When Steve was a little boy, around two or three, he heard the first voice. It came early in the morning, while he lay in bed. From across the room, a well-spoken English voice said, “Don’t worry Stephen, we’ve got a lovely, beautiful day for you today."
The day before, Steve had been upset that spring wasn’t particularly warm or sunny in Northeast England, where he lived. Now, a voice had appeared to comfort him. “I remember distinctly thinking that it was unusual,” Steve, now 56, tells me. “It didn’t freak me out or anything. It was as real as my voice is to you now.”
It was the first of many voices that Steve would hear throughout his life. But unlike some people with diagnoses of psychosis or schizophrenia—who hear voices that cause major disruptions in their daily lives—Steve’s voices never bothered him. He’s never been diagnosed with a mental illness, and never sought treatment from a therapist. Steve is a “healthy voice-hearer”, and some researchers are hoping to study people, like Steve, to understand why they can hear voices and live their lives without the need for clinical care, and others end up plagued by similar voices.
Emmanuelle Peters, a clinical psychologist and researcher at King’s College London, has been interested in the spectrum of psychotic experiences since she began her career over 25 years ago. She says that though we call seeing and hearing things that aren’t there, “psychotic,” these hallucinations are actually very common in the general population, just over seven percent.
Healthy people can have auditory and visual hallucinations, she says, that are just as loud and vivid as those who need clinical help. “The people that we looked at have had fairly frequent hallucinations,” she says. “It’s not just a one-off, say in the context of a bereavement, but people who’ve had them for an average of 31 years. But they’re never problematic for them.”
The difference might partly be explained by what Peters calls appraisals, or how an individual interprets their hallucinations and what meanings they give them. She believes that studying healthy appraisals could lead to novel therapy techniques for people troubled by their voices.
In a study published in December in The Lancet Psychiatry, Peters and her colleagues interviewed a group who’d had psychotic experiences but never needed clinical help, another group who’d had psychotic experiences and did need clinical care, and a control group. They found that the clinical group was more likely to have paranoid or personalizing interpretations of their voices and visions. They thought their psychotic experiences were more dangerous, less controllable, and more negative overall.
Past work has had similar findings, but Peters says it was hard to tease apart the appraisal and the severity of the psychotic experience. In other words, perhaps a person interpreted their voices as more dangerous because the voice was more volatile. In their recent paper, Peters and her group also put their participants through an “anomalous task,”—where a person is placed in a strange experience. For example, in one task they played a card game, in which a computer or human tester seemed to be able to read the participants' minds.
In this experience, which was odd (but neutral) the clinical group still found it to be more threatening than the non-clinical group. Peters says this finding confirms their theories: that the way psychotic experiences are interpreted differs between people with and without a need for care.
“From the work that Emmanuelle Peters has done, we know that the intensity of the voices that one person hears is not the most important factor in determining whether you suffer from the voices or not,” says clinical psychologist Lucia Valmaggia. “It’s much more the attributions that you give to the voices. Where you think the voices are coming from. Whether you think they have power over you, or not. Whether the power that they have, you think is positive or negative.”
"Obviously there are also some biological elements to psychotic disorders that can’t be ignored," Peters says, so it's not all about appraisals. "If you get really nasty voices who say nasty things all day long, that can be biologically determined, and you’re then more likely to end up having a psychotic disorder. iI’s not either or, but I think the cultural element and the social element is often gone underrated."
So how do you arrive at positive appraisals? Peters says that many people who don’t need therapy grow up in families where hearing voices is accepted, or seen as a kind of gift. Many have spiritual or supernatural explanations for their voices; they think they are psychic or can commune with spirits. Regarding such spiritual explanations as valid could shift how therapy currently tries to address hallucinations. Rather than trying to eliminate them, therapists could try to change appraisals to anything that helps a person interpret their experiences in a positive way—even if it utilizes magical thinking.
“Traditional [cognitive behavioral therapy] is about having a more reality-based appraisal,” Peters says. “What we found was that people without clinical problems, the healthy group, were not necessarily appraising their voices as something that was just part of their mind, or something that they were generating themselves. They very much believed that there may have been spirits, there may have been outside forces, entities.”
Peters says that therapists shouldn’t need their patients to believe that their voices are coming from their brain, or are a product of mental illness. If they have an appraisal that works for them, a therapist should go with it, if it helps to make the voices non-threatening.
Steve has nicknames for the voices that he hears the most. “Young Posh Bird,” or Celia, is a young woman’s voice in her mid-20s. “She would make the Queen sound common,” he says. “Really cut-glass, Oxford University English.” There’s also “Old Posh Bloke,” a voice in his 70s, whom Steve says sounds like a college professor, and “Young Posh Bloke,” who Steve thinks is that first voice that appeared in his bedroom.
“Those three crop up time and time again,” he says. “They often say something that is within context. Sometimes very pointed. Sometimes, sounding a bit miffed.”
Voice like Young Posh Bird's sound distinctly like they’re coming from outside his body, he says. “It’s like you hear it with your ears,” he says. “You either hear it with your ears, or it seems to come from the middle of your head. More often with me, it’s slightly around my right shoulder, into my right ear. I can only remember one instance of it coming into my left ear.”
Steve's other voices are more internal—but still easy to differentiate from his own inner thoughts. Those are more random, Steve says, like turning on a radio for a few seconds and hearing a snippet of conversation. Once, while meditating, Steve heard, “Tell him I’ve been to Mimi’s.”
“What on earth does that mean?” He laughs.
Steve has a pleasant relationship with these voices, as a result of his positive appraisals, but others are not so lucky. Tom Ward, a clinical psychologist, says that many feel powerless or scared of their hallucinations, and continually threatened. His belongs to a group at King’s College London that is using virtual reality, to change those relationships with their voices.
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It's called the AVATAR project, and using virtual reality, they give a physical body to the voices their patients hear. Ward then talks, as the voice, to try and change the dynamics of the relationship. The goal is to give the patient a feeling of more power, or allow them to interpret and appraise the voices in a better way, like Steve does with his voices.
Some voices are indisputably bad, Ward says—voices that deal with death, rape, violence, or are angrier and brasher than Old Posh Bloke. But a lot of his patient's voices begin hearing more neutral voices—a disembodied laugh or a vague warning–and in those cases, shaping the interpretation can make a big difference.
Ward asks his patients for as much detail about the voices as possible, and what the patient imagines they looks like (most will already have a corporeal image of their voices). On the computer, they bring the voice to life, matching it visually and vocally with “the tone, the gravely-ness, the breathiness, the gender of the voice, and the roughness of it,” Ward says.
Ward then speaks as the voice in conversation with the patient. At first, he will mimic the negative things the voice says, but eventually give the patient more power in the dialogue, show submissiveness, and shift the nature of the relationship as the person shows more strength and assertiveness.
In a recent study in The Lancet Psychiatry, Ward and his colleagues found that those who received AVATAR therapy had quick and lasting reduction in the severity of their hallucinations by the end of 12 weeks that was significantly better than a group that only got supportive counseling. Ward says that for many patients, the voices changed, and became less threatening or less violent. Others' voices nearly went away, and people could go hours without hearing anything. Some people’s voices didn’t change, but the change in appraisal or relationship helped them to better cope.
Like Peters, Ward thinks that to help his patients the most, his goal shouldn't be only to make the voices go away, but to help them think about them in a different way. “People have been laboring under this misapprehension that what we need to offer people is eradication of their experiences,” he says. “Some of this research from Emmanuelle and myself is actually saying that these experiences are part of human nature, part of their consciousness. The important question is to understand why is it that some people have these experiences and they become even life-enriching, enhancing experiences."
Steve is a somewhat rare case of a healthy voice-hearer because he doesn’t have a spiritual explanation for his voices, and he’s not drawn to the supernatural world at all, he says. The appraisal or interpretation that works for him is a bit simpler: he doesn’t need one.
“I’m comfortable with uncertainty," he says. "I think the problem is that most people aren’t. Especially around this sort of thing. I find it interesting. To me, it’s an interesting problem. It fascinates me–when I can be bothered to think about it.”
It helps, he thinks that his voices never get too negative or violent. I ask him if he's ever heard a mean voice. He said once he was in his house getting ready for bed and he heard, "Oy, wanker!" He said he laughed, and responded, "Well, same to you!"
For the past three years, Steve hasn’t heard any of his voices. On New Years Day in 2015, he got sick with prostatitis. For some reason, he hasn't heard a voice since he's been sick. While other patients struggle to get their voices under control, for Steve, it could be his an absence of voices that finally rattles him.
"I haven’t really got an explanation for it," he says. "Do I miss them? If I think about it. A bit. The longer it goes on. I remember saying: if they haven’t come back in a year, I’ll start to get a bit worried. I don’t really feel that worried, but it would be a shame. To be honest, they’re quite entertaining."
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