Voices in Psychosis: The Experience of Hearing Voices – A Review by Clara Humpston

Voices in Psychosis cover image

Dr Clara Humpston is an Assistant Professor in Mental Health in the Department of Psychology at the University of York. In this review of  Voices in Psychosis edited by Angela Woods, Ben Alderson-Day and Charles Fernyhoughshe reflects on the essays in ‘Part Two: The Experience of Hearing Voices’. 

What is it like to experience voices no one else can hear? This is a fascinating question to many clinicians, researchers, philosophers, theologians and these professions are by no means an exhaustive list. However, fascination is only one of the feelings that the question of hearing voices invokes. Puzzlement is another – how is such an experience possible in the first place? By definition, voices are confined in, if not the products of, subjective space. Yet the experience of hearing them can range from a soundless sense of communication to complex sentences clear as day, fully located in external worlds. The sheer impact of such an experience on the experiencer goes far beyond mere fascination.

In Part Two of Voices in Psychosis, the focus is not solely on fascination or explanation. Rather, the section begins with a powerful poem – ‘The Quickening’ by Gillian Allnutt ­– a first-personal message of what it is like for the individual. Following this vein, the first main article on ‘The Sound of Fear’ by Ben Alderson-Day and Thomas Ward puts forward the notion that fear is a primary emotional response to voices, and not simply reappraisals or results of a meaning-making process. I particularly enjoyed their discussion about fear, agency and the ineffable: the authors present a paradox, which to me is the core of the phenomenology of voice-hearing and related experiences, where the voice is ‘both social and isolative’(p.47), both internal and external, both self and other, and both real and non-existent. Voices are not mere objects of fear but are powerful symbols and manifestations of everything that may be hidden deeply inside one’s mind, distorted into a different reality that has the potential to threaten and destroy. This nicely leads to the next article on ‘Affect and Voice-hearing’ by Åsa Jansson. Current diagnostic systems draw demarcations between ‘affective’ (e.g., bipolar disorder) and ‘non-affective’ psychoses (e.g., schizophrenia), but such a line should not be drawn with the level of clarity of confidence that modern psychiatry proposes to possess. Instead, the role affective states play in both the development and persistence of voices (and delusional thoughts too, I would argue, such as those of persecution) are complex and multifaceted, where the relationship between affect and voices is ‘anything but simple and one-directional’ (p.56).

Looking beyond affective states, bodily sensations are rife in voice-hearing experiences too. When one speaks of voice-hearing phenomena, the assumption is often that the individual undergoes a solely auditory experience. However, this is far from how voices are actually experienced and not simply what is heard or whether the voices are ‘heard’ at all. In ‘Bodily Sensations During Voice-Hearing Experiences’, Jamie Moffatt argues that the body and its understanding of its own signals to itself (interoception), whether conscious of subconscious, may play a major role in related processes such as emotional processing, which includes the interpretation, appraisal and regulation of one’s own emotions. Failures of effective emotional processing could lead to unusual bodily experiences and sensations, for example, dissociation or detachment from the first-person perspective, sensations in other modalities accompanying voices such as tactile feelings, also known as ‘multimodal’ hallucinations that sometimes encompass and impact the entire body. This is also the topic of the next article: Peter Moseley and Kaja Mitrenga present the variability and complexity of such multimodal hallucinations, this time in individuals diagnosed with psychosis. Multimodal hallucinations may induce higher levels of distress, as well as perceived reality of the phenomena and emotional response. They are also likely to be much more frequent than what researchers and clinicians currently estimate, which necessitates further development in the assessment and enquiry of these experiences to drive innovations about intervention and treatment.

The article that resonated with me the most has to be the one on ‘Lost Agency and the Sense of Control’ by John Foxwell. It sounds like such a taken-for-granted idea that we are in control of our thoughts, feelings and actions and we alone are the initiators and executors of such mental and physical events, but for individuals with voices (most often clinical voices such as those reported by people with a diagnosis of schizophrenia) the sense of control can be a luxury or something that requires immense mental effort to implement. This sense of control goes beyond what is known as ‘cognitive control’, and resides in the most basic, most fundamental and pre-reflective layer(s) of one’s self. Without it, we are almost less human because what else defines being human more adequately than the ‘fact’ that we have a (seemingly free) will? Sadly, as Olivia poignantly points out, ‘you don’t realise the advantage of being in control until suddenly it gets taken off you’ (p. 80). For many individuals with clinical voices, the loss of control and agency over mental (and sometimes physical) events induce extreme anguish, confusion and suffering, mental states that frequently lie beyond language and commonsensical expression, which adds to the stigma and isolation people with a diagnosis of  schizophrenia face on a daily basis.

The last article in part two of the volume, ‘Polution and Purity’ by Adam Powell, comes from the angle of theology, which argues that some voices can be understood as punishment for ‘un-wholly’ sins. It is interesting that perceived pollution on the body, whether it is literal or metaphorical, can lead to feelings and thoughts of shame, a lack of wholeness and worthiness, as well as guilt and self-stigmatisation. It is very sad to read about Ryan’s case, where he ‘feels caught in a state of limbo between desiring the act and acting on the desire’ (p.89) – to punish oneself not through physical self-separation (i.e., suicide), but through the symbolism of the act as the breakdown of societal bonds and structures where voices are ‘completely justified punishments’ (p. 89). 

In sum, this part of the volume is an illuminating constellation of articles aimed at shedding some light on the fascinating, puzzling, fearsome, paradoxical and, perhaps most importantly, human experience of hearing voices. The experience of voices is all of the above, yet at the same time, it is so much more – offers so much more – to the understanding of the human psyche, both when things go right and when they go wrong, without taking a particular stance rooted in any pre-assumed model of understanding. This, after all, is what makes us human; this is what makes us fascinating as individuals.

Picture of Clara Humpston
Clara Humpston

Voices in Psychosis is available to download and read freely by clicking the ‘Open Access’ button on the the Oxford University Press website.