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Psicologia USP

Print version ISSN 0103-6564On-line version ISSN 1678-5177

Psicol. USP vol.29 no.3 São Paulo Sept./Dec. 2018

https://doi.org/10.1590/0103-656420180077 

ORIGINAL ARTICLES

Voice hearers: a review about meaning and relationship with voices

Maria Laura de Oliveira Coutoa  * 

Luciane Prado Kantorskia 

aUniversidade Federal de Pelotas, Departamento de Enfermagem em Saúde Coletiva. Pelotas, RS, Brasil


Abstract

This study is a systematized review of literature and aimed to review the findings on the subject of voice hearers, emphasizing their relationship with their voices. The research was performed in two databases, PubMed and LILACS, with no temporal limit and with the following terms in English: “voice hearing” OR “auditory verbal hallucination”. A total of 2,464 article titles were found and examined for suitability regarding our purpose. 126 articles were identified for full text analysis, from which 35 fulfilled the criteria for inclusion. It was observed that the meaning voice hearers attribute to the voices is tied to their life history, and they consider them threatening, intrusive, controlling, or gentle, friendly and positive. Therefore, the meaning attributed to the voices was determinant in the relationship that the voice hearer will establish with them, as well as the way in which they relate socially.

Keywords: mental health; auditory hallucinations; psychosis; voice hearers; relationship with voices

Resumo

Este estudo se trata de uma revisão sistematizada da literatura e teve como objetivo revisar os achados sobre o tema ouvidores de vozes, enfatizando a relação deles com suas vozes. A investigação foi realizada em duas bases de dados, PubMed e Lilacs, sem limite temporal e com os seguintes termos em inglês: “voice hearing” OR “auditory verbal hallucination”. A busca resultou no total de 2.464 títulos de artigos que foram examinados quanto à adequação ao objetivo. Identificaram-se 126 artigos para análise de texto completo, dos quais 35 preencheram critérios para inclusão. Evidenciou-se que o sentido que o ouvidor atribui às vozes está atrelado a sua história de vida, fazendo ele as considerar ameaçadoras, intrusivas, controladoras, ou gentis, amigáveis e positivas. Portanto, o sentido atribuído às vozes se mostrou determinante na relação que o ouvidor estabelecerá com elas mesmas, bem como a forma como ele se relaciona socialmente.

Palavras-chave: saúde mental; alucinações auditivas; psicose; ouvidores de vozes; relação com as vozes

Résumé

La présente étude verse sur un examen systématisée de la littérature et vise à examiner les résultats sur le sujet des entendeurs de voix, avec un accent sur leur relation avec leurs voix. La recherche a été effectuée dans deux bases de données, PubMed et LILACS, sans limite de temps et avec ces termes en anglais: « voice hearing » OR « auditory verbal hallucination ». Un total de 2 464 titres d’articles a été trouvé et examinés pour déterminer leur pertinence à l’objectif. Pour l’analyse du texte intégral, 126 documents ont été identifiés, dont 35 répondaient aux critères d’inclusion. Il a été observé que le sentiment que l’entendeur attribue aux voix est lié à son histoire de vie, et il les considérèrent comme menaçante, intrusive, contrôlante, ou gentille, amicale et positive. Par conséquent, le sens attribué aux voix a été déterminant dans la relation que l’entendeur établira avec elles, ainsi que la manière dont il se rapporte socialement.

Mots-clés: santé mentale; hallucinations auditives; psychose; auditeus vocaux; relation avec les voix

Resumen

Este estudio es una revisión sistematizada de la literatura y tuvo como objetivo revisar los hallazgos sobre el tema oidores de voces, enfatizando la relación de ellos con sus voces. Se ha realizado la investigación en dos bases de datos: PubMed y LILACS, sin límite temporal y con las siguientes expresiones en inglés: voice hearing OR auditory verbal hallucination. La búsqueda resultó en 2.464 títulos de artículos que fueron examinados en cuanto a su adecuación al objetivo. Fueron identificados 126 artículos para el análisis del texto completo, de los cuales 35 rellenaron criterios para inclusión. Se evidenció que el sentido que el oidor atribuye a las voces está atraillado a su historia de vida, lo que hace con que las considere amenazadoras, intrusas, controladoras, o gentiles, amigables y positivas. Por lo tanto, el sentido que se atribuye a las voces se mostró determinante en la relación que el oidor establece con las mismas, así como la manera como él se relaciona socialmente.

Palabras clave: salud mental; alucinaciones auditivas; psicosis; oidores de voces; relación con voces

Introduction

The fact that some people hear voices which are not heard by others is not something new. It is possible to look for examples in historical records dating back to several millennia, when hearing voices was closely associated with spirituality, creativity, and philosophical insight, since it happened to people highly recognized by society, such as Virginia Woolf and Ghandi (Woods, 2013). However, with the advent of psychiatry, the term “hearing voices” gained symptomatic status, and has recently been used to refer to auditory verbal hallucinations (AVH), besides being considered one of the main characteristic symptoms of different mental illnesses, mainly schizophrenia (Ritsher, Lucksted, Otilingam, & Grajales, 2004). Thus, the phenomenon of hearing voices started being considered synonymous with illness and madness.

Nowadays, thanks to the relevance of the subject and the great number of pieces of research on it, it is already known that, despite the fact that most people with schizophrenia hear voices, most of them do not have the disorder, frequently being healthy individuals who do not use mental health services and do not present any type of diagnosis (Ritsher et al., 2004). According to Woods (2013), this discovery occurred in 1987 when Patsy Hague succeeded at persuading her psychiatrist, Marius Romme, to help her make sense of her voices by establishing connections between them and her life history. That same year they appeared together on Dutch television to talk about this new approach to hearing voices and get answers from the general public. On that day, 450 people called the program telling they heard voices. This event originated the First Hearing Voices Congress, held in the Netherlands that same year. Fortunately, this congress was the origin of the Hearing Voices Movement, which began in the UK and has spread to Europe, Australia, America, and beyond (Woods, 2013).

Due to the Hearing Voices Movement creation, a lot of little known data on hearing voices began to be widely disseminated in scientific circles, beginning with Sidgewick’s pioneering study in 1894, which showed that out of a sample of 17,000 people, 8% men and 12% women have had some hallucinatory experience. Another very important research was the work of Tien (1991), which found, in a sample of 18,572 people, a prevalence of 2.3% people who heard voices frequently in contrast to the prevalence of 1% people diagnosed with schizophrenia. This study shows that hearing voices, by itself, cannot be considered a mental illness symptom. This is in line with what Baker says (2016): even if one in three people who hear voices ends up using mental health services, two out of three are able to cope well with the voices and do not need psychiatric care.

According to Romme and Escher (1989), the solution proposed by psychiatry for hearing voices has been to ignore the meaning of the experience for the voice hearer, focusing on the removal of what they consider a symptom by using antipsychotics. It is known that the medication is effective for some people, but 30% people hear voices even when taking very high doses of antipsychotics (Curson, et al., 1985). Due to this fact, other alternatives are needed to deal with the phenomenon, and they should cope with all the negative feelings originated by this experience, such as anguish, stress, devaluation and incapacity, among many others. It is for this purpose that experts by experience (voice hearers) and professionals from different areas have been working in the Hearing Voices Movement, where hearing voices is no longer seen as a symptom, but understood as a human experience, which is not restricted to only one of the senses, the hearing, but encompass all the others, appearing as a phenomenon diverse and unique for each voice hearer.

This article aims to review the literature on the subject of voice hearers, emphasizing their relationship with the voices.

Method

The systematic review was performed on PubMed and Lilacs databases, with the following descriptors in English: “voice hearing” OR “auditory verbal hallucination.” Searches were performed from June 29, 2017 until July 3, 2017, and no time limit was established. The languages included were Portuguese, English and Spanish. The inclusion criteria were: surveys that considered the descriptors regarding hearing voices which others do not hear; research with non-biomedical bias; research focusing on the relationship between voice hearers and the voices; research with adults. The exclusion criteria were: surveys that considered the descriptors regarding hearing impairment, speech pathology, and other types of hallucination; research with biomedical bias; research with children and adolescents, and articles of systematic review.

Document search resulted in 2,151 articles found on PubMed database, and 313 articles on Lilacs database. After reading of titles, we found 577 articles on the descriptors regarding hearing voices which others do not hear, and two were duplicates. After removing duplicates, 575 articles were left for reading of abstracts. Among these, 126 were considered eligible because addressed the subject from a non-pathological perspective and with greater focus on health, and the other 449 were discarded for addressing the subject under biomedical bias, such as: imaging examination (magnetic resonance imaging; electroencephalogram) of voice hearers; transcranial magnetic stimulation; relationships between hallucinations and sense perceptions; psychopathological differential of delusional/hallucinatory syndromes and schizophrenia, and articles of systematic review.

Thirty-four out of 126 eligible articles were selected on PubMed and one on Lilacs (Table 1) for meeting the research purpose, and the others were discarded for addressing the following topics: AVH and suicide (1); the relationship between traumatic events and the type of AVH first episode (9); AVH and types of treatment - cognitive behavioral therapy (CBT), mindfulness, AVATAR, and self-monitoring techniques (44); assessment of reliability and validity of the “Voice and You” Spanish version scale (1); AVH under exclusively psychoanalytic bias (9); AVH related to the age group (5); unavailable (5); linguistic analysis of voices (2); schizophrenia and drug use (1); voice hearers and social stigma (3); nursing students and approaches to assisting voice hearers (4); other perspectives in schizophrenia (2); historical contextualization of hearing voices (1); discussion on religion and pathology in the context of AVH (1); evaluation of phenomenological aspects of voices - loudness, clarity, location, reality (3) (Figure 1).

Chart 1 Articles selected from the systematic review 

Author/origin of the author Magazine/year Methodology Purpose
Albert R. Powers III, Megan S. Kelley, and Philip R. Corlett (USA). Schizophrenia Bulletin, 2017. Case-control qualitative research The study presents a new study population: people from spiritual communities who receive daily auditory messages. There were phenomenological interviews with these subjects and with patients diagnosed with psychotic disorder who hear voices, people with a diagnosis of psychotic disorder who did not hear voices, and adequate control subjects (without voices or diagnosis). Objective: to understand the distinction between anomalous beliefs and illusion.
Esther R. Cole, Clara Strauss, Chris Fife-Schaw and Simon McCarthy-Jones (United Kingdom, Ireland). Psychology and Psychotherapy: Theory, Research and Practice, 2017. Cross-sectional quantitative study Cognitive models suggest that levels of distress associated with auditory verbal hallucinations (“voices”) are influenced by the hearers’ beliefs about their voices (perceived malevolence and omnipotence), their negative beliefs about themselves and others, and their relationship style. This study aims to test a comprehensive model of the relationship between these variables in order to identify distal and proximal interpersonal and cognitive factors that contribute to voice-related distress.
Lyn Ellett, Olga Luzon, Max Birchwood, Zarina Abbas, Abi Harris and Paul Chadwick (United Kingdom). British Journal of Clinical Psychology, 2017. Cross-sectional quantitative study Command hallucinations are considered to be one of the most distressing and disruptive symptoms of schizophrenia. Based on previous studies, we compared key attributes in the symptomatic, affective, and cognitive profiles of people diagnosed with schizophrenia and hearing voices that give (n = 77) or do not give (n = 74) commands.
Berta Britz (USA). Frontiers in Psychology, 2017. Qualitative research; first-person narrative. This article relocates anomalous experiences in their human contexts and asks clinicians and researchers to engage with these contexts. The author shares a first-person narrative of her experience, shifting her relationships with the domain of voices to recovery and accept herself as a human being, a reorientation supported by her involvement in the hearing voices movement.
Adèle De Jager, Paul Rhodes, Vanessa Beavan, Douglas Holmes, Kathryn McCabe, Neil Thomas, Simon McCarthy-Jones, Debra Lampshire and Mark Hayward (Australia, New Zealand and United Kingdom). Qualitative Health Research, 2016. Qualitative research with semi-structured interviews. Narrative analysis of the interview transcripts To investigate the recovery experience of eleven voice hearers.
C. Rosen, N. Jones, K. A. Chase, L. S. Grossman, H. Gin, and R. P. Sharmay (USA). Journal of Schizophrenia Research, 2016. Quanti- qualitative research The main objective of this study was to examine the first-person phenomenological descriptions of the relationship between the self and the auditory verbal hallucinations (AVH). Complex AVHs are often described as entities with clear interpersonal characteristics. Surprisingly, investigations of first-person descriptions (subjective) of relationship phenomenology are practically absent from the literature.
Filippo Varese, Anthony P. Morrison, Rosie Beck, Suzanne Heffernan, Heather Law and Richard P. Bentall (United Kingdom). British Journal of Clinical Psychology, 2016. Cross-sectional quantitative study The study has suggested that to the extent that voices (auditory verbal hallucinations) are experienced as distressing, they may be influenced by negative beliefs about voices and unadapted metacognitive styles involving negative judgment and unadapted control of mental experiences. This cross-sectional study examined the contribution of both specific voice assessments and metacognitive factor (experience avoidance) for voice-related disorders.
T. M. Luhrmann, R. Padmavati, H. Tharoor and A. Osei (USA, India and Ghana). The British Journal of Psychiatry, 2015. Qualitative research with semi-structured interviews To compare auditory hallucinations in three different cultures by means of a study based on interviews.
María de Gracia León-Palacios, Juan Úbeda-Gómez, Silvia Escudero-Pérez, María Dolores Barros-Albarán, Ana María López-Jiménez and Salvador Perona-Garcelán (Spain). The Spanish Journal of Psychology, 2015. Cross-sectional quantitative study This study was designed to find out whether a person’s relationship with his/her voices and the negative affect he/she establishes with them are mediated by beliefs about voices.
Tanya M. Luhrmann, R. Padmavati, Hema Tharoor, Akwasi Osei (USA, India and Ghana). Topics in Cognitive Science, 2015. Qualitative research with semi-structured interviews The study compares 20 individuals with severe psychotic disorder (they meet the inclusion criteria for schizophrenia) who hear voices, comparing their experiences.
George Robson and Oliver Mason (United Kingdom). Behavioural and Cognitive Psychotherapy, 2015. Cross-sectional quantitative study The study investigated links between anxiety to establish bonds, interpersonal aspects of relationship with the voices and distress, considering the impact of beliefs on voices and paranoia.
Neil Thomas, John Farhall, Frances Shawyer (Australia). Behavioural and Cognitive Psychotherapy, 2015. Cross-sectional quantitative study In this study, one examined the relationship between beliefs about voices and cognitive self-representations and representation of the others in people who experience auditory hallucinations.
Joséphine Chaix, Edgar Ma, Alexandra Nguyen, Maria Assumpta Ortiz Collado, Shyhrete Rexhaj, Jérôme Favrod (Switzerland). Psychiatry Research, 2014. Cross-sectional quantitative study To evaluate the auditory hallucinations of 28 patients with schizophrenia and auditory verbal hallucinations.
Bas van Oosterhout, Lydia Krabbendam, Guus Smeets and Mark van der Gaag (Netherlands). British Journal of Clinical Psychology, 2013. Cross-sectional quantitative study This study explores the associations between metacognitive beliefs and beliefs about voices in patients with severe auditory verbal hallucinations, and their hypothetical relationship with levels of depression and anxiety. In addition, it has been hypothesized that metacognitive beliefs are more able to explain differences in levels of depression and anxiety than beliefs about voices.
K. Daalman, I. E. C. Sommer, E. M. Derks and. R. Peters (United Kingdom and Netherlands). Psychological Medicine, 2013. Case-control quantitative research Several cognitive defects are related to psychotic symptoms, including auditory verbal hallucinations (AVH). It is not yet clear whether these trends differ in voice hearers with and without the need for care.
E. Faccio, D. Romaioli, J. Dagani and S. Cipolletta (Italy). Journal of Psychiatric and Mental Health Nursing, 2013. Qualitative research with semi-structured interviews This exploratory research investigates the phenomenon of auditory hallucinations from the perspective of the voice hearer who does not use mental health services, evaluating whether this experience can contribute to maintenance and adaptation of the hearer’s personal identity system.
Simon McCarthy-Jones, Amanda Waegeli e John Watkins (Australia and United Kingdom). Psychosis, 2013. To examine how spirituality can help voice hearers.
K. Berry, A. Wearden, C. Barrowclough, L. Oakland, J. Bradley. (United Kingdom). British Journal of Clinical Psychology, 2012. Cross-sectional quantitative study The study investigated associations between ability to bond in adults and hearing voices. It is believed that there are associations between unsafe bonds, severity of the voice heard and anguish regarding voices. There is also a hypothesis of associations between type of bond and the nature of relationships with the voices.
N. G. Petrus, Ricky W. K. Chun, and Angela Tsun (Hong Kong). The Scientific World Journal, 2012. Qualitative research with semi-structured interviews This study aimed to examine strategies for coping with auditory hallucinations of Chinese people with schizophrenia in Hong Kong.
Charlotte Connor and Max Birchwood (United Kingdom). Clinical Psychology and Psychotherapy, 2011. Cross-sectional quantitative study To explore assessments of the power of voices and emotional support to determine their impact on the prediction of depression and suicidal thinking.
S. Cottam, S. N. Paul, O. J. Doughty, L. Carpenter, A. Al-Mousawi, S. Karvounis and D. J. Done (United Kingdom). Cognitive Neuropsychiatric, 2011. Quanti- qualitative exploratory research It is hypothesized that religious voice hearers would interpret voices according to their beliefs and therefore experience fewer difficulties. To verify whether religious voice hearers interpret voices according to their beliefs.
C. Place, R. Foxcroft, J. Shaw (United Kingdom). Journal of Psychiatric and Mental Health Nursing, 2011. The objective was to make mental health nurses to listen to the voice hearers, helping them tell the story of their experience of hearing voices.
Vanessa Beavan and John Read (New Zealand). The Journal of Nervous and Mental Disease, 2010. Quanti-qualitative exploratory research The purpose of this study is to explore, in a general population sample, the content and impact of voice hearers’ auditory hallucinations.
Lana J. Jackson, Mark Hayward and Anne Cooke (United Kingdom). International Journal of Social Psychiatry, 2010. Qualitative research with semi-structured interviews Research questions: How do people develop positive relationships with their voice (s)? What factors (internal and external) affect these relationships? How do these relationships change over time?
Catherine Lawrence, Jason Jones, Myra Cooper (United Kingdom). Behavioural and Cognitive Psychotherapy, 2010. Quantitative exploratory research with application of questionnaires via the Internet This study investigates beliefs about voices and the pain experienced, providing a topographic report of the experience of hearing voices in a sample of 184 individuals who hear voices in a non-psychiatric population.
Eleanor Sorrell, Mark Hayward, Sara Meddings (United Kingdom). Behavioural and Cognitive Psychotherapy, 2010. Cross-sectional quantitative study Previous research suggests that the anguish experienced by clinical voice hearers (who make use of mental health services) is associated with the perception of the relationship that the hearer has with voices, regardless of beliefs about voices and level of depression. The purpose of this study was to replicate these findings and generate other hypotheses when comparing the experience of hearing voices from two populations: clinical and non-clinical hearers.
Jasmine T. Chin, Mark Hayward and Ange Drinnan (United Kingdom). Psychology and Psychotherapy: Theory, Research and Practice, 2009. Qualitative research with semi-structured interviews The conceptualization of interactions between voice hearers and their voices as a “relationship” has recently become an area of psychological inquiry. So far, the literature that explores the details of a hearer-voice relationship has undeniably privileged the studies that favor the viewer’s perspective on voices. The study aimed to establish the perspectives of voice hearers in relation to any “relationship” they may have developed with their voices.
Neil Thomas, Hamish J. McLeod, Chris R. Brewin (Australia and United Kingdom). British Journal of Clinical Psychology, 2009. Cross-sectional quantitative study Models of interpersonal relationships have proposed that people be designed to respond to others according to a principle of complementarity, whereby perceived hostility creates mutual hostility, and perceived dominance originates submission. This study examined interpersonal assessments and responses to auditory hallucinations to determine whether this principle predicts how patients respond to the voices they hear.
E. M. Andrew, N. S. Gray and R. J. Snowden (United Kingdom). Psychological Medicine, 2008. Population cross-sectional quantitative study This study aimed to explore the path in which traumatic life events contribute to beliefs about voices and any associated suffering.
Andrew Mackinnon, David L. Copolov and Tom Trauer (Australia). The Journal of Nervous and Mental Disease, 2004. Cross-sectional quantitative study Command hallucinations (CH) direct the patient to perform an action. In addition to the problems related to the danger that some CH may represent, little is known about CH broader clinical context.
Graham Cockshutt (United Kingdom). Cognitive Neuropsychiatric, 2004. First-person narrative To talk about the experience of hearing voices, how to deal with them, and what the medical space in that relationship is.
Sam Vaughan e David Fowler (United Kingdom). British Journal of Clinical Psychology, 2004. Cross-sectional quantitative study To explore the relationship between anguish and the perceptions that voice hearers have of their relationship with the voices they hear. The hypothesis is that a dominant voice style and a submissive and distant relationship style of the voice hearer would be related to the levels of distress.
Mark Hayward (United Kingdom). Psychology and Psychotherapy: Theory, Research and Practice, 2003. Cross-sectional quantitative study This preliminary study used Birtchnell’s (1996, 2002) theory of relating to investigate the hypothesis that people who hear voices relate to the voices and people in their social environment in similar ways.
S. Jones, A. Guy e J. A. Ormrod (United Kingdom). Psychology and Psychotherapy: Theory, Research and Practice, 2003. Using Q methodology and structured interviews, this preliminary study was established to explore how a diverse group of voice hearers interpreted their experience of hearing voices.
Octávia Cristina Barros, Octavio Domont de Serpa Júnior (Brazil). Interface - Comunicação, Saúde, Educação, 2014. Ethnographic qualitative research. The article, by means of studying voice hearers’ experience exchange in a virtual environment, explores how those people create strategies to share their experience in a group, in search for alternative to the psychiatric knowledge about verbal auditory hallucination.

Figure 1 Flowchart 

Discussion of the systematic review

Meaning of the voices

Many studies have focused on understanding how the experience of hearing voices is built for those who use mental health services and those who have never had contact with such services. Therefore, the meanings that the voice hearers attribute to their voices and their relationship with various factors are explored, such as: traumatic events, religious beliefs, cognitive tendencies, levels of depression and anxiety, cultural differences, and schemes of self-representation and representation of the others. The studies indicate that these factors are capable of, among other things, directly influencing the meaning attributed to voices, that is, whether the voice hearer perceives them as threatening, controlling, intrusive, and as synonymous with mental illness, or as positive, as a sign indicating he/she is special and has good guides; the voices are good companies and can even help him/her in the daily routine.

The study of Jones, Guy and Ormrod (2003) investigated what reason the voice hearers attribute for hearing voices and how they give meaning to that experience. The results showed that voice hearers using mental health services were more likely to perceive the voices as scary and negative than non-user hearers.

Similar results were found in the study of Lawrence, Jones and Cooper (2010). The authors investigated the experience of hearing voices in a non-psychiatric population by means of application of an online questionnaire to 184 participants, in which levels of emotional stress, such as anxiety and depression, were measured, as well as the meanings, sensations and behaviors associated with the experience of hearing voices. Compared with other studies, it was found that most of participants had much lower scores for anxiety and depression than the psychiatric population. Therefore, voice hearers who do not use mental health services seem to be less distressed by the experience of hearing voices than those who receive help from such services, since they perceive them as being kinder, and present themselves as more prepared to engage with the voices than the others (Lawrence, Jones, & Cooper, 2010).

Another factor that has been widely considered is the relationship between the meaning attributed to the voices by the hearer and the levels of distress caused by them. The studies of Varese, Morrison, Beck and Heffernan (2016), and Cole, Strauss, Fife-Schaw and McCarthy-Jones (2017), focus on this subject. The first examined the associations between the meanings attributed to the voices, behaviors of avoiding the experience of hearing voices and their characteristics, and the levels of anxiety experienced. Self-administered questionnaires were used in a sample of 101 participants, and the result was that negative evaluations of the voices, that is, negative meanings attributed to them, and behaviors of avoiding the experience were specifically related to levels of distress but not to the characteristics of voices, such as duration and frequency (Varese et al., 2016).

Similarly, the study of Cole et al. (2017) also found a direct relationship between the attribution of negative meanings to the voices by the voice hearer and the levels of distress, as well as the relationship between negative meanings in relation to oneself and the levels of distress. In addition to these results, the authors found a connection between negative beliefs about oneself and the others, and persecutory feelings about voices. According to Cole et al. (2017), these findings are in line with the notion that voice-related distress occurs in contexts of unsafe bonds and negative beliefs about oneself and the others.

Thomas, Farhall and Shawyer (2015) call these beliefs schemes of self-representation and representation of the others. According to the authors, these schemes are cognitive representations of previous experiences that end up influencing directly the evaluation that each one makes of daily events, as hearing voices, for example (Thomas et al., 2015). By investigating the relationship between the meanings attributed to the voices and the cognitive self-representation and representations of the others in voice hearers, the authors once again found that these representations, or schemes, as well as the content of the voices, influence the meaning attributed to them by the voice hearer (Thomas et al., 2015).

Besides the possible relationships between cognitive self-representations and representations of the others and the experience of hearing voices, authors as Daalman, Sommer, Derks and Peters (2013) investigated the relationship between this experience and the presence of cognitive bases. According to the authors, “a cognitive bias is the way in which an individual habitually interprets his/her experiences, gathers information about the world, and develops and maintains beliefs” (Daalman et al., 2013, p.2340).

When investigating differences in cognitive bias between voice hearers using mental health service, not using mental health service, and the control group, Daalman et al. (2013) found that the presence of cognitive bias was associated both with high levels of distress and with the attribution of negative meanings to the voices, as well as with the belief that they would have external origin and the voice hearer would have little control over them. Speaking about his experience as a voice hearer, Cockshutt (2004) states that, for him, his voices are a false manifestation of his inner thoughts, but they are external and real. According to the author, this understanding allows him to have control over the voices and his life, which becomes harmful in the presence of cognitive biases, as observed in the study of Daalman et al. (2013).

As previously mentioned, the relationship between the meaning attributed to the voices and levels of depression and anxiety has also been extensively investigated. The study of Van Oosterhout et al. (2013), contrary to what most others have been presenting, found that metacognitive beliefs have more influence on levels of depression and anxiety than the meaning attributes to the voices by the voice hearer. Some examples of metacognitive beliefs: positive beliefs about worrying, “worrying helps me solve things in my mind”; or negative beliefs about thoughts in general, such as responsibility, punishment or superstition, “not being able to control my thoughts is a sign of weakness”; among many others (Oosterhout et al., 2013). In other words, metacognitive beliefs would be relatively stable ways of coping with situations and, according to these authors, the negative meaning attributed to the voices (malevolence and omnipotence) “would be associated with negative metacognitive beliefs, which are more able to explain differences in affective symptomatology than the meaning attributed to the voices” (Oosterhout et al., 2013, page 238).

The relationship between religiosity and the meaning given to the voices is another factor that has received a lot of attention. When investigating how it could facilitate or make the experience of hearing voices difficult, McCarthy-Jones, Waegeli, and Watkins (2013) concluded, after interviewing voice hearers, that religiosity could help give meaning to the voices when no other explanation seemed convincing enough to the voice hearer. Similarly, Cottam et al. (2011) investigated whether religious beliefs would make the experience of hearing voices less distressing. However, contrary to the previous study, the authors found that for the voice hearer being or not a user of mental health services would have greater influence on the experience of hearing voices than the existence or not of voice hearer’s religious beliefs, which is in agreement with the findings of Jones et al. (2003), and Lawrence et al. (2010), presented previously.

Differences between voice hearers who use and do not use mental health services were also considered in the study of Andrew, Gray and Snowden (2008), who investigated how a trauma contributes to the meaning attributed to the voices by the hearer. When comparing the two groups of voice hearers from the application of six instruments (Psychotic Symptom Rating Scales - Auditory Hallucinations Subscale; Beliefs About Voices Questionnaire; Posttraumatic Diagnostic Scale; Impact of Events Scale, Beck Anxiety Inventory, and Beck Depression Inventory - II), the authors found that hearers of both groups had experienced considerable traumatic events, but those who used mental health services had a higher number of sexual abuse situations and a higher prevalence of posttraumatic stress disorder symptoms. These results suggest that traumatic events make people more vulnerable to the experience of hearing voices, but the nature of the trauma and how it remains poorly resolved for the hearer are factors that may determine the meaning he/she attributes to the voices (Andrew et al., 2008).

Finally, very significant studies of Luhrmann, Padmavati, Tharoor and Osei (2015a, 2015b) investigated the experience of hearing voices in places with very different cultures: California, South India and West Africa. They found that there were not only differences in the content of the voices, but mainly in the way the experience was felt by the hearers. In California, they described their voices mostly as unreal and intrusive thoughts; in Southern India, the voices were described as providing useful guidance; and in West Africa, voices were considered to be morally correct and powerful (Luhrmann et al., 2015a). According to the authors, it may be observed that hearers seem to pay selective attention to auditory events, such as

good voices, bad voices, commanding voices, soothing voices, inner voices, external voices, voices neither internal nor external, bangs, scratching, vibrations, etc. - because of different “cultural invitations” - variations in ways of thinking about minds, people, spirits, and so forth. (Luhrmann et al., 2015, p. 648)

Thus, people can pay more attention to certain types of voices due to their culture, which is able to provide, also as presented by Daalmann et al. (2013), important cognitive biases that can determine how each person identifies, responds and remembers auditory experiences (Luhrmann et al., 2015). The authors call this process “social activation.”

From the mentioned above, it can be observed that the main determinant of the meaning that each hearer attributes to his/her voices is his/her life history, since it is the life history that governs the several factors exposed previously, that is, his/her religious beliefs, possible traumatic events, cognitive tendencies and schemes of self-representation and representation of the others, besides one of the most important: the culture from where each hearer comes.

Relationship with the voices

In addition to the meaning attributed to the voices by the voice hearer, another aspect that has been widely investigated is the relationship that this person establishes with the voices. Studies have been presenting several factors that may influence this relationship, such as the meaning that the hearer attributes to them, the way he/she relates socially, and models of complementary relationships. In addition, studies have been developed on possible correspondences between the relationship established with the voices and levels of distress and depression, resistance to commanding voices, fear, and control over the voices.

The study of Hayward (2003) tested the theory of Birtchnell (1996, 2002), which states that voice hearers have relationships with the voices in the same way they socially relate. The study was developed with a sample of 27 mental health service users, who provided information on the characteristics of the voices, their relationships with them, and social relationships. The result was consistent with the theory of Birtchnell (1996, 2002), and further found that the way the voice hearer socially relates has a greater influence on the way he/she connects with the voices than the meaning he/she attributes to them. Thus, the study suggests that changes in one domain of the relationship - both in social relationships and in voice relationships - may have significant implications for the other domain (Hayward, 2003; Robson & Mason, 2015).

Berry, Wearden, Barrowclough, Oakland and Bradley (2012) performed another study that also proposed a parallel between the types of bond that voice hearers establish socially and the experience of hearing voices, and found significant connections between avoiding bonds and themes of rejection, criticism and threat in hearing voices. However, they found no correspondence between the types of bonds that the voice hearers establish and the control exerted by the voices on them, which suggests that the theory of the bond is not capable of promoting a possible understanding for the experience of being controlled by the voices (Berry et al. al., 2012).

The control exercised by the voices is investigated in the study of Mackinnon, Copolov and Trauer (2004), which tried to identify factors that can be associated with the fact that the voice hearer resists or not the commanding voices. For the study, 199 mental health service users were interviewed and more than 2/3 sample reported hearing commanding voices, while ¼ reported feeling unable to resist them. The authors noted the following: not resisting commanding voices is associated with negative voices in terms of tone and content; prevalence of negative symptoms and much higher doses of antipsychotic medication than that used by hearers who did not hear commanding voices, as well as a reduced amount of strategies to copy with them (Mackinnon, Copolov, & Trauer, 2004). Another finding involving commanding voices was that of Ellet et al. (2017), which stated that not only the meaning attributed to the voices by the hearer is associated with the presence of commanding voices and anguish, but also and mainly the belief that the person is responsible for avoiding harm to others. Thus, “the more an individual feels personally responsible for harm prevention, the more distressing it is to have voices commanding damages” (Ellet et al., 2017, p.6).

However, an increasing number of studies show that the relationship with voices may change, as it is the case of Rosen et al. (2015) and Jackson, Hayward and Cooke (2011). The first investigated the first-person description of the relationship between the hearers and their voices, and concluded that this relationship is “dynamic and can be influenced and modified through the engagement of the hearer in the process of conversation and negotiation with the voices” (Rosen et al. 2015). Similarly, Jackson et al. (2011) conducted semi-structured interviews with five mental health service users and seven non-users, and all of them had positive experiences regarding hearing voices. Thus, as in the previous study, the authors concluded that actively interacting with the voices to understand their subjective meaning may bring benefits to the hearer. In addition, they affirm that fear mitigation can have great impacts on the relationship with the voices (Jackson et al., 2011).

Other studies that investigate the origin of the type of relationship that voice hearers establish with the voices are those of León-Palacios et al. (2015), and Thomas, McLeod and Brewin (2009). In the first study, one tried to identify whether the meaning attributed to the voices by the hearers are able to mediate the type of relationship established with them. The authors found that the hypothesis that individuals who maintain a relationship of greater dependence on the voices should have lower levels of depression and anxiety does not correspond to reality, indicating that “a dependence-based style of relationship with the voices does not protect the individual from experiencing anguish and negative affect” (León-Palacios et al., 2015, p.5).

The second study, of Thomas et al. (2009), is based on the model of complementary relationships, suggesting that people tend to respond to others in accordance with a principle of complementarity, “where the perception of hostility elicits a hostile response, and the perception of dominance elicits a submission response” (Thomas et al., 2009, p.411). A sample of 35 mental health service users was used, and it was sought to determine whether the principle of complementarity is able to predict how each person will respond to a particular type of voice. The results showed that the model of complementary relationships did not work in 100% cases. In situations where the person perceived a voice as hostile, he/she also responded in a hostile manner, in accordance with the principle of complementarity. However, the association between the dimensions of control and submission was weaker, since submission to the voices was only a tendency of response to the commanding voices, not happening in 100% cases. This result “suggests that submission is not reliable as a reciprocal response to the voice domain and that other factors will be important in determining this response” (Thomas et al., 2009, p 420).

As mentioned above, in addition to the factors that may influence the relationship established by voice hearers with the voices, another focus of research has been the possible relationships between the connection established with the voices and levels of distress and depression, as it is the case in studies of Connor and Birchwood (2013), Sorrel, Hayward and Meddings (2010), and Vaughan and Fowler (2004).

Connor and Birchwood (2013) studied 102 mental health service users, founding that the relationship with the voices and the meaning attributed to them by the hearer are predictors of depression and suicidal thinking. Similar results were found in the study by Vaughan and Fowler (2004), which found that both the meaning that the voice hearer attributes to the voices and the relationship he/she establishes with them are associated with different emotional responses to the experience of hearing voices, and may generate several levels of anguish and stress, which reinforces the protective character that the relationship between the hearer and the voices may have. Sorrel et al. (2010) investigated the same subject but, differently from the studies mentioned above, this time making a comparison between two populations: voice hearers using and not using mental health services. As the authors’ initial hypothesis, voice hearers not using mental health services had lower levels of distress compared to those using it, and when they perceived the voices as less dominant, intrusive, malevolent and omnipotent, they were able to establish closer relations with them (Sorrel et al., 2010).

Finally, Chin, Hayard and Drinnan (2009) proposed to explore the relevance of the concept of “relationship with voices” for voice hearers. Ten hearers using mental health services underwent in-depth interviews. Their analysis showed that the concept of “relationship” was both accepted and rejected by participants, with acceptance associated with the poverty of social relationships, and rejection associated with self-preservation, personal conflicts about explanatory models for hearing voices, and regarding the very construction of the term “relationship” (Chin et al., 2009). According to the authors, these results suggest that the concept of relationship should be considered a possibility and not an imposition throughout treatment, since it was clear that the acceptance of this concept is not necessarily synonymous with a healthy relationship (Chin et al., 2009).

From the above mentioned, it is evident how significant the relationship between the person and the voices is, and the importance of working therapeutically on this aspect. Knowing the hearer’s life story, possible traumas he/she has faced, and the meaning he/she attributes to the voices has proven to be a key point in understanding his/her relationship with them. A better understanding of this relationship may encourage the person to establish closer proximity to the voice, developing a new narrative about the experience of hearing voices. Thus, engaging with communities that value and embrace the experience of hearing voices may be a very important initiative in developing this process.

Strategies to cope with the voices

Historically, the content of voices has always been a topic that had received little attention from psychiatry, being more discussed within the field of psychology, particularly in the psychodynamic area (Beavan & Read, 2010). Nowadays, there is already a greater interest and investment in exploring the relationship between the content of voices, strategies to cope with them, and contact with mental health services, as there is increasing evidence that the content of the voices may be crucial to understanding and working therapeutically with this experience (Beavan, Read, 2010).

This is the case of the study of Beavan and Read (2010), which points out that the content of the voices is the most significant predictor both of emotional reactions to the experience of hearing voices and of whether the person seeks or not help in order to deal with that experience. Quantitative results showed that hearing voices of negative content increased the probability of negative emotional responses and, consequently, the demand for mental health services. In addition, people who reported negative emotional reactions to the voices were more likely to hear voices discussing and commenting on each other, as well as reporting voices that speak for longer periods and make social contact difficult, taking control of their thoughts (Beavan & Read, 2010). These results reinforce the importance of paying attention to the content of the voices in order to help the hearers know themselves better, creating strategies to have a healthier life with the experience.

A study that presents the work with the content of the voices is that of Place, Foxcroft and Shaw (2011), in which a project inspired by the work of Romme & Escher (1993, 2000) is described, where voice hearer, individual experience and the understanding of this experience are placed in the center of attention as a way to help them in the recovery. Thus, “it is not the professional insight that matters, but the voice hearer understanding” (Place et al., 2011). Based on this work logic, the study of Place et al. (2011) aimed, in a hospital ward for acute cases, to encourage and assist nursing professionals to listen to the voice hearers’ history. The narratives obtained throughout the study showed that, as expected, the “experience of narrating the content of the voices brings the person the opportunity to go back and review their content and possible meanings” (Place et al., 2011, p.840).

However, recovery is a process and, as De Jager et al. (2016) affirm, it does not happen in the same way for all voice hearers. The authors analyzed the narrative of 11 people in order to understand their experience of hearing voices, and noted that after a period of exhaustion, two types of recovery were found: returning to/empowering and deactivating/protecting hibernation. Empowerment narratives “were characterized by a tendency to face problems, to engage actively with the voices, and curiosity about the meaning of the experience” (De Jager et al., 2016, p1414), while in narratives called protecting hibernation, the voice hearers responded by taking advantage of all the resources available to end the storm that was the experience of hearing voices, and it demanded all possible attention and energy. According to the authors, the latter used to feel better, more capable of communicating with others, performing activities and thinking more clearly with use of medications, which contributed to their recovery (De Jager et al. 2016). These results highlight the importance of respecting each person’s recovery style.

However, this does not mean that all sorts of voice hearer’s behavior will lead to recovery and that this person will not need help so that to find more healthy and fruitful ways of dealing with voices, as it is the case of people who feel dependent on safety behaviors. The study of Chaix et al. (2014) found that most voice hearers use these behaviors as a way to reduce the threat associated with the voices, and that dependence on these behaviors “is associated with the voice hearer’s belief regarding the origin of the voices, attribution of omnipotence, and reactions of resistance to the voices” (Chaix et al., 2014, p.160). Thus, safety behaviors play an important role in maintaining dysfunctional beliefs about the origin of the voices (Chaix et al., 2014).

As explained earlier, the way each person deals with the experience of hearing voices and with his/her own recovery is closely related to his/her life history. This is again evidenced by Powers III, Kelley, and Corlett (2017), who show, through a comparison between the hearers who seek help and those who do not need it, that the characteristics of their voices were similar - that is, level of loudness, content and frequency -, but the context of life, the meaning attributed to the voices, and the relationship established with them, were different. An important difference between both was how someone else received information about hearing voices when the hearer first talked about his/her experience. Hearers who did not need help had more positive receptions upon the news; they felt less distressed by the experience and were able to control beginning and end of hearing voices throughout the day; those who needed help had predominantly negative receptions when reporting their experience for the first time, and this was subsequently more harmful to the establishment of social relationships (Powers III et al., 2017).

Thus, the strategies used to cope with the voices arise from an individual process, which is constructed from a life history, a cultural reality and a condition of family/social support. However, there are strategies that seem to be common to a high number of voice hearers, as evidenced in the study of Petrus, Chun and Tsun (2012), which found three types of strategy to cope with voices in the Chinese population of Hong Kong. The first of these was “change of social contacts,” which included increasing these contacts and becoming more actively involved in conversations and discussions. This strategy worked in two ways: the first was to distract oneself from the content of the voices by talking to others; the second was to interrupt subvocal activity concomitant with hearing voices (Petrus et al., 2012).

The second most frequently used strategy was “to manipulate and regulate voices,” with which, even if they took months or years to reach this capacity, many hearers were able to get in touch with the voices and establish a dialogue when they were selectively heard (Petrus et al., 2012). The last strategy found in the study was “to change the perception and meaning attributed to the voices.” According to the authors, “an important aspect of this change appeared to be the development of a balance or compromise between the voices and themselves” (Petrus et al., 2012, p.5). By assigning a new meaning to the voices, it became possible to consider them as part of themselves and their lives, providing a feeling of greater control over the voices (Petrus et al. 2012).

As already mentioned, there are strategies to cope with voices that seem to be common to many hearers, as evidenced in the study of Petrus et al. (2012). However, not everyone can establish these strategies alone, requiring professionals help, such as the case of those seeking mental health services, or others who have already found more useful ways of dealing with the experience of hearing voices and can help a lot by sharing them with others. This is the case of Britz (2017), who, in reporting her first-person story, talks about a crucial moment in her life: when she was asked to help other hearers cop with their experiences on the Internet at a time when she herself was still not satisfied with her own strategies. According to the author, the experience of helping others made her to take control of her voices and achieve greater personal growth.

Based on the premise that mutual aid between voice hearers may be beneficial not only to the requestor but also to the voice hearer who provides it, Barros and Serpa Júnior (2014) developed a study on the exchange of experiences on virtual environment. The authors explored how the voice hearers create strategies to share their experience in a group, in search for an alternative to get psychiatric knowledge. In this study, they met voice hearers who feel this experience by integrating it to their daily life, without causing harm or making tasks difficult: “On the contrary, some consider hearing voices as something pleasant, as something more in the everyday experience, or even as something that accompanies them, and whose presence is comforting” (Barros & Serpa Júnior, 2014, 565). For similar purposes, authors such as Faccio, Romaioli, Dagani and Cipolleta (2013) consider that the voices should be understood as an adaptive system, not as a symptom, and therefore should not be eliminated.

From the above mentioned, it is clear that there are possible ways of coping with the experience of hearing voices beyond psychiatric knowledge, and sharing experiences with voice hearers - that is, between experts by experience - can be a very effective way of helping hearers who feel distressed by the experience cop better with it. Moreover, mental health services need to respect the individuality of each hearer and his/her own recovery paths.

Final Considerations

This study aimed to review the literature on the subject of voice hearers, and showed that the configuration this experience has for each individual allows different ways of life and relationship with the voices. In relation to the contents of the voices, some studies have shown that these are very important predictors of emotional reactions of the hearer to the experience, and may be related to traumas that the person might has experienced and are still not well elaborated. Thus, commanding voices usually bring greater damage to individuals’ daily life, since they are more invasive and frightening. In other words, establishing contact with the voices tends to be more difficult when their characteristics are negative and the content is scary, which leads many hearers to seek help in mental health services.

In addition to the content of the voices, factors such as traumatic events, religious beliefs, cognitive tendencies, levels of depression and anxiety, cultural differences and schemes of self-representation and representation of the others were able to directly influence the meaning attributed to the voices. This highlights the importance of investigating each hearer’s life history, since it is the one that governs these factors, representing a large portion in the meaning attributed by each one to the experience of hearing voices.

In the same way, the meaning attributed to the voices, along with the way the hearer relates socially, and models of complementary relationships, are determinants of the relationship that the hearer will establish with the voices and the experience as a whole. Therefore, when the voice hearer understands the voices as frightening, diabolical, or even synonymous with mental illness, the relationship he/she establishes with them tends to be very harmful to his/her life, leading to social isolation, for example. However, there is expressive number of studies showing that the relationship with the voices is susceptible to modification, and it is in this sense that different strategies appear - other than using medication - to deal with the voices, making this relationship positive.

The main strategy suggested by the Hearing Voices Movement is to talk about the experience, exploring in detail each characteristic of the voices, each feeling entailed by them and how this may be tied to the hearer’s life history. It is in this process that the recovery takes place, and it can mean improvement in the relationship with the voices but, at the same time, it can mean its end. From this perspective, groups of voice hearers appear, which allow the exchange of experience between experts by experience, and not only between voice hearers and health professionals. In these spaces, voice hearers can share their stories, strategies they use, and aspects of their relationships with the voices, helping each other in dealing with the experience.

From the aforementioned, it is clear the potential of new approaches to the subject, which has been strengthened since the emergence of the Hearing Voices Movement in the Netherlands, and also how much it is necessary to work for the voice hearers who do not feel being assisted by what the biomedical model has to offer.

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Received: September 06, 2018; Accepted: September 19, 2018

* Corresponding address: lauracouto@uol.com.br

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