implications both in the way that we offer help to people
and in the way that we manage voice hearing. That ethnography and qualitative methods are
useful. I would be remiss not to draw your attention to a forthcoming book that should
come out in September in which I and a colleague put together a series of case studies in schizophrenia.
And we talk about cultural variation in schizophrenia experience and what inferences we can draw
from it. So, I’ll end there. Thank you. [Fordyce] Thanks Dr. Luhrmann. That was great.
We have a couple questions that have come up over the chat box. Someone wanted to know
if you know of any available data regarding the Hispanic population and their understanding
of the psychotic mind. [Luhrmann] No, I think, a little bit. What
is his name…Steve. There is a psychologist at UCLA whose first name is Steve who has
done work on schizophrenia in the Hispanic community. Also, Janis Jenkins, an anthropologist
at UCSD. I’m not, my memory is that these experiences are often assimilated to nerviosa
and to experiences of anxiety. Steve Lopez, that’s the person. Thank you.
[Fordyce] Someone else just reiterated that it was Steve Lopez. Another questions is,
do you have any thoughts on how multiple personality disorder comes into play with all of your
research? [Luhrmann] Great question. I think one of
the big scientific questions that still reverberates around the domain of psychosis is the relationship
between psychosis and disassociation. And there’s some people, like Richard Bentall,
who are very committed, in the hearing voices movement, to the idea that all voice hearing
is in fact a dissociative experience. And they would support that with the observation
that trauma is closely associated with psychosis. The more people report that they’ve been
beaten up by life in a variety of ways, are more likely to report, more likely to develop
psychosis. I tend to differ. I think that the kinds of phenomena that you see in a religious
setting where people are reporting hearing God’s voice and sometimes auditorily hearing
God’s voice, I think that those are experiences that are connected to dissociation. And I
think that it’s a difference, a different phenomenon for many people who are psychotic
and voice hearing. So there’s a big difference between the clinical population and the non-clinical
population who have these auditory experiences. But I also believe that, within the clinical
population, there is a, you know, how can I defend this? I think there’s a different
feel to many of the phenomena that seem more dissociative and many of the phenomena that
seem more psychotic. We’re doing some work now to see if we can tease apart the patterns
of these symptoms and the ways that people phenomenologically describe them. At the same
time, it’s pretty darn clear that even if it’s a bodily difference between a psychotic
process and a dissociative process which is at the heart of multiple personality disorder.
A lot of people live in the grey area, and many people who meet criteria for psychosis
might also meet criteria for multiple personality disorder or for dissociative identity disorder.
And sometimes I’m talking to somebody who’s been diagnosed with schizophrenia, and their
experience just feels more dissociative than the experience of other people. There’s
more richness. There’s more of a, kind of a, whole narrative frame for the experience.
So, I don’t know, it’s a big question. [Fordyce] Another sort of question building
on your first question is if you could address the ethnic, racial makeup of the American
sample you interviewed and whether you think that had any effect on what you thought and
their comments to you. [Luhrmann] I can’t retrieve the exact figures
right now. I would say that, this is a blunt impression, and I don’t think I could publish
this yet, but I would say, really based more on my recent interviews at San Francisco General
Hospital and also based on my time in uptown, I think that African Americans may be more
comfortable with the symptoms and more uncomfortable with diagnosis, in my completely anecdotal
experience. The people who reported to me, the Americans that reported to me recently
that they had a positive experience with their voice hearing were all African American.
[Fordyce] Ok we have one more question that’s been submitted. What do you think of the concept
of expressed emotion? Is it useful? [Luhrmann] Yes. I think that there is evidence
that it is quite useful. I think there’s also evidence that it is culturally variable
and that, we can’t really know, that there’s, that it’s the meaning of the way that people
express distress rather than, the people who are around the person with schizophrenia,
the meaning of their criticism rather than the criticism itself that is costly. Janis
Jenkins, again, has written about this. One of my students, Joanne Eliason, makes the
argument that pops up in this book of case studies in schizophrenia. So, Joanne Eliason
went off to study the African-Caribbean community in London which, as you may know, has a, the
risk of schizophrenia may run as high as 15 times as high as in the local white population.
And many people have been curious about why that is the case. One of the things that Joanne
Eliason pointed out is that people in this community are often pretty isolated, and she
felt that in general she uses the concept of community expressed emotion to describe
the high levels of anger and distress in the community directed at many members in the
community which she takes to signal their discomfort in living in that social world.
And which she thought contributed to the risk of schizophrenia.
[Fordyce] Thank you so much Dr. Luhrmann. We’re going to end this now. For those of
you who joined us part way through, the recording will be on our website once it’s been made
compliant for all ADA needs. So, you guys can go back and watch anything that you missed.
So I just want to thank you so much for all of you for joining us, and thanks again Dr.
Luhrman for your fascinating talk today. [Luhrmann]. Thank you. It was a pleasure.
[Fordyce] Thanks so much, and you can just turn off your camera when you’re done.

Author: Kennedi Daugherty

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