Dancers perform on stage as the English National Ballet rehearse 'Coppelia' at the Coliseum on July 22, 2014 in London, England. Photo: Ian Gavan/Getty Images
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Hearing disembodied voices as violent or helpful depends on culture, study finds

A Stanford study has found that those who hallucinate voices are influenced by the culture they live in, with differences in mood and tone depending upon where in the world they live.

Ethan Watters's 2010 book Crazy Like Us: The Globalization of the American Psyche details how mental health conditions around the world have changed thanks to globalisation. What the American medical establishment understood as the model of an illness, its causes and even its symptoms, became how it was experienced elsewhere.

For example, Sing Lee, a psychiatrist in Hong Kong, spent much of the late 1980s and early 1990s studying anorexia. His patients did not deliberately avoid eating - in fact, “they complained most frequently of having bloated stomachs”. Then, in 1994, a teenage girl collapsed and died in the middle of a busy street, and the local papers reported her anorexia with language straight from American medical dictionaries:

Western ideas did not simply obscure the understanding of anorexia in Hong Kong; they also may have changed the expression of the illness itself. As the general public and the region’s mental-health professionals came to understand the American diagnosis of anorexia, the presentation of the illness in Lee’s patient population appeared to transform into the more virulent American standard. Lee once saw two or three anorexic patients a year; by the end of the 1990s he was seeing that many new cases each month. … By 2007 about 90 percent of the anorexics Lee treated reported fat phobia. New patients appeared to be increasingly conforming their experience of anorexia to the Western version of the disease.”

While cultural conditioning is an easily acceptable notion, the idea that our mental health is similarly conditioned can feel a little strange. This is because it belies our understanding of illness, especially mental illness - with modern medicine, we’re accustomed to thinking of the human body as a machine, and treatment for disease as akin to the physical repair of a worn-out mechanism. Our inability to completely model a human brain means we’re also groping in the dark when it comes to modelling mental health as only a physiological phenomenon.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders is the most infamous example of this problem - in theory, the definitive catalogue of mental health, and the standard reference for any psychiatric diagnosis. In practice, it conflates everyday personality traits with disorders, relying on changeable mood to decide whether those traits are bad or not. In response to the publication of the most recent edition, DSM-V, the British Psychological Society issued a statement criticising its premise:

The putative diagnoses presented in DSM-V are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements, with little confirmatory physical 'signs' or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations. Many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity."

The manual also “misses the relational context of problems and the undeniable social causation of many such problems”. (This was best skewered by Sam Kriss, who reviewed DSM-V as if it’s a Borgesian dictionary of the dystopian, written by an anonymous author intent on dehumanising its subjects.)

It’s within this context that we should welcome a study, led by anthropologist Tanya Luhrmann of Stanford University, which has found that the nature of aural hallucinations change relative to the local culture of the person experiencing them. Americans who hear disembodied voices are more likely to report them as violent, or “bombardment”; Indian and Ghanian participants more often reported the voices they heard were “playful” or even “entertaining”.

All of the participants in the study had been diagnosed as schizophrenic, with 20 each from San Mateo in California, Accra in Ghana and Chennai in India. All participants, from all three locations, reported both positive and negative experiences with hallucinated voice - yet while the Ghanaians and Indians reported predominantly positive experiences, the Americans all said their experiences were mostly negative.

Crucially, too, Americans perceived their hallucinations as symptomatic of a deeper disease, whether innate or because of a traumatic experience - while 11 of the Indian participants described their voices as deceased relatives giving advice or commands, and 16 of the Ghanaians reported hearing the voice of God.

The voices were treated as a “magic”, “playful” or “entertaining” more often than not, and only some participants saw them as manifestations of a mental illness; the Americans, in contrast, heard voices describing violent imagery, “torturing people” or a “bombardment”, an “assault”, or even a “call to war”. “[The] harsh, violent voices so common in the West may not be an inevitable feature of schizophrenia,” Luhrmann said in a statement.

The study, published in the British Journal of Psychiatry, It gives extra weight to criticisms of mental illness which don’t take account of external, social factors - and to the influence of a model of mental health on the manifestation of an illness. Luhrmann said: “The difference seems to be that the Chennai and Accra participants were more comfortable interpreting their voices as relationships and not as the sign of a violated mind.” As the interpretations didn't seem to correlate with either religious belief or urbanisation, she suspects the underlying cause for this is that Americans were less community-minded than the others. This is speculation, and requires further investigation, but it does point the way to new possibilities in treating schizophrenia and disembodied voices, with the possibility that "befriending" them could lessen their impact.

Ian Steadman is a staff science and technology writer at the New Statesman. He is on Twitter as @iansteadman.

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How did I, obsessed with non-places, not know about the Trafford Centre?

My wife had booked us all in to a showing of the latest Bond film at the IMAX Cinema at the Trafford Centre. “Why the Trafford Centre?” I taxed her. She looked at me as if I were a complete ass, but refused to enlighten me. 

Last year I bought a copy of J G Ballard’s last novel, Kingdom Come, a dystopic tale of the near future in which bored suburbanites descend into anomic violence as they retreat inside a giant shopping mall. Predictably, I bought my copy at the Bluewater shopping mall in north Kent, on the outskirts of London. Bluewater held the title of Britain’s biggest shopping mall for a number of years and it is surpassing large: a huge circular corridor that has become a destination. I asked a police officer where the Waterstones was and discovered she was a good old-fashioned bobby-on-the-beat – her beat having been, for seven years, to walk slowly around and around . . . Bluewater.

But I wasn’t fettered by Bluewater’s surly gravity, any more than I was galvanised by rampant consumerism. Novel purchased, I took a cab over the soaring Queen Elizabeth II Bridge to Essex, where I alighted at Bluewater’s twin establishment: the Lakeside shopping mall in West Thurrock. I headed for the Lakeside branch of Waterstones, where I . . . well, you guessed it: I returned my copy of Kingdom Come. This surreal little exercise was undertaken for the BBC Radio 4 documentary Malled: Sixty Years of Undercover Shopping, and I’ve detailed it here purely in order to illustrate this point: I have more than a passing interest in shopping malls.

This is why the events of a fortnight ago, when Family Self went up to Manchester for what is termed, I believe, a “city break”, seemed quite so bizarre. My wife had booked us all in to a showing of the latest Bond film at the IMAX Cinema at the Trafford Centre. “Why the Trafford Centre?” I taxed her. “It’s in Trafford, which is five miles from the city centre.” She looked at me as if I were a complete ass, but refused to enlighten me. My revelation came later, when we were wandering the rococo halls of the Trafford Centre, marvelling at the lashings of gold leaf applied to the serried columns as our soles slapped on the Italian marble flooring. My wife couldn’t believe that one such as I, obsessed by what the French philosopher Marc Augé has named “non-places”, didn’t know about the Trafford Centre.

But I didn’t – it was a 207,000-square-metre hole in my map of the world. I knew nothing of the bitter and protracted wrangling that attended its inception, as successive planning applications were rejected by ever higher authorities, until our Noble Lords had to step in to ensure future generations will be able to buy their schmutter at TK Maxx and then sip their lattes at Starbucks without having to brave the harsh Lancashire elements. Did I feel small as my savvier spouse led me through these storied halls? You bet your waddling, wobbling, standing-still-on-the-travelator bum I did. How could I not have known about the great central dome of the Trafford mall, which is bigger – and statelier – than that of St Paul’s? How could I have been unaware of the Orient, Europe’s largest food court, with its seating for 1,800 diners, served by a plethora of exciting outlets including Harry Ramsden’s, Carluccio’s and those piquant bun-pushers, McDonald’s?

Actually, the Orient completely bowled me over. The Trafford Centre’s imagineers point to the nearby Manchester Ship Canal as influencing this wholly novel and utterly weird space, which is formed by a sort of Möbius strip of 1930s ocean-liner design, being at once superstructure – railings, funnels, tables arranged to simulate the deckchairs on a sun deck – and interior. However, nothing like this ever cruised by Runcorn. Not that I object to this, any more than I objected to the cluttered corridor full of orientalism – noodle bars, sushi joints, all-you-can-eat Chinese barbecues – that debouched from it and led us back into the weirdly glistering main retail areas, with their ornamental griffins and neoclassical columns bodged up out of medium-density fibreboard.

The Trafford Centre’s imagineers also make great play of design features – such as the aforementioned griffins – that are meant to tie the humongous mall to its hinterland (these are the heraldic symbols of the de Traffords, who used to own hereabouts), and to the north-east’s proud industrial heritage. But this is all ornamental balls; the truth is that the Trafford Centre’s ambience is so sumptuously wacky, it could quite reasonably be twinned with Las Vegas.

While the rest of the family went in search of retail opportunities, I watched the Mancunians process. It occurred to me that if there were any influences at work here – besides the Baudrillardian ones of hyperreality and simulation that underpin so much of the contemporary built environment – it was the presence of a large British Asian community. The only people who didn’t look out of both place and time, wandering about among all the gilded pomp and crystalline circumstance, were women wearing saris, shalwar kameez and burqas. Tracksuit bottoms and hoodies just didn’t cut it – although, I concede, come the breakdown in civil society anticipated in Kingdom Come, this pseudo-sportswear will come into its own as the perfect pillaging outfit.

Next week: Lives of Others

Will Self is an author and journalist. His books include Umbrella, Shark, The Book of Dave and The Butt. He writes the Madness of Crowds and Real Meals columns for the New Statesman.

This article first appeared in the 26 November 2015 issue of the New Statesman, Terror vs the State