As someone with a history of anxiety, I’ve long been intrigued by the complexities of the human mind. Why do some people seemingly cruise through life free of mental illness, while others can’t escape their demons?
Like most US Americans, I was told the answer is that mental illness strikes when there’s a chemical imbalance in the brain. I was also taught that psychiatric medication is the best treatment for this imbalance. It was only when I became a student of cultural anthropology that I discovered just how problematic these assumptions really are.
Anthropology helped me understand that mental illness is often shaped by culture, and that someone who is perceived as "mad" or "sick" in one culture might be seen as perfectly healthy in another. I learned that my own anxiety might be, in part, the product of an unstable and isolating society, not just my brain chemistry.
Rates of diagnosis seem to suggest that depression, anxiety, obsessive-compulsive disorder, bipolar disorder and other mental illnesses are more rampant and severe in the industrialised world, specifically in the United States. While these countries supposedly have the most advanced medical system, a bitter debate exists over western psychiatry’s fixation with medical labels and diagnoses.
Thomas Szasz, the father of the "antipsychiatry" movement, believed that western psychiatry has created a system where, instead of diagnosis following the illness, the diagnosis itself often creates a person’s mental illness.
For instance, it’s not uncommon for people treated under the western model to become chronically depressed only after they’ve been diagnosed with depression based on possibly arbitrary criteria such as "low mood", or potentially ordinary responses to trauma or the vicissitudes of everyday life.
In the western system, a diagnosis uniquely consumes one’s identity, radically transforming one’s self-perception and how one is perceived by others. Nowhere is this more true than with the one illness that psychiatrists have deemed the most unmanageable and debilitating of them all: schizophrenia.
The developing worlds of schizophrenia
In the west, the psychiatric profession has tended to adopt a particularly distinctive approach to schizophrenia. This makes the condition an ideal lens through which to explore different ways in which mental illness is understood around the world.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) – the bible of western psychiatry – schizophrenia is a "severe and chronic mental disorder characterised by disturbances in thought, perception and behaviour". The DSM-5’s list of symptoms includes auditory hallucinations (hearing voices), visual hallucinations, delusions, disorganised speech, disorganised or catatonic behaviour, and diminished emotional expression.
Strikingly, anthropologists have found that for those with schizophrenia, outcomes – in terms of rates of hospitalisation and homelessness, levels of distress and suicide, and overall wellbeing – tend to be substantially better in the developing world than in developed countries such as the US and the UK.
"No matter whether you look at symptoms, disability, clinical profile, or the ability to do productive work, roughly 50% more people do well after a diagnosis of schizophrenia in the developing world than they do in the developed world," says Tanya Luhrmann, Stanford anthropologist and co-author of the book Our Most Troubling Madness with Jocelyn Marrow.
Not only are the outcomes better – the entire experience of schizophrenia is vastly different across cultures. Which raises the vexing question: if mental illness is indeed rooted in biology, shouldn’t it have the same trajectory everywhere?
The dominance of a biological approach to mental illness is often traced back to the German psychiatrist Emil Kraepelin (1856-1926), who asserted that psychiatry is a branch of medical science. As psychologist Brett J Deacon observes: " the rapid and enthusiastic adoption of electroconvulsive therapy (ECT), lobotomy, and insulin coma therapy in the 1930s and 1940s encouraged hopes that mental disorders could be cured with somatic therapies".
The psychopharmacological revolution began in earnest in the 1950s. This was the decade, writes Deacon, which "witnessed the serendipitous discovery of compounds which reduced the symptoms of psychosis, depression, mania, anxiety, and hyperactivity". Theories of chemical imbalance to explain mental disorder emerged over the same period, "providing the scientific basis for psychiatric medications as possessing magic bullet qualities".
I wanted to investigate how exactly are westerners’ experiences of schizophrenia different? And why? I started by acquiring an understanding of how the symptoms or experiences of schizophrenia differ across the world.
The ‘voices’ of schizophrenia sound different across the world
People living with schizophrenia in the west often describe their experience as "nightmarish". Some are plagued by voices and visual hallucinations, which can taunt and terrify them. Other symptoms which surface in that context don’t appear elsewhere. In the US, delusions of grandeur are more widespread.
Not so in traditional villages in southeast Asia where, writes Ethan Watters, author of Crazy Like Us, "it is often frowned upon to strive wilfully for personal status, and delusions of grandeur are rare". In contrast, in the US – where celebrity, wealth, and power are popular fetishes – people with schizophrenia "commonly believe that they are famous or all-powerful".
Even symptoms that may appear universal – for example, hallucinations – manifest themselves differently according to the cultural zeitgeist.
Patients from Chennai and Accra often responded to voices, engaging in pleasant conversation with the positive ones and rebuffing the negative ones
For the US American schizophrenic activist Cecilia McGough, one of her most persistent hallucinations is of Pennywise, the horrifying clown from the movie It. An approximate contemporary in Tanzania, Hemed, whose father lived through Zanzibar’s pre-independence revolution in the 1960s, reported auditory hallucinations of the voices of local politicians.
Overall, voices tend more often to be considered a positive presence in Asia and Africa. Padmavati Ramachandran of the Schizophrenia Research Foundation in Chennai, India, has reviewed existing studies which found these voices are more benign for people with schizophrenia in India than for many patients in the United States: "Those in India are more likely to experience their voices as people they know or as gods."
In the course of Padmavati’s research with Luhrmann, they interviewed schizophrenic patients in Accra, Ghana, Chennai, and San Mateo, California. Here’s what they found:
- Symptoms reported by US Americans were the most severe, including violent and abusive voices telling them that they were "worthless" and deserved to die.
- Ghanaians tended more often to hear divine voices which they attributed to witches and spirits. Ghanaians who heard negative voices often reported that positive ones drowned them out, urging them to ignore the negative voices.
- Both Indians and Ghanaians frequently heard voices of relatives, friends, or acquaintances. Many of the voices were playful, and often even gave advice.
- Conversely, US Americans mostly reported hearing the voices of strangers, while none associated voice-hearing with positive experiences.
Another striking difference emerged among the voice-hearers. Patients from Chennai and Accra often responded to voices, engaging in pleasant conversation with the positive ones and rebuffing the negative ones. In the US, engaging with voices in this way is taboo – many US American psychiatrists view it as counter-productive, and likely to reinforce one’s illness.
US American voice-hearers internalised the notion that talking back to their voices would define them as "crazy". However, by completely ignoring their voices, it became more likely that patients felt afraid of them, which exacerbated their symptoms.
A deeper meaning than ‘madness’
In cultures where mental illness is pathologised, such as the US, people with schizophrenia are much more likely to identify with the diagnostic label. Patients will presume their condition is biological, permanent or incurable. When hearing voices isn’t inherently associated with being ill or "crazy", as Padmavati and Luhrmann found in India and Ghana, a broader array of interpretations – and diagnoses – becomes possible.
A common interpretation in both those countries is that hallucinations are caused by possession by spirits – both good and bad. According to medical anthropologist Anubha Sood: "Spirit possession may participate in the construction of a valued social identity in which voices and visions are signs of the divine and not solely associated with a permanent, crippling illness."
While this alternative interpretation may be preferable to the stigma or shame routinely attached to symptoms such as hearing voices, it can be problematic in other ways. Spiritual interpretations, for example, are sometimes imposed externally: voice-hearers may find themselves, involuntarily, treated as sources of spiritual insight (even when the voices hold no spiritual significance for them).
In parts of the global south, voice-hearers may be respected as spiritually gifted, although in many of those same cultures distinctions are made between "shamans" as spiritual leaders and people with schizophrenia. Most important: shamans are widely believed to actively and consciously will their own spiritual faculty, whereas schizophrenics are seen as lacking the ability to control their own mental state.
A religious element is rarely sought in westerners’ voice-hearing: in cases where westerners with schizophrenia claim to communicate with gods, they’re not taken seriously.
Learning to listen to the voices
In Providence, Rhode Island, Melissa Fundakowski runs a hearing voices group to offer participants a safe space where voice-hearing is not assumed to be pathological. Participants can openly discuss their experiences without stigma.
Fundakowski first heard voices on the night of 9 September 1991, when she was a child. That night, she was hospitalised, and subsequently diagnosed with a form of schizophrenia called schizoaffective disorder. In the following decades, Fundakowski was hospitalised periodically – in and out of group homes, and seen by various psychiatrists who prescribed Clozaril at high dosage. The medication failed to provide much relief, left her "foggy, dizzy, and tired", and made her muscles twitch so that it became almost impossible for her to play the piano.
When she reported hearing voices to psychiatrists, they often seemed "disgusted" and closed down any discussion by saying it was more productive not to talk about voices. That only made her symptoms worse, she told me when we spoke by phone. She described her experience as "hell".
That all changed four years ago, when Fundakowski joined a hearing voices group at Oasis Wellness and Recovery Center in Providence. Although some remain sceptical that hearing voices groups may dissuade people from seeking or taking medication, Fundakowski has found that discussion is not an either/or alternative to medication.
The group was her first experience in a truly supportive, non-judgmental voice-hearing community. The sense of purpose and fulfilment she gained from meetings gave her the strength to break her decades-long habit of self-harming. Fundakowski – like most other members of the group – still takes medication, but her dosage has been lowered to half its previous level.
An integrated response to schizophrenia: four remedies
As I compared approaches to schizophrenia across cultures, I began to recognise common themes. Here are four insights that explain why schizophrenia outcomes vary so widely, and how treatments could be enhanced accordingly.
Family and community are antidotes to individual suffering in western society
In highly industrialised cultures, adults are expected to be self-sufficient, both financially and emotionally. Western society tends to shame people who depend for support on their community or family, often conflating economic disadvantage with personal failure. This toxic form of individualism causes anxiety and isolation, compounded by inadequate support for people with mental illness.
“The most obvious difference in the care of persons with serious psychotic disorder in India, compared to the United States, is that in India people stay with their family and their family remains involved with their care,” says anthropologist Jocelyn Marrow. Family and community support are essential for recovery. After diagnosis, people living with schizophrenia in the US frequently return to socially isolated lives. Some may become homeless, or move through a cycle of institutional care and mental hospitals which may compound their distress.
Social isolation in itself exacerbates schizophrenia’s symptoms. Despite the real challenges in caring for a loved one with schizophrenia, greater emphasis on the role of family and community in western cultures would help reduce rates of homelessness and suicide among people with schizophrenia.
Stigma can be reduced if symptoms are less pathologised
The stigma of mental illness is a significant source of trauma. People who experience trauma and abuse are also more likely to develop schizophrenia and less likely to recover from it. One way to mitigate the intense stigma of schizophrenia is to place less emphasis on diagnostic labels.
In India, some psychiatrists apply an approach known as "diagnostic neutrality", which de-emphasises the pathological aspects of diagnosis. This approach may avoid the term "schizophrenia" altogether in discussion with patients or their families, even after symptoms of schizophrenia have been identified.
Diagnostic neutrality reduces the scope for damaging interpretations by families of a relative’s mental illness, reducing the burdens of stigma and negative stereotypes.
Diagnosis and homelessness in the US can be decoupled
Estimates suggest that around 20% of homeless US Americans have schizophrenia. Living on the street without basic necessities or comforts makes psychosis, paranoia, and delusions more acute – and recovery nearly impossible. Access to housing is a key factor in improving care for people with schizophrenia. In many instances, people with schizophrenia seeking accommodation are required to submit proof of diagnosis as well as abstinence from alcohol and drugs. Helping people off the streets by reducing red tape and the stress of bureaucratic hurdles would break the cycle of homelessness.
Recognise cultural limits in the western paradigm for treatment
Western psychiatrists are often quick to prescribe medication and slow to consider other treatment options. Alternative approaches to living with schizophrenia deserve wider recognition. Hearing voices groups are a promising alternative. Controlled studies have tested this approach and found groups can be effective in diminishing voice-hearing.
"The Hearing Voices Network claims that it is possible to improve a person’s relationship with their voices by teaching them to name, respect, and interact with the voices," writes Marrow in Our Most Troubling Madness, "and that doing so can make the voices less punitive and less mean – sometimes with the eventual result that the voices go away for good."
Everything I learned as I researched this article fascinated me, but more than that, it liberated me from some insidious assumptions – that my anxiety is an immutable "defect" that I was born with, that I need psychiatric treatment to make me "normal", and that my mental health exists in a vacuum, unaffected by the culture I happen to live in.
It reminded me that none of us are truly autonomous, that our suffering is interconnected, and that community support truly is the best antidote. So perhaps instead of incessantly worrying about my individual achievements and failures, I’d be better off devoting that energy to my own community.