Hearing voices: Listening to voice hearers outside the justice system

I read a book last weekend on the subject of hearing voices, titled "Muses, Madmen, and Prophets: Rethinking the History, Science and Meaning of Auditory Hallucination," by Daniel Smith. Anybody who pays much attention to the justice system sees stories all the time, sometimes tragic, of people hearing voices, and this book offered a fresh, sympathetic perspective.

The author had a personal motive for exploring the topic: His father and grandfather heard voices, though he and his siblings do not. For his father in particular, a successful Long Island attorney, it was a source of personal humiliation that he rarely discussed. While most people, myself included, associate voice hearing with schizophrenia, Smith says it can result from a number of different diagnoses and isn't well understood at all, in part because of "pathologizing" the phenomenon beginning in the 19th century.

In other words, people think you're crazy, so people who hear voices tend to keep it to themselves. Most of these folks commit no crimes, ever, and don't get wrapped up in the justice system. In Europe, a network of voice-hearers has sprung up to help folks accept voices and learn to cope, he reports, whereas most modern psychiatrists would prefer to medicate them away.

In centuries past, however, the phenomenon was more commonly recorded, says Smith, all the way back to (and especially including) the ancient Greeks. Indeed, my favorite part of the book was Smith's argument that Socrates' trial was primarily focused on his reliance on a "personal deity," or a voice that ancient authors recorded spoke to the great teacher that other couldn't hear. Another chapter investigated Joan of Arc's voice hearing and visions, which of course instructed her to engage directly in armed conflict.

Despite the wonders of modern science, the brain remains a poorly understood thing, but increasingly it's clear that much of its activity is self-referential. We think of "sight," for example, as gathering information from the outside world through visual cortex, but most of the information making up those images comes from our memory. Similarly, voice hearing can range from something audible like a voice from a tangible person elsewhere in the room, to a silent compulsion, like words repeated in your head when you're memorizing a poem. Smith analogized the sensation to a phantom limb a patient still feels after amputation: Voices seem real to voice hearers, even when they know they're not.

Many voice hearers obey their voices' commands when they don't think it's harmful, Smith reports. His grandfather tried to use them to bet horses. Others with an obsessive compulsive bent may be told to straighten place settings at dinner or clean their house. Apparently this is not uncommon and presumably is only a problem when the voices start saying things like "Attack that young mother" or "Kill your children." Smith emphasized that most people who experience voice hearing, however, don't remotely ever get to that point and all this give and take with silent conversants for the most part goes on in secret.

For much of human history, such internal conversations were likely to be seen through a spiritual lens - most often as prayer or, negatively, as witchcraft - and the experience was as frequently valued as denigrated. A recurring aspect of voice hearing, says Smith, both historically and in the present day, involves religious themes and even direct communication with "God," as typified by examples from the Dallas County Jail to Socrates, and on to Abraham, Joan of Arc, and Andrea Yates.

Perhaps relatedly, Smith described examples of voice hearing, divine and otherwise, where the person involved drew comfort from the experience and didn't want it medicated away. Often people hide what is happening because they know modern medicine would view it as a disease and try to strip away an experience that carries significant meaning for them.

That aspect fascinated me because the justice system basically views "success" in this arena as keeping folks "on their meds." But Smith's book observes that most voice hearers, for most of human history, found ways to cope without the use of antipsychotic drugs. After all, Abraham listened to and obeyed what he presumed to be the voice of God, but withdrew his knife before plunging it into Isaac. While a handful of spectacular incidents dominate these conversations, mentally ill people overall are statistically no more likely to commit crimes than the "sane."

If I had one critique, it's that I'd like to have heard more from Smith about how the justice system treats voice hearing - beyond what a German court ruled in a famous case in the 1890s. And a discussion of voice hearing and post-partum psychosis - evidenced by Andrea Yates drowning her children in its most extreme form, but more common than most people know - would have been a welcome addition to the collection of examples he provided.

OTOH, in a way staying away from those hot-button examples to look at the phenomenon more sympathetically perhaps allowed him to articulate his views free from justice-system dogma, which thinks poorly of voice hearing, as a rule. Generally, the justice system believes it's succeeded only when the voices are extinguished. There are instances, though, where "success" might be reasonably redefined as preventing a worst case scenario.

Smith's book makes me think it's possible that pathologizing mental illness contributes to our continued flailing on "what to do" with these individuals: To institutionalize? To manage, medicated, in the community? If so, with what enforcement? Maybe these are false choices? Perhaps there's merit to building on the successful experience of those, like Smith's father and grandfather, who cope successfully with voice hearing, teaching the skills they use rather than instantly, exclusively relying on drugs? That might mean not always stigmatizing the experience as pathological or criminal, but let's face it: By all appearances, just drugging the symptoms away isn't working that great, anyway.

If Smith is right, it has implications for how voice hearing is treated in the justice system, perhaps complementing research that indicates mental illness is not a primary criminogenic factor. That implies that mental health professionals in the justice system should rethink their goals with an eye toward long-term stability, reinforcing family support, rapid crisis response, and an understanding that the "crisis" might end, but voice hearing may not.