Talking to imaginary people only you can see and hear is a hallmark manifestation of schizophrenia, but schizophrenia can manifest through a large range of symptoms. The only common underlying theme seems to be an inability to distinguish between your own thoughts and the outside reality. However, studies show that even the relationship schizophrenic patients have with the thoughts inside their heads may not be universal and may depend on the country they’re from and their cultural background. 

How cultural background and values shape schizophrenic auditory hallucinations

Schizophrenia is a serious, long-term medical condition that affects the mind, so it’s not surprising that the cultural and social environment influences how the condition manifests for different people. Everyone has unique experiences with this life-shaping disease. For example, some hear vague whispers and murmurs, while others hear clear, distinct voices that interfere with their thoughts and daily activities.

Although schizophrenia has been studied for a long time, neither scientists, nor doctors have paid much attention to the impact of culture on this condition. 

Things changed starting in 2014 when a group of scientists at Stanford University studied the role of culture in shaping auditory hallucinations. They discovered that people from different countries and cultural backgrounds experience schizophrenia differently. Those who grew up in more religious environments are more likely to associate hearing voices with spiritual encounters, while those from highly developed countries are more likely to recognize they have a medical problem. 

Their study reveals that almost all patients hear both good and bad voices, but the voices heard by American patients are mostly negative and threatening, while Indian and African patients reported more positive experiences with their hallucinations. Researchers recruited 60 subjects, 20 from each setting (San Mateo, Accra, and Chennai) who were diagnosed with schizophrenia and interviewed them to compare their relationship with their hallucinations. American patients revealed they are told to do awful things, but they don’t recognize who the voices belonged to. 

“Why don’t you end your life, why don’t you stab yourself”, “jump in front of the train”, are just some examples shared by American patients.

In contrast, people from India and Africa are able to identify the voices they hear by pinning names and even faces to these voices. The Indian patients could recognize the auditory hallucinations as relatives (parents, grandparents, spouses) who, most of the time, give them useful advice and guidance, such as ‘brush your teeth’, ‘drink coffee’, and so on. Although they typically enjoy having conversations with their voices, people from Chennai admitted they want “peace of mind”. African patients, on the other hand, are more likely to believe they hear God, angels or other spiritual entities with a powerful presence; some people even said that these voices saved their lives. 

“They just tell me to do the right thing. If I hadn’t had these voices, I would have been dead long ago,” said one of the patients.  

In addition to good, helpful voices, some African patients hear demonic whispers or folklore monsters, but the supposed angels and divine figures tell them not to listen to the evil voices. 

The difference between hearing ‘good’ or ‘bad’ voices

All these opposing perceptions of voices are the results of different cultural settings. Americans value their independence and free will, so they consider hallucinations an invasion of their privacy, which makes them feel trapped in their own minds. In India, people tend to be more family-oriented, so their hallucinations resemble their relatives. In Africa, people generally have a close relationship with divinity and consequently they believe they are having spiritual encounters whenever they hear voices. What’s worse, they don’t even realize they have a medical condition; only two of the 20 African subjects knew they had schizophrenia, one of whom had been diagnosed in the UK. At the opposite pole were the American patients who didn’t hesitate to recognize they have a medical condition. 

Another study found that auditory hallucinations manifest differently not only for people from other countries, but also from other times. The authors of the article compared the voices heard by people admitted to an East Texas hospital in the 1930s with those of patients admitted to the same hospital in the 1980s. Their analysis shows that in the 1930s the suggestions given by the voices were religious and gentle (“live right”, “lean on the Lord”), while in the 1980s patients heard negative comments demanding them to kill themselves or their loved ones. 

The reason for this change is the social and cultural evolution of a community over time. The same study found that in the 1930s the hallucinations indicated a desire for material goods due to the Great Depression, while hallucinations in the 1980s were shaped by the new technological era. 

Hearing voices is not the only culturally shaped manifestation of schizophrenia. Delusions have also been proven to be strongly influenced by individuals’ internal and external circumstances.  Delusions are beliefs based on mistaken or unrealistic views. People with delusions find alternative explanations for everyday events or personal experiences. For example, some of them believe they are being watched or followed, while others may think there are hidden messages in the television programs.  

While Europeans are prone to experience negative delusions – about sins, poisoning, guilt – Japanese patients, who have a “shame culture”, are likely to have delusions about “being slandered”.  Another study found that Westerners tend to have delusions about thought insertion and removal, which basically means they believe someone is altering their thinking without their will. These delusions may be rooted in Westerners’ desire for autonomy and individualism. African people tend to be more religious, so it’s not surprising that their delusions are associated with the fear of magical punishment. 

Having this medical condition is a huge problem for patients, but also for their families and friends. The way people respond and act around schizophrenic individuals also depends on their culture, education, and way of thinking. Euro-American families have a critical and hostile attitude toward their relatives suffering from schizophrenia. This is why American patients tend to avoid telling people about their mental health problems so they don’t seem ‘crazy’. However, not all people respond in the same way. Mexican-American patients, for example, are more tolerant and sympathetic to their family members who exhibit hallucinations and delusions. 

Schizophrenia is not the same everywhere, growing up in different settings can affect auditory hallucinations. Understanding the role of culture in this condition is important for patients, but also for professionals, who could learn to adapt their treatments to increase their effectiveness.