50-to-life: Why the phenomenology of ‘hearing voices’ matters

Interrogation of Joan of Arc (Delaroche)

The experience of “hearing voices” has been reported for millennia, including by people such as Socrates, Joan of Arc, and the Beach Boy’s Brian Wilson.

It can be experienced in the context of a diagnosed psychiatric disorder (e.g., schizophrenia, borderline personality disorder, PTSD, anorexia), a neurological disorder, or by people without any diagnosis who may highly value these companions.

The study of what these voices are like (formally termed their ‘phenomenology’) can give clues as to what may cause them and inform the development of ways to help people distressed by them.

An accurate knowledge of the phenomenology of hearing voices can also be of great importance for other reasons, one of which involves the law.

The case I will describe here to illustrate this point was discussed in a recent paper I co-authored with the forensic psychiatrist, Dr Phillip J. Resnick. He has previously provided consultation in many high profile legal cases including those of the serial killer Jeffrey Dahmer, the Oklahoma City bomber Timothy McVeigh, Theodore Kaczynski aka the Unabomber, and Andrea Yates. Our paper examined how knowing what hearing voices is like can help to determine whether people are faking the experience for perceived gain (formally termed ‘malingering’).

As part of this we examined the role of the phenomenology of hearing voices in the case of Senque Jefferson who, in 2004, came before the Court of Appeals of California, Third District, to appeal against a verdict he had received in a trial two years earlier; a verdict which, per the ‘three strikes law’, resulted in him being sentenced to ‘50 years to life’.

To be clear from the outset, neither that paper nor this blog aimed to give an opinion as to the veracity of the claims of the Defendant in this specific case. Instead they simply aim to show the importance of an accurate knowledge of the phenomenology of hearing voices in relation to a situation where a Defendant claims to have been having such experiences at the time of a crime.

Let’s begin with a bit of background.

 

The background

In 1994 Senque Jefferson was incarcerated in California as a result of being convicted of first degree murder and a series of armed robberies.

Approximately six years later, on the 10th March 2000, he was to be found in the psychiatric services unit of New Folsom Prison in California.

That morning, Jefferson was being escorted back from the exercise yard by two prison officers. As he was about to be put back into his cell he kicked one officer in the stomach, and the other in the leg. Jefferson was in turn then punched by one of the officers, after which Jefferson spat on both. This led Jefferson to be charged with, and ultimately convicted on, two counts of battery.

Later that same year, on the 3^rd July, Jefferson was in the infirmary of Sacramento jail, where inmates experiencing a mental health crisis were housed. He was taken to a holding cell ahead of a meeting with a committee of mental health professionals to review his placement in the infirmary. Eventually the committee decided it would not see him that day, and ordered him to be taken back to his cell in the infirmary. As he was being taken out of the holding cell, Jefferson kicked one of the prison officers twice in the leg. This act formed the third count of battery upon which he was charged and later convicted on. Under the “Three Strikes Law” he was sentenced to ‘50 years to life’.

 

The defence

Why did Jefferson say he did these acts? In relation to the first incident in March, the court documents tell us that his lawyers argued that:

“As the officers placed him in his cell, [the] defendant heard “voices” outside his head. The voices told him the officers would hurt or kill him when he was in his cell, so he kicked the officers to get them off him”

In relation to the second incident in July, his lawyers stated that:

“the voices became loud while he waited in the holding cell, telling him not to leave the cell because the officers would hurt him”

More generally, his lawyers claimed that Jefferson:

“heard voices ‘everyday, all day’…The voices were usually those of women he knew when he was out on the street. They told him such things as his food was poisoned or a family member had died. At the time of trial, he was on medication — involuntarily — that he felt lowered the voices. Although the voices were powerful, he was able to ignore them better.”

 

Phenomenology and the prosecution

The first part of Jefferson’s trial, termed the ‘sanity phase’, involved establishing whether he was sane or insane. Here, Jefferson’s argument that he was hearing voices came under scrutiny. One of the court-appointed psychologists met with Jefferson and asked him to describe the voices he heard in order to “determine whether [the] defendant was faking a psychological problem”. During this Jefferson stated that his voices “were voices of ‘people that he knew in the past’ and were ‘in his ear’”.

This is where phenomenology has direct application. The court-appointed psychologist attempted to compare the location and nature of the voices Jefferson described against what they thought was the typical phenomenology of the experience. The court documents describe how, in the court-appointed psychologist’s experience:

“schizophrenics typically described voices ‘as coming from inside their head and being of either famous people or strangers or groups of people.’ She [the court-appointed psychologist] thus doubted defendant’s claims.”

But does the research literature support the court-appointed psychologist’s description of the phenomenology of hearing voices in people diagnosed with schizophrenia? Let us look at the specific issues raised by the court-appointed psychologist in turn.

 

Assertion 1: Voices are typically heard as coming from inside the head

The largest study of the phenomenology of ‘hearing voices’, published by myself and colleagues in Melbourne (McCarthy-Jones et al., 2014b), interviewed 199 patients who heard voices (81% who had been diagnosed with schizophrenia) and found that 38% heard both voices coming from inside and outside their head, 34% only heard internally-located voices, and 28% only heard externally located voices.

Nayani & David’s (1996) findings

The largest study before ours was performed by Nayani and David (1996) who examined the phenomenology of the voices heard by 100 psychiatric patients (the majority who had a diagnosis of schizophrenia).

You can see their findings pertaining to the location of patient’s voices in the table on the right.

They found that only 38% of patients described their voices as having a voice which was located inside their head, whereas 49% of the sample “heard their voices through their ears as external stimuli”.

 

Since both these studies, a study in 2015 by Angela Woods and colleagues, of 125 people who heard voices people (with a range of, or no, diagnoses), found that “Voices with a physical location were equally likely to be external or internal”.

Clearly, a substantial number of people (with or without a diagnosis of schizophrenia) hear voices that are not located inside their head. 

This variability has led Resnick and Knoll (2008) to argue that the “location of hallucinations should not be used to determine their genuineness”.

 

Assertion 2: Voices are typically those of famous people or of groups of people or those of strangers.

Formal studies reporting on the number of people diagnosed with schizophrenia who identify their voices as being those of famous people are few in number and small in sample. For example, Leudar et al. (1997) found that 6 of 13 people diagnosed with schizophrenia said that their voices were those of public figures.

Larger studies suggest that voices are likely to be of people personally known to the hearer.

For example, Nayani and David (1996) found that “Hallucinated voices were often known to the patient in real life, indicating that they may be modelled on the memory of a real voice.” In their study 46% of patients heard voices which could be identified as likely being real, known people, such as a relative, neighbour, or doctor.

Similarly, Garrett and Silva (2003) found that 46% of patients (the majority of whom had a diagnosis of schizophrenia) “believed they recognized at least one of their voices as a specific friend, family member, or acquaintance”.

My colleagues in Melbourne and I found that 70% of patients reported that the voices they head were like those of people who had spoken to them in the past (McCarthy-Jones et al., 2014b).

The wider voice-hearing literature is also replete with examples of people hearing voices of people they personally know and have actually encountered in the past (e.g., Romme et al., 2009).

In terms of groups of voices, although Nayani and David found 57% of patients described hearing the sounds of crowds of people mumbling or talking together (in addition to individualised voices), we (McCarthy-Jones et al., 2014b) found that 53% of patients had never heard all their voices speak at the same time (like a chorus).

 

Conclusion

Doubt was cast on Jefferson’s voice-hearing experiences because they did not resemble a characterisation of voices as typically “coming from inside their head and being of either famous people or strangers or groups of people”. I would argue this is a flawed yardstick against which to measure people’s voice-hearing experiences, given the research reviewed above.

By noting this, I am not offering an opinion as to whether or not Jefferson was actually hearing voices (this cannot be determined from a review of court documents) I am simply noting that the stated phenomenology of voice-hearing used in the courtroom appears flawed.

This is just one way in which phenomenology could be used in the court room in relation to voice-hearing. For example, it could have been asked whether or not the changes Jefferson reported to the phenomenology of his voice-hearing experience after taking antipsychotic medication was consistent with the typical experience of patients.

Recall that Jefferson claimed that the:

“medication… he felt lowered the voices. Although the voices were powerful, he was able to ignore them better”

Now, consider one of the earliest reports of how antipsychotics affected the phenomenology of patients’ voice-hearing experience. A 1954 study by Elkes and Elkes found that chlorpromazine did not make voices disappear, but only made patients less bothered by them. Patients didn’t shout and scream at their voices as much. One patient stated that his voices ‘did not worry him so much’

Or take a more recent example from a statement by the respected Shitij Kapur and colleagues (2005) who explain:

“Antipsychotics do not eradicate symptoms, but create a state of detachment from them… it is widely known that for most patients antipsychotics provide only partial remission – and many aspects of psychosis as well as other aspects of the illness remain untouched. While some patients do actually achieve complete resolution of their delusions and hallucinations with antipsychotic treatment, for many patients a detachment from their symptoms is as good a resolution as antipsychotics can provide.”

It is hence clear that in situations such as that described above, a correct knowledge of the phenomenology of ‘hearing voices’ may be of paramount importance. Furthermore, dependent on the circumstances in which it is applied, it may even be a matter of life and death.

 

References and further resources

Appeal document referred to here:

• 2004 appeal (People v. Jefferson)

References

Elkes, J. et al. (1954). Effects of chlorpromazine on the behaviour of chronically overactive psychotic patients. British Medical Journal, 2, 560–76.

Garrett, M., & Silva, R. (2003). Auditory hallucinations, source monitoring, and the belief that “voices” are real. Schizophrenia Bulletin, 29(3), 445-457.

Kapur, S. et al. (2005). From dopamine to salience to psychosis – linking biology, pharmacology and phenomenology of psychosis. Schizophrenia Research, 79(1), 59–68.

Leudar, I., Thomas, P., McNally, D., & Glinski, A. (1997). What voices can do with words: pragmatics of verbal hallucinations. Psychological Medicine, 27(04), 885-898.

McCarthy-Jones, S., & Resnick, P. J. (2014a). Listening to voices: the use of phenomenology to differentiate malingered from genuine auditory verbal hallucinations. International Journal of Law and Psychiatry, 37(2), 183-189.

McCarthy-Jones, S., Trauer, T., Mackinnon, A., Sims, E., Thomas, N., & Copolov, D. L. (2014b). A new phenomenological survey of auditory hallucinations: evidence for subtypes and implications for theory and practice. Schizophrenia Bulletin, 40(1), 231-235.

Nayani, T. H., & David, A. S. (1996). The auditory hallucination: a phenomenological survey. Psychological Medicine, 26(01), 177-189.

Resnick, P. J., & Knoll, J. L. (2008). Malingered psychosis. In R. Rogers (Ed.), Clinical assessment of malingering and deception (pp. 51–68). New York, NY: Guilford Press.

Romme, M., Escher, S., Dillon, J., & Corstens, D. (2009). Living with voices. 50 stories of recovery. Ross-on-Wye: PCCS Books.

Woods, A., Jones, N., Alderson-Day, B., Callard, F., & Fernyhough, C. (2015). Experiences of hearing voices: analysis of a novel phenomenological survey. The Lancet Psychiatry, 2(4), 323-331.

Further resources on hearing voices

• Intervoice: The International Community for Hearing Voices.
• Eleanor Longden’s TED talk: The voices in my head.
• Romme, M., Escher, S., Dillon, J., Corstens, D., & Morris, M. (2009). Living with voices: 50 stories of recovery. Ross-on-Wye: PCCS Books.
• McCarthy-Jones S. (2017). Can’t you hear them? The science and significance of hearing voices. London: Jessica Kingsley.
• The Hearing the Voice project at Durham University.