Following our initial call for two perspectives of ‘The Voices Within,’ we are pleased to publish the first review by Marie C. Hansen. The accompanying review will be published in due course.
The Voices Within by Charles Fernyhough offers an engaging and informative look at an aspect of our experience that typically goes unexamined — our thoughts. In fact, the very process of reading the book provokes an uncanny response, as it inevitably forces the reader to pay attention to the experience of their own inner dialogue. Fernyhough directly engages the reader in this process by offering the following exercise:
Now ask yourself some more questions about the thought you just had. Did it sound like a person speaking? If so, was that person ‘you’? … Would you recognize it if it happened again? How do you know that it was your own? (P. 19)
These questions have particular relevance for me — I am a trainee clinical psychologist who works with people experiencing psychosis. My interest in reading The Voices Within was prompted by two clinical questions: How can ‘typical’ inner speech help us understand ‘unusual’ voice-hearing experiences? And how can this inform therapeutic practices for working with individuals experiencing distressing voices?
Fernyhough’s understanding of inner speech is influenced by the work of Lev Vygotsky, a developmental psychologist who viewed the ‘self-talk’ of a child playing as a form of planning and a way to move into physical action. He positions inner speech as an internalization of this self-talk, and sees thought as dialogical, sharing the same interactional styles and features as conversations we have with others. What makes this important for understanding voice-hearing in psychosis, is that although the experience may be perceived as unusual, it is most likely a variant of common human experience. We all hear voices to some degree, since we are all in constant dialogue with ourselves. Fernyhough examines how some of the areas associated with self-authorship of inner speech — such as the supplementary motor area (SMA) — show less neural activation during a hallucinatory experience (described as the brain “seeing” or “hearing” itself). This concept corresponds with the theoretical work of Sass and Parnas, who view the dual processes of “hyper reflexivity,” or exaggerated awareness of the self, and “diminished self-affection,” or the weakened awareness of one’s agentic qualities, as the fundamental disturbances in psychosis (Sass and Parnas 2003). As such, The Voices Within provides a destigmatizing look at voice-hearing in psychosis. Indeed, Fernyhough is keen to compare and contrast voice-hearing in psychosis to all the varieties of inner speech, from the creation of literary characters, to reading a novel, to laughing at daydreamed jokes. Although the primary focus is on thought more broadly, Fernyhough periodically returns to the topic of individuals who hear voices, contextualizing their experiences within the greater notion of inner speech.
Drawing on previous research, much of which builds on the work of the international Hearing Voices Movement, Fernyhough acknowledges that for voice-hearers, it is often not the voices themselves that are distressing, but the ways in which they are thought about and experienced relationally. He hypothesizes that our inner speech is derived not only from our own experiences, but also from the ‘thoughts, feelings, and attitudes of the people with whom we share our world’ (2016: 76). This concept is particularly relevant for understanding trauma-informed theories of psychosis, as voice-hearers seeking psychotherapy often experience their voices as hostile, abusive, and domineering. Fernyhough expands upon this concept by asking members of the Hearing Voices Network about their experiences of voice-hearing, connecting the experience to the concept of dissociation. Importantly, in addition to peer-support, this aspect of the book has implications for the psychodynamic treatment of psychosis, a modality often shunned for use with individuals diagnosed with schizophrenia or what is commonly termed ‘severe mental illness.’ For example, theories on dissociation and voice-hearing are compatible with the work of Philip Bromberg, an American psychoanalyst interested in concept of ‘multiple self-states,’ both in healthy development and dissociated self-states resulting from trauma (Bromberg 1996). Bromberg’s approach to therapy is predicated on helping people recover lost elements of their experience, a theory in keeping with Fernyhough’s description of the Hearing Voices approach.
The Voices Within stresses the importance of gaining knowledge by attending to the subjective reports of people who hear voices. For example, in Chapter Eight, we meet Jay, a dance-instructor who can hear the voices of three different disembodied individuals. Fernyhough expands on his own concept of inner speech in these instances, while also acknowledging differences — one of Jay’s voices takes the form of a memory, while other times Jay’s voices cannot be heard, but are experienced as physical presences. Fernyhough describes how Jay is undergoing Cognitive Behavioral Therapy (CBT) to help him understand the emotional and psychological processes that underlie his voice-hearing experiences. One of the key things that Fernyhough highlights is how CBT has helped Jay gain control over his voices. For example, by ‘time-guarding’ so that he will only listen to the voices at a certain time each day. Although many clinicians (particularly researchers) base psychotherapy outcomes on a reduction of voices, The Voices Within shows that we may be off the mark — it is not often about reducing or “getting rid” of voices, but changing the voice-hearer’s relationship towards their voices. To eradicate voices is problematic, firstly because for many people voices have positive qualities, and secondly because silencing them in this fashion seems to be contingent on intentionally inducing a dissociative split.
One of the most important elements of The Voices Within is its interdisciplinary approach — no single perspective or ‘voice’ receives privilege over another, as Fernyhough tackles the subject of inner speech across neuroscientific, theological, historical, literary, cultural, and lived perspectives. Strikingly, the format of the book, as well as the implications of the theory, correspond to one therapy that has been gaining a great deal of attention for the treatment of distressing psychosis: Open Dialogue. This community-based group therapy is guided by a founding principle of ‘polyphony’ or “the co-existence of multiple, separate, and equally valid ‘voices’ or points of view, within the treatment meeting” (Olson, Seikkula and Ziedonis 2014: 5). Perhaps herein lies the crucial element for helping those who hear distressing voices — gaining some measure of inner peace depends on allowing for the inevitability of discord. Within my own practice of psychotherapy, I have found a commitment to the multiplicity of meaning to be essential when working with individuals, as they learn to tell their story and make sense of confusing or painful experiences. In this light, the need for multiple perspectives and communal dialogue about voice-hearing within academic discourse seems essential. The Voices Within offers a significant contribution in this direction.
Reviewed by Marie C. Hansen, a postgraduate research student in Clinical Psychology at Long Island University Brooklyn. Marie is the co-editor (with Marilyn Charles) of ‘Women & Psychosis: Multidisciplinary Perspectives’ (Routledge, 2017), and she is an active member of Hearing Voices Network NYC and interested in the phenomenological experience of voice-hearing in postpartum psychosis.
Bromberg, Philip. 1996. Standing in the spaces: The multiplicity of self and the psychoanalytic relationship. Contemporary Psychoanalysis, 32: 509-535
Olson, Mary, Seikkula, Jaakko, Ziedonis, Douglas. 2014. The key elements of dialogic practice in open dialogue: Fidelity criteria. Worcester, MA: The University of Massachusetts Medical School.
Sass, Louis and Parnas, Josef. 2003. Schizophrenia, consciousness, and the self. Schizophrenia Bulletin, 29(3): 427-444.