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<div class="">September 19, 2013</div>
<h1>The Violence in Our Heads</h1>
<h6 class="">By
<span><span>T. M. LUHRMANN</span></span></h6>
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<p>
STANFORD, Calif. — THE specter of violence caused by mental illness
keeps raising its head. The Newtown, Conn., school killer may have
suffered from the tormenting voices characteristic of <a href="http://health.nytimes.com/health/guides/disease/schizophrenia-disorganized-type/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Schizophrenia - disorganized type." class="">schizophrenia</a>;
it’s possible that he killed his mother after she was spooked by his
strange behavior and tried to institutionalize him. We now know that
Aaron Alexis, who killed 12 people at the Washington Navy Yard on
Monday, heard voices; many observers assume that he, too, struggled with
schizophrenia. </p>
<p>
To be clear: a vast majority of people with schizophrenia — a disease we
popularly associate with violence — never commit violent acts. They are
far more likely to be the victims of violence than perpetrators of it.
But research shows us that the risk of violence from people with
schizophrenia is real — significantly greater than it is in the broader
population — and that the risk increases sharply when people have
disturbing <a href="http://health.nytimes.com/health/guides/symptoms/hallucinations/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Hallucinations." class="">hallucinations</a>
and use street drugs. We also know that many people with schizophrenia
hear voices only they can hear. Those voices feel real, spoken by an
external, commanding authority. They are often mean and violent. </p>
<p>
An unsettling question is whether the violent commands from these voices
reflect our culture as much as they result from the disease process of
the illness. In the past few years I have been working with some
colleagues at the <a href="http://health.nytimes.com/health/guides/disease/schizophrenia/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Schizophrenia." class="">Schizophrenia</a>
Research Foundation in Chennai, India, to compare the voice-hearing
experience of people with schizophrenia in the United States and India.
</p>
<p>
The two groups of patients have much in common. Neither particularly
likes hearing voices. Both report hearing mean and sometimes violent
commands. But in our sample of 20 comparable cases from each country,
the voices heard by patients in Chennai are considerably less violent
than those heard by patients in San Mateo, Calif. </p>
<p>
Describing his own voices, an American matter-of-factly explained,
“Usually it’s like torturing people to take their eyes out with a fork,
or cut off someone’s head and drink the blood, that kind of stuff.”
Other Americans spoke of “war,” as in, “They want to take me to war with
them,” or their “suicide voice” asking, “Why don’t you end your life?”
</p>
<p>
In Chennai, the commanding voices often instructed people to do domestic
chores — to cook, clean, eat, bathe, to “go to the kitchen, prepare
food.” To be sure, some Chennai patients reported disgusting commands —
in one case, a woman heard the god Hanuman insist that she drink out of a
toilet bowl. But in Chennai, the horrible voices people reported seemed
more focused on sex. Another woman said: “Male voice, very vulgar
words, and raw. I would cry.” </p>
<p>
These observations suggest that local culture may shape the way people
with schizophrenia pay attention to the complex auditory phenomena
generated by the disorder and so shift what the voices say and how they
say it. Indeed, that is the premise of a new patient-driven movement,
more active in Europe than in the United States, which argues that if
you treat unsettling voices with dignity and respect, you can change
them. </p>
<p>
The <a href="http://www.intervoiceonline.org/">Hearing Voices</a>
movement encourages people who hear distressing voices to identify them,
to learn about them, and then to negotiate with them. It is an approach
that flies in the face of much clinical practice in the United States,
where psychiatrists tend to assume that treating such voices as
meaningful encourages those who hear them to give them more authority
and to follow their commands. </p>
<p>
Yet while there is no judgment from the scientific jury at this point,
there is evidence that at least some people find that when they use the
Hearing Voices approach, their voices diminish, become kinder and
sometimes disappear altogether — independent of any use of drugs.
</p>
<p>
This evidence is strengthened by a recent study in London that taught
people with schizophrenia to create a computer-animated avatar for their
voices and to converse with it. Patients chose a face for a digitally
produced voice similar to the one they were hearing. They then practiced
speaking to the avatar — they were encouraged to challenge it — and
their therapist responded, using the avatar’s voice, in such a way that
the avatar’s voice shifted from persecuting to supporting them. </p>
<p>
All of the 16 patients who received a six-week trial of that therapy
found that their hallucinations became less frequent, less intense and
less disturbing. Most remarkably, three patients stopped hearing
hallucinated voices altogether, even three months after the trial. One
of those three patients had heard voices incessantly for the prior 16
years. </p>
<p>
The more we know about the auditory hallucinations of schizophrenia, the
more complex voice-hearing seems and the more heterogeneous the
voice-hearing population becomes. Not everyone will benefit from the new
approaches. Still, they offer hope for those struggling with a grim
disease. </p>
<p>
Meanwhile, it is a sobering thought that the greater violence in the
voices of Americans with schizophrenia may have something to do with
those of us without schizophrenia. I suspect that the root of the
differences may be related to the greater sense of assault that people
who hear voices feel in a social world where minds are so private and
(for the most part) spirits do not speak. </p>
<p>
We Americans live in a society in which, when people feel threatened,
they think about guns. The same cultural patterns that make it difficult
to get gun violence under control may also be responsible for making
these terrible auditory commands that much harsher. </p>
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<p>T. M. Luhrmann is a professor of anthropology at Stanford University and a contributing opinion writer.</p> </div>
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