Last updated 11/06/2007

Head to head:

Is hearing voices a sign of mental illness?

Two psychologists debate the issue: TONY DAVID says yes, IVAN LEUDAR disagrees.

Most people believe that ‘hearing voices’ is a clear sign of mental illness, but this may not be the case.

In a discussion in The Psychologist magazine, published on Tuesday 1 May 2001, Ivan Leudar, of the University of Manchester, argues that hearing voices is not in itself a sign of madness, and that such experiences should be judged as sane or insane in terms of their consequences for life.

He refers to visionaries from the past such as Joan of Arc, claiming that in the present day, ‘the very fact of hearing voices becomes a cause of mental distress, and this is because of the meaning of the experience in our culture, which is grounded in psychiatry.’

Leudar also points out that the media usually associate hearing voices with violence, even though most people who have psychotic experiences are not dangerous.

The psychiatrist Professor Anthony David of the Institute of Psychiatry, London, points out that, ‘a voice-hearer who is not in any distress, who lives a fruitful and productive life according to commonsense criteria, would never even enter the arena in which the possibility of mental illness was up for discussion.’

Admitting that hallucinations may be a source of inspiration or spiritual guidance, David says this is no reason to abandon the search for the biology, physiology and biochemistry of such phenomena (along with their historical and cultural context).

A report, Recent advances in understanding mental illness and psychotic experiences, was published last year by The British Psychological Society. Recent advances in understanding mental illness and psychotic experiences, ISBN 1 85433 333 X, Cost £15, cheque payable to the Division of Clinical Psychology (including postage and packing) from The British Psychological Society, 48 Princess Road East, Leicester LE1 7DR, or the document can be downloaded from the web, address www.understandingpsychosis.com.

Extract:

IVAN LEUDAR

LET me start by proposing the terms of the debate. I do not accept that auditory and verbal hallucinations must be studied only as hallucinations. The term ‘hallucination ’ implies an intrinsic confusion – something subjective is wrongly experienced as ‘real’ – but in fact most voice hearers are not confused in this way. Even before we investigate the experience, the term tinges it with a logically intrinsic pathology where there may be none. The term ‘ hallucination ’also implies that the (social and personal) dilemma is always whether the experience is private and psychological , as opposed to objective and social. This is simply not the case. The question we are to debate is meant to elicit controversy, and it does; but I am not sure it is one to bring out what is most interesting about ‘hallucinatory’ voices. The questions I like are, for instance, ‘Does everybody take hallucinations to be a sign of insanity?’ or ‘ Was hearing voices always a sign of insanity?’; and the answers to these are clearly ‘no’. One should ask what exactly these experiences have indicated, t o who m , and on what grounds. Psychiatry is not in a privileged position here.

Why were these experiences always noticeable and controversial , historically speaking? Not always on the grounds of their intrinsic pathology and confusedness. One historical debate was held by the French Societé édico-Psychologique in 1855. The debate was essentially about how to distinguish hallucinations of the insane from those of artists , visionaries and more ordinary others, but this turned out surprisingly difficult. The comparisons we re made in terms of (i) control over the experiences , (ii) confusing imagination and memories for perceptions, and (iii) confusing private experiences with the shared public ones.

Some argued that hallucinations we re inconsistent with reason, and that visionaries such as Socrates or Joan of Arc we re mentally ill simply because they had them and acted on them. Others disagreed and distinguished physiological from pathological hallucinations. The former we re seen as reasonable – relevant and sensible in content and appropriate emotionally, providing proper grounds for actions. The lesson is to judge hearing voices (and other such experiences) according to whether they are reasonable, and in terms of their consequences for life: in other words, pragmatically.

A second relevant debate concerned the visions of St Teresa of Avila. Her autobiography detailing them in support of her religious practices was examined by the Inquisition, who clearly distrusted visions. They declared that one should be very careful before granting sainthood on their grounds , but they did not see them as signs of insanity. Visions could be categorised as ‘mere imagination’, as ‘the work of the enemy of mankind’ and as messages from ‘the angel of light’; and the assignment into a category was a matter of their consistency with theological dogma and consequences for life.

What I would suggest then is that hearing voices (and the experiences we may cat ego rise as hallucinations) should be judged as sane or insane in terms of their consequences for life. They are not in themselves signs of madness, any more than, s ay, thinking and remembering; even though some people can have bizarre and false memories, and some people think delusional thoughts. The madness of some hallucinations is in their involuntariness, delirious content, falsity, childish terror of the hallucinator: in other words, nothing specific to hallucinating. Epidemiological research implies that hallucinations are not necessarily concomitants of insanity but may happen to people without any psychiatric problems.

My own work implies that hearing voices is intrinsically rather mundane in content and not necessarily deluded or deluding. There is a problem though. We always have experiences under a description, never just the bare experiences. It is possible that hearing voices under the description ‘a hallucination’ and ‘a symptom’ is not so much an indication of mental illness as a cause of psychological distress.