Wildness, Mindfulness, and the Phenomenology of Voice-Hearing in Thailand

Abstract

Background and Hypothesis

Research has found that the content and valence of voices heard by persons with schizophrenia appear to be shaped by local culture. We interviewed twenty participants about their voices in Suan Prung Hospital in Chiang Mai, Thailand to see if, and how, there appeared to be such local influences.

Study Design

In an ethnographically driven and phenomenological study, we asked participants what their voices said; whether the voices ever told them what to do and if so, what; whether they knew the speakers; whether there were speakers they liked; whether they had hallucinations in other sensory modalities; and other related questions. Interviews lasted between 30 min and 2 h.

Study Results

Much content of these voice-hearing experiences reflected culturally specific themes. Only one person reported hearing violent commands. There were stories about the power of sacred things and powerful lineages, and cosmological stories about the power of nature. In this cultural context where talk about minds is highly elaborated, participants often said that if they had been more mindful, sati, they would not have heard voices. Most strikingly, many persons described their voices as associated with a kind of uncontrolled wildness of nature spirits.

Conclusions

We find that the felt disruption of the self-world boundary appears to be interpreted in Thailand as a kind of literal wildness, best countered by mindfulness. This seems to be an unusually explicit account of phenomenology of ipseity disorder and suggests that ipseity may be understood and experienced differently in different cultural worlds.

Introduction and Background

We use the word “voice” to describe the experience of hearing someone speak when no one is there to have spoken. Voices are the most striking symptoms of the condition we identify as “schizophrenia,” although voices also appear in other forms of serious psychotic disorder, psychosis being the state in which someone’s thoughts and perceptions seem radically different from consensual reality.¹ People who hear voices report that they hear someone else speaking when no one else is there. Yet the experience is more subtle and more strange than the word “voice” suggests. The event can feel thought-like but does not feel like one’s own thought; it can feel neither inside or outside; often there is a quality of insistence and command. People sometimes say that the voice “feels real” even when they know that the experience is a symptom of an illness.² The use of the word “voice” can blind us to how complex these events are for those who experience them. Another thing that can blind us is that these symptoms seem so closely associated with serious psychotic disorder that clinicians, upon hearing that someone has heard a voice, can move quickly to treatment options without exploring what the person is reporting in more detail.

In recent years, scholars and scientists have begun to realize that careful attention to the phenomenology of voice-hearing can teach us much about these disorders which standard biomedical research cannot. In this enterprise, cultural comparison—of the sort anthropologists do well—is crucial. Cultural comparison can show us what features of these events respond to local shaping, and thus whether there are features presumed to be universal which in fact are not. For example, many observers presume that violent commands are a simple organic byproduct of psychotic disease, the way a sore throat is a byproduct of a cold. The work we present here adds to the mounting evidence that violent commands associated with psychosis are more common in the west: it may be the feeling of negative command, rather than a command to do violence, which is basic to the condition of psychosis.^3,4

More profoundly, comparison can show us that the phenomenological features hypothesized to be central to the disorder may be interpreted and experienced in different settings in different ways. Over the past few decades, Parnas and Sass have been arguing systematically that the central phenomenological experience of schizophrenia is the dissolution of the self-world boundary, or what they call “ipseity disturbance.”^5–7 Ipseity disturbances entail both exaggerated self-consciousness (hyper-reflexivity) and diminished self-reflection, or a “weakened sense of existing as a vital and self-coinciding source of awareness and action”.⁵ Sass and Parnas offer these observations as concerning less the content of hallucinations, and more their form. That which is of the self is experienced as not of the self (thoughts, feelings); there is less sense of a person rooted in the world. A person feels both more aware of themself and simultaneously as if what they are aware of is not themselves.⁸ These disturbances are often accompanied by a sense of not being in control of one’s perceptions, leading to perceptual distortions and a sense of detachment from one’s body, and a disruption in the capacity to differentiate self from other.⁹

Ipseity disturbances are understood to be a core phenomenal aspect of schizophrenia. It is not an entirely new claim—Karl Jaspers,¹⁰ Emil Kraepelin,¹¹ and Bleuler¹² can be said to have said something similar. Kraepelin famously remarked that a person with schizophrenia is like an orchestra without a conductor.^13,14 But as the biomedical paradigm has become dominant in psychiatry, the importance of this existential anxiety has tended to fade under the increased importance of a symptom checklist. Its variations in experience, and its ties to culturally elaborated explanations of self and mind are still not well understood. In our current comparative project, we think that we see elements of this existential anxiety interpreted and experienced in culturally particular ways.

Methods

The current project developed from shared interests in the subjective experience of mental disorder, and the cultural influences in the crafting of them: Julia Cassaniti, an anthropologist, had conducted interviews on mindfulness and mental health among hospital staff at Suan Prung^15,16; Chaiyun Sakulsriprasert, a psychologist, regularly runs research projects at the hospital on a range of psychiatric disorders^17,18; and Tanya Marie Luhrmann, an anthropologist, has been investigating unusual experiences with voices as part of a broader research agenda on conceptions of mind and thought in religion, psychiatry, and culture.^19,20 We chose to work together to see whether and, if so, how the local culture might shape the experience of hearing voices.

Participants

Participants comprised 20 in-patients at Suan Prung Hospital who carried an official diagnosis of schizophrenia or paranoid schizophrenia. They were chosen for us by the nurses and doctors as persons who heard voices and were able to give consent to and participate in an interview. Sixteen were male and 4 female, a bias in keeping with the general gender ratio at the hospital. Patients were mostly part of the Northern Thai (kon muang) ethnic group, but some were from other ethnic minority groups (including Hmong, Lisu, and Tai Yai). Most came from poorer, rural areas, although a few were from more urban areas like Bangkok in Central Thailand. Their ages ranged from 19 to 56; their period of stay at the hospital ranged from a few days to a few months. For most of the patients, the time of our interview was not the first time they had been admitted to the hospital: the average number of visits was four to five times, but one man had been admitted 13 times before. All interviews were conducted in Thai, with some local linguistic variations of regional dialects.

Over the course of January and February of 2023, we interviewed 20 participants at the hospital. Chaiyun Sakulsriprasert and Julia Cassaniti carried out the bulk of the interviews; Prim (a graduate student at Chiang Mai University) joined Julia for the interviews with the four women; and Tanya Luhrmann, Chaiyun Sakulsriprasert, and Julia Cassaniti consulted together on each interview at the end of each study day.

After giving their consent to be interviewed, participants were asked a series of questions about their subjective experience with hallucinations, following a modified version of a Voices Interview Protocol developed by Tanya Luhrmann, Hema Tharoor, and R. Padmavati²¹ that has been used in a series of cross-cultural comparative studies on hearing voices.^3,22,23 We asked participants what their voices said; whether the voices ever told them what to do and if so, what; whether they knew the speakers; whether there were speakers they liked; whether they had hallucinations in other sensory modalities; and other related questions. Interviews lasted between 30 min and 2 h.

At the end of the study, Prim transcribed the Thai audio recordings of the interviews into Thai script; Julia, along with a local man named Thongsuk Moonkham, translated them together into English, with the additional assistance of three undergraduate students at Chiang Mai University in the case of three interviews that took place in localized regional dialects. For the translations, Julia and Thong (re)listened to the audio tape recording of each interview and reviewed Prim’s transcription of it in detail. Using these as guides, they discussed how to best translate each utterance, word-by-word, and line-by-line. We included hesitations, sighs, pauses, and other unspoken gestures in our translations, in order to best capture the subtleties of meaning. Because our interlocutors were themselves not always speaking in full or coherent sentences, translating with coherence was sometimes difficult, and we tried to keep the ambiguities of scattered utterances intact in the translations. After a month of daily work, we had 200 pages of interview transcriptions in Thai and English.

Julia, Tanya, and Chaiyun then each read and re-read the transcripts in full, along with two graduate assistants (Finn Staeblin [at Stanford] and Daphne Weber [at Washington State University and Stanford University]). For the most part, we proceeded in an open ethnographic manner; J.C. and T.M.L. are trained as anthropologists. This approach is sometimes described as “grounded theory,” although the method hearkens back to a richer engagement with the setting. J.C. has published two ethnographies on Thailand,^15,24 and T.M.L. has published ethnographic work on psychosis.^19,25 We read separately and then discussed together the themes that seemed to emerge. We then each individually compiled lists of similarities across the interviews, and similarities and differences with other work with which we were familiar. We then individually wrote out and together compared and discussed our answers to the following questions for each participant:

1. What are the voices/hallucinations like, descriptively, and how does the person feel about them?

2. What are general themes in the hallucinations that seem to be inflected with Thai cultural narratives?

3. How do they represent these experiences in relationship to their mind?

4. Do they spontaneously describe practices or states of mind/mindfulness which seem to inhibit voice-hearing?

The five of us also each separately marked moments throughout the transcripts that referred to sensory (eg, smell [], touch [], sound []), evaluative (eg, bully [], tease [], or scold []), explanatory (eg, self-awareness [], mind []), and other relevant descriptions. All work was approved by the Institutional Review Boards of Stanford University (#19538), Washington State University (#17283), and Suan Prung Hospital (#60340).

Results

Many participants initially denied having any hallucinations at all, often explicitly asking if, because they had no hallucinations, they could go home. After talking together for a period of time, however, almost all described unusual encounters in rich, vivid detail. (Again, hospital clinicians were also clear that our participants heard voices.) Some told us about their ability to speak through the elements; others said they could see aliens, hear mountain spirits, the universe, or friends and family. Their hallucinatory experiences were often multi-sensory. They often reported seeing (45%), smelling (25%), touching (35%), and even tasting (17%) in ways that appeared to be hallucination-like. Seven heard people they actually knew; nine reported a dominant positive voice; only six described violent themes. Patients often described their voices as disturbing, with a harassing quality, but some (perhaps seven) reported that their voices were caring and kind. With the exception of one (or possibly two) participants, no one reported violent commands at all. Although commands were often reported, they seemed to be experienced mainly as instructions to care for the self.

More than anything else, participants spoke directly about fraught engagements with a world teeming with infringing spirits, often described in connection to the wilderness, and the difficulty in keeping the mind intact and integrated in the face of these encounters. Here, we turn to the accounts of the ways that the spirits were encountered by these patients at Suan Prung, and how they felt that their minds were affected by them.

Wildness

Wildness is connected in Thailand to concepts about the existence of spirits (Thai: phi). Unlike in western contexts, where the wilderness is often romanticized as a pristine paradise, Southeast Asian conceptions of wilderness are represented as more deeply wild, chaotic, dangerous, and in need of “civilizing.”^26–28 Spirits are seen to represent a powerful and wild kind of energy and to exist especially in wild places, particularly in and in connection to the wilderness—both literally and figuratively.^29–32 They are sometimes also glossed as ghosts. As a noted scholar comments, “Ghosts are part of a Thai Buddhist’s normal life.”³³ They are everywhere in Thailand, but particularly in the countryside, where they haunt people in lonely places, hungry and insatiable.³⁴ Such ghosts/spirits are often thought to be created by chaos: by an unhappy or wrongful death, or an uncremated death, or a death in the wrong place where there are polluting and evil spirits.³⁵ Ghosts are souls who have been unable to move on because of something that has gone wrong. Encounters with spirits are relatively common in Thailand, but they are perhaps especially meaningful for those with schizophrenia because, we think, the ghost evokes the fragmentation and chaos of mental experience which, at its extreme, can be thought of as a disturbance of a sense of self. When describing spirits and wilderness, people are both literally and metaphorically talking about a wildness infringing on the mind.

Spirit Encounters, and the Wilderness

Khun, a 32-year-old Northern Thai man, described hearing spirits like Dut Luat (; the “Spirit of Sucking Blood”), Phi Kat Dud (; the “Spirit of Suction”), and Phi Ga Lon (; the “Spirit of Haunting”), which he explained are in the language of his home of Phrae District. This group of spirits, he tells us, came and “bit my mind, and sucked out my spirit.” He uses the Thai term upanisai, which refers directly to one’s character, one’s self, and seemed clearly to refer to his psychiatric condition. He could talk with his body, he said—with every element of his body, and then the spirits would come out of the forest and take his body away. He spoke to the elements, to wood, and to iron, and they bit him. “They bit my head, my mind in my head…It bit my mind and then it sucked my spirit.” He tried to fight with them in his head, but they drained his spirit. He described them as Phi, the spirits who live in the forest.

Arak, a man in his late 20s from Hot Province, described his voices as spirits he had seen and heard for many years. Most often, they were two female spirits whom he called generically Phi Am (; the very common Thai spirit of controlling, pressuring, and paralyzing people, often encountered in the stage between sleep and wakefulness, which has been glossed as an experience of sleep paralysis). He said that they first appeared to torment his mother (she also had schizophrenia). But then they turned to him. He said that he had been “hit” (; don) by the spirits; they pushed into him from the outside and were scary. He also described them as “spirits” of the forest (; phi ba; and  , phi ba am). Once he fell asleep in an abandoned house in the forest, he explained, and got squeezed/suppressed/controlled by this phi am of the forest. Now, he said, he is too scared to go into abandoned houses at all.

Ayu, a man of Lisu ethnicity, also spoke about his voices in connection with wilderness. Ayu saw trees moving and distorting into strange shapes, their branches waving surreally, and turning into animals. He heard the strange sounds of people very far away, “in the mountains, or it’s like when I go into the jungle. It’s like when I go into the forest to search for mushrooms,” he told us, or to take drugs, “and I’ll hear the sounds, the very strange sounds, [of the forest].” He explains that “in that area it’s the mountain area, and it will have tombs in it, and I’ll hear the sounds of those buried in the mountains—something like that.” The sounds he heard often weren’t words—they were more like “Aaakkk!!” or “Huuu” he tells us—or are like that of an actor, commentators, speaking together. They would seem far away, but sometimes they would seem to be getting closer and closer. Sometimes, they would get very close and shouting. “I hear them say these things in the Lisu language, in,” he paused, “in the echo of my brain.” He saw things at home too: “I’ll be laying down on the bed, and I’ll see the pattern on the cover of the blankets,” he explained: “it’s like it has energy, power. It’s like a shadow, but it’s not a shadow, it’s a power using the shadow, to have me ask, ‘oh, is that real?’” He interpreted the sounds he heard and the things he saw as energy; “energy (, palang gnan) is the best word for it, because spirit—winyan (, soul spirit) people wouldn’t believe.” He seemed to want to say that for him, they are spirit energy. When he heard them, he becomes scared and shakes and did not feel brave enough to talk to them. He felt abandoned.

For Ayu, these experiences of spirits are often directly tied to the wilderness. If Ayu is in the jungle when this happens, he runs out of it. He described this very vividly and did so in a way that suggests that references to the wilderness are not incidental aspects of places that people just happen to invoke because they come from rural areas that are close to the jungle. He appeared to connect them directly to the disturbing, distorting, and infringing power of the wild. Ayu felt he must leave the forest “because I couldn’t stay there; it’s the forest; it’s the mountain, the hills…The lord/guard/guardian of the place is very close there. The Spirit guardian is too strong there.” He explained this at length: “I have the feeling that it’s the guardian/lord/god/spirit of the jungle, of the mountain (, jao ba jao cow), like the place where something haunting is living in the forests (, suu yuu nai ba). One has to leave and go out of there, because this kind of thing will come and chase me out.”

At least nine people used forest metaphors too in describing their voices. Tiew heard the earth and sky fighting with each other. They didn’t used to fight, he said, but now the people of the earth cursed them, he said, and so they fight. Chan saw a ghost by an abandoned corpse in the forest. Kiet ran away from his family into the forest. It was there that he heard his family fighting with him, harassing him, teasing him, and getting into his mind. But their power and their psychic clairvoyance, their ability to bore into his mind—that came from the sun.

There was a quality of wildness to the forest in these stories, and there was a wildness to the voices. Lek loved to meditate, and in our 2 h interview he paused often in what seemed like contemplation. Lek told us that his mother told him that his problems had been caused by his excessive meditation. Lek’s experience, for him, was caused by something that hit him. Something was done to him (he used the Thai term jit lon, a mental hallucination, or mental haunting), that “hit” or “touched” (don) him, psychically: a kind of black magic. Someone went to a “spirit doctor” (Moh Phi; magician, sorcerer, shaman, connected to the spirits of nature), he explained, that has powers to “cure, to fix, to put on a curse, a spell”. He spoke again and again in this way of being “hit” by “something.” “It’s like there’s someone coming to hit me…they spoke rough, rude words…” and caused him to be “like a crazy person.”

Mind and Mindfulness as Understood to Counteract the Powers of the Wild

Many of the people we spoke with at Suan Prung—at least seven, including the individuals above—spoke about mindfulness (sati). Mindfulness in Thailand is a common, colloquial(ized) Buddhist concept that refers to the capacity to bring one’s mind together to focus on the present. A local Southeast-Asian, Theravāda idea, it has come through different routes to greatly influence today’s global mindfulness movement, although the mindfulness promoted by, for example, the UK’s National Health Service differs in many ways from mindfulness as commonly imaged and practiced in northern Thailand.³⁶ In Chiang Mai, local understandings treat mindfulness as a Buddhist spiritual practice of attention in which calmness is a desirable state. At Suan Prung, patients told us that their problems had been caused by their lack of mindfulness or insisted that mindfulness would keep trouble at bay. To the extent that the ghost represents the fragmentation and chaos of mental experience, mindfulness becomes what is lost, and what can repair the fragmentation.

Lek can’t remember exactly what happened, but he said that “when they [the voices] spoke,” he says, “I broke my mindfulness (tang sati).'' He explained what happens when the spiritual ‘thing’ hit him: ``I didn’t know myself; I didn’t have consciousness; mindfulness (sati) wasn’t with me; I lost my mind (kat sati); mindfulness wasn’t with my body.” For Lek, this was why he ended up in the hospital.

Arak told us that it was when his mind was weak that he was more likely to feel spirits. He described his own encounter with Phi Am (spirit of sleep paralysis) this way: “it was between sleep and not sleep, and was just like that, and then, I don’t know what happened, something was put (tap)— superimposed, overlapped on me—well, the spirit.” He thought that the encounter had taken place because he was not mentally strong: “I was vulnerable. Maybe I was ‘soft against the world’ (, ohn ton lok),” a reference to a mental state of weakness. Later he said that he had a “weak khwan,” referring to a Tai model of the mind [a local model] that describes spirits of the self that can get lost in times of stress (pben phraphom khwan ohn;  ). It is not just that his singular self is more or less strong, but that the self itself is more or less constituted as something that was not dispersed and in pieces. That also seemed to be his account of his madness. When we asked Arak how he felt when he saw the spirits [his account of hearing voices], he said it was quite scary and disturbing. When we asked him what he did to feel better, he said “I use my own self, I control myself.” We asked him to clarify: “to sit and get to a high level of meditation?” He nodded: “I sit or lay down, and it goes away naturally, then I contemplate, and lay down and sleep, and close my eyes. It’s like that, between awake and asleep…when I feel something bad like that, I’ll do it for about an hour. Maybe it’s about karma from some high place, karma of mine, something on high that controls me, that put me in the hospital.”

Ayu told us that he doesn’t have good mindfulness these days, but that he tries to. He experienced many auditory hallucinations, and at those times, he said, “well, I try to work on controlling my mindfulness (; payayam khum sati tua eng).” Ayu understood the experiences with the wilderness spirits almost in direct opposition to mindfulness. He would physically leave the forest; he said that the wilderness is “haunted” with voices. Ayu also worked to leave them mentally, through practice on his mind. He said that when the sounds, the voices, “are coming to talk to me, and I, well, I make my mindfulness really good (, tang sati dii), and then I’ll look around and realize ‘eh! No, there’s nothing there!’”

Many others we spoke to made similar kinds of connections. Briefly, here are a few more.

A 30-year-old woman named Fern, who regularly saw aliens, even in the room at the moment of the interview, said that “I believe about spirits, I believe about the Buddha.” In a scattered and energetic conversation, right after noting this, she mentioned that “a friend”—possibly one of the aliens, possibly a real person—went to give something to a monk known for his powers of mind to counteract the negative effects of the spirit encounters.

A 45–year-old man from Lamphun, saw a yellow python by the mouth of a cave at the jungle monastery when he stayed as a monk. As with some other descriptions by patients, it wasn’t clear to us, or perhaps to Daeng himself, whether the snake was physically real or a spirit. He thought quietly and said “maybe it was the guardian spirit (, jao thii) of the place.” He said that the head monk told him to not do anything, and sat in meditation to send it away. “The monk sat in meditation,” Daeng says, “and the snake went away by itself.” It is clear that for Daeng, it was the power of the monk’s meditation that led the snake away, so that the people were left unharmed.

Aek heard his voices and saw his voices, and for him the experience was bound up in dreams and dreaming. “I dream and die by dreaming.” He is upset that his memory is “messed up.” And he felt that if only he could be more mindful, they would stop, or he would at least control them.

In these examples, voices are spirits which disrupt the mind and are appeased by making an offering to the monastery, meditating, or engaging with in some other kind of controlled inner attention. If the monastery (and the monks there) serves as a site for mental training, as it often is understood to be, then the wild “spirits” of the wilderness are in a quite literal sense seen to get appeased, or pacified, by the work on the mind.

Discussion

Research to date on the way culture shapes the voice-hearing experiences of those with serious psychotic disorder has shown that culture affects the content and to some extent the emotional valence of these events. (By “culture” here, we refer to the often implicit ideas, expectations, and practices within a specific community.)³⁷ In a 1960s study of psychosis in northern Ghana, the type of negative, insulting voice so common in the UK and USA was only heard by one of the 14 voice-hearing participants interviewed, while more than half described “kindly voices which said such things as ‘I like you…you are good’.”³⁸ In more recent work, Suhail and Cochrane used case notes to compare the modalities and themes of hallucinations in White British patients, Pakistani patients living in Britain (who had lived an average of 17 years in the UK), and Pakistani patients living in Pakistan. They found that the most dissimilar pair was the White British patients and the Pakistani patients living in Pakistan and that the British patients were more likely to hear commands to kill themselves or others than the Pakistani patients.³⁹ Okulate and Jones reported that commanding, abusive, cursing, arguing, and frightening voices were heard less frequently among their Nigerian patients with schizophrenia than among patients in the UK.^40,41

Luhrmann and colleagues systematically compared auditory verbal hallucinations in patients from the USA (San Mateo, California), India (Chennai), and Ghana (Accra).²³ They found that participants from the USA tended to report voices with more violent content and more violent commands. More than in other settings, the California participants disliked their voices. No American in that sample reported that their primary voice was positive. In Chennai, more than half the sample heard kin speaking, and heard voices of kin more often than those in the other settings. These patients often knew, in the flesh, the person whose disembodied voice they heard. Even when the voice was annoying, these participants often said that they enjoyed the company. In Ghana, half the participants insisted that their primary or only voice was God; some said that God was a lifeline in the troubles they faced. In Chennai and Accra, people seemed to have more personal relationships with their voices.

In more recent work in Shanghai,²² we found that many persons with schizophrenia had political experiences. They heard Chairman Mao, or were called by political operatives. They reported few violent commands. In a study in Kazan, Russia, the participants’ voice-hearing had folklore themes and they, too, reported few violent commands.⁴² This work in Chiang Mai also finds little in the way of violent commands; only one person seems to have reported them. This observation strongly suggests that violent commands are not an essential symptom of schizophrenia.⁴³

The most striking feature of our work in Chiang Mai is that cultural themes seem to reflect ipseity disturbances. At least, Thai culture leads to such destabilizing experience being expressed in the way voice-hearing is understood. Many of our Thai participants used an explicit and culturally elaborated metaphor of the wildness of the forest spirits to describe their experience of their condition. Voices hit them. They flee to the jungle and then they are attacked in ways that feel out of control. Spirits enter them and threaten them from the earth and sky; the inside becomes the outside and then they live within this chaos. The sense of being surrounded and threatened from within and without, the feeling of being fragmented, and out of control: this is what Sass and Parnas name as the core condition of schizophrenia and in the spirits and ghosts of the forest there is a ready-made metaphor to describe it. In a cultural landscape rich with these “animist” spiritual forces of the wild wilderness, those who are diagnosed with schizophrenia often experience these forces in particularly vivid ways.

At the same time, many of these participants describe vivid cultural representations about how to counteract such fragmentation with mindfulness.^44,45 In this predominantly Buddhist cultural area, ideas about the mind, and the importance of work on the mind, are very publicly circulated. Mindfulness (sati in Pali and Thai renderings) is strongly connected to everyday Thai conceptions of mental health. Mindfulness is understood as part of shared practices of meditation (nang samathi in Thai) that are well known to both educated and uneducated people.^46–48 Thai ideas about spirits of the self called khwan suggest a person’s mind to be susceptible to scattering.^49,50 The anthropologist Felicity Aulino has described the implicit Thai model of mind as “kaleidescopic”,⁵¹ by which she means that the self is not imagined as unitary and individual, as typically represented in a western context,⁵² but as constantly changing in relation to the surrounding social world. As a common Thai disciplinary mental practice, mindfulness focuses on what are often understood to be mental aspects of the self that are prone to become scattered and disordered. This perspective on mindfulness is what in Thailand in general practice, and it is especially significant for the experience of these patients. For our participants, the failure to maintain mindfulness—particularly in the presence of these chaos-causing spirits—became the cause of their struggle. They also are likely to assert that the use of mindfulness would reduce their suffering.

In a very literal way, a presence or lack of mindfulness is described not just to increase or decrease mental strength, but rather to constitute or decompose the mind of the individual. It is in this conceptual space that the self is understood to break down through a dissolution of boundaries between inner and outer experience, and the fraught and often disturbing interaction between what is and is not the self at all.

This is what Khun suggests when he describes how the spirits literally “bit my mind.” This is the push and pull that Sass and Parnas’s⁵ account of ipseity disturbance describes. It is particularly elaborated, and elaborated in a culturally particular way, in this Thai case. The descriptors of the wildness of the mind in moments of hallucinatory episodes, and those of the significance of keeping and constructing a mindful mental attitude to counteract them, suggest a model of mind that may shape the phenomenology of ipseity disturbances for these Thai patients.

Our findings suggest that mental models, reflected in the content and experience of hallucinations and influenced by culture, may be important for understanding some of the most significant and central parts of schizophrenia. This breakdown does not only happen to the people we spoke with; it is also something that they try to actively work on. Sometimes they are successful, or at least partially successful. Aek describes his own practical application of this push and pull: when he hears voices, and the doctor at the hospital happens to be passing by, “I make my mind,” he says, by practicing mindfulness, and then he is not “busy” with the voices, and the doctor doesn’t stop and bother him. When participants succeed in “making” their mind, the voices are less intrusive, and when the wildness of the voices instead are present, the mind is understood to be absent, or weak.

It seems clear that for these Thai participants, ipseity disturbances are a highly salient condition of their psychosis. Our work, then, supports the general importance of Parnas and Sass’s theoretical descriptions. More specifically, our work suggests that the felt experience of ipseity disturbance may differ in different social worlds because of different cultural interpretations.

It also has potentially broader implications for our understanding of ipseity disturbance. In a cultural context like Thailand, self-other boundaries are imagined as more normatively permeable than in many other places, and theories of identity emphasize the self’s impermanent and illusory nature. Because of this it may be that ipseity disturbances are less jarring, and less of a distress than elsewhere but also as more available for cultural representation. This raises the possibility that the experience of ipseity may be less or more intense in different cultural contexts with different culturally influenced models of mind, or more or less easy to repair. At the least, we found that the experience itself is culturally inflected, and from that possibly variable. Although a practical attention to the work of mindfulness may not aid people everywhere in combatting this debilitating disease (although see Sheng et al.)⁵³—and it may also not do so even in Thailand—the representation of self-other breakdown of the kind described in this article may point to promising new directions in the study of schizophrenia.

Funding

None declared.

Conflicts of Interest

None declared.