When Spirit Calls: A Phenomenological Approach to Healthy Voice-Hearers

Abstract

We present a mixed-methods study, from an anthropological perspective, of 22 healthy voice-hearers ie, people who report hearing voices but have no need for clinical care. They were interviewed using the Varieties Of Individual Voice-Experiences Scale (VOICES), a new scale assessing phenomenology, beliefs and relationships with voices, and their emotional and behavioral impact. Despite in many cases hearing voices daily, they report remarkably little distress, with almost all mentioning a positive impact on their life. Most interpreted their voices as spirits, and spoke of learning to understand, to manage, and even to train their experience of communicating with spirits productively. There was, however, considerable diversity in their voice experiences. Some described experiences they seemed to have discovered after starting a practice. Others described reaching for a practice to make sense of unusual experiences. This raises the possibility that cultural ideas about spirit communication may have two effects. On the one hand, they may help those who begin to hear voices involuntarily to interpret and manage their experience in a non-threatening way, through a meaning framework imposed on experiences. On the other hand, it also suggests that cultural ideas about spirit communication may lead some people to identify some thoughts as voices, and to come to feel that those thoughts are generated outside of themselves, through a meaning-framework shaping experiences. This should remind us that the culture-mind relationship is complex. There may be different kinds of phenomena described by individuals as “voices,” with practice and interpretation changing how these phenomena are experienced.

Introduction

There has been much scientific interest in people who hear what they describe as “voices,” but do not have a need-for-care.^1–3 Many people in the general population report hallucination-like events, although the rates vary widely.^4–6 Such findings provide evidence for the psychosis continuum: the claim that psychosis symptoms are not restricted to those who are ill but found throughout the population to greater or lesser degree,⁷ and can, in some cases, be unconnected to distress or pathology.^8,9 What is less clear is what kind of continuum it is, whether there is one or more continua,^2,10,11 and what role practice and interpretation play in these reports of voice-hearing.¹²

For example, some who report having heard God’s voice say that they learned to hear God speak when they began to pray with a specific kind of church. They say that they came to recognize God’s voice inside their heads daily, although usually, they can remember only a handful of moments when God spoke in a way they could hear with their ears. This sense that one can learn to hear invisible beings speak is reported among spiritualist mediums, tulpamancers, ayahuasca drinkers, and others.¹³

We know that there are clear individual differences associated with reports of hallucination-like events and that these differences are not self-evidently associated with psychosis. High scorers on the Tellegen Absorption¹⁴ and Dissociative Experiences Scales¹⁵ are more likely to report voice-like events.^16–18 Those involved in spiritual practices like prayer or meditation are more likely to report vivid sensory and quasi-sensory experiences of invisible others.¹⁹ People who are highly hypnotizable, or who practice trance, also seem prone to vivid, unusual sensory events.²⁰

We also know that approximately 20% of those who report psychotic-like experiences in the general population have persistent experiences²¹ and that many observers have raised the question of whether these healthy voice-hearers with persistent experiences are people vulnerable to psychosis but who have managed to handle experiences that are expressed in others to devastating effect.

One of the complicating factors here is the role of culture, which is likely to be central in shaping voice-hearing experiences and their interpretations.^13,22,23 The phrase “hearing voices” is both a clinical phrase describing a phenomenological event, and a theological phrase, interpreted differently in different traditions, which describes a relationship between a spirit and a human. Careful phenomenological interviewing is needed to distinguish an intellectual commitment to the external reality of spirits from the felt sense that an external voice is communicating to the self.

In this study, we introduce a new measure that is phenomenologically sensitive to the potential positive aspects of voice-hearing experiences, and covers a range of contextual and sociocognitive factors. It was used as a semi-structured interview to investigate voice-hearing experiences in a group of diverse, healthy voice-hearers, with specific emphasis on the cultural terrain of such experiences.

Methods

Participants

Participants were recruited from a research register held by the last author, consisting of individuals without a need-for-care who have participated in previous studies investigating persistent (ie, over 5 years) anomalous experiences.^24–28 Original recruitment sources included psychic and spiritualist settings like the College of Psychic Studies, The British Astrological and Psychic Society, The International Academy of Consciousness, Spiritualist Association of Great Britain, as well as resources such as King’s College London circular email list (see Peters et al²⁶ for further details on recruitment strategy).

We attempted to contact everyone on the register who had reported currently hearing voices at the time of joining (N = 37). Of those, 25 consented to participate in the study, but three were excluded due to not meeting the study’s definition of “hearing voices” ie, “an experience that consists of hearing or receiving communication, in the form of spoken words or sentences, in the absence of a source observable by someone around you (who does not have similar experiences). Experiences that only occur under the influence of alcohol or drugs are not included”. Our final sample consisted of 22 voice-hearers (15 women,7 men; mean age = 53, range 27–74).

Measures and Procedures

This study used a new scale, the Varieties of Individual Voice-Experiences Scale (VOICES), which focuses on the phenomenology of the voice-hearing experience, beliefs and relationships with voices, and their behavioral and emotional impact.

VOICES was developed to extend the existing set of primarily pathology-focused measures.²⁹ The goal was to offer an in-depth assessment that includes the spectrum of potentially positive experiences voice-hearers may report. It was developed in 3 phases, and independently followed a similar approach to the in-depth interview reported by Toh et al³⁰ to explore multisensory hallucinations. First, a comprehensive literature search was performed to identify questionnaires and interviews assessing voice experiences. Twenty-three scales were identified (see table 1), from which the main themes and items were derived. The Psychotic Symptoms Rating Scales (PSYRATS³¹) and the Beliefs About Voices Questionnaire-Revised (BAVQ-R³²) provided the main structure and source of items. Second, the themes identified were extended to include positive dimensions, and items from existing scales were reworded to be suitable for healthy as well as clinical populations. Third, clinical and academic experts in psychosis, and voice-hearers from across the clinical and nonclinical spectra, were consulted for feedback on the questionnaire. Final amendments to items and the scale structure were made accordingly.

Table 1.

Published Scales Used For Deriving of VOICES Items (in Alphabetical Order)

Scale	Reference
BAVQ-R (Beliefs About Voices Questionnaire-Revised)	Chadwick et al, 200032
CAHSA (Continuum of Auditory Hallucinations—State Assessment)	Schlier et al, 201733
CAPE (Community Assessment of Psychic Experiences)	Stefanis et al, 200234
CAPS (Cardiff Anomalous Perceptions Scale)	Bell et al, 200635
HPS-VQ (Hamilton Programme for Schizophrenia-Voice Questionnaire)	van Lieshout & Goldberg, 200736
HVQ (Hearing Voices Questionnaire)	Beavan & Read, 201037
IPASE (Inventory of Psychotic-Like Anomalous Self-Experiences)	Cicero et al, 201638
IVI (Interpretation of Voices Inventory)	Morrison et al, 200239
LHSH-M (Launay & Slade Hallucination Scale—Modified)	Laroi et al 200440; Laroi & Van der Linden, 200541
Maastricht interview	Escher et al, 200042
MUPS (Mental Health Research Institute Unusual Perceptions Schedule)	Copolov & Carter, 199543
MUSEQ (Multi-Modality Unusual Sensory Experiences Questionnaire)	Mitchell et al, 201744
PAGE-R (Exceptional Experiences Questionnaire-Revised)	Unterrassner et al, 201745
PAS (Perceptual Aberration Scale	Chapman et al, 197846
PSYRATS (Psychotic Symptoms Rating Scales)	Haddock et al, 199931
SIAPA (Structured Interview for Assessing Perceptual Anomalies)	Bunney et al, 199947
TEQ (Transpersonal Experiences Questionnaire)	Heriot-Maitland, C., Vitoratou, S., Hermans, K., Wykes, T., Brett, C., Peters, E. 1990 (In Press) Detecting anomalous experiences in the community: The Transpersonal Experiences Questionnaire (TEQ). Submitted to Psychology and Psychotherapy: Theory, Research and Practice (unpublished data)
TVRS (Topography of voices rating scale)	Hustig & Hafner, 1990;48; Lawrence et al, 201049
VAAS (Voices Acceptance and Action Scale)	Shawyer et al 200750
VAY (Voice and You)	Hayward et al, 200851
VIS (Voice Impact Scale)	Strauss C, Atterbury K, Hugdahl K, et al. (manuscript in preparation). Voice Impact Scale (VIS): Evaluating the Psychometric Properties of an Expert-Developed Self-Report Measure for Capturing Outcomes from Psychological Therapy for Hearing Voices. UK: University of Sussex (unpublished data)
VPD (Voice Power Differential Scale)	Birchwood et al, 200052
Woods et al Phenomenological Survey	Woods et al, 201553

VOICES has 50 items and is structured into three sections. The first is a descriptive assessment of the phenomenological aspects of the experiences, such as frequency, number of voices, content, or age of onset (24 items). The second explores beliefs and relationships with the voices, for instance, the degree of control the person has over the voices, attributions of intent and power, and social aspects of the experience (16 items). Finally, the behavioral and emotional impact is assessed ie, whether the voice(s) influence affective states or support was sought in response to the experience (9 items). One open-ended question is included at the end. Items are scored using Likert scales and multiple choices. Non-pathologising language was used throughout, including in the introduction to the scale, to facilitate open discussion of individuals’ experiences. The interview was used in a semi-structured way, with participants encouraged to talk freely about their answers.

As a scale, VOICES is significantly more detailed than many existing questionnaires. It can be used purely quantitively, focusing on response scores from the Likert scales and multiple choice. In addition, used in a semi-structured way, VOICES affords an opportunity to understand the phenomenological experience of voices for someone despite the cultural frame they use to talk about their experience. We illustrate both dimensions of these possible uses here.

Our research team comprised 2 psychologists (EP, DB), a psychiatrist (XAC), and an anthropologist (TML). The scale was administered by author XAC under the supervision of TML and EP with open-ended discussion, probing for further clarifications on responses. Participants spoke at length about their experiences and how they understood them. Most interviews were conducted in person. Interviews lasted approximately two hours and were professionally transcribed. XAC and TML spoke frequently during the interview process. TML also read widely in the domain of spiritual mediumship, re-interviewed several of the participants and participated in a training weekend led by one participant to train individuals to hear the voices of the dead. TML then read and reread the transcripts for shared cultural models and different phenomenological experiences using interpretive methods well developed within the discipline of anthropology.^54,55

By administering the VOICES scale as a semi-structured instrument, we were able both to discern the phenomenological differences in the way individuals experiences their voices, and to learn from them their many shared cultural interpretations of these experiences.

The work was approved by the Institutional Review Board at Stanford University.

Quantitative Results

VOICES Responses

Item frequencies are provided in Table 2. The median age at which participants started hearing voices was 16.5 (mode = 5; range = 2–40).

Table 2.

Varieties of Individual Voice-Experiences Scale (VOICES)

Part 1: How would you describe your voices?
1.How would you describe your experience of hearing voices? (Tick all that apply)	(% YES; N)
Clairaudience	(72.7%; 16)
Spirit communications	(86.4%; 19)
Animal/nature communications	(50.0%; 11)
Religious experiences	(27.3%; 6)
Communications from living people	(54.5%; 12)
Demonic possession	(0%; 0)
“Tricks” of the mind	(13.6%; 3)
Results of a traumatic experience	(18.2%; 4)
Mental health problems	(0%; 0)
Past memories or “flashbacks”	(40.9%; 9)
2. How old were you when you first became aware of hearing the voice(s)	<10 years = 40.9% (N = 9)
	10–18 years = 13.5% (N = 3)
	19 + years = 45.2% (N = 10)
3. When did you last hear the voice(s)? (%; N)	More than 1 year (9.1%; 2)
	In last year (18.2%; 4)
	In last month (9.1%; 2)
	In last week (22.7%; 5)
	In last day (31.8%; 7)
	In last hour (9.1%; 2)
4. On average, how often do you hear the voice(s)? (%; N)	Less than once a year (13.6%; 3)
	At least once a year (9.1%; 2)
	At least once a month (13.6%; 3)
	At least once a week (13.6%; 3)
	At least once a day (40.9%; 9)
	Continuously (9.1%; 2)
5. How many voices do you hear? (%; N)	1 (81.8%; 18)
	3 (4.5%; 1)
	5 (4.5%; 1)
	6 (4.5%; 1)
	7 (4.5%; 1)
6. If you hear more than once voice, do you have a main voice? (%; N)	1 voice only (68.2%; 15)
	Not at all (4.5%; 1)
	A little (4.5%; 1)
	Somewhat (4.5%; 1)
	A fair bit (4.5%; 1)
	A lot (9.1%; 2)
7. When you hear the voice(s), how long does the experience typically last for? (%; N)	Few seconds (31.8%; 7)
	Several minutes (36.4%; 8)
	Up to an hour (13.6%; 3)
	Up to several hours (9.1%; 2)
	Continuously (4.5%; 1)
8. Have there been fluctuations in how often and/or for how long you hear the voices(s) over time? (%; N)	Not at all (36.4%; 8)
	A little (13.6%; 3)
	Somewhat (22.7%; 5)
	A fair bit (18.2%; 4)
	A lot (9.1%; 2)
9. How loud are the voice(s) (%; N)	Whispers (22.7%; 5)
	Speaking voice (68.2%; 15)
	Shouting (9.1%; 2)
10. How clear are the voice(s)? (%; N)	Barely comprehensible (4.5%; 1)
	Somewhat comprehensible (4.5%; 1)
	Mostly comprehensible (40.9%; 9)
	Always comprehensible (50.0%; 11)
11. When you hear the voice(s), where do they sound like they are coming from? (%; N)	Inside my head (22.7%; 5)
	Inside and outside my head (45.5%; 10)
	Outside head and close to ears (22.7%; 5)
	Outside head away from ears (9.1%; 2)
12. How complex is what the voice says? (Tick all that apply)
Fragmented words	(36.4%; 8)
Basic sentences	(77.3%; 17)
Complex dialogue	(50.0%; 11)
13. What times of day do you hear the voice(s) (Tick all that apply	(YES %; N)
Fully awake	(90.9%; 20)
Going to sleep	(40.9%; 9)
Waking up	(54.5%; 12)
14. Do(es) the voice(s) have a personality or specific character?	No (27%; 6)
	A little (4.5%; 1)
	Somewhat (9.1%; 2)
	A fair bit (9.1%; 2)
	A lot (50.0%; 11)
15. Who are the voices? (Tick all that apply)	(YES %; N)
People I know, who are alive	(31.8%; 7)
People I know, who have passed away	(81.8%; 18)
People I know, but not personally (e.g., celebrities)	(40.9%; 9)
People I know of, but not personally (e.g., relatives)	(40.9%; 9)
Spirits	(81.8%; 18)
Supernatural entities	(40.9%; 9)
Higher being or deity	(72.7%; 16)
I don’t know who the voices are, or cannot identify them	(50.0%; 11)
16. Are there some situations when you are more likely to hear the voice(s) or which bring it on (Tick all that apply)	(YES %; N)
When on my own	(40.9%; 9)
Being with strangers	(54.5%; 12)
With people I know	(63.6%; 14)
In busy situations	(45.5%; 10)
In nature or peaceful situations	(68.2%; 15)
In trance or meditating	(81.8%; 18)
17. When you hear the voice, do you also sense them in another way? (Tick all that apply)	(YES %; N)
Smell	(31.8%; 7)
See	(68.2%; 15)
Feel	(45.5%; 10)
Feel presence	(81.9%; 18)
Taste	(9.1%; 2)
No other sense	(13.6%; 3)
18. Do the voice(s) say positive things? (%: N)	Never (4.5%; 1)
	Sometimes (9.1%’; 2)
	Often (22.7%; 5)
	Always (63.6%; 14)
19. Do the voice(s) say negative things? (%: N)	Never (68.3%; 15)
	Rarely (13.6%; 3)
	Sometimes (13.6%; 3)
	Always (4.5%; 1)
20. Do the voice(s) say neutral things? (%: N)	Never (22.7%; 5)
	Rarely (4.5%; 1)
	Sometimes (54.5%; 10)
	Often (13.6%; 3)
	Always (4.5%; 1)
21. Does the voice(s) say similar things to your own thoughts or what you think about? (%: N)	Never (9.1%; 2)
	Rarely (18.2%; 4)
	Sometimes (45.5%; 10)
	Often (22.7%; 5)
	Always (4.5%; 1)
22. Does the voice(s) say similar things to specific memories you have? (%: N)	Never (31.8%; 7)
	Rarely (31.8%; 7)
	Sometimes (31.8%; 7)
	Often (4.5%; 1)
23. Is the content of what the voice(s) say repetitive? (%: N)	Never (40.9%; 9)
	Rarely (13.6%; 3)
	Sometimes (31.8%; 7)
	Often (9.1%; 2)
	Always (4.5%; 1)
24. Do(es) the voice(s) (%; N)
give you helpful guidance?	Rarely (9.1%; 2) Sometimes (22.7%; 5) Often (22.7%; 5) Always (45.5%; 10)
give orders on what to do?	Never (86.4%; 19) Rarely (4.5%; 1) Always (9.1%; 2)
give warnings (eg, of dangerous situations	Never (27.3%; 6) Rarely (22.7%; 5) Sometimes (31.8%; 7) Often (9.1%; 2) Always (9.1%; 2)
make comments about you or on what you do?	Never (50.0%; 11) Rarely (4.5%; 1) Sometimes (27.3%; 6) Often (13.6%; 3) Always (4.5%; 1)
motivate you to do good things?	Never (18.2%; 4) Rarely (4.5%; 1) Sometimes (13.6%; 3) Often (31.8%;7) Always (31.8%;7)
insult you or put you down?	Never (95.5%; 21) Rarely (4.5%; 1)
praise you or say nice things to you?	Never (31.8%; 7) Rarely (13.6%; 3) Sometimes (36.4%; 8) Often (9.1%; 2) Always (9.1%; 2)
chat with you (ie, have a conversation with you)?	Never (40.9%; 9) Rarely (13.6%; 3) Sometimes (22.7%; 5) Often (13.6%; 3) Always (9.1%; 2)
try to cause you problems?	Never (95.5%; 21) Rarely (4.5%; 1)
talk amongst themselves?	N/A (31.8%; 7) Never (40.9%; 9) Rarely (9.1%; 2) Sometimes (13.6%; 3) Always (4.5%; 1)
Part 2: Your relationship with your voice(s)
25. Can you bring on the voice(s) when you want to? (%; N)	Never (18.2%; 4)
	Rarely (9.1%; 2)
	Sometimes (18.2%; 4)
	Often (13.6%; 3)
	Always (40.9%; 9)
26. Can you make the voices stop when you want to? (%; N)	Never (13.6%; 3)
	Rarely (4.5%; 1)
	Sometimes (13.6%; 3)
	Often (9.1%; 2)
	Always (59.1%; 13)
27. Do you try to ignore the voice(s)? (%; N)	Never (68.2%; 15)
	Rarely (18.2%; 4)
	Sometimes (13.6%; 3)
28. Do you try to make the voice(s) go away, whether or not you succeed? (%; N)	Never (86.4%; 19)
	Rarely (4.5%; 1)
	Sometimes (4.5%; 1)
	Often (4.5%; 1)
29. Do you deliberately get in touch with the voice(s)or make the experience last? (%; N)	Never (27.3%; 6)
	Sometimes (27.3%; 6)
	Often (36.4%; 8)
	Aways (9.1%; 2)
30. Do you ask for the voice(s)’ opinion on things, or ask it for guidance? (%; N)	Never (18.2%; 4)
	Rarely (9.1% ;2)
	Sometimes (36.4%; 8)
	Often (22.7%; 5)
	Always (13.6%; 3)
31. Do(es) the voice(s) have good intentions towards you? (%; N)	Not at all (4.5%; 1)
	Unsure (4.5%; 1)
	Somewhat (4.5%; 1)
	Definitely (86.4%; 19)
32. Do(es) the voice(s) have bad intentions towards you? (%; N)	Not at all (90.9%; 20)
	Unsure (4.5%; 1)
	Somewhat (4.5%; 1)
33. Are the voice(s) unpredictable? (%; N)	Not at all (40.9%; 9)
	A little (13.6%; 3)
	Somewhat (18.2%; 4)
	A far bit (4.5%; 1)
	A lot (22.7%; 5)
34. Has your relationship to the voice(s) changed over time? (%; N)	Stayed the same (36.4%; 8)
	Got better (18.2%; 4)
	Got much better (45.5%; 10)
35. Is/Are the voice(s) powerful (for instance, does it have the means to make things happen)? (%; N)	Not at all (50.0%; 11)
	A Little (13.6%; 3)
	Somewhat (9.1%; 2)
	A fair bit (13.6%; 3)
	A lot (13.6%; 3)
36. Who’s in control, you or the voices? (%; N)	Definitely me (68.2%; 15)
	Somewhat me (9.1%; 2)
	Equal power (18.2%; 4)
	Definitely the voice(s) (4.5%; 1)
37. Do(es) the voice(s) keep you company? (%; N)	Not at all (50.0%; 11)
	A little (13.6%; 3)
	Somewhat (18.2%; 4)
	A fair bit (4.5%; 1)
	A lot (13.6%; 3)
38. Do you keep the voice(s) a secret from people you know? (%; N)	Not at all (36.4%; 8)
	Only a few people (9.1%; 2)
	It depends (27.3%; 6)
	Most people (18.2%; 4)
	Definitely (9.1%; 2)
39. Do you know other people who have a similar experience of voice(s)? (%; N)	I’ve heard other people do, but don’t know anyone (9.1%; 2)
	Not sure (4.5%; 1)
	A few people (31.8%; 7)
	Lots of people (54.5%; 12)
40. Do you believe hearing voice(s) (%; N)
is abnormal?	Strongly disagree (81.8%; 18) Disagree (9.1%; 2) Undecided (9.1%; 2)
is something created by your own mind or brain?	Strongly disagree (50.0%; 11)
	Disagree (18.2%; 4)
	Undecided (27.3%; 6)
	Agree (4.5%; 1)
Do you believe the voice(s) have supernatural origins?	Strongly disagree (18.2%; 4)
	Undecided (31.8%; 7)
	Agree (22.7%; 5)
	Strongly agree (27.3%; 6)
are caused by difficult or stressful situations in your life?	Strongly disagree (36.4%; 8)
	Disagree (18.2%; 4)
	Undecided (13.6%; 3)
	Agree (22.7%; 5)
	Strongly agree (4.5%; 1)
	Missing (4.5%; 1)
has been caused by taking drugs?	Strongly disagree (90.9%; 20)
	Disagree (9.1%; 2)
is a rare gift?	Strongly disagree (18.2%; 4)
	Disagree (22.7%; 5)
	Undecided (13.6%; 3)
	Agree (9.1%; 2)
	Strongly agree (36.4%; 8)
is part of normal human experience?	Strongly disagree (0%; 0)
	Undecided (9.1%; 2)
	Agree (36.4%; 8)
	Strongly agree (54.5%; 12)
means you are an outsider (eg, being on the fringe of society)?	Strongly disagree (13.6%; 3)
	Disagree (36.4%; 8)
	Undecided (13.6%; 3)
	Agree (31.8%; 7)
	Strongly agree (4.5%; 1)
means you are special?	Strongly disagree (9.1%; 2)
	Disagree (45.5%; 10)
	Undecided (31.8%; 7)
	Agree (9.1%; 2)
	Strongly agree (4.5%; 1)
Part 3: How the voices make you feel
41. How pleasant is the experience of hearing voice(s) for you? (%; N)	Not at all (4.5%; 1)
	Somewhat (18.2%; 4)
	A fair bit (22.7%; 5)
	A lot (54.5%; 12)
42. How distressing is the experience of hearing voice(s) for you? (%; N)	Not at all (81.8%; 18)
	A little (13.6%; 3)
	Somewhat (4.5%; 1)
43. Does the experience of hearing voice(s) have a positive or beneficial impact on daily life, whether the voice(s) is/are good or bad? (%; N)	Somewhat (9.1%; 2)
	A fair bit (22.7%; 5)
	A lot (68.2%; 15)
44. Do the voice(s) make your life more difficult, whether they are good or bad? (%; N)	Not at all (68.2%; 15)
	A little (13.6%; 3)
	Somewhat (9.1%; 2)
	A lot (9.1%; 2)
45. Have/has the voice(s) helped you with difficult or stressful experiences in your life? (%; N)	A little (4.5%; 1)
	Somewhat (18.2%; 4)
	A fair bit (22.7%; 5)
	A lot (54.5%; 12)
46. Do(es) the voice(s) affect your concentration? (%; N)	Not at all (68.2%; 15)
	A little (13.6%; 3)
	Somewhat (9.1%; 2)
	A lot (9.1%; 2)
47. Do the voice(s) make you feel (%; N)
ashamed or bad about yourself?	Not at all (100%; 22)
stressed or threatened?	Not at all (100%; 22)
like life has meaning and purpose?	Not at all (13.6%; 3)
	A little (9.1%; 2)
	Somewhat (9.1%; 2)
	A fair bit (4.5%; 1)
	A lot (63.6%; 14)
alone or isolated?	Not at all (72.7%; 16)
	A little (13.6%; 3)
	Somewhat (9.1%; 2)
	A lot (4.5%; 1)
angry or annoyed?	Not at all (90.9%; 20)
	A little (9.1%; 2)
fearful or sad?	Not at all (90.9%; 20)
	A little (9.1%; 2)
confident or good about yourself?	Not at all (13.6%; 3)
	A little (9.1%; 2)
	Somewhat (13.6%; 3)
	A fair bit (31.8%; 7)
	A lot (31.8%; 7)
useless or worthless?	Not at all (95.5%; 21)
supported or connected to others?	Not at all (9.1%; 2)
	A little (9.1%; 2)
	Somewhat (22.7%; 5)
	A fair bit (9.1%; 2)
	A lot (50.0%; 11)
hopeless about the future?	Not at all (95.5%; 21)
	A little (4.5%; 1)
safe or comforted?	Not at all (4.5%; 1)
	A little (18.2%; 4)
	Somewhat (4.5%; 1)
	A fair bit (9.1%; 2)
	A lot (63.6%; 14)
48. Have your views or feelings about the voice(s) changed over time? (%; N)	Not at all (27.3%; 6)
	A little (4.5%; 1)
	Somewhat (22.7%; 5)
	A fair bit (13.6%; 3)
	A lot (31.8%; 7)
49. Have you ever sought help or treatment because of the voice(s)? (Tick all that apply)	(YES %; N)
Others suggested that I seek help	(9.1%; 2)
I have sought or received spiritual support to help me cope with the voice(s)	(36.4%; 8)
I have sought or received medical care to help me cope with the voice(s)	(0%; 22)
I have sought or received support for other voices hearers from the voices	(40.9%; 9)
I have received medical care for the voice(s) against my wishes	(0%; 22)
I have not needed help for the voice(s)	(72.7%; 16)
I have sought or received psychological care to help me cope with the voices	(4.5%; 1)
I have received a diagnosis because of voice(s)	(0%; 22)

Sixty-four percent of the sample heard voices at least weekly (50% daily or continuously), with most hearing them at times “outside the head” (77%), speaking clearly and comprehensibly (91%) with the same loudness as their own voices (77%). Generally, they heard one voice at a time (82%), but also reported multisensory hallucinations (86%). None regarded their voices as symptoms of mental illness, and 27% worked as professional mediums or healers.

Although there was variety in their voice-hearing experiences, overall the sample considered hearing voices as part of normal human experience (91%), interpreted as a clairaudient gift (73%) and spirit communications (86%), and were most likely to hear them when in a trance, praying or meditating (82%). They reported little or no distress (95%) and found hearing voices a pleasant experience (77%): they had voices with positive content (86%), which did not insult or put down the voice hearer, tried to cause problems, or made the person feel ashamed, stressed or threatened (all 0%).

Participants reported that their relationship with the voice(s) got better over time (64%). They could control their onset (73%) and offset (82%) at least some of the time, but did not ignore them (86%) or tried to make them go away (91%). They had trusting and supportive relationships with the voices: eg, received positive and helpful guidance from them (91%), the voices had a positive impact on their life (91%) and helped with difficult experiences in life (77%). They lacked paranoid and threatening appraisals: eg, believed that the voices have good intentions towards them (86%), were not powerful (73%), and not in control of the voice-hearer (96%).

Qualitative Results

Despite some common overall patterns, the experiences described by these participants and identified as “voices” seemed quite varied. Some participants hesitated with the word “voices” to describe their experience, said that the experiences were minimally or never audible, insisted that they were always positive and under their control, and spoke as if it had been a choice to enter into this world of spirits because it gave them such an interesting way to interact with others. Others spoke more as if they had experienced distressing, often clearly audible voices, and that they sought out spiritualist ideas to make sense of and to manage their experience.

Here we describe the broadly similar framework shared by participants and the different ways this framework was used.

Most participants understood their experiences as expressions of psychic energy or spiritual presence. This cultural terrain is a repertoire of ideas about supernatural beings and forces with whom humans can interact, often described as occult, metaphysical, or new age.⁵⁶ There are different kinds of spirits, some of them dead humans, who they are thought to contact humans and transmit power to and through them. The skilled person learns to interact with them, draw positive power to themselves, and protect themselves from negative power.

These ideas run, in different forms, through many contemporary books and videos on reiki, tarot card reading, crystals, spirit mediumship, lucid dreaming, and so forth. Most speak of the need for training, with the expectation that training gives people access to unusual knowledge and power. In Where Two Worlds Meet,⁵⁷ for example, Janet Nohavec (a teacher at the college where some of our participants trained) writes that “If you are like me—a born medium—you may have been hearing, seeing or sensing spirits all your life, but for any number of reasons you downplayed your gifts. …. If you have only come to realize your mediumship abilities later in life, there’s every reason to believe that you can develop them to a much greater degree . . . [But] this isn’t something you learn overnight.” (pages 27-8).

Professional mediums are paid for their services, which typically involve contacting the dead. They perform in the mediumship sessions of Spiritualist Churches. They also perform on stages, where audience members pay to see the performance. In these sessions, the medium will be contacted by spirits who wish to speak to members of the audience. Mediums also do individual readings, in which they give messages from the dead, and in which they heal by channeling power from the spirit world into a client’s body. People come to mediums for consolation, entertainment, and spiritual advice and healing.

What the Cultural Framework Affords

The ideas in this cultural terrain seemed to afford opportunities to our participants. The first is that participants are able to interpret or reframe their experiences as positive.^11,23 The spirits are there to help, to guide, to inspire, to heal. For example, one participant [#2] described the voices as: “It’s always a guidance and it’s always positive”; “they think highly of me, more so than I do. They’re always positive, always, I can’t stress that enough.” Another [#18] described his experiences as a “completion” of his being: “When they come close to me, it was like a completion, like we were all connected again. I feel a lot happier. A real sense of love comes out of there.”

The second is that participants may be able to alter their voice-hearing experience through their repeated practice, as well as through their labeling of their experience.¹² Many participants spoke of learning how to work with their voices, and of developing better relationships with their voices through this work. Some mentioned hearing negative voices amongst the predominantly positive ones, and attributed the negative voices to bad spirits and learned to not pay attention to them. They spoke of building good relationships with the positive voices who have their best interests in mind. For example, a participant [#7] in her early sixties, reported that since her parents and daughter had died, she could feel their energy and sometimes physical manifestations of their existence. She would hear their voices on the left side of her head. Then she began to hear other voices, sometimes negative. One told her, “You are worthless.” After her initial experience, she had read many books on spirits, and attended a Spiritualist Church. She felt that over time, she had learned to develop good relationships with these spirits. “Every morning, before I get up, because I’m retired I can do this, I stay in bed for at least 10, 15 minutes, and I do a little tiny meditation. In my head I talk to them, I see them and I talk to them in my head, and out loud. Every morning.” When she heard the negative voice, she would call to mind the stanza from “The Sound of Music,” when Julie Andrews sang that the hills are alive. She loved that verse, and when she thought of it, the negative voice would go away.

Phenomenological Biographies

Here we offer four detailed accounts of individual participants to illustrate the diverse ways in which people use cultural ideas about spirits.

In these short biographies, as in the overall sample, there are some participants who give accounts in which they seem to name thoughts or daydreams as spirits. Over time, they come to recognize and experience these spirits as beings in the world. Their experiences seem less audible, less intrusive, less unusual, more pleasant, and more under their control. Others give accounts, which seem closer to what a clinician might call psychosis, in which experiences seemed less controlled, less positive, more auditory, and thought content seemed more loosely embedded in common cultural ideas.

Two examples of participants with voices which seem less audible, less intrusive, less unusual, more pleasant, and more under their control

Participant #1 was a mid-age professional medium in her early sixties. She had heard a voice for the first time in her early thirties, following the death of her mother-in-law, although “voice” was not the term she would have chosen to describe the experience. In fact, she only came to call these experiences voices after talking with a scientist interested in exploring her spirit mediumship (to be clear, “voice” is also often an inadequate word for the complex experiences of psychosis). After a long discussion, they decided, or the scientist decided, that the “voice” would be used to refer to her spirit guide. She then came to use the word “voice” to refer to spirit communications in general. She has infrequent auditory experiences, perhaps a few times a year.

She became involved with spirit mediumship after her mother-in-law died, and after she had spiritual healing for a back problem and found it effective. She followed the healer’s advice to take a course at a psychic college. Here she describes how she communicated with spirits:

Every time I worked for healing or meditation or just watching somebody else work I would be in this energy of this other [spirit] person. … For eight years, my husband and I ran a hotel. And I didn’t have time to meditate or to do my own development. We had cleaners but I did the vacuuming. The good thing about doing the vacuuming is that nobody can talk to you because it’s so noisy. I used to talk to the spirit world as if they were real, doing the vacuuming. I’d say, “Look what they’ve left.” I used to talk to the spirit world like that.

This medium “feels” information with her body, which she then translates into words. “The seeing and the hearing first worked together for quite a long while and the hearing came later.” She reported both internal and external voices. Yet the auditory dimension of her experience seemed quite vague—as if it was more like a commitment to the out-thereness of the spirit rather than an experience with a hearing quality. She felt completely in control of the experiences and earned her living from her practice. She could decide whether to hear the spirits or not: “I’ve told them [spirits] they’re not allowed in my bedroom.” She had seldom found the voices distressing. She clearly understood the experiences as an ability she had learned to develop, and insisted that anyone could learn to be a medium. “It’s about training a skill.” She holds conferences open to the paying public to teach people how to communicate with spirits.

In short, Participant #1 decided that she was fascinated by mediumship. She began to explore mediumship after the death of her mother-in-law, and began to interpret her mental experiences as evidence of the dead. Only then did she begin to hear voices consistently. She explained—and taught—that the voices heard by mediums were never negative.

Participant #14 also works as a professional medium. She always knew she was different. “I’ve always been very intuitive, so I can see and perceive things apparently in other ways than other people can. I never really thought much of it.” Not, that is, until a friend “dragged” her to a Reiki weekend, where she felt that she could put a name to her way of being and learn to use what she called “energy” more effectively. She eventually became certified in Reiki, and took a course in a local college of psychic studies. She was clear that training improved her abilities. She would “pick up” on “energy” even over email or over the phone. The spirits would give her “information” that she would share with clients.

I get information, sometimes in words sometimes in visuals, sometimes in feelings, like dogs or cats, sensations like hot, cold, warm, wind. With the window closed sometimes I can feel the wind on my face. These are obviously not real, but they feel real enough to me to be perceived, because they have some kind of meaning to the person, to what’s going on, to the transformation, to the trauma, to the energy. (8-9)

Yet by “perceived” here, she really meant that she “felt energy.”

“It’s not like I hear you [14] … When you speak there is voice, real sound that comes to my ears, that I process. The communication that you get during a healing session or from, call it a ghost or a spirit or other beings, whatever they are, or living people that send you messages, is not real as in it’s not sound that travels through the air into your ears. It’s somehow a knowing that comes in the form of an image that is shown to you in a sentiment, like a sensation; hot, cold, pain.” (28)

Her examples were primarily images that she interpreted with words to herself and to her clients. She insisted that she never heard words audibly. “It is inside as the sound appears in your head, as my favorite music, you start hearing it. Not in your ears but you know in your head.” It seems more like a deliberate daydream, which she wants to experience as an external presence.

In short, Participant #14 felt like she was “different” from other people growing up. Yet as she became a medium she was not so much interpreting voice-like events as spiritual as deciding that she recognized herself in this talk of spiritual energies and special sensitivity. She never heard audible events, but she was able to learn to recognize and experience energies as present.

Two participants whose voices seemed less controlled, less positive, more auditory, and whose content seemed more loosely embedded in common cultural ideas about spiritualism.

Participant #8 was 47, and was not a professional medium. He said that he had developed voices from Lyme disease in his thirties, although he also mentioned a depression following a breakup and the loss of his job.

“I saw [a doctor] in August 2008 and three weeks after, in September 2008, one morning I was woken up at 5:30 in the morning and I heard, it was on the left side, I heard voices saying …. “Don’t be frightened, we’ve come to help you. We know you’re suffering.” They said something along the lines of, “We know you’re being manipulated,” something like that. “Don’t be frightened.” “Oh my god, I’m now schizophrenic” I thought to myself. They said, “No, you have a friend.”

He heard many voices, with one dominant voice. He had no ability to bring on the voices, although he could make them stop if he chose. He spent some time exploring books on spirits. Eventually he found a spiritualist church and met someone who became a mentor and taught him how to work with his guides. Over time he had a series of human and then spirit mentors whom he felt had helped him. He also described his voices as giving him specific instructions. “I was in Cyprus on holiday and my [spirit] guide said to me, ‘Pick up a book and I’ll tell you something to write down.’ And then it’s like a magnetism. It’s almost like I feel energies coming through me, and I can hear them. They’re telling me now, ‘Read it to her.’” He also localized his voices: they were on the left-side, not the right. He described them as having more physical qualities.” He also heard angels, infinite in number, that spoke to him often. When he was ill, many bad spirits tried to attack or enter his body, but his guides would help him fight them off.

In short, Participant #8 heard voices whose physical quality was striking. They were also far more active and directive than for the first 2 participants. He had those active and directive experiences before he developed ideas about mediumship. At least some of those experiences were unpleasant and they seemed more active than the descriptions in some common books on spiritualism.^54,55 He had only partial control of them, at best, and they gave him commands. Still, he found his spiritualist practices helpful.

Participant #18 came from a home with great poverty and chaos. He talked about hallucinating food and described his siblings as unstable at times, with mental illness “running in the family.” He had visual experiences when he was about four or five, seeing towering fairies standing over his brother’s body at night, trying to heal him. He also saw faces looming out of the darkness at him from the foot of the bed. Now he thinks they were his guides. He had many poltergeist experiences as a child and teen, and began reading widely about these kinds of events then. At sixteen he began to develop an active prayer and medication practice. He would go into a trance, and have vivid experiences.

“I get voices, I get entities come through and they speak through me and I call it “channeling” or whatever, it became a form of mediumship then because I realized then that these entities, these things that were talking through me were related to people that were in the room. I used to bring them through, sense them, I take on the personality of the person’s father or mother or sister. They take over my body and I end up giving them messages.”

He said that he lived in a house where ghosts had tried to kill each other and he would hear them grumbling out loud (audibly) at the bottom of the bed during the night. He had many visual events, often at night. These spirits had become more loving over time; it had been like a marriage, exciting and perhaps a bit tumultuous at the beginning, and now had become deeply loving. He described them as speaking outside of his head, in general near his ear.

“It can change. It can be different. Sometimes I get it right in my ear and I’ll get a buzzing noise to start with and it starts buzzing and then I’ll get a little voice that’s right next to my ear. Other times it can be like they’re in the room, opposite me, rather than right next my ear.”

He said the voices were always positive, but he also said that “sometimes they can be a bit hard with me.” Sometimes we see things as negative, he said, but they are really positive. “When you start accepting them and building relationships with them, they do become your friends.”

In short, Participant #18 had audible multisensory events which were clearly hallucination-like. Not all were pleasant, although as he worked with them they became more pleasant. Even now however, they could be “hard” on him. He described changing his attitude towards the experiences, rather than deciding to learn to have them. These experiences are more angry and conflictual than those described in some common books on spiritualism.⁵⁷

Discussion

The findings of this study are in line with previous reports of healthy voice-hearers.^2,6 Participants generally reported their experiences not just as non-distressing, but as life-enhancing experiences with which they had trusting and supportive relationships that got better over time. There was active engagement with the experiences, which were almost always multisensory, supporting previous findings that hallucinations in other modalities are common in nonclinical groups.^12,28 It seems possible that training practices within their cultural framework enabled people who might have been vulnerable to developing psychosis to experience their voices differently. Some aspects of the practice (such as encouraging interaction with the voice) can be found in Voice Dialogue,^58,59 Hearing Voices groups^,60, and other so-called “relational” therapies.⁶¹

This in-depth investigation also finds that there is a variety of voice-hearing experiences within healthy voice-hearers. Although the vast majority identified their voices as spirit communications, and therefore shared similar cultural understandings, the way in which people experienced voices were quite different. Some reported clearly audible voices, but for others, the word “voices” did not quite capture their multisensory experiences of communicating with and channeling spirits. Similarly to previous findings,¹² the initial onset for some of our participants occurred spontaneously, but came to be understood—and valued—within a spiritualist framework. For others, their experiences emerged through their immersion in a cultural setting that promotes such experiences.

Some participants reported experiences which are more resonant with those found in psychosis. Their voices are more audible, more negative, and less under their control. They appear to come to the cultural ideas in spiritualism and the new age to make sense of and manage their unusual experiences. Others reported experiences which are often not audible, were usually quite positive, and entirely under their control. They may be drawn to the same ideas for reasons quite different from the need to make sense of pre-existing unusual experiences. They seem like the charismatic Christians who come to church and learn that they can hear God speaking by identifying thoughts in their mind that seem like God—and are taught by the church how to do this.

It may be the case that there are healthy voice-hearers who learn to manage something like a psychotic process through a cultural context that normalizes and validates their experiences, and others whose experiences arise through another, “top-down” pathway like imagination and the determination to identify some thought-like events as autonomous (and thus, as proof that spirits exist). These observations are in line with proposals that there may be different kinds of “continua”^10,62—and suggest that one may be closer to psychosis, and the other more like an interest in daydream-like, imagination-rich experience, of the sort associated with absorption.

That is why careful phenomenological exploration of these experiences is so important.⁶³ People may use the same words to describe their experiences, and share a common discussion around their experiences, without experiencing a common event. The VOICES scale offers a new phenomenological instrument to examine these experiences more carefully, beyond the cultural representations that individuals provide. Future research should focus on whether specific training practices, of the kind found in local cultures like spiritualism, might alter voice-like experiences, as well as facilitating more ordinary inner experiences to feel autonomous and external.

Conclusion

The emerging clinical work on voice-hearers without a need for clinical care has focused on the possibility that the early interpretation of such experiences as non-pathological, in a cultural context where there is support for that interpretation, may change the experience of the voice-hearer so deeply that the voice-hearer comes to experience that voice as an advantage. This observation is of great importance. It is however also important to raise the possibility that there are different pathways to these experiences. The detailed phenomenological scale we call VOICES offers a new tool with which to explore this domain.

Varieties Of Individual voiCe-Experiences Scale (VOICES)

Many people report experiences of hearing voices. Some people describe them as hearing spirits, communications from objects or animals around them, telepathic messages, or “clairaudient” experiences (i.e., psychic hearing); for others they are seen as tricks their mind plays on them and/or a mental health problem. We are interested in all these experiences – we want to understand the different ways people live with voices, and make no assumption about what they are, where they come from, or what they mean.

In this questionnaire, we will be describing such experiences as “hearing voices”, by which we mean hearing or receiving communication, in the form of spoken words or sentences, in the absence of a source observable by someone around you (who does not have similar experiences). Please note we are NOT looking at experiences that only occur when under the influence of alcohol or drugs, or that do not have a ‘hearing quality’ eg thoughts being transmitted or communications received through the body only.

Does this description match an experience that you have previously had or still have?

□ Yes

□ Yes, but only once or twice in my life

□ No

if “no”, please describe your experience:

Throughout the questionnaire there are no right or wrong answers; we are interested in all the different ways people experience their voices. If you have more than one voice, please rate the items below either in terms of what they are like generally, or in terms of your main voice, if that applies.

Throughout the questionnaire there are no right or wrong answers; we are interested in all the different ways people experience their voices. If you have more than one voice, please rate the items below either in terms of what they are like generally, or in terms of your main voice, if that applies.

If you do not currently have voice experiences, but have had them in the past, please rate the items based on the last time you can clearly remember.

Part 1 – How you currently describe your voice(s)

• 1 How would you describe your experience of hearing voices? (Tick all that apply)

□ Clairaudience	□ “Tricks” of the mind
□ Spirit communications	□ Result of a traumatic experience
□ Animal/nature communications	□ Mental health problem
□ Religious experiences	□ Past memories or ‘flashbacks’ □ Communications from dead people/the afterlife □ Other: ______________
□ Communications from living people □ Demonic possession

• 2 How old were you when you first became aware of hearing the voice(s)? __________

• 3 When did you last hear the voice(s)?

□ more than a year ago

□ in the last year

□ in the last month

□ in the last week

□ in the last day

□ in the last hour

• 4 On average, how often do you hear the voice(s)?

□ less than once a year

□ at least once a year

□ at least once a month

□ at least once a week

□ at least once a day

□ at least once an hour

□ continuously or almost continuously

• 5 How many voices do you hear?

□ 1

□ 2

□ 3

□ 4

□ 5

□ 6

□ 7

□ 8

□ 9

□ 10 +

• 6 If you hear more than one voice, do you have a ‘main’ one?

□ Not applicable (only hear 1 voice)

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 7 When you hear the voice(s), how long does the experience typically last?

□ a few seconds, fleeting

□ several minutes

□ up to an hour

□ up to several hours

□ continuously

• 8 Have there been changes in how often and/or for how long you hear the voice(s) over time?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 9 How loud are the voice(s)?

□ quieter than my own voice, whispers

□ same loudness as my own voice

□ louder than my own voice

□ extremely loud, shouting

• 10 How clear are the voice(s)?

□ muffled or mumbled, not comprehensible

□ barely comprehensible

□ somewhat comprehensible

□ clear, mostly comprehensible

□ clear, always comprehensible

• 11 When you hear the voice(s), where do they sound like they’re coming from?

□ Inside my head/mind

□ Both inside and outside my head

□ Outside my head, but close to ears or head

□ Outside my head, away from ears

• 12 How complex is what the voice(s) say(s)? (Tick all that apply)

□ Fragmented words

□ Brief or basic sentences

□ Complex dialogue

• 13 What times of the day do you hear the voice(s)? (Tick all that apply)

□ When I’m fully awake

□ When I’m going to sleep

□ When waking up

• 14 Do(es) the voice(s) have a personality or specific character?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 15 Who are the voice(s)? (Tick all that apply)

□ People I know, who are alive	□ Spirits
□ People I know, who have passed away	□ Supernatural entities
□ People I know of, but not personally (e.g., celebrities; relatives of others)	□ Higher being or deity □ I don’t know who the voices are, or cannot identify them

• 16 Are there some situations where you are more likely to hear the voice(s) or which bring it on? (Tick all that apply)

□ When on my own

□ Being with strangers

□ Being with people I know

□ In busy situations like on a bus

□ In nature or peaceful situations

□ When in a trance, praying or meditating

• 17 When you hear the voice(s), do you also sense them in another way? (Tick all that apply)

□ I can smell them

□ I can see them

□ I can feel their touch

□ I can feel their presence or aura

□ I can taste them

□ I don’t sense them in any other way

• 18 Do(es) the voice(s) say(s) positive things?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 19 Do(es) the voice(s) say(s) negative things?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 20 Do(es) the voice(s) say(s) neutral things (e.g., single words like “listen” or brief sentences)?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 21 Does the voice(s) say(s) similar things to your own thoughts or what you think about?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 22 Does the voice(s) say(s) similar things to specific memories you have?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 23 Is the content of what the voice(s) say(s) repetitive?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 24 Do(es) the voice(s):

  • a … give you helpful guidance (e.g., in making decisions)?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• b … give you orders on what to do?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• c … give you warnings (e.g., of dangerous situations)?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• d … make comments about you or on what you do?

□ Never

□ Rarely

□ Sometimes

□ Very often

□ Always

• e … motivate you to do good things?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• f … insult you or put you down?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• g … praise you or say nice things to you?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• h … chat with you (i.e., have a conversation with you)?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• i … try to cause you problems?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• j … talk amongst themselves?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

□ Not applicable (only hear 1 voice)

Part 2 – Your current relationship with your voice(s)

• 25 Can you bring on the voices when you want to?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 26 Can you make the voices stop when you want to?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 27 Do you try to ignore the voice(s)?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 28 Do you try to make the voice(s) go away, whether or not you succeed?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 29 Do you deliberately get in touch with the voice(s), or try to make the experience last?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 30 Do you ask the voice(s)’ opinion on things, or ask it for guidance?

□ Never

□ Rarely

□ Sometimes

□ Often

□ Always

• 31 Do(es) the voice(s) have good intentions towards you?

□ Not at all

□ Unsure

□ Somewhat

□ Quite a bit

□ Definitely

• 32 Do(es) the voice(s) have bad intentions towards you?

□ Not at all

□ Unsure

□ Somewhat

□ Quite a bit

□ Definitely

• 33 Are the voice(s) unpredictable (e.g., switch from nice to nasty in surprising ways)?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 34 Has your relationship to the voice(s) changed over time?

□ Got much worse

□ Got worse

□ Stayed the same

□ Got better

□ Got much better

• 35 Is/Are the voice(s) powerful (for instance, does it have the means to make things happen)?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 36 Who’s in control, you or the voice(s)?

□ Definitely me

□ Somewhat me

□ Equal power

□ Somewhat the voice(s)

□ Definitely the voice(s)

• 37 Do(es) the voice(s) keep you company?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 38 Do you try to keep the voice(s) a secret from people you know?

□ Not at all

□ only a few people

□ It depends

□ Most people

□ Definitely

• 39 Do you know other people who have similar experiences of voice(s)?

□ Not at all

□ I’ve heard other people do, but don’t know anyone

□ Not sure

□ A few people

□ Lots of people

• 40 Do you believe hearing voice(s):

  • a … is abnormal?

□ Strongly disagree

□ Disagree

□ Undecided

□ Agree

□ Strongly agree

• b … is something created by your own mind or brain?

□ Strongly disagree

□ Disagree

□ Undecided

□ Agree

□ Strongly agree

• c … has supernatural origins?

□ Strongly disagree

□ Disagree

□ Undecided

□ Agree

□ Strongly agree

• d … has been caused by difficult or stressful experiences in your life?

□ Strongly disagree

□ Disagree

□ Undecided

□ Agree

□ Strongly agree

• e … has been caused by taking drugs?

□ Strongly disagree

□ Disagree

□ Undecided

□ Agree

□ Strongly agree

• f … is a rare gift?

□ Strongly disagree

□ Disagree

□ Undecided

□ Agree

□ Strongly agree

• g … is part of normal human experience?

□ Strongly disagree

□ Disagree

□ Undecided

□ Agree

□ Strongly agree

• h … means you are an outsider (e.g., being on the fringe of society)?

□ Strongly disagree

□ Disagree

□ Undecided

□ Agree

□ Strongly agree

• i ... means you are special?

□ Strongly disagree

□ Disagree

□ Undecided

□ Agree

□ Strongly agree

Part 3 – How the voices currently make you feel

• 41 How pleasant is the experience of hearing voice(s) for you?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 42 How distressing is the experience of hearing voice(s) for you?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 43 Does the experience of hearing voice(s) have a positive or beneficial impact on your daily life, whether the voices(s) is/are good or bad?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 44 Do the voice(s) make your life more difficult, whether the voice(s) is/are good or bad?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 45 Have/has the voice(s) helped you with difficult or stressful experiences in your life?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 46 Do(es) the voice(s) affect your concentration?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 47 Do(es) the voice(s) make you feel…

  • a … ashamed or bad about yourself?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• b … stressed or threatened?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• c … like life has meaning and purpose?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• d … alone or isolated?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• e … angry or annoyed?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• f … fearful or sad?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• g … confident or good about yourself?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• h … useless or worthless?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• i … supported or connected to others?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• j. … hopeless about the future?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• k. … safe or comforted?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 48 Have your views or feelings about the voice(s) changed over time?

□ Not at all

□ A little

□ Somewhat

□ A fair bit

□ A lot

• 49 Have you ever sought help, support or treatment because of or for the voice(s)? (Tick all that apply)

□ Others have suggested I seek help for the voice(s)		□ I have sought or received medical care to help me cope with the voice(s)	□ I have received medical care for the voice(s) against my wishes	□ I have sought or received psychological care to help me cope with the voice(s)
□ I have sought or received spiritual support to help me cope with the voice(s) □ I have sought or received spiritual training to help me hear the voice(s) more clearly or often		□ I have sought or received support from other voice-hearers for the voice(s)	□ I have not needed help for the voice(s)	□ I have received a diagnosis because of the voice(s) (please specify):

• 50 Is there anything else we have not asked you about you feel is important to tell us?

THANK YOU FOR YOUR TIME

Funding

We gratefully acknowledge support from Stanford University and the University of California, Los Angeles.