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June 2018 Issue [Report]

The Sound of Madness

Can we treat psychosis by listening to the voices in our heads?

Sarah was four years old when her spirit guide first appeared. One day, she woke up from a nap and saw him there beside her bed. He was short, with longish curly hair, like a cherub made of light. She couldn’t see his feet. They played a board game—she remembers pushing the pieces around—and then he melted away.

After that, he came and went like any child’s imaginary friend. Sarah often sensed his presence when strange things happened—when forces of light and darkness took shape in the air around her or when photographs rippled as though shimmering in the heat. Sometimes Sarah had thoughts in her head that she knew were not her own. She would say things that upset her parents. “Cut it out,” her mother would warn. “This is what they put people in psychiatric hospitals for.”

Wormholes, 1919, by August Klett, who was a patient at the psychiatric clinic at the University of Heidelberg, in Germany. Under the alias August Klotz, he was one of the ten “schizophrenic masters” whose work was collected in the book Artistry of the Mentally Ill (1922). The book was compiled by Hans Prinzhorn, a psychiatrist and art historian, who recorded Klett as hearing voices that were obscene, accusatory, and threatening. © Prinzhorn Collection, University Hospital Heidelberg, Inv. No. 568

Sarah was the youngest of four siblings. Her father was a sales manager for a pharmaceutical company, and he traveled a lot while his wife stayed home with the kids. Sarah’s mother was a strict disciplinarian. She was determined to straighten out her children, whom she felt had been spoiled by the housekeeper they’d left behind when they moved to California. Sarah remembers one day, not long after she played the game with her spirit guide, when she and some neighborhood kids tried to set up a barbecue in the back yard. Her babysitter found them in the basement, burning strips of paper in the pilot light of the furnace. When Sarah’s mother came home, she held the girl’s fingers in the flame of a cigarette lighter as punishment.

As Sarah grew up, she started to dislike the strange experiences she had, and she decided that they could not be real. Then she went to college and became a nurse, and she began to see the souls of dead patients leave their bodies. Sometimes what emerged was a transparent version of the corpse. Other times she saw what the patients must have looked like when they were young. A few would stand next to the bed. More floated up to the ceiling and looked down. They were usually startled to see their own bodies and horrified to witness the pummeling they took from doctors trying to keep them alive.

Sarah found that the dead would speak to her. It sounded like they were really talking, as if she could hear them with her ears, although she quickly learned that no one else could hear them. They gave her messages to give to people they’d left behind, but mostly she helped them release their grip on life. That was her task, the reason they became visible to her. “Some people get very distraught,” she told me. “They’re terrified of the transition.” Most of the time, the souls would be visible only for a minute, but occasionally they stayed as long as an hour. Eventually they would dissipate, like mist into air.

When I met Sarah, in the summer of 2016, she was sixty-two and still working full time. I am an anthropologist, and I was interested in Sarah because she said she still heard voices, sometimes as often as every day. For decades, hearing voices—having auditory or quasi-auditory perceptions of the speech of invisible others—has been seen as a definitive sign of the radical break with reality that we call psychosis. Voice hearing is one of the identifying features of schizophrenia, the most devastating and intractable of psychiatric disorders. But Sarah is not psychotic. To use the language of psychiatric nosology, she has no “functional impairment.” She can work and care for herself and others; her marriage is good and stable. She has never been hospitalized. At the time of our interview, Sarah was long past the danger zone of early adulthood, during which most people with serious psychoses are diagnosed. By any normal measure, she is completely healthy. Sarah is one of many people who are challenging what psychiatrists think they know about mental illness.

Hearing voices is, it turns out, surprisingly common. In 1894, a team led by Henry Sidgwick, a philosopher at the University of Cambridge, published the Census of Hallucinations, which surveyed 17,000 people in the United Kingdom and found that around 10 percent of them reported having seen, heard, or felt something “which impression, so far as you can discover, was not due to any external physical cause.” Many more recent studies have supported that observation. In 1983, two psychologists, Thomas Posey and Mary Losch, modified Sidgwick’s basic question and found that the rate skyrocketed to 70 percent when participants were given the opportunity to say that they had heard a voice but decided that it wasn’t real. And as many as 80 percent of people who have lost a loved one report hearing, seeing, or feeling them in the months after their death.

An untitled painting by Eugen Gabritschevsky, c. 1950. Gabritschevsky completed advanced degrees in genetics and biology and worked at the Pasteur Institute before being diagnosed with schizophrenia. Collection abcd/Bruno Decharme © Estate of Eugen Gabritschevsky

For years, I have spoken with such people. I study the odd and the uncanny—voices, visions, the supernatural. I seek out people who have experienced otherworldly events, and as I have published my research they have sought me out in turn. People have told me that while they were driving, God spoke up from the back seat and said that he would always love them, or that as they stood looking at the ocean, the waves became light and language. Others have shrugged and said that they were speeding and God’s voice came over the radio to tell them to slow down.

I wrote my dissertation on Londoners who called themselves pagans, witches, and druids. They were people with ordinary, stable jobs who nevertheless claimed to live in a lush garden of wizards and goblins and to travel on an astral plane. These adults gave themselves permission to play with invisible others and refused to be embarrassed about whether or not they were real. I knew people who had whole rooms devoted to goddesses—altars to Cerrid­wen, Artemis, and Freya. They brought them gifts and talked to them. Sometimes, the goddesses would respond.

Later, I spent years with Charismatic Christians in the United States, most of whom would hate to be identified with so motley and marginal a crowd. Yet much about the blunt structure of their spirituality was similar. They, too, longed for intimacy with an invisible being and used their minds to imagine him. They immersed themselves in stories about him and spent hours contemplating those stories in intense daydreams. They went for walks with him, danced with him, sat in his lap as they prayed. They told me that God sometimes talked with them in ways they could hear with their ears. And, like the Londoners, they had subtle and complex ideas about the relationship between fantasy and reality. As one pastor said, “The excruciatingly delightful tension between what is imagined and what is real is where I live.”

People who claim to have seen or heard invisible beings tend to score high on the Tellegen Absorption Scale, a measure introduced in 1974 that assesses a person’s responses to engaging stimuli. They are often people who lose themselves in nature, become captivated by books, or pray ardently—in other words, people who get caught up in their inner worlds. When the witches and druids in London performed rituals, they sat in the dark with their eyes closed, trying to see, hear, and feel what the leader was describing. During my research at Stanford University, I randomly assigned about a hundred Charismatic Christians to either daily lectures on the Gospels or daily prayer practice, which involved listening to story sequences based on Scripture. I found that those in the prayer group were more likely to report that they had heard a voice or seen a vision.

But the great majority of people who hear voices—whether they take the voice to be a god or goddess, a recently dead mother, or the bark of an absent dog—experience very few such events. The invisible other speaks to them once, maybe twice. The voices are brief and transient: “I will always be with you,” “I love you,” “Yes.”

On the surface, these seem nothing like the voices that torment people with schizophrenia. The voices of madness are horrifying. People who are mentally ill often feel besieged by their voices, as if their heads have been thrust into a beehive of sneering, attacking, commanding words. The words are sounds or quasi sounds, or even thoughts that seem to come from an exterior source. Elyn Saks, the author of a remarkable memoir of living with schizophrenia, wrote, “Thoughts crashed into my mind like a fusillade of rocks someone (or something) was hurtling at me—fierce, angry, jagged around the edges, and uncontrollable.” Mad voices speak from outside the mind, sometimes only two or three, sometimes hundreds at a time.

One man diagnosed with schizophrenia told me that his voices would peel off the cars that drove past, as if the tumbling air had formed itself into a weapon. “I hear voices constantly,” he said. “I hear voices in other rooms. I hear it from down the street, down the stairs. Like God is leading a chorale of voices.” The voices cursed him and put him down and made him feel trapped. “The world is watching you,” they said. “We’re watching you.” People with psychosis often hate their voices and find them terrifying.

And yet one of the new ideas in psychiatric research is that these two seemingly distinct types of voice hearing might be related. A group of highly respected, mostly European scientists—among them Jim van Os in Maastricht, the Netherlands, and Charles Fernyhough in Durham, England—have started to argue for the maverick idea that all auditory hallucinations exist on what they call the psychotic continuum. In other words, voices heard by healthy people are simply less severe manifestations of those heard by the mentally ill. These scientists suggest that hearing voices is like experiencing sadness. Some people are clearly sadder than others, and terrible sadness may require hospital care. But there is nothing inherently abnormal about sadness itself. Van Os, Fernyhough, and others have started to ask whether healthy people who hear voices frequently, like Sarah, somehow learned early on to manage their unusual perceptions and so never spiraled into mental illness. They believe that the voices of madness could be softened, if we could only teach people to harness them.

Voices are remarkably hard to study in the laboratory. Scientists have shown that areas of the brain associated with language are active during an auditory hallucination, but the neuroscience of voice hearing remains poorly understood. We talk about such events as “voices,” but even for someone with psychosis, the experience is often more like having a thought that does not feel like your own. Many people say that the voice was not in their head but cannot be sure that they heard it with their ears. These subtleties of human awareness are impossible to study without talking to people and, as a result, getting mired in the swamp of subjective reporting and the limits of language. And so for decades, psychiatry has more or less ignored voices, even though around 70 percent of those diagnosed with schizophrenia hear them.

In the middle of the twentieth century, when psychoanalysis dominated the field of psychology, many clinicians believed that schizophrenia arose from a child’s response to her mother’s emotional conflict. The most famous illustration of this dynamic, described by the En­glish anthropologist and early cyberneticist Gregory Bateson in 1956, was this: a mother comes to the psychiatric ward to see her son; he reaches out to hug her; she flinches; he withdraws; and then she asks, “Don’t you love me?” The great psychoanalyst Frieda Fromm-Reichmann labeled this mother schizophrenogenic: she drove her son insane because he could not handle the hostility she felt but refused to acknowledge. He went mad because he could not allow himself to know what was real. Psychoanalysts who wrote about schizophrenia puzzled over family dynamics. Theodore Lidz, a professor of psychiatry famous for his work on schizophrenia, once wrote grimly, “We now know that the patient’s family of origin is always severely disturbed.”

An untitled drawing, c. 1910, by Barbara Suckfüll, who heard voices that ordered her to write and to draw © Prinzhorn Collection, University Hospital Heidelberg, Inv. No. 1955recto

During this period, psychologists were so focused on therapy—on the meaning behind the symptoms, on the impact of being in a room with an empathic listener—that few of them paid attention to diagnosis, let alone to the brain. In 1973, David Rosenhan, a professor of psychology at Stanford, exposed those biases in an article that hugely embarrassed the psychiatric community. Rosenhan persuaded seven friends to join him in an experiment. He asked them to make appointments at multiple psychiatric hospitals across the country and explain to the doctors that they had heard voices that said things like “empty,” “hollow,” and “thud.” Apart from their names and professions, they were to change no details about their lives. Each participant was admitted as an inpatient to a psychiatric ward, and in every case but one they were diagnosed with schizophrenia. Doctors released them after, on average, nineteen days, but one was held for nearly two months. “It is clear,” Rosenhan wrote, “that we cannot distinguish the sane from the insane in psychiatric hospitals.”

By that point, psychoanalytic psychiatry was already on its way out. Psychoanalysis seemed to help people who functioned more or less normally in society—they were soon called the worried well—but it did little for patients with serious disorders. The new diagnostic manual that appeared in 1980 replaced language about emotional conflict with specific criteria that patients needed to meet, establishing a clear dividing line between health and illness. When the writer Lauren Slater set out to replicate the Rosenhan experiment thirty years later—presenting herself unkempt, unshowered, and with unbrushed teeth at nine hospitals, where she explained that she’d heard a voice saying “thud”—not one doctor gave her a diagnosis of schizophrenia. But they did give her medication for depression and psychosis.

In the intervening years, leadership in the field had shifted to scientists who sought to make psychiatry a rigorous branch of medicine by identifying the neural pathways responsible for mental illness. Voices were imagined as simple byproducts of brain disorder, no more important than the scratched welt of a mosquito bite. By 1990, pharmaceutical companies had introduced more than forty medications that tried to dampen the major symptoms of psychosis by blocking the reception of dopamine and other mood-changing chemicals in the brain. 

But the biomedical model has not fulfilled its promise. The medications work modestly at best, and none is the miracle drug the fanfare once suggested. In 2005, the New En­gland Journal of Medicine published a study in which scientists tested a group of newer and older antipsychotic medications on 1,493 people; they found that only a quarter of participants were sufficiently helped by the drug they had been given to finish the eighteen-month trial. It also turned out that the new medications had unexpected side effects. Patients on Zyprexa, one of the newer antipsychotics, can put on a hundred pounds in a year.

The theory of the psychotic continuum has emerged as psychiatric scientists have lost faith that schizophrenia has distinctive markers—that it is defined by a specific set of symptoms or a single neurological deficit. As one group of researchers observed in 2009, “Virtually no two patients present with the same constellation of symptoms.” Decades of studies have shown that schizophrenia is the complex result of many unrelated factors—the genes you inherited, the health of your mother during pregnancy, whether you were beaten as a child or stressed as an adolescent, even how much time you spend in the sun.

With that has come an understanding that voice hearing can shape the course and outcome of the illness. What voices say affects what the person who hears them does. About a third of people with schizophrenia try to commit suicide, and around 20 percent hear voices that order them to do so. Scientists have begun to take seriously that people with psychosis sometimes say they went mad because their voices drove them crazy.

In June 2016, I drove from Stanford to Sarah’s home in the Santa Cruz Mountains, hoping to understand whether her voices were similar to those heard by people with psychosis and how she had learned to manage them. Her house was an old Craftsman, built by an early Californian with a seafarer’s imagination—the rooms were wood-paneled and intricate, with nooks and built-in shelves. Sarah, a warm woman with short brown hair, greeted me at the door and showed me into an elegant living room. There was iced tea waiting on the table, and family pictures hung on the walls. Her two kids had started lives of their own. She now lived with her husband, a contractor, and a cat called Winston, who was busy pawing at a scratching post in the corner.

An untitled double-sided painting, 1961, by Carlo Zinelli. Admitted to a psychiatric institution and diagnosed with schizophrenia after World War II, Zinelli began drawing in 1955. Courtesy Collection de l’Art Brut, Lausanne, Switzerland, Inv. No. cab-2128

Sarah told me that she thought of herself as “intuitive.” She read books that treat hallucinations as special and spiritual—New Age manuals by Native Americans, books on death and dying, on portals and the other side. She thought that people could tell she had a gift. She would know things they hadn’t told her, and she believed that she helped them by allowing them to talk about things they often kept hidden. She didn’t share everything she experienced with her husband, and he didn’t quite know what to make of what she did say. “I have enough troubles in my life without having other voices in my head,” he remarked wryly. He was a big man, charming and chatty like his wife. He laughed when I asked him what he made of Sarah’s stories. But then he mentioned that he’d had an odd experience of his own—his dead aunt showed up in his armchair one evening and told him not to be so upset about a spat in the family—and it became clear that he treated Sarah’s experiences with deference.

When I asked Sarah about her spirit guide, the one who had played the board game with her when she was four, she said that she had tried to ignore his presence for years. “I thought I was making it up,” she said. But in her mid-thirties, her husband gave her a spiritual retreat as a birthday gift. She went off to Sedona, Arizona, with her older sister to join the members of the retreat at a small bed-and-breakfast in the desert. Around midnight on the first night, something ripped through the wall of their bedroom with the metallic roar of a jet engine. It was oblong and humanoid and it glowed a brilliant red, so bright that Sarah had to squint. There was a sucking sound, and then a pop. She was terrified. (Her sister, on the other hand, simply rolled over and went back to sleep.) Sarah told herself that she was imagining things and turned away from the red shape. But then it spoke to her. It reassured her, although she couldn’t remember much of what it said.

The next morning, Sarah reported what had happened to the retreat leader. “She could see I was deer-in-the-headlights,” Sarah told me. The leader believed Sarah had a gift she had ignored, and that the being had come because she needed something “to blow the barn doors open.” She encouraged Sarah to work with her gift and to find a spirit guide. 

It was then that Sarah decided to treat her invisible childhood friend as real. Many conversations later, she asked him to introduce himself. He told her his name was Tom. “That’s not a very good name,” she responded. And Tom, she said, answered back: “What’s wrong with it?”

Sarah told me that talking with Tom helped her make sense of the other voices she experienced, some of which were far less pleasant. These voices came into her life later than Tom did, not until after Sedona, when she was in her forties. She called them the council. Sarah could sometimes hear them talking to one another as if they were in the next room, sometimes murmuring, sometimes speaking more clearly. She had no difficulty distinguishing their voices from her own thoughts. It wasn’t only the way they spoke—they had a particular cadence—but what they said. “They don’t mince words,” she told me.

When the council really wanted to get her attention, she said, they would become physical. They would throw fruit on the floor and knock down picture frames. Sarah spoke as if the council took action only in her best interest. She described one instance when they had thrown a rock at her to draw her attention to some loitering men, and she had known that she should leave the area fast. But she clearly had a more distant relationship with these voices than she did with Tom. He knew the council; in some ways, she thought, he was one of them. But when Tom spoke, he was animated. He sounded like a friend. The council’s voices were monotone. Sarah did not seem to like them as much. I asked her whether, when she heard the council, she ever turned her head to see who was speaking—the unambiguous mark of an audible voice. She said she did. Sometimes the council spoke to her for as long as two hours a day.

The voices of the council have many of the formal features of psychotic voices: they talk with one another; they murmur; they are sometimes negative and even downright mean; they command; they are weirdly auditory. Sarah cannot control them. Tom told her that everyone on the council was a teacher but that he could be the spokes­person if it was easier for her to respond to one voice at a time. “I think he’s been there for me so that perhaps I didn’t go crazy,” she said to me at one point, “to help me make sense of this, and to kinda keep me from being a danger to myself.” She said it was akin to having an internal dial, like one on an old radio—she could turn it so that the conversation was clear, or keep it static. Tom helped her to feel in charge of the dial.

It seemed that, with the help of the retreat leader, Sarah had decided to build a narrative in which her experiences were not alien, and she used Tom to help her manage the things that frightened her. It was as though she had invented him as a protector. She said he would show up when she needed him; she called him a mentor. So the council couldn’t frighten her, even when they were throwing fruit around. 

These days, Sarah talks to Tom often. She says that he tells her things she needs to know and corrects her when she makes a mistake. “That’s not the way it truly happened,” he might say. She consults him when her cat gets sick and when she has a strange dream. Most of the time he speaks in her mind, but sometimes he speaks out loud. Several times a year, often when Sarah is at the edge of sleep, Tom appears in the room. At first, he showed up in clothes that looked like they were cut in an earlier century—in an Edwardian dinner jacket, say, sometimes with women wearing bustles in the background. These days he mostly wears a blazer and slacks. Sarah told me that she and Tom have known each other a long time. How long? I asked. She paused and gave me a little smile. “He’s saying, in the Sumerian period.”

Sarah’s methods for managing her experiences are strikingly similar to two treatment approaches that have recently become popular in Europe, both of them peculiar but also promising. One is the Hearing Voices movement, a grassroots, patient-driven campaign whose members often reject the teachings of psychiatry. It emerged in the late Eighties through the leadership of Marius Romme, a Dutch psychiatrist, and his wife, Sandra Escher. The movement is ardent, excited, and chaotic. There are now hundreds of Hearing Voices groups across Europe and the United States. Many different ideas about voice hearing float around in these groups—that everyone hears voices, that voices always carry a memory of sexual trauma, or that voices are “real.” What people seem to mean when they use the word “real” is that they do not consider their voices to be symptoms, fragments, or mistaken perceptions but instead believe that they belong to invisible people in the world. When I attended a Hearing Voices meeting in Maastricht, one of the participants announced that her group had seventeen members. “Three of them are human,” she said.

Request No. 2,345, The Mysterious Affairs of the Attempted Murders, by Johann Knopf, who claimed to understand the voices of birds. Knopf was a patient at the Heidelberg psychiatric clinic and was included in Artistry of the Mentally Ill under the alias Johann Knüpfer. © Prinzhorn Collection, University Hospital Heidelberg, Inv. No. 1494/4

Despite the range of views, the groups have basic practices in common. Participants in a Hearing Voices group are asked to name their voices, to respect what the voices have to say, and then to negotiate with them. The goal is to turn your voice into something closer to a person with whom you can have a reasonable and positive relationship. At a training in San Francisco in September 2013, I watched Ron Coleman, a burly movement leader, work with a young man who hated his voices. “What’s the name of your most important voice?” Coleman asked. “I don’t know,” the man replied. “It doesn’t have one.” “You don’t know?” Coleman asked. “How does that make sense? If someone came to the front door and wanted to talk with you and didn’t tell you his name, you’d shut the door in his face!”

A man I met in Maastricht told me that he had been hearing voices for years by the time he began attending a Hearing Voices group. His voices would yell at him for hours, cursing him, screaming that they should drag him out to the forest and leave him to die in the leaves. The members of his group told him that he should learn who was speaking and what the voices wanted to tell him. They encouraged him to respect his voices, even though he hated them, and helped him to practice what he would say in response. It was hard because he was afraid. Once he got comfortable, the group insisted that he negotiate with the voices. And then he and his voices cut a deal: he would do what they wanted for an hour a day, and then they would leave him alone. As it happened, one of the man’s voices was obsessed with Buddhism, so he agreed to read Buddhist texts and offer prayers during the allotted hour. By the time I met him, he hadn’t heard voices in a year, and he had almost completely transitioned off his medication.

Slowly, researchers are studying the efficacy of these groups, despite the disdain many members have for psychiatry and science in general. Self-report measures find that they work. That is, the methods make hearing voices less aggravating for most people, and some find that their voices become kinder, softer, or even go away. In the United Kingdom and the Netherlands, Hearing Voices groups have become almost mainstream, and many European clinicians have abandoned the oversimplified biomedical approach that treats voices as irrational byproducts of a disordered brain. In 2014, the British Psychological Society published a basic manual, Understanding Psychosis and Schizophrenia. The introduction reads: 

We hope that in future services will no longer insist that service users accept one particular view of their problem, namely the traditional view that they have an illness which needs to be treated primarily by medication.

The society recommends Hearing Voices groups.

The second method, which is similar in approach, is avatar therapy. It was developed in 2008 by Julian Leff, a London researcher who has studied schizophrenia for decades. Leff asked patients to sit in front of a computer and choose an avatar—a head and a vocal timbre—to represent their most distressing voice. The head is suspended on the screen like a character in a video game, eerily robotic, hovering. From another room, a therapist guides the experience, like the Wizard of Oz behind the green curtain. In one demonstration of the method, now posted on ­YouTube, the voice says, “You’re worthless. You’re a waste of space.” Then the therapist coaches the patient on how to respond. “I want you to talk back to the avatar as strongly as you can.” You see the uneasy patient staring at the screen, scared to reply. But he does. Over time—usually six sessions, which can be as short as ten minutes each—the therapist makes the computerized voice kinder and more respectful in response to what the patient says. In January, a British paper in The Lancet Psychiatry described a study that took 150 people whose condition had not been sufficiently helped by medication and gave them a twelve-week course of either avatar therapy or supportive counseling. Avatar therapy was shown to be significantly more effective, at least in the short run.

The central insight of these methods is that the way people respond to their voices can change the course of their lives. This way of thinking is very different from treatment as usual in biomedical psychiatry. Particularly in America, the tainted history of the schizophrenogenic mother has made psychiatrists hesitant to look for answers beyond brain chemistry. It runs against the grain to think of treating voices as people: naming them, interacting with them. It seems dishonest, because voices are not real people. But doing so may help patients make voices respond as if they were reasonable human beings. This is the new axiom of the psychotic continuum theory: that voices are not the problem. The problem is the way people react to their voices.

Both of these approaches seem promising. They offer hope. But serious psychotic disorder can be very difficult to treat. No one method is likely to work for everyone, and developing a more positive relationship with one’s voices does not guarantee a good outcome. In Pittsburgh in 2014, I met a woman whose son had done more or less what Sarah had. When he began hearing voices, he interpreted them as angels and demons. The woman’s sister was deeply religious, and she helped her nephew exorcise the demons. Soon he was able to make them go away for short periods of time. He liked the other voices, the angels. But one of the angels did not like his grandmother. The angel thought she was a witch. One morning before breakfast, the angel told the son that the witch must die. He grabbed a kitchen knife and stabbed his grandmother at the table. She bled to death on the floor.

Hearing voices is possible because of the nature of thought itself—our thoughts are made by us and yet feel, at times, independent of us. The ability to create an interior world that can be experienced as real has long been cultivated by religious believers, like the Charismatic Christians I studied, but also by writers. Many novelists talk as if writing were like taking dictation. Charles Dickens once told a friend that he distinctly heard his characters speaking. “I don’t invent it,” Dickens remarked in a letter, “really do not, but see it, and write it down.” When Charles Fernyhough, one of the advocates of the psychotic continuum theory, asked writers at the Edinburgh International Book Festival whether they heard the voices of their characters, a quarter said that they heard them as clearly as if they were in the room.

In the memoir Moments of Being, Virginia Woolf writes that after her father died, she heard birds singing in Greek. On the day she went to the river, filled her pockets with stones, and walked beneath the water, she left a note for her husband, Leonard, that read: “I begin to hear voices, and I can’t concentrate. So I am doing what seems the best thing to do. You have given me the greatest possible happiness.” In Mrs. Dalloway, Woolf writes Clarissa’s thoughts as though she overheard them, as if she were Clarissa’s scribe.

An untitled painting, c. 1932–35, by Augustin Lesage, who was a miner until the age of thirty-five, when he heard voices that told him he would become a painter. Courtesy Collection de l’Art Brut, Lausanne, Switzerland, Inv. No. cab-1987

Are these the same voices, the voices of madness and the voices of creativity? In some measure, it does not matter. Whatever led Dickens to say that he heard his characters speak, he was nevertheless able to edit and shape the story. What Sarah seems to have done, and what these methods teach, is to harness a writer’s techniques—to coax and change menacing voices into characters that can be controlled.

There is much more research to do. My own fieldwork has led me to doubt that the psychotic continuum theory can explain all forms of voice hearing. Of the hundreds of people I have spoken to over the years, Sarah is one of a very few who seem to function normally while experiencing multiple voices every day. She is the exception, not the rule. These conversations suggest to me that the neural networks associated with psychosis are distinct from those that lead to daydreaming, absorption, and spirituality. For many people, hearing voices may have more to do with the activity of the brain when it’s on the edges of sleep, with grief, with creativity, or with religious practice than with mental illness. Yet whatever the fate of the psychotic continuum theory, it seems clear that the techniques of the Hearing Voices movement and avatar therapy should be made more readily available to people with serious psychotic disorders.

At the end of our interview, Sarah and I stood together for a moment on her porch, which overlooked a ravine behind the house. I envied the view. Sarah told me that she often worried about kids who heard voices and assumed they were insane. “We come in blind to the human condition,” she said. She meant that humans are shaped by a culture duller and dumber than it should be. She paused and looked out at the hills. “I like my life. As crazy as it is.”

 is the Watkins University Professor of Anthropology at Stanford University. Her article “Worlds Apart” appeared in the February issue of Harper’s Magazine.

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