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    What can we learn from religious figures who heard voices?
    January 14, 2011
    Today research into the experience of hearing voices is typically done within a biomedical paradigm. Although this has furthered our understanding of the causes of hearing voices, it has also limited certain aspects of our understanding of the phenomenon. When researchers try and understand what the phenomenon of hearing voices is like, they typically do this against the backdrop of their contemporary theories of what causes voices. What theory they hold can bias them towards making certain assumptions about what voices are like. Today, the assumption, held by some researchers, that voices are random productions of a diseased brain (a position I do not subscribe to) shapes their view of the hearing voices experience. This view can lead to the idea that the content of voices is unlikely to be meaningful, useful or related to the person’s life. Thus, when asking people about their voices researchers do not enquire about these potential facets, and hence they are sidelined. This is problematic for a number of reasons, one of which is that we don’t get an accurate picture of the phenomena that we are trying to explain. How could a visitor from another planet understand what humans were like if they only ever dropped in when we were having wars? (yes, I know we're always having wars, but you see my point). This problem, is related to what elsewhere I’ve termed ‘theory-phenomenology drift’ (Laroi, de Haan, Jones, & Raballo, 2010), in which there is a tendency for what theories of x explain, to drift apart from the actual phenomenology of x, coming eventually to concentrate only on a subset of the varied phenomenology of x. This problem has long existed, and has manifested in a variety of ways. For example, as Leudar and Thomas (2000) have noted, the French psychiatrist, Pierre Janet (1859-1947) disbelieved certain aspects of what his patients told him about phenomenology of their hallucinations (what they were like) because they were not consistent with the model of hallucinations he held. One way to get a different sense of what properties of voices and visions our presently dominant biological/medical model may cause us to overlook is to head back in time to a different time, culture, and context, which didn’t have a predominantly medical view of such experiences. One such account is given by the 16th century Spanish theologian, St John of the Cross.   St John of the Cross St John of the Cross has been called the greatest psychologist in the history of mysticism. He was a member of the Catholic Order of Our Lady of Mount Carmel, which was characterised by prayer, silence, meditation and contemplation. Just like the early Desert Hermits, silence and contemplation seems to have opened the door to voices and visions for St John. He was born in a poor family in Spain in 1542, and led a varied and dramatic life, at one point being imprisoned for nine months in solitary confinement in a dark, cramped cell, measuring only 6 by 10 feet. Errol Flynn: The definitive Robin Hood After an escape worthy of Errol Flynn, made using a rope constructed from strips of bed-sheets, he spent the rest of his life writing, guiding, praying and directing the spiritual development of others across Spain. It has been written that no person knows what to do with the divine when it falls into their hands. Fortunately for us, St John decided to write about it, and he left behind him a systematic analysis of his experiences, which he termed supernatural communications. When we look at St John’s analyses of these experiences, we find that there are a number of experiences that he describes that are not given significant attention by contemporary research. The first can be called ‘voices that save’. St John classified hearing voices (or ‘locutions’ as he termed them) into three types: successive, formal and substantial. The latter type, substantial locutions, is probably the most interesting. St John argued that “one of these words works greater good within the soul than all that the soul itself has done throughout its life”. St Teresa of Avila, a colleague of St John’s, also noted that people who heard phrases such as “It is I (God), fear not” found them exceedingly powerful, calming and influential, and the memory of these voices could last for a lifetime. Such powerful and positive voices are still reported today. For example, Heathcote-James (2001) cites a contemporary account of a healthy woman, in a distressing situation, hearing a voice saying “But you have trust in God”. As a result of this, the woman described how she “felt great consolation and joy. I just cannot describe the sense that I felt, it was so beautiful it was indescribable”. These voices often seem to occur when people are in danger, under stress, or under physical or existential threat. For example, the mountaineer Joe Simpson, after a horrific climbing accident, was forced to crawl for four days back to his friends’ base-camp. During the latter stages of his agonising journey he began to hear a voice which was “clean and sharp and commanding” and which told him to “Go on, keep going”. These are clearly not random productions of a diseased brain. In a biological/medical model that ignores the meaningfulness or usefulness of voices, such experiences get swept under the carpet. St John’s contemporary, St Teresa, further noted that voices could refer to things that “one never thought would or could happen, so that the imagination cannot possibly have invented them”. This highlights the potentially creative nature of such experiences, and links into the relation between voices and creativity. Today, scattered reports show that voices can give novel and creative information. For example, authors report receiving inspiring and novel ideas directly from their voices and visions (Malone, 2006) and many personal accounts highlight the novel and original nature of such experiences (e.g., Romme & Escher, 1993). However, this aspect of AVHs is not formally researched today. This is possibly again due to the bio-medical paradigm encouraging the idea that AVHs are simply random, worthless productions of an abnormal brain. Overall, St John of the Cross’s writings show that his era was able to identify aspects of voices and visions that have been neglected by the modern biological/medical model. St John was well aware of positive, useful voices, as well as voices that give novel and original information, which have been mainly ignored by psychiatry today. When voices and visions become medicalised there is the risk that all such experiences are seen as worthless symptoms of an illness. Thus, it may be that it is only once we widen our stance to include other viewpoints in addition to a biological/medical model, that we can really start to understand voices.  For further discussion of many of these themes, references to sources, and a more detailed examination of St John of the Cross’s understanding of voices and visions, please see my paper: Jones, S.R. (2010). Re-expanding the phenomenology of hallucinations: lessons from sixteenth century Spain. Mental Health, Religion, and Culture, 13, 2, 187-208.  For an excellent article on St Teresa of Avila’s voices and visions, see the paper: Cangas, A.J., Sass, L.A., &  Pérez-Álvarez, M. (2008). From the Visions of Saint Teresa of Jesus to the Voices of Schizophrenia. Philosophy, Psychiatry, & Psychology, 15, 3, 239-250. Other references: Heathcote-James, E. (2001). Seeing angels. London: John Blake.  Laroi, F., de Hann, S., Jones, S.R., & Raballo, A. (2010). Auditory verbal hallucinations: dialoguing between the cognitive sciences and phenomenology. Phenomenology and the Cognitive Sciences, 9, 225-240. Leudar, I., & Thomas, P. (2000). Voices of reason, voices of insanity: Studies of verbal hallucinations. London: Routledge. Malone, D. (Producer and Director). (2006, June 18). Voices in My Head [Television broadcast]. London: Channel 4. Romme, M., & Escher, S. (1993). Accepting voices. Shaftesbury, UK: Mind.
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    Voices on Radiolab
    March 21, 2011
    Last year I had the opportunity to talk to the Radiolab team about the topic of voice-hearing. The interview went out as part of their Words episode, and also formed part of a follow-up podcast. In the podcast, you will hear an interview that Pat Walters did with a voice-hearer in Denver. More details on the show, and the ideas discussed there, are in this blog post.
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    The Peopled Wound
    March 29, 2011
    What does it mean to hear voices? Many, if not most, would claim it to be a symptom of a brain disease or a mental illness. Indeed, hearing voices is listed in the Diagnostic and Statistical Manual of Mental Disorders as a characteristic symptom of schizophrenia (APA, 2000). Whatever meaning is given to the experience there is no doubt that often it is associated with great distress and impairment of life’s journey. Yet many people will cope well with the experience, and never feel the need to contact mental health professionals. The meaning society gives to hearing voices is of crucial importance, as it impacts upon both how society treats people who hear voices, and how the person who hears voices comes to understand and cope with their own experiences. At present, the biomedical model is the dominant explanatory paradigm for hearing voices. Yet this biomedical understanding can have many negative effects on how society treats people with voices, which, as noted above, are seen as synonymous with mental illness. One study (Mehta & Farina, 1997) found that members of the general population gave a person they were told had a mental illness (which was actually a confederate of the experimenter) stronger electric shocks on a learning task if they though that person’s mental illness was caused by biochemistry than if they thought they had it was due to psychosocial factors (“some things that happened to me as a kid”). Aside from the stigmatic effects of this model, a good reason to reconsider a purely biomedical model of hearing voices is that such models predominantly focuses on neural changes in the brain associated with voices without considering the events in the life of the voice-hearer that may have led to such changes. Over the past two decades much research has demonstrated that hearing voices is linked to traumatic and adverse life events (irrespective of what diagnosis the person has been given). For example, hearing voices has been shown to be associated with an increased probability of having experienced childhood abuse, e.g., being physically, sexually or emotionally abused (Read et al., 2003). Other life events that have been highlighted as potentially triggering voices include being bullied, one’s parents going through a divorce, and experiencing bereavement. It is of great importance to note that the voices resulting from such events are not just random utterances. Many voice-hearers are able to link the identity of their voices to people involved in these traumatic events, be it the voice of some who has abused them, or in the case of combat veterans with PTSD, the voice of someone they have killed in combat, who is now telling them to kill themselves (e.g., Mueser & Butler, 1987; Romme et al., 2009). Thus, I would like to suggest that hearing voices is the result, in many but not all cases, of a mental wound one has received. Harold Pinter, in an essay on Shakespeare, uses the phrase “the wound is peopled”, which seems like an excellent metaphor to apply to voice hearing (Pinter, 2005). I would thus like to suggest that we can understand the experience of hearing voices as a peopled wound. Once we start to seriously consider this proposal, it will help us to reconceptualise the meaning of hearing voices, and will in turn affect the way in which mental health services might try to help people distressed by their experiences. This might not be a wound that can simply be medicated away. Indeed, if feelings of shame or guilt are involved these might not be best treated with a pill… References APA (2000). Diagnostic and Statistical Manual of Mental Disorders (4th revised edn). American Psychiatric Press: Washington, DC. Mehta, S., & Farina, A.  (1997). Is being "sick" really better? Effect of the disease view of mental disorder on stigma. Journal of Social and Clinical Psychology, 16, 405-419. Mueser, K. T., & Butler, R. W. (1987). Auditory hallucinations in combat-related chronic posttraumatic stress disorder. American Journal of Psychiatry, 144, 299-302. Pinter, H. (2005). Various Voices Prose, Poetry, Politics (1948-1998). London: Faber and Faber. Read, J., Agar, K., Argyle, N., & Aderhold, V. (2003). Sexual and physical abuse during childhood and adulthood as predictors of hallucinations, delusions and thought disorder. Psychology and Psychotherapy: Theory, Research and Practice, 76, 1–22.
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    Voices in the head
    May 2, 2011
    Celebrated writer Jon Ronson has been looking at the experience of hearing voices in the latest episode of his radio series 'Jon Ronson On'. You can listen to the programme here.
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    IAS support for 2011-2012
    May 6, 2011
    Hearing the Voice is being supported in the 2011-2012 academic year by Durham University's Institute of Advanced Study. You can read details of the IAS Hearing the Voice theme, including our exciting Fellowship visitors, here.
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    Neuroimaging voice-hearing experiences in healthy participants
    June 14, 2011
    Image via Wikipedia There is considerable support nowadays for a continuum model of psychosis, whereby symptoms associated with psychosis also occur in psychiatrically healthy populations (e.g. van Os et al., 2009; although see e.g. David, 2010, for a recent sceptical view). A new article by Dutch researchers (Diederen et al., in press) reports on an fMRI study designed to test whether neural activation associated with ‘healthy’ voice-hearing experiences differs from that observed in psychiatric patients. To our knowledge, this is only the second neuroimaging study to include a non-psychiatric voice-hearing group (the first was Linden et al., 2010). To see how the 21 healthy voice-hearers were recruited, we need to go back to an earlier report from this group. In an article published last year in Schizophrenia Bulletin (Sommer et al., 2010) scores from around 4,000 respondents to a website questionnaire (a version of the Launay-Slade Hallucination Scale) led to the identification of a group of 103 people who had genuine voice-hearing experiences but no psychopathology. The 42 people who were scanned in the new study were selected from this larger sample, and matched to data from an existing fMRI dataset from psychiatric patients with a range of disorders (including schizophrenia, schizoaffective disorder and psychosis Not Otherwise Specified). The researchers used quite stringent criteria for including participants’ scan data in their analyses. To be included, participants had to have had at least four AVH experiences during the 8-minute scan period, with a minimum total duration of fifty seconds. Participants indicated when they were hearing a voice by squeezing a balloon and releasing it when the voice stopped. Half of the 42 subjects met these criteria, giving a sample of 21 nonclinical voice-hearers whose data could be matched with those from psychosis patients. Although the team was interested in differences in activation across the brain, they constrained their analyses by focusing in on regions known to be involved in AVHs, such as the bilateral inferior frontal gyri (including Broca’s area), insula, superior and middle temporal gyri, cerebellum and parahippocampal gyrus. They made no specific hypotheses, however, about particular regions of difference in activation. To determine whether the groups differed in activation, they compared data from the two samples first in their specific region of interest and then (in an exploratory fashion) across the whole brain. The results of these analyses were rather simple. In both groups, the areas that were expected to activate mostly did activate. There were no differences in activation between the groups, however, leading the researchers to conclude that nonclinical and clinical AVHs do not differ in terms of their underlying neural activation. Do these findings support the continuum hypothesis of psychosis? The continuum model would hold that voice-hearing experiences, no matter to whom they are occurring, will result from the same underlying neurophysiological processes. The researchers conclude, however, that their results cannot be used either to support or refute the continuum hypothesis, as the common patterns of activation they reported might have arisen through different mechanisms. The authors also point out that it would be interesting (although impossible in this study because of limitations on sample size) to compare patients with different diagnoses, such as schizophrenia and psychosis Not Otherwise Specified. A number of further interesting questions arise from this report. One possible criticism is that the study did not gather any information about the content of the voice-hearing experiences, such as information about what the voices were saying, or other qualitative details. As voice-hearing experiences are highly heterogeneous, this would seem to be an important issue for future research. A second point is that, as you would expect, the psychosis group presented with other symptoms such as delusions. This makes the lack of differences in activation even more striking. If neural activations between deluded psychosis patients and non-deluded healthy controls are so similar, what does that tell us about the neural basis of these other psychotic symptoms? Although the nonclinical group did not have clinical delusions, they did score more highly (relative to controls) on a schizotypy measure, which may well indicate relatively high levels of delusionality. That might point to the conclusion that the two groups were not actually all that different in terms of symptomatology, and that a more salient difference between them might be their levels of social functioning. David, A. S. (2010). Why we need more debate on whether psychotic symptoms lie on a continuum with normality. Psychological Medicine, 40, 1935-1942. Diederen, K. M. J., Daalman, K., de Weijer, A. D., Neggers, S. F. W., van Gastel, W., Blom, J. D., Kahn, R. S., & Sommer, I. E. C. (in press). Auditory hallucinations elicit similar brain activation in psychotic and nonpsychotic individuals. Schizophrenia Bulletin. Linden, D. E. J., Thornton, K., Kuswanto, C. N., Johnston, S. J., van de Ven, V., & Jackson, M. C. (2010). The brain's voices: Comparing nonclinical auditory hallucinations and imagery. Cerebral Cortex, 21, 330-337. Sommer, I. E. C., Daalman, K., Rietkerk, T., Diederen, K. M., Bakker, S., Wijkstra, J., & Boks, M. P. M. (2010). Healthy individuals with auditory verbal hallucinations: Who are they? Psychiatric assessments of a selected sample of 103 subjects. Schizophrenia Bulletin, 36, 633-641. van Os, J., Linscott, R. J., Myin-Germeys, I., Delespaul, P., & Krabbendam, L. (2009). A systematic review and meta-analysis of the psychosis continuum: Evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychological Medicine, 39, 179-195. [twitter-follow screen_name='hearingvoice']
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    Marius Romme and Sandra Escher - Accepting and Making Sense of Hearing Voices - Public Lecture Wednesday 19 October
    October 12, 2011
    Professor Marius Romme and Dr Sandra Escher Accepting and making sense of hearing voices 19 October 2011, 5.30-6.30pm Penthouse Suite, Collingwood College, Durham University Prof. Dr. Marius Romme: In this lecture I will explain: the core concept of the new approach towards hearing voices, the outline of its beginning and development, the main results of our research and the consequence for the traditional psychosis concept. Dr. Sandra Escher: In children as in adults, auditory hallucinations, or hearing voices, is generally seen as a sign of psychopathology. In psychiatry, hearing voices is often interpreted as a symptom of an illness, perhaps a life-long one, which has no relationship to the individual's life history. However, contemporary research challenges these assumptions. A group of 80 children, both patients and non-patients, were interviewed at baseline and three times at yearly intervals thereafter. The rate of voice discontinuation over the three-year period was 60%. In 85% of children there were trauma or problematic circumstances at the onset of voice hearing, suggesting a relationship between the onset of the voice hearing and life events. All welcome.
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    International Consortium on Hallucination Research
    October 16, 2011
    Last month some of us attended a two-day meeting at the Institute of Psychiatry at which researchers and clinicians from around the world got together to discuss future directions in hallucinations research. Several review papers on different aspects of the Consortium's interests are in preparation and will appear next year. A full report on the meeting will be published shortly (details to follow); in the meantime, there is further information on the Consortium's activities here. I found the meeting tremendously exciting. It was wonderful to witness such an open, collaborative atmosphere, and the talks were all of the highest class. The second day resulted in some fascinating discussions in small working groups, and I made several new friends whose work I had previously only been able to admire from afar. I learned a lot about computational modelling of hallucinations, for example, from Renaud Jardri and Sophie Deneuve and their excellent position paper. The meeting resulted in the agreement of a number of principles and recommendations for future research, which will be published in due course. One of the main themes was a need for better phenomenological characterization of voice-hearing experiences, which is of course a major concern for the Hearing the Voice team.
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    Reflections on Marius Romme and Sandra Escher - Accepting and Making Sense of Hearing Voices
    October 20, 2011
     Professor Marius Romme and Dr Sandra Escher are visiting Durham as fellows of the Institute of Advanced Study, associated with our work on Hearing the Voice. Last night, to a packed audience of around 200 people, they gave an inspiring public lecture on the topic Accepting and Making Sense of Hearing Voices; an introduction to their twenty-five years of research into voice-hearing. It would be too great a challenge to summarise the ideas so eloquently introduced in this double presentation, so here instead are some of the highlights: Marius' outlined four core concepts in accepting and making sense of voices: (1) hearing voices is not a sign of mental illness but points to other life problems; (2) there are more healthy voice-hearers than patients (i.e. more people hear voices in absence, rather than presence, of a psychiatric diagnosis); (3) people who hear voices become patients or service-users because they are not able to cope with distress, including the distress of voice-hearing; and (4) the characteristics of the voices refer to what has happened to the hearer and his or her problems. These points were expanded and elucidated through descriptions of their empirical research. And, Sandra went on to explain, they apply equally to the case of children. Presenting findings from her three-year longitudinal study of children who hear voices, Sandra suggested that while there was no measurable difference in the experience itself, the children who had become psychiatric patients before or during the course of her study were more likely (than children without a psychiatric diagnosis): to have more triggers for their voices, to have experienced greater childhood anxiety and depression, to have more frequently a negative emotional appraisal of their voices, to find their emotions and behaviour more influenced by their voices, to adopt more passive coping strategies, and to have experienced a greater number of traumatic events. All of this points to a paradigm shift in the way that voice are understood in the context of psychiatry and more broadly in our everyday lives. As Marius and Sandra so persuasively show, voices are meaningful – they convey messages in their everyday presence (what do the voices actually say to me?), onset (when did I first hear a voice, and why?), triggers (do I hear voices when I feel abandoned, euphoric, humiliated, distressed?), and characteristics (who is speaking to me, what sex and age are they, where do they come from and how do I relate to them?). If you were at last night's event and would like to write about it for this blog please don't hesitate to get in touch. Plans are already in place to arrange a follow-up lecture in December, details will be available here or you can [twitter-follow screen_name='hearingvoice']

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