When people hear voices, but only when they want to

Yale psychiatrist Albert Powers didn’t know what to expect as he strolled among the tarot card readers, astrologers, and crystal vendors at the psychic fair held at the Best Western outside North Haven, Connecticut, on a cloudy November Saturday in 2014.

At his clinic, Powers worked with young people, mostly teenagers, who had started hearing voices. His patients and their families were worried that the voices might be precursors of psychosis such as schizophrenia. Sometimes, they were. But Powers also knew that lots of people occasionally heard voices — between 7 and 15 percent of the population, according to studies — and about 75 percent of those people lived otherwise normal lives.

He wanted to study high-functioning voice hearers, and a gathering of psychics seemed like a good place to find them. If clinicians could better distinguish voice hearers who develop psychosis and lose touch with reality from those who don’t, he thought, then maybe he could help steer more patients down a healthier path.

Powers introduced himself to the fair’s organizer and explained the sort of person he hoped to find. The organizer directed him to a nearby table where he met a smiley, middle-aged medium. The woman had a day job as an emergency services dispatcher, but the voices made frequent appearances in her daily life, and her side hustle was communicating with the dead.

“We had a really nice time talking to her,” Powers recalled. The medium described her first disorienting experiences hearing voices as a teenager, and her initial fear and distress. It sounded a lot like the stories Powers heard from his patients. But then, the woman said something Powers would never forget.

“She said,” Powers recalled, “if I couldn’t control this, I would go crazy.”

Outside the realm of psychosis, of course, a lack of control over what we hear can turn otherwise unremarkable sounds into intolerable noise. But in all his years as a psychiatrist, Powers had never asked patients if they could influence the voices they heard. There were scattered stories of extraordinary people like John Nash, the Nobel-winning mathematician who was diagnosed with schizophrenia and famously claimed to have interrogated the concept of hearing voices, which led him to reject them, but the conventional wisdom among clinicians was that people hearing voices were, by definition, not in control.

Yet the medium cheerily explained that she could make the voices come and go as she pleased. “That was completely mind-boggling to me,” Powers said.

Suddenly, he had a new research target: the meaning and mechanisms of control and its potential to transform auditory hallucinations from the distressing noise of psychosis into just another part of someone’s life.

Powers and his colleague, Philip Corlett, a psychologist and cognitive neuroscientist, reached out to other high-functioning voice hearers through local clinics as well as certain religious communities where voice hearing was common. Some of these people attributed what they heard to the spirit world, and others did not, but none of them were seeking clinical treatment, and the researchers stressed that they weren’t setting out to “fix” these folks but rather to learn from them.

For their first experiment, they divided several dozen research subjects into four groups: people diagnosed with schizophrenia who heard voices, those with schizophrenia but no voices, psychics who heard voices but had no psychiatric diagnosis, and a control group with neither a diagnosed mental illness nor a history of hearing voices.

All the subjects took turns in an MRI machine, where the researchers induced auditory hallucinations with classical conditioning, following the example of Pavlov and his dogs. Powers and his team repeatedly paired a projected checkerboard visual display with a one-second tone. The subjects in the brain scanner would indicate when they heard the sound and rate their confidence in their perception. After a while, the checkerboard visual would sometimes (randomly) be followed only by silence. Who would hear a tone anyway? How confident would they be? And would brain activity differ when perceiving sounds that did or did not exist?

The medium cheerily explained that she could make the voices come and go as she pleased. “That was completely mind-boggling to me,” Powers said.

The researchers published their findings in the journal Science in 2017, and the results showed that the parts of the brain responsive to the tone were more active when participants reported hearing the tone — whether or not there was a real sound to perceive. In addition, people who regularly heard voices, both with and without a diagnosis, perceived more nonexistent sounds than did the two categories of people who did not hear voices (up to 35 percent, compared to between 5 and 10 percent). Voice hearers were also more confident in what they perceived.

Despite these differences, however, the researchers noted a broader uniformity — they successfully induced hallucinations in people from all four groups.

Hearing voices that don’t exist “can be a really stigmatizing experience,” Powers said. “The fact that anybody can be made to do this, and that we all have the mechanism to make this happen, is something that I find to be a really normalizing aspect of this work.”

The overall findings fit a model of sensory perception that explains our sense of reality as a mix of top-down expectations learned from experience (aka “priors”) and bottom-up sensory inputs. Constantly building our realities from the ground-up would be way too noisy and paralyzingly slow, the theory holds, and so the brain uses predictive inferences to filter and smooth the barrage of sensory noise into useful perceptual signals, filling in gaps with illusion where necessary. (The theory dates to the work of the 19th-century German scientist and physician Hermann von Helmholtz, and more recently it’s been advanced by Karl Friston at University College London, and Andy Clark and Anil Seth at the University of Sussex, among others.)

Accordingly, for voice hearers with serious psychotic disorders, it might be that their brains struggle to process noisy sensory information that is somehow being corrupted or degraded, thus, they update their expectations less readily. Indeed, in the brain scan study, voice hearers with diagnosed schizophrenia were the last to catch on when the researchers made the appearance of the checkerboard more independent from the tone. Their brains kept on discounting this new, noisier reality in favor of continued auditory hallucinations.

In follow-up research, Powers and his team dug deeper into the possibilities of control mentioned by the medium he’d first encountered. Interview-based studies confirmed that the biggest difference between people with and without a diagnosed psychiatric disorder was that the latter group were more likely to report control over voice onset and offset, and that they had learned this control through a variety of practices and rituals. While the possibility of helping patients by fostering control was exciting, Powers understood that before he or anybody proposed new clinical therapies based on the idea, they would need a lot more evidence.

By 2019, the research had expanded into the Yale COPE (Influence/Control Over Perceptual Experience) Project. Their first objective was to define control. Was it trying to drown voices out by talking over them or blasting music? Or was control limited to more direct influence like the medium had described it? However they defined control, the researchers also needed to create and validate a way to measure it.

"The fact that anybody can be made to do this, and that we all have the mechanism to make this happen, is something that I find to be a really normalizing aspect of this work.”

They needed to recruit hundreds of voice hearers from diverse backgrounds, so they partnered with people from the mental health community, spiritualists, religious leaders, and advocacy groups such as the Hearing Voices Network to form an advisory board for COPE. The goal of the board, called the “SPIRIT Alliance,” was to review study plans and help build trust among people who were normally wary of clinical psychiatry and the labels they associated with it.

Within a couple of years, about 1,100 people had enrolled, and more than 300 had completed surveys about their mental health and voice experiences, providing enough data to winnow down more than 150 control-related questions to the 18 strongest predictors of a person’s clinical outcomes and quality-of-life, whether or not they sought treatment or had a diagnosed disorder.

In 2022, the team published a paper titled “Measuring Voluntary Control Over Hallucinations: The Yale Control Over Perceptual Experiences (COPE) Scales.” People who scored higher on the scale had greater control, which correlated with lower measures of hallucination severity and lower perceived malevolence and omnipotence of the voices. These people also reported less distress and a better quality of life.

However, the patterns only held for direct control, which the researchers termed “engagement-based” approaches to turning the voices on and off rather than attempts to ignore, distract, or drown them out. Somewhat ironically, people who accepted the voices to some degree had greater control over them, compared to people who resisted the voices.

In 2022, the COPE Project was awarded five years of NIH funding to study people who hear voices with varying levels of control according to the COPE scale. They are currently about two and a half years into data collection, including both brain scans and a longitudinal study of about 60 voice hearers to track any changes in their ability to control the voices, and to spot any common predictors or correlates of those changes.

“This grant is really trying to understand how people accomplish this feat of being able to voluntarily turn the voices on or off,” Powers said. Specifically, are people exercising top-down control or is it more about changing the balance of perception by giving more weight to incoming sensory stimuli?

For instance, in one brain-scan experiment using conditioned hallucinations, the researchers periodically change the color of the paired visual cue — with red telling subjects to try and turn off the voices and green meaning the opposite (white being a neutral cue). Will people have fewer conditioned hallucinations when the visual cue is red and will the corresponding brain activity changes be more concentrated in areas linked more with inhibition or with sound perception?

Meanwhile, Powers and his team have also begun to study the impacts of pharmaceuticals on the frequency of conditioned hallucinations, and are interested in looking at recently approved antipsychotic medication called Cobenfy that mimics the neurotransmitter acetylcholine and enhances sensory neurons, perhaps shifting the balance of perception toward sensory inputs and away from hallucinating.

People who scored higher on the COPE scale had greater control, which correlated with lower measures of hallucination severity and lower perceived malevolence and omnipotence of the voices.

Knowing that the psychiatric establishment will be wary of new treatment approaches for psychosis based on studies of mediums and psychics, the researchers are moving deliberatively. Non-diagnosed voice hearers follow a range of practices to foster the development of control, such as finding community, normalizing, and engaging with the voices, which leads to the ability to set boundaries with them. But Powers emphasized that his team is working to build an iron-clad case around how voice control works in the brain, as well as the pathways to enhancing that control, before they test any clinical interventions with psychotherapy, pharmaceuticals, or some combination. One of the more exciting possibilities, Powers said, is to develop interventions based on neurofeedback — a technique that teaches patients how to intentionally change their brain activity — that could help people develop control over voices without engaging with them.

With all that said, Powers emphasized the fact that wanting more control over these voices is not necessarily the same as wanting them to shut up forever and disappear from one’s life. For the people who come into his clinic, Powers said there is a mixture in whether they experience the voices as annoying or pleasant, terrifying or comforting. “When we talk about the mechanisms behind the hallucinations, it can be easy to forget that this happens in the context of a really complex system, which is someone’s ability to conceive of themselves as a piece of the outside world.”

Chris Berdik is a Boston-based science journalist.

This article was originally published on Undark. Read the original article.