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January 2021 Article of the Month
 
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA

 

Cook, C. C. H., Powell, A., Alderson-Day, B. and Woods, A. "Hearing spiritually significant voices: a phenomenological survey and taxonomy." Medical Humanities 2020): published online ahead of print, 12/7/20.

[Editor's Note: This month's selection is available as an open access article from BMJ.]

SUMMARY and COMMENT: This month's selection, out of the United Kingdom, opens up the topic of voice hearing beyond the literature of psychopathology. The study sample is predominantly Christian, but the authors contextualize their findings to guard against overgeneralization while detailing how this sample may support a critical perspective and provisional taxonomy. This may be useful to chaplains working with patients who share experiences of hearing voices, though the article is aimed at psychiatrists. Lead author Christopher C. H. Cook is a Professor in the Department of Theology and Religion at Durham University, and one goal of this research was to bring the fields of theology and religious studies into the medical dialogue around voice hearing.

Cook and colleagues express concern about recent proposals to place "non-clinical voice-hearing experiences on a continuum with those associated with psychosis," saying: "Whereas for those with psychosis the continuum hypothesis may be destigmatising, for those who hear spiritually significant voices, it may in fact have the opposite effect and risk pathologisation of essentially normal and socially integrated human experiences" [MS p. 2]. For some religious communities, they observe, hearing voices would not be understood as "voice-hearing" in the current clinical sense or as any sign of a mental disorder, but rather as "evidence of good spiritual health" [MS p. 2].

To get a fresh sense of hearing voices, the authors sought first-person accounts using open-ended questions in addition to quantitative items. They amended and adapted an instrument used by Angela Woods, et al., in a 2015 study of "Experiences of hearing voices..." [--see Related Items of Interest, §I, below]. The core questions are lined out in the Methodology section [--see MS p. 2], for example: How, if at all, are these experiences different from hearing the voice of someone who is present in the room? ...and... Does it feel as though the voices that you hear have their own character or personality?

Data were collected via an online form [--see Related Items of Interest, §II, below] advertised through Church Times, an independent Anglican weekly newspaper founded in 1863 and based in London, with a print distribution of 20,000 and a website that receives 26,000 unique visitors a week. There were 58 respondents.

Among the results:

  • "Seventy-nine per cent of respondents either reported having never received a psychiatric diagnosis or else gave no response. Among those who did report a diagnosis, the most commonly reported conditions were depression (n=5) and post-traumatic stress disorder (n=3)." [MS p. 4]

  • "More than half of participants reported voice hearing for the first time at age 21 years old or older." [MS p. 4]

  • "For most respondents, the hearing of a voice had been a relatively infrequent experience, occurring ten times or less over the course of a lifetime. For a quarter, it had been a once in a lifetime experience. For a minority (12%) it had occurred on eleven or more occasions...." [MS p. 4]

  • "All but one (98%) claimed not to be able to predict the experience. A small subset of six participants, however, did provide responses suggesting that they could increase the likelihood of hearing a divine voice by entering into specific contexts, such as a 'worship service' or a state of 'prayer.'" [MS p. 4]

  • "Approximately half of participants reported only having auditory voices. The remainder were fairly evenly split between either experiencing only thought-like voices or experiencing a combination of both. Approximately half of our participants felt that the voices originated internally, with the other half reporting external voices." [MS p. 4]

  • "The majority of our participants (86%) recalled only hearing a single voice...." [MS p. 4]

  • "Most voices were not accompanied by bodily sensations.... Among those who did report bodily sensations, these sensations included 'touch,' 'warmth,' 'a physical pull' or even a 'trance state.'" [MS p. 4]

  • "When taking into account all forms of reference to God, 51 respondents (88%) identified the voice as divine. Only two identified demonic voices." [MS p. 5]

  • "Participants, on the whole, reported the significance of their voices in highly favourable terms. Only eight (14%) participants reported hearing voices that were 'not spiritually significant.'" [MS p. 6]

  • "It is surprising that half of our subjects identify their voices as personal spiritual entities without characterful qualities." [MS p. 7]

Cook and colleagues propose a taxonomy based upon eight categories: Comfort, Calling, Confirming/clarifying, Conversion, Communications, Crisis, Conversational, Companions, and Other. These are developed into a table [--see Table 1, MS p. 4], according to Frequency, Context, Affect, and Identity; and are also used in a breakdown report of results [--see Table 5, MS p. 6]. For the participants in the study, the most common taxonomic categories were Comfort (26%) and Calling (24%). The authors note: "Although some research has focused on voice hearers' own interpretations of their experiences, taxonomies of voice-hearing experiences do not hitherto seem to have taken the content of what the voice says, or the context of voice hearing, very seriously" [MS p. 7].

The authors conclude with three major takeaways: First, to protect against misdiagnosis, clinicians should be aware that hearing voices is an "entirely normal phenomena in spiritual and religious context" [MS p. 9]. In fact, "the fear that a psychiatrist might misdiagnose such experiences is likely to make patients reticent in discussing them" [MS p. 9]. Therefore, "Not only do psychiatrists need to be well informed about such matters, but also they must be known to be well informed" [MS p. 9]. Second, exploration of spiritual significance for those who hear voices may provide insight into new approaches to treatment for those who may be distressed by the phenomenon, perhaps by paying closer "attention to the context, content and identity of the voices" [MS p. 9]. And third,...
...our findings draw attention to the need to attend to the possible spiritual/religious significance of all experiences of hearing a voice. While not everyone identifies as spiritual or religious, for those who do, their spirituality may well shape both the experience itself, and their interpretation of their experience, in significant ways. For some people, the voice is experienced, in the moment, as self-evidently spiritual. ...Even for those who would not self-identify as spiritual/religious...we might imagine that similar processes occur. The meaning and significance of the voice may be understood as self-evidently not spiritual. However, on later reflection, this assessment may be revised in favour of spiritual or religious interpretations. While this process of reassessment will have positive consequences for some, it may prolong the distress for others. [MS p. 9]

For chaplains, this study suggests a way to articulate an assessment of patients' voice-hearing as more than a normalization of the auditory-verbal hallucinations emphasized in the psychiatric literature, but instead in terms of the particular context, content and identity of the voices, and with a sense of the process for understanding that experience as spiritually significant (right away or after some time). Chaplains might be ideally placed to assist patients in their meaning-making process, in light of the patient's own theological and religious life. And, since it is possible that patients may disclose the hearing of voices to a chaplain before doing so to a physician/psychiatrist whom the patient may fear will pathologize the experience, chaplains could help facilitate nuanced and constructive communication between patients and their medical providers. Finally, while the present study focuses on a Christian sample, the basic concepts here could have wider application, and the typology might be a productive starting point for comparisons and contrasts with data from more diverse studies to come, and chaplains might consider how to channel the stream of primary information they receive on this topic from regular visitation into systematic research.

The article includes both a bibliography of 45 references and a listing of 58 notes, comprising a great deal of supportive material to plumb. Five tables offer a good amount of raw data, and there are two additional boxes for Bodily sensations accompanying voices and Participants' reported significance of voices [MS p. 6].

Two final notes: First, our authors use the word characterful a number of times as a quality descriptor of heard voices, but they do not define it. Perhaps its meaning is clear to readers, but it's worth noting that it connects directly to the 2015 study by Woods, et al., which clarifies its meaning in terms of voices that are believe to be from "people or person-like entities with distinct characteristics, such as gender, age, patterned emotional responses, or intentions" [--p. 325 of that article; see Related Items of Interest, §I, below]. Second, while the article states, "Research conducted over the last 10 years and more has shown that voices (auditory-verbal hallucinations (AVHs)) are experienced widely in the general population..." [MS p. 1], the incidence is not specified. However, Durham University's Understanding Voices website [--see Related Items of Interest, §III, below] gives the statistic that 5-15% of adults will experience hearing voices at some point in their lives, and up to 1% of people have frequent voice-hearing experiences and no need for psychiatric care.


 

Suggestions for Use of the Article for Student Discussion: 

The group could be asked at the outset to share any non-psychiatric patient's stories of hearing voices and how the chaplain had thought about that at the time, perhaps especially in light of any stories they'd been told by psychiatric patients. (The discussion leader should also be prepared for the possibility that one or more chaplains might share their own personal experiences of hearing voices.) Does the group have any comment on the fact that the study's population was predominantly Christian? The input of any non-Christian chaplains should be noted especially, before the discussion proceeds too far. What has been their general understanding of the phenomenon of hearing voices, and was this altered in any way by this month's article? What of the study's results stand out? (Since the findings are well laid out in both the Results and Discussion sections, there may be some back-and-forth in the article when considering the findings.) The positive experience of hearing voices is manifest in Box 2 [MS p. 6]: Participants/reported significance of voices, and should be worth some attention. One a particular point the authors speculate about is: "Given that the God of Christian scripture and tradition is clearly characterful, it was unexpected that our respondents would report that the voice of God (as they believed that they heard it) was not characterful" [MS p. 7]. What do students' make of this? If it has not already come up in the group, what do the students think of the periodic comparative references to spiritualists? Of course, the proposed taxonomy should be a topic for discussion, and the group should spend some time with Table 1 [MS p. 4], as well as with results presented in Table 5 [MS p. 6]. Turning back to the clinical setting of patient encounters, the group might take up two questions: First, how might a chaplain optimally respond to a patient's disclosure of hearing voices, the possibilities that the patient may be fearful in sharing such information and may be still working out their own understanding of it all? Second, what might a chaplain do with that information as part of a multidisciplinary care team (e.g., documentation, consultation with other team members, and dialogue with the patient about bringing their experience into wider view by the team)? Finally, the group might muse about potential discussions with any psychiatrists in their institution, and the opportunity for a follow-up session with one or more psychiatrists.


 

Related Items of Interest:

I.  Our study this month significantly builds upon and plays off against the following research (available as an open access article from the journal, along with supplementary material).

Woods, A., Jones, N., Alderson-Day, B., Callard, F. and Fernyhough, C. "Experiences of hearing voices: analysis of a novel phenomenological survey." The Lancet. Psychiatry 2, no. 4 (April 2015): 323-331. [(Abstract:) BACKGROUND: Auditory hallucinations--or voices--are a common feature of many psychiatric disorders and are also experienced by individuals with no psychiatric history. Understanding of the variation in subjective experiences of hallucination is central to psychiatry, yet systematic empirical research on the phenomenology of auditory hallucinations remains scarce. We aimed to record a detailed and diverse collection of experiences, in the words of the people who hear voices themselves. METHODS: We made a 13 item questionnaire available online for 3 months. To elicit phenomenologically rich data, we designed a combination of open-ended and closed-ended questions, which drew on service-user perspectives and approaches from phenomenological psychiatry, psychology, and medical humanities. We invited people aged 16-84 years with experience of voice-hearing to take part via an advertisement circulated through clinical networks, hearing voices groups, and other mental health forums. We combined qualitative and quantitative methods, and used inductive thematic analysis to code the data and [chi square] tests to test additional associations of selected codes. FINDINGS: Between Sept 9 and Nov 29, 2013, 153 participants completed the study. Most participants described hearing multiple voices (124 [81%] of 153 individuals) with characterful qualities (106 [69%] individuals). Less than half of the participants reported hearing literally auditory voices -- 70 (46%) individuals reported either thought-like or mixed experiences. 101 (66%) participants reported bodily sensations while they heard voices, and these sensations were significantly associated with experiences of abusive or violent voices (p=0.024). Although fear, anxiety, depression, and stress were often associated with voices, 48 (31%) participants reported positive emotions and 49 (32%) reported neutral emotions. Our statistical analysis showed that mixed voices were more likely to have changed over time (p=0.030), be internally located (p=0.010), and be conversational in nature (p=0.010). INTERPRETATION: This study is, to our knowledge, the largest mixed-methods investigation of auditory hallucination phenomenology so far. Our survey was completed by a diverse sample of people who hear voices with various diagnoses and clinical histories. Our findings both overlap with past large-sample investigations of auditory hallucination and suggest potentially important new findings about the association between acoustic perception and thought, somatic and multisensorial features of auditory hallucinations, and the link between auditory hallucinations and characterological entities.]

 

II.  Data for our featured study were collected via an invitation in Church Times (www.churchtimes.co.uk). Cook and colleagues reprint the introductory statement that was on the form linked to that advertisement [-see MS p. 3], but the originally advertised invitation that appeared as of June 6, 2018 may be of interest to researchers. It read as follows:

The Revd Professor Christopher C. H. Cook, the Co-investigator on the Hearing the Voice Project at Durham University, funded by the Wellcome Trust, would be grateful for any readers who have had experiences of spiritually significant voices to complete an online survey. The project's aim is to develop a better understanding of all experiences of hearing voices, God, angels, saints, demons, or other spiritual beings, or of sounds. Anyone over the age of 16 who has first-hand experience of hearing such a voice can complete the survey at https://durham.onlinesurveys.ac.uk/spiritvoices. For more details, contact Professor Cook at c.c.h.cook@durham.ac.uk.

 

III.  Durham University hosts an ongoing interdisciplinary research project: Hearing the Voice (hearingthevoice.org), which holds a good deal of research information. In connection with this project, Durham also launched on September 11, 2019, the Understanding Voices website (https://understandingvoices.com) in close collaboration with voice-hearers, their families and allies, and mental health professionals. The site also includes a listing of research, under its Resources section. [Note: on the page for Voices and Spirituality, the link to the Welsh Hearing Voices Network is currently incorrect and should instead be https://www.hearing-voices.org. That site may not offer much in the way of research, but it does collect a great number of links for other sites on the subject at https://www.hearing-voices.org/resources/links.]

 

IV.  Articles by lead author Christopher C. H. Cook are noted in the bibliography of this month's selection, but also see also the following books:

Cook, C. C. H. Christians Hearing Voices: Affirming Experience and Finding Meaning (Jessica Kingsley, 2020). [See the announcement on the hearingthevoice.org site.]

Cook, C. C. H. Hearing Voices, Demonic and Divine: Scientific and Theological Perspectives (Routledge, 2019). [Available freely online from the NCBI Bookshelf.]

Additionally, chaplains may find interesting a popularly-focused 14-minute audio presentation on spirituality and voices especially in Christian tradition, "Visionary Voices," which may he heard via Soundcloud.

 

V.  This month's article has a selective but quite up-to-date bibliography. However, the following recent articles on hearing voices may be of interest:

Lewis, S. H., Sanderson, C., Gupta, A. and Klein, C. "'Maybe it's kind of normal to hear voices': The role of spirituality in making sense of voice hearing." Journal of Spirituality in Mental Health 22, no. 1 (2020): 49-64. [(Abstract:) First-person accounts of voice hearing are scarce. This research aims to explore the role of spirituality in the sense-making process of hearing voices. Five semistructured interviews explored experiences of spirituality and hearing voices. Qualitative data was analyzed using interpretive phenomenological analysis (IPA). Three superordinate themes were identified: need for connection, values about self and identity, and making sense. The findings suggest a relationship between spirituality and voice hearing, and relate to the need for belongingness and self-identity. Acknowledging the sense making process and engaging in conversations about spirituality are implicated when providing clinical interventions for distressing voice hearing. Future research could explore further the differences between voices associated with spiritual experiences and "psychosis."]

Phalen, P., Warman, D., Martin, J. M., Lucksted, A., Drapalski, A., Jones, N. and Lysaker, P. "Public understanding of different kinds of voice-hearing experiences: causal beliefs, perceptions of mental illness, and stigma." Psychiatric Rehabilitation Journal 42, no. 4 (December 2019): 331-340. [(Abstract:) OBJECTIVE: Voice-hearers tend to face a high degree of stigma that can impact subjective well-being and social functioning. However, researchers have hypothesized that the content of the voice-hearing experience and its cultural context are relevant to stigma responses. This study experimentally tested how perceptions of voice-hearing experiences change as a function of the voice's content and the perceiver's characteristics. METHOD: In total, 143 nonclinical participants were presented with vignettes describing people who heard voices that were attributed to either "God" or "Abraham Lincoln" and were described as either complimentary/encouraging or insulting/threatening. For each vignette, participants were asked about the likelihood that the voice-hearer had schizophrenia or mental illness. The Causal Beliefs Questionnaire was also delivered, with two new subscales added to test for belief in positive and negative religious causes for the voices. Stigma was measured by perceived dangerousness and desire for social distance. RESULTS: Voice-hearing experiences elicited greater stigma from participants who endorsed greater likelihood that the voice-hearer was mentally ill, greater belief in biological causes of the voice-hearing, negative religious causes, psychosocial causes, socialization causes, and causes related to personal responsibility. Endorsing positive religious causes was associated with lower stigma. Participants who were more religious were more likely to attribute voice-hearing experiences to negative religious causes (possession, lack of/misguided faith), except when the target was described as hearing the voice of God saying positive things. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The stigma of voice-hearing experiences depends upon what the voice is saying and perceptions about the cause of the voice.]

Reddyhough, C., Locke, V., Badcock, J. C., and Paulik, G. "Changing attitudes towards voice hearers: a literature review." Community Mental Health Journal (2020): online ahead of print, 10/17/20. [(Abstract:) Auditory verbal hallucinations, or voice hearing, is increasingly understood as a common experience. Despite this, voice hearers still experience a great deal of stigma, which can have serious negative impacts on the person's experience of their voices, and their recovery. Research has demonstrated that healthcare professionals may be a major source of the stigma surrounding voice hearing, with service-level implications for the development and delivery of evidence-based interventions. Therefore, reducing this stigma is a critical intervention target. The purpose of this narrative review is to examine evidence for interventions aimed at reducing stigma towards people who hear voices, in populations of healthcare professionals, students, and the general public. The available evidence supports the use of anti-stigma interventions based around direct contact with voice hearers and education about voice hearing. However, further research is necessary in this area to confirm these findings.]

Reddyhough, C., Locke, V. and Paulik, G. "Changing healthcare professionals' attitudes towards voice hearers: an education intervention." Community Mental Health Journal (2020): online ahead of print, 8/11/20. [(Abstract:) Despite being a relative common experience, hearing voices remains highly stigmatised, with serious consequences. Numerous interventions have been developed to reduce stigma towards mental illness in general, however most have failed to include implicit measures of stigma, and these have yet to be applied to hearing voices. The current study examined the efficacy of an education intervention in changing the explicit and implicit stigma held by healthcare professionals (N = 59) towards voice hearers. Results indicated that the education intervention led to significant decreases in explicit but not implicit measures of stigma, though participants demonstrated relatively positive baseline implicit attitudes towards voice hearers. These findings suggest that education interventions could be one way of reducing stigma towards voice hearers. Further research is necessary to explore the impact of education interventions in samples with more negative baseline attitudes, such as early career professionals, students, and the general population.]

 

 
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