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January 2021 Article of the Month
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.
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:
...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).
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:
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.]
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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