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‘Can’t you hear them?’: A new paradigm for voice-hearers

The experience of ‘hearing voices’, or auditory hallucinations, is a very ancient one. Early literature from most cultures includes accounts of people hearing voices of various kinds, often interpreted through literary, religious or cultural prisms rather than medical ones.

Over the past 150 years, however, the dominant interpretative paradigm for such experiences in much of Europe and North America has been increasingly rooted in medicine, with auditory hallucinations often suggesting mental disorders such as schizophrenia, mania or severe depression. And there is no doubt that hearing voices often occurs in these disorders, sometimes causing significant distress and even generating risk, especially with the voices that command action.

Prior to psychiatry, however, explanations for many experiences of hearing voices tended to be more deeply informed by culture, religion and social circumstances and tended to offer significant personal meaning and cultural context for the experience. And even in an era when psychiatric interpretations came to the fore, different conceptualisations of hearing voices persisted, albeit that they were often relatively ignored as psychiatry became a more established branch of clinical practice and the central paradigm for interpreting ‘voices’.

In recent years, however, evolving attitudes towards ‘hearing voices’ reflect important, iconic changes in both psychiatry and society, as there is greater awareness that while auditory hallucinations can indeed be associated with (what we currently understand as) mental illness, there are many occasions when they are not. Or, rather, there are many occasions when a psychiatric paradigm is not the most appropriate, meaningful or helpful paradigm to apply to such experiences, and when other interpretative paradigms make more sense.

Against this background, the recent ‘hearing voices’ movement reflects an exceptionally powerful re-interpretation of the experience of hearing voices based on more nuanced interpretations of the experience, formulated chiefly by those having such experiences themselves, rather than mental health professionals, philosophers, sociologists or various others. As such, the ‘hearing voices’ movement reflects the development of mental healthcare, psychiatry and society in new and exciting directions.

In essence, the ‘hearing voices’ movement says that one size does not fit all: Some voice-hearers find their voices helpful and consoling, others find them challenging and distressing, and yet others find that accepting their voices helps them develop coping mechanisms and explore their meanings in a more rewarding way.

Some people use medication to assist with some or all of these tasks; others rely solely on group support and other psychological or social resources; and yet others use various combinations of these activities to integrate voices into their lives, maximising the positives and minimising the negatives associated with this particular experience — just as everyone already does with all of the other experiences in their lives. While some voice hearers are indeed mentally ill, others are not.

These newer, more tolerant approaches to hearing voices and the neuroscience underpinning these developments are expertly explored in a very timely, recent book by Simon McCarthy-Jones, titled Can’t You Hear Them? The Science and Significance of Hearing Voices (Jessica Kingsley Publishers, 2017). Simon is a colleague of mine and an Associate Professor in the Department of Psychiatry at Trinity College Dublin. He is the Director of the first-year behavioural science course and the third-year course on psychology and psychiatry as applied to medicine, at Trinity. His research interests are child sexual abuse and auditory verbal hallucinations, the subject of his excellent new book.

Can’t You Hear Them? is an exceptionally lucid, readable and well-informed guide to the world of auditory verbal hallucinations. It balances accounts of neuroscience with explorations of many other aspects of hearing voices and presents a compelling call for greater tolerance, understanding and appreciation of the richness of auditory hallucinations and the diversity of associated meanings.

Simon touches on the key issues with insight and intelligence. What is the role of antipsychotic medication? What is the relevance of neurodevelopmental theories of psychosis? Genetics? Epigenetics? And how do all of these theories and approaches fit together, if at all? Simon manages to identify links between these themes where they exist, highlight gaps in our understanding, and identify how different languages (scientific, experiential, etc) can be combined to shape meaning and understanding, so as to offer the very real possibility of progress.

Simon’s book appears at a critical juncture in this process. There is growing interest in the experience of hearing voices, both in Ireland and across the world. Hearing Voices Ireland was founded in Limerick in 2006 by Brian Hartnett, with the aim of fostering acceptance of voice-hearing as a valid human experience. By 2015, there were ‘hearing voices’ groups in Cork, Donegal, Dublin, Kerry, Kildare, Kilkenny, Longford, Tipperary and Belfast. This development is part of a larger international ‘hearing voices’ movement (www.voicesireland.com).

New ways of thinking and talking about auditory hallucinations are important, compelling and exciting. While some people with auditory hallucinations are highly distressed by them and fit current criteria for ‘mental disorder’, many do not. Good primary care and psychiatric care need to be available to those who require them, but a psychiatric approach is not always the best, wisest or most helpful approach to take with everyone who hears voices. One size does not fit all.

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