Traditionally, when a person says they can hear voices that don’t exist in external reality (not to be confused with inner speaking), psychiatry has treated this as a sign of mental illness. However, it’s become clear in recent years that many people hear hallucinated voices without it causing them distress. To improve our understanding of how voice-hearing becomes problematic it’s clear we need to understand more about the different ways that people experience hearing voices.

Now Lucy Holt and Anna Tickle have published a “meta-ethnographic synthesis” of what we know so far about the varieties of people’s voice-hearing experiences. The researchers trawled the peer-reviewed literature using key-word searches to find studies of adequate quality that involved asking adults to describe their voice-hearing experiences first-hand. This process uncovered seven papers, published between 2003 and 2011, involving the first-hand accounts of 139 people aged 19 to 84 (52 per cent were women).

Holt and Tickle analysed the papers looking for recurring themes in people’s descriptions of their voice-hearing. The results are fascinating and some insights potentially useful for clinicians. The first theme is that most people gave the voices they heard an identity – often they named them, or they attributed a gender to them. Some people heard voices that belonged to real people encountered in the past, other voices were seen as belonging to God or a spiritual force.

Another important theme was the amount of power that people perceived their heard voices as having, and, related to that, how much power they felt they had over them. There was a continuum such that some people felt completely powerless over their heard voices, while others felt they could take them over. Intriguingly this appeared to be related to the explanations people gave for their heard voices. Those who subscribed to a biomedical account, believing that their voices were caused by a chemical imbalance in the brain, tended to feel less in control of their voices. The perceived power of voices was also linked to the voices’ identity, particularly if they were attributed to an authoritarian figure.

People also spoke of the strategies that their voices used to maintain power, such as criticising the person and exploiting his or her weaknesses. Other participants described strategies they used to regain control of their voices, such as using distraction or, opposite to that, deliberately engaging with the voices.

The way that heard voices affected people’s relationships was another theme. People described how hearing voices made it difficult to lead an ordinary life. Heard voices could interfere with social relationships, for example by making critical comments about friends or family. But voices could also play a beneficial role by reducing loneliness. “I have not got many friends … so the only thing I can stay very close to are the voices and I do stay very close to them,” said one person.

Yet another theme related to whether people saw a distinction between their own thoughts and the voices they heard. Most people recognised a clear difference between the two, perceiving heard voices as “coming from outside the self but manifested inside the body”. One exception to this was a study conducted in a psychiatric setting. Here most of the participants endorsed a biomedical explanation for their voices, and they saw their heard voices and own thoughts as one.

Holt and Tickle said their review contained useful insights for therapists, most of all by showing that “‘voice hearing’ is clearly not a homogenous experience.” The findings also suggest ways that therapists might help their clients who hear voices, for example by boosting their feelings of self-worth. Therapists could also benefit by realising that heard voices sometimes have an adaptive function.

Unfortunately, the quality of the studies identified in this review was disappointing. Many failed to provide quotes from participants; others failed to acknowledge the influence of the researcher’s own interpretative stance on the results. “It is evident that the quality of research investigating the first person perspective of hearing voices warrants improvements,” Holt and Tickle said.

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Holt L and Tickle A (2013). Exploring the experience of hearing voices from a first person perspective: A meta-ethnographic synthesis. Psychology and psychotherapy PMID: 24227763

—further reading—

The same voices, heard differently?

A new approach to help those who hear voices

Hearing music that isn’t there

The science of how we talk to ourselves in our heads

A Community of One: Social Cognition and Auditory Verbal Hallucinations

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.