189

Psychology and Psychotherapy: Theory, Research and Practice (2003), 76, 189209
2003 The British Psychological Society
www.bps.org.uk

A Q-methodological study of hearing voices:

A preliminary exploration of voice hearers
understanding of their experiences
S. Jones, A. Guy and J. A. Ormrod*
Hartlepool, UK
Using Q-methodology and structured interviews, this preliminary study set out to
explore how a diverse range of voice hearers construed their experience of hearing
voices. Following factor analysis of 20 completed Q-sorts, six factors emerged.
Pejorative media stereotypes about voice hearers were rejected, and despite the
dominance of the biomedical model in our culture, on no factor did participants adhere
to all of the biomedical concepts. All six factors endorsed some elements of
psychological discourse on voice-hearing experiences. It is argued that attempting to
understand voice hearers within a single theoretical framework may limit or adversely
affect engagement and understanding of an individual. Consistent with previous
research, users of mental-health services were more likely to nd voices frightening
and perceive them as negative experiences than non-users. However, some non-users
found managing some of their voices dif cult despite having seemingly positive beliefs
about the experience of hearing voices. Comment is made on the potential therapeutic
implications of this study along with some acknowledgement of its limitations.

Hearing voices speaking when no one is there is often conceptualized in Western

culture as indicating serious mental illness. Reports of ongoing voices by an individual,
in situations not related to drug use, sensory deprivation (Zuckerman &Cohen, 1964) or
sleep beginnings or endings (McKellar, 1968), are often taken as presumptive evidence
for the presence of schizophrenia (Kaplan & Sadock, 1985), a disorder within the
broader category of psychotic conditions (American Psychiatric Association, 1994).
DSM-IV explicitly recognizes hearing voices frequently as one of the characteristic
indicators of schizophrenia alongside a constellation of other symptoms (American
Psychiatric Association, 1994). From this predominantly biomedical perspective,
psychotic symptoms, including hearing voices (auditory hallucinations), are inherently
meaningless (Berrios, 1991; Jaspers, 1962). For the practitioner within this tradition,
* Requests for reprints should be addressed to John Ormrod, Stewart House, 53 Church Street, Hartlepool TS26 7ED, UK
(e-mail: john.ormrod@tney.northy.nhs.uk).

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S. Jones et al.

exploration of the content and meaning of voices to the individual, beyond that which is
considered necessary to establish rapport and make a diagnosis, may not be required
(Leudar & Thomas, 2000).
Historically, however, the experience of voice hearing has sometimes been considered to be rich in meaning and positively valued as a source of creative or even divine
guidance (Al-Issa, 1978). Inuential world gures such as Mahatma Gandhi were
reported as relying on voices for inspiration and authority (Heery, 1989). Similarly, in
some cultures, people hearing voices continue to be regarded as gifted. For example, in
the Xhosa culture of South Africa, voice hearers are trained to become indigenous
healers (Sodi, 1995).
Certain schools within psychology have also challenged the proposal that such
phenomena are meaningless. Freud held that voices had meaning and were the result of
intra-psychic conict and a return to the defensive functioning of early childhood
(Freud, 1924). Accusatory voices were perceived as stemming from a harsh super-ego
expressing criticism towards the drives of the id, and advisory voices were understood
as stemming from the both the ego and the super ego. Some psychoanalytic theory
draws attention to the similarity between hallucinations and dreams, and it has been
suggested that both express, sometimes metaphorically, wishes that may be unacceptable to the conscious mind. For example, in Jungian theory, an emotional complex (a
set of feelings) can become overpowering, break away from the psyche and take the
form of voices or visions that speak to the person (Jung, 1939). Jung (1969) also
advocated that each of us is in touch with the unconscious spiritual life of all other
people, the collective unconscious, at the deepest level of our psyche and spoke of
voices as the call of a higher principle (Assagioli, 1973).
Recent cognitive research has addressed the relevance of the self in psychosis and
develops the psychoanalytic idea of hallucinations functioning as defences (Bentall,
1990; Haddock, Bentall, & Slade, 1993; Kinderman, 1994). Thus, Bentall, Haddock, and
Slade (1994) argue that voices may externalize certain mental events which otherwise
would be experienced as a threat to the self (Chadwick, Birchwood, & Trower, 1996).
This account ts with cognitive dissonance theory (Festinger, 1957) where attributing
thoughts to an external agent may prevent dissonance as personal responsibility is
removed (for example, god told me to), and guilt, self-blame, or anger can be avoided
(Hingley, 1992).
Cognitive theorists have also acknowledged the role that emotional disturbance may
play in the development and maintenance of psychotic symptoms, such as hearing
voices (Fowler, Garety, & Kuipers, 1995). Hearing voices may be a meaningful response
metaphorically expressing emotionally undigested events related to relationships and
life events (Fowler et al., 1995; Haddock et al., 1993; Honig et al., 1998; Romme &
Escher, 1989). Consistent with this is evidence of people hearing voices, subsequent to
trauma, for example, soldiers after war, victims of torture (Romme & Escher, 1993), and
following sexual abuse (Ensink, 1994). It has also been shown that voices may disappear
when underlying problems are resolved or integrated (Escher, Romme, & Buiks, 1998;
Hulme, 1996).
Most recently, psychological understanding in the Western world has shifted towards
the normalization of psychotic symptoms, including hearing voices (British Psychological Society, 2000; Thomas & Leudar, 1996). Research has emphasized how people
hear voices in the general population, even when there is no evidence of psychiatric
illness (Eaton, Romanoski, Anthony, & Nestadt, 1991; Posey & Losch, 1983; Romme &
Pennings, 1994; Tien, 1991). It has been claimed that the mechanisms that produce and

Q-methodological study of hearing voices

191

maintain voices can be understood in terms of ordinary psychological principles

(Hingley, 1992; Maher, 1988) and that hearing voices should not be judged, in itself,
as a sign of madness, any more than thinking or remembering (David & Leudar, 2001).
Voice hearing therefore can be perceived as being on a continuum with normality
consisting of a seamless graduation from absence of symptoms, through degrees of
eccentricity, to serious problems (British Psychological Society, 2000; Clarke, 2001).
Like professionals in the eld, voice hearers themselves often look for a theoretical
explanation to account for the existence of their voices. Romme and Escher (1993)
invited voice hearers to contact researchers, after the broadcast of a television
programme about hearing voices. They described how many individuals who contacted
them adopted a theoretical frame of reference, such as parapsychology, reincarnation,
metaphysics, the collective unconscious or the spirituality of a higher consciousness.
(Romme & Escher, 1993, p. 7)
Researchers have asserted that voice-hearing experiences are more accessible to
individuals who are psychologically open to them or to those who hold interests in the
spiritual realm (Heery, 1989; Jackson, 1997; Peters, Day, McKenna, & Orbach, 1999).
Some voice hearers use prayer and meditation to facilitate contact with voices,
suggesting that intention can be an important aspect of some individuals relationship
with their voices (Heery, 1989). Chadwick (1997), talking of his own psychotic
experiences, likened the early euphoric stage of psychosis to the beginning of a spiritual
enlightenment. His personal belief was that productive use could be made of such
experiences.
Understanding the range of beliefs that voice hearers hold about their voices should
therefore be of great importance to researchers and clinicians. It has been shown that an
individuals distress about their voices may be related not to the content of the voices
but to beliefs about their origin, identity, and purpose (Chadwick & Birchwood, 1996).
It has been claimed that the voices and visions experienced by both mental-health
service users and non-service users are similar, irrespective of diagnosis (Honig et al.,
1998). Two factors reported to distinguish voice hearers who do not use services from
those who do are the degree of distress caused by the experience and the extent to
which these experiences are seen as normal (Romme & Escher, 1993). It has also been
claimed that beliefs about voices have an important inuence upon how voice-hearing
experiences are maintained (Chadwick & Birchwood, 1996).
Such ndings emphasize the importance of therapy addressing where the client
perceives the voices to be coming from and their beliefs about their experiences. The
need for a clearer understanding of voice hearers own accounts, beliefs and views
about their experiences has been recognized (Leudar & Thomas, 2000; Thomas &
Leudar, 1996), and valuing and respecting the clients perspective is important for
therapeutic engagement (Barker, 2000).
This preliminary study uses Q-methodology to address the following question: Why
do voice hearers believe they hear voices, and how do they make sense of their
experiences?

Method
Brief overview of Q-methodology
Q-methodology was devised by Stephenson (1935, 1953) as a simple alternative
methodology to those employed in traditional psychometric assessment. The research

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S. Jones et al.

instrument is the Q-sample, a collection of items, usually in the form of statements that
represent the broadest possible variety of attitudes and/or perspectives on a topic.
Participants rank order each Q-sample item along a continuum of signicance from
most agree ( 5) to most disagree ( 5), according to how accurately it represents
their view. The arranged statements comprise a Q-sort reecting the participants
viewpoint within the boundaries of the quasi-normal distribution grid provided. This
approach to evaluating a large set of statements means that participants avoid having to
repeatedly apply ranking scales, and it also diminishes the possibility of halo effects or
biased response patterns emerging. The forced distribution design of the Q-sort
obviously means that each statement must be allocated to one of the spaces in the
grid so that each complete grid can be mapped/compared in relation with every other.
This potentially constrains responses in that participants may have to distinguish
between statements that they feel have the same signicance (e.g. they may feel that
they most disagree with four statements when only two may be placed at the extreme
point of the grid). Nevertheless, participants have full control over where each
statement is placed, and the range of response choice (extending from 5 to 5) is
wider than other mainstream ranking instruments (Stainton-Rogers, 1995). Each
completed grid represents an ipsative construction of the Q-sample, where all statements have been rated and organized in relation to each other, thereby maintaining a
holistic viewpoint.
Q-sorting provides data for factoring. Q-sorts obtained from several individuals can
be correlated and are factor-analysed by person rather than the traditional analysis by
variables or statements. The resulting factors indicate clusters of individuals who ranked
statements in the most similar way as well as indicating dimensions of the phenomenon.
Factors are explained and interpreted in terms of commonly shared perspectives.
Producing the Q set
To design the Q-sort, it was necessary to sample the domain relevant to the subject of
investigation as widely as possible. This included reading relevant literature, self-help
booklets, and information sheets; sampling popular discourse and the media; and having
discussions with voice hearers. Care was taken to recruit a disparate range of discussion
participants so as to provide a rich and diverse range of perspectives from which items
were selected. Discussions took place with the following voice hearers: eight members
of a hearing-voices group (run within mainstream psychiatric services), two individuals
who used adult mental-health services who described themselves as having schizophrenia, two who attended spiritualist churches, two who attended evangelical
Christian churches and two individuals who neither attended adult mental-health
services nor held religious beliefs.
A sample of statements is considered representative if it samples the diversity of
beliefs adequately, without favouring some to the exclusion of others and without
omitting sections of known constructions of belief (Stephenson, 1953). Three broad
categories emerged, namely:
(1)
(2)
(3)

Biomedical: Items grounded in classical psychiatric understandings of voice

hearing.
Psychological: Items grounded in psychodynamic and cognitive behavioural
understandings of voice hearing.
Spiritual: Items grounded in spiritual and new-age explanations for voice
hearing.

Q-methodological study of hearing voices

193

The initial sample of 350 statements obtained was reduced to yield a representative
and clear set of 45 items, a sample size consistent with reputable studies using this
technique (see e.g. Dennis, 1986). Care was taken to ensure that a logical and reexive
procedure structured the item reduction. From the original list, the research team noted
and eliminated duplicate statements and rephrased complex expressions. Further
renement of the statement set was based on consultation with independent scrutineers, four mental-health professionals, and four laypeople. The professionals had
experience of working with clients who had voice-hearing symptoms, and the lay
participants were volunteers from the original discussion groups. These participants
also helped ensure that items were intelligible and germane to the topic. This process
resulted in three categories of statement that included an equivalent number and
balance across the statements (Stainton-Rogers, 1995). A nal validation process was
undertaken to conrm the validity of the three categories. The statements and a list of
the category headings were given to eight clinical psychology colleagues who were
asked to read each statement and place it into the most appropriate category. This
process led to the conrmation of the nal Q-sample of 45 statements (see Table 1).
Participants
The decision was made to include a range of voice hearers in this study, including those
who do not access mental-health services. Very little research to date has been
conducted comparing voice hearers who use mental-health services and those that do
not (exceptions include Honig et al., 1998; Romme & Escher, 1993). It has been
reported that mental-health-service users experience their voices as largely negative,
and most non-service users experience them as largely positive (Romme & Escher,
1999). Furthermore, voice hearers experience is usually accounted for in terms of
either pathology or spirituality (divine inspiration or demonic possession). However,
very little attention has been paid to individuals who fall into neither group (Heery,
1989). It was therefore felt important to include non-religious individuals in the study
who were not using mental-health services.
In Q-methodology, sampling is different from that used in conventional methodology. Participants have the status of variables rather than sample elements. For the
purpose of the analysis, the sample is each participants set of Q-items (McKeown &
Thomas, 1988). The group of participants should include individuals who are likely to
hold pertinent viewpoints on the topic under investigation. Within Q-methodology, the
breadth and diversity of the participant sample are considered more important than
proportionality (Brown, 1996).
The host NHS Trust research ethics committee granted ethical approval for the study,
and consent was obtained from all the participants after they had been fully briefed
about the purposes and nature of the study.
Research participants were recruited from a variety of sources, including a hearing
voices group, from the caseload of eight community psychiatric nurses, the National
Union of Spiritualist Churches, and subsequently two spiritualist churches, one evangelical Christian church and advertisements placed in the National Hearing Voices
Network magazine and the Northern Echo newspaper, and on notice boards of the
local university, library, and supermarket.
The nal sample consisted of 10 men and 10 women whose ages ranged between 27
years and 75 years, with a mean age of 47.3 years. Of these, 11 were currently using
mental-health services; four had never sought such help, and the remaining ve had

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S. Jones et al.

Table 1. Q-sample
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.

Given the right circumstances, most of us would hear voices

People who hear voices are making contact with a different spiritual plane of reality
People hear voices when the Devil or other evil spirit possesses them
Hearing voices is a life-long condition
Hearing voices is a result of stress in vulnerable people
People who hear voices have lost contact with reality
Voice hearers have an imbalance of chemicals in their brains
Voices are divine messages from God, the Holy Spirit, and other guiding spirits
Voice hearers listen to the voices of their ancestors
People who hear voices are insane
Voice hearers are at an advanced spiritual stage
Untreated voice hearers are a risk to society
Hearing voices is a symptom of mental illness
Voices happen when a person mishears actual sounds as being voices
Painful memories sometimes imprint themselves on a persons mind as voices
Voices can help people cope with problems in their life by giving comfort
People who hear voices are psychic or have a sixth sense
Voice hearers have a special sensitivity, which allows them to act as a channel or medium for spirits
Voices need to be controlled by psychiatric treatment
People hear voices when, by mistake, the brain interprets thoughts as voices
Voices often disappear when a persons problems are worked through
Medication improves the quality of life for voice hearers
Voice hearers rise above most peoples awareness and beyond normal experiences
Voices are reminders of past-life experiences
Hearing voices results from being mentally injured as a child
Voices can help a person take action that they have lacked courage to perform
People hear voices because they have schizophrenia
The messages of voices contain a sensitive awareness of what other people are thinking
All people who hear voices need to take medication
People may hear voices when a spirit possesses their body
Voices bring unsolved problems from the past, into a persons mind
Damage in certain parts of the brain causes a person to hear voices
People hear voices because of their family genes
Witchcraft and curses can bring on voices
Voices bring messages from a persons imagination or unconscious mind
Many people without mental illness hear voices
Voices are the result of a persons brain not working properly
The origin of voices relates to the forces of the planets
Voice hearers are listening to the voices of the wandering deceased (ghosts)
Voices can begin after a major life event
Voices may be fantasies to relieve boredom and loneliness
Voices are a gift and allow people to develop special abilities
People hear voices because they have taken illegal drugs
Voices help people think things through so that they can reach solutions to problems
Hearing voices indicates a severe personality disturbance

briey used mental-health services in the past although not necessarily regarding voice
hearing. The length of time that voices had been heard ranged from 3 to 57 years, with a
mean of 20.6 years. The mean age for the onset of voices was 26.2 years of age. Three of
the participants attended a Spiritualist Church, and one attended a non-conformist

Q-methodological study of hearing voices

195

Christian church. Additional details were collected on the onset, nature, and content of
voices.
Participants were instructed to familiarize themselves with the 45 statements and
then sort them into three piles: disagree, neutral/not sure, agree. They were then asked
to choose the two statements with which they most agreed from the disagree pile and
place them accordingly on a blank grid similar to that illustrated in Fig. 1. They then
selected the two statements with which they most agree from the agree pile and placed
these on the grid. A similar process continued until all the items were sorted. When
sorting was completed, each participant was asked to re-examine the entire array of
statements and re-arrange items if they wished. Clinical judgment suggested that no
participant seemed unduly confused, distracted, or distressed by the process, and all
seemed to have the concentration necessary to complete the task. Alongside the Q-sort,
a semi-structured interview was undertaken to complement each participants sort. The
interview covered participants demographic details, their use of mental-health services,
and information about their experience of voice hearing.

Figure 1. Q-sort grid.

Results
The 20 completed Q-sorts were entered into SPSS (version 8.0) and analysed using
factor analysis (principal components). Six factors emerged, which were rotated to
simple structure using a varimax criterion. This allowed for the most distinctive
features of voice hearers understandings to be highlighted, those which are shared
with some voice hearers and differentiated from others. Using an eigenvalue
greater than unity (>1.00), the results indicated that the original 20 sets of
rankings reduce to six independent orderings, which together explain 69% of
the variance.

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S. Jones et al.

Thus, six constellations of beliefs held by voice hearers were differentiated within
the completed Q-sorts. Factor loadings for each participant (using pseudonyms) are
given in Table 2. Only those participants Q-sorts, which signicantly and solely loaded
on a given factor, were taken to dene that factor. Signicance was taken at .45, which is
considered to be a rigorous level in Q-methodology (Brown, 1980; Stephenson, 1953).
All participants loaded signicantly on at least one of the six of the factors. As Table 2
reveals, two confounded sorts were identied (Maddy and Aaron), which loaded
signicantly upon two sets of factors (factors 2 and 3 and factors 1 and 2, respectively).
Although these participants were not used to dene the factor, their sorts were viewed
by the researchers (alongside the dening sorts) as part of the interpretative process in
accounting for the factors.
Table 2. Rotated factor matrix
Participant
Rod
Sam
Beth
Ray
Gary
Jo
Tom
Maddy
Dan
Pam
Aaron
Maxine
Adam
Simon
Anthea
Anth
Theresa
Katy
Delia
Chris

Factor 1
87*
82*
80*
78*
73*
68*
58*
65

Factor 2

53
74*
65*
62

Factor 3

Factor 4

Factor 5

Factor 6

50
88*
59*
83*
71*
75*
61*
60*
85*
56*

Note. Decimal points omitted from loadings, which are correct to two signi cant gures (i.e. 0.782
reads 78).
a
Loadings (participants) used in the next stage of calculation.

Having identied which participants Q-sorts dened each factor, further calculations were conducted to reect the magnitude of the extent to which each dening sort
contributed to that factor. Each dening Q-sort was proportionately weighted, and this
weighting was applied to each Q-item. The scores for each Q-item were summed and
then rank ordered into the original Q-sort continuum which participants had followed in
sorting the statements. This produced a best estimate, idealized Q-sort for each of the
six factors (see Stainton-Rogers, 1995; pp. 188189). Each idealized Q-sort for each
factor is displayed in the so-called factor array (Table 3). The factor array also allows
researchers to view how Q-items are distinguished from each other across the factors,

Q-methodological study of hearing voices

197

and this comparative process assists in the interpretation of factors. For example, Item
19; Voices need to be controlled by psychiatric treatment, is ranked as 5 (most
strongly disagree) in Factor 1 but as 5 (most strongly agree) in Factor 6.
Table 3. Factor arrays for factors 16
Q-item
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45

Factor 1
1
5
1
0
1
3
2
3
1
5
3
4
3
1
1
3
4
3
5
0
0
2
4
0
2
2
2
1
4
2
1
3
0
0
2
5
3
2
1
2
0
4
1
2
4

Factor 2
4
2
0
1
2
5
3
2
0
1
0
4
0
4
2
5
4
1
2
1
4
3
1
0
3
3
1
2
1
5
0
3
3
1
0
5
3
3
2
4
1
2
2
2
1

Factor 3
1
2
5
5
0
3
0
4
3
5
0
2
1
1
3
3
1
2
1
4
3
0
2
4
0
2
1
2
1
0
5
1
2
4
4
3
3
2
2
1
3
4
2
0
1

Factor 4
2
3
1
3
2
2
0
1
5
5
2
3
1
4
2
2
1
1
2
4
0
3
0
3
4
4
1
0
4
4
5
1
0
2
1
1
2
1
3
0
4
0
5
2
3

Factor 5
0
1
5
0
2
4
4
2
0
4
2
1
2
3
4
2
0
1
4
4
0
5
2
3
1
3
2
2
5
3
3
2
3
1
1
0
1
5
1
1
1
0
3
2
3

Factor 6
1
0
5
2
3
3
2
0
2
3
0
1
5
3
2
1
1
1
5
4
0
2
1
3
1
4
2
4
0
5
2
2
2
2
3
0
1
3
4
4
0
3
4
1
1

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S. Jones et al.

Qualitative analysis was used to identify the perspectives represented by each factor,
to clarify the distinct conceptual differences between factors, and to name the factor
arrays that reect participants beliefs. Although it would have been useful to validate
interpretations by returning to participants who exemplied each factor (i.e. those with
sorts that most strongly loaded on the factor), this was not practical in terms of either
the timescale of the study or the additional demand this would place on participants.
Nevertheless, interpretations were informed by the semi-structured interviews conducted during the sorting procedure, alongside the existing literature. An account of
each of the six factors is presented below, together with illustrative responses. The
factor score for each statement is given in parentheses after the item.
Factor 1: The positive spiritual perspective
Respondents who loaded onto this factor perceived voices as positive experiences,
derived from spiritual sources. They condemned a biomedical framework on voice
hearing. They were mildly supportive of some psychological perspectives; thus, they
acknowledged the positive psychological functions voices may full and the role of
stress in the mediation of voice-hearing experiences.
As indicated in Table 2, seven participants (Rod, Ray, Tom, Gary, Jo, Beth and Sam)
dened this factor. Also, one respondent with a confounding Q-sort (Maddy) loaded
signicantly on this factor. It accounted for 26.18%of the total variance and was the
principal component. This was the only factor that strongly endorsed the following
items:
2. People who hear voices are making contact with a different spiritual plane of
reality ( 5)
17. People who hear voices are psychic or have a sixth sense ( 4)
23. Voice hearers rise above most peoples awareness and beyond normal
experiences ( 4)
42. Voices are a gift and allow people to develop special abilities ( 4)
11. Voice hearers are at an advanced spiritual stage ( 3)
18. Voice hearers have a special sensitivity, which allows them to act as a channel or
medium for spirits ( 3)
Three participants reported they believed they had always been psychic or clairsensient. Two others explained how they had developed an ability to open themselves
up to voices by undertaking relaxation, meditation, or prayer; Beth described her
spiritual development, including the ability to hear voices, as a natural progression.
They were very critical of pejorative media or psychiatric images of voice hearers
such as:
10. People who hear voices are insane ( 5)
12. Untreated voice hearers are a risk to society ( 4)
45. Hearing voices indicates a severe personality disturbance ( 4)
They disagreed, more strongly than participants dening all other factors, that voice
hearing indicates a mental-health problem or that voice hearers need psychiatric help:
19. Voices need to be controlled by psychiatric treatment ( 5)
13. Hearing voices is a symptom of mental illness ( 3)
27. People hear voices because they have schizophrenia ( 2)
One participant who had received brief counselling in the past (but no other mentalhealth-service input) stated he could choose to hear voices whenever he wished.

Q-methodological study of hearing voices

199

However, he had taught himself to block them out. This is congruent with the stated
ability of all participants loading on this factor to take control over their own voices.
This is the only factor in which participants disagreed with the following item:
37. Voices are the result of a persons brain not working properly ( 3)
The participants who loaded on this factor did not strongly disagree with any
psychological perspectives and mildly endorsed most of them. They agreed that
voices served functions such as:
16. Voices can help people cope with problems in their life by giving comfort ( 3)
26. Voices can help a person take action that they have lacked courage to perform
( 2)
44. Voices help people think things through so that they can reach solutions to
problems ( 2)
They mildly disagreed that voices resulted from psychologically traumatic
experiences. This is the only factor on which participants disagreed with the following:
25. Hearing voices results from being mentally injured as a child ( 2)
15. Painful memories sometimes imprint themselves on a persons mind as voices
( 1)
Interestingly, all the participants who attended spiritualist or non-conformist Christian
churches loaded onto this factor. Voices are conceived only as positive for them and
most denitely not as an indicator of mental-health difculties. They believe that all
voice hearers are listening to the voice of spirits but that they overwhelm some
individuals who do not understand the experience.
Factor 2: Personal relevance perspective
The respondents who loaded onto this account related voice-hearing experiences to
personal life events within a psychological framework. They strongly acknowledged the
role that talking therapies might play in ameliorating voices. They viewed some voices in
a positive light. They did not adhere to a biomedical treatment model or spiritual model
of understanding voices.
Two respondents (Dan and Pam) loaded signicantly on this factor, as did two others
with confounding Q-sorts (Aaron and Maddy). This factor accounted for 15.72%of the
total variance. The participants who loaded on this factor support the perspective that
voices relate to life experiences. All the individuals who loaded on this factor reported
difcult childhoods with elements of sexual, emotional, or physical abuse, and related
this to their voice hearing:
15. Painful memories sometimes imprint themselves on a persons mind as voices
( 5)
21. Voices often disappear when a persons problems are worked through ( 4)
40. Voices can begin after a major life event ( 4)
25. Hearing voices results from being mentally injured as a child ( 3)
26. Hearing voices is a result of stress in vulnerable people ( 2)
Item 21 is only strongly agreed with by participants who load on this factor.
They indicated that voices could potentially serve various positive functions:
16. Voices can help people cope with problems in their life by giving comfort ( 5)
26. Voices can help a person take action that they have lacked courage to perform
( 3)

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44. Voices help people think things through so that they can reach solutions to
problems ( 2)
The participants loading on this factor reacted strongly against the following media
stereotypes:
6. People who hear voices have lost contact with reality ( 5)
12. Untreated voice hearers are a risk to society ( 4)
They disagreed with the need for psychiatric treatment including medication. Their
mildly anti-medication stance may be consistent with their response to the following
item:
7. Voice hearers have an imbalance of chemicals in their brains ( 3)
Spiritual interpretations are not viewed favourably by those who loaded onto this factor.
They were sceptical about items that referred to spiritual possession or mediumship and
were the only participants who strongly disagreed with the following item:
17. People who hear voices are psychic or have a sixth sense ( 4)
However, assertions that voice hearers may have a sensitive awareness to what others
are thinking and that voices are a gift that allows people to develop special abilities were
considered favourably. This may be because both these items are very positive in nature,
and the participants who loaded on this factor are able to maintain an optimistic outlook
on voice hearing, despite their own difcult life histories.
Factor 3: Resigned pessimist perspective
Respondents who loaded onto this factor feel depressed about their troublesome voices
and hold a pessimistic outlook for the future. They acknowledged that voices might
relate to problematic life experiences but felt hopeless about the potential of therapy.
They used mental-health services but felt disillusioned about them. They did not adhere
to spiritual accounts of voice hearing.
Two respondents (Maxine and Adam) loaded signicantly on this factor. One
respondent with a confounding Q-sort (Aaron) also loaded on this factor. It accounted
for 8.06%of the total variance. The participants that loaded onto this factor accepted
some of the pejorative media and traditional biomedical portrayals of voice hearers:
6. People who hear voices have lost contact with reality ( 3)
12. Untreated voice hearers are a risk to society ( 2)
45. Hearing voices indicates a severe personality disturbance ( 1)
This is the only factor in which participants agreed with item 6.
It is also the factor in which participants most strongly agreed with the item
advocating that voices are genetically inherited. These individuals believed that voices
are for life:
4. Hearing voices is a life-long condition ( 5)
And consistent with this, they disagreed with the following item:
21. Voices often disappear when a persons problems are worked through ( 3)
They appeared to hold a resigned and hopeless outlook on the potential for ridding
themselves of their voices, despite conceding that their voices may relate to their
problematic life experiences:
31. Voices bring unsolved problems from the past, into a persons mind ( 5)
40. Voices can begin after a major life event ( 1)

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Both respondents reported that they heard voices every day and experienced them as
extremely distressing. They believed that voice hearers brains are damaged or not
working properly. However, they mildly disagreed or were neutral about items that
advocated a mental-illness model in which psychiatric treatment would be needed. They
may have been disillusioned with psychiatric care. They both reported that they take
psychiatric medication and still nd their voices very distressing.
Participants on this factor disagreed more strongly than participants loading on other
factors about the positive functional roles that voices might play:
16. Voices can help people cope with problems in their life by giving comfort ( 3)
41. Voices may be fantasies to relieve boredom and loneliness ( 3)
They agreed with one functional role that voices may play:
26. Voices can help a person take action that they have lacked courage to perform
( 2)
However, conversation with Adam revealed that this included the courage to perform
suicidal acts.
The participants who loaded on this factor were able to accept normalizing
perspectives on voices:
36. Many people without mental illness hear voices ( 3)
1. Given the right circumstances, most of us would hear voices ( 1)
These participants showed antipathy towards spiritual perspectives. They strongly
disagreed with items that promote biblical Christian concepts of spirit possession by
God or the Devil. They were disparaging of the concepts of special awareness,
mediumship or special psychic abilities. Both respondents loading onto this factor
acknowledged that they considered voices to be both frightening and powerful. Their
depressed outlook and sense of hopelessness may perhaps be inuenced by the
perceived omnipotence of their voices.
Factor 4: Pragmatic response perspective
The participants that loaded onto this factor understood hearing voices in terms of
communication with spirits. Despite not endorsing a psychiatric model of understanding voices, they believed that psychiatric treatment, including medication, was important in the management of voices. They also believed that voices might relate to
traumatic life experiences.
Table 2 indicates that two respondents (Anthea and Simon) loaded signicantly on
this factor, which accounted for 7.52% of the total variance. The participants who
loaded on this factor believed that:
29. All people who hear voices need to take medication ( 4)
22. Medication improves the quality of life for voice hearers ( 3)
19. Voices need to be controlled by psychiatric treatment ( 2)
Item 29 was strongly endorsed, and this was the only factor on which participants
agreed with this statement. Despite advocating the role of psychiatric medication, they
disagreed with psychiatric or media portrayals of voice hearers as insane, out of touch
with reality, personality disturbed, or a risk to society. Both participants who loaded on
this factor stated that they felt more of a risk to themselves than to others. They mildly
disagreed that hearing voices indicated mental health problems:
13. Hearing voices is a symptom of mental illness ( 1)
27. People hear voices because they have schizophrenia ( 1)

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One participant (Anthea) described how she thought voice hearing can be irritated by
mental illness, implying that she perceived voice hearing as a different phenomenon.
Neither of the participants who loaded onto this factor dened themselves as being
schizophrenic. Anthea used no label to describe why she heard voices, whereas Simon
believed that his voices were the result of a rapid ageing process in the brain.
Consistent with this, the items asserting that voice hearing may reect damage to the
brain, or the brain not working properly, were supported.
The participants who loaded on this factor were the only participants who strongly
agreed with the following items:
9. Voice hearers listen to the voices of their ancestors ( 5)
39. Voice hearers are listening to the voices of the wandering deceased (ghosts) ( 3)
They also endorsed the items asserting that voices are reminders of past-life experiences
and that voice hearers make contact with a different spiritual plane. Therefore, it was
evident that they held strong beliefs about the spiritual causation of voices. One
respondent elaborated on this and described how he heard the voice of his deceased
brother. However, they were disparaging about some other spiritual claims, including
those about spiritual possession:
30.
11.
34.
3.

People may hear voice when a spirit possesses their body ( 4)

Voice hearers are at an advanced spiritual stage ( 2)
Witchcraft and curses can bring on voices ( 2)
People hear voices when the devil or other evil spirits possesses them ( 1)

Both participants loading signicantly onto this factor delayed seeking psychiatric help
for years after they started to struggle coping with their voices. However, both now used
psychiatric services and felt they had beneted from this help. The participants that
loaded onto this factor disagreed with items that imply that voices are self-imposed or
illusory:
43.
14.
41.
20.

People hear voices because they have taken illegal drugs ( 5)

Voices happen when a person mishears actual sounds as being voices ( 4)
Voices may be fantasies to relieve boredom and loneliness ( 4)
People hear voices when, by mistake, the brain interprets thoughts as voices
( 3)

The participants who loaded on this factor do not believe that hearing voices is a lifelong condition. Their sorting of items indicated that they believed voices related to
traumatic life experiences. They do not perceive voices to serve positive functions and
disagreed with the following items:
41. Voices may be fantasies to relieve boredom and loneliness ( 4)
16. Voices can help people cope with problems in their life by giving comfort
( 2)
44. Voices help people think things through so that they can reach solutions to
problems ( 2)
Both Anthea and Simon disagreed more strongly with item 41 and 44 than participants
on any other factor. Interestingly, however, they did endorse the following item:
26. Voices can help a person take action that they have lacked courage to perform
( 4)
Again, both participants loading on this factor revealed that their voices encouraged
them to undertake self-destructive action and hurt themselves, and this is why they

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agreed with this item. They used psychiatric services and took medication for their
voice hearing, and perceived this to play an important role in the management of their
voices. There is a potential contradiction in that they understood voices in spiritual
terms but have beneted from psychiatric treatment. Conceivably, this is resolved by
endorsing the use of medication for non-specic uses (such as it calms me down or
taking it keeps the doctor happy).

Factor 5: Passivity to forces perspective

Participants who load on this factor perceived themselves to be passive to the inuence
of forces that caused their voice-hearing experiences. They believed that voices are
caused by spiritual possession and neurochemical imbalances. This was a powerless
perspective. The use of psychiatric services was endorsed.
Table 2 indicates that three respondents (Anth, Theresa, and Katy) loaded signicantly on this factor, which accounted for 6.20%of the total variance. The participants
that loaded onto this factor agreed with some psychiatric conceptualizations of voice
hearing:
19.
45.
13.
27.
12.

Voices need to be controlled by psychiatric treatment ( 4)

Hearing voices indicates a severe personality disturbance ( 3)
Hearing voices is a symptom of mental illness ( 2)
People hear voices because they have schizophrenia ( 2)
Untreated voice hearers are a risk to society ( 1)

No participants loading on other factors agreed more strongly with items 19 or 45. The
participants who loaded onto this factor all describe themselves as schizo-affective or
as experiencing psychosis. Also, they had all used psychiatric services for over 10 years.
They believed more strongly than participants loading onto other factors that medication improves the quality of life for voice hearers and also strongly believed that voices
need to be controlled by psychiatric treatment. However, they disagreed with the
following statement:
29. All people who hear voices need to take medication ( 5)
This was the only factor on which participants strongly agreed that voice hearers have
an imbalance of chemicals in their brain. They agreed that traumatic or difcult life
experiences were related to the experience of hearing voices. This is consistent with the
reports of all three participants loading onto this factor, of abuse being the initial trigger
for their voice hearing. They disagreed that voices served positive functions, and they
disagreed more strongly than participants on other factors that voices can help a person
take action that they have hitherto lacked the courage to perform. The participants who
loaded onto this factor were very disparaging of negative media stereotypes about voice
hearing.
The participants who loaded onto this factor held very strong beliefs about
possession by spirits, particularly evil spirits:
3. People hear voices when the devil or other evil spirits possesses them ( 5)
30. People may hear voices when a spirit possesses their body ( 3)
They were more tolerant than most of the magico-religious concept of witchcraft and
curses. However, they were neutral towards or mildly disagreed with other spiritual
conceptualizations. Theresa stated that voice hearers might falsely believe that they are
psychic when they are ill.

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Factor 6: Generic mental illness perspective

The participants who loaded onto this factor adhered to a mental illness framework
regarding voice hearing. They advocated the use of mental-health services and psychiatric medication. They recognized psychological factors that mediate voices, particularly
stress and problematic life events. They accepted that voices might be illusory.
Table 2 indicates that two respondents (Delia and Chris) loaded signicantly on this
factor, which accounted for 5.4%of the total variance. They strongly agreed with the
following items:
13. Hearing voices is a symptom of mental illness ( 5)
19. Voices need to be controlled by psychiatric treatment ( 5)
They also mildly agreed that hearing voices indicates schizophrenia and that medication improves the quality of life for voice hearers. Both participants who loaded onto
this factor described themselves as schizophrenic and took psychiatric medication.
They disagreed with media stereotypes of voice hearers as insane or having lost contact
with reality.
They endorsed all psychological perspectives that referred to the role of stress and
problematic life events:
40. Voices can begin after a major life event ( 4)
5. Hearing voices is a result of stress in vulnerable people ( 3)
15. Painful memories sometimes imprint themselves on a persons mind as voices
( 2)
31. Voices bring unsolved problems from the past, into a persons mind ( 2)
They strongly agreed that voices might be the result of cognitive misattribution:
20. People hear voices when, by mistake, the brain interprets thoughts as voices
( 4)
14. Voices happen when a person mishears actual sounds as being voices ( 3)
35. Voices bring messages from a persons imagination or unconscious mind ( 3)
Both participants who loaded onto this factor used psychiatric services. One respondent
had used services for many years. Denise elaborated on how she believed she had been
psychic since she was young and therefore originally believed that her voices were from
spiritual sources. She described how her psychiatrist had persuaded her against this
belief and told her that this belief was part of her illness. Therefore, she chose to
abandon her spiritual beliefs and now holds a mental-illness framework on voice
hearing. She added that she now believed that mediums are different from other
voice hearers.
The participants who loaded onto this factor held very anti-spiritual beliefs and were
particularly unsympathetic to ideas linking voice hearing to spiritual possession or
ghosts.

Discussion
This study explored how hearing voices is conceptualized and understood by a diverse
range of voice hearers (including mental-health-service users, non-users, spiritualists and
non-conformist Christian church-goers). Using Q-methodology, six distinct factors have
been identied and proled. These were positive spiritual perspective, personal
relevance perspective, resigned pessimist perspective, pragmatic response perspective,
passivity to forces perspective, and generic mental illness perspective. All six factors

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205

that emerged in the study include a complex constellation of different beliefs about
voice-hearing experiences. This study supports the assertion that the explanations
adopted by voice hearers seldom correspond completely with any existing theory
(Romme & Escher, 1993). Participants loading onto all six factors recognized that the
pejorative media stereotypes about voice hearers are inappropriate. Despite the
dominance of the biomedical model in our culture, on no factor do participants
adhere to all of the biomedical concepts. All six factors endorsed some elements
of psychological discourse on voice-hearing experiences. Clearly, psychological
perspectives on voice hearing are resonant with the voice hearers included in this study.
Service users in this study were more likely to nd voices frightening and perceive
them as negative experiences, than non-users. This supports the results of other studies
such as Romme and Escher (1996). This may demonstrate that non-users of mentalhealth services are more able to frame their experiences positively because of their
belief constructions and/or that because their voices are less problematic, they are less
likely to need to seek help from services. However, it also emerged that some non-users
of mental-health services found managing their voices difcult.
It has been suggested that the degree of distress caused by voices is linked to the
degree to which voices are seen as normal (Romme & Escher, 1993). For some of the
participants in this study, voices are construed as part of a normal spiritual development,
and none of these individuals felt sufciently distressed by their voices to seek
psychiatric help. It may be that their positive and optimistic belief constellations
about voice-hearing experiences actually protect them from needing to seek help.
Interestingly, participants who were voice hearers in spiritualist churches and nonconformist churches talked about learning techniques to close off at times from voices.
This seems similar to cognitive-therapy techniques such as learning to set boundaries on
voices and developing the ability to turn voices on and off (Chadwick & Birchwood,
1996). Difcult voices were construed by spiritualists as reecting the character of the
person in spirit, and some voice hearers nd such voices distressing or frustrating but
are able to function without mental-health-service input. The ndings from this study
illustrate the need for further work with non-service users to explore the variety of
voice-hearing experiences that they have.
The participant prole information revealed that 18 of the participants did not
believe that others could hear the voices they heard. The two individuals who did
believe that, in certain circumstances, voices could be heard by others, were spiritualists
referring to work with other mediums. This may have important treatment implications,
as basic cognitive challenging of voice hearers in mental-health services often involves
refuting the reality of voices, by emphasizing that others cannot hear the voices
(Greene, 1978). However, clearly, the voice hearers participating in this study acknowledge this, without it affecting their personal perception of the reality of the voices. A
total of 14 people stated that they could communicate with their voices. Cognitive
behavioural therapists (Fowler & Morley, 1989) often encourage this. Two participants
did add that telling their voices to leave them alone frequently was not an effective
strategy.
The process of a mental-health assessment often involves the client in the role of
relatively ignorant consulting a professional in the role of relatively knowledgeable
(Dryden & Felham, 1992). In this situation, professional wisdom is often accepted as an
unequivocal body of knowledge. However, attempting to understand voice hearers
within a single theoretical framework may limit or adversely affect engagement and
understanding of an individual. Voice hearers all hold their own theories on the

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aetiology of their experiences, and it has been suggested that clinicians should take an
individual and holistic approach (British Psychological Society, 2000). It is also worth
noting that psychologists who allow users to be themselves are often highly valued
(Davis, Holden, & Sutton, 2001).
Administration of a Q-sample, similar to that described in this study, may be an
appropriate tool for professionals as part of the assessment process of voice hearers
accessing mental-health services. It potentially yields a wealth of information as to how
the individual makes sense of their experiences and does so in a way that, for some, may
be less threatening than having to answer direct questions. Clients may also nd it
reassuring to be presented with an array of different conceptualizations of voice hearing
if they have concerns about being forced to adhere to a particular framework of
understanding. It may also give the client a sense that they can choose how to interpret
the meaning of their experience. Also, the Q-sort encourages the client to take an active
role, which potentially can boost self-esteem, as the implicit message is that the clients
beliefs and opinions are of worth. This is consistent with therapies that encourage
collaborative working with clients.
The examination of emergent factors may help to guide therapeutic interventions
(Beutler & Consoli, 1993; Roth &Fonagy, 1996). For example, adherents to the personal
relevance perspective might particularly welcome a therapeutic intervention that
attempted to address early traumatic experience, and for some people at least, it has
been claimed that voices disappear when underlying problems are resolved or integrated (Escher et al., 1998). Conversely, it would be easy to imagine how someone who
construes their voice-hearing experience in this way is going to be sceptical about the
value of neuroleptic medication. For people experiencing difculties with voices whose
beliefs are similar to those identied in factor 5, passivity to forces perspective, a
therapy that facilitates a move from their stance of powerlessness, passivity, and
vulnerability might be helpful.
It has been stated that Q-sorting requires high-level cognitive processing and that,
therefore, some participants may not fully understand the requirements of the tasks
(Tubergen & Olins, 1979). In this study, all participants were invited to offer feedback on
how they found the task after completion. Very few respondents described having any
problems with completion. Noone failed to make distinctions between statements and
to complete the Q-sorting. It is likely that the process was facilitated by ensuring that
statements were grounded in the participants own language and phrasing.
Q-methodology claims to avoid the imposition of structure upon the ndings
(Kitzinger & Stainton-Rogers, 1985). However, this is not strictly true, as factor analysis
fundamentally searches for common patterns, although, in this case, patterns are based
around whole constructions rather than individual statements. As previously noted,
some limitations may arise from the forced, quasi-normal distribution of the Q-sort, but
within the design, participants do have freedom to organize statements as they choose.
According to standard procedure in Q-methodology, no formal sampling of participants
is necessary (McKeown & Thomas, 1988). However, somewhat contradictory to this,
Brown (1996) stated that the breadth and diversity of participant sample are important.
In this study, efforts were made to ensure that a wide diversity of individuals were
chosen to partake, and the sample size is not inconsistent with other studies employing
this methodology. However, a larger number of participants in the study may have
enabled the ndings to be developed further.
Across a range of people who hear voices, this study has highlighted the breadth and
complexity of beliefs about the experience of hearing voices. It has been suggested that

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207

awareness of lay perspectives on voice hearing may have important therapeutic

implications, and future research might usefully investigate further the range of
constructions that people have about voice hearing.

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Received 14 March 2002; revised version received 23 December 2002