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Auditory verbal hallucinations: Dialoguing between the cognitive sciences and

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Phenom Cogn Sci
DOI 10.1007/s11097-010-9156-0

Auditory verbal hallucinations: Dialoguing

between the cognitive sciences and phenomenology

Frank Larøi & Sanneke de Haan & Simon Jones &

Andrea Raballo

# Springer Science+Business Media B.V. 2010

Abstract Auditory verbal hallucinations (AVHs) are a highly complex and rich
phenomena, and this has a number of important clinical, theoretical and methodological
implications. However, until recently, this fact has not always been incorporated into the
experimental designs and theoretical paradigms used by researchers within the cognitive
sciences. In this paper, we will briefly outline two recent examples of phenomenolog-
ically informed approaches to the study of AVHs taken from a cognitive science
perspective. In the first example, based on Larøi and Woodward (Harv Rev Psychiatry
15:109–117, 2007), it is argued that reality monitoring studies examining the cognitive

F. Larøi (*)
Cognitive Psychopathology Unit, Department of Cognitive Sciences, University of Liège,
Bd. du Rectorat (B33), 4000 Liège, Belgium
e-mail: flaroi@ulg.ac.be

F. Larøi
Intercommunale de Soins Spécialisés de Liège (Mental Health Sector), Liège, Belgium

S. de Haan
Phenomenological Psychopathology, Department of Psychiatry, University of Heidelberg, Heidelberg,
Germany

S. Jones
Department of Psychology, Durham University, Durham, UK

A. Raballo
Danish National Research Foundation: Centre for Subjectivity Research, University of Copenhagen,
Copenhagen, Denmark

A. Raballo
Department of Psychiatry, Psychiatric Centre Hvidovre, Hvidovre Hospital, Hvidovre, Denmark

A. Raballo
Department of Mental Health, AUSL di Reggio Emilia( Reggio Emilia, Italy
 F. Larøi et al.

underpinnings of hallucinations have not reflected the phenomenological complexity

of AVHs in their experimental designs and theoretical framework. The second
example, based on Jones (Schizophr Bull, in press, 2010), involves a critical
examination of the phenomenology of AVHs in the context of two other prominent
cognitive models: inner speech and intrusions from memory. It will be shown that, for
both examples, the integration of a phenomenological analysis provides important
improvements both on a methodological, theoretical and clinical level. This will be
followed by insights and critiques from philosophy and clinical psychiatry—both of
which offer a phenomenological alternative to the empiricist–rationalist conceptualisa-
tion of AVHs inherent to the cognitive sciences approach. Finally, the paper will
conclude with ideas as to how the cognitive sciences may integrate these latter
perspectives into their methodological and theoretical programmes.

Keywords Hallucination . Phenomenology . Cognitive science . Philosophy

Experimenting with phenomenology

In their article entitled ‘Experimenting with phenomenology’, Gallagher and Sørensen

(2006) offer examples of how phenomenological methods may be used in
experimental settings. One approach they discuss involves ‘front-loading phenome-
nological insights into experimental design’. This involves using insights developed in
independently conducted phenomenological analyses in order to inform experimental
designs. One particularly prolific example of this has been the transfer of knowledge
concerning the concept of a sense of agency to experimental paradigms. Furthermore,
in addition to using such phenomenologically informed experimental tasks in normal,
healthy participants, researchers have also extended this to pathological populations,
such as patients diagnosed with schizophrenia, and this has in turn helped inform
cognitive theoretical models of psychopathological experiences. Thus, in the context
of psychopathology, phenomenological analyses are valuable on both a methodolog-
ical and theoretical level. However, research on AVHs has not yet benefitted from this
transfer of phenomenology to research and cognitive models—that is, until recently.
Important to underline is that the term ‘phenomenology’ may be used differently.
One use refers to the (detailed) description of the clinical and/or descriptive features
of signs and symptoms observed in psychopathological conditions. Another use of
the term ‘phenomenology’ refers to a method of analysis of the constitution of the
embodied and embedded subjective experience, in this case, of patients suffering
from psychopathological conditions. These two uses will be employed in the article.
In particular, the cognitive sciences seem to adopt the former use, whilst the
philosophical and clinical psychopathological traditions will tend to use the term
‘phenomenology’ in the latter sense.

Examining the phenomenological fit of the reality monitoring model of AVHs

The approach proposed by Larøi and Woodward (2007) is largely based on a

phenomenological study of AVHs carried out by Stephane et al. (2003). A group of
Auditory verbal hallucinations

100 psychiatric patients (with schizophrenia, schizoaffective disorder and psychotic

depression) were interviewed regarding the phenomenological characteristics of their
AVHs. A total of 20 phenomenological AVH variables were identified based on the
literature and the clinical experience of the authors. Multidimensional scaling was
then performed to investigate the dimensional structure underlying 11 of these
variables. Results revealed three dimensions: (1) linguistic complexity, (2) self-other
attribution and (3) inner–outer space location. The linguistic dimension ranged from
low linguistic complexity (i.e. hearing words) at one end of this dimension, through
medium complexity (i.e. hearing sentences), to high complexity (i.e. hearing
conversations) located at the other end of the dimension. The self-other dimension,
ranged from attribution of the auditory–verbal hallucinations to self (‘I hear my own
voice’) at one end and to attribution to others (‘I hear someone else talking to me’) at
the other end. Inner–outer space dimension ranged from inner space location (e.g. ‘I
hear the voice in my head’) to outer space location (e.g. ‘The voice is coming from
behind that plant’).
One experimental paradigm that has often been used in the context of examining
the cognitive underpinnings of hallucinations is the source memory paradigm.
Johnson et al. (1993) define a source as ‘a variety of characteristics that, collectively,
specify the conditions under which a memory is acquired (e.g., the spatial, temporal,
and social context of the event; the media and modalities through which it was
perceived) (p 3)’. Furthermore, they refer to source monitoring as ‘the set of
processes involved in making attributions about the origins of memories, knowledge,
and beliefs (p 3)’. Hallucinations have been particularly attributed to difficulties in a
subcategory of source monitoring, namely ‘reality monitoring’, or the process by
which a person attributes a memory, knowledge or belief to an external (obtained
through perceptual processes) or to an internal (e.g. by reasoning, imagination and
thought) source (Johnson and Raye 1981). One influential cognitive model (Bentall
1990) proposes that hallucinations can be explained by a difficulty in reality
monitoring and, furthermore, that those with hallucinations might have a specific
bias towards attributing their thoughts to an external source, or a so-called
externalising bias. A number of studies have provided evidence for an externalising
bias in hallucinations (for a review, see Aleman and Larøi 2008).
A typical reality monitoring task involves, for example, presenting stimuli (such
as words) to participants from an external source (e.g. the experimenter saying a
word out loud), in addition to having participants generate their own words, thus
representing stimuli coming from an internal source. In the recognition phase, these
stimuli are presented randomly and participants are required to recall if the word
came from an external (i.e. the experimenter) or an internal (i.e. themselves) source.
One problem with this methodology is that although the event is self-generated, it
contains both inner and outer localisation qualities. Specifically, the generation of the
word is indeed an inner event, but the production of the word also leads to
stimulation of sensory organs, thereby adding outer localisation qualities. Thus, there
is no purely inner, self-generated event, and instead, there is typically a mixture of
inner and outer qualities that characterises a self-generated event. Another problem
with this methodology is that only one internal source and one external source is
included in the task. Consequently, the only choice for misattribution is the outer,
non-self-generated source, leaving two equally possible (e.g. based on the findings
 F. Larøi et al.

of Stephane et al. 2003) misattribution errors unexamined, namely misattributing

towards an outer, self-generated source and towards an inner, non-self-generated
source.
Based on Stephane et al. (2003), Larøi and Woodward (2007) distinguish between
two important phenomenological dimensions in hallucinations: (1) the self-
generated/non-self-generated dimension and (2) the inner/outer dimension. The
former dimension refers to the perceived/subjective origin of a given cognitive
event. For example, a cognitive event that is perceived as produced by the person
him/herself is considered a self-generated event, but a cognitive event that is
perceived as not generated by the person but, rather, by an external agent, is
characterised as a non-self-generated event. The second dimension refers to the
localisation of the cognitive event in space. When an event is located in the inner
space, this is referred to as an inner event. In contrast, when an event is located in the
outer space, that is, outside of the subject, this is referred to as an outer event. It is
important to underline that it is the subjective experience of an event being inner,
outer, self-generated or non-self-generated that is decisive.
A combination of these two dimensions gives rise to four different types of
cognitive events. The first, inner, self-generated cognitive events are healthy and
normal and may include a variety of experiences such as daydreams, memories,
songs, imagery, pain, melodies, bodily sensations, images, voices, thoughts, ideas,
sounds and impulses. For all these events, the subjective origin is the person (i.e.
self-generated) and the subjective spatial location is internal (i.e. inner). However,
either because of changes in terms of the event’s subjective origin (i.e. becomes less
‘self-generated’) or due to changes in the event’s subjective spatial location (i.e.
becomes less internal or inner), or a combination of both—the inner, self-generated
event is transformed into a hallucination. In this context, hallucinations may be
viewed as erroneously attributed inner, self-generated events. Based on this
assumption, two steps underlie the onset of hallucinations: (1) the alienation of
inner, self-generated events and (2) the misattribution of inner, self-generated events
to some specific origin/location combination. The first type of cognitive process
involves loss of the cognitive representations that code the inner, self-generated
nature of what will become a hallucination. In other words, an inner, self-generated
event is (subjectively speaking) not clearly experienced as being either inner, self-
generated or both. The second type of cognitive processes involves hallucinators
attributing inner, self-generated events to the specific origin/location combination
that determines their hallucinatory experience. Thus, the three other types of
cognitive events (which are three relatively distinct ‘types’ of hallucinations, in
cognitive terms) are (a) outer, self-generated, (b) outer, non-self-generated and (c)
inner, non-self-generated cognitive events.

Examining the phenomenological fit of inner-speech based and memory-based

models of AVHs

It seems obvious to state that a theory of x should always reflect the phenomenology
of x. However, there may be a tendency for what theories of x explain, to drift apart
from the actual phenomenology of x, coming eventually to concentrate only on a
Auditory verbal hallucinations

subset of the varied phenomenology of x. If the phenomenology of an experience is

highly heterogeneous, this risk of ‘theory-phenomenology drift’ may be especially
high. In such circumstances, theories may come to concentrate their explanatory
power on only certain aspects of the heterogeneous experience. It hence behoves us
to hold theories accountable to the phenomenology of the experience they claim to
explain. As noted in the previous section, hallucinations have a highly heteroge-
neous phenomenology, and as such, this places them at high risk for theory-
phenomenology drift. This section of the paper will illustrate how such drift can be
seen in the relation between two leading theories of AVHs and the actual, reported
phenomenology of AVHs and how the use of a phenomenological analysis results in
important improvements both on methodological, theoretical and clinical levels.
Waters et al. (2006) have argued that AVHs are a result of the ‘unintentional
activation of memories’ (p 65) or ‘the failure to inhibit memories of prior events’
(Badcock et al. 2005, p 132). This can be termed the AVHs-as-memories model.
These authors claim that ‘the proposal of auditory hallucinations as memories’ is
consistent with the phenomenology of the experience and can explain aspects of the
phenomenology such as ‘entire dialogues from a conversation may be recalled’ and
‘why voices often refer to the patient’s personal details’ (p 76). The phenomenology
of some AVHs does indeed appear to be consistent with the AVHs-as-memories
account, particularly where the content of the AVH can be linked to memories of
previous traumatic/abuse experiences. It seems likely such AVHs are related to
decontextualised intrusions of this material from memory. This has led some, such as
Read et al. (2005), to claim that ‘some psychotic hallucinations appear to be nothing
more or less than memories of traumatic events’ (p 341). However, the important
word here is ‘some’. Not all AVHs seem to have the quality of memories. For
example, Fowler (1997) found that only in 17% of voice hearers studied could the
content of voices be seen as ‘sometimes’ being suggestive that these were memories.
In the remainder of his sample, meaningful connections could be made between
traumatic events and AVHs but these were thematic (e.g. both the voices and trauma
involved humiliation) rather than involving a direct relation between the content of
the voices and what was said during and surrounding the trauma. We may also
consider that the phenomenological survey of AVHs of Leudar et al. (1997)
concluded that they were often ‘focused on the regulation of everyday activities’
(p 896). Similarly, Nayani and David’s (1996) phenomenological survey noted that
AVHs are typically ‘minutely engaged in the apprehension of objective reality’
(p 185). It is hard to reconcile such phenomenological characteristics with the AVHs-
as-memories model. Nayani and David (1996) also observed that AVHs tend to
evolve over time with the voices ‘fashioning increasingly detailed dialogues with or
about the patient’ (p 187). Again, it is hard to see how verbal intrusions from
memory are consistent with such a phenomenology. In this sense, AVHs are just not
memory like.
Another prominent type of model proposes AVHs to result from inner speech
which has not been recognised as self-produced and instead has been perceived as an
autonomous, non-self-voice (e.g. Seal et al. 2004). It has been argued that based on a
consideration of the form, function and development of private and inner speech, the
phenomenology of many AVHs is consistent with a basis in inner speech (Jones and
Fernyhough 2007). For example, the high frequency of command AVHs, such as
 F. Larøi et al.

‘get the milk’ or ‘go to the hospital’, which were reported by 84% of voice hearers in
Nayani and David’s (1996) phenomenological survey, is consistent with inner
speech’s developmental role in controlling our actions (Vygotsky 1987). The
phenomenology of some unusual forms of AVHs is also consistent with inner
speech. For example, Jones (2010) has argued that as the developmental end point of
inner speech is the ‘thinking in pure meanings’ (Vygotsky 1987), we should expect
to find AVHs with this quality of ‘pure meaning’. Such AVHs are indeed found in
the psychiatric literature. Bleuler (1911/1952) termed these ‘soundless voices’
(p 110). An example of such AVHs is given by Janet who describes a patient who
reported of their AVH that ‘it is not a voice, I do not hear anything, I sense that I am
spoken to’ (Leudar and Thomas 2000). Given such parallels, a recent review
concluded that ‘the phenomenology of inner speech, including its regulatory nature,
its linkage to ongoing events, its ability to involve the voices and perspectives of
others, its ability to take the form of “thinking in pure meanings”, and its creative
nature, are consistent with the phenomenological properties of a large number of
AVHs.’ (Jones 2010).
However, inner speech-based models have a number of limitations when
compared to the phenomenology of AVHs. For example, firstly, they do not seem
appropriate for the ∼10–20% of individuals (Fowler 1997; Hardy et al. 2005) whose
voices have content which can be linked directly back to memories of trauma. These
instead appear better modelled using the AVHs-as-memories model. Secondly, as
Waters et al. (2006) have argued, inner speech-based models are not consistent with
the phenomenology of other AVHs such as those involving the voices of crowds, or
multiple people mumbling.
The above arguments show that neither inner speech based nor memory-based
models of AVHs are able to account for the full phenomenological range of the
experience. In this sense, we can see theory–phenomenology drift occurring, with each
theory of AVHs only being in accordance with a subset of AVHs and having a significant
blindspot for other types of AVH. It may be that as both the inner speech-based model
and the memory-based model are consistent with a specific subset of AVHs that different
types of AVHs may have different underlying mechanisms, and we should model both
types separately. This would imply the need to subcategorise AVHs (Jones 2010). For
example, one type of AVH would be that with content directly linked to intrusive
memories of early abuse/trauma, which could be understood via a neurocognitive
model that sees AVHs as a failure to inhibit memories. A second type would be
typified by novel statements that attempt to regulate the actions of the voice hearer,
linked to their ongoing activities and which cannot be linked directly to a verbatim
memory, can be delineated. Such AVHs appear to be phenomenologically best
accounted for by a neurocognitive inner speech-based model. If correct, this has
important methodological implications for the study of AVHs. For example,
historically, in neuroimaging studies of AVHs, a group with AVHs are compared to
a control group who have never experienced AVHs. However, if we honour the
phenomenological heterogeneity of AVHs, we are bound to consider the possibility
that potentially different underlying mechanisms associated with different subsets of
AVHs will likely lead to confounding errors when comparing neural activation
associated with AVHs to controls. In line with this argument, researchers are now
designing studies which examine groups of patients with phenomenologically
Auditory verbal hallucinations

homogenous hallucinations (e.g. García-Martí et al. 2008). At a clinical level, we may

also consider whether phenomenologically distinct types of AVHs respond differently
to different types of treatments and interventions. To our knowledge, no work has yet
been done to see if particular phenomenological subsets of AVHs respond
differentially to treatments such as antipsychotic medication. Thus, in these ways,
the use of a phenomenological analysis can be seen to have important implications
both on methodological, theoretical and clinical levels.

A phenomenological–philosophical critique

Hallucinations have fascinated philosophers from the very beginning—and even if

they were not particularly fascinated by them, they were forced to take hallucinations
into account when contemplating topics including the nature of perception and the
possibility of knowledge. A phenomenological–philosophical interest in hallucina-
tions often involves a general interest in hallucinations, that is, without, for example,
necessarily taking into account specific hallucinations modalities such as AVHs.
Hallucinations have thus often served as a critical test case for philosophical
theories. What will follow, in this section of the paper, is a philosophical critique of
the empiricist and rationalist takes on hallucinations, as utilised within the cognitive
sciences. This will be followed by a discussion of the phenomenological approach to
hallucinations, with a final section discussing Merleau-Ponty’s (1945/2002) theory
of perception as it relates to hallucinations.

Empiricist, rationalist and phenomenological views

Views on hallucinations can be very crudely divided into empiricist, rationalist and
phenomenological approaches. Based on a rationalist account, a hallucination is
defined as a faulty judgment on whether the stimulus is internal (memory, dreams,
imagination) or external (world ‘out there’). The underlying assumption is that
perception involves a reality judgment. Hence, hallucinations are explained in terms
of difficulties in metacognitive abilities (e.g. judging, believing, attributing). An
empiricist or materialistic view defines hallucinations as perceptions without an
object or more precisely as: ‘perceptions that occur in the absence of a corresponding
external stimulus’ (Asaad and Shapiro 1986). This definition assumes that
perception is a mechanical, material process of stimulus and response. Hallucina-
tions are considered to reveal a problem with the perceptual apparatus, ultimately
due to some neurobiological deficiency. Although the two views disagree on the
underlying cause of hallucinations (metacognitive difficulties versus neurobiological
malfunctioning), there are some similarities as well. Both approaches regard
hallucinations as perceptions, both assume a split between perception and reality
in the sense that perception can arise without an actual external input and, lastly,
both try to explain the process rather than the specific content of hallucinations.
In contrast, a phenomenological approach would first of all deny that hallucinations
are perceptions because a perception always involves an object. This may seem a mere
terminological gimmick, but it in fact reflects a deeper divergence between the different
approaches. The phenomenological concept of intentionality points to the irresolvable
tie between perceiver and perceived, between noema and noesis. Perceiving is of an
 F. Larøi et al.

object, hallucinating precisely not. Admittedly, hallucinations are intentional as well, but
they are no longer directed at the objects of a shared world; they remain within a
monadic realm. We cannot properly speak of the ‘object’ of a hallucination because the
constitution of objects depends on an intersubjective structure. Since my present
perspective shows me just one side of an object, I am never able to perceive an object in
its entirety. The realness of the object is constituted by other persons who are able to see
these other sides. This does not need to be an actual other; it is rather that the possibility
of being perceivable by other people is a necessary component of the perception itself.
Perception is thus not regarded as a monadic, mechanistic data collecting but is, at its
very roots, an intersubjective process. Phenomenological approaches would stress that
perception is not a mere passive sensory process but rather involves the whole person—
and so do hallucinations. From this, it also follows that the distinction between process
and content is to a certain extent an artificial one. The content does matter, both
clinically for a better understanding of the patient and empirically for a more subtle
taxonomy of hallucinations. As we remarked above, it would be very interesting to see
if these differences in content could be related to the effectiveness of different
treatment strategies a well.
According to a phenomenological account, perception does not involve a
judgment either, and neither do hallucinations. Of course, someone may express
all kinds of speculations, beliefs, judgments and interpretations about the reality of
the hallucinated ‘object’, but these are all retrospective. The immediate experience is
not believed, but precisely experienced. If hallucinations were a faulty judgment,
then they could be corrected, but both hallucinations and perceptions are not
judgments and thus cannot be false or true: They are experiences. Jaspers calls this
the ‘objectivity-character’ of experiences (Jaspers, 1911, p 494; cited in Silva and
Silva 1975, p 109). The fact that people suffering from hallucinations are usually
able to distinguish between their hallucinations and perceptions also speaks against
this rationalist idea. Apparently, many people do make accurate judgments on the
non-reality of their hallucinations as they can, for example, distinguish between
genuine and hallucinated voices (cf. Moritz and Larøi 2008). At first sight, it may
seem paradoxical that people know when they are hallucinating, but as Silva and
Silva (1975) point out, in light of the phenomenological distinction between noema
and noesis, it makes perfect sense. We should differentiate between the ‘noetic’
claim that one’s experience is real and the ‘noematic’ claim that the object one
hallucinates actually exists in reality. The certainty of schizophrenic patients may
well concern the realness of their experience of the AVH and need not entail a
noematic claim. In perception, these two coincide: Perceiving is the awareness of a
real object. This can also be related to the distinction made by Ey (1973) between
hallucinosis (i.e. hallucinations with preserved insight; sometimes referred to as
‘pseudo-hallucinations’) and true hallucinations (i.e. hallucinations without pre-
served insight).

Merleau-Ponty: hallucinations as a changed being-in-the-world

For a phenomenological alternative, we can turn to Merleau-Ponty’s (1945/2002)

view on hallucinations as a changed being-in-the-world. The person’s whole
existence is set into play—especially their interaction with the world and with other
Auditory verbal hallucinations

people. For a better understanding of the specificity of hallucinations, we can

compare them to perceptions. A first, salient characteristic of hallucinations is that
they are private. Perceptions refer to a shared world, but hallucinations do not.
Hallucinations are not part of our world—and therefore are not accessible. They are
neither connected to the person’s other sensations nor to the experiences of the
persons around her. As Minkowski (1933, cited in van den Berg 1982) remarked,
hallucinations ‘appear immediately as being part of a desocialised world’ (p 109).
Furthermore, hallucinations are uni-sensory. Whereas perceptions are given to us by
multiple senses, hallucinations usually involve only one sense modality. Schilder
(1920) writes: ‘the division into optical, tactile, acoustic, etc. is in the end artificial;
we perceive the whole thing in every perception’ (p 172; cited in Silva and Silva
1975, p 114). In hallucinations, this is clearly lacking. Thirdly, hallucinations are not
isolated defects but rather express the existence of the person hallucinating.
According to Merleau-Ponty: ‘The hallucinating person makes use of his relation
to the natural world to create an artificial one that corresponds to the total
intentionality of his being’ (1945/2002, p 399). This is, for instance, supported by
the fact that different modalities of hallucinations tend to dominate within different
pathologies (e.g. patients diagnosed with schizophrenia have mainly auditory
hallucinations and alcoholics mainly visual ones). Taken together, these character-
istics suggest that hallucinations are expressive of a disturbance of the relation
between the individual and her (interpersonal) world.
If hallucinations are expressive of a specific being-in-the-world, it is intelligible
that the sense modality that is affected varies by the type of pathology. But how
could we relate the two? Take the hallucinations characteristic of schizophrenia:
Why are they so often auditory and why, more specifically, ‘voices’ (instead of
persons)? A phenomenological perspective may draw some interesting and clinically
relevant parallels.

A clinical phenomenological approach and the unfolding of AVHs

AVHs are a common symptom of schizophrenia and florid psychotic conditions.

From the viewpoint of their content, AVHs are most often offensive and blasphemic;
they can give orders, critically address the behaviour (hallucinatory comment of
actions) or loudly repeat the thoughts of the subject (thought echo). Furthermore,
due to their emotional resonance and the semantic meaning, AVHs acquire a
profound pragmatic value for the person (Schneider 1959). Hence, audible thoughts
and imperative voices—arguing or commenting on the subject’s acts—have been
almost univocally considered as of important clinical value as they represent
experiences that are highly characteristic of psychotic disorders.
However, despite such prolonged semiological codification, AVHs remain elusive
to ascertain in the clinical context. First, due to their idiosyncratic nature, AVHs are
one of the less empathically understandable phenomena of psychosis: They involve
profound transformations of self-awareness and experience (Moreau de Tours 1845;
Straus 1966; Schneider 1959; Ey 1973; Stanghellini and Cutting 2003; Dalle Luche
2006; Cermolacce et al. 2007). Furthermore, by their very private experiential
quality, they are excluded from the shared field of intersubjective experience.
 F. Larøi et al.

Secondly, independently of the mainstream ascription to the conceptual realm of

deranged perceptions, AVHs are somehow resilient to pure behaviourally informed,
operational assessment as well as to any perceptocentric-oriented clinical investiga-
tion. On the contrary, patients often clarify that the largely recurrent designation of
AVHs as ‘voices’ does not exhaust their phenomenic richness, suggesting that the
descriptive levels implied in exploring AVHs should take into consideration
contextual, gestaltic changes in subjectivity not as a mere epiphenomena, but as
constitutive dimensions.
The following self-description, reported in Sechehaye (1951), helps illustrate such
psychoexistential intertwining:
At these times my ear took some part in hearing the voices. This was not so
before when I responded to the voices without any auditory sensation. Now
even though I distinguished them readily from real voices, I could say I
actually heard them resounding in my room. And then I kept seeing everything
in a confusion of terrible unreality: each object cut off, under a cold and
blinding light.
In particular, two phenomenological characteristics of AVHs that are difficult to
ascertain will be described in more detail: (1) a gestalt change of psychotic
consciousness and (2) certain clinical saliences such as the ubiquitous and
omnipotent character of AVHs and the fact that they are experienced as disembodied
voices.

AVHs and the gestalt change of psychotic consciousness

The clinical manifestation of AVHs, besides being necessarily merged into the
extended narrative of the patients, is further confounded by the broader
metamorphosis of psychotic consciousness (Conrad 1959; Bovet and Parnas 1993;
Sass and Parnas 2003; Stanghellini and Cutting 2003; Cermolacce et al. 2007). Such
a transformation of the core structure of subjectivity—which is clinically and
heuristically inextricable from the very experience of AVHs—is always contextual
with a compromised grasp of the world’s natural significations and a distorted
intersubjective constitution of the self. The latter are constitutive aspects that
invariably transpire into the formal structure of AVHs, offering a deeper
phenomenological characterisation which is indispensable for an appropriate
translational understanding.
In this context, for example, many classical authors (e.g. Gruhle 1952; Schneider
1959; Conrad 1959; Ey 1973) have described a transformation of the form of
consciousness with a diminished sense of self-presence, with reduced immediate sense
of ‘mineness’ of experience and increasing distance between the sense of self and the
experiential stream (see Sass and Parnas 2003 for a comprehensive overview). This
gestalt change may also involve an overwhelming experience of persecutory passivity,
in addition to autopsychic disturbances of the stream of consciousness, such as thought
pressure, thought interference, thought block, obsessive-like perseveration and failure
to discriminate between thought and perception (Klosterkötter 1988, 1992). Similar
progressions are described by most patients with schizophrenia, who point out how
acute hallucinatory episodes are often experienced as exacerbations of previous trait-
Auditory verbal hallucinations

like anomalies of the tacit neutrality of the interior dialogue. Inner speech in daily life
rhythmically articulates the immersion of the subject in the world. However, in pre-
psychotic conditions, an increasing gap is experienced between the sense of selfhood
(ipseity) and the flow of consciousness, and inner speech becomes increasingly
objectified, spatialised and localised in a perceptual-like way (Sass and Parnas 2003).
Furthermore, the sonorisation of thought (Gedankenlautwerden) emerges before well-
established psychotic hallucinations. Thus, an appropriate clinical appraisal of AVHs
presupposes that AVHs are not defined as atomistic, self-sufficient, thing-like
symptoms but rather as meaningfully interrelated facets of a more comprehensive
and characteristic gestalt change in the patient's experience (field of consciousness)
and existence.

Atmospheric ubiquity, omnipotence and AVHs as disembodied voices

Once psychosis is externalised with full-blown diagnostic symptoms, what qualifies

the clinical salience of AVHs is not their being taken for real (as concrete objects in
the environment) but rather their intrusive appearance in the realm of real things
(Cutting 1999; Raballo 2009). Indeed, as observed by Bleuler (1911/1952),‘the
“voices” of our patients embody … their entire transformed relationship to the
external world’ (p 97). That is, AVHs manifest the imposing, inescapable quality
inherent to the actual unfolding of psychotic consciousness. Furthermore, such
phenomenological features appear quite invariant through autobiographical narra-
tives and self-descriptive statements.
Struck by the irresistible power of the voices, the subject is not primarily
concerned in testing the physical–perceptual reality of the AVHs but is rather
captured by their overwhelming ubiquity. This feature has been brilliantly condensed
by Chadwick and Birchwood (1994):
without exception, voices were seen as omnipotent…For many patients this
[…] was supported by an experience of control […] and by the patient having
no influence over the voice. Also, all voices were seen as omniscient, again
emphasising their superhuman quality.
Also, AVHs totally overcome topographic limitations and physical barriers and
the ‘general order of things—assigning definite places with limited zones of reach
and influence—disintegrates’ in the unique, dominant ‘mode of being caught’
(Straus 1966, p 287). Thus, the entire physiognomy of the world (as well as the
intimacy of the psychic field) is changed and pervaded by hostile, irresistible powers
leading to the thematic externalisation of xenopathic delusions.
Together with ubiquity and omnipotence, a third feature of AVHs should be
mentioned: Voices are incorporeal and disincarnated. As elegantly showed by Straus: ‘In
the auditory hallucinations of the schizophrenic, the normal pattern of the acoustical
modality is deformed. The severance of the sound from the sounding body is brought to
a pathological extreme. Voice and speaker are radically disjoined’. (Straus 1966, p 286).
Furthermore, he observes that ‘voices are atmospheric, they behave like the
elements—the wind, the rain, the fire—and yet they speak, deride, and threaten.’
(Straus 1966, p 287). Thus, since voices are not persons intercorporeally accessible
in a shared social space, every chance of reciprocity—even at the mere level of
 F. Larøi et al.

conversational symmetry—is lost. Hearing voices is ‘more specifically feeling at the

centre of a network of disembodied voices’. (Stanghellini 2004, p 161). Such
feeling, however, is deeper than the contingent experiential interference produced
by the AVHs as such and rather points to more fundamental changes in the tacit
embeddedness in the world. More specifically, this metamorphosis indicates that
the patient ‘has lost his place in the human world’: The intersubjective framing of
existence (i.e. the fluid, unproblematic accessibility of the world shared with others—
koinos kosmos) is collapsed (Straus 1966; Bovet and Parnas 1993; Stanghellini 2004),
and the subject is confined to an idios kosmos (private world) totally exposed to the
atmospheric presence of the voices.
The following narrative fragments, written at almost two centuries of distance,
help illustrate such features, particularly the overwhelming power of the ‘voices’ in
their absolute access to the innermost intimacy of the subject:
Only a short time before I was confined to my bed I began to hear voices, at
first only close to my ear, afterwards in my head, or as if one were whispering
in my ear,—or in various parts of the room… These voices commanded me to
do, and made me believe a number of false and terrible things. (Perceval 1838)
At school, nobody teaches us we will hear voices later… at the beginning, I
went outside to search for their origin…and suddenly, my name is said, and I
can’t stand it. I feel as if I was inwardly raped, by voices which are not mine.
(Cermolacce et al. 2007)

Conclusion

The cognitive sciences have recently taken into account the phenomenology of
hallucinations, which has resulted in a refinement of methodology and theory. Two
examples of such refinements were given. However, being based on an empiricist–
rationalist approach, there are clear limits to the manner in which the cognitive
sciences view hallucinations on a definitional and theoretical level. The philosoph-
ical and clinical psychopathological approaches, both entrenched in a phenomeno-
logical view of hallucinations, provided clear indications of these limits. For
instance, whilst the empiricist–rationalist approach adopted by the cognitive
sciences views a hallucination as both a perception and a voice, a phenomenological
stance rather emphasises the primordial transformation of self-awareness and
experience.
This may be related, at least in part, to the differences in uses of the term
‘phenomenology’. As used by the cognitive sciences, ‘phenomenology’ refers to the
characteristics of a certain experience based on subjective reports and which are
eventually further differentiated and refined. In particular, elements of the
hallucination such as the attribution of the voice (self-generated versus non-self-
generated), in addition to examining the content of voices (e.g. trauma-related versus
non-trauma-related) are examples of characteristics that were integrated into the
methodological and theoretical discussions. In contrast, the term ‘phenomenology’
used by the philosophical and clinical psychopathological approaches refers not just
to the inclusion and appraisal of subjective experiences but rather to a philosophical
Auditory verbal hallucinations

method for the analysis of specific experiences and consciousness in general. Indeed,
phenomenological analyses in this sense (as the one from Merleau-Ponty) cast doubt
on the very rationalist–empiricist assumptions that still underlie even phenomeno-
logically informed research paradigms from the cognitive sciences. Although
interesting examples of a mutual enrichment between phenomenological analysis
and the cognitive sciences can be identified, more work needs to be done to enable a
phenomenological ‘front loading’ (Gallagher and Sørensen 2006) of experimental
design since the outcomes of phenomenological analyses are often not readily
translatable into specific experimental paradigms.
Clearly, there are important elements of hallucinations that the cognitive science
approach will need to integrate into future empirical studies and upcoming theoretical
models. For instance, one important property of hallucinations from a phenomeno-
logical stance is the idea that they represent an intersubjective process. A consequence
of this is that the subject of study should be the whole person, not ‘hallucinations’ as
an artificially isolated (atomistic) phenomenon. It is not immediately clear, however,
how to design an experiment that takes the ‘whole person’ into account, whilst at the
same time meeting the criteria for scientific research. Furthermore, detailed clinical
phenomenological analyses of hallucinations reveal that a broad metamorphosis of
psychotic consciousness precedes the appearance of florid hallucinations. Such a
transformation of the core structure of subjectivity would also merit empirical
examination. Moreover, such an example illustrates the importance of exploring pre-
hallucinatory states and experiences. Both traditional psychiatry and the cognitive
sciences have almost exclusively investigated hallucinations in their most flamboyant
manifestation, neglecting the generative sequences that lead to such psychopatholog-
ical end points. That is, there has been not only a general disinterest in those processes
that occur before the clinical emergence of AVHs but also a substantial lack of holistic
understanding of AVHs as dynamic phenomena antedated by subtle modifications of
the field of consciousness (Klosterkötter 1992; Sass and Parnas 2003). This is partly
due to the over-reliance on clear-cut, usually behavioural, criteria (such as DSM-IV)
which—although originally designed to increase reliability—have inadvertently lead
to a generalised disinterest for the complex and richly nuanced experiential features
that qualify psychopathological phenomena (see Andreasen 2007). Similarly, current
research—despite its increasing technical and psychometric sophistication—has
overlooked the transformation of the core structure of subjectivity that precedes the
emergence of AVHs. Nevertheless, considering the importance of these states and
experiences (i.e. without them, hallucinations would probably not even develop), a
better understanding of them is crucial.
In this respect, the availability of phenomenologically inspired assessment
instruments, such as the Bonn Scale for the Assessment of Basic Symptoms (Gross
et al. 1987), the Schizophrenia Proneness Instrument (Schultze-Lutter et al. 2007)
and the Examination of Anomalous Self-Experience (Parnas et al. 2005), provides
indispensable resources to investigate concomitant subtle, not-yet psychotic
disorders of subjectivity. Revitalising such careful and sophisticated focus on the
subjective dimension of experience is not only fundamental for contemporary
research but also has eminent clinical–therapeutical impact. The nature of the
intervention strategies proposed for people suffering from hallucinations is indeed
subordinated to a better understanding of their psychopathological genesis.
 F. Larøi et al.

In general, treatment of hallucinations involves either modifying the primitive

salience of the experience itself (e.g. a goal in pharmacological treatment is to reduce
the frequency and intensity of AVHs) or aspects associated with its psychological
elaboration and interpretations (e.g. cognitive appraisals and perceptions, coping
responses, emotional dysfunction, safety behaviours, cognitive processes such as
reasoning biases—often typical in psychological treatment schemes such as
cognitive–behavioural therapy (CBT)). However, more articulated treatment strate-
gies would also need to take into account the psychotic metamorphosis of the field
of consciousness, as well as pregnant features of the hallucinatory experiences (e.g.
atmospheric ubiquity, omnipotence and distorted intersubjectivity). In this respect,
recent developments in CBT (see Trower et al. 2010) propose treatment strategies
that try to reduce the impact of the ubiquity and omnipotence of AVHs, attempting to
modify the person’s relationship with their AVHs by modulating their personification
of it. Other, similar, developments in treatment schemes are needed that take into
account the various phenomenological characteristics of AVHs.

Acknowledgements Sanneke de Haan and Andrea Raballo are supported by the EU Marie Curie
Research Training Network 035975: Disorders and Coherence of the Embodied Self (DISCOS).

References

Aleman, A., & Larøi, F. (2008). Hallucinations: The science of idiosyncratic perception. Washington:
American Psychological Association.
Andreasen, N. (2007). DSM and the death of phenomenology in America: An example of unintended
consequences. Schizophrenia Bulletin, 33, 108–112.
Asaad, S., & Shapiro, B. (1986). Hallucinations: theoretical and clinical overview. American Journal of
Psychiatry, 143, 1088–1097.
Badcock, J. C., Waters, F. A. V., Maybery, M. T., & Michie, P. T. (2005). Auditory hallucinations: Failure
to inhibit irrelevant memories. Cognitive Neuropsychiatry, 10, 125–136.
Bentall, R. P. (1990). The illusion of reality: A review and integration of psychological research on
hallucinations. Psychological Bulletin, 107, 82–95.
Bleuler, E. (1952). Dementia Praecox or the group of schizophrenias. New York: International
Universities Press (Original work published 1911).
Bovet, P., & Parnas, J. (1993). Schizophrenic delusions: A phenomenological approach. Schizophrenia
Bulletin, 19, 579–597.
Cermolacce, M., Naudin, J., & Parnas, J. (2007). The “minimal self” in psychopathology: Re-examining
the self-disorders in the schizophrenia spectrum. Consciousness and Cognition, 16, 703–714.
Chadwick, P., & Birchwood, M. (1994). The omnipotence of voices: Part I. British Journal of Psychiatry,
164, 190–201.
Conrad, K. (1959). Die Beginnende Schizophrenie. Bonn: Das Narrenschiff im Psychiatrie.
Cutting, J. (1999). Psychopathology and modern philosophy. Scaynes Hill: Forest.
Dalle Luche, R. (2006). Una ricognizione fenomenologica delle allucinazioni acustiche verbali. Rivista
Sperimentale di Freniatria, CXXX, 65–86.
Ey, H. (1973). Traité des hallucinations (2 volumes). Paris: Masson et Cie.
Fowler, D. (1997). Direct and indirect links between the content of psychotic symptoms and past traumatic
experience: Evidence from therapists reports from the London-East Anglia study of cognitive
behaviour therapy for psychosis. British Association of Behavioural and Cognitive Psychotherapy
Annual Conference. Southport, July.
Gallagher, S., & Sørensen, J. B. (2006). Experimenting with phenomenology. Consciousness and
Cognition, 15, 119–134.
García-Martí, G., Aguilar, E. J., Lull, J. J., Martí-Bonmatí, L., Escartí, M. J., Manjón, J. V., et al. (2008).
Schizophrenia with auditory hallucinations: A voxel-based morphometry study. Progress in Neuro-
Psychopharmacology & Biological Psychiatry, 32, 72–80.
Auditory verbal hallucinations

Gross, G., Huber, G., Klosterkoetter, J., & Linz, M. (1987). Bonner Skala fur die Beurteilung von
Basissymptomen. Berlin: Springer.
Gruhle, H. W. (1952). Schizophrenia. Die Medizinische, 20, 1585–1588.
Hardy, A., Fowler, D., Freeman, D., et al. (2005). Trauma and hallucinatory experiences in psychosis.
Journal of Nervous and Mental Disorder, 193, 501–507.
Johnson, M. K., & Raye, C. L. (1981). Reality monitoring. Psychological Review, 88, 67–85.
Johnson, M. K., Hashtroudi, S., & Lindsay, D. S. (1993). Source monitoring. Psychological Bulletin, 114, 3–28.
Jones, S. R. (2010). Do we need multiple models of auditory verbal hallucinations? Examining the
phenomenological fit of cognitive and neurological models. Schizophrenia Bulletin, in press.
Jones, S. R., & Fernyhough, C. (2007). Neural correlates of inner speech and auditory verbal
hallucinations: A critical review and theoretical integration. Clinical Psychology Review, 27, 140–154.
Klosterkötter, J. (1988). Basissymptome und Endphänomeneder Schizophrenie. Eine empirische
Untersuchung der psychopathologischen Übergangsreihen zwischen defizitären und produktiven
Schizophreniesymptomen. Berlin: Springer.
Klosterkötter, J. (1992). The meaning of basic symptoms for the genesis of the schizophrenic nuclear
syndrome. Japanese Journal of Psychiatry and Neurology, 46, 609–630.
Larøi, F., & Woodward, T. (2007). Hallucinations from a cognitive perspective. Harvard Review of
Psychiatry, 15, 109–117.
Leudar, I., & Thomas, P. (2000). Voices of reason, voices of insanity: Studies of verbal hallucinations.
London: Routledge.
Leudar, I., Thomas, P., McNally, D., & Glinski, A. (1997). What voices can do with words: Pragmatics of
verbal hallucinations. Psychological Medicine, 27, 885–898.
Merleau-Ponty, M. (2002). Phenomenology of perception. London: Routledge (Original work published
1945).
Moreau de Tours, J. J. (1845). Du hachisch et de l’aliénation mentale: Études psychologiques. Paris:
Masson et Cie.
Moritz, S., & Larøi, F. (2008). Differences and similarities in the sensory and cognitive signatures of
voice-hearing, intrusions and thoughts. Schizophrenia Research, 102, 96–107.
Nayani, T. J., & David, A. S. (1996). The auditory hallucination: A phenomenological survey.
Psychological Medicine, 26, 177–189.
Parnas, J., Handest, P., Jansson, L., & Sæbye, D. (2005). Anomalies of subjective experience in first-
admitted schizophrenia spectrum patients: Empirical investigation. Psychopathology, 38, 259–267.
Perceval, J. T. (1838). A narrative of the treatment experienced by a gentleman, during a state of mental
derangement. London: Wilson. Republished in G. Bateson (Ed.), 1962 Perceval’s narrative: A
patient’s account of his psychosis 1830–1832. London: The Hogarth Press
Raballo, A. (2009). Incoercible voices: Clinical and phenomenological architecture of auditory
hallucinations. European Psychiatry, 24, 152.
Read, J., Van Os, J., Morrison, A. P., & Ross, C. A. (2005). Childhood trauma, psychosis and
schizophrenia: A literature review with theoretical and clinical implications. Acta Psychiatrica
Scandinavica, 112, 330–350.
Sass, L. A., & Parnas, J. (2003). Schizophrenia, consciousness and the self. Schizophrenia Bulletin, 29,
427–444.
Schneider, K. (1959). Clinical psychopathology. New York: Grune and Stratton.
Schultze-Lutter, F., Addington, J., Ruhrmann, S., & Klosterkoetter, J. (2007). The Schizophrenia
Proneness Instrument (SPI-A). Rome: Giovanni Fioriti Editore.
Seal, M. L., Aleman, A., & McGuire, P. K. (2004). Compelling imagery, unanticipated speech and
deceptive memory: Neurocognitive models of auditory verbal hallucinations in schizophrenia.
Cognitive Neuropsychiatry, 9, 43–72.
Sechehaye, M. (1951). Autobiography of a schizophrenic girl. New York: Grune & Stratton.
Silva, F., & Silva, M. C. (1975). Die Theorie der Halluzinationen bei M. Merleau-Ponty. Zeitschrift für
klinische Psychologie und Psychotherapie, 23, 100–137.
Stanghellini, G. (2004). Disembodied spirits and deanimated bodies. The psychopathology of common
sense. Oxford: Oxford University Press.
Stanghellini, G., & Cutting, J. (2003). Auditory verbal hallucinations—breaking the silence of inner
dialogue. Psychopathology, 36, 120–128.
Stephane, M., Thuras, P., Nasrallah, H., & Georgopoulos, A. P. (2003). The internal structure of the
phenomenology of auditory hallucinations. Schizophrenia Research, 61, 185–193.
Straus, E. W. (1966). Phenomenology of hallucinations. In E. W. Straus (Ed.), Phenomenological
psychology (pp. 277–287). New York: Basic Books.
 F. Larøi et al.

Trower, P., Birchwood, M., & Meaden, A. (2010). Appraisal: voices’ power and purpose. In: F. Larøi & A.
Aleman (Eds.), Hallucinations: A guide to treatment and management. Oxford: Oxford University
Press, in press.
van den Berg, J. H. (1982). On hallucinating: Critical–historical overview and guidelines for further study.
In A. J. J. de Koning & F. A. Jenner (Eds.), Phenomenology and psychiatry (pp. 97–110). London:
Academic.
Vygotsky, L. S. (1987). Thinking and speech. The collected works of L.S. Vygotsky, vol. 1. New York:
Plenum.
Waters, F. A. V., Badcock, J. C., Michie, P. T., & Maybery, M. T. (2006). Auditory hallucinations in
schizophrenia: Intrusive thoughts and forgotten memories. Cognitive Neuropsychiatry, 11, 65–83.

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