How individuals who hear voices relate with therapists about voice experiences

Hearing Voices, Patients/Therapists

In an issue that aimed to reconsider the contributions that phenomenology offers to the practice of clinical psychology, Davidson outlined the ways in which transcendental psychology reconceptualized both research and clinical practice. One of the things he attempted to do in his investigation was to bring 'suspicious' events, such as hearing voices (auditory hallucinations) into a more mainstream setting, one in which a "phenomenology of respect" held the high ground. Davidson was not attempting to convince anyone that the heard voices were real; rather, "by virtue of the phenomenological reduction, to suggest that people who hallucinate actually ("really") do have experiences of hallucinations. Hearing a voice when no one else is around is an actual experience just like any other" (2004, p. 149+). Using the language of pop psychologists, Davidson suggested that the experiences of hearing voices "are what they are" and that "The question for us is how this changes our approach to psychological research and treatment" (Davidson, 2004, p. 149+).

Davidson traced phenomenology into clinical psychological and psychiatric practice through Karl Jaspers, a follower of the philosopher Heidegger's work. He notes, too, that while the existential and empirical approaches to clinical practice that were based on this work were nonetheless heavily influenced by Freud, with various schools regarding phenomenology having been developed by Freud's students (Davidson, 2004, p. 149+).

It is by way of this path that Davidson legitimizes phenomenology as an appropriate means of dealing with auditory hallucinations. While Davidson is a purist regarding phenomenology, he also posits the fact that Jung, Ferenzi and Erickson also offered views of events such as auditory hallucination that were seductive to phenomenologists. "In this respect, phenomenology and psychoanalysis make, at best, curious bedfellows" (Davidson, 2004, p. 149+). Still, the insistence on articulation of the obvious would clearly have something to impart to a clinician dealing with 'voices,' if only in the fact that the therapist would necessarily need, then, to determine the 'reality' of the issue, perhaps indeed lending respect to the work with the patient.

Freud, of course, would have been "highly skeptical" of any such approach both because of the nature of subjectivity (which is clearly what the therapist would be dealing with, from any angle) and because of what he considered the latent content of experience that could not be drawn forth by reflection alone: The vast majority of psychic life is considered by psychoanalysis to lie outside of the person's awareness, at various levels of the unconscious. And even for Freud, the only access to this unconscious was through the (further) indirect means of interpretation" (Davidson, 2004, p. 149+). Clearly, then, to Freud and his followers, a phenomenological approach to auditory hallucination would be anathema.

Davidson does, however, offer a cogent way for therapists to look at the experience of auditory hallucinations. He asks what it means for phenomenologists to insist that auditory hallucinations are legitimate experiences. He suggests it is similar to asthma; not everyone who gasps for breath under various circumstances is asthmatic; likewise, he suggests, not everyone who hears voices from time to time is experiencing psychosis. He argues, finally, that auditory hallucinations mean nothing in themselves, just as gasping for breath means nothing, until it is viewed in a constellation of other events/behaviors that, in the aggregate, add up to a problematical issue (Davidson, 2004, p. 149+).

Earlier work by Davidson (2002) noted " Through an exploration of the constitution of sense of self in the experiences of two people with schizophrenia, we see how cognitive disruptions, auditory hallucinations, and delusional ideation may be related to funda- mental peculiarities in a person's experiences of intentionality and his/her resulting sense of agency and identity" (p. 39+). While he did not claim phenomenology could provide complete explanations of psychosis, he asserted that it can shed light on that transcend single disciplines, such as auditory hallucinations, which are of interest to therapists, anthropologists, and even clergy.

Thalbourne & Delin tried even harder to make auditory hallucination fit into the parameters of recognized psychosis, contending that religious luminaries such as Theresa of Avila and St. John of the Cross may have been, as they put it, 'manic depressives,' manifesting various abnormal states such as the hearing of voices (1994, p. 3+).

Moreover, they note:

To anticipate our results, we believe that we have serendipitously made something of a breakthrough in our understanding of the findings in this area by discovering significant linkages between the topic of paranormal belief and other psychological phenomena, including mystical experience, creative personality, and a number of variables of psychiatric interest (Thalbourne & Delin, 1994, p. 3+).

Thalbourne (1991) had examined the psychological aspects of mystical experience and had concluded that understanding the phenomena involved, including auditory hallucination, would require reports by normal individuals rather than by manic-depressives and schizophrenics. "Because mystical experience is usually considered a benign and even valuable phenomenon, it was of great theoretical interest to see whether in a statistical study -- as opposed to case study ... --there would be any association with mental illness, especially mania, which involves a type of elation that seems to have much in common with religious ecstasy" and often includes hearing voices (Thalbourne & Delin, 1994, p. 3+).

One of their most interesting conclusions, particularly for therapists, is the correlation they found between creativity and mystical experienced. They noted that Auerbach (1987) had also found that "the voices and visions of mystics are often an artistic expression of a creative mind. One also of such persons as William Blake, in whom there were combined the talents of poet, painter, and mystic, and closer to our time, the poet Anne Sexton, whose final opus was deeply mystical (Shurr, 1985)" (Thalbourne & Delin, 1994, p. 3+).

Thalbourne & Delin studied "transliminal" people -- those who are prone to transcending the thresholds of consciousness in more significant ways than most (Thalbourne & Delin, 1994, p. 3+) -- and found that they:

.Tend to a greater extent to be willing to undertake psychological experimentation, to regard dreams as meaningful and containing guidance, to report experiences of ESP (of the present and of the future), visions of the dead, healing powers, and contact from the Divinity. They report hearing voices and seeing more hallucinations; they experience more paranoid ideation, and are probably more likely to have consulted a psychiatrist (Thalbourne & Delin, 1994, p. 3+).

While the Thalbourne & Delin work may be at the outer edge of credible scientific investigation, work by Bemak & Epp concerning the mind-body dichotomy in schizophrenia is much closer to being a standard medical study. Indeed, they propose that, voices or no voices, psychotherapeutic interventions are "indispensable to the treatment of schizophrenia" (Bemak & Epp, 2002, p. 14+).

Some of their report, however, seems to echo some of the thoughts of the phenomenologists; they note that others who have observed schizophrenia describe the "glass wall" effect, which is characterized by flat affect, glazed eyes and agitation form stimuli only the schizophrenic individual is experiencing. All this, they say, seems to indicate a "private psychological experience more magnetic and absorbing than the questions of the clinical interviewer attempting to unravel the meaning of the visions and voices reported by these clients" (Bemak & Epp, 2002, p. 14+).

(One effort to provide information that provides nothing but a medical rubric, in the form of clozepine, a psychoactive drug costing almost $10,000 per year to administer to schizophrenics, also cited auditory hallucinations as one of the symptoms it would stop (Higgins, 1995, p. 124+).)

Laing also had theories concerning the voices heard by schizophrenics. Laing, too, seems to acknowledge some truth to the phenomenologists' viewpoint, noting that in addition to seeing illusions and hearing voices, the schizophrenic can also be 'real' "Among these (normal) attributes are the ability to see and think clearly, to experience inner tranquility, to relate to others meaningfully, to approach the world with trust, and to love others without deluding the true nature of their character (Laing, 1969).

Bemak & Epp, again acknowledging phenomenology as important to states in which hallucinations are present, wrote that "The phenomenology of schizophrenia may be compared to living within the imagery of Salvador Dali's surrealistic painting ...." (2002, p. 14+).

Bemak & Epp, despite providing a wealth of medical/scientific information geared toward the therapists' understanding of how to manage schizophrenics, conclude by agreeing more than disagreeing with the phenomenologists about the character of the condition that produces auditory hallucinations. They admit that "The prevalence of schizophrenia in creative individuals is a troubling thorn in psychiatry's disease model" (2002, p. 14+). And they also provide a 'laundry list' of those historical figures believed to have heard voices and yet who were not only considered normal (if eccentric or brilliant), but made major contributions to human knowledge. Their list includes "Kant, Swift, Shelley, Faraday, Newton, Copernicus, Linnaeus, Pascal, Socrates, Mozart, Beethoven, Handel, Kafka, Michelangelo, Poe, Da Vinci, Rembrandt, Schopenhauer, Spinoza, Dostoyevsky, Tolstoy, and Van Gogh ...." (Bemak & Epp, 2002, 0-. 14+).

While phenomenology constitutes one major thrust in understanding auditory hallucinations, being very loosely allied with Freudian concepts, and Laing's work as well, another viewpoint is held by the Jungians.

Jung and auditory hallucinations

Meyer (2003), in a discussion of Jungian symbolism in the movie, Spider-Man, notes that both masks and voices are essential to the movement of heroic characters through the plotline. Meyer is not, however, a psychologist, nor even an anthropologist; rather, she is a write about communications. Still, her work on Spider-Man tied several of the movie's themes to Jungian thought.

Halifax's work goes farther in bringing Jungian thought into the mainstream of psychological study. His work with shamans and shamanic ritual, important subjects to Jungians, posited aspects of schizophrenia in the initiatory journey of the shaman. Halifax cited Julian Silverman's conclusions in which schizophrenia was characterized as a disorder in which the "individual withdraws form society and the outer world and becomes preoccupied by internal processes with a resulting disintegration of the personality. The symptoms, broadly described, include autism and unreal ideation, disturbed perception and thinking, emotional liability and volatility, and bizarre behavior" (Halifax, 1990, pp. 53-58).

Likewise, "The initiatic crisis of the shaman in many ways resembles what is called schizophrenia. It also has features that are comparable to the journey of mythic heroes, to death-rebirth experiences in rites of passage, to the posthumous journey of the soul, to clinical death experiences and LSD experiences," according to Halifax (1990, pp. 53-58). Halifax claims that studying shamanism from a psychological viewpoint has helped in understanding the nature of what Halifax is careful to call "so-called mental disorders in Western culture" (Halifax, 1990, pp. 53-58).

In addition, and relevant for this investigation of the experience of hearing voices for both patient and therapist, "There are usually auditory and tactile hallucinations and distortions of the body image; individuals often suffer from an experience of dismemberment or dying, hearing voices, ritualistic behavior, fusion of higher and lower referential processes, and the individual can cognitively reorganize, including the reintegration of the personality and the assimilation of unconscious content into the sphere of consciousness" (Halifax, 1990, pp. 53-58.) It is interesting to note that Halifax mentions the idea of cognitive reorganization; it is possible, then, that cognitive therapies can work for schizophrenics hearing voices, despite the fact that this seems to hint at a greater role for phenomenology as well. It is equally interesting to note that Halifax contends that shamans are 'wounded healers,' or those who can help others because they have experienced various disease and/or abnormal states themselves and have transcended them. Although Halifax does not make a direct connection, it seems that this points, also, to a role for phenomenology. Jungian psychiatrist John Weir Perry, too, has outlined the roles found by Halifax, describing the schizophrenic process as a "Renewal of the Self," in which case, auditory hallucinations might be seen -- at least in a phenomenological perspective, as no more than 'self-talk' or a version of the "Dr. Phil" treatment by, for and about schizophrenics inhabiting their own phenomenological universe.

In another wave at cognitive therapy, Halifax also proposes that both schizophrenics in Western society and novice shamans can use their altered perception to good advantage "in the process of cognitive reorganization. That shamanism (with its voices) and schizophrenia (with its auditory hallucinations, to use more medically oriented terminology) simply reflect each other was also a belief held by the famous mythologist, Joseph Campbell, who once commented that "the schizophrenic is drowning in the same water in which the mystic is swimming with delight" (Halifax, 1990, pp. 53-58).

Pettid also investigated shamanic cultures and their alliance with hearing voices; his viewpoint was that such cultures were normal, if secondary, to the main culture (2003, p. 113+). In this viewpoint, too, auditory hallucinations can be seen as normal, although 'alternative'.

Others, too, have made the connection in their own rubrics. Anthropologist Anthony Wallace referred to "mazeway synthesis" in which the world is restructured by an individual in response to an overwhelming crisis and anxiety. Gregory Bateson felt that an acute psychotic event, such as hearing voices, could be a means to solving a pathological situation so that the individual could return to normal life with new insight. Anthropologist Victor Turner called such episodes a means for "transforming the obligatory into the desirable" (quoted by Halifax, 1990, pp. 53-58.)

Shamanic traditions and psychotherapy

It is clear that auditory hallucinations are often studied as part of a mystical complex, and not as unwanted mental/emotional aberrations per se. In a combination religious/historical/anthropological study, Ardery suggested that auditory hallucinations not only date to the start of what we now recognize as civilization, but in fact probably had something to do with humans becoming civilized to begin with. If Ardery is right, then hearing voices may not be the proper province of psychologists and psychiatrists.

Ardery contends that the best hypothesis to explain verbal hallucinations is that they were "a side effect of language comprehension which evolved by natural selection as a method of behavioral control.... " (Ardery, 2004, p. 83+).

Ardery's viewpoint is that of semantics, so it is not surprising that he creates a sort of vignette of an early society to explain the usefulness of auditory hallucinations:

[I]n fashioning a tool, the hallucinated verbal command of 'sharper' enables nonconscious early man to keep at his task alone. Or an hallucinated term meaning 'finer' for an individual grinding seeds on a stone quern into flour. It was indeed at this point in human history that I believe articulate speech, under the selective pressure of enduring tasks, began to become unilateral in the brain, to leave the other side free for these hallucinated voices that could maintain such behavior ....(Ardery, 2004, p. 83+).

He also maintains it was the invention of names that allowed auditory hallucinations to be recognized. At this point, Ardery appears to have joined the phenomenologists and others who actually see little to correct in the case of hearing voices. Ardery notes:

But once a specific hallucination is recognized with a name, as a voice originating from a particular person, a significantly different thing is occurring. The hallucination is now a social interaction with a much greater role in individual behavior...." (Ardery, 2004, p. 83+). It almost seems as if Ardery is using the 'tree falling in the forest' analogy. Does it make a noise? Likewise, are auditory hallucinations anything even worth dealing with? He seems to go beyond phenomenology on this score, suggesting that the only reason that we have any phenomena -- hearing voices or otherwise -- is because we have named them, bringing them to that side of the brain that must be conscious to see/feel/hear, etc.

Ardery also proposes that auditory hallucinations are essential to keep humans evolving, or even 'on task.' He compares them to simply individuals speaking to themselves from the subconscious about what needs to be done (Ardery, 2004, p. 83+).

Ardery suggests some highly unusual origins for auditory hallucinations, certainly. However, he also constructs plausible reasons that in the far reaches of pre-recorded history, the "stress threshold" for hallucinations was much lower than in either normal people or schizophrenics today. He also makes the point that a voice, any voice, is difficult for humans to ignore. He asks:

Why should such voices have such authority... Sound is a very special modality. We cannot handle it. We cannot push it away. We cannot turn our backs to it.... Sound is the least controllable of the sense modalities.... Consider what it is to listen and understand someone speaking to us. In a certain sense we have to become the other person; or, rather, we let him become part of us for a brief second. We suspend our own identities, after which we come back to ourselves and accept or reject what he has said. However, that brief second of dawdling identity is the nature of understanding language; and if that language is a command, the identification of understanding becomes the obedience. To hear is actually a kind of obedience (Ardery, 2004, p. 83+).

Religious viewpoint of hearing voices, vis-a-vis therapeutic issues

As is obvious, there are thinkers from many disciplines who have studied hearing voices. Not surprisingly, especially in view of the proposition that some of its own saints heard voices, the Episcopal Church has something to say concerning auditory hallucinations, or at least, concerning the traditions in which hearing voices seems to have found some acceptance irrespective of their position as indicators of mental illness. In explaining the basic beliefs of that church, Temple noted, "many Episcopalians find the psychology of C.G. Jung to be especially attractive. The Episcopal Church embraces among its members any number of skillful lay analysts whose attraction to Jung expresses the same interest others confine to spiritual direction (2002, p. 303+). In addition, church leaders in that denomination today have studied other traditions in which 'hearing voices' is much more acceptable than in Western society. Many Episcopal Church spiritual directors, according to Temple, are familiar with and embrace the Sufi tradition within Islam, as well as Zen, Taoist and Kabbalist traditions.

Medical considerations of 'hearing voices'

England has prepared a straightforward assessment not of what auditory hallucinations might mean vis-a-vis mental health, or world thought, or religion, although all of those surely have an impact on a working therapist and, often, the patient as well. England had noted that 'voice hearing and other subjective experiences pose serious challenges for nursing because of their implications for health and safety of voice hearers and others" (2002, p. 22+). She therefore set out to produce a practical manual for nurses in dealing with voice hearing.

England provides epidemiological information indicating that 10-15% of the population "experiences verbal auditory hallucinations at some point in life and 4% claim to have heard voices in the past year (Johns et al., 2002; Tien, 1991)" (England, 2002, p. 22+). This makes a case for Ardery's concept that auditory hallucinations were at one time even more prevalent among humans and may be, in fact, essential to human life. On the other hand, England points out that:

Research also points out that 25% of voice-hearing individuals meet diagnostic criteria for serious mental illness. These voice hearers commonly describe self-directed malevolent voices that are powerful and controlling (Gilbert et al., 2001). Those who are entrapped by powerful negative voices report low self-esteem, real or perceived victimization, and poor quality of life (2002, p. 22+).

England's work is fascinating, whether one accepts a psychopathological viewpoint of voice-hearing, a mystical concept, or an anthropological one. She notes that while many nurses have been taught that all voice-hearing is the same, there are gradations. She says schizophrenic voice hearers with a history of victimization usually report paranoid ideation and high intensity, high frequency voices, particularly voices commanding them to commit suicide. Those who suffered childhood physical abuse show potential to act on such voice commands (England, 2002, p. 22+).

Despite all the suppositions regarding hearing voices, England notes that very little is known about how such subjective experiences are tied to the integrity of the functional nervous system and self-esteem. Her research in that regard was intended to open new ways of "exploring the contribution that hallucinated voices make to health and illness. This information, in turn, will justify future efforts to empower voice hearers in the direction of health" (England, 2002, p. 22+), a suggestion that, in fact -- as anthropologists and others have said -- hearing voices may not necessarily be indicative of serious mental illness, or even of mental illness at all.