Psychological Bulletin

1977, Vol. 84, No. 3, 570-587

Social and Cultural Aspects of Hallucinations

Ihsan Al-Issa
The University of Calgary, Calgary, Canada

A review of clinical and anthropological studies shows that social and cultural
factors affect both the definition of, and the sensory systems involved in, hallu-
cinations. It appears that the pejorative labeling of certain reported experiences
as hallucinatory is dependent on linguistic factors as well as social and cultural
beliefs (e.g., the consideration of hallucinations as an index of social maturity,
social competence, and social conformity). It is pointed out that the degree of
rationality in the culture is associated with attitudes, emotional response, and
the attribution of pathology to hallucinatory experiences. The implications of
social and cultural factors for the behavioral and psychoanalytical approaches
to hallucinations are also discussed.

Recently there has been an increasing in- investigations of stimulus deprivation and
terest in the study of mental imagery in drug-induced hallucinatory experiences.
general and in hallucinations in particular In the study of anomalous perception there
(Keup, 1970; Paivio, 1971; Pylyshyn, 1973; has been much emphasis on the investigation
Richardson, 1969; Segal, 1971a; Siegel & West, of the stimulus situation (e.g., presence or
1975; West, 1962b). Since hallucinations are absence of stimulus in psychophysics) and its
considered to be the result of an abnormal relationship to the mental state of the sub-
interaction of the senses with the physical jects (e.g., psychiatric diagnosis of psychotic
environment (i.e., misperception), they appear states). Textbooks of psychiatry and abnormal
to reflect the biological rather than the social psychology have characteristically defined
adaptation of the organism. It is therefore hallucinations as perception in the absence
not surprising that social and cultural aspects of external stimulation. However, recent
of hallucinations have not been given as much theory and research have rejected the concept
attention as have other clinical symptoms of hallucinations as misperception involving
such as delusion, in which social evaluation a pathological process. Studies have tended
and interpersonal relationships seem to be to postulate organic or psychological mecha-
clearly implicated (Kiev, 1963; Murphy, 1967; nisms common to both hallucinatory expe-
Weinstein, 1962a). The relative neglect of riences and imagery (Dement, 1965; Evarts,
social and cultural aspects of hallucinations 1962; Fischer, 1969; Hebb, 1968; Hefferline,
may well be contrasted with the numerous Bruno, & Camp, 1973; Klttver, 1965; Sarbin
& Juhasz, 1970; Stoyva, 1973; West, 1962a).
The evidence surveyed in this paper shows
This article was part of a research project entitled that the study of the social and cultural
Schizophrenic Symptoms: A Cross-Cultural Approach. situations in which hallucinations occur may
It was supported by The Canada Council, Grant have a substantial effect on the labeling of
No. S71-0171-S1. A shorter version of the article was
prepared for a symposium entitled Cross-Cultural these experiences as pathological. Data from
Factors Relevant to Symptoms, Diagnosis, and Treat- cross-cultural studies as well as from clinical
ment Factors in Promoting Mental Health, part of the and experimental research indicate that social
program of the 18th International Congress of Applied and cultural factors, and particularly atti-
Psychology, Montreal, July 28-August 2, 1974. The
author is grateful to Charles Costello, Ronald Schaub, tudes, affect the definition, frequency, and
David Schonfield, and John Yardley for their com- emotional response to hallucinations. These
ments on the paper. factors also seem to have some bearing on
Requests for reprints should be sent to Ihsan
Al-Issa, Department of Psychology, University of the development and termination of halluci-
Calgary, Calgary, Alberta, Canada. natory experiences.
570
 HALLUCINATIONS
Social and Cultural Factors in the Definition
of Hallucinations
A basic problem in the definition of hal-
lucinations is to establish a criterion to dif-
ferentiate psychotic or schizophrenic from
other hallucinatory experiences and normal
imagery. In psychiatric circles, much im-
portance seems to have been assigned to the
situation, conditions, and circumstances in
which hallucinations are reported. When the
precipitating conditions in which, or the
process by which, the individual comes to
have his hallucinations are not detectable,
they are considered by the psychiatrist to be
an indication of functional psychosis and/or
schizophrenic disorder. Hallucinations with a
known physical basis (acute brain syndrome,
intoxication, fever, etc.) are, on the other
hand, considered to be a manifestation of
organic psychosis rather than due to unknown
schizophrenic process. Similarly, whether
dreams are differentiated from or confused
with visual hallucinations depends on whether
or not it is clearly indicated that the visions
occurred in a state of wakefulness or sleep.
The individual's control of both the occur-
rence and content of the hallucinatory ex-
perience is also used to differentiate waking
imagery, as well as eidetic imagery, from the
schizophrenic experience. It is generally be-
lieved that schizophrenic hallucinations are
spontaneous and beyond the control of the
patient. This belief is expected to pose prob-
lems to the diagnostician, since these charac-
teristics of hallucinations seem to overlap
with those of normal imagery. For instance,
behavioral research reviewed below shows
that hallucinations are not unrelated to in-
ternal and external cues. Furthermore, studies
of the imagery of normal subjects show
that imagery is by no means voluntary or
subject to personal control (Bugelski, 1971;
McKellar, 1957; McLemore, 1972; Richard-
son, 1969;Stoyva, 1973).
The projection of the content of fantasy
and imagination and a belief in the reality
of the experience by the individual are also
considered as criteria for the determination
of the abnormality of the experience (Hare,
1973). According to these criteria, normal
people may talk to themselves, but they are
571
expected to know not only that the voices
are in their heads, but also that they are
imaginary and not real. In auditory hallu-
cinations, on the other hand, the schizophrenic
patient not only believes that the voices are
real, but he also tends to attribute these
voices to other people. It should be noted,
however, that when the individual (patient)
expresses some disbelief in the objective
reality of his perceptual experiences (hearing
voices), they are labelled as pseudo-halluci-
nations (Buss, 1966; Strauss, 1969). These
criteria seem to be based more on the
conviction of the individual concerning the
reality of his experience, rather than on his
misperception of external stimuli. Whenever
he is unable to tell the difference between
an image and a percept, he is likely to be
considered out of touch with reality or to be
hallucinating (Sarbin, 1967). Below, I deal
with some of the social conditions that might
contribute to the confusion between images
and percepts. Suffice it to say here that
investigations of the Perky effect show that
normal subjects under some conditions are
liable to the confusion between vivid imagery
and externally generated signals (Perky, 1910;
Segal, 197 Ib).
Little research has been carried out to
investigate the reliability and validity of
these criteria (i.e., autonomy and spontaneity
of hallucinations, and belief in the reality of
the experience), as applied by psychiatrists
to schizophrenic patients. Strauss (1969), for
example, investigated the frequency of hal-
lucinations and pseudo-hallucinations in a
group of hospitalized schizophrenic patients.
In this group he found almost three fourths
as many questionable or pseudo-hallucina-
tions as definite hallucinations. This would
indicate that a large number of diagnosed
schizophrenics tend to report imagery-reflect-
ing experiences that are more ideational
(thoughts in the head of the patient) than
perceptual (objects in the outside environ-
ment). A cross-national study by Edwards
(1972) has recently reported that American
psychiatrists seem to be less aware than their
British counterparts of the difference between
schizophrenic hallucinations, pseudo-halucina-
tions, hypnagogic and hypnopompic imagery,
and other mental imagery. A broad concept
572 IHSAN AL-ISSA
of hallucinations that includes various kinds
of imagery would be expected to predispose
the American psychiatrist to see more hallu-
cinations in his patients than would his
counterpart in Britain. In an attempt to
explain these differences, Edwards considered
the possibility that British textbooks of psy-
chiatry, which stress phenomenology (e.g.,
Anderson & Threthowan, 1967; Fish, 1962)
as well as the influence of the European
phenomenological schools, have led to the
differentiation of more varieties of halluci-
natory experiences than in the United States.
Hare (1973) has also recently reported that
American textbooks of psychiatry tend to use
hallucinations in a broad sense to cover
hallucinatory experience as well as other kinds
of imagery.
In addition to British-American differences
in the definition of hallucinations, Edwards
(1972) found American psychiatrists to be
less aware than British psychiatrists of the
occurrence of hallucinations in conditions
other than schizophrenia (psychogenic, hys-
terical states, depression). In the rank order
of importance of symptoms in the diagnosis
of schizophrenia, American psychiatrists
ranked hallucinations higher than did British
psychiatrists. The orientation of psychiatrists
in the United States and Britain toward
hallucinations and other symptoms may have,
in part, brought about diagnostic differ-
ences between the two countries, biasing the
Americans toward the diagnosis of schizo-
phrenia (Cooper, Kendell, Gurland, Sharpe,
Copeland, & Simon, 1972; Sandifer, Horden,
Timbury, & Green, 1968). It may be con-
cluded that British-American differences in
the definition of hallucinations, as well as in
diagnosis, may not only reflect differences in
training (Cooper et al., 1972; Edwards, 1972;
Hare, 1973) but also in social beliefs about
these experiences, which will be discussed
below.
Non-Western Definition of Hallucinations
In contrast to the psychiatric definition of
hallucinations, many non-Western societies
make no distinction between spontaneous
schizophrenic hallucinations, pseudo-halluci-
nations, dreams, and other products of fantasy
and imagination. All hallucinatory experiences,
imagery, dissociational states (fugue, hypnotic,
hysterical states), and altered states of con-
sciousness are attributed to possession by
spirits or to contact between the individual
and a spirit. Possession is considered as a
socially sanctioned role that serves public as
well as private needs and is accepted within
a certain social context. Though experiences
similar to the spontaneous hallucinations of
Western psychotic and schizophrenic patients
do occur in these cultures, the emphasis ap-
pears to be on the social meaning of the
experience rather than on the conditions and
the process by which hallucinations occur
(Bourguignon, 1970, 1973; R. Rabkin, 1970;
Wallace, 1959). Furthermore, the content of
these hallucinations tends to be similar from
one individual to another within the tribe,
but to differ between tribes (Benedict, 1934).
A question that should be of interest to
Western investigators concerns the social and
cultural conditions that may affect the degree
to which those who are in a state of posses-
sion, and suffer from psychiatric disorder in
the Western sense, derive social benefits from
entering these states. There is some evidence
to show that urban African patients who
report possession are still diagnosed as men-
tally ill, for example, hospitalized cases in
Nigeria described by A. H. Leighton, Lambo,
Hughes, J. M. Leighton, and Macklin (1963).
There are also certain conditions in which
some non-Western societies differentiate hal-
lucinations as part of a socially accepted state
of possession from those which are considered
pathological. Bourguignon (1970), for in-
stance, reported that among the Mohave
Indians, there is a taboo against the hunter
eating his kill. A hunter who does eat his
kill tends to have hallucinations: He sees
game everywhere. This is considered a type
of pathology brought about by the infraction
of culturally accepted rules and seems to be
clearly linked to culturally derived concepts
of guilt.
The tendency of some non-Western socie-
ties to ignore differences among hallucinations
on the basis of precipitating conditions does
not imply an inability to discriminate between
hallucinations and veridical perception. It may
be argued that it is their awareness of the
 HALLUCINATIONS
difference between these two experiences
(interaction with the physical environment in
veridical perception versus interaction with
the spirits in hallucinations) that makes
hallucinations of distinctive value to these
societies. As will be noted in the next section,
certain social and cultural attitudes might
increase the tendency of the individual to
give a reality status to his visual and auditory
images and thus to become pathological.
Attitudes Toward Hallucinations
In psychiatric practice it is implicitly as-
sumed that hallucinations, as well as other
symptomatology, are directly related to speci-
fic diagnostic categories. Psychiatric interest
in the frequency of hallucinations seems to be
motivated mainly by the belief that these
symptoms are related to psychosis. Recent
evidence, however, is inconsistent with this
belief. Zigler and Phillips (1961), for instance,
found that among hospital patients, halluci-
nations occur in only 35% of schizophrenics
and to a lesser extent in patients suffering
from character disorders (12%), manic de-
pressive reaction (11%), and psychoneurosis
(4%). More recently, McKellar (1968) has
cited two studies of normal subjects in whom
the occurrence of hallucinations, in the psy-
chiatric sense, was 10% and 25%, respec-
tively.1 It thus appears that psychotic symp-
toms such as hallucinations not only occur
at a low rate in the hospital population, but
are also found in different diagnostic groups
and in the general population. This tenuous
relationship between symptoms and mental
illness has been highlighted by field studies
showing that psychiatric symptoms occur in
such large numbers in the general population
that it is difficult to accept them as the sole
criterion for defining the true pathological
population (D. C. Leigh ton, Harding, Macklin,
MacMillan, & A. H. Leighton, 1963; Srole,
Langner, Michael, Opler, & Rennie, 1962).
The evidence seems to indicate that in the
study of factors in the diagnosis of mental
illness, it is necessary to go beyond symptoms
to the study of social conditions and social
attitudes that may be crucial in determining
whether or not these symptoms are patho-
logical (Draguns, Note 1; Hammer, 1972).
573
The major emphasis would not be on the
presence or absence of certain symptoms in
various social and cultural groups (e.g., Al-
Issa, 1970; Wittkower & Rin, 1965), but on
the study of beliefs, feelings, and behavior
(behavior intentions, action tendencies) rele-
vant to these symptoms. The relevance of
this approach to the study of hallucinations
is that it indicates a need to explore the
"subjective culture" of the patient, the psy-
chiatrist, and representative samples of the
community (Triandis, Vassiliou, Vassiliou,
Tanaka, & Shanmugam, 1972).
In two important papers, Sarbin (1967)
and Sarbin & Juhasz (1967) have pointed out
that the labeling of reported experiences as
hallucinatory is influenced by both the beliefs
and verbal sophistication of the diagnostician
and of the patient. The study of these two
factors seems necessary for the understanding
of the process underlying the diagnosis of
hallucinations as pathological behavior.
Linguistic Factors
The first step in the process of labeling is
the inspection of the verbalization of the
individual (e.g., I see . . ., I hear . . ., etc.).
Before the diagnostician can label the ex-
perience as hallucinatory, he must decide
whether the patient's statements are true or
false. If the diagnostician declares these state-
ments false and therefore hallucinatory, many
linguistic factors seem to affect this decision.
There is, for instance, the possibility that the
statement may contain ellipses and that the
individual is only foreshortening his utter-
ances. Indeed, the linguistic sophistication of
the suspected hallucinator seems to play a
dominant part in influencing the decision of
the diagnostician. His public report is, for
example, unlikely to be declared false or1 con-
sidered hallucinatory if he includes in his
statements such qualifiers as "it is as if I
1
If hallucinations are to be considered pathological,
it is necessary to obtain data on base rates in the
general population. This work would parallel recent
investigations of base rates of hallucinations under
hypnosis and waking states (Barber, 1970; Barber
& Calverley, 1964; Bowers, 1967; Sarbin & Andersen,
1963; Spanos & Barber, 1968).
574 IHSAN AL-ISSA
hear . . ., I thought I saw . . . ." That this
linguistic problem interacts with the social
context is expressed by Sarbin (1967):
A special problem exists for the diagnostician when
the suspect lacks language sophistication and cannot
indicate his ellipses with appropriate qualifiers. This
is especially true of children, adults with limited
language skills, persons with meager vocabularies such
as recent immigrants, etc. Expressing the concept of
as if requires a fair degree of linguistic skill. Thus
when a four-year-old child insists on talking to an
imaginary playmate, the as if is supplied by the
mother and the child is not likely to be referred to
a therapist for help in stamping out hallucinations.
When reading the productions of great poets, the
readers supply the suppressed as if. In order to inter-
pret any sentence properly, the listener must consider
the total context, i.e., he must be ready to supply
missing qualifiers, (p. 371)
Another linguistic problem raised by Sarbin
(1967) is the use of metaphor. If a report
such as "I see . . ." is interpreted literally
where it is metaphorically used, the indi-
vidual's statement is automatically judged
false. This situation may arise not only when
the listener mistakes the metaphorical intent
of the speaker, but also when the latter is
ignorant of "current norms regarding language
constraints" to be used when describing certain
experiences (Sarbin & Juhasz, 1970, p. 66).
Finally, when an individual states "I see
an elephant," there are at least two ways
of reacting to this statement (Sarbin, 1967).
The listener may concentrate either on the
phenomenological reality of the reported
object, "elephant," or on the predicate,
"seeing an elephant." Although the first
reaction follows the psychiatric tradition, that
is, to find out whether the experience is
pathological or not, the other is concerned
with the meaning of what the individual is
trying to communicate by his statement.
This latter reaction considers hallucinations
to be in the realm of reported imagery, rather
than as misperceptions of the physical en-
vironment. As Sarbin (1967) has pointed out,
the appropriate questions to be asked by the
professional in this situation would be as
follows:
(1) What biographical and stimulus conditions lead
to covert imaginative behavior? How does the claimed
experience come about? In other words, what is the
background for imagining?
(2) What are the biographical and stimulus condi-
tions that lead to public reporting of imaginings?
Patently, one does not report all his imaginary ex-
periences to all possible auditors. People are selective
in what they report and to whom. And if a person
inhibited the public reporting of all his imaginings,
there would be little basis for a judge to use the label
hallucination.
(3) What are the psychological and social criteria
that lead a professional to declare that certain reported
imaginings are hallucinations and others are not?
(p. 363)
In a series of papers, Sarbin (Sarbin, 1967;
Sarbin & Juhasz, 1967, 1970) has extensively
dealt with the first two questions. The next
part of the present article deals with research
relevant to the third question posed by
Sarbin, about the social conditions associated
with hallucinations.
Social and Cultural Beliefs
Earlier in my discussion of hallucinations,
I have pointed out cross-cultural as well as
cross-national (American versus British) dif-
ferences in beliefs relating to hallucinations.
I discuss here some of the social correlates
of psychiatric beliefs and the reaction of the
individual and his group to the report of
subjective hallucinatory experience.
One aspect of psychiatric beliefs about
hallucinations is the social implication and
relevance of hallucinatory experiences to the
social functioning of the individual. Phillips,
Broverman, and Zigler (1966) have shown
that hallucinations, more than other symp-
toms, appear to reflect lower levels of social
competence and/or social maturity of pa-
tients. One finding of particular importance
to the understanding of the social process
involved in diagnosis is that the combination
of low level of social competence and symptom
expression (hallucinations) is necessary in de-
termining the diagnosis a patient receives
(schizophrenia). As social competence is de-
fined in terms of level of education, steady
employment, and marital status, it is not
surprising that certain aspects of social com-
petence are related to social class (Chapman
& Baxter, 1963). Similarly, social competence
as an underlying factor in the judgment of
severity of symptoms and in the diagnosis
of patients may explain in part the excess
of schizophrenia in the lower class (Hollings-
head & Redlich, 1958).
The association of hallucinations with
severe pathology may also reflect the indi-
 HALLUCINATIONS
vidual's social conformity and his suscepti-
bility to social influence. Studies using the
Asch procedure in comparing schizophrenic
and normal subjects may elucidate such an
association, since the experimental situation,
in fact, involves social influence in the per-
ception of physical stimuli (i.e., length of
lines). The evidence is, however, inconsistent
in this area of research, showing schizo-
phrenics less susceptible to social influence in
some studies, but not in others (Diamond,
1957; Gill, 1963; Schooler & Spohn, 1960;
Shean, 1973; Whitman, 1961). Since these
studies did not differentiate between halluci-
nating and nonhallucinating schizophrenics,
their data do not clarify the relationship be-
tween social conformity and hallucinations.
If hallucinations reflect a generalized tendency
toward nonconformity to social pressure, hal-
lucinating schizophrenics would be expected
to respond to the veridical length of the lines
rather than to conform perceptually in the
Asch situation.
Consistent with the hypothesis that hallu-
cinations are related to social conformity is
a study by Sarbin, Juhasz, and Todd (1971).
They demonstrated that hallucinating schizo-
phrenics tended to "hallucinate" the taste of
salt in distilled water significantly less often
than did college students. Similarly, these
patients were less susceptible to hearing a
tone that was not delivered by the experi-
menter (an auditory hallucination). The same
trends were found when they compared hal-
lucinating with nonhallucinating schizo-
phrenics. It should be noted that in both
experimental situations, subjects were given
the strong expectation that they would taste
salt or hear a tone. It appears that halluci-
nating schizophrenics were less likely to "hal-
lucinate" when the physical stimulus condi-
tions called for a veridical perceptual report
but the social pressure called for mispercep-
tion. When subjects in the Sarbin et al. study
were assessed for interest in the social en-
vironment on the basis of scores from the
Motoric-Ideational Activity Preference Scale
(Stein, 1968), hallucinating schizophrenics
were found to be lower in interest than were
nonhallucinating schizophrenics and normals.
It thus appears that the classification of these
patients is associated with lack of interest in
the social environment rather than with a
575
tendency toward misperception in the experi-
mental situation. It may be concluded from
these studies that the investigation of social
factors such as social competence and social
conformity will increase understanding of the
diagnostic process in general and of the rela-
tionship between hallucinations and psychi-
atric diagnosis in particular.
The differentiation between hallucinations
on the basis of the conditions and the process
involved (e.g., psychosis, drug, stimulus de-
privation) seems to have affected beliefs and
expectations about the content of different
hallucinatory experiences. Although psychotic
and schizophrenic hallucinations have been
expected to be predominantly meaningful in
content, hallucinations induced by drugs and
stimulus deprivation have been described as
meaningless "form constants" (e.g., arcs,
circles, wheels, stars, spirals, etc.). Horowitz
(1964) has, however, put forward the hy-
pothesis that these often-observed, meaning-
less visual experiences could serve as the
sensory core around which different types of
imagery, including schizophrenic hallucina-
tions, are elaborated. Horowitz presented evi-
dence that indicated that when schizophrenics
were carefully questioned and asked to draw
their visual hallucinations, simple forms were
so common that they could be used to ex-
plain the origin of the more elaborated and
meaningful hallucinations. Summing up the
evidence, Richardson (1969) pointed out that
the Horowitz hypothesis has some support in
that it explains the content of other imagery,
such as hypnagogic imagery, meditation im-
agery, pulse-current imagery, perceptual isola-
tion imagery, and even everyday experiences
of normal subjects. If the Horowitz hypothesis
is taken into consideration to explain the
origin of different hallucinatory experiences,
then social and cultural factors should play
a predominant part in the elaboration of the
content of these experiences.2 In the study
2
A similar proposition has been put forward by
Segal (1971b) to explain the content of auditory
hallucinations, which tend to be common in both
schizophrenic and alcoholic withdrawal psychoses.
Segal cited the Saravay and Pardes (1967, 1970) hy-
pothesis that local effects in the middle ear may
underlie auditory hallucinations in these two groups.
According to Saravay and Pardes, slight shifts in the
states of contraction of the muscles of the middle
576 IHSAN AL-ISSA
of drug effects, psychological reaction to drugs
(placebo effect) has, of course, been widely
recognized, but no social or cultural controls
have been used. If social and cultural factors
were important in the effects of drugs, one
would expect wide deviations from the
meaningless experiences observed in Western
subjects. This has, in fact, been clearly dem-
onstrated by anthropological studies of the
effects of hallucinogenic drugs on white North
Americans and native Indians. Wallace (1959)
has contrasted the auditory and visual dis-
tortion reported in a clinical research setting
with the socially meaningful visions and
voices experienced by the Indians who take
drugs in a socially prescribed context. Wallace
has also noted that the emotional reaction
to the drug experience seems to be different.
The calm mood and personal satisfaction of
the Indian after achieving hallucinations is
quite the opposite of the mood shifts (agita-
tion, depression, anxiety, euphoria) experi-
enced by white subjects under the influence
of drugs.
Cultural beliefs concerning the origin of
hallucinations, discussed early in this article,
would be predicted to play an important part
in the social control of both the occurrence
and content of the experience. Considering
the schizophrenic hallucinations as random,
spontaneous, and unpredictable, with un-
known causation, puts them beyond the con-
trol of the psychiatrist or the individual
himself. By attributing them to the spirits,
social expectation of their content and occur-
rence tends to be prescribed. What the spirits
are expected to communicate to the individual
may thus be socially stereotyped and could
be predicted by the individual, his group,
and the professionals. The general belief that
external factors rather than individual ones
are responsible for behavior during possession
may very well facilitate social influence and
cultural controls (Lefcourt, 1972).
ear may yield sound sources that ordinarily pass
unnoticed but under certain conditions do register in
the brain. Segal (1971b) explained hallucinations with
meaningful content in schizophrenic and alcoholic
withdrawal psychoses as originating from these sounds,
which are "modified by central expectancies, past
memories, or current cognitions" (p. 89).
Attitudes and Rationality
The rationality of the culture and its dis-
tinction between reality and fantasy3 may
well result in different attitudes toward hal-
lucinations, and these in turn could affect
both the detection and report of hallucinatory
experiences. Rational cultures that make a
rigid distinction between reality and fantasy
tend to consider hallucinations negatively, as
they are expected to interfere with daily
activities and interaction with the physical
environment. Individuals are thus discouraged
from assigning credibility to certain imagin-
ings. They even learn to ignore these ex-
periences and to remain unaware of their
existence. These cultures would generally be
conducive to a high threshold in the ob-
servation of hallucinations and imagery and
to a negative attitude toward these experi-
ences. The fact that the individual is un-
familiar with his own imagery and defensively
protected against it (i.e., it tends to arouse
anxiety in the individual) may make him
attribute a reality status to it when it is
occasionally experienced, and he is thus con-
sidered pathological.4 In a discussion of the
adaptive function of the practice of day-
dreaming, Singer (1966) pointed out that
the constant exploration of one's daydream world
makes it a familiar realm, less likely to evoke anxiety.
It remains a distinct possibility, worthy of more
3
Categorizing experience into reality and fantasy
is based on the scientific materialistic criterion used
by psychiatrists to evaluate an individual's report of
his private imaginings. It is possible that individuals
who act as if their imaginings are "real" are using
a different criterion. The question is, whose criterion
is one expected to accept? How the criterion defining
reality changes with time and place has been exten-
sively discussed by Sarbin (1967) and Sarbin and
Juhasz (1967).
4
Relevant to this point of view is a perceptual
isolation study reported by Silverman, Cohen, Shma-
vonian, and Greenberg (1961). They noted that field-
dependent subjects tended to report meaningful visual
imagery to which they gave reality status, whereas
none of the field independent subjects reported this
type of imagery. It would be of interest to find out
the relationship between social and cultural differences
in cognitive styles (Witkin, 1967; Witkin & Berry,
1975) and the frequency of the confusion between
fantasy and reality or the report of meaningful
hallucinations.
 HALLUCINATIONS
thorough research exploration, that many persons who
have failed to indulge in fantasy play may misinter-
pret vivid daydreams or images as hallucinations and
may be made more anxious by the sudden, seemingly
autonomous occurrence of a fantasy image or phrase
of conversation, (p. 27)
The rational psychiatric approach to mental
illness may very well explain negative atti-
tudes toward schizophrenic hallucinations and
the emotional response of the patient to his
own experience. It may, for instance, partly
explain the recent finding that hallucinations
are reciprocally augmented by anxiety; they
tend to be preceded as well as followed by
anxiety (Slade, 1972). Similarly, clinical ob-
servation of the initial symptoms of anxiety
and tension, shame, and guilt at the acute
stage of mental breakdown may only indicate
a negative reaction of the patient to his
hallucinations and to other symptoms. It
might also be observed that negative attitudes
may reduce the patient's trust in his group
and thus make him unwilling to report his
hallucinations. The prime example is the
isolated, suspicious paranoid patient, who
seems to be more prevalent in technological
and Westernized societies (Al-Issa, 1970;
Murphy, 1967). The isolation of the patient
and. his attempt to conceal his hallucinatory
experiences would be expected to make the
experiences less amenable to the control of
social stimuli and perhaps more liable to
chronicity.
Holt (1964) has succinctly summed up
Western reaction to imagery and hallucinatory
experiences:
In a factually oriented, skeptical, anti-intraceptive,
brass-tacks culture like ours, where the para-normal
is scoffed at and myth and religion are in decline,
the capacity for vivid imagery has little survival
value and less social acceptability. We live in an age
of literalism, an era that distrusts the imagination,
while at the same time it develops its beat fringe of
avid seekers after drugs that may artificially restore
the capacity for poetic vision. It is little wonder that
our children rapidly lose their eidetic capacity and
that adults are made uneasy by the admission that
they can experience things that are not factually
present, (p. 262)
In less rational cultures where the dis-
tinction between reality and fantasy is more
flexible, individuals are encouraged to observe
their hallucinations, imagery, and other private
events. Since these experiences are positively
577
valued in relation to individual and group
daily activities, they tend to be frequently
noticed and communicated to others. Although
the content of hallucinations may have posi-
tive or negative connotations, the experience
itself is not anxiety-arousing or disturbing to
the individual. Indeed, in some primitive soci-
eties, the experience is actually sought, and a
variety of methods (lack of sleep, fasting,
prolonged physical pain, social isolation, drugs,
special exercises, etc.) are used to achieve it
(Bourguignon, 1970; Wallace, 1959). Cultural
conditions in such cultures seem to be con-
ducive to positive attitudes and a low
threshold in the perception of hallucinations
and imagery. These conditions may also
breed more introspective people than does a
rational culture. It is possible that in these
societies the high frequency of reported hal-
lucinations may not be because more of them
occur, but because they come more often into
the public domain through self-description.
A flexible distinction between reality and
fantasy may not only encourage the report
and positive regard of hallucinations, it may
also help absorb these experiences into the
cultural stream and thus facilitate their social
control. In this cultural context, hallucina-
tions may start as an individual spontaneous
experience, but the duration and termination
of the experience may ultimately be brought
under the control of social stimuli and be
integrated with other ritualized activities (cf.
Murphy, 1967). Social control may be postu-
lated to explain, in part, the transitory nature
of psychotic behavior in general, and in
particular, hallucinations observed by African
psychiatrists (Collomb, 1965; Lambo, 1965).
(Toxic psychoses and other organic conditions
may also explain transitory symptoms in
African patients.) Hence, social and cultural
factors would be expected to have certain
implications in the therapeutic situation.
Therapeutic Implications
There are at least three aspects of the
social and cultural approach to hallucinations
that might have some therapeutic implica-
tions for the psychologist and psychiatrist.
First, there is the tendency of the psychiatric
approach to give more attention to the ex-
578 IHSAN AL-ISSA
perience of hallucinations per se, with little
consideration of its meaning and content;
second, the tendency of the patient to react
with anxiety and tension to his hallucina-
tions; and finally, the patient's unwillingness
to reveal his hallucinations and private ex-
periences. I would like to consider these three
aspects in relation to behavioral and psycho-
analytical approaches to hallucinations.
Behavioral Approach
Early studies of sensory conditioning have
brought about a basic modification in the
concept of hallucinations (Ellson, 1941a,
1941b; Seashore, 1895). Hallucinations are
not regarded as a response to nonexistent
stimuli (cf. Buss, 1966; Sarbin and Juhasz,
1967), but as
a (verbal) report of sensory perception made in the
absence of the adequate external stimulus (UCS) but
in the presence of another external stimulus (CS)
that in the past has occurred in close temporal con-
tiguity to the UCS and probably to its accompanying
report. (Hefferline et al., 1973, p. 311)
This definition, unlike its psychiatric counter-
part, does not distinguish between normal
and abnormal hallucinations, but attributes
them all to the same conditioning process.
One of its disadvantages, however, is to imply
that the hallucinations of the schizophrenic
are only elicited in the presence of specific
external stimuli. The reliance of the definition
on external stimulation has been recently cor-
rected by Hefferline and his associates (Hef-
ferline et al., 1973; Hefferline, Bruno & Da-
vidowitz, 1971; Hefferline & Perera, 1963) by
seeking, within the organism itself, the ante-
cedents of hallucinations. They have demon-
strated that covert events (proprioceptive
responses) can, in fact, serve as conditioned
stimuli that can be discriminated by the
individual and can come to elicit hallucinatory
reports in the absence of external stimuli.
A step in the same direction are the studies
reported by Stoyva (1973) that attempt to
show some of the physiological conditions
under which hallucinations are likely to occur.
These studies relating hallucinations to private
events are not without clinical support (Gould,
1948, 1950; Inouye and Shimizu, 1970;
McGuigan, 1966, 1973). The evidence pre-
sented by these authors in support of the
association between the report of auditory
hallucinations and electromyographic activity
in the speech musculature of the schizophrenic
patient suggests that the voices heard in
auditory hallucinations may be the result of
the subvocal speech of the patient himself.
The relevance of these data to the present
analysis of the concept of hallucinations is
that the patient may sometimes report the
occurrence of a mediating event that is con-
sidered to be a response to a nonexistent
external stimulus (Hefferline et al., 1973).
In addition to the experimental approach
to hallucinations, there have been many at-
tempts to apply behavioral techniques to
reduce or eliminate the report of hallucina-
tions. Systematic desensitization and asser-
tiveness training, as originally used by Wolpe
(1958), were applied to deal with anxiety-
arousing situations associated with halluci-
nations, that is, being alone or interacting
with family members at home (Slade, 1972),
smoking (Alumbaugh, 1971) and social situ-
ations requiring decision making (Nydegger,
1972). Results of treatment indicate that a
decrease of anxiety level and an increase in
the social adaptation of the patient tend to
reduce the report of hallucinations. These
findings are consistent with my early ob-
servation that anxiety-free attitudes toward
hallucinations and other imagery might con-
tribute to the speedy termination of these
experiences in some non-Western cultures
(Wallace, 1959).
Aversion therapy has also been used to
deal with hallucinations. The evidence seems
to show that the effect of self-administered
shock in the treatment of hallucinations is
either temporary (Bucher & Fabricatore, 1970)
or tends to be confounded by other factors,
such as the patient's expectation for im-
provement (Weingaertner, 1971). In the ap-
plication of aversion therapy, the personal
meaning of hallucinations may pose certain
problems that are rarely encountered in the
treatment of neurotic symptoms. Behavior
therapists have been interested in the elimi-
nation of maladaptive neurotic behavior (e.g.,
phobias) and this goal tends to be welcomed
by both patient and therapist. Schizophrenic
patients may want to get rid of unpleasant
 HALLUCINATIONS
hallucinations but might resent attempts to
eliminate those that are positively self-rein-
forcing (McKellar, 1957, 1968; Will, 1962).
Indeed, hallucinations may reflect evaluative
standards of self-reinforcement that mirror
the past experiences of the patient (cf.
Bandura, 1971). Thus, any attempt to elimi-
nate hallucinations, particularly those with
pleasant content, may be anxiety arousing to
the patient. It is instructive to point out
that in the selection of the Weingaertner
(1971) patients, 50% did not cooperate and
had to be excluded because they either denied
hallucinations or were unwilling to take part
in aversion therapy. The concealment of the
report of hallucinatory experience by patients
in the face of aversive stimuli may explain,
in part, the return of hallucinations after the
termination of treatment or discharge from
the hospital (Bucher & Fabricatore, 1970).
Though operant conditioning seems to rep-
resent one of the most promising areas in
the behavioral study of hallucinations, the
early findings by Lindsley (1959, 1963) justi-
fied the conclusion that "vocal psychotic
symptoms are under some form of internal
control that resists direct differential positive
reinforcement" (Lindsley, 1963, p. 269). Later,
however, Ayllon and Haughton (1964) dem-
onstrated that psychotic speech is amenable
to social reinforcement received on the ward,
for example, the attention given by the staff to
the verbalization of symptoms. Two studies
by Rutner and Bugle (1969) and Anderson
and Alpert (1974) have demonstrated the
effects of social reinforcement and token
economy on hallucinatory reports. Just how
much the report and content of hallucina-
tions are under the control of social stimuli
may be illustrated in the following case of a
36-year-old schizophrenic Negro female who
continually reported being in communication
with famous personalities:
Three student assistants assumed the role of listeners
during daily twenty-minute visits with the patient.
One of the male students wore sandals, a beard, open
collar, loose jacket and a SNCC button. Another
presented a picture of a clean-cut young man with
military bearing who carried a Rockwell anti-Semite
and anti-Negro pamphlet quite visible to the patient.
The third, a friendly girl, tried to appear nondescript
in both dress and demeanor. As predicted, the patient
reported to the student who emulated a freedom
579
fighter that she was in communication with Martin
Luther King and other similar notables. To the
student whom she apparently identified as a Nazi
party member, she said she was not really a Negro,
but a Latin and that she hated Negroes for their
fifthy ways. She claimed that many of the rallies
Rockwell conducted had actually resulted from con-
versations she had had with him in which he sought
her advice. To the girl, her hallucinatory references
were at first about religious figures, then movie stars.
(Schaefer & Martin, 1969, pp. 145-146)
The Schaefer and Martin case is reminiscent
of the ceremonial control of hallucinations
wherein the shaman and the audience in-
fluence the content of hallucinations (Bour-
guignon, 1970, 1973; Kiev, 1972; Wallace,
1959). The evidence thus far from the be-
havioral analysis of hallucinations, as well as
from anthropological data, indicates that
social control of hallucinations may, in fact,
partly involve an operant learning procedure
in which the individual (patient) learns to
discriminate among audiences and different
situations or in which the audiences control
the content of hallucinations.
Psychoanalytical Approach
The interpretation of hallucinations and
other imagery as related to delayed gratifica-
tion (Freud, 1908/1962, 1911/1962) is not
dissimilar to the emphasis on the inter-
personal and social function, as well as on
the motivational aspects of hallucinatory ex-
perience. In interpreting dreams as wish-
fulfillment, Freud recognized that dreams are
motivated and that their content is a fulfill-
ment of a motive. Dream analysis, in essence,
is an attempt to uncover the underlying
motivation or to locate the various elements
of the content of dreams among events in the
dreamer's past life. The analytical approach
of applying dream analysis procedures to
hallucinations seems to be as much a search
for precipitating factors as is the behavioral
approach to hallucinations (McKellar, 1957).
One important area of research that is
relevant to both psychoanalytical and be-
havioral approaches to hallucinations is the
controversial area of the cathartic effects of
fantasy and imagination. Since hallucinations
are considered by the analyst as the mani-
festation of delayed gratification, they are
expected to be directly related to the reduc-
580 IHSAN AL-ISSA
tion of specific drives (Bandura, 1969; Fesh-
bach, 1970; Singer, 1970). The present social
approach would suggest that the concealment
of hallucinations and the reluctance of the
individual to share these experiences with
others are expected to make their content
unrelated to and somehow remote from the
immediate life situation. Hallucinations would
thus serve a generalized function rather than
one specific to the present drive state of the
individual. As pointed out by Singer (1970),
fantasy and hallucinations are adaptive be-
cause of their flexibility for self-stimulation
to increase the affective state of the individual
and to maintain his general interest in a dull
and barren environment. It is only with
deliberate and extensive inquiry into the
adaptive and role-taking function of halluci-
nations and imagery that they may become
comprehensible within the context of the
patient's social and interpersonal situation
(Juhasz, 1972; Sarbin & Juhasz, 1970; Singer,
1970).
Cultural Variation in Hallucinations
The content of hallucinations, like that of
dreams and other products of fantasy and
imagination, is clearly based on the individu-
al's past experience within a certain socio-
cultural context and is therefore expected to
vary from one culture to another (Kiev, 1972;
Weinstein, 1962b). Less obvious, however, is
the extent to which hallucinatory experience
involves different senses across cultures. Audi-
tory hallucinations are the most frequently
reported by schizophrenic patients in the
West, with visual hallucinations appearing in
the most deteriorated patients (Buss, 1966;
Feinberg, 1962; Mayer-Gross, Slater & Roth,
1960; Straus, 1962). Feinberg, for instance,
found that in the admission ward of a large
hospital there were only between 3% and 4%
of schizophrenic patients who reported visual
hallucinations. Hallucinations involving other
senses are rarely reported by patients. Though
in a hospital survey, American black schizo-
phrenic patients showed more hallucinations
than did white patients, the prevalence of
auditory over visual hallucinations appears to
be true for both groups (Vitols, Waters,
& Keeler, 1963).
In their pioneering research of schizophrenic
symptomatology of selected regions of the
world, Murphy, Wittkower, Fried, and Ellen-
berger (1963) found that whereas visual hal-
lucinations are the least frequently reported
in urban Euro-Americans, they are most fre-
quently reported in Africa and the Near
East. It was, however, noted by Murphy
et al. that although there are variations in
the frequency of different kinds of hallucina-
tions, in all countries studied, auditory hal-
lucinations are in no instance reported as
being infrequent by the psychiatrists. Though
it is not used as frequently as vision by
non-Western patients, it appears that audi-
tion is universally employed by schizophrenic
patients as a medium for the expression and
communication of symptoms.
Another aspect of non-Western hallucina-
tions has been described by Collomb (1965).
Hallucinations of Senegalese patients tend to
have an unstable and transitory quality. They
consist of transformation of odors into sounds
and sounds into concrete shapes. A man, for
instance, hearing voices, especially the devil's
voices, gradually perceives these auditory
hallucinations as visible animals that want
to kill him.
Cross-temporal studies give the impression
that hallucinations of Western patients in the
past were predominantly visual, a finding
similar to those presently reported with non-
Western patients. Lenz (1964) has studied
changes in symptomatology during the last
hundred years in Vienna. His data show that
though visual hallucinations decreased during
the period of study, there was an increase in
auditory hallucinations during the same period.
Similar findings were reported by Diethelm
(cited in Opler, 1956). Since cross-temporal
studies use case histories of patients, it is
difficult to know whether the findings reflect
differences in the background of psychiatrists
throughout history, during which vision and
audition have been differentially emphasized
in the observation of patients, or whether
they reflect true changes in symptomatology.
Although the validity of these cross-temporal
studies may be in doubt, it should be noted
that the religious concern with the report of
visions in the Middle Ages has been well
documented (Sarbin & Juhasz, 1967).
 HALLUCINATIONS 581

Interpretation of Cultural Variation 1950; Buss, 1966). Though clinical observa-

tion indicates that visual hallucinations reflect
Social and cultural factors are not only more severe symptoms than do auditory hal-
involved in the definition and labeling of lucinations, McCabe, Fowler, Cadoret, and
certain experiences as hallucinatory, but they Winokur (1972) found that they are related
may also affect the report of different kinds to a good prognosis. This finding is in agree-
of hallucinations. The decreasing frequency of ment with an early study by Zubin, Sutton,
different kinds of hallucinations reported dy Salzinger, Salzinger, Burdock, and Peretz
Western patients seems to parallel the be- (1961), which indicates that although hallu-
creasing involvement of the senses in inter- cinating patients, regardless of modality, tend
personal and social interaction. The most to have a poor outcome, even so, visual
common type of communication between hallucinations tend to improve the outcome.
people is by means of speech (audition), next Jenkins (1952) has also observed that during
is communication by observing each other the recovery process, the course of improve-
(vision); the remaining senses tend to be ment of schizophrenic disorganization tends
relatively unimportant in social interaction to disappear first from the olfactory, gusta-
(Buss, 1966). If hallucinations constitute a tory, and visual senses, and remain longest
direct or symbolic expression of the indi- in the auditory sense. The differential resist-
vidual's social needs, these needs could be ance of hallucinations to treatment may reflect
more easily communicated by speech (auditory the relative use of the senses in interpersonal
hallucinations) than pictures (visual halluci- communication. Since audition is more easily
nations). Words are more ambiguous than used in communication, it is not surprising
visual images and hence more amenable to that auditory hallucinations are resistant to
distortion and reconstruction to suit the treatment. It thus appears that the involve-
individual's needs. When hallucinations are ment of the sense organ in interaction with
occasionally used by patients to present an the social environment seems to hinder rather
"objective" support of their delusional beliefs, than to facilitate treatment.
words are more suitable for the task than McCabe et al. (1972) found that visual
visions. It is, for instance, easier to hear an hallucinations tend to occur significantly more
insulting remark, "You are a wicked person," in the acute (less than 2-month duration)
than to conjure up a visual image that would than in the chronic (more than 2-year dura-
convey the same message. The general im- tion) schizophrenic state. Fischer (1972) also
plication of the present interpretation of pointed out that the chronicity process may
cross-temporal and cross-cultural data is not explain the frequency of different kinds of
that the rate of verbal discourse has changed, hallucinations in schizophrenia as well as
but that there may be cultural differences in during the drug experience. He stated that
the tendency to communicate with significant
authority figures; and words are more suitable the chronicity of the schizophrenic, as contrasted with
for communication with such figures (cf. the acuteness of the drug-induced state, may possibly
Lemert, 1962). account for the difference between auditory and visual
The social and interpersonal implication of hallucinations. Healthy volunteers who have lived
with the visual dimension of physical space-time
different kinds of hallucinations is also re- cannot denounce the dimension during the short
flected in diagnosis and treatment. Since the period of an acute drug-induced experience. It is well
patient is able to communicate to his social known that chronic abuse of amphetamine may pre-
environment more meaningful and explicit cipitate a psychosis which is almost indistinguishable
from schizophrenia, whereas the perceptual and
ideas through the voices he hears than through especially visual experiences of the incipient stages
other sensory impressions, it is not surprising of schizophrenia "are not unlike those induced by
that auditory hallucinations are considered a LSD or mescaline and auditory hallucinations only
sign of better contact with reality, indicating become prevalent after the process has lasted for
some weeks or months." (Fischer, 1972, p. 82)
good orientation of time and place. Confused
patients who are relatively disoriented tend Evidence showing similarities between hallu-
to have visual hallucinations (Bleuler, 1911/ cinations in schizophrenia and in chronic
582 IHSAN AL-ISSA
alcoholic psychosis give some support to the
Fischer proposition (Bagley & Binitie, 1970;
Freed, 1975; Norman, 1945). These studies
suggest that the clinical findings referred to
earlier, concerning the prevalence of auditory
hallucinations in schizophrenia, may not in-
clude the acute early stage of the illness,
particularly before the patient contacts psy-
chiatric services.
There seems to be a striking similarity
among the acute early stage of schizo-
phrenia, drug-induced states, and the episodic
confusional psychotic states in African pa-
tients (Fischer, 1972; Lambo, 1955). The
sudden onset of these acute confusional states
tends to bring about visual rather than
auditory hallucinations. Since physical and
nutritional factors are more common in the
psychotic reaction of preliterate primitive
patients, the prevalence of visual hallucina-
tions in non-Western societies could be attri-
buted in part to these factors. It is therefore
important that organic factors in visual hal-
lucinations should be borne in mind when
considering any sociocultural hypothesis.
Level of Abstraction and Hallucinations
The relationship between perception and
conceptualization has long been documented
(Bruner, 1957). In the study of abnormal
thinking and perception, if one considers a
continuum ranging from concept to percept,
auditory hallucinations and particularly de-
lusions could be located nearer to the con-
ceptual and ideational end of the continuum.
On the other hand, visual hallucinations, as
well as others involving contact receptors
(gustatory, olfactory, tactile), are bound to
physical stimuli and should be located near
the perceptual end of the continuum. This
suggestion is supported by descriptions by
patients of their own hallucinations. Jenkins
(1952), for instance, indicated that
the hallucinatory "voice" seems almost as close to
a conceptual as to perceptual disorder, as most pa-
tients, when queried, will describe it as something
heard in the mind or in the head, rather than as
something heard with the ears. (p. 743)
Consistent with this point of view is the
finding that auditory hallucinations tend to
be more prevalent among paranoid delusional
patients than other schizophrenics (Lowe,
1973; Swanson, Bohmert, & Smith, 1970).
The association of delusions with auditory
hallucinations may reflect their proximity on
a conceptual-perceptual continuum. The ques-
tion that arises here, however, is whether the
relative use of symbolization and abstraction
influences to some extent the prevalence of
auditory and visual hallucinations. It is not
unreasonable, for instance, to suggest that
the prevalence of visual hallucinations in
non-Western patients may be relevant to a
general orientation toward the perceptual
(concrete) rather than the conceptual (ab-
stract) aspects of the environment. Using a
Middle Eastern sample, Al-Issa (1967) found
that illiterate schizophrenic and normal sub-
jects gave more concrete definitions of words
than did their literate counterparts. Price-
Williams (1970) also found a relationship
between literacy and concept formation in
Nigerian children. It is also possible that
in illiterate societies where people are taught
more through actions (interacting with the
physical environment) than through words
(as in Western school education), vision
is more culturally emphasized than audition
in communication with the environment, and
this may bring about a tendency toward visual
hallucinations and imagery. This tendency
may be enhanced by the cultural (social and
religious) connotation of vision in some non-
Western societies.
The finding that visual eidetic imagery is
more prevalent among unacculturated non-
Western subjects than European or Western
educated native subjects is compatible with
the present hypothesis. It is in accord with
my interpretation of visual hallucinations that
visual eidetic imagery is attributed to the
dependence of the society on the develop-
ment of visual skills and representations
rather than on verbalization and symboliza-
tion (Mountford, 1961; Porteus, 1931; Sheehan
& Stewart, 1972).
The present proposition of relating halluci-
nations to different levels of conceptualization
is not incompatible with recent theory and
research in schizophrenia. On the conceptual-
perceptual continuum, overinclusive patients
seem to function nearer to the conceptual
level and they tend to develop delusions and
 HALLUCINATIONS 583

auditory hallucinations more frequently than attitudes toward these symptoms, for example,
do their underinclusive, withdrawn counter- social and cultural beliefs about hallucinations
parts (Lowe, 1973; Payne, Caird, & Laverty, may play a certain part in the consideration
1964). These two groups of overinclusive and of these symptoms as pathological in certain
underinclusive patients have been found to situations, but less pathological or even normal
attend differently to stimuli in the environ- in others. American-British comparisons and
ment (broad vs. narrow span of attention) studies relating hallucinations to social com-
and to use different strategies in processing petence or social conformity are important
information (low redundancy vs. high redun- steps in understanding the effect of social
dancy) (Cromwell, 1972; Silverman, 1964). factors on the relationship between pathology
The differentiation between conceptual and and symptoms.
perceptual functions in the study of thinking The investigation of factors involved in the
disorder in schizophrenia has also been em- tendency of the individual to attribute reality
phasized recently by Al-Issa (1972), Al-Issa, status to his imagery and/or to confuse reality
Bakal, and Larkin (1975), and Magaro (1974). with fantasy may elucidate the process under-
Though these approaches to schizophrenia lying hallucinations. The hypothesis that nega-
have not been validated in a non-Western tive attitudes might contribute to this con-
context, descriptive studies of Asian and fusion between reality and fantasy and to the
African hospitalized schizophrenics seem to pathological connotation of hallucinations
indicate that although paranoid schizophrenics needs to be investigated within different social
with auditory hallucinations are rare, with- and cultural contexts.
drawn schizophrenics with visual hallucina- Anthropological and behavioral data sug-
tions are the dominant type (Al-Issa, 1970; gesting a relationship between awareness of
Murphy, 1967). Systematic cross-cultural re- external conditions precipitating hallucinations
search is needed to validate these observa- (spirits, environmental factors) and the modifi-
tions and to provide evidence for the rela- cation or termination of the experience present
tionship between thinking and perception an interesting area of research (Bourguignon,
disorders in schizophrenia as investigated in 1970; Rutner & Bugle, 1969; Weingaertner,
the laboratory, and hallucinatory experiences. 1971). There seem to be some similarity be-
tween these data (e.g., non-Western interpreta-
Summary and Conclusions tion of hallucinations in terms of possession and
the social control of these experiences) and
Clinical and anthropological data indicate data from research on beliefs in the external
social and cultural differences in the frequency locus of control and the amenability of these
of, and attitudes toward, hallucinations. There beliefs to social influence (Lefcourt, 1972).
appears to be a paucity of data in this area Studies are needed to investigate the relation-
of research relating hallucinations to specific • ship between the disturbed reaction of the indi-
social and cultural factors, such as social vidual, and his faulty labeling of, or his at-
class, ethnicity, ecology, Westernization, and tribution of different causes to private ex-
acculturation. I have indicated that atti- periences, including imagery and hallucinations
tudes toward hallucinations may affect both (Singer, 1974).
the frequency and the content of hallucinatory Both reinforcement and drive-reduction
experience and emotional response to it. Un- (cathartic effects) theories of fantasy do not
fortunately, the attitudes of the professional, seem to explain the persistence and resistance
of the patient, and of his group toward hal- to treatment of schizophrenic hallucinations
lucinations have not been as systematically with aversive content. The present discussion
investigated as those toward mental illness suggests that sociocultural factors (e.g., nega-
(J. G. Rabkin, 1972). It has often been tive attitudes and the reluctance of patients
observed that hallucinations and other symp- to communicate their hallucinations) may
tomatology tend to be inconsistently related make hallucinations functionally autonomous
to specific psychiatric entities. This incon- and less relevant to the immediate social
sistency may, however, reflect differences in stimuli, though they may remain adaptive to
584 IHSAN AL-ISSA
the individual. It may be of interest to in-
vestigate the effects of institutionalization
and chronicity on the degree of accessibility
of hallucinations to social stimuli and social
control.
Reference Note
1. Draguns, J. G. Problems in comparing psycho-
pathology across cultures. Paper presented at the
International Congress of Applied Psychology,
Montreal, July-August 1974.
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Received February 9, 1976 •