535757 research-article2014
ISP0010.1177/0020764014535757International Journal of Social PsychiatryVilhauer
E CAMDEN SCHIZOPH
Article International Journal of Social Psychiatry 2015, Vol. 61(1) 58–63 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014535757 isp.sagepub.com
Depictions of auditory verbal hallucinations in news media Ruvanee P Vilhauer
Abstract Background: The characterization of auditory verbal hallucinations (AVH) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), diverges from recent research literature, which demonstrates the occurrence of AVH in individuals who are psychologically healthy. This discrepancy raises the question of how the public perceives AVH. Public perceptions are important because they could potentially affect how individuals with AVH interpret these experiences and how people view voice hearers. Aims: Because media portrayals can provide a window into how phenomena are viewed by the public, an archival study of newspaper articles was carried out to examine depictions of AVH. Methods: A sample of 181 newspaper articles originating in the United States was analyzed using a content analysis approach. Results: The majority of articles examined contained no suggestion that AVH are possible in psychologically healthy individuals. Most articles suggested that AVH were a symptom of mental illness, and many suggested that AVH were associated with criminal behavior, violence and suicidality. Conclusion: The news media examined tended to present a misleading and largely pathologizing view of AVH. More research is needed to shed light on how, and to what extent, public perceptions may influence those who experience AVH. Keywords Voice hearing, auditory verbal hallucination, stigma, media, psychosis, schizophrenia
Introduction The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) lists auditory hallucinations (AH) among the symptoms of a number of psychotic disorders, including schizophrenia and schizophreniform disorder, but allows that AH may also be the result of medical or substance-induced disorders. According to the DSM-V (pp. 87–88), AH are not within the range of normal experience unless they occur during hypnogogic or hypnopompic states, or as religious experiences within certain cultural contexts. This characterization of AH is at odds with an emerging body of research literature demonstrating the occurrence of AH in individuals who are psychologically healthy (De Leede-Smith & Barkus, 2013; Johns, Nazroo, Bebbington, & Kuipers, 2002; Larøi, 2012; Lawrence, Jones, & Cooper, 2010; McCarthy-Jones, 2012). Auditory verbal hallucinations (AVH) are the most extensively studied of hallucinatory phenomena (Larøi et al., 2012), perhaps because they are the type of hallucination most commonly reported in schizophrenia (Pierre, 2010). Recent literature reviews report AVH prevalences in the general population of 5%–28% (De Leede-Smith &
Barkus, 2013) and 1%–3% (McCarthy-Jones, 2012, p. 188). Although estimates vary widely, a conservative estimate of the proportion of individuals who have AVH without being socially or occupationally impaired is 0.45% (McCarthy-Jones, 2012, p. 188). Some reports indicate that, of those with AVH, the majority do not have a diagnosable mental illness (Johns et al., 2002; Lawrence et al., 2010; Linden et al., 2011; Tien, 1991). In one survey of the general population, Johns et al. (2002) found that only 25% of individuals who reported AH satisfied the criteria for a psychotic disorder. The presence of AVH in the non-clinical population has led some researchers to postulate that AVH occur along a continuum from healthy to unhealthy (Goldstone, Farhall,
Psychology Department, Felician College, Lodi, NJ, USA Corresponding author: Ruvanee P Vilhauer, Psychology Department, Felician College, 262 South Main Street, Lodi, NJ 07644, USA. Email: [email protected]
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Vilhauer & Ong, 2012), and others have examined AVH as a normal response to traumatic events (Morrison, 1998; Romme, Escher, Dillon, Corstens, & Morris, 2009). Pierre (2010) suggested that AH could be considered similar to coughs in that they are common experiences that are often, but not always, symptomatic of pathology. The divergence between accounts of AVH in the DSM-V and in the recent research literature raises the question of how the public perceives AVH. Public perceptions are important because they have the potential to affect how an individual with AVH interprets hallucinatory experiences and how others view voice hearers. Research indicates that public perceptions of mental illness are guided to an important extent by media depictions (Coverdale, Nairn, & Claasen, 2002; Wahl, 1992). Although media portrayals of mental illness (Coverdale et al., 2002; Thornicroft, Brohan, Rose, Sartorius, & Leese, 2009; Wahl, 1992; Wilson, Nairn, Coverdale, & Panapa, 2000) and particularly schizophrenia (Dubugras, Evans-Lacko, & De Jesus Mari, 2011; Duckworth, Halpern, Schutt, & Gillespie, 2003) have been studied; no studies of media portrayals of AVH have been conducted. An archival study of US newspaper articles was carried out to examine the following research question: How are AVH depicted in the news media?
Methods A sample of newspaper articles was obtained from LexisNexis Academic, a database which provides access to over 5,600 sources including national and regional newspapers. An advanced search was carried out using the Boolean OR operator and the search terms, ‘auditory hallucination’, ‘aural hallucination’, ‘voice hearing’, ‘hearing voices’, ‘voice-hearing’ and ‘hearing a voice’. The United States was selected as the geographic location. Excluded news sources were Web-based publications, newswires and press releases, blogs, news transcripts, magazines and journals, industry trade press, aggregate news sources, legal news, newsletters, country and region reports, scientific materials, statistics and unclassified documents. All articles meeting the search criteria for the year between 7 February 2012 and 7 February 2013 were downloaded, which amounted to a total of 493 articles. Of these, 275 articles were eliminated because they referred to real, imagined or metaphorical voices and were therefore not relevant to the study objective. Another 35 articles were eliminated because they contained duplicate content. In order to prevent bias in the results, whenever duplicated articles were present, all but one were eliminated. Duplicate articles usually had identical or very similar titles, bylines, word count and content, but could be in the same or different newspapers. Articles about the same event were kept (not considered duplicates) if the content was different even if by the same author (e.g. if details of a
crime were reported before trial, after conviction and after sentencing). In a few instances, it was difficult to decide whether articles were different or the same (e.g. in the scenario above, if article word counts were similar). If so, the decision to retain in or eliminate from the sample was based on the consensus of three independent raters. The final sample included 181 non-duplicated articles relevant to the study objective. The articles in the sample were from a wide range of newspapers that included large circulation dailies such as the New York Times, the Washington Post and the Los Angeles Times, as well as smaller newspapers such as the Janesville Gazette (Wisconsin), the Chico EnterpriseRecord (California) and the Sunday News (Lancaster, Pennsylvania). A content analysis approach was used to analyze the articles (Bernard, 2000; Frankfort-Nachmias & Nachmias, 2008). The units of analysis were articles. Coding categories were determined after an initial reading of all the articles. An attempt was made to include positive, negative and neutral themes as coding categories. Each article was then read carefully and coded to indicate whether it suggested that AVH were possible or not possible in ‘normal’ people (with ‘normal’ defined as being psychologically healthy enough to function adequately in society); were symptoms of mental illness, medical conditions or drug use; were related to criminal behavior, violence or suicide; or were experienced as related to supernatural or religious factors. Each article was also coded as to whether it suggested that treatment would be helpful for the voice hearer. In addition, coders noted whether each article related AVH to creativity or any other positive attribute. Of these articles, 90% were coded by the author and two independent coders who were trained in the coding system. The other 10% were coded by the author and one independent trained coder. Disagreements between coders were discussed until consensus was reached.
Results The frequencies of themes suggested by the 181 articles in the sample are shown in Table 1. Because the question of psychological health was highly relevant to the objective of this study, two separate codes relating to this issue, with opposite valences, were applied to each article. In an overwhelming majority of articles (84%), there was no suggestion that AVH could occur in individuals who are ‘normal’. Only 23 articles (12.7%) suggested that voice hearers could be ‘normal’. Five of these 23 articles were reviews of a book, Hallucinations, by Oliver Sacks (2012), which has an explicit goal of trying to dispel misunderstandings and reduce stigma relating to these phenomena. Another 10 of the 23 related to AVH experiences that had religious or spiritual overtones (e.g. an article describing Joan of Arc).
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International Journal of Social Psychiatry 61(1)
Table 1. Frequency of themes relating to AVH in news media. Theme
N
%
No suggestion that AVH could occur in ‘normal’ people Symptom of mental illness Symptom of schizophrenia Associated with other mental illness Symptom of medical condition Due to drug use Associated with criminal behavior Associated with violence toward others Associated with suicidality Benefits of drug treatment Benefits of non-drug treatment AVH could occur in ‘normal’ people Associated with creativity Other positive aspect of AH suggested Experienced as related to supernatural factors Experienced as related to religious factors
152
84.0
148 67 47 12 23 94 85 33 34 10 23 10 13 27
81.8 37.0 26.0 6.6 12.7 51.9 47.0 18.2 18.8 5.5 12.6 5.5 7.2 15.0
22
12.2
AVH: auditory verbal hallucinations; AH: auditory hallucinations.
An overwhelming majority of articles suggested that AVH are a symptom of mental illness (81.8%), sometimes equating AVH with mental illness (e.g. ‘…the psychiatrists and other experts who specialize in psychopathy routinely point out that these people are not insane the way we typically think of insane – hearing voices, seeing things that aren’t there, having delusional thought patterns about worlds that don’t exist and so forth’.). Some articles suggested that voice hearers lack self-control (e.g. ‘When a psychologist asked him afterward [after he had killed 3 people] why he went with guns to his school, he said, “I had no choice”, referring to auditory hallucinations commanding him to do so’), and some suggested that having AVH was frightening (e.g. ‘In extreme cases [of bipolar disorder], patients can suffer psychotic symptoms such as visual or auditory hallucinations. That fact makes the disease deeply scary, both for the person experiencing it and for friends and family members’.) In some cases, a specific psychological disorder was not mentioned, but 37% of the articles suggested that AVH are a symptom of schizophrenia and 26% suggested that AVH are associated with one or more other psychological disorders, sometimes in conjunction with schizophrenia. Other psychological disorders mentioned in voice hearers were bipolar disorder (12.2% of the total sample), depression (10.5%), schizoaffective disorder (4.4%), anxiety (2.2%), posttraumatic stress disorder (1.1), psychosis not otherwise specified (NOS) (0.6%), alcoholism (0.6%), dissociative amnesia (0.6%), borderline intellectual functioning (0.6%) and conversion disorder (0.6%). A total of 12 articles (6.6%) suggested that AVH were associated with medical conditions. Of these, 7 articles were reviews of the
previously mentioned book by Sacks, in which multiple medical causes of hallucinations are discussed. (Sacks considers a discussion of hallucinations in schizophrenia to be outside the scope of his book, although he points out (p. 56) that the equating of hallucinations with schizophrenia is mistaken as most people who hear voices do not have schizophrenia.) The remaining 5 articles mentioned delirium complicating sickle-cell trait, musical ear syndrome, seizure disorder, brain injury, rapid biological aging and concussion. Drug use was implicated as a cause of AVH in 12.7% of articles. Drugs were sometimes not specified, but some articles mentioned one or more of the following: marijuana, synthetic marijuana, alcohol, a variety of recreational hallucinogens, unspecified medications, Artane, an antidepressant medication (Zoloft), an antiseizure medication (Neurontin), dextromethorphan, paint, cocaine, an antibiotic (Biaxin) and methamphetamine. AVH were represented as being associated with criminal behavior (e.g. murder, assault, arson, burglary, car theft, selling and/or using illegal drugs) in 51.9% of articles. Most of these involved violent crimes. AVH were associated with violence toward others in 47% of articles. Suicide or suicidality of voice hearers was suggested in 18.2% of articles. Some articles suggested that AVH were experienced as supernatural (e.g. associated with ghostly figures, vampires, gremlins, religious figures or intimations of magical power), and some suggested that AVH were associated with religious figures or experiences (e.g. hearing the voice of God, Jesus or Satan). Almost a fifth of the articles suggested that drug treatment could be beneficial for individuals with AVH, while a little over 5% suggested that non-drug treatments, such as self-help programs and day programs, could be beneficial. In all, 10 articles, 4 of which were reviews of Sacks’ book, suggested that AVH were linked to creativity. Overall, 13 articles, 3 of which were reviews of Sacks’ book, mentioned other positively represented attributes linked to AVH (e.g. spirituality, saving lives).
Discussion These results indicate that the news media examined tend to present a misleading and largely pathologizing view of AVH. The majority of articles examined were not consistent with the recent research literature, which indicates that AVH can occur in individuals who are psychologically healthy. Rather, most articles suggested that AVH are a symptom of mental illness, and many suggested that AVH are associated with criminal behavior, violence and suicidality. Many studies have shown that the media tend to depict individuals with mental illness negatively and inaccurately, with violence and dangerousness being common themes (Clement & Foster, 2008; Duckworth et al., 2003;
Vilhauer Jorm & Reavley, 2013; Wilson et al., 2000). Individuals with AVH are depicted similarly negatively. While the cooccurrence of AVH with several psychological disorders has been amply documented (e.g. American Psychiatric Association, 2013; De Leede-Smith & Barkus, 2013; Larøi, 2012), numerous studies indicate that voice-hearing experiences, and their sequelae, vary widely and that the experience of AVH per se is not always indicative of pathology (De Leede-Smith & Barkus, 2013; Hill, Varese, Jackson, & Linden, 2012; Johns et al., 2002; Larøi, 2012; Larøi et al., 2012; Lawrence et al., 2010; Pierrre, 2010; Sorrell, Hayward, & Meddings, 2010; Waters et al., 2012). Comparisons of healthy voice hearers and voice hearers with a clinical diagnosis have shown that while characteristics of voices such as number, loudness and personification were similar in the two groups, distress elicited by AVH tends to be greater in those with a clinical diagnosis (De Leede-Smith & Barkus, 2013). Distress does not appear to be caused by AVH per se, but rather by the way AVH are interpreted (Sorrell et al., 2010). As explained below, media depictions of AVH have the potential to affect how AVH are interpreted, because such depictions can affect how people view voice hearers, as well as how voice hearers view themselves. Media portrayals of AVH as indicative of mental illness, criminality and violence can influence the way people view voice hearers. Research has demonstrated a relationship between consumption of media and distancing attitudes toward people with schizophrenia (Angermeyer, Dietrich, Pott, & Matschinger, 2005). Low social acceptance of individuals with mental illness, and particularly schizophrenia, (Pescosolido et al., 2010; Schomerus et al., 2012; Thornicroft et al., 2009; Wahl, 1992), may be related to stigmatizing media portrayals (Coverdale et al., 2002; Dubugras et al., 2011; Duckworth et al., 2003; Wilson et al., 2000). Although social acceptance of voice hearers has not been studied specifically, McCarthy-Jones and Davidson (2013) noted that the experience of AVH can lead to withdrawal from society. Such a withdrawal would not be surprising if AVH are viewed as negatively as this study suggests. Other people’s reactions when individuals disclose having AVH appear to affect not only the distress experienced by the voice hearers (McCarthy-Jones & Davidson, 2013; Pierre, 2010) but also the voice hearers’ ability to cope with their hallucinatory experiences (Milligan, McCarthy-Jones, Winthrop, & Dudley, 2013). For this reason, Milligan et al. (2013) note that public education campaigns might be beneficial to voice hearers. If other people’s reactions are perceived as negative, voice hearers may resort to trying to suppress these unwanted experiences. Studies of experiential avoidance (Goldstone et al., 2012) suggest that attempts to inhibit unpleasant perceptions tend to increase the distress associated with such experiences.
61 Distress about AVH appears to be a defining factor for determining need for care in voice hearers (De LeedeSmith & Barkus, 2013). Several studies have indicated that maladaptive cognitive appraisals of AVH (Larøi, 2012; Mawson, Cohen, & Berry, 2010) and negative beliefs about AVH (Hill et al., 2012; Morrison, Nothard, Bowe, & Wells, 2004; Morrison, Wells, & Nothard, 2002) are more associated with distress about AVH than are inherent features of the voices heard, such as their loudness and number. Appraisals of AVH, and beliefs about AVH, such as those relating to their meaning and controllability, may be influenced by stigmatizing media depictions. Just as internalization of negative stereotypes, or selfstigma, can be harmful to those who suffer from mental illness (Corrigan, Watson, & Barr, 2006; Livingston & Boyd, 2010), it is conceivable that self-stigma may be harmful to those who experience AVH. Goffman (1963) used the term stigma to refer to ‘an attribute that is deeply discrediting’. Power and status loss are key features of stigma (Link & Phelan, 2001). Voice hearers who perceive themselves to have less power and status in the social world also appraise their voices as being more powerful (Birchwood et al., 2004; Thomas, Farhall, & Shawyer, 2013; Paulik, 2012). Perceived voice dominance is related to distress in voice hearers (Paulik, 2012). Voice hearers diagnosed as psychotic tend to find their AVH to be less controllable than healthy voice hearers (Daalman et al., 2011). Barrowcliff and Haddock (2006), reviewing literature on factors associated with compliance with voices, note that lower perceived social rank is associated with the tendency to comply with command hallucinations. Research suggests that voice hearers’ feelings of powerlessness are often rooted in early traumatic experiences (Larøi, 2012), but little attention has been paid to how voice hearers’ current social/cultural milieu, including media representations, may maintain or support those feelings, although a few researchers have written about the stigma, fear and confusion that voice hearers encounter when their hallucinatory experiences begin (McCarthyJones, 2012; Romme et al., 2009). Some have suggested that interventions to help individuals with AVH could include ways of increasing perceived social rank in comparison with others, such as assertiveness training, social skills training and/or ways to improve self-esteem (Paulik, 2012), as well as ways to diminish fears of voices, the unknown, others’ reactions and losing their sanity (Jackson, Hayward, & Cooke, 2011). Improving media depictions of AVH and campaigns to decrease public stigma may be helpful for achieving these ends. Sample size was a limitation of this study. Although a systematic method was used to locate newspaper articles originating in the United States, within a 1-year period, the number of articles found was relatively small. The use of multiple databases would likely have yielded a larger sample. The depictions described here are only relevant to US
62 newspapers and cannot be generalized to newspaper depictions of AVH in other countries, which may differ. Comparisons between countries may be informative and worthy of future study. It should be noted that although only US newspapers were selected for the search in LexisNexis Academic, 17 of the articles found and analyzed were published in non-US newspapers (6 in Canada, 6 in the United Kingdom, 2 in South Africa, 1 in Singapore, 1 in New Zealand 1 in Australia). It was assumed that these articles appeared in the search results because they originated in the United States, and so they were not eliminated from the sample. Interestingly, 8 of these 17 articles presented non-pathologizing views of AVH (3 were reviews of Sacks’ book, 4 mentioned spiritual themes and the other decried the mocking of people who hear voices). As such, eliminating the 17 articles from the sample would have resulted in a higher percentage of articles containing no suggestion that AVH could occur in psychologically healthy individuals (87.2% of the sample) and a lower percentage of articles (9.1%) suggesting that voice hearers could be psychologically healthy. Because this study was purely descriptive, no conclusions can be drawn about the impact of media depictions on voice hearers. However, the literature reviewed in the discussion above suggests that studies exploring media influences are warranted. The ways in which mass media influence the development of some other disorders have been studied (e.g. for a review of media influences on eating disorders, see Lopez-Guimera, Levine, SanchezCarracedo, & Fauquet (2010)), but little empirical research has been done to see whether and to what extent media, or more broadly the social/cultural milieu of a voice hearer, may contribute to making the voice-hearing experience pathological. More research is needed to shed light on the influence public perceptions may have on those who experience AVH. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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ISP0010.1177/0020764014535757International Journal of Social PsychiatryVilhauer
E CAMDEN SCHIZOPH
Article International Journal of Social Psychiatry 2015, Vol. 61(1) 58–63 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014535757 isp.sagepub.com
Depictions of auditory verbal hallucinations in news media Ruvanee P Vilhauer
Abstract Background: The characterization of auditory verbal hallucinations (AVH) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), diverges from recent research literature, which demonstrates the occurrence of AVH in individuals who are psychologically healthy. This discrepancy raises the question of how the public perceives AVH. Public perceptions are important because they could potentially affect how individuals with AVH interpret these experiences and how people view voice hearers. Aims: Because media portrayals can provide a window into how phenomena are viewed by the public, an archival study of newspaper articles was carried out to examine depictions of AVH. Methods: A sample of 181 newspaper articles originating in the United States was analyzed using a content analysis approach. Results: The majority of articles examined contained no suggestion that AVH are possible in psychologically healthy individuals. Most articles suggested that AVH were a symptom of mental illness, and many suggested that AVH were associated with criminal behavior, violence and suicidality. Conclusion: The news media examined tended to present a misleading and largely pathologizing view of AVH. More research is needed to shed light on how, and to what extent, public perceptions may influence those who experience AVH. Keywords Voice hearing, auditory verbal hallucination, stigma, media, psychosis, schizophrenia
Introduction The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) lists auditory hallucinations (AH) among the symptoms of a number of psychotic disorders, including schizophrenia and schizophreniform disorder, but allows that AH may also be the result of medical or substance-induced disorders. According to the DSM-V (pp. 87–88), AH are not within the range of normal experience unless they occur during hypnogogic or hypnopompic states, or as religious experiences within certain cultural contexts. This characterization of AH is at odds with an emerging body of research literature demonstrating the occurrence of AH in individuals who are psychologically healthy (De Leede-Smith & Barkus, 2013; Johns, Nazroo, Bebbington, & Kuipers, 2002; Larøi, 2012; Lawrence, Jones, & Cooper, 2010; McCarthy-Jones, 2012). Auditory verbal hallucinations (AVH) are the most extensively studied of hallucinatory phenomena (Larøi et al., 2012), perhaps because they are the type of hallucination most commonly reported in schizophrenia (Pierre, 2010). Recent literature reviews report AVH prevalences in the general population of 5%–28% (De Leede-Smith &
Barkus, 2013) and 1%–3% (McCarthy-Jones, 2012, p. 188). Although estimates vary widely, a conservative estimate of the proportion of individuals who have AVH without being socially or occupationally impaired is 0.45% (McCarthy-Jones, 2012, p. 188). Some reports indicate that, of those with AVH, the majority do not have a diagnosable mental illness (Johns et al., 2002; Lawrence et al., 2010; Linden et al., 2011; Tien, 1991). In one survey of the general population, Johns et al. (2002) found that only 25% of individuals who reported AH satisfied the criteria for a psychotic disorder. The presence of AVH in the non-clinical population has led some researchers to postulate that AVH occur along a continuum from healthy to unhealthy (Goldstone, Farhall,
Psychology Department, Felician College, Lodi, NJ, USA Corresponding author: Ruvanee P Vilhauer, Psychology Department, Felician College, 262 South Main Street, Lodi, NJ 07644, USA. Email: [email protected]
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Vilhauer & Ong, 2012), and others have examined AVH as a normal response to traumatic events (Morrison, 1998; Romme, Escher, Dillon, Corstens, & Morris, 2009). Pierre (2010) suggested that AH could be considered similar to coughs in that they are common experiences that are often, but not always, symptomatic of pathology. The divergence between accounts of AVH in the DSM-V and in the recent research literature raises the question of how the public perceives AVH. Public perceptions are important because they have the potential to affect how an individual with AVH interprets hallucinatory experiences and how others view voice hearers. Research indicates that public perceptions of mental illness are guided to an important extent by media depictions (Coverdale, Nairn, & Claasen, 2002; Wahl, 1992). Although media portrayals of mental illness (Coverdale et al., 2002; Thornicroft, Brohan, Rose, Sartorius, & Leese, 2009; Wahl, 1992; Wilson, Nairn, Coverdale, & Panapa, 2000) and particularly schizophrenia (Dubugras, Evans-Lacko, & De Jesus Mari, 2011; Duckworth, Halpern, Schutt, & Gillespie, 2003) have been studied; no studies of media portrayals of AVH have been conducted. An archival study of US newspaper articles was carried out to examine the following research question: How are AVH depicted in the news media?
Methods A sample of newspaper articles was obtained from LexisNexis Academic, a database which provides access to over 5,600 sources including national and regional newspapers. An advanced search was carried out using the Boolean OR operator and the search terms, ‘auditory hallucination’, ‘aural hallucination’, ‘voice hearing’, ‘hearing voices’, ‘voice-hearing’ and ‘hearing a voice’. The United States was selected as the geographic location. Excluded news sources were Web-based publications, newswires and press releases, blogs, news transcripts, magazines and journals, industry trade press, aggregate news sources, legal news, newsletters, country and region reports, scientific materials, statistics and unclassified documents. All articles meeting the search criteria for the year between 7 February 2012 and 7 February 2013 were downloaded, which amounted to a total of 493 articles. Of these, 275 articles were eliminated because they referred to real, imagined or metaphorical voices and were therefore not relevant to the study objective. Another 35 articles were eliminated because they contained duplicate content. In order to prevent bias in the results, whenever duplicated articles were present, all but one were eliminated. Duplicate articles usually had identical or very similar titles, bylines, word count and content, but could be in the same or different newspapers. Articles about the same event were kept (not considered duplicates) if the content was different even if by the same author (e.g. if details of a
crime were reported before trial, after conviction and after sentencing). In a few instances, it was difficult to decide whether articles were different or the same (e.g. in the scenario above, if article word counts were similar). If so, the decision to retain in or eliminate from the sample was based on the consensus of three independent raters. The final sample included 181 non-duplicated articles relevant to the study objective. The articles in the sample were from a wide range of newspapers that included large circulation dailies such as the New York Times, the Washington Post and the Los Angeles Times, as well as smaller newspapers such as the Janesville Gazette (Wisconsin), the Chico EnterpriseRecord (California) and the Sunday News (Lancaster, Pennsylvania). A content analysis approach was used to analyze the articles (Bernard, 2000; Frankfort-Nachmias & Nachmias, 2008). The units of analysis were articles. Coding categories were determined after an initial reading of all the articles. An attempt was made to include positive, negative and neutral themes as coding categories. Each article was then read carefully and coded to indicate whether it suggested that AVH were possible or not possible in ‘normal’ people (with ‘normal’ defined as being psychologically healthy enough to function adequately in society); were symptoms of mental illness, medical conditions or drug use; were related to criminal behavior, violence or suicide; or were experienced as related to supernatural or religious factors. Each article was also coded as to whether it suggested that treatment would be helpful for the voice hearer. In addition, coders noted whether each article related AVH to creativity or any other positive attribute. Of these articles, 90% were coded by the author and two independent coders who were trained in the coding system. The other 10% were coded by the author and one independent trained coder. Disagreements between coders were discussed until consensus was reached.
Results The frequencies of themes suggested by the 181 articles in the sample are shown in Table 1. Because the question of psychological health was highly relevant to the objective of this study, two separate codes relating to this issue, with opposite valences, were applied to each article. In an overwhelming majority of articles (84%), there was no suggestion that AVH could occur in individuals who are ‘normal’. Only 23 articles (12.7%) suggested that voice hearers could be ‘normal’. Five of these 23 articles were reviews of a book, Hallucinations, by Oliver Sacks (2012), which has an explicit goal of trying to dispel misunderstandings and reduce stigma relating to these phenomena. Another 10 of the 23 related to AVH experiences that had religious or spiritual overtones (e.g. an article describing Joan of Arc).
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International Journal of Social Psychiatry 61(1)
Table 1. Frequency of themes relating to AVH in news media. Theme
N
%
No suggestion that AVH could occur in ‘normal’ people Symptom of mental illness Symptom of schizophrenia Associated with other mental illness Symptom of medical condition Due to drug use Associated with criminal behavior Associated with violence toward others Associated with suicidality Benefits of drug treatment Benefits of non-drug treatment AVH could occur in ‘normal’ people Associated with creativity Other positive aspect of AH suggested Experienced as related to supernatural factors Experienced as related to religious factors
152
84.0
148 67 47 12 23 94 85 33 34 10 23 10 13 27
81.8 37.0 26.0 6.6 12.7 51.9 47.0 18.2 18.8 5.5 12.6 5.5 7.2 15.0
22
12.2
AVH: auditory verbal hallucinations; AH: auditory hallucinations.
An overwhelming majority of articles suggested that AVH are a symptom of mental illness (81.8%), sometimes equating AVH with mental illness (e.g. ‘…the psychiatrists and other experts who specialize in psychopathy routinely point out that these people are not insane the way we typically think of insane – hearing voices, seeing things that aren’t there, having delusional thought patterns about worlds that don’t exist and so forth’.). Some articles suggested that voice hearers lack self-control (e.g. ‘When a psychologist asked him afterward [after he had killed 3 people] why he went with guns to his school, he said, “I had no choice”, referring to auditory hallucinations commanding him to do so’), and some suggested that having AVH was frightening (e.g. ‘In extreme cases [of bipolar disorder], patients can suffer psychotic symptoms such as visual or auditory hallucinations. That fact makes the disease deeply scary, both for the person experiencing it and for friends and family members’.) In some cases, a specific psychological disorder was not mentioned, but 37% of the articles suggested that AVH are a symptom of schizophrenia and 26% suggested that AVH are associated with one or more other psychological disorders, sometimes in conjunction with schizophrenia. Other psychological disorders mentioned in voice hearers were bipolar disorder (12.2% of the total sample), depression (10.5%), schizoaffective disorder (4.4%), anxiety (2.2%), posttraumatic stress disorder (1.1), psychosis not otherwise specified (NOS) (0.6%), alcoholism (0.6%), dissociative amnesia (0.6%), borderline intellectual functioning (0.6%) and conversion disorder (0.6%). A total of 12 articles (6.6%) suggested that AVH were associated with medical conditions. Of these, 7 articles were reviews of the
previously mentioned book by Sacks, in which multiple medical causes of hallucinations are discussed. (Sacks considers a discussion of hallucinations in schizophrenia to be outside the scope of his book, although he points out (p. 56) that the equating of hallucinations with schizophrenia is mistaken as most people who hear voices do not have schizophrenia.) The remaining 5 articles mentioned delirium complicating sickle-cell trait, musical ear syndrome, seizure disorder, brain injury, rapid biological aging and concussion. Drug use was implicated as a cause of AVH in 12.7% of articles. Drugs were sometimes not specified, but some articles mentioned one or more of the following: marijuana, synthetic marijuana, alcohol, a variety of recreational hallucinogens, unspecified medications, Artane, an antidepressant medication (Zoloft), an antiseizure medication (Neurontin), dextromethorphan, paint, cocaine, an antibiotic (Biaxin) and methamphetamine. AVH were represented as being associated with criminal behavior (e.g. murder, assault, arson, burglary, car theft, selling and/or using illegal drugs) in 51.9% of articles. Most of these involved violent crimes. AVH were associated with violence toward others in 47% of articles. Suicide or suicidality of voice hearers was suggested in 18.2% of articles. Some articles suggested that AVH were experienced as supernatural (e.g. associated with ghostly figures, vampires, gremlins, religious figures or intimations of magical power), and some suggested that AVH were associated with religious figures or experiences (e.g. hearing the voice of God, Jesus or Satan). Almost a fifth of the articles suggested that drug treatment could be beneficial for individuals with AVH, while a little over 5% suggested that non-drug treatments, such as self-help programs and day programs, could be beneficial. In all, 10 articles, 4 of which were reviews of Sacks’ book, suggested that AVH were linked to creativity. Overall, 13 articles, 3 of which were reviews of Sacks’ book, mentioned other positively represented attributes linked to AVH (e.g. spirituality, saving lives).
Discussion These results indicate that the news media examined tend to present a misleading and largely pathologizing view of AVH. The majority of articles examined were not consistent with the recent research literature, which indicates that AVH can occur in individuals who are psychologically healthy. Rather, most articles suggested that AVH are a symptom of mental illness, and many suggested that AVH are associated with criminal behavior, violence and suicidality. Many studies have shown that the media tend to depict individuals with mental illness negatively and inaccurately, with violence and dangerousness being common themes (Clement & Foster, 2008; Duckworth et al., 2003;
Vilhauer Jorm & Reavley, 2013; Wilson et al., 2000). Individuals with AVH are depicted similarly negatively. While the cooccurrence of AVH with several psychological disorders has been amply documented (e.g. American Psychiatric Association, 2013; De Leede-Smith & Barkus, 2013; Larøi, 2012), numerous studies indicate that voice-hearing experiences, and their sequelae, vary widely and that the experience of AVH per se is not always indicative of pathology (De Leede-Smith & Barkus, 2013; Hill, Varese, Jackson, & Linden, 2012; Johns et al., 2002; Larøi, 2012; Larøi et al., 2012; Lawrence et al., 2010; Pierrre, 2010; Sorrell, Hayward, & Meddings, 2010; Waters et al., 2012). Comparisons of healthy voice hearers and voice hearers with a clinical diagnosis have shown that while characteristics of voices such as number, loudness and personification were similar in the two groups, distress elicited by AVH tends to be greater in those with a clinical diagnosis (De Leede-Smith & Barkus, 2013). Distress does not appear to be caused by AVH per se, but rather by the way AVH are interpreted (Sorrell et al., 2010). As explained below, media depictions of AVH have the potential to affect how AVH are interpreted, because such depictions can affect how people view voice hearers, as well as how voice hearers view themselves. Media portrayals of AVH as indicative of mental illness, criminality and violence can influence the way people view voice hearers. Research has demonstrated a relationship between consumption of media and distancing attitudes toward people with schizophrenia (Angermeyer, Dietrich, Pott, & Matschinger, 2005). Low social acceptance of individuals with mental illness, and particularly schizophrenia, (Pescosolido et al., 2010; Schomerus et al., 2012; Thornicroft et al., 2009; Wahl, 1992), may be related to stigmatizing media portrayals (Coverdale et al., 2002; Dubugras et al., 2011; Duckworth et al., 2003; Wilson et al., 2000). Although social acceptance of voice hearers has not been studied specifically, McCarthy-Jones and Davidson (2013) noted that the experience of AVH can lead to withdrawal from society. Such a withdrawal would not be surprising if AVH are viewed as negatively as this study suggests. Other people’s reactions when individuals disclose having AVH appear to affect not only the distress experienced by the voice hearers (McCarthy-Jones & Davidson, 2013; Pierre, 2010) but also the voice hearers’ ability to cope with their hallucinatory experiences (Milligan, McCarthy-Jones, Winthrop, & Dudley, 2013). For this reason, Milligan et al. (2013) note that public education campaigns might be beneficial to voice hearers. If other people’s reactions are perceived as negative, voice hearers may resort to trying to suppress these unwanted experiences. Studies of experiential avoidance (Goldstone et al., 2012) suggest that attempts to inhibit unpleasant perceptions tend to increase the distress associated with such experiences.
61 Distress about AVH appears to be a defining factor for determining need for care in voice hearers (De LeedeSmith & Barkus, 2013). Several studies have indicated that maladaptive cognitive appraisals of AVH (Larøi, 2012; Mawson, Cohen, & Berry, 2010) and negative beliefs about AVH (Hill et al., 2012; Morrison, Nothard, Bowe, & Wells, 2004; Morrison, Wells, & Nothard, 2002) are more associated with distress about AVH than are inherent features of the voices heard, such as their loudness and number. Appraisals of AVH, and beliefs about AVH, such as those relating to their meaning and controllability, may be influenced by stigmatizing media depictions. Just as internalization of negative stereotypes, or selfstigma, can be harmful to those who suffer from mental illness (Corrigan, Watson, & Barr, 2006; Livingston & Boyd, 2010), it is conceivable that self-stigma may be harmful to those who experience AVH. Goffman (1963) used the term stigma to refer to ‘an attribute that is deeply discrediting’. Power and status loss are key features of stigma (Link & Phelan, 2001). Voice hearers who perceive themselves to have less power and status in the social world also appraise their voices as being more powerful (Birchwood et al., 2004; Thomas, Farhall, & Shawyer, 2013; Paulik, 2012). Perceived voice dominance is related to distress in voice hearers (Paulik, 2012). Voice hearers diagnosed as psychotic tend to find their AVH to be less controllable than healthy voice hearers (Daalman et al., 2011). Barrowcliff and Haddock (2006), reviewing literature on factors associated with compliance with voices, note that lower perceived social rank is associated with the tendency to comply with command hallucinations. Research suggests that voice hearers’ feelings of powerlessness are often rooted in early traumatic experiences (Larøi, 2012), but little attention has been paid to how voice hearers’ current social/cultural milieu, including media representations, may maintain or support those feelings, although a few researchers have written about the stigma, fear and confusion that voice hearers encounter when their hallucinatory experiences begin (McCarthyJones, 2012; Romme et al., 2009). Some have suggested that interventions to help individuals with AVH could include ways of increasing perceived social rank in comparison with others, such as assertiveness training, social skills training and/or ways to improve self-esteem (Paulik, 2012), as well as ways to diminish fears of voices, the unknown, others’ reactions and losing their sanity (Jackson, Hayward, & Cooke, 2011). Improving media depictions of AVH and campaigns to decrease public stigma may be helpful for achieving these ends. Sample size was a limitation of this study. Although a systematic method was used to locate newspaper articles originating in the United States, within a 1-year period, the number of articles found was relatively small. The use of multiple databases would likely have yielded a larger sample. The depictions described here are only relevant to US
62 newspapers and cannot be generalized to newspaper depictions of AVH in other countries, which may differ. Comparisons between countries may be informative and worthy of future study. It should be noted that although only US newspapers were selected for the search in LexisNexis Academic, 17 of the articles found and analyzed were published in non-US newspapers (6 in Canada, 6 in the United Kingdom, 2 in South Africa, 1 in Singapore, 1 in New Zealand 1 in Australia). It was assumed that these articles appeared in the search results because they originated in the United States, and so they were not eliminated from the sample. Interestingly, 8 of these 17 articles presented non-pathologizing views of AVH (3 were reviews of Sacks’ book, 4 mentioned spiritual themes and the other decried the mocking of people who hear voices). As such, eliminating the 17 articles from the sample would have resulted in a higher percentage of articles containing no suggestion that AVH could occur in psychologically healthy individuals (87.2% of the sample) and a lower percentage of articles (9.1%) suggesting that voice hearers could be psychologically healthy. Because this study was purely descriptive, no conclusions can be drawn about the impact of media depictions on voice hearers. However, the literature reviewed in the discussion above suggests that studies exploring media influences are warranted. The ways in which mass media influence the development of some other disorders have been studied (e.g. for a review of media influences on eating disorders, see Lopez-Guimera, Levine, SanchezCarracedo, & Fauquet (2010)), but little empirical research has been done to see whether and to what extent media, or more broadly the social/cultural milieu of a voice hearer, may contribute to making the voice-hearing experience pathological. More research is needed to shed light on the influence public perceptions may have on those who experience AVH. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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