Most of us have come across the odd person on the street mumbling to themselves, as if they were engaging in a conversation with someone else.
They often appear totally preoccupied with their invisible companions, yet somehow confused or even distressed at times.
What would your reaction be if I told you the most likely reason for their erratic behaviour is that they are hearing voices, or as the medical professionals would say, experiencing auditory-verbal hallucinations?
Most of us would not hesitate to call such individuals ‘mad’.
Perhaps those of us who avoid their glances and consider them weird or even dangerous have good reasons to believe so. Surely, nothing defines madness better than hearing voices. Nothing erodes our very sense of self more fundamentally than losing touch with reality.
Naturally, we are afraid of ‘those mad people’ who have lost touch with reality, who act as a constant reminder that it could – no matter how unlikely – happen to us one day as well.
What if I also told you that normal people can hear voices too? What would your reaction be then, if I told you there is no clear demarcation between ‘us normal people’ and ‘them’?
Of course, I am not denying the fact that hearing voices can be extremely distressing and cause no end of problems to one’s daily functioning. Many people who hallucinate have a diagnosable psychotic illness, but there are far more people out there who do not need any kind of psychiatric care – yet hear voices constantly.
My PhD research focuses on the ‘at-risk mental state’ of psychosis, the critical period before developing a psychotic illness such as schizophrenia, which is often characterised by subtle changes in one’s thoughts and perceptions.
However, this is far from the full story. The majority (over 60%) of individuals with these risk factors will never transition to full blown psychosis, and these are the people who have sought help from psychiatric services. Compared to everyone with unusual experiences, those who eventually go on to receive a diagnosis are, in fact, the minority.
I am also a member of the International Consortium on Hallucination Research (ICHR); together with colleagues from ‘Hearing the Voice’ project at Durham University and also many others worldwide, we have published a series of Open Access papers on hallucinations. One of them is called ‘Auditory Verbal Hallucinations in Persons with and without a Need for Care’.
We found that the most important factors differentiating individuals who need psychiatric input and those who do not are not the presence of voices themselves, but how much distress the voices cause (usually linked with high emotional negativity in voice content) and how much control the individual has over them.
It shouldn’t be counter-intuitive that you would not cope very well if you have very little or no control over the voices that are constantly tormenting you. Indeed, when we think of ‘mad people’ these are the cases we refer to, not the ‘normal’ ones who just get on with their lives.
In other words, there is a bias to the image and representation of ‘hearing voices’. When we do not understand something, many of us either romanticise or stigmatise the phenomena in question.
Hearing voices is of no exception. People are afraid to seek help when it becomes a problem because people are afraid of those who seek help. Portrayal of ‘the mentally ill’ in the mass media seems to dichotomise into either the mad genius or the psychotic killer.
The middle ground – those who hear voices and also function well – receives no recognition because there is no ‘thrill’ associated with healthy voice-hearing.
In the first year of my PhD, I carried out various cognitive tasks about learning and memory in over a hundred healthy individuals who are highly intelligent and function extremely well. They included undergraduate and postgraduate students as well as junior members of staff at Cardiff University.
Yet almost every one of them also reported having various levels of unusual experiences, sometimes frequently. Clearly this does not make them all ‘mad’.
In fact, if all those who heard voices were labelled mad, there wouldn’t be many normal ones left amongst us. Granted, a proportion of them will go on to experience mental health problems. But that is just statistics, probabilities to which we are all susceptible.
Even in people who are at high genetic or environmental risk to developing psychosis (such as those who have experienced severe traumatic events), there is no single factor that predicts future illness with perfect accuracy. Hearing voices certainly is not such a factor.
So what about those who hear non-stop persecutory voices which dominate their entire life? Those who do not respond to treatment? Surely they must be mad!
To me, labelling someone in clear need of psychiatric help ‘mad’ is like calling someone with terminal cancer ‘a failure in cellular proliferation’. Sounds absurd, doesn’t it? One’s symptom does not define the suffering individual. Just like we all have cellular proliferation mechanisms, every single one of us also has the potential to ‘go mad’.
I am not scare-mongering, neither am I offering false hopes and promises. Just like some people die from cancer others never fully recover from psychosis. But this does not mean we should treat them any differently.
The next time you hear someone call your name, only to find no one is there when you turn around – perhaps, think to yourself: have you crossed the boundary between ‘normality’ and ‘madness’? Perhaps we should all think twice before drawing that line.