Hearing voices in your head when there’s no one around … that’s a sign of madness, right?
In the popular imagination voice-hearing is often viewed with fear and suspicion, frequently reified as a chaotic, corrupted symptom of illness. But that is changing, with a growing acceptance of voice-hearing as a profoundly human experience that can no longer be reduced to a mere symptom of psychiatric disorder. The work of Intervoice: The International Hearing Voices Network, and the enthusiastic response to Eleanor Longden’s 2013 TED talk, which recounts her own journey to recovery from a demoralising psychiatric diagnosis, indicate the growing possibilities for people living with the experience to raise their voices with a sense of power and pride.
This movement towards a better public understanding of voice-hearing has been mirrored by an increased interest in the scientific issues it raises. In recent years, academics from such diverse disciplines as psychology, philosophy, medical humanities, cognitive neuroscience, anthropology, theology and cultural studies have begun to reclaim it as a rich, diverse and complex human experience – one that offers abundant possibilities for scientific inquiry.
Take, for example, the idea that voices often relate to trauma or adversity, particularly those suffered in childhood. This view, which has found expression in the personal stories of many voice-hearers, has been supported by a growing body of scientific evidence. But why should traumatic experiences early in life lead many years later to the experience of hearing a voice, or what psychiatrists call an auditory verbal hallucination?
Recent investigations suggest that voice-hearing may provide fresh insights into traumatic memory, and how real-life conflicts become embodied in voices via dissociation (a defensive psychological response to trauma in which thoughts, emotions and memories become disconnected from one another). In turn, the experience that many voice-hearers describe – that of a disembodied “other” dynamically interacting with and intruding upon one’s sense of self – invites exploration into how representations of selfhood are generated and maintained.
Another approach that has proved fruitful is the idea that voice-hearing relates to one very ordinary aspect of people’s experience: their inner speech. Most of us report talking to ourselves silently in our heads as we go about our business, and it has been proposed that voices result when a person generates a bit of inner speech but, for whatever reason, doesn’t recognise it as their own. This view has received support from numerous studies with voice-hearing psychiatric patients, including findings that similar networks in the brain are activated when people hear voices as when they produce inner speech.
Many problems remain however, including the fact that we know very little about the phenomenal properties of ordinary inner speech, such as whether it has the qualities of a dialogue or a monologue, whether it is fully expanded like ordinary conversation or whether it sometimes has a compressed, note-form quality. Voice-hearing itself comes in an even more baffling array of varieties, from experiences that have the full perceptual force of listening to a person speaking to those that are much more ephemeral and thought-like.
Perhaps most importantly, the view of voices as disordered inner speech does not ring true with many voice-hearers’ experience. And yet, at some level, an explanation of voice-hearing must have something to do with how language operates in the brain. Perhaps the biggest challenge facing research in this area is to try to link, and draw on the relative merits of, the trauma and inner speech models. How can adverse experiences early in life, perhaps through the complex, multifaceted mechanisms of memory, lead to alterations in the way words are processed in the brain, and in turn to the sense that one’s self has been overtaken by other selves? Whatever the future for research in this area, it will require a continued focus on voice-hearing as a complex, heterogeneous phenomenon with many scientific secrets to reveal.
The first time I took part in an operation I had no idea what was going on. As a new medical student I hadn’t learned the language of surgery. I didn’t even know there was a language of surgery. A few years later, as a surgeon myself, this language had become second nature and I didn’t even know I was using it.
Of course there are many voices in the operating theatre. They don’t always say what they mean or mean what they say. And sometimes the most important voices are those that don’t use words at all.
For several years I’ve been leading research projects that investigate how people communicate during surgery. At Medicine Unboxed in Cheltenham, I’m going to explore how to read some of these surgical voices and make sense of what they say.
Of course the story starts with the patient. What happens to their voice during surgery? At first glance, it seems to have disappeared altogether, especially if the operation needs a general anaesthetic. In the anaesthetic room the patient gradually relinquishes autonomy, leaving behind their personhood and their power to speak for themselves as powerful drugs make them unconscious.
But they haven’t stopped communicating. Speech mutates into a language of the unconscious body. Functions that we take for granted and scarcely notice – our heart beating, our lungs breathing, our blood circulating – are represented by wavy lines on a screen or the beep of a machine. Words have turned into traces, and the voice of the anaesthetised patient has become transformed.
Throughout the operation the surgical team monitors this wordless commentary, this constant unconscious broadcast of the body. Any variation – a change in rhythm, a subtle inflection of pitch – will put the team on high alert. The team has become fluent in the language of unconsciousness.
When the operation is over, when the wound is closed and the dressings are in place, the anaesthetist disconnects these machines and hands back the power of speech.
In the operating theatre, different voices are in play. At the centre is the scrub team – those who operate on the body itself. Around them are other members of the group – equally important but differently so – and all have different voices.
The surgeon’s voice is often muted, soft, muffled by a mask. Intended for the scrub team only, it may be inaudible beyond. Voices spread out in ripples from the scrub team: requests for instruments, instructions to others in the theatre. The anaesthetist, the operating department practitioner, the runner nurse – all have their ways of speaking, their vocabularies, their own vocal fingerprint.
The voices you hear depend on where you’re standing. Like conversation at a party, there are ebbs and flows, natural rhythms and patterns. Often you can’t make out the words, but you have to interpret the many meanings within this soundscape of surgery and recognise when they involve you. You develop new sensitivities, new ways of reading what is said.
What do these voices convey? Some are the voices of people talking in ordinary words. But others are different. Some are distorted voices, pulled out of shape by their peculiar setting. Some are transformed voices, expressed through machines instead of words. And some are silent voices, conveying their message by what they do not say.
Reading voices isn’t easy. For a newcomer, the operating theatre is an overwhelming place. Sound is all around: beeps, alarms, the noise of people moving. Sometimes music. And speech, when it surfaces, uses an alien language, peppered with abbreviations and jargon.
Once you get used to it, you can tell how things are going the instant you step in. If all is well, there’s a general buzz of conversation, movement, activity. But if things are going badly, you sense the tension without even knowing how. The most eloquent voice of all is the voice of silence: the voice that says ‘we’ve got a problem here and we all need to focus on fixing it’.
In my conversation at Medicine Unboxed, I hope to unpick some of these ideas, exploring what’s different about surgical voices and what they can and cannot say.