This is a pretty good article on schizophrenia from PBS's Nova Next blog. However, they adhere to the standard "biological disease" model of schizophrenia, which is a partial truth, and one that prevents many researchers from looking into the interpersonal antecedents of schizophrenia.

I especially appreciate, however, the take on hearing voices presented in the article. They mention Intervoice, a mostly European organization that holds voice hallucinations to be a natural and non-frightening phenomenon.

I feel it's important to make another point here - a lot of people with PTSD hear voices and how we, as therapists, deal with that is much different (in my opinion) than how we handle the voices in schizophrenia, or even dissociative identity disorder. The voices are qualitatively different in PTSD.

What Schizophrenia Can Teach Us About Ourselves

By Allison Eck on Wed, 22 Oct 2014

“I don’t believe in anything. That’s my cardinal rule. I do it for my mental health. If I believe in God, then I start talking to God and God starts talking to me. As soon as I start believing in something, then it talks to me. So, I don’t believe in anything.”

Sara, whose name we changed to protect her identity, was diagnosed with schizophrenia at age 19 during her senior year at New York University. She had not experienced any trauma as a child—no abuse, no bouts of depression, nothing that would raise any red flags. She led a more or less happy life. But in high school she experimented with drugs, and upon travelling abroad around the same time, she experienced intense culture shock.

This series of events may have been Sara’s personalized recipe for mental illness, cooked up with all the flavors of her unique position in life, her temperament, and her family’s history. Her mind became a prison; she felt as though people were constantly laughing at her. She could no longer distinguish fantasy from reality. She assumed she wouldn’t go back to school.

“I thought that my life was over, that I would never be able to do anything,” she says. “Because that’s what the doctors told me.”

Then she began to hear voices.

The Schizophrenic Brain

Schizophrenia is a disease that afflicts almost all walks of life. Because it can be so debilitating, scientists have been feverishly searching for its genetic basis. In July, researchers affiliated with the Psychiatric Genomics Consortium compared the genomes of nearly 37,000 people with schizophrenia to the genomes of more than 113,000 people without the disease. In the end, they identified 108 locations where the DNA sequence in schizophrenic people tends to differ. The finding was a major advance in the field of psychiatric genomics, one that could ultimately help scientists understand who is susceptible and why.

Still, the biological markers aren’t always clear—often, a patient’s genes for schizophrenia can lay dormant until certain circumstances trigger their expression, making a diagnosis based on DNA alone less than clear-cut. And with no blood test or brain scan available to detect schizophrenia’s symptoms elsewhere in the body, diagnosis is based almost entirely on what the patient reports.

Treatment of mental illness is nested in confusion, too. Many therapists approach their practice from a different medical perspective than a cognitive psychologist or a geneticist. And while a geneticist might have access to the most current research, she isn’t going to have direct daily contact with a patient’s behavioral nuances like a psychiatrist. What’s going on in the lab, in other words, is often divorced from what’s being implemented “on the couch.”

But it doesn’t have to be that way.

Some scientists are arguing that our new understanding of a particular network in the brain is allowing neuroscientists, psychologists, and psychiatrists—even artists and writers—to understand each other in ways that wouldn’t have made sense ten years ago. Called the default mode network, or DMN, it’s a set of brain regions that are typically suppressed when a person is engaged in an external task (playing a sport, working on a budget), but activated during a so-called “resting state” (sitting quietly, day-dreaming).

“It’s an extremely important platform for any kind of thought that is disengaged from the ‘here-and-now,’" says Mary Helen Immordino-Yang, assistant professor of psychology at the University of Southern California’s Brain and Creativity Institute. That includes processing other people’s stories, reflecting on our own lives, planning for the future, or making important decisions. Immordino-Yang says the default mode network is “metabolically expensive.” In other words, when your head is lost in the clouds, your brain is hard at work.

The default mode network, which is hyperactive in schizophrenic people, plays an important role in self-reflection, identity, and mind-wandering.

Though not the only “resting state” network that’s active when we’re staring off into space, the DMN is unusual in that it is reliable and identifiable, making it easy for scientists to study. Like a web of taut ropes overlaying and intersecting one another, the regions of the DMN—which include the medial prefrontal cortex and the posterior cingulate, both of which are involved in self-awareness, self-reflection, and so on—light up in concert, despite any distance separating them.

When neurologist Marcus Raichle and his colleagues discovered the DMN in 2001, it took the scientific community by surprise. How could rest and self-reflection excite the same brain regions in us all? Why are those regions so intimately correlated? Wouldn’t a brain scan vary more from person to person depending on the content of an individual’s thoughts? It turned out that the DMN has nothing to do with content and everything to do with context. This network is functioning all the time—focusing on a task merely tempers and subdues it.

“This is first time we’ve found a neural system that actually reveals your inner self,” says Susan Whitfield-Gabrieli, a research scientist at MIT. In 2009, she and her colleagues found that in schizophrenic people, the DMN operates on overdrive. When clinically diagnosed patients enter an fMRI scanner and are asked to perform various tasks, the dial on their DMN doesn’t turn down like it should. And when the patients are at rest, their DMN is hyper-connected, buzzing with surplus energy. What’s more, they lack the ability to toggle out of the DMN, this highly self-referential state of being. “They’re actually stuck in their default mode network,” Whitfield-Gabrieli says.

So how does a schizophrenic person get unstuck? That’s a question hundreds of experts from diverse backgrounds are trying to answer.

Coping with Voices

One lens through which experts are studying schizophrenia is anthropology. If the default mode network is related to identity and self-reflection—and if schizophrenia, in turn, is associated with the default mode network—then considering culture may help us understand how psychosis manifests itself globally. After all, how you experience your inner world depends partly on where you live and how you’ve grown up. The same is true of mental illness. “When immigrant groups move to a new cultural group, they take on the mental illness liabilities of the culture where they are,” Immordino-Yang says. Because 60 to 80% of people diagnosed with schizophrenia hear voices, a good indicator of how a given culture views the disease might be how its people cope with its most well known but most misunderstood facets: auditory verbal hallucinations.

“Americans hate their voices. Their voices mean schizophrenia to them,” says Tanya Luhrmann, an anthropologist at Stanford University. By contrast, people in India and Africa don’t typically label their illnesses or their voices, she revealed in a study published in the British Journal of Psychiatry. “It’s not that they don’t recognize that they’re struggling,” she says. “But they talk about their experience as having much more of a natural role.” For example, they may think of their auditory hallucinations as benevolent or spiritual—like a friend or even the voice of God.

People not diagnosed with a mental illness, too, hear voices. In some cases, what they experience may be something that would be classified as a hallucination if reported by a clinically psychotic person. “If you ask someone, ‘have you ever heard a voice when you’re alone?’ the rate is somewhere between 15 to 80% depending on how you ask the question,” Luhrmann says. If you couple it with an example of what might be considered an auditory verbal hallucination, the percentage of people who say “yes” goes up.

Testimonies from people who experience varying kinds of auditory hallucinations support the idea that voice-hearing is complex and culturally-dependent. Their range of experiences is vast. Some say they hear audible, crystalline voices that emanate from inside their heads. Others report cacophonous screeches and bangs coming from outside their bodies. Still others sense murmurs and whispers that crawl over from the next room. Finally, some people describe a phenomenon similar to what cognitive psychologists call “inner speech,” the wordless soup of dialogue that you “hear” when deep in thought. For some, inner speech is acoustically more intense than it is for others. For example, they might say their mental landscape is made up of “loud thoughts” or “soundless voices.”

For Sara, the voices she heard began as disembodied, made-up personalities. Then, after about a year of taking a handful of different medications to varying degrees of success, her voices became solely associated with real people and their private thoughts. Sara is now 33—and though she’s been well enough to go without medication for 11 years, she still hears this latter type of voice.

“If I hear somebody psychically communicating with me—which I don’t believe in; I’m a complete atheist—then the sound will come from above their head or behind their hair…even from inside their stomach. It’s somewhere besides their actual mouth,” she says. “It’s not as loud as their real voice. It’s softer, but I don’t think the tone and quality of the voice is compromised.”

The reason why Sara can talk about her voices so intelligently is because she’s cultivated a relationship with them, in a sense. Though she tries not to engage too much with them, she’s learned to understand her voices and even use them to her advantage. If she’s bored, they’re sometimes entertaining. Occasionally she even asks them questions.

“Sometimes I’m worried about what people think of me,” she says. “And so I ask them [what they think of me] in the air above their head, and I hear their voice say it.”

Sara enjoys and even values some of her auditory hallucinations now, which is atypical of most American psychotic and post-psychotic patients. But that’s not the case everywhere. A simple internet search in her early 20s led Sara to Intervoice, a network established in the U.K. and now widely recognized in 29 (mostly European) countries. The organization’s central tenet is that hearing voices is a meaningful human experience and not necessarily a sign of mental illness. Members set up support groups where people can meet and talk about their experiences without fear of stigma.

Still, Intervoice has not caught on in the U.S. like it has in the U.K. and elsewhere. “There are real differences in the way Americans and Europeans think about voices,” Luhrmann says. In Europe, people are generally more comfortable with the ambiguity between psychosis and religion, and there’s more interest in applying humanities research to medicine.

For Sara, the idea that people could handle and live with their voices made the difference. “I decided I was going to be one of those people,” she says. “Just a small glimmer of hope was all I needed.”

Angela Woods, a medical humanities researcher at Durham University in the U.K., is leading a team of experts in a project called “Hearing the Voice,” which works closely with the broader Intervoice network. It aims to dispel some of the myths about voice-hearing and to see how cognitive neuroscientists can work with writers, artists, clinicians, theologians, and even philosophers to grasp the full spectrum of schizophrenia itself.

A "Voice Walk" in a U.K. cemetery earlier this year encouraged voice-hearers to tell their stories.

“We wanted to call for a more nuanced, richer account of what it is like to hear voices,” Woods says. An initial step in their research involved sending surveys to 158 people from around the world in an attempt to better understand what the experience is like. The team has hosted a number of different events to raise public awareness of schizophrenia and its many shades, including a “VoiceWalk” in a U.K. cemetery to bring people’s voice-hearing stories to the fore and an event at the Durham Book Festival to promote a better understanding of how writers cope with disparate inner voices—their characters, their muse, their narrators, and so on.

Another way people can learn to cope with their voices is by bringing them into the lab. Whitfield-Gabrieli, in collaboration with Margaret Niznikiewicz of Harvard University, is training patients to regulate their auditory hallucinations by consciously controlling activation in their auditory cortex. Participants attempt to push their cortex activation levels up and down, without receiving any auditory stimuli other than the background noise of the fMRI scanner. Meanwhile, they receive visual feedback from the fMRI on their progress. Whitfield-Gabrieli says the hope is that patients can learn to mitigate their voices by focusing on what’s going on in their own brain.

“Teaching people with psychosis to use their imagination to handle their voices is a promising tool,” Luhrmann says. As a society, we can encourage positive relationships with auditory hallucinations by helping patients—schizophrenic or not—better understand them. That means allowing people to tag their voices as “me” or “not me,” give the voices names, recognize what they’re saying and why, and discover what personal significance, if any, a particular voice might have.

Whatever the auditory input may be, Luhrmann says people can have positive or negative experiences depending on the attitude they adopt. “People attend to different pieces of that good-bad spectrum depending on the way their culture invites them to attend,” she says.

While there’s no evidence yet that a learning-based method will work, Whitfield-Gabrieli has reason to believe it’s possible. Research has linked increased DMN activity to the phenomenon of voice-hearing. While scientists still aren’t entirely certain how or why people hear voices, they think that auditory hallucinations may be a misattributed form of inner speech. A hyperactive DMN agitates the auditory cortex, resulting in what could be a fundamental confusion between what the brain “hears” inside itself and what it actually hears as a result of real, external stimuli. Many factors, though—including social isolation—contribute to the health of a person’s brain. Imagination can help with the healing process and reclaim a functioning relationship between the self, the auditory cortex, and inner speech.

Woods’ and Luhrmann’s work—as well as their colleagues’—dovetails with a study published about a month ago in the American Journal of Psychiatry, which concluded that the term “schizophrenia” actually encompasses eight genetically distinct disorders, not just one. The assertion, whether or not it holds up, suggests that mental well being comes in a variety of different “packages” depending on your genetic makeup. That goes for clinically diagnosed patients as well as healthy individuals.

“We should be wary of seeing a schizophrenic person as someone with a kind of deficiency,” Woods says. Rather, it may be just another part of what it means to be human. A person might simply process language differently or ruminate on social interactions for too long. His or her inner speech might be more fragmented or circuitous. Individual differences in DMN activity account for the diverse ways the human mind freely wanders.

Searching for Answers

The default mode network may sound like a gold mine to psychiatrists and neuroscientists alike. The reality, though, is somewhat more complicated. Brain imaging, while promising, has yet to definitively solve major mental health issues like schizophrenia, depression, anxiety, and bipolar disorder.

Daniel Margulies of the Max Planck Institute for Human Cognitive and Brain Sciences argues that even if our scientific understanding of the DMN evolves, its weight in the science world has “opened up a way of talking about the relationship between the self and these disorders.” The default mode network (and its relationship to voice-hearing), he says, can provide a gateway to understanding the full range of how people comprehend themselves—even if anomalies in the network aren’t proven to be a direct cause of schizophrenia.

That may be what matters most, since schizophrenia is not necessarily about neurons or synapses. It’s about the people it affects.

“Technology is giving us important information, but not the final answers,” says David Farb, professor and chair of the Department of Pharmacology and Experimental Therapeutics at the Boston University School of Medicine. He advocates an approach that views diseases and disorders as “vast and complex chimeras of symptoms that can be mixed and matched.” For example, depression may share symptoms with other disorders, like severe anxiety. It’s also possible, he says, that a person may develop an anxiety disorder as they grow increasingly self-conscious of their schizophrenia, for example. In that case, Farb says that schizophrenia may be made even more complex by “an expression of learned helplessness.”

By acquiring as much genetic and neurological information about a patient as possible, we may be able to intervene at an earlier stage and prevent schizophrenia before it develops. Whitfield-Gabrieli and Larry Seidman of Harvard University are studying at-risk people in Shanghai to find brain markers that predict whether or not someone will become schizophrenic. Interestingly, they’ve noticed a skew toward more female than male schizophrenic patients in China; in the U.S, schizophrenia is a predominantly male disorder, again pointing to the cultural element.

And that is what’s so striking to the U.K. researchers associated with Hearing the Voice. We shouldn’t assume that nature (rather than nurture) is the primary culprit when it comes to schizophrenia, they say. “If the default mode network is somehow connected with mind-wandering, self-referential cognition, you can’t simply use objective measures,” says Felicity Callard, another Durham University researcher involved in the project. “You have to get at what people think is going on in their own heads.” In other words, to find a cure, we might have to put ourselves in other peoples’ shoes.

“We should direct energy and funding and resources into exploring people’s lives—not just their chemistry, their neuroanatomy, or their genes,” Woods says. PSTD, for example, is a legitimate response to a traumatic event. Likewise, schizophrenia is a legitimate response to a lifetime of accumulated events, thoughts, interactions, and engrained beliefs. “We need to be able to ask, ‘What happened to you?’ That’s not ruling genetics out, but it’s taking things from another angle.”

Farb suspects the answer might be simpler than that. Drugs that target genes regulating DMN connectivity or surgery that modifies key points of DMN activity, for example, could resolve schizophrenic symptoms. He acknowledges, though, that there may be other factors at play. Schizophrenia—like PTSD or chronic pain—may have a cumulative effect on the brain that’s hard to anticipate. “While we may be able to correct the original deficit, we may still be left with others because they are a consequence of all of those years spent living with the disorder,” he says. “It’s really complicated to get a cure.”

As a patient, Sara believes that the process needs to be individualized. Doctors should ask patients questions about their experiences and how they want to go about getting better. Woods agrees. “The more we treat schizophrenia as a mysterious entity that we’re going to pin down in a piece of DNA,” she says, “the more we’ll miss the complicated, multifaceted aspects of existence that go into making someone have an experience of psychosis.”

“And if people don’t feel as though they’re able to tell stories about their experiences, then it’s hard to see that a cure would be particularly welcome, rich, or meaningful.”

Tell us what you think on Twitter #novanext, Facebook, or email.

Photo Credits: © Frederic Cirou/PhotoAlto/Corbis, Angela Woods


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Allison Eck is a production assistant for NOVA Online.

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Vaughan Bell - A Social Visit with Hallucinated Voices

In this brief article from the PLOS Neuroscience Community blog, Vaughan Bell looks at the experience of hallucinated voices and how the hearer responds to them. Most who experience voices conceptualize them as distinct entities in some way, often as people they knew or know.

This piece looks at the why of experiencing these voices as unique entities.

A Social Visit with Hallucinated Voices

September 8, 2014
By Vaughan Bell

I’ve met a lot of people who hear hallucinated voices and I have always been struck by the number of people who feel accompanied by them, as if they were distinct and distinguishable personalities. Some experience their hallucinated entourage as hecklers or domineering bullies, some as curious and opaque narrators, others as helpful guardians, but most of the time, the voice hearer feels they share a relationship with a series of internal vocal individuals. Not everyone who hears voices experiences them as social entities but this type of social hallucinated voice is not rare or exotic.

Photo: LifeMentalHealth.com

Studies show that the majority of voice hearers experience their voices as individuals who can be distinguished by the characteristics of their speech and even their personalities. For some, this means the voice is experienced as a specific person that others are aware of. It may be someone they know (perhaps a family member), a famous person, a religious figure, or even a fictional character from popular culture.

For others, the voices have an identity named solely by that person (“Jeremy, a little boy”), and sometimes, the voice is unnamed and just recognised by its personal characteristics like the “unknown old woman” or “a man with a deep voice”, as reported in a 1997 study by Leudar et al. Surprisingly, scientific theories of how auditory verbal hallucinations are formed have rarely attempted to explain this social, even personal, aspect of the experience.

Currently, the main scientific theories of voice hearing suggest that hallucinated voices occur through a combination of atypical activity in the language and memory systems of the brain and a tendency to attribute internally generated mental phenomena as coming from an external source. The idea is that voice hearers think phrases to themselves as part of their internal monologue but hear them as coming from outside due to problems with adequately distinguishing internally from externally generated experiences. There is lots of evidence from experimental studies to back up these theories, but they don’t really address the issue of how voices are perceived as social identities.

So how do internal thoughts become experienced as other people?

It seems not many people are interested. A recent paper, published in 2012, aimed to synthesise all the existing research to give an up-to-date cognitive model of how hallucinated voices occur, and had very little to say on how voices come to be perceived as social identities. This is most of it: “The content of AH [auditory hallucinations] may be determined by factors such as perceptual expectations, mental imagery, and prior experience/knowledge (e.g. memories) that shape a perception of reality that is idiosyncratic and highly personalized.” Considering that the personal nature of hallucinated voices is a central and defining feature for most voice hearers, this is a striking omission for a causal theory.

The paper I wrote for PLOS Biology, “A Community of One: Social Cognition and Auditory Verbal Hallucinations” aimed to encourage a better understanding of this issue for hallucinated voices by taking the aspect of social experience seriously and looking at the current evidence that would support a social cognitive and social neurocognitive theory for voice hearing.

As I point out in the paper, clinical psychologists in particular have looked a great deal at people’s social experience of voices.

Numerous studies have now found that voice hearers understand their connection with the voices in terms of relationships and interact with their voices in ways that “share many properties with interpersonal relationships within the social world” [6]. Most obvious in this regard is the fact that over 80% of people who experience auditory verbal hallucinations have reported that they are able to engage in interactive conversations with their voices [7],[8]. Judgments about the identity of hallucinated voices rely on perceptual features similar to those required to judge identity when listening to the voices of other speakers, with perceived identity being an important mediator of distress [11].

But these findings haven’t been well integrated into research on auditory hallucination formation completed by experimental psychologists and neuroscientists who have tended to focus on individualistic, information processing theories. However, if you look at which neural circuits turn up in brain imaging studies, and how people perceive their voices in psychology studies, which is the evidence I review in detail in the paper, there is a good case for making social processing in the mind and brain a central part of understanding voices. I also suggest that one place to start making sense of this data could be in how we generate and use internal models of other ‘social actors’ when we’re thinking and reasoning about social situations.

Essentially, we spend a lot of time thinking about how certain people might react in certain situations, what they might say, and what they might do, even when they’re not present.

Here, again, from my PLOS Biology article:

It would be most parsimonious to assume that these phenomena stem from our normal ability to internalise models of people we know and their voices, rather than auditory hallucinations involving a de novo generation of persistent and internally vocal social identities. Accounts including internalised models of social actors suggest that we internalise others' voices and personalities so that we can predict what someone would say or do in any given situation [30]. These internal models can be for specific people, so I can imagine how my spouse might respond in a hypothetical conversation, or for generic stereotypes, so I can imagine how a policeman or shopkeeper might respond.

A Different Approach

I argue it’s more likely that the content of hallucinated voices comes from a normal ability to internalise models of people we know and their voices, rather than involving a separate step when we re-interpret our own thoughts as being from a range of individual characters based on some vague notion of ‘perceptual expectations’.

In the (PLOS Biology) article, I also make a series of predictions as to what this approach would entail. If you’re not familiar with science, making a series of predictions is research talk for ‘come and have a go if you think you’re hard enough’ based on the collective belief that reality ends up kicking everyone’s ass.

As a result, I’ve begun working with people who want to knock the ideas into shape or who are interested in stress testing similar concepts. I’ve been working on the role of agent representation – essentially how we make sense of other autonomous beings in the world and how we understand them in terms of their choices, actions and mental states – and how it applies to hallucinations, with philosopher of mind Sam Wilkinson. We’re just finishing a paper so hopefully we can continue the debate and spark some new approaches to hallucinations. We’re also working on the scientific implications with two cognitive neuroscientists who are much cleverer (and harder) than me, but we’re still getting our first draft of the paper down, so I’ll wait to we’ve got the details hammered out to say a bit more.

Finally, there is something important to note in how causal models of hallucinated voices have tended to ignore content and personal significance as irrelevant, while clinical models have tended to ignore neurocognition as inconsequential.

This is a trend present to varying extents throughout psychopathology research and it tends to distance lived experience from an integrated scientific approach to an experience that needs to be better addressed when distressing or disabling, and better understood as part of human nature.

We need to develop an understanding of difficult experiences that span mind and brain and ensure that clinicians, psychologists and neuroscientists talk to each other more than they presently do.

Vaughan Bell is a neuropsychologist at Kings College London and a clinical psychologist at the Maudsley Hospital. He blogs at MindHacks and serves as a PLOS ONE Academic Editor. On Twitter @VaughanBell

Click here to listen to “Hallucinations and Designer Drugs,” an August 2013 Mind the Brain Podcast interview with Vaughan Bell, conducted by former PLOS Biology Senior Editor Ruchir Shah.

Hallucinatory 'Voices' Shaped by Local Culture

Stanford anthropologist Tanya Luhrmann studies the phenomena of voices in people diagnosed with psychosis. In a new study, published in the British Journal of Psychiatry (BJP), she and her team interviewed American subjects who here voices, as well people from Ghana and India.

Subjects were asked how many voices they heard, how often, what they thought caused the auditory hallucinations, and what their voices were like. The differences were striking.

The striking difference was that while many of the African and Indian subjects registered predominantly positive experiences with their voices, not one American did. Rather, the U.S. subjects were more likely to report experiences as violent and hateful – and evidence of a sick condition.

The Americans experienced voices as bombardment and as symptoms of a brain disease caused by genes or trauma.

For those subjects who were not American, the voices were decidedly different:

Among the Indians in Chennai, more than half (11) heard voices of kin or family members commanding them to do tasks. "They talk as if elder people advising younger people," one subject said. ... Also, the Indians heard fewer threatening voices than the Americans – several heard the voices as playful, as manifesting spirits or magic, and even as entertaining. Finally, not as many of them described the voices in terms of a medical or psychiatric problem, as all of the Americans did. 

How different would the experience of psychosis be in this country if we took a different view on the voices that often come with PTSD and psychosis?

However, I suspect that the way our culture creates the experiences of voices (as a product of trauma) is why the voices are so negative and sometimes violent. In non-Western cultures schizophrenia and psychosis have much better prognoses (Kulhara, 1994; Hopper & Wanderling, 2000; Jilek, 2001) than in the West where schizophrenia is seen as a life-long illness.

References

Kulhara P. (1994). Outcome of schizophrenia: some transcultural observations with particular reference to developing countries. Eur Arch Psychiatry Clin Neurosci.; 244(5):227-35.

Hopper, K, Wanderling, J. (2000). Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative follow up project. International Study of Schizophrenia. Schizophrenia Bulletin; 26(4): 835–46. doi: 10.1093/oxfordjournals.schbul.a033498.  PMID 11087016.

Jilek, WG. (2001). Cultural Factors in Psychiatric Disorders. Paper presented at the 26th Congress of the World Federation for Mental Health, July 2001.

Hallucinatory 'voices' shaped by local culture, Stanford anthropologist says

Stanford Report, July 16, 2014
By Clifton B. Parker 

Stanford anthropologist Tanya Luhrmann found that voice-hearing experiences of people with serious psychotic disorders are shaped by local culture – in the United States, the voices are harsh and threatening; in Africa and India, they are more benign and playful. This may have clinical implications for how to treat people with schizophrenia, she suggests.

Tanya Luhrmann, professor of anthropology, studies how culture affects the experiences of people who experience auditory hallucinations, specifically in India, Ghana and the United States.

People suffering from schizophrenia may hear "voices" – auditory hallucinations – differently depending on their cultural context, according to new Stanford research.

In the United States, the voices are harsher, and in Africa and India, more benign, said Tanya Luhrmann, a Stanford professor of anthropology and first author of the article in the British Journal of Psychiatry.

The experience of hearing voices is complex and varies from person to person, according to Luhrmann. The new research suggests that the voice-hearing experiences are influenced by one's particular social and cultural environment – and this may have consequences for treatment.

In an interview, Luhrmann said that American clinicians "sometimes treat the voices heard by people with psychosis as if they are the uninteresting neurological byproducts of disease which should be ignored. Our work found that people with serious psychotic disorder in different cultures have different voice-hearing experiences. That suggests that the way people pay attention to their voices alters what they hear their voices say. That may have clinical implications."

Positive and negative voices

Luhrmann said the role of culture in understanding psychiatric illnesses in depth has been overlooked.

"The work by anthropologists who work on psychiatric illness teaches us that these illnesses shift in small but important ways in different social worlds. Psychiatric scientists tend not to look at cultural variation. Someone should, because it's important, and it can teach us something about psychiatric illness," said Luhrmann, an anthropologist trained in psychology. She is the Watkins University Professor at Stanford.

For the research, Luhrmann and her colleagues interviewed 60 adults diagnosed with schizophrenia – 20 each in San Mateo, California; Accra, Ghana; and Chennai, India. Overall, there were 31 women and 29 men with an average age of 34. They were asked how many voices they heard, how often, what they thought caused the auditory hallucinations, and what their voices were like.

"We then asked the participants whether they knew who was speaking, whether they had conversations with the voices, and what the voices said. We asked people what they found most distressing about the voices, whether they had any positive experiences of voices and whether the voice spoke about sex or God," she said.

The findings revealed that hearing voices was broadly similar across all three cultures, according to Luhrmann. Many of those interviewed reported both good and bad voices, and conversations with those voices, as well as whispering and hissing that they could not quite place physically. Some spoke of hearing from God while others said they felt like their voices were an "assault" upon them.

'Voices as bombardment'

The striking difference was that while many of the African and Indian subjects registered predominantly positive experiences with their voices, not one American did. Rather, the U.S. subjects were more likely to report experiences as violent and hateful – and evidence of a sick condition.

The Americans experienced voices as bombardment and as symptoms of a brain disease caused by genes or trauma.

One participant described the voices as "like torturing people, to take their eye out with a fork, or cut someone's head and drink their blood, really nasty stuff." Other Americans (five of them) even spoke of their voices as a call to battle or war – "'the warfare of everyone just yelling.'"

Moreover, the Americans mostly did not report that they knew who spoke to them and they seemed to have 
less personal relationships with their voices, according to Luhrmann.

Among the Indians in Chennai, more than half (11) heard voices of kin or family members commanding them to do tasks. "They talk as if elder people advising younger people," one subject said. That contrasts to the Americans, only two of whom heard family members. Also, the Indians heard fewer threatening voices than the Americans – several heard the voices as playful, as manifesting spirits or magic, and even as entertaining. Finally, not as many of them described the voices in terms of a medical or psychiatric problem, as all of the Americans did.

In Accra, Ghana, where the culture accepts that disembodied spirits can talk, few subjects described voices in brain disease terms. When people talked about their voices, 10 of them called the experience predominantly positive; 16 of them reported hearing God audibly. "'Mostly, the voices are good,'" one participant remarked.

Individual self vs. the collective

Why the difference? Luhrmann offered an explanation: Europeans and Americans tend to see themselves as individuals motivated by a sense of self identity, whereas outside the West, people imagine the mind and self interwoven with others and defined through relationships.

"Actual people do not always follow social norms," the scholars noted. "Nonetheless, the more independent emphasis of what we typically call the 'West' and the more interdependent emphasis of other societies has been demonstrated ethnographically and experimentally in many places."

As a result, hearing voices in a specific context may differ significantly for the person involved, they wrote. In America, the voices were an intrusion and a threat to one's private world – the voices could not be controlled.

However, in India and Africa, the subjects were not as troubled by the voices – they seemed on one level to make sense in a more relational world. Still, differences existed between the participants in India and Africa; the former's voice-hearing experience emphasized playfulness and sex, whereas the latter more often involved the voice of God.

The religiosity or urban nature of the culture did not seem to be a factor in how the voices were viewed, Luhrmann said.

"Instead, the difference seems to be that the Chennai (India) and Accra (Ghana) participants were more comfortable interpreting their voices as relationships and not as the sign of a violated mind," the researchers wrote.

Relationship with voices

The research, Luhrmann observed, suggests that the "harsh, violent voices so common in the West may not be an inevitable feature of schizophrenia." Cultural shaping of schizophrenia behavior may be even more profound than previously thought.

The findings may be clinically significant, according to the researchers. Prior research showed that specific therapies may alter what patients hear their voices say. One new approach claims it is possible to improve individuals' relationships with their voices by teaching them to name their voices and to build relationships with them, and that doing so diminishes their caustic qualities. "More benign voices may contribute to more benign course and outcome," they wrote.

Co-authors for the article included R. Padmavati and Hema Tharoor from the Schizophrenia Research Foundation in Chennai, India, and Akwasi Osei from the Accra General Psychiatric Hospital in Accra, Ghana.

What's next in line for Luhrmann and her colleagues?

"Our hunch is that the way people think about thinking changes the way they pay attention to the unusual experiences associated with sleep and awareness, and that as a result, people will have different spiritual experiences, as well as different patterns of psychiatric experience," she said, noting a plan to conduct a larger, systematic comparison of spiritual, psychiatric and thought process experiences in five countries.

Media Contact

• Tanya Luhrmann, Anthropology: (650) 521 1243 or (650) 723-3421, luhrmann@stanford.edu
• Clifton B. Parker, Stanford News Service: 650-725-0224, cbparker@stanford.edu

* * * * *

Full Citation:
Luhrmann, TM, Padmavati, R, Tharoor, H, and Osei, A. (2014, Jun 26). Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: Interview-based study. British J of Psychiatry; Epub ahead of print. doi: 10.1192/bjp.bp.113.139048

Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: Interview-based study

T. M. Luhrmann, R. Padmavati, H. Tharoor and A. Osei
 
Background
We still know little about whether and how the auditory hallucinations associated with serious psychotic disorder shift across cultural boundaries.

Aims
To compare auditory hallucinations across three different cultures, by means of an interview-based study.

Method
An anthropologist and several psychiatrists interviewed participants from the USA, India and Ghana, each sample comprising 20 persons who heard voices and met the inclusion criteria of schizophrenia, about their experience of voices.

Results
Participants in the USA were more likely to use diagnostic labels and to report violent commands than those in India and Ghana, who were more likely than the Americans to report rich relationships with their voices and less likely to describe the voices as the sign of a violated mind.

Conclusions
These observations suggest that the voice-hearing experiences of people with serious psychotic disorder are shaped by local culture. These differences may have clinical implications.

This new article from Frontiers in Psychiatry: Schizophrenia is a response to Cho and Wu (2013) on their proposal for the mechanisms of auditory verbal hallucination (AVH) in schizophrenia.

Inner speech is not so simple: a commentary on Cho and Wu (2013)

Peter Moseley [1] and Sam Wilkinson [2] 

1. Department of Psychology, Durham University, Durham, UK
2. Department of Philosophy, Durham University, Durham, UK

A commentary on
Mechanisms of auditory verbal hallucination in schizophrenia
by Cho R, Wu W (2013). Front. Psychiatry 4:155. doi: 10.3389/fpsyt.2013.00155

We welcome Cho and Wu’s (1) suggestion that the study of auditory verbal hallucinations (AVHs) could be improved by contrasting and testing more explanatory models. However, we have some worries both about their criticisms of inner speech-based self-monitoring (ISS) models and whether their proposed spontaneous activation (SA) model is explanatory.

Cho and Wu rightly point out that some phenomenological aspects of inner speech do not seem concordant with phenomenological aspects of AVH; Langdon et al. (2) found that, while many AVHs took the third person form (“he/she”), this was a relatively rare occurrence in inner speech, both for patients with a diagnosis of schizophrenia who experienced AVHs and control participants. This is indeed somewhat problematic for ISS models, notwithstanding potential problems with the introspective measures used in the above study. However, Cho and Wu go on to ask: “how does inner speech in one’s own voice with its characteristic features become an AVH of, for example, the neighbor’s voice with its characteristic features?” (p. 2). Here, it seems that Cho and Wu simply assume that inner speech is always experienced in one’s own voice, and are not aware of research suggesting that the presence of other people’s voices is exactly the kind of quality reported in typical inner speech. For example, McCarthy-Jones and Fernyhough (3) showed that it is common for healthy, non-clinical participants to report hearing other voices as part of their inner speech, as well as to report their inner speech taking on the qualities of a dialogic exchange. This is consistent with Vygotskian explanations of the internalization of external dialogs during psychological development (4). In this light, no “transformation” from one’s own voice to that of another is needed, and no “additional mechanism” needs to be added to the ISS model (5).

In any case, this talk of transformation is misleading. There is no experience of inner speech first, which is then somehow transformed. The question about whether inner speech is implicated in AVHs is about whether elements involved in the production of inner speech experiences are also involved in the production of some AVHs. There seems to be fairly strong evidence to support this.

That inner speech involves motoric elements has been empirically supported by several electromyographical (EMG) studies [e.g., Ref. (6)]. Later experiments made the connection between inner speech and AVH, showing that similar muscular activation is involved in AVH (7, 8). The involvement of inner speech in AVH is further supported by the findings from Gould (9), who showed that when his subjects hallucinated, subvocalizations occurred which could be picked up with a throat microphone. These subvocalizations were causally responsible for the AVHs, and not just echoing them (as has been hypothesized to happen in some cases of verbal comprehension [cf. e.g., Ref. (10)]) was suggested by Bick and Kinsbourne (11), who demonstrated that if people experiencing hallucinations opened their mouths wide, stopping vocalizations, then the majority of AVHs stopped.

Cho and Wu argue that ISS models are no better than SA models at explaining the specificity of AVHs to specific voices and content; we would argue that an ISS model, with recognition that inner speech is more complex than one’s own voice speaking in the first person, explains more than the SA model, because it explains why voices with a specific phenomenology are experienced in the first place, as opposed to more random auditory experiences that might be expected from SA in auditory cortex. The appeal to individual differences in gamma synchrony as an underlying mechanism of SA also does not seem capable of explaining why this would lead to activations of specific voice representations.

Cho and Wu go on to say that “once we allow that a given episode of AVH involves the features of another person’s voice with its characteristic acoustic features, it is simple to explain why the patient misattributes the event to another person: that is what it sounds like” (p. 2). Taken to its extreme, this implies that any episode of inner speech that involves a voice other than one’s own would be experienced as “non-self”, and hence experienced as similar to an AVH, a proposition that would clearly not find much support in empirical research. Taking this view, it is the SA model that needs an additional mechanism to explain why neuronal representations of other people’s voices are experienced not just as sounding like someone else’s voice, but also having the non-self-generated, alien quality associated with AVHs. This is exactly the type of mechanism built into ISS models of AVHs.

Indeed, the authors do go on to argue that many problems with the inner speech model of AVHs can be solved if we stop referring to “inner speech”, and instead refer to “auditory imagination”, which, supposedly, is characterized by actual acoustical properties, unlike inner speech (the authors do not cite any literature to support this claim). We would argue that this falls within the realm of typical inner speech, and that the view put forward by Cho and Wu is based on unexamined assumptions about the typical form of inner speech. We would argue that a separate “type” of imagery is not needed, and it is probable that inner speech recruits at least some mechanisms of auditory imagery. Therefore, it does not make sense to argue that AVHs resemble one, but not the other.

Finally, it should be pointed out that auditory cortical regions are not the only areas reported to lead to AVHs when directly stimulated; for example, Bancaud et al. (12) reported that stimulating the anterior cingulate cortex (ACC), an area often associated with error monitoring and cognitive control, caused auditory hallucinations, a finding that seems more compatible with self-monitoring accounts of AVH. Admittedly, it is possible that stimulation of ACC could have distal effects, also stimulating auditory cortical regions; we mention this finding simply to highlight the fact that the potential top–down effects of other brain regions on auditory cortical areas should not be overlooked.

Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
 
Acknowledgment
This research was supposed by a Wellcome Trust Strategic Award WT098455MA
 
References
1. Cho R, Wu W. (2013). Mechanisms of auditory verbal hallucination in schizophrenia. Front Psychiatry; 4:155. doi:10.3389/fpsyt.2013.00155 Pubmed Abstract | Pubmed Full Text | CrossRef Full Text
2. Langdon R, Jones SR, Connaughton E, Fernyhough C. (2009). The phenomenology of inner speech: comparison of schizophrenia patients with auditory verbal hallucinations and healthy controls. Psychol Med; 39(4):655–63. doi:10.1017/S0033291708003978  Pubmed Abstract | Pubmed Full Text | CrossRef Full Text
3. McCarthy-Jones SR, Fernyhough C. (2011) . The varieties of inner speech: links between quality of inner speech and psychopathological variables in a sample of young adults. Conscious Cogn; 20(4):1586–93. doi:10.1016/j.concog.2011.08.005 Pubmed Abstract | Pubmed Full Text | CrossRef Full Text
4. Fernyhough C. (2004). Alien voices and inner dialogue: towards a developmental account of auditory verbal hallucinations. New Ideas Psychol; 22(1):49–68. doi:10.1016/j.newideapsych.2004.09.001  CrossRef Full Text
5. McCarthy-Jones SR. (2012). Hearing Voices: the Histories, Causes and Meanings of Auditory Verbal Hallucinations. Cambridge: Cambridge University Press.
6. Jacobsen E. (1931). Electrical measurements of neuromuscular states during mental activities. VII. Imagination, recollection, and abstract thinking involving the speech musculature. Am J Physiol; 97:200–9.
7. Gould LN. (1948). Verbal hallucinations and activation of vocal musculature. Am J Psychiatry; 105:367–72.
8. McGuigan F. (1966). Covert oral behaviour and auditory hallucinations. Psychophysiology; 3:73–80. doi:10.1111/j.1469-8986.1966.tb02682.x  CrossRef Full Text
9. Gould LN. (1950). Verbal hallucinations as automatic speech – the reactivation of dormant speech habit. Am J Psychiatry; 107(2):110–9.
10. Watkins KE, Strafella AP, Paus T. (2003). Seeing and hearing speech excites the motor system involved in speech production. Neuropsychologia; 41:989–994. doi:10.1016/S0028-3932(02)00316-0  Pubmed Abstract | Pubmed Full Text | CrossRef Full Text
11. Bick P, Kinsbourne M. (1987). Auditory hallucinations and subvocalizations in schizophrenics. Am J Psychiatry; 14:222–5.
12. Bancaud J, Talairach J, Geier S, Bonis A, Trottier S, Manrique M. (1976). Manifestations comportementales induites par la stimulation electrique du gyrus cingulaire anterieur chez l’homme. Rev Neurol; 132:705–24.

Full Citation: 
Moseley, P, and Wilkinson, S. (2014, Apr 22). Inner speech is not so simple: a commentary on Cho and Wu (2013). Frontiers in Psychiatry:Schizophrenia; 5:42. doi: 10.3389/fpsyt.2014.00042

Eleanor Longden - Why I Thank the Voices in My Head - Video, Essay, and Responses

 

I posted this video of Eleanor Longden talking about her experience hearing voices when it first showed up as a TEDx Talk. Her talk was the subject of a TED Weekends edition on Huffington Post.

Along with her original TEDx talk, there is an accompanying essay by Longden and 10 responses from other mental health professionals and neuroscientists.

I want to post the TED video and her new essay, then I will offer links and introductory paragraphs to the 10 responses posted at Huffington Post.

Why I Thank the Voices in My Head

A New Voice In Mental Illness

Eleanor Longden
Posted: 08/23/2013

A few months ago, a colleague of mine brandished an article in front of me with a rather bemused expression. "Read this!" he said, "I'd never have believed it." It was a piece about a man who hears voices. Intrigued, I began to read:

"The voice is identified as Ruah... the Old Testament word for Spirit of God. It speaks in a feminine voice and tends to express statements regarding the Messianic expectation... It has spoken to me sporadically since I was in high school. I expect that if a crisis arises it will say something again. It's very economical... It limits itself to a few very terse, succinct sentences... I have to be very receptive to hear it. It sounds as though it's coming from millions of miles away."

The reason for my colleague's surprise wasn't so much the content (he's a psychologist and is well accustomed to accounts from people who hear things no one else can). Rather, it was who was relating their encounter with this "tutelary spirit" that surprised him. Because this wasn't a report from a distressed, disorientated psychiatric patient; they were the words of award-winning, visionary author Philip K. Dick whose works, amongst others, inspired the movies Blade Runner and Total Recall. To me, this wasn't particularly surprising; why shouldn't someone of accomplishment and renown also happen to be a voice-hearer? But to my colleague it seemed to present a puzzling, almost unsettling, dissonance. And, to an extent, I can empathize with his surprise. After all, voice hearing is closely entwined with schizophrenia (with all the sinister connotations that this controversial diagnosis implies). And in the popular imagination, voices are commonly linked with derangement, madness, and mental corruption. As such, many contemporary voice-hearers inhabit hostile territory -- it's an experience that is literally marinated with fear, suspicion, and mistrust.

Yet despite these florid associations, psychiatry has long recognized that voice hearing features in a range of non-psychotic mental health difficulties, particularly trauma-based conditions like post-traumatic stress and the dissociative disorders. Perhaps more unexpectedly, research also suggests that approximately 13 percent of people with no record of psychiatric problems may also report voice hearing at some point in their lives. In itself voice hearing is an absorbing topic -- conjuring the nuances of perception and the nature of self -- and has alternatively been feared, reviled, celebrated, and consecrated, and forensically scrutinized within such diverse specialties as psychology, neurology, anthropology, theology, medical humanities, and cultural studies. Furthermore, accounts of voice hearing have been documented throughout human history: recounted by a wide array of pioneers, geniuses, rebels, and innovators that span across the centuries -- and also by normal, unexceptionable people like myself. You see, I'm a voice-hearer too.

It was the delirious, frenzied depths and exhilarating rewards of my own voice hearing voyage that would eventually take me to the Long Beach stage for TED 2013. Over the years, my voices have changed, multiplied, terrorized, inspired, and encouraged. Today they are an intrinsic, valued part of my identity, but there was also a time when their presence drove me to delirious extremes of misery, desperation, and despair. They brought me cringing and rocking to a psychiatric ward and pulled me down into the bleakest depths of madness; yet they would also lift me up to help me pass my University exams and ultimately elevate me to discover fundamental, healing truths about myself. The evolution of this understanding -- and the remarkable privileges and terrible penalties it incurred -- form the basis of my talk and accompanying TED book, Learning From the Voices in My Head.

Sharing my experiences so publicly could have felt overwhelming, but at every step the solidarity of friends and colleagues in the International Hearing Voices Movement fortified and sustained me. This organization has taken huge strides to reclaim voice hearing as a meaningful human experience; one which, for many of us, embodies figurative, emotional metaphors that communicate compelling information about pain and conflicts in our lives. This is not about pathologizing voices as symptoms; rather it is about understanding, accepting, and reclaiming them. In my own pilgrimage to recovery, it was learning to see the voices in more respectful, compassionate ways -- as adaptations, survival strategies, and representations of emotional pain - that made my healing possible. After years of shame, horror, and heartbreak, I finally made peace with my voices which, fundamentally, meant making peace with myself. And it was this framework that empowered me to take to the TED stage; not as an ex-psychiatric patient with a 'bad brain,' but as a proud and maddened survivor with an assortment of valuable and valued voices. In fact, at the end of my talk June Cohen, one of the conference's wonderful co-hosts, came onto the stage and asked me, with a respectful interest, whether I still hear voices. For a split second I hesitated, wondering whether to feign 'normal' and play it down with an airy "oh, not all that much now." Instead I opted for the truth: "All the time," I said cheerfully, "In fact I heard them while I did the talk... they were reminding me what to say!" Pride, empowerment, and the support to listen to one's voices without distress should, I believe, be a natural right of everyone who hears voices. So too, the right to freedom, dignity, respect, and a voice that can be heard.

 * * * * *

Here are the 10 responses, in no particular order.

'Learning' Our Way to Mental Healing

Patric K. Stanton  

Watching and hearing Eleanor Longden talk about her experiences of hearing voices may, for many of us, feel both odd and familiar. I am a neuroscientist, but first, I am a person living my own human experience. So I found myself thinking how often, in the course of life, these things we call thoughts and emotions appear, unbidden, from some recess of our minds and make themselves known to us, as if "we" are not quite the same as everything going on in our "conscious" and "unconscious" brains. Many of us, at some time or other, may even have had the experience of hearing a distinct voice, a parent or coach, speaking to us. Eleanor's voices seemed more coherent and more separate, but might they not be on a continuum of states of mind that we all have? When should society (namely us) view this form of internal experience as a disease, instead of a rare, but acceptable, part of life?

* * *

Madness, Revolution, and Making Peace

Ron Unger

While some will frame Eleanor's story, told in her awesome TED video, as the triumph of an individual struggling against "mental illness," I believe the story might better be seen as a refutation of the whole "illness of the mind" metaphor, and as an indication of a desperate need for a new paradigm.

When human experiences like hearing voices are framed as "illness," the strategy of attempting to eradicate them naturally follows. When Eleanor was first hospitalized, she was trained in this model, which directly led to what she describes as her engagement in a "psychic civil war," where the voices multiplied and became overwhelmingly nasty. Unfortunately, this is not unusual: research shows that fearing experiences, and attempting to avoid and/or suppressing them, often predicts the escalation of difficulties.  
* * * 

Listening to the Soul

Mark Rubinstein
As a novelist and psychiatrist, I listened to Eleanor Longden's lyrical presentation with a mixture of awe, admiration and humility.
She hauntingly described the "toxic, tormenting sense of helplessness" accompanying severe mental disturbance. "My voices were a meaningful response to traumatic life events. Each voice was related to aspects of myself... that I'd never had an opportunity to process or resolve, memories of sexual trauma and abuse, of anger, shame, guilt, low self-worth." I found these statements deeply insightful.
I was particularly impressed when she said the voices "represented the parts of me that had been hurt most profoundly."
* * * 

Eleanor Longden's TEDTalk: "The Voices In My Head"

Lloyd I. Sederer, MD

Damage is not destiny. That is Eleanor Longden's lived experience and the message delivered in her warm, poignant and illuminating TED talk.

She casts a striking figure, statuesque in the beam of the TED lights with her long, golden blond hair and crystal clear blue eyes, telling a story about psychosis -- her own. I watched, mesmerized, and saw both her confidence and her fragility as she revealed how what started as benign voices commenting on her behavior escalated to sinister, accusatory and demoralizing demons. She was told she had schizophrenia, a severe and persistent mental illness. Like many people in a psychotic state she was given medication that -- while generally necessary -- left her feeling more "drugged and discarded" than having assisted her in overcoming a serious illness.
* * *

Mind Wide Open: Listening to Disturbing Voices, Thoughts and Feelings

Dr. Gary Trosclair
"Is that crazy?" my patients sometimes ask me when they've told me something they're feeling or thinking that they're worried about. "No, it's not crazy," I say, "but I get that it can be crazy-making." I understand that while their feelings or thoughts don't necessarily qualify them for a trip to the hospital, they can be very disturbing. But I've also come to learn that while what comes up inside can be distressing, it may well also have meaning. And while the experience that psychologist Eleanor Longden describes in her TEDTalk is far more dramatic than what most of us go through, her talk shows the way to a more informed and fulfilling way of living; we should all listen to our voices.
* * *

Psychiatry and Recovery: Finding Common Ground And Joining Forces

Allen Frances
Eleanor Langdon is an extraordinary woman who has shown remarkable grit and creativity in transforming her disturbing symptoms into useful tools. Hats off to her for finding such a fruitful path to personal recovery and for sharing her techniques and inspiring story so that others may benefit from what she has learned. 

There are many precious lessons we can draw from this tape- never give up hope; never forget the person who is ill by focusing only on the illness; normalize the experience of mental illness rather than stigmatizing it; and use the symptoms as a way of gaining self understanding and self acceptance.
* * *

The Hope Within

Ashley L. Smith
Eleanor Longden's TEDTalk, "The Voices in My Head," provided insight into a world I know all too much about -- living with schizophrenia. Schizophrenia can be characterized by irrational thoughts, bizarre behavior, hallucinations, delusions, and psychosis, or lack of understanding of reality. Hallucinations can come in all five bodily senses -- sight, hearing, feeling, taste, and smell. Despite popular belief, not all people with this type of mental illness experience hallucinations. Sometimes people with different mental illnesses including bipolar disorder, depression, and schizoaffective disorder experience hallucinations too.

Eleanor's experiences seemed to parallel some of my own which helped me identify with her even more than simply sharing diagnoses.
* * *

Why Mental Health Is Losing Its Soul

Jeffrey Rubin, Ph.D.
Many years ago I worked with a man in his early 30s, who was sent to me by a psychiatrist because he suffered from "delusions of persecution." Short and slight, "Roger" believed rays were being beamed into the bus he was on.

Schizophrenics are supposedly people who are crazy and "out of touch with reality."

At the end of our first session, Roger leaned forward and asked if I would treat him using only intensive psychotherapy, without forcing him to take drugs and become a "zombie."

"Let's try it and be honest about how it goes," I said.
* * *

The Real Dangers of Self-Stigmatization

Katy Gray
Being sectioned and locked in a hospital ward wasn't on my bucket list, but it's something that has happened to me twice. The first time, I was 20 and in the middle of my studies at university. I had been hearing a voice for two years, a voice I believed was the devil. He made me do many harmful things to myself, but his latest command was even more extreme. He commanded me to stop eating, and for two weeks, I obeyed him. I was physically and mentally exhausted after this fortnight, but being sectioned still managed to take my breath away.

Around ten minutes after being sectioned, I was told I was being prescribed an antipsychotic.

"Wait, an antipsychotic? Does this mean I'm psychotic?" I thought.
* * *

Realize Your Mind's Intrinsic Power 

Marie Pasinski, M.D.

Holding a human brain for the first time was a powerful moment. Cradling the fragile organ in my hands, I had this overwhelming realization that every thought, every emotion, every experience and every dream this person ever had was coded within. As a neurologist, my awe for this miraculous structure intensifies with every new breakthrough in neuroscience and each personal triumph that I encounter. Eleanor Longden's talk, "The Voices in My Head" is a testament to the intrinsic power of the human brain and its ability to redesign itself. 

Only recently have we begun to understand that thoughts are structurally encoded within the brain. Every time you think a specific thought, certain pathways of neurons fire up. With repetition, these pathways are strengthened.

TED Blog - Everything You Ever Wanted to Know About Voice Hearing (But Were Too Afraid to Ask)

Eleanor Longden is the author of Learning from the Voices in My Head, a book in which she chronicles her experience of hearing voices, struggling with a diagnosis of schizophrenia, and her eventual befriending of the voices.

This is a topic close to my heart - many of the clients I deal with hear voices and none of them are schizophrenic. As an advocate of the Internal Family Systems model of therapy, I generally attempt to bring the voices into the therapeutic alliance. This process requires the client to befriend the voices and approach them with compassion and curiosity - two of the 8 c-words indicating the client is in Self and not in a part (all 8 of the c-words: calmness, curiosity, clarity, compassion, confidence, creativity, courage, and connectedness).

Everything you ever wanted to know about voice hearing (but were too afraid to ask)

Posted by: Michelle Quint
August 8, 2013

Eleanor Longden gave a candid talk about the fact that she hears voices at TED2013. Today, we also release her TED Book, which delves further into her experience in the mental health system. Below, all the questions you’d want to ask Longden. Photo: James Duncan Davidson

During her freshman year of college, Eleanor Longden began hearing voices: a narrator describing her actions as she went about her day. Diagnosed with schizophrenia, Longden began what she describes as a “psychic civil war,” fighting to stop the voices as they became antagonistic. Eleanor Longden: The voices in my head. What helped her was something unexpected: making peace with them. By learning to see the voices as a source of insight rather than a symptom, Longden took control.

What’s it like to hear voices? Read Eleanor’s FAQ below — where she tells you everything you wanted to know about voice hearing, with her signature honesty and humor.

Want more? Longden first spoke during our Worldwide Talent Search; then told a longer version of her journey toward acceptance of her own mind on the mainstage at TED2013. And today, Longden premieres her TED Book, delving deeper into her experience. Learning from the Voices in My Head is available for the Kindle, the Nook and through the iBookstore.

Do your voices ever talk to each other (and exclude you)?

Sometimes. In the old days they would talk about me a lot more, but now they usually speak to me directly. And when they do discuss me, it’s more likely to be compliments or positive encouragement. Or sometimes they’ll discuss something I’m worried about and debate possible solutions. There’s one particular voice that will repeat helpful mantras to the others. A recent one was: “If you can do something about it, there’s no need to worry. And if you can’t do anything about it, there’s no point in worrying!”

Do the voices sound like they are coming from inside your head or through your ears?

This is something else that’s changed a bit over time. They used to be more external, but now tend to be internal or outside, but very close to my ears. It can also vary depending on which voice is speaking.

What would you miss if you lost the voices? Would you be lonely?

My voices are an important part of my identity – literally, they are part of me – so yes, I would miss them if they went. I should probably insure them actually, because if they do ever go I’ll be out of a job! This seems extraordinary given how desperate I used to be to get rid of them. But they provide me with a lot of insights about myself, and they hold a very rich repertoire of different memories and emotions. They’re also very useful when I do public speaking, as they’ll often remind me if I’ve missed something. They can be helpful with general knowledge quizzes too! One of them even used to recite answers during my university exams. Peter Bullimore, a trustee of the English Hearing Voices Network, published a beautiful children’s book that was dictated to him by his voices.

Do your voices ever overlap? Could they harmonize?

They sometimes talk over each other, but don’t really say the same things in unison. I’ve met people whose voices do that though, like a chorus. Other people sometimes describe voices that sound like a football crowd, or a group talking at a party. At a recent conference, I heard a really extraordinary fact: that people who’ve been deaf from birth don’t hear voices, but see hands signing at them.

Do your voices happen all the time? Like, even during sex? Do you have to shush them during a movie?

No, not all the time! Although they’re often more active (and sometimes more negative or antagonistic) when I’m stressed. Even this can be useful though, as it’s a reminder to take some time out and look after myself. I relate to them so much better now, so if they become intrusive and I ask them to be quiet in a calm, respectful way — then 99% of the time they would.

Can you make certain voices pop up at will?

Yes, some of the time. Actually, this was something I used several years ago during therapy – my therapist would say for example, “I’d like to speak with the voice that’s very angry,” or “the voice that talks a lot about [a particular traumatic event],” and he’d dialogue with it.

Is there a time when you want to hear voices or are you always trying to get them to be quiet?

I sometimes discuss dilemmas or problems with them, or ask their opinion about decisions, although I would never let them dictate something to me that I didn’t want to do – it’s like negotiating between different parts of yourself to reach a conclusion ‘everyone’ is happy with. So, for example, maybe there’s a voice that represents a part of me that’s very insecure, which will have different needs, to a part of me that wants to go out into the world and be heard. Or the needs of very rational, intellectual voice may initially feel incompatible with those of a very emotional one. But then I can identify that conflict within myself and try to resolve it. It’s quite rare now that I have to tell them to be quiet, as they don’t intrude or impose on me in the way that they used to. If they do become invasive then it’s important for me to understand why, and there’ll always be a good reason. In general, it’ll be a sign of some sort of emotional conflict, which can then be addressed in a positive, constructive way.

Do you ever confuse your internal voice with ‘the voices’?

No, they feel quite distinct.

When you talk back to the voices, do they react differently if you speak out loud or just think your response?

I rarely respond to them out loud now, but they wouldn’t react differently to when I ‘speak’ to them internally.

What’s the difference between schizophrenia and voice hearing?

While the experiences that get labeled as symptoms of schizophrenia –and the distress associated with them — are very real, the idea that there’s a discrete, biologically-based condition called schizophrenia is increasingly being contested all over the world. While voice hearing is linked with a range of different psychiatric conditions (including many non-psychotic ones), many people with no history of mental health problems hear voices. It’s also widely recognized as part of different spiritual and cultural experiences.

Do you feel like other voice hearers understand you better?

They can appreciate what it’s like more precisely, but I’m fortunate enough to have met some really empathic, imaginative non-voice hearers who really want to understand too. In this respect, I think there’s actually more continuity between voices and everyday psychological experience then a lot of people realize. For example, everyone knows what it’s like to have intrusive thoughts. And most of us recognize the sense of having more than one part of ourselves: a part that’s very critical, a part that wants to please everyone, a part that’s preoccupied with negative events, a part that is playful and irresponsible and gets us into trouble, and so on. I think voices often feel more disowned and externalized, but represent a similar process.

What makes the voices talk more at some moments than others?

Usually emotional experiences, both positive and negative. In the early days, identifying these ‘triggers’ were very helpful in making more sense of why the voices were there and what they represented.

Do the voices ever make you laugh out loud?

Yes, sometimes! Some can be very outrageous with their humor, very daring, whereas others have a droll, Bill Hicks-like cynicism. Well, maybe not quite like Bill Hicks. Wouldn’t that be great though … having Bill Hicks in your head!