Myreille St-Onge, Psychologist, Ph.D.
I am an associate professor at the School of Social Work and Criminology at Université Laval in the province of Québec, Canada. Previously a full professor at this school, I was interested in the field of mental health, which I taught at the undergraduate and graduate levels. Some themes were particularly dear to me, including the possibility for people with mental health problems to recover and participate fully in society. I have conducted a number of research projects, including some related to the phenomenon of voice hearing, funded by the Social Sciences and Humanities Research Council of Canada. I was a Visiting Research Fellow at the Institute of Psychiatry in London to further investigate the subject. I have been involved in the development of innovative practices in this area. In parallel to this development, a provincial network of voice hearers was created. I am currently involved in works conducted by this group. I obtained a doctorate in community psychology from the School of Psychology at Université Laval. I did a postdoctoral fellowship at the Douglas Hospital (now the Douglas Mental Health University Institute). I am a member of the Board of Psychologists of Quebec.
The content of this article was last updated on January 15, 2023.
Introduction
The phenomenology of auditory hallucinations
Their prevalence
The characteristics of the voices
Another systematic review of 36 studies conducted with adults compared voice hearers who received clinical care (clinical voice hearers) with voice hearers who did not receive such care (healthy voice hearers) (Baumiester and colleagues, 2017). For 17 of the studies that reported data on the phenomenology of the voices, certain physical characteristics (source, audibility) were comparable between the clinical population and the healthy population. As for the frequency and duration of the voices, they were less frequent and the episodes were shorter in the healthy population compared to the clinical one. The fact that some voice characteristics are similar in these two populations suggests that AH are based on a continuum of experiences rather than being a phenomenon in discontinuity of experience (Baumiester et al., 2017; Beck et al., 2009; Linszen et al., 2022). In the clinical population, AH are more negative and more systematically attributed to external sources. Thus, these individuals tend to believe that their voices are very powerful and this causes negative affective reactions (for a detailed description of the characteristics of voices, see the chapter on this topic in my 2017 book [written in French]).
In one of the first studies comparing voice hearers with a psychiatric diagnosis (schizophrenia or dissociative disorder) and voice hearers with no diagnosis (n = 48), important differences were found between these three groups (Honig et al., 1998). These significant differences were as follows: 1) the onset of the voices was earlier for those without a diagnosis (primary school) than for those with schizophrenia; and 2) both groups of people with a diagnosis heard their voices more regularly, these voices spoke more often about them (in the third person), commanded their thoughts, and were more often negative (100% of those with schizophrenia, 93% of those with a dissociative disorder, and 53% for the group without a diagnosis). None of those without a diagnosis were frightened or controlled by their voices, whereas 78% of those with schizophrenia and 84% of those with a dissociative disorder were frightened by them, and felt controlled by them in almost the same proportion (Honig et al., 1998, in St-Onge et al., 2005, p. 139). In addition, 50% of all participants (three groups combined) had experienced abuse and neglect during childhood (Honig et al., 1998). The more recent systematic review by Baumiester and colleagues (2017) – which included Honig and colleagues’ study – comes to the same conclusions.
The findings that the prevalence of the phenomenon is higher in children and adolescents and that it is related to traumatic experiences point toward the usefulness of a preventive and early intervention. Indeed, several findings support the link between traumatic experiences and the experience of AH (Cameron & McGowan, 2013; Escher, 2012; Hayward, Strauss, & Kingdon, 2018). Sandra Escher (2012), a specialist in the study of the phenomenon in children and adolescents notes that, despite a 16-fold increase risk of later developing a psychotic disorder in children who hear voices, the actual number of children who develop such disorder remains small (Escher, 2012). In her doctoral study that she carried out over three years with 80 of these children and adolescents, 60% no longer heard voices at the end of the study. She highlighted that the most important factors in explaining this outcome were accepting the experience of hearing the voices as real and exploring the issues that led to this experience (e.g., a bullying situation at school), while normalizing the fact that it is not uncommon for the voices to reflect this experience. Thus, the relationship that the children have with their voices change and their development is no longer compromised (Escher et al., 2002; Escher, 2012).
Beliefs in relation to the voices
There are four types of beliefs: their identity, their purpose (benevolent or malevolent), their power, and finally, the consequences of obeying or disobeying them. This conceptualization comes from the pioneering work of English psychologists Chadwick, Birchwood, and Trower of the University of Birmingham.
The identity of the voices
Identity is what the voices represent for the person: a deceased parent, a child, a spiritual entity, an individual who abused them, etc. For example, for people who have experienced a trauma, it is common for the voices to take on the identity of the people connected to that trauma (Hayward, Strauss, & Kingdon, 2018; Romme, 2012). Traumas are also associated with the persistence of the voices (Maijer et al., 2019). According to Hayward, Strauss, and Kingdon (2018), when a person has been bullied or experienced a traumatic event, it is very common for them to hear the threats they experienced during that event multiple times in the form of the bully’s or abuser’s voice (for instance, the person might hear “I’ll kill you if you tell,” or the voices might tell them to kill themselves). For Romme (2012), a social psychiatrist from the Netherlands who initiated the international Intervoice movement, “The identity of the voice and its characteristics combined with the content give the most information about who the voices represent (often people involved in the trauma) […]” (Romme, 2012, in St-Onge, 2017, p. 25).
The purpose of the voices
The power of the voices
The consequences of obeying or disobeying the voices
According to individuals who hear malevolent voices, obeying or disobeying the voices could lead to consequences. For example, when imperative voices give orders to the person and they choose not to follow those orders, they might believe that something negative will happen to them. Even if the voices do not give orders, the person may believe that by ignoring them, the voices will become angry and harm them (Chadwick et al., 2003). Furthermore, the content of the voices can refer to weaknesses that the person does not wish to reveal and over which they do not seem to have control. When faced with this lack of control, the person believes that they cannot escape them, thus developing beliefs in the omnipotence of the voices (Chadwick et al., 2003). People who feel they have more control over their voices have significantly fewer depressive and anxiety symptoms (Morrison et al., 2004).
Why might psychologists be more interested to work with people who hear voices?
There are several reasons why psychologists might be more interested in working with these individuals. First, this phenomenon is prevalent in clinical populations, but also in the general population – one out of ten people according to Maijer et al. (2018). Berry and colleagues (2022) demonstrated with 335 individuals who hear voices that many of these individuals want to receive a psychological treatment. The majority mentioned that they would start a psychological therapy if it were offered to them. It should be noted that antipsychotic medications do not improve auditory hallucinations for a large proportion of individuals – 25-50% according to Newton et al. (2005) – and that their use is associated with important side effects (Berry et al., 2022). Thus, according to Berry et al. (2022), “psychological therapies offer an arguably safer and more collaborative form of treatment.” (p. 2).
More recently, the phenomenon has been addressed from a transdiagnostic approach. Indeed, there is a growing recognition that the phenomenon of voice hearing is found in people with diagnoses other than the schizophrenic disorder (Merrett et al., 2022). These researchers, who published a phenomenological study comparing voice hearers with a borderline personality disorder and voice hearers with schizophrenia, showed that their experiences were similar. This reinforces the relevance of adopting such an approach to work with voices. Also, the fact that voices, in the new paradigm, are no longer conceptualized strictly as symptoms, has allowed for the development of voice-specific therapeutic approaches such as acceptance and engagement therapy coupled with mindfulness interventions (Strauss, 2015).
Psychologists, with their specific knowledge, could act early to prevent the deterioration of the mental state of young people who hear voices. Several studies have shown that a traumatic experience precedes the experience of voice hearing. By normalizing voice hearing – as Sandra Escher did in her doctoral study – we can ensure that young people will be more inclined to accept this phenomenon and benefit from psychological help. Moreover, validated questionnaires and interviews that are adapted to their age can facilitate the description of their experience (Escher, et al. 2011; Majier et al., 2019). As the latter authors point out, children and adolescents, as well as their parents, have a need for help and information, preferably through a global and destigmatizing approach.
Interviews have also been developed for adults (Escher et al., 2011; St-Onge, 2017). These tools were created in a research setting – both for children and adults – but they are also valuable in a clinical setting to explore the experience of voice hearing. These tools can help professionals developing their confidence in working with people who hear voices.
Using the framework created in the study by St-Onge et al. (2008-2011), and other research that I have conducted in the field, I have demonstrated that the different forms of voices, either malevolent or benevolent, have a function for the voice hearers. In other words, they have a utility based on the conceptualization of the third wave of cognitive behavioral therapies (Dionne & Neveu, 2010). Of all the functions identified (see St-Onge, 2017, p. 36-39), only one could lead to immediate intervention: the one that commands the person to kill themselves or someone around them (imperative voices). Similar to intervening with individuals who present a high risk for suicide, tools for risk-management can be used. If the risk is imminent, a psychiatric emergency is required. Moreover a therapeutic guide has been published for working with these types of imperative voices (Meaden et al., 2013). Furthermore, all functions (critical, comminatory, imperative, insulting, counseling, humorous, reassuring, predictive, and protective) can help to create a “scenario” in which the voices play various roles. This allows us to draw a complex picture of the relationships between the different voices, and ultimately, to help people recognize that these voices come from themselves (St-Onge, 2017). But for this to happen, it is essential that these people have access to psychological or psychosocial help to succeed in emancipating themselves from these voices.
The team of Chadwick and his collaborators (2003) showed that voices can be understood with the ABC cognitive model (A for activating event, B for belief system, and C for consequences). In this model applied to the phenomenon, voices are an activating event – which is qualified as internal – in relation to which the hearer develops a belief system, leading to possible negative consequences such as depression, anxiety, self-mutilation, avoidance, etc. This team later incorporated social rank theory into this model by emphasizing the role of reassurance and avoidance behaviors in maintaining and even exacerbating the negative consequences of the voices (Trower et al., 2010). In doing so, they highlighted that the voices are a reflection of social relationships, and that people hearing voices often feel inferior to other people in the community. Hearing powerful voices increases this sense of subordination. In this refined ABC model – the social rank theory –, it is indicated that voices (A) are perceived as dominant by the people who subordinate themselves, leading to a belief system in the omnipotence of the voices (B), which leads the individual to experience distress and engage in avoidance behaviors (C). This loop prevents them from disproving the power of the voices and challenging the self-deprecating beliefs that are fostered by these malevolent voices (Trower et al., 2010).
Based on this cognitive model, psychological therapies for disturbing voices have been developed (Hayward et al., 2011). These authors, however, focus more on people’s relationship with their voices rather than on their beliefs in relation to the voices. Indeed, research has shown that the relationships that people develop with their voices share many similarities with the relationships they have developed through their social network (Hayward et al., 2011). These authors conducted a systematic review of the research that was conducted in this field between 1999 and 2010. The results showed that it is possible to change a dominant relationship with one’s voices (which is very common in people with a psychiatric diagnosis) into a more assertive and caring relationship. It is also known that voices sometimes result from the fact that the hearers are isolated. Thus, the voices serve a relational function – that is, they are useful for breaking isolation – when hearers do not have access to interactions in their social network (Hayward et al., 2011; Hayward & Paulik, 2015).
The cognitive behavioral therapy developed by the teams of psychologists Hayward and Paulik aims at enabling the person to change the nature of their voices: from malevolence to benevolence, just as it is done with people who are in conflict with others. Through a series of role-plays, the person is invited to defend their right to be treated with respect, whether by the people around them or by the voices. A randomized pilot study showed significant quantitative results, with a large between-groups effect on distress that was maintained at the follow-up. These results suggest that relational therapy may be an effective intervention for reducing voice-related distress (Hayward, Bogen-Johnson, & Deamer, 2018). At the end of the therapy, these authors conducted interviews with nine participants to give them the opportunity to share their opinion on the changes they perceived or did not perceive regarding their disturbing voices. They conducted a thematic analysis of the content of the interviews, which allowed them to identify three themes related to these changes: 1) changes in relation to themselves (a higher sense of well-being by discovering hidden strengths; learning to become more assertive with the voices by gaining more control and breaking the cycle of powerlessness; positive effects on their ability and desire to connect with others); 2) changes in relation to the voices (for some, the voices became calmer or more positive, for others, they became more vocal and threatening, and for one, the voices stopped) and 3) changes in relation to the role-plays (the participants found the role-play to be anxiety-provoking at first, but despite their reservations, they thought that it was important in the therapeutic process and an essential part of the changes they observed).
The fact that the voices become more vocal in the context of therapy (or group intervention, for example) is a phenomenon that is often encountered. One possible explanation is that the anticipated change in an intervention may cause anxiety. A voice may tell them “don’t listen to him, he doesn’t know what he’s saying”. The person, at that point, may respond with an avoidance behavior. It is therefore important to know this. At this point, the psychologist can ask the person directly if they hear a voice telling them not to not to initiate a change. In this way, the psychologist can reassure the person about his or her real motivations and encourage him or her to continue the work.
It is also possible to use a guide developed by Hayward, Strauss, and Kindgon (2018) in which there are exercises to help voice hearers question the veracity and power of their voices. This guide is a valuable tool for psychologists who work with these individuals.
Finally, it is important to consider that voice hearers, regardless of their diagnosis, often experience distress or anxiety as a result of their interpretation of the powerful and negative voices they hear. Psychologists possess the necessary training to treat depression and anxiety, regardless of the source of the distress.
Summary and conclusion
Although voices (and related delusions) may at first seem impossible to understand (Kingdon & Turkington, 2005), contrary to popular beliefs, these manifestations are connected to past experiences; therefore, they are not in discontinuity with experience and it is possible to find their meaning in order to question them and reduce their influence. It is important to realize that this work is not exclusive to the discipline of psychiatry. In the new paradigm, we invite professionals from all disciplines related to mental health, including psychologists, I would say first and foremost, to be open to the possibility of intervening with people who hear voices and to develop alliances with them. The new psychological approaches specific to voices lead us “to no longer consider AH as symptoms, but as voices with rich and meaningful content that can be explored” (St-Onge, 2017, p. 14) with the aim of helping voice hearers to break their isolation.
I want to highlight, once more, one of the central factors related to the maintenance and exacerbation of the voices: avoidance. As with OCD, when voices are distressing (like obsessive thoughts), people tend to neutralize them by resorting to safety behaviors (rituals). For people who hear voices, these behaviors can take many forms: saying “stop”, being hostile toward the voices, using ear plugs, etc. All of these behaviors provide short-term relief, but in the long run they are ineffective. This is why it is important to use methods that allow people to engage with their voices. In my chapter on new therapeutic approaches (St-Onge, 2017), I focused on approaches that allow people to engage with their voices rather than confront them, since confrontational strategies contribute to the emotional or behavioral avoidance of the voices. Working with voices can be done through a variety of methods that I have discussed in this chapter. One that has been the object of several studies and shows promising outcomes – in reducing distress associated with the voices – is relational cognitive behavioral therapy, which I discussed above (Hayward et al., 2009; Hayward & Paulik, 2015; Hayward et al., 2021; Paulik, Hayward, & Birchwood, 2013; Paulik, Hayward, & Stein, 2013).
Finally, since the late 1980s, people who hear voices – including professionals – have created support networks around the world (see the Intervoice website) that have allowed for the development of experiential knowledge that can be drawn upon to help these individuals. In England alone, there are over 180 support groups dedicated exclusively to people who hear voices (Dillon & Longden, 2012). In Quebec, since 2012, a network – “le réseau des entendeurs de voix québécois” (REVQ) – has been developed including more than thirty community organizations that offer supportive group sessions, but also other activities to accompany and empower voice hearers. Some institutions in the public health and social services network have also developed such support groups. We can collaborate with these organizations to integrate our different forms of knowledge for the benefit of people who are stigmatized by the experience of hearing voices.
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