Tuesday, March 5, 2013
The second CMBC lunch of Spring 2013 was a bit unusual in that it featured only one speaker. Tanya Luhrmann (Anthropology, Stanford University), known for her work on modern-day witches, evangelical Christians, and psychiatrists, shared some of the findings of her recent research on the auditory hallucinations of schizophrenics. Her guiding question was: does the experience of hearing voices shift across cultural boundaries?
The presentation began with an audio clip designed to approximate the experience of someone hearing distressing voices. The eerie clip consisted of a background of ambiguous murmurs and whispers which resolved into discernible words and phrases, such as “Don’t touch me”; “Stop it”; “I came for you.” A majority of schizophrenic people hear voices, but is the experience the same across cultures?
To answer this question, Luhrmann conducted a comparative study of three groups of twenty schizophrenic people from three culturally distinct places: San Mateo, California; Accra, Ghana; and Chennai, India. Results were drawn from participants’ responses to standardized questions about the nature of their auditory hallucinations. Participants were asked questions like: How many voices do you hear? How real are the voices? Do you recognize the voices? Do you have control over the voices? What causes the voices? And so on. On the basis of these interviews, Luhrmann identified some clear differences in the experience of auditory hallucinations across cultures, which she described in her presentation.
Americans with schizophrenia, in general, explained Luhrmann, see themselves as suffering from mental illness, are comfortable with identification as “schizophrenic,” and have a sophisticated understanding of diagnostic criteria. The voices they hear are most often violent, making commands like “cut off their head,” or “drink their blood.” Positive experiences of the voices are only seldom reported. The voices tend to be unknown, unwelcome, and most American participants reported little interaction with them.
The study suggested that Ghanaians, for their part, rarely talk about hearing voices in terms of schizophrenia, but rather tend to give voices a spiritual interpretation. Many Ghanaians were reluctant to talk about their mean voices, which they often regard in demonic terms, because another voice, identified as that of God, warned them against paying any attention to them. Luhrmann noted that compared to Americans, Ghanaians exhibited a more interactive relationship with their voices, and in about half the cases, considered their voices to be positive.
Finally, in the case of the Indian participants, two distinctive features stood out. Firstly, the voices were more often identified as those of kin than was the case with Americans and Ghanaians; and, secondly, the voices, whether they were identified as good or bad, often consisted in mundane practical injunctions, such as not to smoke or drink or to eat this or that food. In these cases Luhrmann noted even more interaction, which often took the form of a playful relationship with the voices. Luhrmann described the relationship that one woman had with the voice of the Indian god, Hanuman. The voice initially would tell her to do despicable things like to drink out of a toilet bowl, but eventually the relationship became such that she would have parties with Hanuman, they would play games together, and she would tickle his bottom. Luhrmann added that the voices the Indian participants heard would more often talk about sex than in the other cases.
Having outlined some striking differences in the auditory hallucinations of schizophrenics across cultures, Luhrmann went on to speculate about the reasons for the differences. Her central proposal highlighted differences in local theory of mind. At some point between the ages of 3 and 5, children come to learn that others’ behavior can be explained in terms of what they understand. When children come to learn in this way that other people have minds, developmental psychologists say they have developed a “theory of mind.” Luhrmann explained that while theory of mind per se is universal, there are cultural variations in how mind is understood. In the case of Americans, Luhrmann suggested, there is a sense that the mind is a place, and that it is private. The experience of foreign voices is consequently viewed as intrusive and unwelcome. In Accra, by contrast, according to Luhrmann, the boundaries between mind and world are seen as more porous. Many Ghanaians believe that thoughts can hurt people whether they are intended to do so or not – a belief consistent with the prevalence of witchcraft in Ghanaian culture, and with the emphasis on keeping thoughts clean, for example, in prayer. Luhrmann explained how this view of the mind as porous is seen in Chennai as well, where it is commonly believed that seniors should know what juniors should be thinking.
In closing, Luhrmann reflected on the significance of her findings, singling out two upshots in particular. First, before Luhrmann’s work, most psychiatrists had not considered that auditory hallucinations might differ significantly across cultures. The second, and perhaps more consequential, contribution concerns the treatment of schizophrenic patients. Luhrmann mentioned some pioneering clinicians in Europe who argue that the auditory hallucinations of schizophrenics could be rendered less distressing if patients were taught to interact with their voices. In Chennai, in general, schizophrenia has a more benign course than it does, say, in the United States. There are a number of possible explanations for this, including the fact that patients generally remain with their families, and that there is little stress on the diagnosis of mental illness. But part of the explanation could well be the interactive relationship with voices that Luhrmann’s research found to be a feature of Indian schizophrenic experience. If so, then Luhrmann’s work provides support for the European theory and points the way to an effective form of treatment. Let it be clear that even if people report a positive experience of voices, schizophrenia is usually still an unpleasant affliction.
As a philosopher, I find the notion that interacting with hallucinatory voices may be palliative and, hence, encouraged by psychiatrists rather curious. I say “as a philosopher” because philosophers have tended to hold some variation on “the truth sets you free” theme. Spinoza, for example, thought that when we understand the causes of our afflictions, they afflict us less, because they are more in our power. To encourage interaction with hallucinatory voices seems, at least, tantamount to encouraging a form of magical thinking. If Chennaians can have positive experiences of voices and their schizophrenia is more benign as a result, then there may well be reason to fear that any “cure” might be worse than the disease. It is not so clear that Americans, however, could so easily strike up the kind of interactive relationship with their voices that Chennaians maintain, if, as Luhrmann contended, Americans’ view of their voices is tied to a more fundamental theory of mind, which might be both difficult and undesirable to uproot.
The reason I imagine it might be difficult is the same as the reason it might be undesirable: alternative theories of mind might simply be false, or at least inferiorqua theories. Even if there is much about the mind we do not know, surely there is something true about the belief that thoughts are only in our heads; and surely the notion that the mind is not something that can influence the external world on its own is not equally tenable as the notion that thoughts by themselves can cause harm to other people. Perhaps Americans with schizophrenia could come to interact with their voices in the same way that a parent might play along with their child’s personification of a stuffed animal. And perhaps such a playful comportment would be palliative. But then the difference is not in theory of mind, since, presumably, parents do not change their conception of how minds work when they play make-believe with their children; rather, the change is in the attitude adopted. Would pretending that the voices are real, i.e., play-personifying them, suffice to render their presence sufferable, even a positive experience? Or does such an interactive comportment with the voices only truly work if it is rooted in a theory of mind whereby such pretense is unnecessary?
There is some prima facie reason to think that merely pretending that the voices are real so as to facilitate a more interactive relationship might actually help. Even though it would not constitute or effectuate Spinoza’s prescription to understand the causes of an affliction, it might still bring about the desired result of bringing the affliction more within one’s own power. Treating the voices as objects of play would subject the voices to rules of one’s own making, and this element of control might mitigate the distress of hearing voices.