Voice-hearing Across The Continuum: A Phenomenology of Spiritual Voices

Peter Moseley; Adam Powell; Angela Woods; Charles Fernyhough; Ben Alderson-Day

Schizophr Bull. 2022;48(5):1066-1074.

Abstract and Introduction

Abstract

Background and Hypothesis: Voice-hearing in clinical and nonclinical groups has previously been compared using standardized assessments of psychotic experiences. Findings from several studies suggest that nonclinical voice-hearing is distinguished by reduced distress and increased control. However, symptom-rating scales developed for clinical populations may be limited in their ability to elucidate subtle aspects of nonclinical voices. Moreover, such experiences often occur within specific contexts and belief systems, such as spiritualism. We investigated similarities and differences in the phenomenology of clinical voice-hearing and nonclinical voice-hearer (NCVH).

Study Design: We conducted a comparative interdisciplinary study which administered a semi-structured interview to NCVH individuals (N = 26) and psychosis patients (N = 40). The nonclinical group was recruited from spiritualist communities. We used content analysis and inductive thematic analysis to create a coding frame which was used across both spiritual and patient groups to compare phenomenological features of voice-hearing.

Study Results: The findings were consistent with previous results regarding distress and control. Additionally, in the NCVH group, multiple modalities were often integrated into 1 entity, and there were high levels of associated visual imagery, and subtle differences in the location of voices relating to perceptual boundaries. Most NCVHs reported voices before encountering spiritualism, suggesting that their onset was not solely due to deliberate practice.

Conclusions: Nonclinical spiritual voice-hearing has important similarities and differences to voices in psychosis. Future research should aim to understand how spiritual voice-hearers cultivate and control voice-hearing after its onset, which may inform interventions for people with psychosis with distressing voices.

Introduction

Alongside featuring in schizophrenia^[1] and other psychiatric disorders,^[2] hearing voices (or "auditory verbal hallucinations") occur in nonclinical populations, with some individuals reporting recurring but nondistressing experiences.^[3,4] This offers the opportunity to investigate voice-hearing without the confounds of antipsychotic medication use or comorbid symptoms. Previous studies comparing the phenomenological, cognitive, and neural characteristics of voice-hearing in psychosis patients and nonclinical voice-hearers (NCVHs) have used a combination of standardized scales and clinical interviews for assessing hallucinations. Daalman et al^[5] used the Psychotic Symptoms Rating Scale (PSYRATS) and Auditory Hallucination Rating Scale (AHRS) with 111 NCVHs, reporting that nonclinical voice-hearing was more controllable, less frequent, and less negative. Peters et al^[6] showed that individuals in the general population with persistent psychotic-like experiences often experienced hallucinations across more perceptual modalities than individuals with psychosis, a finding observed elsewhere.^[7] Using the number of different semi-structured and self-report questionnaires with a group of self-reported "clairaudient" psychics, Powers et al^[8] reported NCVHs having higher levels of control over voices (ie, initiating or stopping them at will).

While such findings are important, tools developed for clinical assessment may miss more nuanced aspects of these voice-hearing experiences. The phenomenology of voice-hearing can be highly varied and multimodal: semi-structured and open-ended interviews with psychosis patients have shown the complexity and variation of voice-hearing across individuals, in aspects such as personification, agency, and perceived location.^[9,10] Thus, alternative and interdisciplinary approaches are needed to evaluate the phenomenology of voice-hearing properly.^[11]

A case in point is the intersection of spiritual and paranormal experiences with NCVH. Although few studies have sought to recruit people with clairaudient experiences explicitly,^[8] such research often involves people with high levels of spiritual and paranormal belief. Sommer et al^[12] reported that 58% of the participating NCVHs believed their voices came from "benevolent spirits." Ninety-one percent of healthy individuals with psychotic experiences in Peters et al^[6] classed themselves as "spiritual" (compared to 41% of non-voice-hearing controls, and 76.5% of psychosis patients). Assessing such groups using clinical tools may identify apparently comparable levels of hallucination, but may not sufficiently consider the roles of context, belief, and expectation specific to each community.^[13] For example, a recent online open-ended survey with Christians reporting hearing the voice of God noted key differences from voices in psychosis, including personal significance, positive emotions, and occurrence in the context of prayer.^[14]

Important questions remain concerning the development of voice-hearing in such groups. Research with NCVHs has frequently reported an earlier age of onset than in psychosis;^[6,8,12] however, it is often unclear whether voice-hearing developed before (perhaps leading to) spiritual beliefs, or whether spiritual beliefs emerged first, with people actively cultivating their voice-hearing experiences. As well as being sharply distinguished from voices in psychosis (unlikely to be purposely developed), this issue may be of relevance to neurocognitive models of voice-hearing that foreground expectations and beliefs.^[15,16] One study regarding spiritual beliefs and voice-hearing^[17] indicated that voice-hearing experiences preceded spiritual beliefs. Although qualitative analysis of mediumistic experiences has emphasized the importance of anomalous childhood experiences,^[18] within-sample variability suggests a more complex relationship between beliefs and voice-hearing. Some participants report voice-hearing starting only when they actively engaged with relevant spiritual practices,^[17] consistent with other research emphasizing the practice ("kindling") of such experiences.^[19]

Here, we investigated nonclinical voice-hearing experiences in individuals with spiritualist and related beliefs (eg, mediums, psychics). Within the United Kingdom, spiritualists typically believe in the possibility of communicating with the dead, often receiving messages they believe should be passed on to other people and working as professional mediums to do so. While there is large variability in specific beliefs surrounding spiritualism, one core tenet is that such experiences should be cultivated and controlled. We used an open-ended, semi-structured interview with spiritualist voice-hearers, developed by an interdisciplinary team for use in both clinical and nonclinical populations. Interviews were coded and directly compared to an extant patient dataset.^[10] We aimed to explore similarities and differences with voices in psychosis that may be missed by standardized scales. While the study was primarily descriptive (ie, not hypothesis-driven), based on previous research, we expected spiritual voices to be less negative, more controllable, and more likely to occur across multiple modalities than voices in psychosis. We also aimed to provide data on the cultivation of voices over time, the nature of the messages communicated by the voices, and the levels of personification and social agency associated with them.

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Abstract and Introduction
Method
Results
Discussion
References

Table 1. Sensory Qualities, Location, Control, and Development of Voices
Code	Spiritual (%)	Psychosis (%)	Log Odds	95% CI (Low)	95% CI (High)
Visual imagery	100	5.0	6.705^a	3.628	9.781
Auditory	84.6	92.5	−0.808	−2.395	0.780
Internally located	84.6	62.5	1.194	−0.049	2.437
Egocentric	80.8	70.0	0.588	−0.599	1.775
Thought-like	76.9	52.5	1.104^a	0	2.207
Externally located	73.1	80.0	−0.388	−1.55	0.775
Felt presence	69.2	52.5	0.711	−0.328	1.749
Multimodal	69.2	27.5	1.780^a	0.696	2.864
Visual	60.0	75.0	−0.693	−1.767	0.380
Bodily states	53.8	65.0	−0.465	−1.473	0.543
Olfactory	50.0	37.5	0.511	−0.490	1.511
Dissociative	46.2	30.0	0.693	−0.332	1.719
Tactile	46.2	22.5	1.083^a	0.012	2.153
Gustatory	26.9	0	3.439^a	0.526	6.352
Nonverbal	26.9	40.0	−0.593	−1.666	0.480
Allocentric	23.1	37.5	−0.693	−1.808	0.421
Boundary	11.5	35.0	−1.418^a	−2.785	-0.050

Note:
^a95% CIs do not cross 0.

Table 2. Affect, Agency, and Content of Voices
Code	Spiritual(%)	Patient (%)	Log Odds	95% CI (Low)	95% CI (High)
Elicit positive emotions	100	35	4.573^a	1.703	7.443
Voice knowledge	96.2	45	3.42^a	1.326	5.513
Volitional	92.3	2.5	6.148^a	3.695	8.602
Nonvolitional	92.3	100	−2.112	−5.19	0.965
Positive/helpful	92.3	42.5	2.787^a	1.214	4.360
Recurring	92.3	92.5	−0.027	−1.889	1.834
Ability to influence	84.6	27.5	2.674^a	1.403	3.946
Change in frequency	80.8	70	0.588	−0.599	1.775
Recognizable	76.9	47.5	1.304^a	0.201	2.407
Change in influence	73.1	12.5	2.944^a	1.668	4.221
Simple structure	69.2	40	1.216^a	0.171	2.262
Conversational	65.4	47.5	0.736	−0.283	1.755
Direct address	61.5	82.5	−1.081	−2.216	0.055
Structural change	50	80	−1.386^a	−2.478	−0.295
First voice traumatic event	42.3	65	−0.929	−1.943	0.084
Companionship	42.3	32.5	0.421	−0.601	1.442
Elicit negative emotions	38.5	100	-4.846^a	−7.741	−1.952
Commanding	26.9	67.5	−1.729^a	−2.820	−0.639
Commenting	19.2	45	−1.234^a	−2.392	−0.077
Character change	11.5	17.5	−0.486	−1.94	0.967
Abusive/violent	11.5	87.5	−3.983^a	−5.508	−2.458

Note:
^a95% CIs of log ORs do not cross 0.

Table 3. Personification, Narratives Around Voices, and Effects on Relationships
Code	Spiritual (%)	Patient (%)	Log Odds	95% CI (Low)	95% CI (High)
Supernatural narrative	100	20	5.311^a	2.414	8.209
Internally individualized	100	75	2.904^a	0.020	5.788
Externally individualized	80.8	50	1.435^a	0.28	2.591
Minimal personification	61.5	60	0.065	−0.948	1.077
Important to identity	57.7	12.5	2.256^a	1.038	3.474
Complex personification	38.5	40	−0.065	−1.077	0.948
Agency w/o individuation	38.5	45	−0.269	−1.275	0.737
Self-stigma	30.8	47.5	−0.711	−1.749	0.328
Negative on relationships	26.9	77.5	−2.235^a	−3.376	−1.094
Biophysical narrative	23.1	25	−0.105	−1.265	1.054
Archetypal	23.1	42.5	−0.902	−2.009	0.205
Family narrative	19.2	22.5	−0.198	−1.424	1.027
Positive on relationships	15.4	5	1.24	−0.537	3.016
Trauma narrative	15.4	25	−0.606	−1.89	0.677
Sleep disruption	15.4	62.5	−2.216^a	−3.458	−0.973
Idiosyncratic narrative	11.5	32.5	−1.306	−2.679	0.067
Stress narrative	11.5	37.5	−1.526^a	−2.889	−0.163
Absent agency	11.5	15	−0.302	−1.786	1.181
Suicidality	3.8	50	−3.219^a	−5.312	−1.126

Note:
^a95% CI of log ORs do not cross 0.

Box 1. Modality and Imagery
Thought-like voices I'm getting told information… to relay to the people who are in the church, so the congregation, if you will… and how I get that is I "hear," and I use the word in inverted commas because it's not like I'm hearing you, it's kind of like thoughts or impressions…[William, age 58 years] Visual hallucinations you know there's a gentleman here, he's taller than yourself, [I can] describe his hair, you know, black hair with a parting and like, his clothes, because they show you how they look… they might adjust their attire…So you can see all that, and then you can say, oh hasn't he got a deep voice, you know … that's how it works for me. To me it's real. But I can understand why you're asking the question, because if it's real and they're standing there, why can't you see them, yeah?' [Heather, age 69 years] Visual imagery and then suddenly I just got a, just an image of a baby and you know just in my head, just an image of a baby, and then just a feeling [John, age 30 years] Multimodal voices So the next thing that normally comes in will be … either who they were or I'll hear them say their name, and so I may hear the name, for instance, you'll get a person who'll say, "it's OK, I'm Margaret." OK, who are you? "Well I'm gran." At the same time as a picture coming in, as she's showing what she looked like. Then I'd be asking, well OK, give me more details about yourself, things like age, what did you pass from … And the funny thing is, the voice that you get back very much mimics the personality of who they were. [Samuel, age 48 years]

Box 2. Onset, Cultivation, and Control
Spontaneous onset I think the first time I ever heard a voice was when I was about eighteen, and I thought I heard somebody calling my name, well I was positive I heard somebody calling my name. And I was the only person in the house at the time. And it sounded like it was coming from outside the house. So I went to the front door, nobody there, went to the back door, walked all the way round the house, nothing, came back in and thought, oh that was weird, wasn't a radio on, there wasn't TV on, there was nothing, and I heard it again, calling my name, Laura, Laura, [said with urgency]. And I had to go round the house again, outside, opening all the doors, and I thought, well that's bizarre, dismiss it, ignore it. So that was the first time it ever happened, I didn't know anything about spirit or anything like that. [Laura, age 56 years] I think for me, when I very first started, the only thing that would happen was I'd get my name shouted when I was at work, you know, when there was nobody around… and I think for me sort of I almost questioned if it was real… you know there's no one else heard it… I think in terms of feelings when I first started having experiences, like I said, I didn't really have many clairaudient experiences, but I sort of had this feeling of presences… And I think initially I was almost a little bit concerned. And sort of thinking, is there something wrong, you know and being honest, was I mental, was there some sort of illness happening? [John, age 30 years] Volitional control What I do is I kind of take my consciousness out and allow the spirit world to come in basically…However, sometimes I may not even consciously be thinking about anything and certain words will come into my head. For example if I have, like for example, the other day there I wanted to ask spirit a question and I asked them the question and for the last three days I've been getting the same answer… How I do it is I have a little mantra I go through, which is, and I just basically say to the spirit world that I am ready to work… [Ruth, age 50 years] Spontaneous onset and cultivation There was things happening when I was younger that I didn't understand at the time, which, once I started learning about it, started to make more sense […] I deliberately developed it, well I'm saying deliberately, I kinda got drawn to it, I was brought up as a Catholic, and I got to… typically get to teenage years and you start questioning things. And I found that the Catholic faith created more questions than answers, and I started looking around for something else. And by the time I think I first went, I would have been about … nineteen, twenty, when I started going to spiritualist churches [William, age 58 years]

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Voice-hearing Across The Continuum: A Phenomenology of Spiritual Voices

Abstract and Introduction

Abstract

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