Hearing voices

A substantial proportion of the population is prey to auditory hallucinations. Among those concerned, there are many who hear voices. At the University of Liège, Professor Frank Larøi has studied this problem in depth. Member of the International Consortium on Hallucinations Research and Related Symptoms created in 2011, he has contributed to four review papers in the past few months(1)(2)(3)(4) concerning hallucinations. At the same time, he is closely monitoring the evolution of a support group for voice hearers, founded jointly by ULg and the not-for-profit association Psy'Cause.

When the football player Zinédine Zidane announced in 2005 that he had decided to join the French team again a year after having retired, he was the victim of sarcasm. Was this because he was considered incapable of maintaining his level on the field at the age of 33? No, because he confided in the magazine France Football that he had woken up at three in the morning to the sound of an unknown voice telling him the decision he needed to make.

Socrates also heard voices. And Freud reported in his diary that, as a young man travelling in a foreign town, he sometimes mistakenly thought that someone was saying his name. Beethoven, Sartre and Churchill, to name but a few, were also voice hearers. In 2011, the authors of a study on the issue reported that, according to sources, the percentage of voice hearers among the population was between 3 and 55 %. ʺThe disparity between these figures can be explained by the variability of the criteria used in the different studiesʺ, points out Frank Larøi, lecturer and research leader at ULg’s Cognitive and Behavioural Clinical Psychology Unit. ʺIf the subjects are asked: "Have you ever had the feeling of hearing the voice of someone who isn’t physically there?", the prevalence rate will be extremely high. On the other hand, if you ask about last week, only approximately 2 % of the general population will report an experience of this sort. According to all the available data, we can reasonably consider that 5 to 15 % of people regularly hear voices.ʺ

A ghost or an FBI agent?

Whether or not they have a psychiatric past, voice hearers are characterised by the high frequency of their hallucinations. This differentiates them from people who have had random hallucinatory experiences. But as the work of the psychiatrist Iris Sommer from the University of Utrecht tends to show, the hallucinations of non-clinical subjects are different from those of psychotic patients in terms of their content. It is generally benevolent or neutral, and the nature of the alleged voices is more spiritual rather than concrete (the ghost of a grandmother, for instance, rather than a neighbour, an FBI agent or the devil).

ʺThe more abstract nature of this type of hallucination makes it easier to control and prevents the subject from becoming delusionalʺ, Frank Larøi explains. ʺA key element differentiating voice hearers suffering from a psychiatric disorder and those who don’t is that the emotional experience of the former in relation to hallucinatory experiences is far more negative, and they are far less able to control their hallucinations. This would suggest that it is the individual’s emotional and cognitive resources that determine the clinical or non-clinical status of their hallucinations.ʺ

According to the work of Iris Sommer, it would also appear that non-clinical voice hearers generally had their first auditory verbal hallucinations at the beginning of adolescence, while psychiatric patients had their initial experience later, around 18 or 19 years old, the age when a person is often diagnosed with psychosis. Although no formal proof has yet been provided, it would however seem that although these individuals have no psychiatric past, the majority of non-clinical voice hearers have been the victim of one or more traumatic experiences during their childhood.

And in the brain?

A remarkable fact: functional magnetic resonance imaging (fMRI) of the brain has revealed that during a hallucination, the area associated with the sensory channels involved (visual, auditory, olfactory, etc.) is activated in the cortex, whereas, by definition, there is no perception there. In addition, the Broca and Wernicke areas, which are essential for language, play a part in auditory verbal hallucinations. ʺHowever, there is a nuance here because these activation patterns (auditory areas ‘switched on’ during an auditory hallucination, etc.) aren’t present in all patientsʺ, says Frank Larøi. Furthermore, this type of data doesn’t explain several essential aspects of the experience, such as the negative content of the auditory verbal hallucinations in psychotic patients.

Other regions of the brain are involved in hallucinatory experiences, but they are difficult to map. In particular, the frontal regions, among others, may be involved in  ʺreality monitoringʺ. In addition, the activation of one of the small networks in the hippocampus has been revealed in auditory verbal hallucinations. Furthermore, according to Flavie Waters, from the University of Western Australia, hallucinations partly depend upon an inappropriate mnesic mechanism. ʺIn her opinion, they could be linked to memories that surface owing to inhibition deficits together with deficits in contextual memory, which is related to elements of the context (place, temporal organisation, etc.) in which a piece of information was acquiredʺ, Frank Larøi further explains.

Support groups  

Traditionally, in psychiatry, hearing voices is considered a sign of psychosis. The solution? To prescribe neuroleptic drugs, which can essentially help schizophrenic patients to control the so-called positive symptoms of their illness, such as hallucinations and delusions. ʺHowever, it is believed that despite these drugs, 30 to 60 % of patients continue to have difficulty managing their symptomsʺ, Frank Larøi specifies. In fact, antipsychotics aren’t specifically directed at auditory verbal hallucinations. Hence, they aren’t really appropriate for dealing with the difficulties related to these symptoms.

In some cases, the voices aren’t a problem and the hearers even seek them out. This is also the case among a proportion of psychotic patients, as revealed in a study carried out in 1993 by Laura Miller from the University of Illinois. Not only did 52 % of the patients interviewed consider that their hallucinations had an adaptive function, but, even more surprising, 20 % of them didn’t want to take a drug that might protect them against their hallucinations. According to Jonathan Burnay, a clinical psychologist and doctoral student at ULg under the direction of Frank Larøi, the pathological aspect is more the fact of not knowing how to manage the voices, i.e. how to prevent them from being intrusive and not respond to their demands, rather than the fact of hearing them and even believing that they are real, that they are the voice of God, an angel or someone who has died, etc., as is the case in the majority of people concerned.

That’s why, on the basis of the work he undertook at the end of the 1970s, Dutch psychiatrist Marius Romme succeeded in shaking off the shackles of mental illness and assimilate these voices as an experience that can be managed. Of course, they may ʺtake hold ofʺ psychotic patients, insult them, threaten to kill them, push them to carry out extreme acts, but, when approached from a non-medical perspective (though often as a complement to treatment with neuroleptic drugs, and even psychotherapy), they appear easier to control. This led to the creation of small support groups in Holland some 20 years ago, attended by both clinical and non-clinical voice hearers. The initiative then spread to many other countries, including France and French-speaking Belgium quite recently, in the last 20 months. Two groups were set up in Brussels, followed by one in Namur and one in Liège. The four entities are part of the association REV-Belgium - Réseau belge des entendeurs de voix - based on its French counterpart REV-France.

With the help of the University of Liège, the Liège-based support group was set up under the aegis of the not-for-profit association Psy'Cause and ULg’s Psychology and Speech Therapy Clinic.

ʺThe origin of the voices is never discussed within the support groups, because this discussion would serve no purposeʺ, says Jonathan Burnay, who is one of the ʺfacilitatorsʺ of the Liège group. He adds: ʺIt doesn’t matter if the subject attributes the voices they hear to God, elves, the devil or the deceased! The ultimate goal is to help these hearers to manage them so that they leave them alone when their presence is undesirable. For instance, when they’re concentrating on work or they’re with the family.ʺ

Neither marginalisation nor discrimination

In these groups, the possible pathological aspect is erased and, similar to Alcoholics Anonymous meetings, everyone shares their experiences with everyone else, explaining their helplessness or their progress and the strategies they use to take control of ʺtheirʺ voices. As underlined by Élodie Azarian, facilitator at one of the two groups in Brussels, these aren’t therapy groups, but self-help groups. In fact, there is no mention of auditory hallucinations but of hearing voices. ʺHaving got rid of their label of someone suffering from an illness, the members of the group have better self-esteem, and regain their dignity and hopeʺ, she confirms.

In Belgium, these groups work horizontally; the facilitator is only there to ensure the meetings run smoothly. The example of those who have succeeded in controlling their voices opens the way for the other participants, who find motivation and comfort, and renewed self-esteem. An essential element in these groups is that the voice hearers aren’t subject to marginalisation or discrimination. ʺIn society, the weight of the stereotypes and prejudices weighing them down is enormousʺ, Jonathan Burnay tells us. ʺIn some families, they’re not even allowed to look after the children.ʺ

According to Frank Larøi, some voice hearers have never told anyone about their problem before joining a support group. They want to protect themselves. ʺIt’s absolutely necessary to create an atmosphere of trust, because some psychiatric patients are even afraid that if anyone finds out they’re coming to a support group, the dose of the antipsychotics they’re prescribed by their psychiatrist may be increasedʺ, the psychologist adds.

The attitude of psychiatrists and other mental health professionals towards hearing voices support groups ranges from confirmed interest, to hostility, to scepticism. It is true that for the time being, although several studies have been carried out (and a meta-analysis has been published on these studies (5)), the results and methodologies of these studies vary enormously and therefore, at present, no clear and substantial scientific evidence proving the method’s efficacy is available. That is why the support group in Liège is partly conceived as a pilot study.

(1) Flavie Waters, Daniel Collerton, Dominique H. ffytche, Renaud Jardri, Delphine Pins, Robert Dudley, Jan Dirk Blom, Urs Peter Mosimann, Frank Eperjesi, Stephen Ford and Frank Larøi, Visual hallucinations in the psychosis spectrum and comparative information from neurodegenerative disorders and eye disease, Schizophrenia Bulletin, 40 suppl. no 4, S233-245, 2014.
(2) Frank Larøi, Tanya Marie Luhrmann, Vaughen Bell, William A. Christian Jr, Smita Deshpande, Charles Fernyhough, Janis Jenkins and Agela Woods, Culture and Hallucinations: Overview and Future Directions, Schizophrenia Bulletin, 40 suppl. n° 4, S213-S220, 2014.
(3) Louise C. Johns, Kristiina Kompus, Melissa Connell, Clara Humpston, Tania M. Lincoln, Eleanor Longden, Antonio Preti, Ben Alderson-Day, Johanna C. Badcock, Matteo Cella, Charles Fernyhough, Simon McCarthy-Jones, Emmanuelle Peters, Andrea Raballo, James Scott, Sara Siddi, Iris E. Sommer and Frank Larøi, Auditory Verbal Hallucinations in Persons With and Without a Need for Care, Schizophrenia Bulletin, vol. 40 suppl., n° 4, S255-S264, 2014.
(4) Angela Woods, Nev Jones, Marco Bernini, Felicity Callard, Ben Alderson-Day, Johanna C. Badcock, Vaughan Bell, Chris C. H. Cook, Thomas Csordas, Clara Humpston, Joel Krueger, Frank Larøi, Simon McCarthy-Jones, Peter Moseley, Hilary Powell, Andrea Raballo, David Smailes and Charles Fernyhough, Interdisciplinary Approaches to the Phenomenology of Auditory Verbal Hallucinations, Schizophrenia Bulletin, 40 suppl. n° 4, S246-S254, 2014.

(5) Anna Ruddle, Olivier Masson, Til Wykes, A review of hearing voices groups: Evidence and mechanisms of change, Clinical Psychology Review 31 (2011) 757-766.