Hearing Voices

The Voices Within: The History and Science of How We Talk to Ourselves
by Charles Fernyhough
Basic Books. 305 pages.
9781781252796

Our brains, like our minds, are full of voices,” writes psychologist Charles Fernyhough in The Voices Within: The History and Science of How We Talk to Ourselves, his exploration of the thoughts and images that course through our heads. “I am interested in all of these voices: the kindly ones, the guiding ones, the encouraging and commanding ones, the voices of morality and memory, and the sometimes terrible, sometimes beneficent voices that some people hear when there is no one else around.”

With this premise, Fernyhough had me hooked. As someone with a history of struggling with obsessive-compulsive ruminations, I’ve always felt a certain confusion in the midst of an episode about the point of origin of the unstoppable irrational voice that would suddenly spring up, as if from nowhere, and overwhelm any coexisting calming thoughts. The rational part of me never doubted that these ruminations emanated from somewhere within, and yet the unending barrage of self-critical thoughts also felt like an invasive weed of unknown origin, an intrusive voice that was both me and anti-me. How could that voice have gotten there in the first place? And how could it have coexisted with the mostly benign, even banal, internal musings that usually accompany me as I go about my daily rounds?

Fernyhough, who directs the Hearing the Voice research project at the UK’s Durham University, believes that answers to these questions, and others, must begin with an understanding of the experience of thought itself: the ways we each make sense of the particular internal mix of words, conversation, music, and images that natter away at us nonstop. Attaining this information sounds easier than it is, Fernyhough explains, because even if we could somehow tap and record someone else’s internal thought process, we wouldn’t necessarily understand its meaning. The reason is that thoughts embody language within so private and personalized, a stream of impressions and sensations, that the meanings of the thoughts wouldn’t make sense to anyone else.

Despite such obstacles, Ferny-hough still wanted to identify the neurological and psychological mechanisms underlying inner speech—the phrase he uses to describe the internal commentaries that loop through our minds. And so he helped develop some novel methodologies for eavesdropping on people’s private thoughts. These experiments ranged from asking subjects to keep a type of thought log (whenever they’d receive an electronic beep from a smartphone-like device, they’d have to stop everything and jot down whatever had been going through their minds at that moment) to having them undergo high-tech neuroimaging and brain scans.

The results, he says, showed that there most likely does exist a neural underpinning for what he terms “dialogic inner speech,” or simply put, how we talk to ourselves. Other research studies with toddlers and young children further demonstrated that self-talk develops hand-in-hand with language and helps the processes of social and cognitive development. “When we internalize dialogue, we internalize other people,” Fernyhough explains. The child incorporates the voices of parents, teachers, friends. The athlete internalizes the voice of her coach urging her to succeed in competition. And we each engage in inner conversation with members of our very own chorus of inner voices to gain needed perspective on how to behave in and interact with the world around us.

Reading, he maintains, engages us in yet another type of inner dialogue—and adds to the chorus of voices in our heads as we converse with the voice of the author, along with the characters on the page. And with whom do the creators of these characters converse? Authors’ diaries (such as the one kept by Virginia Woolf) and letters (like those of Vincent van Gogh to his brother Theo) shed light on the role their self-questioning and self-dialogues play in the development of their creative ideas. Our ongoing inner conversations probably also have a role, Fernyhough says, in helping us organize and tie together different types of information to help us plan and process what we need to do and how to go about it effectively.

Some voices aren’t always so benign, however, and Fernyhough is particularly astute as he discusses voice-hearing and other darker, more perplexing aspects of self-talk and inner speech. In one case history, Jay, a man once hospitalized as an intractable schizophrenic who sank into depression and alcoholism, reports hearing three main voices that come from somewhere outside him, usually from another room. One voice, which appears only when he’s upset, he calls The Witch. He traces another voice to a doctor he heard only once, over the telephone; she always speaks about him in the third person, declaring, “He’s different.” The third belongs to a man with a voice he describes as having “a reflecting tone, like it’s having a conversation. It never shouts or anything.” Recently, a therapist has used cognitive behavioral therapy to help Jay understand the triggers that make these voices appear, and learn how to respond to or ignore them. Though he continues to hear voices several days a week, Jay now holds down a job and lives on his own.

That speaks to one of Fernyhough’s key points: that not everyone who hears voices is mentally ill. “Voice-hearing is a diverse experience, and understanding it requires that we pay attention to that diversity, rather than lumping together experiences that might be very different,” he asserts. He quotes one study in which three percent of respondents said they’d heard voices at some point in their lives. By his own estimate, between 5 and 15 percent of people have at some point experienced a voice hallucination of some sort. Yet the stigma attached to voice-hearing remains prevalent, with most people equating voice-hearing with violence and schizophrenia.

Not only is that not necessarily the case, Fernyhough points out, but historically, hearing voices has often been associated with receiving messages from deities. As an example, he presents the stories of two Englishwomen from the late 14th and early 15th centuries, Margery Kempe and Dame Julian of Norwich, who left accounts of their hallucinatory-seeming visions and conversations with what they perceived were divine voices. Both women struggled with spiritual doubt and worried about the authenticity of their revelations, wondering if they were receiving holy wisdom or being fooled by an unholy imposter. But as strange as their experiences strike us today, we shouldn’t reduce them to medical or psychiatric symptoms, Fernyhough warns. Instead, they “need to be understood in the context of their faith,” as part of their attempts to understand their relationship to God. In attempting to interpret such conversations, historical context matters.

So does the hearer’s personal history of trauma. And there’s a particularly strong link between hearing voices and early childhood trauma such as sexual abuse, says Fernyhough. “Images and impressions from horrific events can remain in a free-floating state, ready to intrude upon consciousness detached from the contextual information that would typically allow them to be recognized as a memory,” he writes. Unable to integrate the trauma, the mind defends itself by dissociating or splitting off memories or fragmented “parts” of the self, which can emerge later as external voices. This kind of model—of stray voices breaking away from the self—can begin to explain how a voice can be perceived as both “me” and “not me” by those subject to a wide range of symptoms of distorted thinking (including me, with my obsessive ruminations).

Such a view opens up a broader range of possibilities for therapy aimed at disentangling conflicting voices, a process that allows clients to converse with and control, and at times live with, the conflicting voices within. The key, he believes, is “recognizing that one’s voices are strange, disruptive, twisted facets of the self—but they are still parts of the self. If they’re in some sense about memory, the voice-hearer can come to terms with them in the same way that an individual can come to terms with unpleasant memories: by integrating them back into the psyche from which they have become split away.”

That is, of course, easier said than done. But he does provide a variety of therapeutic suggestions garnered from the Hearing Voices Movement, a worldwide network of people seeking to destigmatize the experience of voice-hearing. The movement was originally inspired by Dutch psychiatrist Marius Romme, whose clinical work, starting about 25 years ago, led him to understand externally heard voices as “messengers communicating important information about unresolved emotional problems,” Fernyhough writes. To help get at what the voices are actually saying, Romme developed the Maastrict Interview research protocol, which includes questions about the hearer’s trauma history, the age when voices first emerged, thoughts on the source of the voices (supernatural or emanating from a real person, for instance) and their intentions, and common triggers associated with the voices. Today, some therapists use this information to help bring the voices directly into therapy to find out more about the role they play in the hearer’s life and how best to address them.

Therapists have also used puppets as a component of therapy to “represent the things [clients’] voices say in order to detach themselves from them and make them easier to deal with,” Fernyhough reports. He emphasizes that not all voice-hearers want to get rid of voices that have been part of them for so long; some prefer to learn to have a better relationship with them—which the Hearing Voices Movement feels should be a respected goal.

Jacqui, for instance, who hears about 100 voices, describes her experience as similar to receiving “a telephone call from your unconscious.” She tells Fernyhough that hearing voices is “an aspect of self. . . . There’s this sense that they’re part of me in some way, even if they’re saying these really troubling, upsetting things.” The bottom line is that hearing voices is real to the hearer, and should be explored as a part of that person’s experience, rather than checked off as nothing more than a symptom of schizophrenia.

Anyone who reads Fernyhough’s book will come away with an enhanced awareness of the complexity of the multitudinous voices that inhabit our minds. The trouble is that his pace is leisurely, and his prose can be dense in research data. I also wish he’d addressed the potential impact that the output from ear buds and the 24/7 thrum of social media voices have on the patterns of our inner thoughts and speech. But perhaps that will be the subject of a future book.