The ways some "healthy voice hearers" cope might be able to help people with psychotic disorders.

© Sarah Jung
Jessica Dorner was lying in bed at her cousin's house when her grandmother, a "pushy lady" in an apron who had been dead for several years, appeared in front of her. "I know you can see me," Jessica heard her say, "and you need to do something about it."

It was a lonely time in Jessica's life. She was living away from home for the first time, and she thinks her grandmother was drawn by some sense of that. She eventually told her parents what happened, and according to her they were concerned, but not overly panicked. "My parents are probably the least judgmental people I know," she said.

As Jessica tells it, over the next two years, spirits visited her every now and again. Her brother-in-law's deceased father began forming before her, ghostlike, just as her grandmother did. And while the experiences were intense and at times made her feel "crazy," she said, they were infrequent, and insists that they were never a real source of suffering.

Jessica later moved back home and got a job as a pharmacy technician, all the while figuring out how to cope with what was happening to her. At a co-worker's suggestion, she went to the Healing in Harmony center in Connecticut. In 2013, she says, she enrolled in classes there that taught her to use her "gift." A self-described psychic medium, Jessica tells me she hears voices that other people do not (in addition to sometimes seeing people others do not see), at varying intensity, and mostly through her right ear.

Meeting others like her at the center gave Jessica a sense of relief. "Just being around people who are going through similar things—that helps a lot, because I could talk to anybody about those things and not feel like I was crazy," she said.

It was through a friend from the center that Jessica ended up in the lab of Philip Corlett and Albert Powers, a psychologist and a psychiatrist at Yale. In a study published last fall in Schizophrenia Bulletin, Powers and Corlett compared self-described psychics with people diagnosed with a psychotic disorder who experience auditory hallucinations.
"A lot of the time, if someone says they hear voices, you immediately jump to psychotic illness, bipolar disorder, schizophrenia," Corlett said. But research suggests hearing voices is not all that uncommon. A survey from 1991—the largest of its kind since—found that 10 to 15 percent of people in the U.S. experienced sensory hallucinations of some sort within their lifetime. And other research, as well as growing advocacy movements, suggest hearing voices isn't always a sign of psychological distress.
The researchers at Yale were looking for a group of people who hear voices at least once a day, and had never before interacted with the mental-health-care system. They wanted to understand, as Corlett put it, those who do not suffer when "the mind deviates from consensual reality."

What Corlett calls consensual reality—the "normative shared experience we all agree on"—is probably not something you spend too much time thinking about. But you know when it's being violated. The sky is blue, the sun is hot, and as Corlett points out, most would generally agree that people don't receive extrasensory messages from one another.

Jessica was quite frank with me about the way some people may view her.
"We know these experiences are weird and they're seen as weird," she said. "You just can't go into a room and say 'Hey, I'm a psychic medium' and people are gonna accept you."
Finer points of what counts as reality can change over time, and vary based on geography or culture. For centuries people walked the earth believing the sun orbited around them, which today would be considered unreasonable. Who decides that consensus, and where along its boundaries voice hearers fall, depends on a wide range of circumstances.

The anthropologist Tanya Luhrmann, who has studied voice hearing in psychiatric and religious contexts, has written that
"historical and cultural conditions ... affect significantly the way mental anguish is internally experienced and socially expressed." Noting that there is no question psychiatric distress and schizophrenia are "real" phenomena that call for treatment, Luhrmann adds that "the way a culture interprets symptoms may affect an ill person's prognosis." Every psychiatrist I spoke to shared the belief that unusual behavior should only enter into the realm of diagnosis when it causes suffering.
On the other hand, Luhrmann tells me
"it's a terribly romantic idea" to overinterpret the effects of culture. To say, for instance, that "anybody who would be identified with schizophrenia in our culture would be a shaman in Ecuador" is, in her mind, a clear mistake: "Flagrant psychosis" exists in some form in every culture where anthropologists have looked.
In the past decade, researchers have taken a greater interest in the experience of hearing voices outside the context of psychological distress. In his book The Voices Within, the psychologist Charles Fernyhough traces the way thoughts and external voices have been understood by science and society throughout time.*

Reflecting on Fernyhough's book, Jerome Groopman notes that in the early parts of the Bible, the voice of God gave direct commands to Adam, Abraham, and Noah. It spoke to Moses through the Burning Bush, going by the Book of Esther, making itself known again to the apostle Paul in the New Testament. Socrates, who wrote nothing down, heard a "sign" from childhood. The voices of three saints guided Joan of Arc as she rebelled against the English. Groopman cites Martin Luther King, Jr.'s autobiography, in which he describes "the quiet assurance of an inner voice" telling him to "stand up for righteousness."

The social context in which these people lived can impact how they're seen. It's impossible to say how the prophet Ezekiel was understood within his cultural moment. But in most places today, if a person claimed—as Ezekiel does—that he ate a scroll because the Lord commanded him to do so, some eyebrows might be raised. In a community where a personal, verbal relationship with God is normal, the reception may be different.

Powers and Corlett's work orbits the idea that schizophrenia is, as Powers put it, an "outmoded" label that describes a cluster of different symptoms rather than a single unified condition, he says.
"Goodness knows what psychosis actually is," Luhrmann said. "There are clearly different kinds of events in the domain we call psychosis," and when it comes to the relationship between voice hearing and psychosis, she says, "there's so much we don't understand."
Many now antiquated psychiatric diagnoses reified fear, misunderstanding, or prejudice toward people at society's margins. At the time of the women's suffrage movement in London, hysteria was leveled as a charge against women who broke social codes. A Mississippi psychiatrist in the 19th century proposed that slaves who attempted escape suffered from "drapetomania." And until 1973, homosexuality was considered a disease of the mind rather than an accepted way of being in the United States—and was only fully removed from the Diagnostic and Statistical Manual of Mental Disorders in 1987.

In his book Hallucinations, the late Oliver Sacks details a controversial experiment in which eight participants showed up at hospitals throughout the U.S. in the early '70s and complained only of "hearing voices." All of them were immediately diagnosed with a psychotic disorder and hospitalized for two months, despite reporting no other medical symptoms, family history, or signs of personal distress. The single symptom, Sacks writes, was seen as cause enough.

People with psychiatric disorders do hear auditory hallucinations in relatively high numbers. According to Ann Shinn, a psychiatrist at Harvard Medical School and McLean Hospital, 70 to 75 percent of people with schizophrenia or schizoaffective disorder and between one-third and one-tenth of people with bipolar disorder report hearing voices at some point in their life.

In the case of voice hearing, culture may also play a role in helping people cope. One study conducted by Luhrmann, the anthropologist, found that compared to their American counterparts, voice-hearing people diagnosed with schizophrenia in more collectivist cultures were more likely to perceive their voices as helpful and friendly, sometimes even resembling members of their friends and family. She adds that people who meet criteria for schizophrenia in India have better outcomes than their U.S. counterparts. She suspects this is because of "the negative salience" a diagnosis of schizophrenia holds in the U.S., as well as the greater rates of homelessness among people with schizophrenia in America.

The influence of social context was part of what motivated Corlett and Powers: The two were interested in whether the support of a social group can help them understand where disorder and difference intersect. When they set out to design their study, they needed an otherwise healthy group of people who hear voices on a regular basis, and whose experiences are accepted in their social group.

Next, they needed to find some psychics. Corlett told me he got the idea to reach out to a Connecticut-based organization for psychics after noticing the ads for psychics and tarot-card readers on his daily bus route. When the two interviewed those participants, they noticed something striking: The psychics described hearing hearing voices of similar volumes, frequencies, and timbres as the patients. Powers and Corlett took this to mean that the psychics were actually hearing something. The two also vetted their participants with the same techniques that forensic psychiatrists use to determine whether a person is pretending to experience psychiatric symptoms, giving them more reason to believe what they were told.

Compared to their diagnosed counterparts, more of the psychics described the voices as a force that "positively affects safety." And all of the psychics attributed the voices to a "god or other spiritual being." The patients, meanwhile, were more likely to consider their voices a torment caused by a faulty process in their brain. Many of them described the voices as "bothersome," and also claimed that the first time they told anyone what they were hearing, they received a negative response.

Just like Jessica, the psychics were more likely to say that they received a positive reaction the first time they spoke about their experience. Jessica's mother, Lena, told me she maintained a supportive, nonjudgmental attitude toward her daughter's accounts, just as she did when her other daughter converted to Scientology. She waited for Jessica to bring them up and discussed them with an open mind. She says she was happy Jessica found the center, adding that her only concern was that Jessica's experiences did sometimes seem to be distressing her and leaving her "drained."

When Jessica tells me about the people and things she hears, she describes a range of experiences rather than one consistent phenomenon. Her most meaningful episodes of voice hearing are those like the visits she had from her grandmother and her brother-in-law's father. But she also describes things like hearing the number a friend is thinking, and the persistent and vivid presence of a childhood imaginary friend (her mother told me Jessica demanded the table be set for him at every meal). To Jessica, these experiences differ in degree rather than kind from the ghosts of the dead who appear in front of her with persistent messages for her and for others. Though these might not all fit into the popular conception of a psychic, she understands them to exist along that same continuum.

In his book, Fernyhough describes a series of experiments meant to provide evidence for the connection between inner speech and hearing voices. In one, participants were played recordings of other people's speech alongside recordings of their own, disguised and distorted, and told to mark whether the voice was their own or someone else's. Those who experienced hallucinations were more likely to misidentify their own altered voices. A much older experiment found a kind of unconscious ventriloquism among a group of people with schizophrenia: When participants began to hear voices, researchers noted "an increase in tiny movements in the muscles associated with vocalization." The voices they heard came, in some sense, from their own throats.

© Sarah Jung
These experiments suggest that auditory hallucinations are the result of the mind failing to brand its actions as its own. Watching what the brain does during these hallucinations may clarify how that works, and what differences in the brain create these experiences.
"When your brain signals to generate a movement," Shinn, the psychiatrist at Harvard, told me, "there is a parallel signal [known as an efference copy] that basically says 'this is mine, it's not coming from outside.'" This helps creates the sense of where a person is in space, that their hand belongs to them and it is moving from point A to B. In this way, the body labels its motions, and a possible parallel may exist for speech and thought. When people hear voices, they may be hearing 'unmarked' thoughts they do not recognize as their own.
Beyond that, Shinn told me, what is understood about the experiences of people who hear voices is limited. She sees Corlett and Powers's study as part of a growing interest in the lives of "healthy voice hearers"—an interest spurred, in part, by the Hearing Voices Movement. A network of advocacy groups, the Hearing Voices Movement presents an alternative to the medical approach based on the belief that the content of a person's voices can reflect the hearer's mental and emotional state. The groups encourage an approach in which, with the help of a facilitator or counselor, hearers listen to, speak back to, and negotiate with the messages they hear in hopes of learning to cope.

The hearing-voices advocate Eleanor Longden has said she considers her voices "a source of insight into solvable emotional problems" rooted in trauma rather than "an aberrant symptom of schizophrenia." As Longden tells it, that's how her own experiences with voices were understood when she first sought treatment for anxiety. Her psychiatrist told her how limited her life would be by her voices, she says, and the voices grew more adversarial.

Many mental-health-care providers—Shinn, Corlett, and Powers included—seem receptive to the Hearing Voices Movement's critiques, including an overemphasis on medication and an imperative for patient-focused treatment. Shinn credits the network with encouraging an approach that treats voice hearing as more than a checklist item adding up to a diagnosis of schizophrenia, and helping to reduce the stigma attached the experience of voice hearing.
But "there are certainly a lot of people for whom that will not be enough," she says. For some patients, voices can be impossible to reason with, and the burden of other symptoms of psychosis—disordered thought, delusions, the inability to feel pleasure—can be too great. And Powers and Corlett expressed concerns that the Hearing Voices Network may promote a false divide: the idea that the voices' perceived roots in trauma—rather than some accident of biology—means hearers should avoid medication. Biology and experience, they say, can't be so neatly separated. (Longden has written that "many people find medication helpful," and that the International Hearing Voice Network advocates for "informed choice.")
While Powers and Corlett don't believe the psychics and patients are experiencing the exact same thing, the two are cautiously hopeful that about a potential lesson in the greatest difference between those groups: the ability to control the voices they hear, which is something the psychics, including Jessica, showed in greater number than their counterparts. "When I'm in certain situations, I'm not open," Jessica said. For instance, when she's at work, the voices "can come in," she says, they "can hang out, but I'm not gonna talk right now. ... I still have to live this human life."

While learning control was a major part of Jessica's experience, so was learning to summon the voices she heard. Before training as a medium, she heard voices sporadically, she says, and began to hear them every day only after intentionally practicing at the center. Powers and Corlett acknowledge this general trend in their study: The psychics they spoke tended to seek out and cultivate the voice-hearing experiences.

In her work, Luhrmann has come across groups of people who—unlike Jessica—hear voices only as a result of practice. She gives the example of tulpamancers: people who create tulpas, which are believed to be other beings or personalities that co-exist along inside a person's mind along with their own. "Somebody in that community estimated to me that one-fifth of the community had frequent voice hearing experiences with their tulpas, that their tulpas talked in a way that was auditory or quasi auditory," Luhrmann said, a practice that she was told takes two hours a day to develop."That's connected to work. Psychosis is not connected to effort. It happens to people."

Longden, the Hearing Voices Network advocate, describes how she later learned to extract metaphorical meaning from the sometimes disturbing messages the voices had for her. Once when the voices warned her not to leave the house, she thanked them for making her aware that she was feeling unsafe, and firmly reassured the voices—and by extension, herself—that they had nothing to fear.

Though Jessica has a different understanding of her voices' source, it's hard not to hear echoes of Longden's account when she speaks about the sense of control she's developed. Longden talks to the voices as aspects of herself that call for a response, while Jessica addresses them as visitors who need to learn the rules.

Instead of tying these experiences to a discrete diagnosis, Powers and Corlett imagine a new kind of frame for voice hearing. Drawing a parallel with Autism Spectrum Disorder, the two are interested in the extent to which the psychics they saw
"might occupy the extreme end of a continuum" of people who hear voices. "Much of what we perceive and believe about the world is based on our expectations and our beliefs," Corlett said. "We can see hallucinations as an exaggeration of that process, and the psychics as a sort of way-station on that continuum, and slowly but surely we can creep towards a better understanding of the clinical case and therefore better treatment. We haven't had new treatment mechanisms in schizophrenia for many years now."
The two freely admit the gaps between their ambitions and what they know so far. The study is preliminary, qualitative work—a follow-up brain-imaging study is in the works—and they did only interview a small number of people. Psychics, they say, are not so easy to come by.

Luhrmann speculates that most of the psychics are experiencing something separate from psychosis:
"I think it's also true that there are people who have psychosis who manage it such that they don't fall ill and avoid this stigma and who really function effectively." This difference aside, she says, "it may still be possible to learn from people who have more control over their voices. .... to think about how to teach people."
At least as subtext, Powers and Corlett's study might suggest a kind of chicken-or-egg question: Were the psychics insulated from suffering because they were socialized to accept and cope with their voices, and were the psychotic patients suffering because they weren't? The better question is: to what extent were the two groups experiencing the same thing?

Shinn believes the fact that far fewer diagnosed participants were employed at the time of the study (25 percent, versus 83 percent of the psychics), and that the diagnosed participants experienced more symptoms of psychosis, suggests that they were suffering beyond the point of being useful comparisons. She thinks, rather, that a "constellation" of symptoms—not just auditory hallucinations or the stigma associated with auditory hallucinations—explain the difference in functionality. "The Powers study provides interesting results with potentially helpful clinical implications," she added, "but they compare very different groups."

Shinn, Powers, and Corlett are all adamant that people who hear voices and experience psychological distress shouldn't turn away from conventional psychiatric treatment, and that a "symptom"—in this case, voice hearing—only calls for clinical attention if it is a cause of suffering. But for those who are distressed, the level of understanding of their experience and the treatments available to them are still lacking. As Powers notes, many of psychiatry's more effective drug treatments were developed by accident. Shinn likens the current body of knowledge of schizophrenia to a group of people describing different parts of an elephant while looking through a high-power lens: There are robust bodies of work on the trunk, the tail, and the ear, but no clear picture of the entire animal.

Shinn's all too aware of the ways in which the diagnosis can overshadow the patient.
"There have been psychiatrists," she says, "who will tell a patient: You have a diagnosis of schizophrenia and you need to modify or adjust your goals in life, forget grad school, forget that Wall Street career," Shinn said. "And that absolutely can be compounding and impairing. I don't disagree that that's a problem."
As Luhrmann put it:
"Are those cultural judgments the cause of the illness? Absolutely not. Do those cultural judgments make it worse? Probably."
Jessica doesn't live near the center anymore. While she'd love to find fulltime work as a medium, she says, she's focusing on her graduate studies to become a dietitian for now.

Still, she's grateful for the community she found at the center, she says, and for the help they gave her.
"I cannot imagine having no control over this," she told me. "I don't know, if I never went to the center, maybe I'd be diagnosed with schizophrenia."
* This article originally stated that Charles Fernyhough hears voices himself. We regret the error.