Anthropological Perspectives on Schizophrenia: How Cultural Narrative Affects Prevalence, Course, and Outcome

Western medical literature classifies schizophrenia (SZ) as a mental illness characterized by significant changes in thought processes and speech. Symptoms include delusions, such as false beliefs of control or persecution; hallucinations, such as hearing voices, having visions, or feeling bizarre physical sensations; reduced emotional intensity, flat affect, or catatonia; inappropriate social responses, such as spontaneous laughter or shouting; and sometimes, disturbances in motor behavior, such as repeated, aimless movement patterns.[1] According to the World Health Organization (WHO), hallucinations and false beliefs of control or persecution are the most frequently observed symptoms, found in about 70 percent of patients.[2]

SZ typically presents during late adolescence or early adulthood, between the ages of 16 and 30, yet earlier and later ages of onset are frequently noted. [3] Due to variable diagnostic models and lack of clinical data from developing nations, it is estimated that people with SZ represent as few as .46 percent and as many as 1 percent[4] of the global population, which is currently approximated at 7.4 billion people.[5] These point estimates translate into ~34,000,000 to ~76,000,000 people experiencing SZ at any given time. The highest incidence figures come from the United States; central and northern Europe, particularly among racially disadvantaged Afro-Caribbean communities in the U.K. [6]; and from marginalized populations within industrialized worlds, such as indigenous groups in Canada and Australia. It has been suggested that social disruption caused by the exposure to western lifestyles may increase risk in these groups.[7]

Developed vs. Developing Nations

While SZ is found all over the world, in both developed and developing nations, there are drastic differences in severity, course, and recovery outcomes depending on geographic region. A large body of research shows a more benign course and better outcomes in developing countries and a worse course/outcomes in industrialized nations.[8] A WHO 10-country study showed that the percentage of cases with full remission after a single “psychotic” episode ranged between 3 percent in the U.S., an industrialized nation, and 54 percent in India, a developing nation.[9]

The WHO believes that more favorable outcomes (in developing nations) are due to a combination of factors, such as greater tolerance of illness, more availability of suitable jobs, and better support from kinship groups and communities.[10] These findings have led anthropologists and medical professionals to focus their research on elucidating the many cultural factors that contribute to better outcomes in developing nations.

Anthropological Study of People With Schizophrenia

A large body of research shows that environment and level of social stigma surrounding mental illness play significant roles in both illness course and outcome.[11] Stigma is defined as, “a set of deeply discrediting attributes, related to negative attitudes and beliefs towards a group of people, likely to affect a person’s identity and thus leading to a damaged sense of self through social rejection, discrimination, and social isolation.”[12]

Level of societal stigma is rooted in cultural narratives, which help societies organize experiences so that they are recognizable, thus projecting past experiences into imagined futures. Cultural narratives and stigma exist in three realms: the larger community (generalized stigma), within mental health services (its own culture, which fosters segregation, dependency, and powerlessness), and as internalized negative self-perceptions held by people with SZ. Cultural narratives are particularly impactful for how medical professionals approach SZ because the narratives outline, “what story they [the doctors] are in, what they are likely to encounter, and what the resolution should look like.”[13]

Medical anthropologists and cultural psychiatrists research cultural narratives by investigating a person’s subjective experiences while gaining additional feedback from kinship groups and/or medical care teams. Anthropologists have found that cultural narratives dramatically impact how individuals, families, and communities support people with SZ, thus influencing the person’s ability to navigate the illness’ onset, make sense of their experience, and whether or not the person goes on to live a meaningful life and feel valued within society.

For example, Stanford anthropologist, Tanya Luhrmann, recently found that voice-hearing experiences of people with SZ are largely shaped by cultural context and that people with SZ in different cultures have different voice-hearing experiences. For this study, Luhrmann and her colleagues interviewed 60 adults diagnosed with SZ: 20 in San Mateo, California; 20 in Accra, Ghana; and 20 in Chennai, India. While all the study participants heard similar voices, many of the African and Indian subjects reported predominantly positive experiences, yet not one American did. The research team discovered notable differences between the study participants’ perception of voices, dependent on region.

Participants in San Mateo, California, were more likely to report their voices as violent, scary, and hateful. They were also less likely to develop personal relationships with their voices. Most of the Americans used clinical terms to describe themselves as “sick,” and 17 of the 20 participants self-identified as “schizophrenic.” This group was much more likely to attribute their voices to being little more than symptoms of a brain disease caused by genes or trauma, which accurately reflects the western biomedical model of SZ diagnosis and treatment.[14]

Participants in Chennai, India, were more likely to describe positive experiences with their voices, and many of them heard the voices of family members or deities. Overall, this group believed their voices to be more helpful, talking as relatives do; offering guidance and giving beneficial commands, such as reminders to complete domestic tasks. Overall, the Indian participants were more likely to associate the voices with social relationships and entertainment. Only four of the sample (of 20) said that the voices commanded them to do harm, and only four used the diagnostic term, “schizophrenia,” to describe their condition.[15]

Participants in Accra, Ghana, mostly spoke about the positive aspects of hearing voices, and 16 of the sample (of 20) said they heard God or another divinity speaking to them. Their culture accepts that there are “human-like, non-embodied spirits that can talk,”[16] which researchers believed, led participants to take on a more relaxed perception of their voices. Even when the voices were “bad,” people described being able to maintain a social relationship with them. Furthermore, only two of the 20 used the term, “schizophrenia” when describing their condition.[17]

What is behind these differences in experience? Psychological anthropological studies consistently find that European and American cultures place more emphasis on self-identity, whereas outside the west, people “imagine mind and self as interwoven with others and defined through relationships.[18] The participants in Africa and India were better able to interpret their voices as relationships with the spirit world, rather than as the sign of a violated or “sick” mind, as the Americans did.

Differences in Cultural Narratives and Treatment of SZ: Developed vs. Developing Nations

In the west, where cultural emphasis is placed on self-sufficiency and capitalistic values, severe SZ makes it increasingly difficult—if not impossible—to survive without direct financial support from family and/or government assistance programs. As result, many people with SZ wind up isolated, worse off in their conditions, homeless, and/or incarcerated. SZ becomes an identity, rather than a temporary condition. Societal struggles are further compounded by social stigma, which exists (in part) due to the strict biomedical model of mental healthcare, lack of public health education, and limited access to affordable and effective care for those who suffer.

The media also plays a role in pushing negative cultural perceptions. From fictional crime shows to emotion-evoking pharmaceutical advertisements, western culture is bombarded with images that associate SZ with violence and danger, often sensationalized for profit. The truth is: In the west, people with severe mental illness are 11 times more likely to be the victims of violent crime than to perpetrate it. And, the greatest risk of harm is to oneself rather than another.[19] For example, people with SZ are 12 times more likely to complete suicide than the rest of the population.[20]

Social stigma and negative sense of self is perpetrated not only by western individualistic cultural values, but also how SZ is diagnosed and treated. Western doctors aggressively pursue explanations as to the biological causes of SZ. It is a commonly held belief that the condition is little more than a set of pathological “chemical imbalances” that can be corrected with pharmacological interventions. Antipsychotic medications are the go-to treatments of the west, often used in combinations (polypharmacy).

Poor compliance with SZ medication is common due to high prices and negative side effects. Medication adjuncts such as psychosocial support and personal case management are sometimes implemented as well. Regardless of the modality, western interventions primarily focus on symptom reduction.[21] In the west, science has disregarded spirit and those experiencing SZ are rarely encouraged to “make peace” with their voices, let alone develop relationships with them. American clinicians tend to “treat the voices heard by people with psychosis as if they are the uninteresting byproducts of disease which should be ignored.”[22]

Western clinicians hold firm to the belief that SZ is a disease like any other; that those with SZ have a “brain disease” due to biological aberrations or genetics. On the surface, this viewpoint seems helpful, as if it removes causal blame from the person with SZ. However, this industrialized cultural narrative may unintentionally change SZ experiences and outcomes for the worse.

Does the Biomedical Narrative Increase Compassion and Improve Self-Esteem?

Psychology professor, Sheila Mehta, conducted a Milgram-like experiment (involving electric shock), to test whether the “brain disease” narrative increased compassion. She found that it did not and that people who were given the label of “brain disease” were treated more harshly by their peers. Reflecting on the study results, she told The New York Times Magazine:

The problem, it appears, is that the biomedical narrative about an illness like schizophrenia carries with it the subtle assumption that a brain made ill through biomedical or genetic abnormalities is more thoroughly broken and permanently abnormal than one made ill though life events. Viewing those with mental disorders as diseased sets them apart and may lead to our perceiving them as physically distinct. Biochemical aberrations make them almost a different species.[23]

The western agenda of biomedical “mental health literacy” is being pushed on the rest of the world as well. The “disease model” has spread through globalization, affecting layperson perceptions as well as medical training in developing nations. While research shows that stigmatizing attitudes have reduced in developing nations such as Pakistan, Nigeria, and Sri Lanka, physicians who adopted the biomedical model in Nigeria thought of people with SZ as more dangerous and unpredictable and wanted less contact with them.[24] It is clear that cultural narratives shape the experience and depth of suffering of those with SZ. Instead of a condition that can be navigated with the support of community, SZ often becomes a new identity—one with very little value or purpose in society. There are, however, western physicians who are encouraging cultural paradigm shifts in regards to the value and purpose of SZ symptoms.

Schizophrenia as a Gift

Joseph Polimeni, a cultural psychiatrist and author of Shamans Among Us, studies the commonalities between the western biomedical model of SZ symptoms and the traits of traditional shamans throughout time, dating back tens of thousands of years. He believes that traditional shamans are/were people with SZ “symptoms” that were given purpose by their kinship group and thus, were able to hone their innate skills to benefit society.

Dr. Polimeni believes that shamanistic behaviors are “spontaneous reflexes” that initially emerged to help hunter and gatherer societies solve complex evolutionary problems. As we understand, humans naturally produce task specialists, or “roles that seem to be written in the genes.”[25] Polimeni says that shamanism represents a form of task specialization in egalitarian, small-scale cultures that “helped ancient tribal societies outmaneuver other competing tribes.”[26]

By studying old anthropological literature, he found that regardless of geographic location, shamans were/are given similar designations, such as medicine man, diviner, sorcerer, witch doctor, magician, exorcist, or medium. The commonality between these roles is the ability to serve as a conduit to the spiritual world beyond the observable realm. He believes that SZ symptoms and shamanism are intrinsically bound, and he advocates the cultural importance of people who experience hallucinations and delusions. In a video connected to his book, he says:

Shamans were considered the religious leaders of their communities and would involve themselves with specific tribal activities. For example, they would lead rituals involving rites of passage, such as birth, coming of age, marriage and death. They also endeavored to heal the sick. Shamans often lead divining rituals, which focused on the tribe’s procurement of food and water, such as rain dances or predicting the movements of animals of prey. Shamans were also routinely consulted about matters of war. It should be noted that most shamans were probably not grossly psychotic and some may have never been psychotic at all. However, in most traditional societies, those persons who were overcome by hallucinations in young adulthood were more often than not destined to become shamans.[27]

There is evidence of spiritual purpose for people with SZ symptoms throughout time and in cultures all over the world. For example, The State Oracle of Tibet, or Nechung kuten, is a spirit medium who is dedicated to protecting the health and safety of the Dalai Lama. The kuten also helps make political decisions and predicts future harvest conditions, weather, and events.[28] Thupten Ngodup, the current kuten, recalled an SZ-like experience just before being identified as the (14th) State Oracle to serve the Dalai Lama:

In the period before I was possessed at the Nêchung Monastery, in March, 1987, I became seriously ill, felt unusual emotions, exhibited odd behaviors. I did things that were out of character for me, but I could not control myself. Then, while on pilgrimage to Bodhgaya [the site where Buddha Shakyamuni attained enlightenment, in Bihar, in eastern India] I started bleeding from the mouth and nose. Doctors were unable to stop the flow of blood, which continued for two days. My colleagues feared for my life. During this time of great difficulty, I lost consciousness and had repeated vivid visions of Nêchung.[29]

Upon return to the Nechung Monastary in Dharamsala, Ngodup was “seized” by the Nechung god as the monks were reciting texts. He remembered, “losing motor functions, seeing a bright flash of light, and falling into unconsciousness.”[30] After this experience, Thebten Ngodup began specialized ritual training with mentors to ripen and stabilize his abilities. He was later appointed head lama at the monastery and given the high position of Deputy Minister in the Tibetan government in exile, a role with great responsibility and prestige.[31] Instead of being shunned, Ngodup was looked up to and nurtured, for he had special gifts to contribute.

The Importance of Cultural Acceptance in SZ Outcomes

Developing nations may experience better outcomes in SZ recovery because these groups help people make sense of symptoms by applying a meaningful narrative while keeping the person bound to the kinship group vs. isolated. Anthropologist Juli McGruder witnessed this first-hand as she studied families of schizophrenics in Zanzibar.

McGruder found that although the population is primarily Muslim, the people still believe in traditional Swahili spirit-possession, which is used to explain the actions of anyone behaving outside of social norms. Communities in Zanzibar keep the ill person safe and secure within the kinship group, rather than isolating them. In this culture, the entire community rallies around the person, offering small acts of kindness—song, dance, food, and gifts—to coax the spirit from the body. This type of treatment helps the person feel valued throughout the course of their illness, allowing them to recover and return to their societal responsibilities faster. Perhaps most importantly, McGruder believes that because the illness is viewed as caused by outside forces, the person was not as likely to take on the symptoms as “their identity.”[32]

Conclusion

While the biomedical model of the west satisfies scientific curiosity, it leaves much to be desired in terms of cultural and spiritual support for people living with SZ. Human beings have lived in small, egalitarian groups for many thousands of years. Guidance and reassurance from the spirit world has helped navigate human experience for equally as long. Unfortunately, modern medicine and western psychiatry—as institutions—do not fully utilize the power of spirituality and community when addressing patients’ physical health and emotional wellness; thus affecting cultural narratives and perhaps public policy as well. An ongoing point of research, stemming from this inquiry, should include evidence of “the placebo effect,” which measures the power of human will, intention, and belief, to certain degrees.

 

Footnotes

[1]. Angelo Barbato, “Schizophrenia and Public Health.” (World Health Organization), 4.

[2]. Ibid., 4.

[3]. “Schizophrenia.” (National Institute of Mental Health), 1.

[4]. Dinesh Bhugra, “The Global Prevalence of Schizophrenia.” (PLoS Medicine 2, no. 5), 0372.

[5]. “U.S. and World Population Clock,” (Population Clock by Census.gov), single page.

[6]. Angelo Barbato. “Schizophrenia and Public Health.” (World Health Organization), 6.

[7]. Ibid., 7.

[8]. Ibid., 8.

[9]. Ibid., 8.

[10]. Ibid., 8.

[11]. Ibid., 8.

[12]. Angelo Barbato, “Schizophrenia and Public Health.” (World Health Organization, 1998), 13.

[13]. Andrew R. Hatala, James B. Waldram, and Tomas Caal. “Narrative Structures of Maya Mental Disorders.” (Culture, Medicine, and Psychiatry 39, no. 3, 2015), 452.

[14]. Tanya Luhrmann, et. al, “Differences in Voice-hearing Experiences of People with Psychosis in the USA, India and Ghana: Interview-based Study.” (The British Journal of Psychiatry 206, no. 1, 2014), 2.

[15]. Ibid., 2.

[16] Ibid., 3

[17] Ibid., 3

[18] Stanford University. “Stanford Researcher: Hallucinatory ‘voices’ Shaped by Local Culture. (Stanford News. July 16, 2014), accessed online, included interviews with the researchers, 3.

[19]. R.J. Frances. “Crime Victimization in Adults With Severe Mental Illness: Comparison With the National Crime Victimization Survey.” (Yearbook of Psychiatry and Applied Mental Health, 2007), 1.

[20]. Angelo Barbato, “Schizophrenia and Public Health.” (World Health Organization), 12.

[21]. “Schizophrenia.” (National Institute of Mental Health), single page.

[22]. Stanford University. “Stanford Researcher: Hallucinatory ‘voices’ Shaped by Local Culture. (Stanford News. July 16, 2014), accessed online, included interviews with the researchers.

[23]. Ethan Watters, “The Americanization of Mental Illness.” (The New York Times. January 09, 2010), 4.

[24]. Jajadisha Thirthalli, et. al, “Stigma and Disability in Schizophrenia: Developing Countries’ Perspective,” (International Review of Psychiatry 24, no. 5, 2012), Table 3, 428.

[25]. Shamanism and the Evolutionary Origins of Schizophrenia. Performed by Dr. Joseph Polimeni. (YouTube), a video-summarization of his book, which was not accessible.

[26]. Ibid., 16:50 to 18:00.

[27]. Ibid., 19:05 to 21:14.

[28]. Homayun Sidky. “The State Oracle of Tibet, Spirit Possession, and Shamanism. (Numen 58, no. 1, 2011), 81.

[29]. Ibid., 84.

[30]. Ibid., 84.

[31]. Ibid., 84.

[32]. Juli H. McGruder, “Madness in Zanzibar: An Exploration of Lived Experience.” (Schizophrenia, Culture, and Subjectivity), 275.

Bibliography

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University, Stanford. “Stanford Researcher: Hallucinatory ‘voices’ Shaped by Local Culture.” Stanford News. July 16, 2014. Accessed November 27, 2017. https://news.stanford.edu/2014/07/16/voices-culture-luhrmann-071614/.

“U.S. and World Population Clock Tell Us What You Think.” Population Clock by Census.gov. Accessed November 26, 2017. https://www.census.gov/popclock/.

Watters, Ethan. “The Americanization of Mental Illness.” The New York Times. January 09, 2010. Accessed November 26, 2017. http://www.nytimes.com/2010/01/10/magazine/10psyche-t.html.

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