Yesterday I had the opportunity to facilitate a moderately sized focus group on voices & psychosis at the CMHC where I work (another group is scheduled for next week and then follow-up interviews). I was particularly stoked by how the group went given that the participants involved were on the far side of the class spectrum from the bulk of interviewees for my parallel phenomenology of unusual experiences project (in which about 70% of participants have at least an MA and most would describe themselves, whether formally trained or not, as “intellectuals”) . Yesterday, conversely, I had the opportunity to speak with folks who have been entrenched in the US public mental health & welfare systems for most of their lives; Vietnam vets; former “gangbangers;” forensic patients; addicts in recovery; 95% black or Latino, and so on.
In spite of these differences, most of the same themes I’ve tapped in my phenomenology study quickly emerged: the profound heterogeneity of “voices,” of explanatory conceptual frameworks, of treatment preferences; deep-rooted definitional and discursive limitations (in the status quo conceptualization of psychotic ‘symptoms’) that clinicians and researchers are only beginning (if that) to take seriously.
Although focus groups almost always end up frustrating me (compared to full individual phenomenological interviews), the possibility of immediate quantification and comparison can be very helpful. Yesterday, about three quarters of the group reported—at least some of the time—voices that could incontrovertibly not be described as phenomenological identical to “real” voices (or even sounds); another three quarters said that they nevertheless, at least some of the time, experienced voices with an equally incontrovertibly “auditory” component. Nevertheless, as one participant pointed out, “don’t all thoughts have a sound component?” Another started by describing both his “good” and “bad” voices, but on further probing explained that the good voices were in fact his own thoughts, and thus not ‘really’ voices, whereas thoughts that become unpleasant and challenging or derogatory were (or become) his “voices” proper. Similarly, another older participant explained the difference between the voice of God and the voices of demons in that the latter were more sound-like, the former closer to his own thoughts. “Or perhaps more like a presence.” Others offered distinctions such as “when the thoughts start to race they become voices” or “when the thoughts are no longer controllable they’re voices.”
A smaller (but still substantial) sub-set of participants described their “voices” almost wholly (or at least part of the time) as “presences” or “feelings” rather than articulated words (whether taking the form of voices or thoughts). “I see them,” one participant said, but could not fill in any details as to what he saw; another: “I just know something’s there.” “Maybe it’s just the feeling of being surrounded by people, even when you’re alone”; another ventured that it felt most like the mostly silent figures on park benches or subway cars were simply “trying” to communicate; soundlessly, telepathically. What they could “feel” was really nothing more than the communicative intention.
Religious or spiritual voices seemed to be present about half the time (usually split along these lines in expectable ways with respect to content and messaging), traumatogenic (critical, derogatory) voices the other half. (With just a few people noting that their voices were, of course, instead “symptoms of mental illness.”) A congenitally Deaf participant explained that he had simply never not heard (and seen) voices; they occupy his very earliest memories of childhood.
There are many, many directions to take these observations and insights. At the moment, the most compelling line of analysis suggested (to me, personally) concerns the perhaps culturally ubiquitous overlap between voice (or articulated sound), verbal content, and (for lack of a better phrase) receptive communication. To put it another way, significance or meaning (in the semiotic sense) are perhaps so tied to language (in our culture and perhaps many others) that it may be difficult not to “hear” meaning, even when no “true” external or internal auditory component is involved. (Admittedly, given the inter-imbrication of “top down” and “bottom up” sensory processing, it may never be possible to disambiguate expectations, interpretation and passive processing in the neat ways some scientists would like.)
Further implications? I’ve said it before and will say it again: at least when the full spectrum of voice hearing is considered, I strongly believe that current clinical distinctions between so called voices (or “auditory verbal hallucinations”), “other” hallucinations, passivity symptoms, Schneiderian “thought” symptoms, and delusions will not and cannot stand. In order to re-open the question of what service users are “actually” experiencing, we thus need to move away from research that, in advance of the game, assumes (and naturalizes) categorical or domain-based differences that are likely little more than late Modern cultural artifacts. Instead we should probably be asking, why and how, from the extraordinarily confusing and complex “flux” of psychotic change, are certain culturally-entrained categories, “senses,” and modalities privileged, centered or taken up in explanatory discourse? And what, at the level of both culture and “the individual,” are some of the psychodynamic and psychopolitical (maybe psychobiological or biopolitical) reasons and motivations for doing so?
Doing this—“suspending” or bracketing the obvious, “playing the stranger” to our own cultural assumptions, to our early-learned processing of meaning and sense—is obviously no easy task. But, if we want to do “good” work (whether work in the context of philosophy or neuroscience), do we really have a choice?
As the International Consortium on Hallucination Research rapidly approaches, my curiosity re to what extent my concerns will be (or already have been) taken seriously be the researchers in attendance grows… I will of course be reporting on the gathering.