Hearing voices can be described as the experience of hearing one or more voices in the absence of anyone in the immediate physical environment to whom the voice belongs (Hayward and May, 2007; Chadwick and Hemingway, 2017). Often referred to as auditory hallucinations, hearing voices is traditionally associated with diagnoses such as schizophrenia, bipolar disorder or affective psychoses (Chadwick et al, 1996). However, it is important to note that voice hearing itself is not an illness (Kingdon and Turkington 1994).
Making sense of voice hearing
Traditionally, based on a biomedical model of disease, such experiences have been understood as symptoms of psychiatric illness requiring treatment (Payne et al, 2017).
However, a variety of frameworks have been used to describe voice-hearing experiences, with a growing interest in psychological explanations (Hayward and May, 2007). Traumatic life experiences, for example bereavement or sexual abuse, have been identified as triggers to voice hearing experiences, particularly in children.
In one study, 70% of participants reported that hearing voices started following a traumatic event (Romme and Escher, 1989). In a study of 22 participants with a diagnosis of schizophrenia, Harrison et al (2008) found that half of the participants understood their experiences as having mystical or religious significance, rather than a pathological cause. Similarly, Boumans et al (2017) investigated the experiences of individuals having ‘psychotic-like symptoms’ including hallucinations, with only half of the participants considering their experiences were linked to mental illness.
Other participants gave meaning to their experiences by using interpretive frameworks related to stress, vulnerability, psychic/spiritual meaning, and the use of voice hearing as a defence mechanism in relation to social or psychological problems. This unconscious mental defence mechanism may be triggered for many reasons, but could be something seemingly harmless such as deprivation of sensory stimuli (Morrison et al, 2008). It is therefore important to consider the person's own understanding of their experiences.
Hearing voices may or may not be disturbing for the person experiencing it. Some voice-hearing experiences cause significant distress, for example hearing screaming, personal taunts, or commands to act in a certain way (often referred to as ‘command hallucinations’) (Forchuk et al, 2017). Hearing such commands is often regarded as high risk as well as distressing (Trower et al, 2004), leading to concern that people may act in a way that causes harm to themselves or others. Factors such as intensity, frequency and uncontrollability of the voices have also been identified as causing distress (Freeman and Garety, 2003).
Such experiences are understandably disabling and distressing for the person; however, the experience of hearing voices does not necessarily cause distress for everybody. As Longden (2017) reports, it is estimated that around 13.2% of the general adult population have experienced such phenomena, although only one-third to one-fifth of these actually seek help from mental health services. Such individuals may not require professional services for a variety of reasons, including: personal choice, a lack of distress at their experiences, or because they identify their experiences within a non-medical framework (Slade and Longden 2015).
Contact with mental health services is more likely when the content of the voices is insulting or abusive because of the ways individuals respond to such negative experiences (Beavan and Read, 2010). This suggests that how an individual relates to the voice(s) is an important consideration in determining the emotional impact of voice hearing.
Some people may experience voice hearing in a positive way, engaging with the voices and having control over the situation (Harrison et al, 2008). Others may connect with the spiritual meaning of the voices, considering that they have ‘an ability not a disability’ (Boumans et al, 2017).
Hearing voices is also reported to serve an important function in combatting social factors such as loneliness, therefore becoming a solution to the problem rather than being the problem itself (Boumans et al, 2017).
So, is voice hearing normal? In some societies voice hearing is valued and interpreted as coming from evangelical Christianity or Shamanism and are therefore accepted; if the voices are deemed to be distressing then they are not regarded as normal (Turkington et al, 2009).
Supportive interventions
Traditional approaches to voice hearing have included nurses encouraging individuals to ignore such experiences to avoid reinforcing ideas of a false reality (Chadwick and Hemingway, 2017). Harrison et al (2008) found such an approach to be more distressing for individuals than the experience itself, because their reality is denied or rejected. Chadwick and Hemingway (2017) challenge such an approach and offer a more contemporary understanding by viewing voice hearing as meaningful rather than nonsensical.
Therefore, nurses are encouraged to accept the reality of voices and, within the context of a therapeutic relationship, support individuals in exploring the nature of their voice hearing in order to make sense of such experiences (Lakeman, 2001; Chadwick and Hemingway, 2017). Enhancing understanding of the cause of any distress for people who hear voices is a priority and reduction of this distress is a primary therapeutic aim (Sorrell et al, 2010). This view was supported by service users engaged with community-based services in research by Coffey and Hewitt (2008), who reported that nursing interventions aimed at exploring the content and meaning of the voices they experienced was most beneficial.
Antipsychotic medication can help some people manage their distressing voice-hearing experiences (Royal College of Psychiatrists 2019), although people taking this type of medication will need monitoring for potential side effects. Other approaches may also be helpful in minimising the voices and dealing with the potential distress. Initially, it is important not to ignore this aspect of their experience and instead focus on discussing their experience; this should be performed in an encouraging and supportive manner using empathy, respect and honesty (Bowers et al, 2009).
Questionnaires or rating scales, for example the Belief about Voices Questionnaire revised version (BAVQ-r) (Chadwick et al, 2000) and ‘PSYRATS’ for auditory hallucinations (Haddock et al, 1999), can be used as a foundation for conversations with people experiencing voices. Used in a compassionate way, such tools can be used to gain understanding of the experience and the impact on the person's level of functioning as a consequence of the voice(s). This demonstrates a move away from a dismissive approach that may imply a lack of interest or confidence from the nurse.
Distraction techniques are practical and short-term ways of approaching voice hearing. Examples from Coleman and Smith (1997) include:
Longer-term inter-personal approaches such as dialoguing with the voice(s) aim to change the power relationship when there is an oppressive influence over the person (Hayward and May, 2007). This includes activities such as:
Conclusion
Experiences of voice hearing can vary significantly. While some may hear positive voices and not require any contact with mental health services, others experience extreme distress that places the person at significant risk. Nursing assessment and interventions should therefore adopt an individualised approach that:
Such an approach challenges the traditional view of denying the reality of the person's experience. With a change of focus, nurses can engage in meaningful dialogues with individuals in distress, offering interventions that support the person to successfully adapt to living with voices.