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Psychology and Psychotherapy: Theory, Research and Practice (2003), 76, 189209 2003 The British Psychological Society www.bps.org.uk

A Q-methodological study of hearing voices: A preliminary exploration of voice hearers understanding of their experiences
S. Jones, A. Guy and J. A. Ormrod*
Hartlepool, UK
Using Q-methodology and structured interviews, this preliminary study set out to explore how a diverse range of voice hearers construed their experience of hearing voices. Following factor analysis of 20 completed Q-sorts, six factors emerged. Pejorative media stereotypes about voice hearers were rejected, and despite the dominance of the biomedical model in our culture, on no factor did participants adhere to all of the biomedical concepts. All six factors endorsed some elements of psychological discourse on voice-hearing experiences. It is argued that attempting to understand voice hearers within a single theoretical framework may limit or adversely affect engagement and understanding of an individual. Consistent with previous research, users of mental-health services were more likely to nd voices frightening and perceive them as negative experiences than non-users. However, some non-users found managing some of their voices dif cult despite having seemingly positive beliefs about the experience of hearing voices. Comment is made on the potential therapeutic implications of this study along with some acknowledgement of its limitations.

Hearing voices speaking when no one is there is often conceptualized in Western culture as indicating serious mental illness. Reports of ongoing voices by an individual, in situations not related to drug use, sensory deprivation (Zuckerman &Cohen, 1964) or sleep beginnings or endings (McKellar, 1968), are often taken as presumptive evidence for the presence of schizophrenia (Kaplan & Sadock, 1985), a disorder within the broader category of psychotic conditions (American Psychiatric Association, 1994). DSM explicitly recognizes hearing voices frequently as one of the characteristic -IV indicators of schizophrenia alongside a constellation of other symptoms (American Psychiatric Association, 1994). From this predominantly biomedical perspective, psychotic symptoms, including hearing voices (auditory hallucinations), are inherently meaningless (Berrios, 1991; Jaspers, 1962). For the practitioner within this tradition,
* Requests for reprints should be addressed to John Ormrod, Stewart House, 53 Church Street, Hartlepool TS26 7ED, UK (e-mail: john.ormrod@tney.northy.nhs.uk).

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exploration of the content and meaning of voices to the individual, beyond that which is considered necessary to establish rapport and make a diagnosis, may not be required (Leudar & Thomas, 2000). Historically, however, the experience of voice hearing has sometimes been considered to be rich in meaning and positively valued as a source of creative or even divine guidance (Al-Issa, 1978). In uential world gures such as Mahatma Gandhi were reported as relying on voices for inspiration and authority (Heery, 1989). Similarly in , some cultures, people hearing voices continue to be regarded as gifted. For example, in the Xhosa culture of South Africa, voice hearers are trained to become indigenous healers (Sodi, 1995). Certain schools within psychology have also challenged the proposal that such phenomena are meaningless. Freud held that voices had meaning and were the result of intra-psychic con ict and a return to the defensive functioning of early childhood (Freud, 1924). Accusatory voices were perceived as stemming from a harsh super-ego expressing criticism towards the drives of the id, and advisory voices were understood as stemming from the both the ego and the super ego. Some psychoanalytic theory draws attention to the similarity between hallucinations and dreams, and it has been suggested that both express, sometimes metaphorically, wishes that may be unacceptable to the conscious mind. For example, in Jungian theory, an emotional complex (a set of feelings) can become overpowering, break away from the psyche and take the form of voices or visions that speak to the person (Jung, 1939). Jung (1969) also advocated that each of us is in touch with the unconscious spiritual life of all other people, the collective unconscious, at the deepest level of our psyche and spoke of voices as the call of a higher principle (Assagioli, 1973). Recent cognitive research has addressed the relevance of the self in psychosis and develops the psychoanalytic idea of hallucinations functioning as defences (Bentall, 1990; Haddock, Bentall, & Slade, 1993; Kinderman, 1994). Thus, Bentall, Haddock, and Slade (1994) argue that voices may externalize certain mental events which otherwise would be experienced as a threat to the self (Chadwick, Birchwood, & Trower, 1996). This account ts with cognitive dissonance theory (Festinger, 1957) where attributing thoughts to an external agent may prevent dissonance as personal responsibility is removed (for example, god told me to), and guilt, self-blame, or anger can be avoided (Hingley, 1992). Cognitive theorists have also acknowledged the role that emotional disturbance may play in the development and maintenance of psychotic symptoms, such as hearing voices (Fowler, Garety, & Kuipers, 1995). Hearing voices may be a meaningful response metaphorically expressing emotionally undigested events related to relationships and life events (Fowler et al., 1995; Haddock et al., 1993; Honig et al., 1998; Romme & Escher, 1989). Consistent with this is evidence of people hearing voices, subsequent to trauma, for example, soldiers after war, victims of torture (Romme & Escher, 1993), and following sexual abuse (Ensink, 1994). It has also been shown that voices may disappear when underlying problems are resolved or integrated (Escher, Romme, & Buiks, 1998; Hulme, 1996). Most recently, psychological understanding in the Western world has shifted towards the normalization of psychotic symptoms, including hearing voices (British Psychological Society, 2000; Thomas & Leudar, 1996). Research has emphasized how people hear voices in the general population, even when there is no evidence of psychiatric illness (Eaton, Romanoski, Anthony, & Nestadt, 1991; Posey & Losch, 1983; Romme & Pennings, 1994; Tien, 1991). It has been claimed that the mechanisms that produce and

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maintain voices can be understood in terms of ordinary psychological principles (Hingley, 1992; Maher, 1988) and that hearing voices should not be judged, in itself, as a sign of madness, any more than thinking or remembering (David & Leudar, 2001). Voice hearing therefore can be perceived as being on a continuum with normality consisting of a seamless graduation from absence of symptoms, through degrees of eccentricity, to serious problems (British Psychological Society, 2000; Clarke, 2001). Like professionals in the eld, voice hearers themselves often look for a theoretical explanation to account for the existence of their voices. Romme and Escher (1993) invited voice hearers to contact researchers, after the broadcast of a television programme about hearing voices. They described how many individuals who contacted them adopted a theoretical frame of reference, such as parapsychology, reincarnation, metaphysics, the collective unconscious or the spirituality of a higher consciousness. (Romme & Escher, 1993, p. 7) Researchers have asserted that voice-hearing experiences are more accessible to individuals who are psychologically open to them or to those who hold interests in the spiritual realm (Heery, 1989; Jackson, 1997; Peters, Day, McKenna, & Orbach, 1999). Some voice hearers use prayer and meditation to facilitate contact with voices, suggesting that intention can be an important aspect of some individuals relationship with their voices (Heery, 1989). Chadwick (1997), talking of his own psychotic experiences, likened the early euphoric stage of psychosis to the beginning of a spiritual enlightenment. His personal belief was that productive use could be made of such experiences. Understanding the range of beliefs that voice hearers hold about their voices should therefore be of great importance to researchers and clinicians. It has been shown that an individuals distress about their voices may be related not to the content of the voices but to beliefs about their origin, identity, and purpose (Chadwick & Birchwood, 1996). It has been claimed that the voices and visions experienced by both mental-health service users and non-service users are similar, irrespective of diagnosis (Honig et al., 1998). Two factors reported to distinguish voice hearers who do not use services from those who do are the degree of distress caused by the experience and the extent to which these experiences are seen as normal (Romme & Escher, 1993). It has also been claimed that beliefs about voices have an important in uence upon how voice-hearing experiences are maintained (Chadwick & Birchwood, 1996). Such ndings emphasize the importance of therapy addressing where the client perceives the voices to be coming from and their beliefs about their experiences. The need for a clearer understanding of voice hearers own accounts, beliefs and views about their experiences has been recognized (Leudar & Thomas, 2000; Thomas & Leudar, 1996), and valuing and respecting the clients perspective is important for therapeutic engagement (Barker, 2000). This preliminary study uses Q -methodology to address the following question: Why do voice hearers believe they hear voices, and how do they make sense of their experiences?

Method
Brief overview of Q-methodology Q -methodology was devised by Stephenson (1935, 1953) as a simple alternative methodology to those employed in traditional psychometric assessment. The research

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instrument is the Q -sample, a collection of items, usually in the form of statements that represent the broadest possible variety of attitudes and/or perspectives on a topic. Participants rank order each Q -sample item along a continuum of signi cance from most agree ( 5) to most disagree ( 5), according to how accurately it represents their view. The arranged statements comprise a Q -sort re ecting the participants viewpoint within the boundaries of the quasi-normal distribution grid provided. This approach to evaluating a large set of statements means that participants avoid having to repeatedly apply ranking scales, and it also diminishes the possibility of halo effects or biased response patterns emerging. The forced distribution design of the Q -sort obviously means that each statement must be allocated to one of the spaces in the grid so that each complete grid can be mapped/compared in relation with every other. This potentially constrains responses in that participants may have to distinguish between statements that they feel have the same signi cance (e.g. they may feel that they most disagree with four statements when only two may be placed at the extreme point of the grid). Nevertheless, participants have full control over where each statement is placed, and the range of response choice (extending from 5 to 5) is wider than other mainstream ranking instruments (Stainton-Rogers, 1995). Each completed grid represents an ipsative construction of the Q -sample, where all statements have been rated and organized in relation to each other, thereby maintaining a holistic viewpoint. Q -sorting provides data for factoring. Q -sorts obtained from several individuals can be correlated and are factor-analysed by person rather than the traditional analysis by variables or statements. The resulting factors indicate clusters of individuals who ranked statements in the most similar way as well as indicating dimensions of the phenomenon. Factors are explained and interpreted in terms of commonly shared perspectives. Producing the Q set To design the Q -sort, it was necessary to sample the domain relevant to the subject of investigation as widely as possible. This included reading relevant literature, self-help booklets, and information sheets; sampling popular discourse and the media; and having discussions with voice hearers. Care was taken to recruit a disparate range of discussion participants so as to provide a rich and diverse range of perspectives from which items were selected. Discussions took place with the following voice hearers: eight members of a hearing-voices group (run within mainstream psychiatric services), two individuals who used adult mental-health services who described themselves as having schizophrenia, two who attended spiritualist churches, two who attended evangelical Christian churches and two individuals who neither attended adult mental-health services nor held religious beliefs. A sample of statements is considered representative if it samples the diversity of beliefs adequately, without favouring some to the exclusion of others and without omitting sections of known constructions of belief (Stephenson, 1953). Three broad categories emerged, namely: (1) (2) (3) Biomedical: Items grounded in classical psychiatric understandings of voice hearing. Psychological: Items grounded in psychodynamic and cognitive behavioural understandings of voice hearing. Spiritual: Items grounded in spiritual and new-age explanations for voice hearing.

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The initial sample of 350 statements obtained was reduced to yield a representative and clear set of 45 items, a sample size consistent with reputable studies using this technique (see e.g. Dennis, 1986). Care was taken to ensure that a logical and re exive procedure structured the item reduction. From the original list, the research team noted and eliminated duplicate statements and rephrased complex expressions. Further re nement of the statement set was based on consultation with independent scrutineers, four mental-health professionals, and four laypeople. The professionals had experience of working with clients who had voice-hearing symptoms, and the lay participants were volunteers from the original discussion groups. These participants also helped ensure that items were intelligible and germane to the topic. This process resulted in three categories of statement that included an equivalent number and balance across the statements (Stainton-Rogers, 1995). A nal validation process was undertaken to con rm the validity of the three categories. The statements and a list of the category headings were given to eight clinical psychology colleagues who were asked to read each statement and place it into the most appropriate category. This process led to the con rmation of the nal Q -sample of 45 statements (see Table 1). Participants The decision was made to include a range of voice hearers in this study, including those who do not access mental-health services. Very little research to date has been conducted comparing voice hearers who use mental-health services and those that do not (exceptions include Honig et al., 1998; Romme & Escher, 1993). It has been reported that mental-health-service users experience their voices as largely negative, and most non-service users experience them as largely positive (Romme & Escher, 1999). Furthermore, voice hearers experience is usually accounted for in terms of either pathology or spirituality (divine inspiration or demonic possession). However, very little attention has been paid to individuals who fall into neither group (Heery, 1989). It was therefore felt important to include non-religious individuals in the study who were not using mental-health services. In Q -methodology, sampling is different from that used in conventional methodology. Participants have the status of variables rather than sample elements. For the purpose of the analysis, the sample is each participants set of Q -items (McKeown & Thomas, 1988). The group of participants should include individuals who are likely to hold pertinent viewpoints on the topic under investigation. Within Q -methodology, the breadth and diversity of the participant sample are considered more important than proportionality (Brown, 1996). The host NHS Trust research ethics committee granted ethical approval for the study, and consent was obtained from all the participants after they had been fully briefed about the purposes and nature of the study. Research participants were recruited from a variety of sources, including a hearing voices group, from the caseload of eight community psychiatric nurses, the National Union of Spiritualist Churches, and subsequently two spiritualist churches, one evangelical Christian church and advertisements placed in the National Hearing Voices Network magazine and the Northern Echo newspaper, and on notice boards of the local university, library, and supermarket. The nal sample consisted of 10 men and 10 women whose ages ranged between 27 years and 75 years, with a mean age of 47.3 years. Of these, 11 were currently using mental-health services; four had never sought such help, and the remaining ve had

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Table 1. Q-sample 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. Given the right circumstances, most of us would hear voices People who hear voices are making contact with a different spiritual plane of reality People hear voices when the Devil or other evil spirit possesses them Hearing voices is a life-long condition Hearing voices is a result of stress in vulnerable people People who hear voices have lost contact with reality Voice hearers have an imbalance of chemicals in their brains Voices are divine messages from God, the Holy Spirit, and other guiding spirits Voice hearers listen to the voices of their ancestors People who hear voices are insane Voice hearers are at an advanced spiritual stage Untreated voice hearers are a risk to society Hearing voices is a symptom of mental illness Voices happen when a person mishears actual sounds as being voices Painful memories sometimes imprint themselves on a persons mind as voices Voices can help people cope with problems in their life by giving comfort People who hear voices are psychic or have a sixth sense Voice hearers have a special sensitivity, which allows them to act as a channel or medium for spirits Voices need to be controlled by psychiatric treatment People hear voices when, by mistake, the brain interprets thoughts as voices Voices often disappear when a persons problems are worked through Medication improves the quality of life for voice hearers Voice hearers rise above most peoples awareness and beyond normal experiences Voices are reminders of past-life experiences Hearing voices results from being mentally injured as a child Voices can help a person take action that they have lacked courage to perform People hear voices because they have schizophrenia The messages of voices contain a sensitive awareness of what other people are thinking All people who hear voices need to take medication People may hear voices when a spirit possesses their body Voices bring unsolved problems from the past, into a persons mind Damage in certain parts of the brain causes a person to hear voices People hear voices because of their family genes Witchcraft and curses can bring on voices Voices bring messages from a persons imagination or unconscious mind Many people without mental illness hear voices Voices are the result of a persons brain not working properly The origin of voices relates to the forces of the planets Voice hearers are listening to the voices of the wandering deceased (ghosts) Voices can begin after a major life event Voices may be fantasies to relieve boredom and loneliness Voices are a gift and allow people to develop special abilities People hear voices because they have taken illegal drugs Voices help people think things through so that they can reach solutions to problems Hearing voices indicates a severe personality disturbance

brie y used mental-health services in the past although not necessarily regarding voice hearing. The length of time that voices had been heard ranged from 3 to 57 years, with a mean of 20.6 years. The mean age for the onset of voices was 26.2 years of age. Three of the participants attended a Spiritualist Church, and one attended a non-conformist

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Christian church. Additional details were collected on the onset, nature, and content of voices. Participants were instructed to familiarize themselves with the 45 statements and then sort them into three piles: disagree, neutral/not sure, agree. They were then asked to choose the two statements with which they most agreed from the disagree pile and place them accordingly on a blank grid similar to that illustrated in Fig. 1. They then selected the two statements with which they most agree from the agree pile and placed these on the grid. A similar process continued until all the items were sorted. When sorting was completed, each participant was asked to re-examine the entire array of statements and re-arrange items if they wished. Clinical judgment suggested that no participant seemed unduly confused, distracted, or distressed by the process, and all seemed to have the concentration necessary to complete the task. Alongside the Q -sort, a semi-structured interview was undertaken to complement each participants sort. The interview covered participants demographic details, their use of mental-health services, and information about their experience of voice hearing.

Figure 1. Q-sort grid.

Results
The 20 completed Q -sorts were entered into SPSS (version 8.0) and analysed using factor analysis (principal components). Six factors emerged, which were rotated to simple structure using a varimax criterion. This allowed for the most distinctive features of voice hearers understandings to be highlighted, those which are shared with some voice hearers and differentiated from others. Using an eigenvalue greater than unity (>1.00), the results indicated that the original 20 sets of rankings reduce to six independent orderings, which together explain 69% of the variance.

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Thus, six constellations of beliefs held by voice hearers were differentiated within the completed Q -sorts. Factor loadings for each participant (using pseudonyms) are given in Table 2. Only those participants Q -sorts, which signi cantly and solely loaded on a given factor, were taken to de ne that factor. Signi cance was taken at .45, which is considered to be a rigorous level in Q -methodology (Brown, 1980; Stephenson, 1953). All participants loaded signi cantly on at least one of the six of the factors. As Table 2 reveals, two confounded sorts were identi ed (Maddy and Aaron), which loaded signi cantly upon two sets of factors (factors 2 and 3 and factors 1 and 2, respectively). Although these participants were not used to de ne the factor, their sorts were viewed by the researchers (alongside the de ning sorts) as part of the interpretative process in accounting for the factors.
Table 2. Rotated factor matrix Participant Rod Sam Beth Ray Gary Jo Tom Maddy Dan Pam Aaron Maxine Adam Simon Anthea Anth Theresa Katy Delia Chris Factor 1 87* 82* 80* 78* 73* 68* 58* 65 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6

53 74* 65* 62

50 88* 59* 83* 71* 75* 61* 60* 85* 56*

Note. Decimal points omitted from loadings, which are correct to two signi cant gures (i.e. 0.782 reads 78). a Loadings (participants) used in the next stage of calculation.

Having identi ed which participants Q -sorts de ned each factor, further calculations were conducted to re ect the magnitude of the extent to which each de ning sort contributed to that factor. Each de ning Q -sort was proportionately weighted, and this weighting was applied to each Q -item. The scores for each Q -item were summed and then rank ordered into the original Q -sort continuum which participants had followed in sorting the statements. This produced a best estimate, idealized Q -sort for each of the six factors (see Stainton-Rogers, 1995; pp. 188189). Each idealized Q -sort for each factor is displayed in the so-called factor array (Table 3). The factor array also allows researchers to view how Q -items are distinguished from each other across the factors,

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and this comparative process assists in the interpretation of factors. For example, Item 19; Voices need to be controlled by psychiatric treatment, is ranked as 5 (most strongly disagree) in Factor 1 but as 5 (most strongly agree) in Factor 6.
Table 3. Factor arrays for factors 16 Q-item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Factor 1 1 5 1 0 1 3 2 3 1 5 3 4 3 1 1 3 4 3 5 0 0 2 4 0 2 2 2 1 4 2 1 3 0 0 2 5 3 2 1 2 0 4 1 2 4 Factor 2 4 2 0 1 2 5 3 2 0 1 0 4 0 4 2 5 4 1 2 1 4 3 1 0 3 3 1 2 1 5 0 3 3 1 0 5 3 3 2 4 1 2 2 2 1 Factor 3 1 2 5 5 0 3 0 4 3 5 0 2 1 1 3 3 1 2 1 4 3 0 2 4 0 2 1 2 1 0 5 1 2 4 4 3 3 2 2 1 3 4 2 0 1 Factor 4 2 3 1 3 2 2 0 1 5 5 2 3 1 4 2 2 1 1 2 4 0 3 0 3 4 4 1 0 4 4 5 1 0 2 1 1 2 1 3 0 4 0 5 2 3 Factor 5 0 1 5 0 2 4 4 2 0 4 2 1 2 3 4 2 0 1 4 4 0 5 2 3 1 3 2 2 5 3 3 2 3 1 1 0 1 5 1 1 1 0 3 2 3 Factor 6 1 0 5 2 3 3 2 0 2 3 0 1 5 3 2 1 1 1 5 4 0 2 1 3 1 4 2 4 0 5 2 2 2 2 3 0 1 3 4 4 0 3 4 1 1

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Qualitative analysis was used to identify the perspectives represented by each factor, to clarify the distinct conceptual differences between factors, and to name the factor arrays that re ect participants beliefs. Although it would have been useful to validate interpretations by returning to participants who exempli ed each factor (i.e. those with sorts that most strongly loaded on the factor), this was not practical in terms of either the timescale of the study or the additional demand this would place on participants. Nevertheless, interpretations were informed by the semi-structured interviews conducted during the sorting procedure, alongside the existing literature. An account of each of the six factors is presented below, together with illustrative responses. The factor score for each statement is given in parentheses after the item. Factor 1: The positive spiritual perspective Respondents who loaded onto this factor perceived voices as positive experiences, derived from spiritual sources. They condemned a biomedical framework on voice hearing. They were mildly supportive of some psychological perspectives; thus, they acknowledged the positive psychological functions voices may ful l and the role of stress in the mediation of voice-hearing experiences. As indicated in Table 2, seven participants (Rod, Ray, Tom, Gary, Jo, Beth and Sam) de ned this factor. Also, one respondent with a confounding Q -sort (Maddy) loaded signi cantly on this factor. It accounted for 26.18%of the total variance and was the principal component. This was the only factor that strongly endorsed the following items: 2. People who hear voices are making contact with a different spiritual plane of reality ( 5) 17. People who hear voices are psychic or have a sixth sense ( 4) 23. Voice hearers rise above most peoples awareness and beyond normal experiences ( 4) 42. Voices are a gift and allow people to develop special abilities ( 4) 11. Voice hearers are at an advanced spiritual stage ( 3) 18. Voice hearers have a special sensitivity, which allows them to act as a channel or medium for spirits ( 3) Three participants reported they believed they had always been psychic or clairsensient. Two others explained how they had developed an ability to open themselves up to voices by undertaking relaxation, meditation, or prayer; Beth described her spiritual development, including the ability to hear voices, as a natural progression. They were very critical of pejorative media or psychiatric images of voice hearers such as: 10. People who hear voices are insane ( 5) 12. Untreated voice hearers are a risk to society ( 4) 45. Hearing voices indicates a severe personality disturbance ( 4) They disagreed, more strongly than participants de ning all other factors, that voice hearing indicates a mental-health problem or that voice hearers need psychiatric help: 19. Voices need to be controlled by psychiatric treatment ( 5) 13. Hearing voices is a symptom of mental illness ( 3) 27. People hear voices because they have schizophrenia ( 2) One participant who had received brief counselling in the past (but no other mentalhealth-service input) stated he could choose to hear voices whenever he wished.

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However, he had taught himself to block them out. This is congruent with the stated ability of all participants loading on this factor to take control over their own voices. This is the only factor in which participants disagreed with the following item: 37. Voices are the result of a persons brain not working properly ( 3) The participants who loaded on this factor did not strongly disagree with any psychological perspectives and mildly endorsed most of them. They agreed that voices served functions such as: 16. Voices can help people cope with problems in their life by giving comfort ( 3) 26. Voices can help a person take action that they have lacked courage to perform ( 2) 44. Voices help people think things through so that they can reach solutions to problems ( 2) They mildly disagreed that voices resulted from psychologically traumatic experiences. This is the only factor on which participants disagreed with the following: 25. Hearing voices results from being mentally injured as a child ( 2) 15. Painful memories sometimes imprint themselves on a persons mind as voices ( 1) Interestingly, all the participants who attended spiritualist or non-conformist Christian churches loaded onto this factor. Voices are conceived only as positive for them and most de nitely not as an indicator of mental-health dif culties. They believe that all voice hearers are listening to the voice of spirits but that they overwhelm some individuals who do not understand the experience. Factor 2: Personal relevance perspective The respondents who loaded onto this account related voice-hearing experiences to personal life events within a psychological framework. They strongly acknowledged the role that talking therapies might play in ameliorating voices. They viewed some voices in a positive light. They did not adhere to a biomedical treatment model or spiritual model of understanding voices. Two respondents (Dan and Pam) loaded signi cantly on this factor, as did two others with confounding Q -sorts (Aaron and Maddy). This factor accounted for 15.72%of the total variance. The participants who loaded on this factor support the perspective that voices relate to life experiences. All the individuals who loaded on this factor reported dif cult childhoods with elements of sexual, emotional, or physical abuse, and related this to their voice hearing: 15. Painful memories sometimes imprint themselves on a persons mind as voices ( 5) 21. Voices often disappear when a persons problems are worked through ( 4) 40. Voices can begin after a major life event ( 4) 25. Hearing voices results from being mentally injured as a child ( 3) 26. Hearing voices is a result of stress in vulnerable people ( 2) Item 21 is only strongly agreed with by participants who load on this factor. They indicated that voices could potentially serve various positive functions: 16. Voices can help people cope with problems in their life by giving comfort ( 5) 26. Voices can help a person take action that they have lacked courage to perform ( 3)

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44. Voices help people think things through so that they can reach solutions to problems ( 2) The participants loading on this factor reacted strongly against the following media stereotypes: 6. People who hear voices have lost contact with reality ( 5) 12. Untreated voice hearers are a risk to society ( 4) They disagreed with the need for psychiatric treatment including medication. Their mildly anti-medication stance may be consistent with their response to the following item: 7. Voice hearers have an imbalance of chemicals in their brains ( 3) Spiritual interpretations are not viewed favourably by those who loaded onto this factor. They were sceptical about items that referred to spiritual possession or mediumship and were the only participants who strongly disagreed with the following item: 17. People who hear voices are psychic or have a sixth sense ( 4) However, assertions that voice hearers may have a sensitive awareness to what others are thinking and that voices are a gift that allows people to develop special abilities were considered favourably. This may be because both these items are very positive in nature, and the participants who loaded on this factor are able to maintain an optimistic outlook on voice hearing, despite their own dif cult life histories. Factor 3: Resigned pessimist perspective Respondents who loaded onto this factor feel depressed about their troublesome voices and hold a pessimistic outlook for the future. They acknowledged that voices might relate to problematic life experiences but felt hopeless about the potential of therapy. They used mental-health services but felt disillusioned about them. They did not adhere to spiritual accounts of voice hearing. Two respondents (Maxine and Adam) loaded signi cantly on this factor. One respondent with a confounding Q -sort (Aaron) also loaded on this factor. It accounted for 8.06%of the total variance. The participants that loaded onto this factor accepted some of the pejorative media and traditional biomedical portrayals of voice hearers: 6. People who hear voices have lost contact with reality ( 3) 12. Untreated voice hearers are a risk to society ( 2) 45. Hearing voices indicates a severe personality disturbance ( 1) This is the only factor in which participants agreed with item 6. It is also the factor in which participants most strongly agreed with the item advocating that voices are genetically inherited. These individuals believed that voices are for life: 4. Hearing voices is a life-long condition ( 5) And consistent with this, they disagreed with the following item: 21. Voices often disappear when a persons problems are worked through ( 3) They appeared to hold a resigned and hopeless outlook on the potential for ridding themselves of their voices, despite conceding that their voices may relate to their problematic life experiences: 31. Voices bring unsolved problems from the past, into a persons mind ( 5) 40. Voices can begin after a major life event ( 1)

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Both respondents reported that they heard voices every day and experienced them as extremely distressing. They believed that voice hearers brains are damaged or not working properly. However, they mildly disagreed or were neutral about items that advocated a mental-illness model in which psychiatric treatment would be needed. They may have been disillusioned with psychiatric care. They both reported that they take psychiatric medication and still nd their voices very distressing. Participants on this factor disagreed more strongly than participants loading on other factors about the positive functional roles that voices might play: 16. Voices can help people cope with problems in their life by giving comfort ( 3) 41. Voices may be fantasies to relieve boredom and loneliness ( 3) They agreed with one functional role that voices may play: 26. Voices can help a person take action that they have lacked courage to perform ( 2) However, conversation with Adam revealed that this included the courage to perform suicidal acts. The participants who loaded on this factor were able to accept normalizing perspectives on voices: 36. Many people without mental illness hear voices ( 3) 1. Given the right circumstances, most of us would hear voices ( 1) These participants showed antipathy towards spiritual perspectives. They strongly disagreed with items that promote biblical Christian concepts of spirit possession by God or the Devil. They were disparaging of the concepts of special awareness, mediumship or special psychic abilities. Both respondents loading onto this factor acknowledged that they considered voices to be both frightening and powerful. Their depressed outlook and sense of hopelessness may perhaps be in uenced by the perceived omnipotence of their voices. Factor 4: Pragmatic response perspective The participants that loaded onto this factor understood hearing voices in terms of communication with spirits. Despite not endorsing a psychiatric model of understanding voices, they believed that psychiatric treatment, including medication, was important in the management of voices. They also believed that voices might relate to traumatic life experiences. Table 2 indicates that two respondents (Anthea and Simon) loaded signi cantly on this factor, which accounted for 7.52% of the total variance. The participants who loaded on this factor believed that: 29. All people who hear voices need to take medication ( 4) 22. Medication improves the quality of life for voice hearers ( 3) 19. Voices need to be controlled by psychiatric treatment ( 2) Item 29 was strongly endorsed, and this was the only factor on which participants agreed with this statement. Despite advocating the role of psychiatric medication, they disagreed with psychiatric or media portrayals of voice hearers as insane, out of touch with reality, personality disturbed, or a risk to society. Both participants who loaded on this factor stated that they felt more of a risk to themselves than to others. They mildly disagreed that hearing voices indicated mental health problems: 13. Hearing voices is a symptom of mental illness ( 1) 27. People hear voices because they have schizophrenia ( 1)

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One participant (Anthea) described how she thought voice hearing can be irritated by mental illness, implying that she perceived voice hearing as a different phenomenon. Neither of the participants who loaded onto this factor de ned themselves as being schizophrenic. Anthea used no label to describe why she heard voices, whereas Simon believed that his voices were the result of a rapid ageing process in the brain. Consistent with this, the items asserting that voice hearing may re ect damage to the brain, or the brain not working properly, were supported. The participants who loaded on this factor were the only participants who strongly agreed with the following items: 9. Voice hearers listen to the voices of their ancestors ( 5) 39. Voice hearers are listening to the voices of the wandering deceased (ghosts) ( 3) They also endorsed the items asserting that voices are reminders of past-life experiences and that voice hearers make contact with a different spiritual plane. Therefore, it was evident that they held strong beliefs about the spiritual causation of voices. One respondent elaborated on this and described how he heard the voice of his deceased brother. However, they were disparaging about some other spiritual claims, including those about spiritual possession: 30. 11. 34. 3. People may hear voice when a spirit possesses their body ( 4) Voice hearers are at an advanced spiritual stage ( 2) Witchcraft and curses can bring on voices ( 2) People hear voices when the devil or other evil spirits possesses them ( 1)

Both participants loading signi cantly onto this factor delayed seeking psychiatric help for years after they started to struggle coping with their voices. However, both now used psychiatric services and felt they had bene ted from this help. The participants that loaded onto this factor disagreed with items that imply that voices are self-imposed or illusory: 43. 14. 41. 20. People hear voices because they have taken illegal drugs ( 5) Voices happen when a person mishears actual sounds as being voices ( 4) Voices may be fantasies to relieve boredom and loneliness ( 4) People hear voices when, by mistake, the brain interprets thoughts as voices ( 3)

The participants who loaded on this factor do not believe that hearing voices is a lifelong condition. Their sorting of items indicated that they believed voices related to traumatic life experiences. They do not perceive voices to serve positive functions and disagreed with the following items: 41. Voices may be fantasies to relieve boredom and loneliness ( 4) 16. Voices can help people cope with problems in their life by giving comfort ( 2) 44. Voices help people think things through so that they can reach solutions to problems ( 2) Both Anthea and Simon disagreed more strongly with item 41 and 44 than participants on any other factor. Interestingly, however, they did endorse the following item: 26. Voices can help a person take action that they have lacked courage to perform ( 4) Again, both participants loading on this factor revealed that their voices encouraged them to undertake self-destructive action and hurt themselves, and this is why they

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agreed with this item. They used psychiatric services and took medication for their voice hearing, and perceived this to play an important role in the management of their voices. There is a potential contradiction in that they understood voices in spiritual terms but have bene ted from psychiatric treatment. Conceivably, this is resolved by endorsing the use of medication for non-speci c uses (such as it calms me down or taking it keeps the doctor happy).

Factor 5: Passivity to forces perspective Participants who load on this factor perceived themselves to be passive to the in uence of forces that caused their voice-hearing experiences. They believed that voices are caused by spiritual possession and neurochemical imbalances. This was a powerless perspective. The use of psychiatric services was endorsed. Table 2 indicates that three respondents (Anth, Theresa, and Katy) loaded signi cantly on this factor, which accounted for 6.20%of the total variance. The participants that loaded onto this factor agreed with some psychiatric conceptualizations of voice hearing: 19. 45. 13. 27. 12. Voices need to be controlled by psychiatric treatment ( 4) Hearing voices indicates a severe personality disturbance ( 3) Hearing voices is a symptom of mental illness ( 2) People hear voices because they have schizophrenia ( 2) Untreated voice hearers are a risk to society ( 1)

No participants loading on other factors agreed more strongly with items 19 or 45. The participants who loaded onto this factor all describe themselves as schizo-affective or as experiencing psychosis. Also, they had all used psychiatric services for over 10 years. They believed more strongly than participants loading onto other factors that medication improves the quality of life for voice hearers and also strongly believed that voices need to be controlled by psychiatric treatment. However, they disagreed with the following statement: 29. All people who hear voices need to take medication ( 5) This was the only factor on which participants strongly agreed that voice hearers have an imbalance of chemicals in their brain. They agreed that traumatic or dif cult life experiences were related to the experience of hearing voices. This is consistent with the reports of all three participants loading onto this factor, of abuse being the initial trigger for their voice hearing. They disagreed that voices served positive functions, and they disagreed more strongly than participants on other factors that voices can help a person take action that they have hitherto lacked the courage to perform. The participants who loaded onto this factor were very disparaging of negative media stereotypes about voice hearing. The participants who loaded onto this factor held very strong beliefs about possession by spirits, particularly evil spirits: 3. People hear voices when the devil or other evil spirits possesses them ( 5) 30. People may hear voices when a spirit possesses their body ( 3) They were more tolerant than most of the magico-religious concept of witchcraft and curses. However, they were neutral towards or mildly disagreed with other spiritual conceptualizations. Theresa stated that voice hearers might falsely believe that they are psychic when they are ill.

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Factor 6: Generic mental illness perspective The participants who loaded onto this factor adhered to a mental illness framework regarding voice hearing. They advocated the use of mental-health services and psychiatric medication. They recognized psychological factors that mediate voices, particularly stress and problematic life events. They accepted that voices might be illusory. Table 2 indicates that two respondents (Delia and Chris) loaded signi cantly on this factor, which accounted for 5.4%of the total variance. They strongly agreed with the following items: 13. Hearing voices is a symptom of mental illness ( 5) 19. Voices need to be controlled by psychiatric treatment ( 5) They also mildly agreed that hearing voices indicates schizophrenia and that medication improves the quality of life for voice hearers. Both participants who loaded onto this factor described themselves as schizophrenic and took psychiatric medication. They disagreed with media stereotypes of voice hearers as insane or having lost contact with reality. They endorsed all psychological perspectives that referred to the role of stress and problematic life events: 40. Voices can begin after a major life event ( 4) 5. Hearing voices is a result of stress in vulnerable people ( 3) 15. Painful memories sometimes imprint themselves on a persons mind as voices ( 2) 31. Voices bring unsolved problems from the past, into a persons mind ( 2) They strongly agreed that voices might be the result of cognitive misattribution: 20. People hear voices when, by mistake, the brain interprets thoughts as voices ( 4) 14. Voices happen when a person mishears actual sounds as being voices ( 3) 35. Voices bring messages from a persons imagination or unconscious mind ( 3) Both participants who loaded onto this factor used psychiatric services. One respondent had used services for many years. Denise elaborated on how she believed she had been psychic since she was young and therefore originally believed that her voices were from spiritual sources. She described how her psychiatrist had persuaded her against this belief and told her that this belief was part of her illness. Therefore, she chose to abandon her spiritual beliefs and now holds a mental-illness framework on voice hearing. She added that she now believed that mediums are different from other voice hearers. The participants who loaded onto this factor held very anti-spiritual beliefs and were particularly unsympathetic to ideas linking voice hearing to spiritual possession or ghosts.

Discussion
This study explored how hearing voices is conceptualized and understood by a diverse range of voice hearers (including mental-health-service users, non-users, spiritualists and non-conformist Christian church-goers). Using Q -methodology, six distinct factors have been identi ed and pro led. These were positive spiritual perspective, personal relevance perspective, resigned pessimist perspective, pragmatic response perspective, passivity to forces perspective, and generic mental illness perspective. All six factors

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that emerged in the study include a complex constellation of different beliefs about voice-hearing experiences. This study supports the assertion that the explanations adopted by voice hearers seldom correspond completely with any existing theory (Romme & Escher, 1993). Participants loading onto all six factors recognized that the pejorative media stereotypes about voice hearers are inappropriate. Despite the dominance of the biomedical model in our culture, on no factor do participants adhere to all of the biomedical concepts. All six factors endorsed some elements of psychological discourse on voice-hearing experiences. Clearly, psychological perspectives on voice hearing are resonant with the voice hearers included in this study. Service users in this study were more likely to nd voices frightening and perceive them as negative experiences, than non-users. This supports the results of other studies such as Romme and Escher (1996). This may demonstrate that non-users of mentalhealth services are more able to frame their experiences positively because of their belief constructions and/or that because their voices are less problematic, they are less likely to need to seek help from services. However, it also emerged that some non-users of mental-health services found managing their voices dif cult. It has been suggested that the degree of distress caused by voices is linked to the degree to which voices are seen as normal (Romme & Escher, 1993). For some of the participants in this study, voices are construed as part of a normal spiritual development, and none of these individuals felt suf ciently distressed by their voices to seek psychiatric help. It may be that their positive and optimistic belief constellations about voice-hearing experiences actually protect them from needing to seek help. Interestingly, participants who were voice hearers in spiritualist churches and nonconformist churches talked about learning techniques to close off at times from voices. This seems similar to cognitive-therapy techniques such as learning to set boundaries on voices and developing the ability to turn voices on and off (Chadwick & Birchwood, 1996). Dif cult voices were construed by spiritualists as re ecting the character of the person in spirit, and some voice hearers nd such voices distressing or frustrating but are able to function without mental-health-service input. The ndings from this study illustrate the need for further work with non-service users to explore the variety of voice-hearing experiences that they have. The participant pro le information revealed that 18 of the participants did not believe that others could hear the voices they heard. The two individuals who did believe that, in certain circumstances, voices could be heard by others, were spiritualists referring to work with other mediums. This may have important treatment implications, as basic cognitive challenging of voice hearers in mental-health services often involves refuting the reality of voices, by emphasizing that others cannot hear the voices (Greene, 1978). However, clearly, the voice hearers participating in this study acknowledge this, without it affecting their personal perception of the reality of the voices. A total of 14 people stated that they could communicate with their voices. Cognitive behavioural therapists (Fowler & Morley, 1989) often encourage this. Two participants did add that telling their voices to leave them alone frequently was not an effective strategy. The process of a mental-health assessment often involves the client in the role of relatively ignorant consulting a professional in the role of relatively knowledgeable (Dryden & Felham, 1992). In this situation, professional wisdom is often accepted as an unequivocal body of knowledge. However, attempting to understand voice hearers within a single theoretical framework may limit or adversely affect engagement and understanding of an individual. Voice hearers all hold their own theories on the

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aetiology of their experiences, and it has been suggested that clinicians should take an individual and holistic approach (British Psychological Society, 2000). It is also worth noting that psychologists who allow users to be themselves are often highly valued (Davis, Holden, & Sutton, 2001). Administration of a Q -sample, similar to that described in this study, may be an appropriate tool for professionals as part of the assessment process of voice hearers accessing mental-health services. It potentially yields a wealth of information as to how the individual makes sense of their experiences and does so in a way that, for some, may be less threatening than having to answer direct questions. Clients may also nd it reassuring to be presented with an array of different conceptualizations of voice hearing if they have concerns about being forced to adhere to a particular framework of understanding. It may also give the client a sense that they can choose how to interpret the meaning of their experience. Also, the Q -sort encourages the client to take an active role, which potentially can boost self-esteem, as the implicit message is that the clients beliefs and opinions are of worth. This is consistent with therapies that encourage collaborative working with clients. The examination of emergent factors may help to guide therapeutic interventions (Beutler & Consoli, 1993; Roth &Fonagy, 1996). For example, adherents to the personal relevance perspective might particularly welcome a therapeutic intervention that attempted to address early traumatic experience, and for some people at least, it has been claimed that voices disappear when underlying problems are resolved or integrated (Escher et al., 1998). Conversely, it would be easy to imagine how someone who construes their voice-hearing experience in this way is going to be sceptical about the value of neuroleptic medication. For people experiencing dif culties with voices whose beliefs are similar to those identi ed in factor 5, passivity to forces perspective, a therapy that facilitates a move from their stance of powerlessness, passivity, and vulnerability might be helpful. It has been stated that Q -sorting requires high-level cognitive processing and that, therefore, some participants may not fully understand the requirements of the tasks (Tubergen & Olins, 1979). In this study, all participants were invited to offer feedback on how they found the task after completion. Very few respondents described having any problems with completion. Noone failed to make distinctions between statements and to complete the Q -sorting. It is likely that the process was facilitated by ensuring that statements were grounded in the participants own language and phrasing. Q -methodology claims to avoid the imposition of structure upon the ndings (Kitzinger & Stainton-Rogers, 1985). However, this is not strictly true, as factor analysis fundamentally searches for common patterns, although, in this case, patterns are based around whole constructions rather than individual statements. As previously noted, some limitations may arise from the forced, quasi-normal distribution of the Q -sort, but within the design, participants do have freedom to organize statements as they choose. According to standard procedure in Q -methodology, no formal sampling of participants is necessary (McKeown & Thomas, 1988). However, somewhat contradictory to this, Brown (1996) stated that the breadth and diversity of participant sample are important. In this study, efforts were made to ensure that a wide diversity of individuals were chosen to partake, and the sample size is not inconsistent with other studies employing this methodology. However, a larger number of participants in the study may have enabled the ndings to be developed further. Across a range of people who hear voices, this study has highlighted the breadth and complexity of beliefs about the experience of hearing voices. It has been suggested that

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awareness of lay perspectives on voice hearing may have important therapeutic implications, and future research might usefully investigate further the range of constructions that people have about voice hearing.

References
Al Issa, I. (1978). Social and cultural aspects of hallucinations. Psychological Bulletin, 84, 570587. American Psychiatric Association (1994). Diagnostic criteria from DSM . Washington, DC: -IV American Psychiatric Association. Assagioli, R. (1973). The act of will. New York: Viking Press. Barker, P (2000, September). In Moving beyond maintenanceMaking recovery a reality in . mental health services. Conference. Birmingham, UK: Handsell. Bentall, R. (1990). The illusion of reality: A review and integration of psychological research on hallucinations. Psychological Bulletin, 107(1), 8295. Bentall, R., Haddock, G., & Slade, P (1994). Cognitive behaviour therapy for persistent auditory . hallucinations: From theory to therapy. Behavioural Therapy, 25, 51 66. Berrios, G. (1991). Delusions as wrong beliefs: A conceptual history. British Journal of Psychiatry, 159(Suppl. 14), 6 13. Beutler, L. E., & Consoli, A. J. (1993). Matching the therapists interpersonal stance to the clients characteristics: Contributions from systematic eclectic psychotherapy. Psychotherapy, 30(3), 417422. British Psychological Society, Division of Clinical Psychology (2000). Recent advances in understanding mental illness and psychotic experiences. Leicester, UK: The British Psychological Society. Brown, S. R. (1980). Political subjectivity: Applications of Q methodology in political science. New Haven, MI: Yale University Press. Brown, S. R. (1996). Q methodology and qualitative research. Qualitative Health Research, 6(4), 516567. Chadwick, P (1997). Recovery from psychosis: Learning more from patients. Journal of Mental . Health, 6(6), 577588. Chadwick, P & Birchwood, M. (1996). Cognitive therapy for voices. In Haddock, G., & Slade, P ., . (Eds.), Cognitive-behavioural interventions with psychotic disorders. London: Routledge. Chadwick, P Birchwood, M., & Trower, P (1996). Cognitive therapy for delusions, voices and ., . paranoia. Chichester, UK: Wiley. Clarke, I. (2001). Psychosis and spirituality: Finding a language. Clinical Psychology Forum, 149, 1922. David, T., & Leudar, I. (2001). Head to head: Is hearing voices a sign of mental illness? The Psychologist, 14(5), 256259. Davis, F Holden, L., & Sutton, R. (2001). User involvement and psychosocial rehabilitation. ., Clinical Psychology Forum, 150, 34 42. Dennis, K. E. (1986). Q -methodology: Relevance and application to nursing research. Advances in Nursing Science, 8(3), 6 17. Dryden, W & Felham, C. (1992). Psychotherapy and its discontents. Buckingham, UK: Open ., University Press. Eaton, W W Romanoski, A., Anthony, J. C., & Nestadt, G. (1991). Screening for psychosis in the . ., general population with a self -report interview. The Journal of Nervous and Mental Disease, 179(11), 689693. Ensink, B. (1994). Trauma: A study of child abuse and hallucinations. In M. Romme & S. Escher (Eds.), Accepting voices (pp. 165171). London: Mind Publications. Escher, S., Romme, M., & Buiks, A. (1998). Small talk: Voice hearing in children. Open Mind, 92, 1214.

208

S. Jones et al.

Festinger, L. (1957). A theory of cognitive dissonance. Stanford: Stanford University Press. Cited in: Morrison, A., Haddock, G., & Tarrier, N. (1995). Intrusive thoughts and auditory hallucinations: A cognitive approach. Behavioural and Cognitive Psychotherapy, 23. Fowler, D., Garety, P & Kuipers, E. (1995). Cognitive behaviour therapy for psychosis: Theory and ., practice. Chichester, UK: Wiley. Fowler, D., & Morley, S. (1989). The cognitive-behavioural treatment of hallucinations and delusions: A preliminary study. Behavioural Psychotherapy, 17, 267282. Freud, S. (1924). Neurosis and psychosis. S.E. IXX. Republished (1961). London: Hogarth Press, 1961. Greene, R. J. (1978). Auditory hallucination reduction: First person singular. Journal of Contemporary Psychology, 9, 167170. Haddock, G., Bentall, R., & Slade, P (1993). Psychological treatment of chronic auditory . hallucinations. Two case studies. Behavioural Cognitive Psychotherapy, 21, 335346. Cited in: Bentall, R. (1996). 3. Cognitive processes in psychotic symptoms and novel psychological treatments for psychosis. Clinician, 14(6). Heery, M. W (1989). Inner voice experiences: An exploratory study of thirty cases. Journal of . Transpersonal Psychology, 21(1), 7382. Hingley, S. (1992). Psychological theories of delusional thinking: In search of integration. British Journal of Medical Psychology, 65, 347356. Honig, A., Romme, M., Ensink, B., Escher, S., Pennings, M., & deVries, M. (1998). Auditory hallucinations: A comparison between patients and non-patients. Journal of Nervous and Mental Disease, 186(10), 646651. Hulme, P (1996). Everything means something: Collaborative conversation explored. Cha nges, . 14(1), 6772. Jackson, M. C. (1997). Benign schizotypy? The case of spiritual experience. In G. S. Claridge (Ed.), Schizotypy, relations to illness and health. Oxford: Oxford University Press. Jaspers, K. (1962). General psychopathology. Chicago: University of Chicago Press. Jung, C. (1969). Memories, dreams, re ections. New York: Pantheon Books. Jung, C. G. (1939). On the psychogenesis of schizophrenia. In: The psychogenesis of mental disease. Collected works 3. London: Routledge. Cited in Hingley, S. (1997). Psychodynamic perspectives on psychosis and psychotherapy I: Theory. British Journal of Medical Psychology, 70, 301312. Kaplan, H. I., & Sadock, B. J. (1985). Modern synopsis of the comprehensive textbook of psychiatry/IV Baltimore: Williams & Wilkins. . Kinderman, P (1994). Attentional bias, persecutory delusions and the self . -concept. British Journal of Medical Psychology, 64, 5366. Kitzinger, C., & Stainton-Rogers, R. (1985). A Q -methodological study of lesbian identities. European Journal of Social Psychology, 15, 167187. Leudar, I., & Thomas, P (2000). Voices of reason, voices of insanity. London: Routledge. . Maher, B. (1988). Anomalous experience and delusional thinking: The logic of explanations. In T. Oltmanss & B. Maher (Eds.), Delusional beliefs (pp. 1533). New York: Wiley. Cited in: Fowler, D., Garety, P & Kuipers, E. (1995). Cognitive behaviour therapy for psychosis: ., Theory and practice. Chichester, UK: Wiley. McKellar, P (1968). Experience and behaviour. Baltimore: Penguin Books. Cited in Barrett, T. B., . & Etheridge, J. B. (1992). Verbal hallucinations in normals, I: People who hear voices. Applied Cognitive Psychology, 6, 379387. McKeown, B., & Thomas, D. (1988). Q -methodology. Beverly Hills, CA: Sage. Peters, E. R., Day, S., McKenna, J., & Orbach, G. (1999). The incidence of delusional ideation in religious and psychotic populations. British Journal of Clinical Psychology, 38, 8396. Posey, T. B., & Losch, M. E. (1983). Auditory hallucinations to hearing voices in 375 normal subjects. Imagination, Cognition and Personality, 3, 99 113. Romme, M., & Escher, A. (1989). Hearing voices. Schizophrenia Bulletin, 15, 209216. Romme, M., & Escher, S. (1993). Accepting voices. London: Mind Publications.

Q-methodological study of hearing voices

209

Romme, M., & Escher, S. (1996). Empowering people who hear voices. In Haddock, G., & Escher, S. (Eds.), Cognitive beha vioural interventions with psychotic disorders. London: Routledge. Romme, M., & Escher, S. (1999). Making sense of voices. London: Mind Publications. Romme, M., & Pennings, M. (1994). Hearing voices in patients and non-patients. Cited as presented at World Congress of Social Psychiatry. Roth, A., & Fonagy, P (1996). What works for whom? A critical review of psychotherapy. New . York: Guildford. Sodi, T. (1995). A call to become an indigenous healer: An integrative or disintegrative experience. Paper presented at Hearing Voices Conference, Discourse Unit, Manchester Metropolitan University July 8th 1995. Cited in: Thomas, P & Leudar, I. (1996). Verbal , ., hallucinations or hearing voices: What does the experience signify? Journal of Mental Health, 5(3), 215218. Stainton-Rogers, R. (1995). Q -methodology. In: J. A. Smith, R. Harre, & L. Van Langenhove (Eds.), Rethinking methods in psychology (pp. 178195). London: Sage. Stephenson, W (1935). Techniques of factor analysis. Nature, 136, 297. . Stephenson, W (1953). The study of behaviour: Q . -technique and its methodology. Chicago: University of Chicago Press. Thomas, P & Leudar, I. (1996). Verbal hallucinations or hearing voices: What does the experience ., signify? Journal of Mental Health UK, 5(3), 215218. Tien, A. Y (1991). Distributions of hallucinations in the population. Social Psychiatry and . Psychiatric Epidemiology, 26, 287292. Tubergen, G., & Olins, R. A. (1979). Mail vs. personal interview administration for Q sorts: A comparative study. Operant Subjectivity, 2(2), 5759. Zuckerman, M., & Cohen, N. (1964). Sources of reports of visual and auditory sensations in perceptual-isolation experiments. Psychological Bulletin, 62, 120. Cited in Barrett, T. B., & Etheridge, J. B. (1992). Verbal hallucinations in normals, I: People who hear voices. Applied Cognitive Psychology, 6, 379387. Received 14 March 2002; revised version received 23 December 2002