Abstract and Introduction
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.
Alongside featuring in schizophrenia and other psychiatric disorders, 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 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 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. Using the number of different semi-structured and self-report questionnaires with a group of self-reported "clairaudient" psychics, Powers et al 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.
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, such research often involves people with high levels of spiritual and paranormal belief. Sommer et al 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 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. 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.
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 indicated that voice-hearing experiences preceded spiritual beliefs. Although qualitative analysis of mediumistic experiences has emphasized the importance of anomalous childhood experiences, 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, consistent with other research emphasizing the practice ("kindling") of such experiences.
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. 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.
Schizophr Bull. 2022;48(5):1066-1074. © 2022 Oxford University Press