5

THE TYRANNY OF MEANING

One must be so careful with names….

—RAINER MARIA RILKE,Letters to a Young Poet

In 1972, David Rosenhan, a professor of psychology and law at Stanford University, organized and directed the secret admission of eight men and women—a graduate student, three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife—into the psychiatric wards of several American hospitals. Rosenhan’s purpose was to measure the extent to which psychiatric authorities could distinguish the mentally ill from the mentally healthy. To make his experiment as fair and accurate as possible, he stripped it of all but an elementary dishonesty. Rosenhan instructed his volunteers, whom he termed “pseudopatients,” to present themselves in hospital admissions offices complaining that they were hearing voices that said the words empty, hollow, and thud. Beyond that, they were to stop feigning the experience as soon as they were admitted, to act in the hospital precisely as they would in normal life, and to answer all questions truthfully except for those that might lead to their being discovered.

The results of the study were stark. Not one of the volunteers was detected. All were admitted to the hospital, diagnosed with severe mental illness—seven of the eight with schizophrenia—and prescribed potent antipsychotic medications. Furthermore, all reported that upon being admitted they were treated by the hospital staff as if they were like any other psychiatric inpatient at the time—which is to say, they were ignored, to the point where some were able to take copious notes in open view without drawing attention to themselves. Only the legitimate patients suspected the illegitimate ones. “You’re not crazy,” one patient insisted. “You’re a journalist, or a professor. You’re checking up on the hospital.”¹

Rosenhan’s study, published the following year in the prestigious journal Science under the title “On Being Sane in Insane Places,” caused a furor. Psychiatry’s many critics, flourishing in the wake of a series of damaging books—Thomas Szasz’s The Myth of Mental Illness, Ronald Laing’s The Divided Self, Michel Foucault’s Madness and Civilization, Ken Kesey’s One Flew Over the Cuckoo’s Nest—gloated over what appeared to be a decisive victory for the madman-as-social-victim school of thought. The article seemed proof that mental illness was at best a fluid concept and at worst a projection of the observer’s beliefs. The profession’s practitioners, meanwhile, were put even more firmly on the defensive than they had been before. Robert Spitzer, a doyen of the psychiatric establishment, published a lengthy critique in the Journal of Abnormal Psychology in which he pointed out that all branches of medicine rely on the honest reporting of experience:

If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behaviour of the staff would be quite predictable. If they labelled and treated me as having a peptic ulcer, I doubt I could argue convincingly that medical science does not know how to diagnose that condition.²

Rosenhan’s study still has the power to cause controversy. In 2004, the psychologist and author Lauren Slater reported that she had attempted to replicate the experiment. For days she let her personal hygiene lapse and then presented herself at nine psychiatric emergency rooms with the complaint that she was hearing a voice saying the word thud. Universally denied admission, she was nevertheless prescribed antipsychotic medication on several occasions. Spitzer responded with a second lengthy critique, this time in the Journal of Nervous and Mental Disease.³

This is how “On Being Sane” is usually discussed: as a central document in the ongoing debate over the validity of psychiatric classifications. Yet it is also a piece of literature that more than any other encapsulates the status of voice-hearing in the modern West. This is unspoken in the original article. Rosenhan offers two reasons for choosing a voice that said empty, hollow, and thud as the phenomenon with which he would breach the ramparts of institutional psychiatry. First, the experience had never before appeared in the clinical literature and therefore would not corrupt the experiment with precedent. Second, it had “an apparent similarity to existential symptoms”—in other words, empty, hollow, and thud suggested despair. But the tacit, predominant reason Rosenhan chose the phenomenon was that of all the experiences he might have used—suicidal thoughts, paranoia, obsessions, compulsions, phobias, panic attacks—auditory hallucination was the most patently, the most unequivocally, the most definitively indicative of mental illness. Nothing quite suggested pathology like hearing a voice.

How did an experience of such great antiquity and cultural import come to be considered not only pathological but definitively so—the pinnacle of mental disturbance? The most obvious answer is that voice-hearing draws its status from the status of the illness with which it is most commonly associated. Schizophrenia is the clinical centerpiece of psychiatry. It accounts for half of all admissions to psychiatric hospitals, costs $40 billion a year to treat in the United States, and is one of the top ten causes of disability worldwide.⁴ According to the National Institute of Mental Health, schizophrenia is “a devastating brain disorder—the most chronic and disabling of the severe mental illnesses.”⁵ And hearing voices is one of its prototypical symptoms.

Voices and schizophrenia have not always been so closely related, however. In the late nineteenth century, when the concept of schizophrenia was first developed by the German psychiatrist Emil Kraepelin, it was called “dementia praecox.” The term means “senility of the young,” and it was meant to reflect the typical onset of the illness in late childhood or early adulthood. Kraepelin considered the all but inevitable outcome of the disorder to be a sort of catatonic recoiling into the self. He didn’t ignore the existence of auditory hallucinations; they were, he wrote, “peculiarly characteristic” of dementia praecox, and he provided many examples in his work. But he didn’t see the experience as the disorder’s primary feature. What distinguished a patient with dementia praecox, Kraepelin argued, was that he became slowly and irreversibly mentally disabled.

Eugen Bleuler, the Swiss psychiatrist who rechristened the disorder “schizophrenia” in 1908, deemphasized auditory hallucinations to an even greater extent. Kraepelin believed voices were connected biologically to an underlying disease; Bleuler believed they were psychological reactions. The true symptoms of schizophrenia, Bleuler wrote, had to do with thought and emotion. Schizophrenics had trouble making clear associations between ideas; they held conflicting attitudes about other people; they displayed inappropriate emotions; they withdrew into an inner world of imagination. By the word schizophrenia, Bleuler meant to imply not a split personality, as is often thought, but a disconnect among psychological functions such as thinking, memory, and perception.

This dynamic model of schizophrenia held for decades, until it became clear that it wasn’t much of a help to psychiatrists in the field, who needed a good way to determine who was sick and who was not. Kurt Schneider, a psychiatrist who was hired to rebuild the University of Heidelberg’s medical school after the fall of Nazi Germany, answered this call with a simple checklist of “first-rank” symptoms of schizophrenia. Schneider agreed with Kraepelin and Bleuler that voices weren’t fundamental to schizophrenia. They were undeniably easy to recognize, however, and so when he wrote up his list, he placed them at the top. The primary symptoms of schizophrenia, Schneider wrote, were “audible thoughts,” “voices heard arguing,” and “voices heard commenting on one’s actions.”⁶

Schneider’s system took some years to catch on, but when it did, it dramatically altered the way psychiatrists thought about schizophrenia. The British psychologist Richard Bentall has noted that when Schneider’s list was first translated into English, in the late 1950s, many researchers in the United States and England assumed he had found “a more precise way of identifying ‘real cases’ of schizophrenia.”⁷ His model began to appear with increasing frequency in academic journals and was incorporated into structured clinical interviews. Then the architects of psychiatry’s influential diagnostic manuals caught on. The World Health Organization’s International Classification of Disease, used by psychiatrists to diagnose patients throughout Europe, relies heavily on Schneider’s list. So has every edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders since 1980.⁸

The placement of voice-hearing at the center of the idea of schizophrenia didn’t make diagnosis a foregone conclusion. Just as the average neurologist encountering a headache does not reflexively diagnose brain cancer, the average psychiatrist encountering voices does not reflexively diagnose schizophrenia. Still, the close relationship between symptom and syndrome has deeply colored the experience. The public’s understanding of unusual experiences follows psychiatric thought closely, and the vast majority of academic research on voice-hearing examines the phenomenon not in its own right but through the lens of psychosis—as “schizophrenic” voices. In public, psychiatrists are usually careful to note that voice-hearing is not exclusive to schizophrenia or, for that matter, to mental illness. But some, through a zeal to provide a safe medical haven for potential sufferers, incautiously conflate the two. In his best-selling Surviving Schizophrenia, the psychiatrist E. Fuller Torrey writes that voices “are so characteristic of the disease that a person with true auditory hallucinations should be assumed to have schizophrenia until proven otherwise.”⁹

And yet, the relationship between voice-hearing and schizophrenia is not what caused the experience to take on such a patently pathological feel. For one, the concept of schizophrenia appeared too late in history to be the main culprit. It ramped up the pathological profile of voice-hearing, but it didn’t create that profile. What it did is more elemental and was well illuminated by a debate that occurred a few years ago in the pages of the British journal The Psychologist between Anthony David, a psychiatrist at London’s Institute of Psychiatry, and Ivan Leudar, a psychologist at the University of Manchester. The subject of the debate was the question “Is hearing voices a sign of mental illness?” David argued in the affirmative, Leudar in the negative.

The debate was strained from the start. David and Leudar had no trouble agreeing that voice-hearing is not in and of itself an indication of mental illness. But beyond that basic point they were unable to settle on what criteria they should use to answer the question. Should they examine the content of voices? The level of distress caused? The grammatical form the voices take? If the first, what would this do to the reliability of psychiatric taxonomy, which traditionally focuses on form? And what if the “pathological” content did not cause any distress? If the second, what if the distress was caused by something other than voices? If the third, on what authority were they to pass judgment on the madness of grammatical tenses? The debate did more to reveal the philosophical muddle into which discussions of psychopathology inevitably devolve than to answer the question that sparked it.

But like all useful philosophical discussions, the debate helped highlight the linguistic difficulties at the core of the subject. The pitfall of language tripped up the clinicians from the beginning, when Leudar proposed terms for the debate. “I do not accept that auditory and verbal hallucinations must be studied only as hallucinations,” he wrote. “The term ‘hallucination’ implies an intrinsic confusion—something subjective is wrongly experienced as ‘real.’…Even before we investigate the experience, the term tinges it with a logically intrinsic pathology where there may be none.” The initial bracketing of hallucination in quotation marks hovered over the remainder of the debate, clearly distinguishing the two men. Whereas Leudar used the word only once after his opening salvo, and then in explicit criticism of orthodox psychiatry, David used it frequently and without compunction.¹⁰

The difference isn’t negligible. In the history of voice-hearing, no event has been as consequential in creating the modern meaning of the phenomenon as the introduction of that simple word hallucination.

 

The Spanish nun, mystic, and reformer Teresa of Ávila composed The Interior Castle, her classic work of mystical theology, over the course of six months in 1577. Intended as a spiritual map for the nuns under her direction, The Interior Castle imagines the human soul as a seven-chambered castle “made entirely from a diamond or very transparent crystal.” Teresa’s purpose in writing the book was to lead her nuns toward the innermost seventh chamber, where they would receive an understanding of the Holy Trinity and become married for eternity to Jesus Christ. She was, apparently, a well-qualified guide. At sixty-two she was known throughout Spain for her spiritual purity, and, as numerous self-abasements throughout the book make clear, she knew what could threaten the apprehension of God’s glory. One of the dangers she was concerned about pertained to sensory visitations from God. The reader, Teresa argued, was likely to receive divine favors, but she had to be certain that they were in fact divine and not the result of, for example, melancholy or a hyperactive imagination. For in these latter instances a person could not be considered visionary at all. Instead, she had to be considered “como enferma”: “as if sick.”

Como enferma. In an influential 1967 article, the American psychologists Theodore Sarbin and Joseph Juhasz claimed for this phrase an illustrious place in the history of the senses. It was, they argued, a deliberate attempt by Teresa to protect her nuns from the Spanish Inquisition. For years Teresa had been on the brink of persecution because of her flamboyant raptures, which often overcame her in public. She did not want her students to run the same risk, so she proposed that voices and visions could be caused by mental illness as well as by divine or demonic influence. By doing so, Sarbin and Juhasz wrote, Teresa set into action a momentous passing of social control over unusual sensory experiences from the confessional to the doctor’s office:

By declaring those nuns who were visionaries enferma (sick) Teresa could prevent the Inquisition from acting against them. Infirmity (sickness) is not something that one does, but rather something that happens to one, and therefore, one cannot be blamed (or praised) for it. This humane act was one of a series by religious and lay authorities aimed at removing the Inquisition from a position of control over reported imaginings.¹¹

It is a matter of conjecture whether Teresa’s book had as formative an impact on history as Sarbin and Juhasz maintained. It is also a matter of conjecture whether her use of the word enferma was a savvy political decision or whether it was, as theologians might have it, an honest description of a physical pitfall along the metaphysical path. Likely it was both: Teresa was at once pragmatic and spiritually scrupulous. But whatever the historical and religious particulars, the example serves as an important reminder of the complexity inherent in the pathologization of voice-hearing. Between the beginning of the Reformation in the early sixteenth century and the rise of psychiatry in the late eighteenth, there rests a 250-year blooming of a new empirical frame of mind, a “scientific revolution” that mitigated the centuries-old authority of the Church and instituted the Enlightenment ideals of rationality and skeptical inquiry. That revolution is what made the transformation of voice-hearing from a religious to a pathological experience possible.

Teresa’s use of the word enferma also serves as a reminder of the singular importance of language in the weakening of religion’s authority over experience. Theological reformation, political instability, technological innovation, scientific advancement—all contributed to the alteration in human consciousness that we now refer to as the rise of modernity. But the way that those contributions registered themselves in the human mind, the mechanism by which they took root and spread, and often even the way that they began was through language. The alteration of words served as the vehicle for the alteration in understanding that has led us to our present point of view.

For psychiatry this is particularly true. The profession arose as an organized discipline in the late eighteenth century, when physicians embraced the notion that institutionalization, previously thought of in terms of warehousing, could be curative. But its growth as a cultural force—the triumph of its interpretation of human experience—began in the nineteenth century, when psychiatrists made an energetic attempt to devise and propagate new medical names for age-old experiences. Like the early theorists of Christianity, these early psychiatrists embraced an intellectual mission: They systematized what had hitherto been a trend of thought. They codified a mood.

With hindsight, it is clear that the psychiatric codifiers were responding to the achievements of their predecessors. From about 1750 to 1800 the work of proto-psychiatrists was characterized by a revolutionary fervor. (The term psychiatry was not coined until 1808.) With a sense of the inevitability of progress that defined the Enlightenment, men such as William Battie (1704–1776) in London, Vincenzo Chiarugi (1759–1820) in Florence, and Philippe Pinel (1745–1826) in Paris preached the therapeutic gospel of compassion and seclusion from society. Their efforts were an unmitigated success. There occurred an increase not only in a commitment to hospital medicine but in the number of patients actually committed to asylums. Yet the most lasting effect of the reforms instituted by the first psychiatrists was arguably the boon it offered to the scientific minded. Given more patients, subsequent doctors could establish a clearer picture of insanity.

Of the second wave of psychiatrists, one benefited directly from the initial reforms. Jean-Etienne-Dominique Esquirol (1772–1840) was Pinel’s favorite student, the anointed disciple of the most influential psychiatrist in Europe. He eagerly took up the causes of his mentor, lecturing extensively on the need to treat the insane with kindness and fighting to imbue the discipline with a sense of scientific legitimacy. In 1817, Esquirol introduced the first formal course of clinical instruction in France. What is more, throughout the early decades of the nineteenth century he almost single-handedly poured the diagnostic foundation of the profession by transforming, in a series of landmark papers, the raw data of the crowded asylums into specific classifications of mental disorders, identifiable by way of their symptoms. He collected and revised these papers into his 1838 book Des Maladies Mentales, which the historian Roy Porter has called “the outstanding psychiatric text of his age.”¹² And the most outstanding and influential paper was one in which Esquirol for the first time in history identified, labeled, and offered a strict medical definition of unshared sensory experiences. He termed these experiences “hallucinations.”

When Esquirol introduced the word hallucination into the medical lexicon, it had only a modest etymological pedigree. Its roots are the Latin verb alucinor, meaning “to wander in the mind” or “to ramble on,” and the related noun allucinatio. Both seldom appear in classical Roman texts. (“Sic vestras halucinationes fero quemadmodum Iuppiter…ineptias poetarum,” Seneca wrote in De Vita Beata: “I shall put up with your ramblings as Jupiter puts up with the nonsense of poets.”)¹³Hallucination appeared just as seldom in the modern European languages. Its first appearance in English was in a 1572 translation of a monograph by the Swiss cleric Ludwig Lavater (the title, beginning “Of ghostes and spirites walking by nyght, and of strange noyses, crackes, and sundry forewarnynges,” runs for nearly a full page). It was used there as it was used elsewhere—to describe not only perceptions for which there was no external evidence but also for misperceptions for which there was external evidence.¹⁴ In this sense the word hallucination had something in common with other sensory terms in circulation in early modern Europe. It was just another way to point to unusual experiences. Most of these terms were religious, such as locution, apparition, possession, revelation, and inspiration.

The first generation of psychiatrists had not noted this lexical confusion so much as they had sidestepped it. They simply resolved to call all unshared sensory experiences “visions,” no matter the sense to which they applied. It was a state of descriptive affairs that plainly offended Esquirol’s notion of order. In his 1838 book, the pertinent section of which was a modest revision of a paper that had appeared in an 1817 medical dictionary, he laid out the problem with obvious irritation. “Who would dare say visions of hearing, visions of taste, visions of smell?” he asked. “And yet the images, ideas and notions, which seem to belong to the functional alteration of these three senses, present to the mind the same characters, have the same seat, that is to say, the brain, and are produced by the same causes.” He concluded that something needed to be done:

A generic term is wanting. I have proposed the word hallucination, as having no determinate signification, and as adapted consequently, to all the varieties of delirium which suppose the presence of an object proper to excite one of the senses, although these objects may be beyond their reach.¹⁵

Esquirol had two goals in mind in introducing the term hallucination. First, he wanted to bring under a single medical canopy all the previous existing names used to describe sensory experiences for which there was no external basis. This would allow doctors everywhere to speak in a common scientific language, with a common scientific reference point. To accomplish this goal, Esquirol not only named the experiences, but offered them their first explicitly clinical definition. His formulation bespoke an awareness of the cultural transformation taking place. “A man…who has the inward conviction of a presently perceived sensation at a moment when no external object capable of arousing this sensation is within the field of his senses, is in a state of hallucination,” Esquirol wrote. “He is a visionary.”¹⁶

Second, Esquirol wanted to institute a clear theoretical demarcation between the concept of hallucinations and what he now called, again offering the first explicitly clinical definition, “illusions.” For Esquirol, hallucinations had a centralized cause. They occurred as a result of the brain creating sensory impressions out of whole cloth. Illusions were “sensory errors.” They required a combination of the external world and the invention of the brain. Again he was insistent about the need for linguistic clarity:

The ancients did not distinguish visions from illusions of the senses. Some moderns adopting the term which I proposed as a substitute for visions have confounded hallucinations with illusions; dividing them, indeed, into mental hallucinations (visions), and sensorial hallucinations (illusions of the senses). Their authors have not distinguished with sufficient clearness the essential difference which exists between these two orders of phenomena. In hallucinations everything goes on in the brain. Visionaries, and those in a state of ecstasy, are hallucinated. They are in a reverie, though quite awake…. In illusions, on the contrary, the sensibility of the nervous extremities is altered: it is exalted, enfeebled, or perverted. The senses are active, and the actual impressions solicit the reaction of the brain.¹⁷

Esquirol’s innovations did not meet with immediate success. As the British historian Tony James has discovered, the word hallucination appeared seldom in medical texts prior to 1830. After that date, the innovations gained pace and were soon adopted by the medical establishment. This slow growth in momentum is not particularly surprising. Esquirol was the primary psychiatric educator of his time, and his students did not come of intellectual age until the 1830s. What is surprising is the peculiar and forceful mechanism by which Esquirol’s terminology drove a new logic of pathology. Esquirolian terminology was not accepted without discussion by the psychiatrists of the nineteenth century. Those who followed him recognized the perils of pathologizing voices and visions. Indeed, the most vigorous debate that took place in French psychiatry into the mid-century regarded the question of whether hallucinations were inherently pathological. But the overwhelming sense that one gets from those debates is of their futility. By the time psychiatrists were arguing over the extent to which medicine should claim ownership over unshared sensory experiences, they had already adopted Esquirol’s strictly medical terminology. The inevitable result was that even those who had misgivings about psychiatry’s land grabs could not avoid tilling the soil.

Naturally, there were those who did not have misgivings and who made the job of dissent that much more difficult. Like many of history’s great medical theorists, Esquirol was diligent in outlining the limits of his theories. Though hallucinations were “most frequently the lot of feeble minds,” he allowed, they could also occur in “men the most remarkable for their strength of understanding, the depth of their reason, and their vigor of thought.”¹⁸ But he had students whose apostolic zeal led them to abandon moderation. Notable among these was François Leuret (1797–1851), whose main contribution to the success of the concept of hallucination, an 1834 book titled Psychological Fragments on Insanity, took up Esquirol’s arguments with great rigidity. Contradicting his teacher, Leuret presented hallucinations as indisputably pathological, and he made this point in a way that was sure to gain attention and that set off a trend that has been termed “retrospective medicine”: he diagnosed the heroes of the past. Evaluating such famous instances of mystical experience as Moses’ vision of God, Ezekiel’s vision of the wheel, and Teresa of Ávila’s ecstasies, Leuret concluded that their subjects could only have been insane. “Seeing such obvious cases of madness, considered by theologians as evidence of sainthood,” he wrote, “the reader will doubtless absolve me from the reproach which he might have felt entitled to make, that I have so frequently appeared to exceed the bounds of the psychology of the insane.”¹⁹

Louis François Lélut (1804–1877), who was not a student of Esquirol’s, was more circumspect. In the same year that Psychological Fragments appeared, Lélut published In Search of Analogies Between Madness and Reason. This essay had a plainly humanistic purpose. Lélut’s project was to show that there was no strict dividing line between madness and sanity. To accomplish this he compared various manifestations of insanity with the mundane psychological extremes of rage, fear, despair, and love. Hallucinations gave him more trouble than other aspects of madness—he strained to find contemporary analogies—but unlike Leuret he did not conclude from this that hallucinations were inherently pathological. Rather, he argued that the dearth of everyday hallucinations was a reflection of cultural and historical forces at work. There were no hallucinators outside of the asylums in nineteenth-century France because “that is all that may happen for our modern times, in which, because of the risk of being taken for a hallucinated madman, one can no longer claim to be in communication with the divinity or with any supernatural agents whatever.” This had not always been the case. Throughout history, men and women of genius—he named Socrates, Muhammad, Joan of Arc, Martin Luther, and Ignatius Loyola—had proudly claimed to hear voices and to see visions. Framing the debate in the clearest terms yet, Lélut positioned himself with those who did not want hallucinations conceived of as a singularly medical phenomenon:

Can there exist more or less continual, chronic hallucinations, considered by the hallucinator as real sensations, which are nevertheless compatible with an apparently whole state of reason, and which allow the individual who suffers them, not only to continue to live with his fellow men, but even to bring to his conduct and the management of his interests all the soundness of judgment which is desirable? One would be inclined to reply in the negative, yet observation shows that this would be wrong.²⁰

But Lélut was not uniform in his stance. As Tony James has shown, his essay was marked by conflicting tendencies: If he mainly attempted to prevent psychiatry’s sole ownership of hallucinations, he at times seemed to advocate the universality of its theories. It was a paradox that was contained in his frequent use of the word hallucination, and he could not ward off the inevitable resolution. A mere two years later Lélut swung toward Leuret with the publication of his famous Du Démon de Socrate (On Socrates’ Personal Deity). In that book, to which he strangely appended his earlier essay, Lélut proved himself a staunch defender of medicine as an interpreter of human experience. Utilizing all the clinical resources at his disposal and applying them methodically to ancient Greek sources, Lélut came to the conclusion that Socrates was in reality no different from the patients housed in Parisian asylums. James has summarized his thesis as follows: “Unless we are to believe that the ancients misinterpreted Socrates’ own words about the nature of his inspirations, or that these words were a form of hoax, we must conclude that Socrates suffered from auditory—and perhaps an occasional visual—hallucinations. Since only mad people so suffer, Socrates, in spite of all other virtues he may have possessed, must have been mad.”²¹

The sheer audacity of this argument was a challenge not only to philosophers, who received the book warily, but to rearguard orthodox thinkers, for whom it was a terrifying precedent. Whom, they wondered, would Lélut diagnose next: Jesus? The first to accept the challenge was the Roman Catholic doctor Alexandre Brierre de Boismont (1798–1881). In his 1845 book On Hallucinations, Brierre mounted a direct protest against Leuret and Lélut. Yet while he embraced the historical relativism that the latter had displayed in In Search of Analogies, he refused to get bogged down in clinical discussion. The subject, he wrote with a flair for polemic, was much broader and much more grave. He was defending nothing less than Europe’s cultural inheritance: “If all hallucinations had to be placed amongst the products of a delirious imagination, then sacred works would no longer be anything but a mistake; Christianity, that powerful motivating force for social and individual movement, a mistake; our fathers’ beliefs, our own, our children’s, mistakes.”²²

On Hallucinations was what today would be called a crossover hit. It went into three editions and was read and discussed by a number of leading writers of the time, including Alphonse de Lamartine, George Sand, and Baudelaire. But as one of its reviewers made painfully apparent, Brierre’s arguments were ultimately stymied by the same paradox that had forced Lélut’s hand. Writing in the prestigious, newly established journal Annales Medico-Psychologiques, Alfred Maury decimated Brierre’s book. It was, he wrote, a simple matter of logic:

For we shall say to our author: you recognize that these great characters whom you are honourably defending may have had hallucinations; you recognize, and history records, that they took these illusions for celestial or diabolical apparitions, for real facts; therefore you admit that they were hallucinators, that they were insane; for what are the latter, if not minds who believe in their hallucinations as if they were serious facts? In addition you put forward the view…that for these characters these hallucinations were motives for action, determining causes, giving rise to great projects. Thus the illustrious characters in question had hallucinations like today’s hallucinators; like them they gave them credence; like them they acted in consequence of the imaginary sensations they experienced. What difference does M. Brierre persist in recognizing between these characters and those who are before our eyes?²³

The trap, then, was inescapable. The mere adoption of the word hallucination meant the adoption of its definition, and that definition left no room in which to maneuver. And though the discussion did not end there—from February 1855 to April 1856 the Paris-based Société Médico-Psychologique held a series of wide-ranging debates on hallucinations that again found Brierre, the organization’s secretary, on the defensive—in a sense nothing more needed to be said. The language packed its own internal logic, and that logic could not be breached. With one linguistic swoop, Esquirol had diagnosed not only his patients but the entirety of Western culture.

The effects of that act can still be felt. Esquirol’s definition of hallucination as “the inward conviction of a presently perceived sensation at a moment when no external object capable of arousing this sensation is within the field of [the] senses” is nearly identical to the definition currently on offer by the American Psychiatric Association, the publisher of the Diagnostic and Statistical Manual. A hallucination, that book’s editors write, is “a sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ.”²⁴ More important, the word hallucination continues to project a kind of syllogistic radiance. Used universally as a description for sensory experiences for which there are no external stimuli, and associated with a profession the express purpose of which is to treat mental illness, it bathes all such experiences in the glow of pathology.

 

In the mid-1980s, Marius Romme, a professor of social psychiatry at the University of Limburg, in the Netherlands, began to worry about the fate of one of his patients. Patsy Hage, thirty years old, heard voices telling her what and what not to do. She had been hospitalized several times, diagnosed as schizophrenic, and prescribed antipsychotic medication. The drugs lessened the anxiety that Hage’s voices caused, but they failed to quiet the voices themselves and had the unfortunate side effect of making her thinking foggy and dull. Therefore, she frequently didn’t take them, and the voices had begun to take over her daily life. She fell into a depression that Romme felt powerless to pull her out of. She talked more and more about suicide. The only aspect of their meetings that seemed positive to Romme was that Hage had recently read the work of Julian Jaynes, the psychologist who suggested that voice-hearing was universal in ancient times; she took comfort in the theory. Desperate and with no other leads, Romme began to wonder whether she might benefit from communicating what she had read with other voice-hearers and finding others who would accept it.

With this in mind, Romme arranged to appear with Hage on a popular Dutch talk show on which they invited people who heard voices to contact them. The strength of the response surprised him: 450 people called in. Even more surprising, one-third of the respondents claimed that they were able to live alongside their voices without great difficulty. It immediately struck him that this smaller group, whose members interpreted their voices in a variety of ways, would serve as a valuable therapeutic resource for those who had a harder time coping with their voices. He identified twenty men and women who were able to speak articulately about how they had learned to manage their voices and asked them to serve as the speakers at a conference for voice-hearers. The governing principle of the meeting, which was held in October 1987 in a labor union hall in Utrecht, was that all interpretations of voice-hearing, no matter how unusual, would be accepted. Clinicians would be in attendance, but only as guides and observers. John Strauss, an eminent Yale psychiatrist who was there as a guest, later described the mood:

The general atmosphere of the entire congress was of a meeting of a group of people with common interests and experiences. Although medical aspects of these experiences were discussed, there was no sense that this was a medical meeting or a meeting of medical patients. The participants freely shared their experiences, their many interpretations of these experiences including religious views or a range of other human reactions, and their approaches to coping. Some people were obviously troubled by their voices and saw them as part of a mental illness, but many had very different ways of understanding these experiences and appeared to be competent, not disabled, and depending on one’s view of the nature of voices, not in any way “ill.”²⁵

The meeting was a success. Its inclusive stance struck a chord among the participants. A self-help organization, Foundation Resonance, grew out of the conference and quickly began to gain notice elsewhere. Grassroots voice-hearing organizations began to pop up in Denmark, Finland, Italy, Portugal, Sweden, Germany, Japan, Australia, Malaysia, and England. Before long a full-fledged “Hearing Voices Movement” had formed, motivated by a therapeutic philosophy that Romme developed with his partner and colleague, a journalist named Sandra Escher. They called this philosophy “An Emancipatory Approach.” It was clear what the emancipation was meant to be from. In lectures, journal articles, and books, Romme and Escher argued that referring to voices as auditory hallucinations was not only technically incorrect—many people heard voices that were not signs of mental illness—but stigmatizing and harmful. The orthodox psychiatric model was to eradicate or mitigate voices. According to Romme, this failed to take into account the ineradicable importance that the phenomenon played in people’s lives. The insistence that the experience was pathological, he and Escher argued, was maladaptive. The people who coped best were those who found ways to bring their voices in line with their experiences. Those who tried to escape suffered the most.

Not surprisingly, Romme and Escher’s work met with criticism. In 1993, they published Accepting Voices, the core of which was the stories of thirteen voice-hearers who had learned to interpret their experiences in a positive way. Reviewing the book in the British Medical Journal, Raymond Cochrane, a British psychologist, called it “ill advised” and “potentially dangerous.” “Anything that may encourage people to accept the reality of delusional belief, and even to attribute to these beliefs some mystical supernatural power,” he wrote, “can only prolong the existence of these beliefs and make recovery from schizophrenia more protracted and more uncertain.”²⁶ But not everyone was pessimistic. Indeed, many were enthusiastic. Romme and Escher’s initial report on the Utrecht conference, published in the journal Schizophrenia Bulletin, was cited widely in academic journals, and their conclusion that “the real problem is not so much the hearing of…voices, but rather the inability to cope with them” has helped spawn a new “cognitive” approach to hallucinations. In 1994, the psychologists Max Birchwood, of the University of Birmingham, and Paul Chadwick, of the Royal South Hampshire Hospital in Southampton, published a landmark study in which they proposed that the anguish experienced by voice-hearers is directly related to a belief in the experience’s malevolence and power.²⁷ (Romme and Escher’s work has been embraced most enthusiastically in England, which has always been less conservative in clinical matters than the United States.) The psychologist Anthony Morrison, of the University of Manchester, similarly found that negative beliefs about voices increase both the incidence and the distress of the experience, and further observed that these negative beliefs are sometimes linked to the cultural dominance of the pathological interpretation of voice-hearing. Interpretations of loss of control, Morrison has written, “largely concern impending madness, and as such, may be related to patients’ negative appraisals of their psychosis, which are often reinforced by both [psychiatric] services and the media.”²⁸

But the greatest enthusiasm has come from voice-hearers themselves, who have responded as much to Romme and Escher’s often electrifying rhetoric as to their theoretical innovations. (Hallucinators, Romme has said, “are like homosexuals in the 1950s—in need of liberation, not cure.”)²⁹ These voice-hearers have coalesced into groups of increasing vocality and influence in psychiatric circles. Arguably the most vocal and influential has been a British self-help organization that was formed in 1988 on the model of the original Dutch voice-hearing organization. The Hearing Voices Network, based in Manchester, describes itself as “a network of people who hear voices, relatives, carers and workers who work toward gaining a better understanding of the experience of hearing voices and seeing visions and reducing ignorance and anxiety about these issues.” It has dozens of affiliated groups throughout the United Kingdom, and each summer it holds its annual gathering in a large Methodist hall in downtown Manchester. In 2003, I attended.

Like the first Utrecht meeting, HVN’s annual gathering attracts a wide array of voice-hearers, both those who are visibly troubled by their experiences and those who glory in them. (Ron Coleman, a prominent member, has declared himself “psychotic and proud,” and wants to work toward a day when he can “walk the streets talking to his voices and not be denied his freedom.”)³⁰ It also attracts mental health workers who attend for moral support and, frequently, because they consider HVN to be a paradigm of consumer-driven psychiatric reform. One clinician, to whom both reasons apply, chaired the gathering. Philip Thomas, a robust man with short gray hair and a thin white beard, is a psychiatrist affiliated with the University of Bradford and the coauthor, with Ivan Leudar, of Voices of Reason, Voices of Insanity, an iconoclastic study of verbal hallucinations. At the morning session, held in a sweltering auditorium, he announced from the stage that HVN’s main achievement was in “creating a space for people to experience their voices outside of the influence of psychiatry and psychology.” Sitting next to him at a long folding table was Peter Bullimore, a cochair of the organization. Bullimore, a voice-hearer, former psychiatric patient, and longtime critic of traditional medical interventions for psychosis, announced to loud applause the advances that HVN had made in the previous year: a new, confidential helpline; growth to more than 1,200 members; and nearly 150 regional self-help groups across Great Britain.

The juxtaposition of psychiatrist and antipsychiatric activist sitting next to each other on stage and working toward the same goal was jarring, and over lunch, served buffet-style in a narrow vestibule outside the auditorium, I asked Thomas about the potential irony of a psychiatrist working to diminish the influence of his own profession. Thomas has been criticized by colleagues for his active role in the consumer survivor movement, but he told me that he found no contradiction in his participation. “My role as a clinician is to help people reduce their suffering,” he said. “In many cases, I’m not convinced medical psychiatry is well equipped to accomplish that.”

In fact, Thomas resists not only the pathological interpretation of voice-hearing but all interpretations that claim to be authoritative. In Voices of Reason, he and Leudar argue that even to ask what causes voice-hearing “impoverishes” the phenomenon, robbing it of its true existence as an experience driven by a number of psychological and cultural factors, and that in our time psychiatry has done this by locating the origins of distress exclusively within the individual. “This serves two functions that are important politically,” Thomas and Leudar write. “First, it plays down the importance of social, cultural, economic and political factors in understanding human distress. Second, because the distress is constructed in terms of disordered brain function, it means that both the person and the social contexts in which the person exists have no control or influence on what happens.”³¹

This emphasis on lack of control is what has driven HVN’s success. The organization’s appeal is that it offers its members a level of ownership over their experiences that many feel psychiatry has stripped them of. This feeling is not always theoretical. Several people at the conference told me stories of having been institutionalized, or “sectioned,” against their will, and many more complained about the deadening effects of antipsychotic medication. Some of these complaints were couched in tones of underdoggish irreverence. Carol Batton, a diminutive, hyperkinetic woman referred to in the organization’s literature as the “HVN poet,” recited antipsychiatric doggerel at steady intervals throughout the day. (“Paranoid doctors, / Scared you might kill—/ Kill you by medicating / Over the hill. / They do it to anyone, / moderately ill.”) Others were grave. In an HVN newsletter distributed at the conference, Bullimore wrote of being diagnosed as schizophrenic and placed on tranquilizers. “After a few weeks,” he wrote, “I became a walking zombie living in a drug induced world not knowing one day from another wondering if life was worth living. I stayed in this surreal existence for ten years losing my family and my business.”³² But all made the very serious claim that a frightful experience was being made even more frightful by the practical implications of the psychiatric model.

A story told to me by Jacqui Dillon, a member of HVN’s management committee and a mental health activist, whom I met at the conference, vividly illustrates HVN’s animating complaint. Dillon, a mother of two with bright eyes and a broad smile, first began to hear voices after being subjected to sexual and physical abuse as a child. Her voices were a source of both solace and discomfort; they eased her loneliness, but they also sometimes told her to harm herself. When Dillon decided to tell a psychiatrist about her experiences, however, she found that her doctor was prepared to interpret her voices only as a symptom of psychosis. “I explained to her that my voices were parts of me and that I just wanted support in being able to listen to them,” she later wrote to me in an e-mail.

She looked confused. For her, the fact that I listened to my voices was evidence of my illness, and wanting to keep them in order to understand more about myself was seen as me being resistant to treatment. I believed that she was only focusing on the negative aspects of my voices…but she didn’t stop to consider that this might be because of the desperation I sometimes felt. Or to consider the ways that my voices helped me—how only they could soothe me at 3 o’clock in the morning when everybody else was asleep, or the voices that helped me work things out, with their insightful, and often witty comments. All the psychiatrists that I tried to tell either feared me, denied my experience or told me that I would never, ever recover from what had happened. They told me that I had an illness. I was mentally ill.

Dillon’s story is emblematic of the quarrel that HVN and its sister organizations have with psychiatry. According to traditional psychiatric manuals, voice-hearing is not an inherently pathological phenomenon. The controversy lies in how this diagnostic neutrality plays out in real life. The accusation that HVN makes is that no matter how noncommittal it is in its theoretical understanding of hearing voices, in practice psychiatry interprets the experience in a manner that leaves little room for the hearer. If you go to a psychiatrist and announce that you are hearing voices, you will likely be diagnosed with a mental illness and asked to consider your experiences within a biomedical framework. Your subjective experience of your voices will be downplayed so that the voices can be treated as the physician has been trained to treat them—which is to say, in objective, pathological terms. You will be asked to remove your experience from yourself. In a 2000 speech to HVN, Romme claimed that an individual who goes to a psychiatrist complaining of voice-hearing has an 80 percent chance of being diagnosed with schizophrenia.³³

It is partly to HVN’s credit that this portrait of psychiatric intervention is slowly growing outdated. In the United Kingdom and increasingly in the United States, a less stringently biomedical approach to voice-hearing has steadily been encroaching upon the traditional one. Whereas the latter emphasizes syndromes and pharmacological compliance, the former emphasizes symptoms and an engagement with the patient’s personal beliefs and experiences. As an article in the American Journal of Psychiatry recently explained, this model does not require that a patient accept a diagnostic label: “The goal…is not to try to persuade or force the patient to agree that he or she has symptoms of a mental illness. Rather, the goal is to reduce the severity of, or distress from, the symptom regardless of whether the patient accepts a diagnostic label.” If a patient chooses to view his voices in terms of the biomedical model, fine. But it is destructive, this model states, to foist that interpretation on him. Instead, the clinician should work to find an explanation of voice-hearing that is acceptable to the patient. The approach is “designed to work directly on understanding and coping with the positive symptoms of psychosis rather than ‘containing’ them.”³⁴

This new therapeutic philosophy, which hopes to extend the success of cognitive-behavioral therapy in treating depression and anxiety to experiences typically deemed redolent of schizophrenia, seems perfectly suited to the concerns of HVN. It is pragmatic and oriented toward recovery rather than pathology. It even adopts some of HVN’s characteristic language: The word coping is a hallmark of Romme’s work. And yet, in a sense, even this approach does not go far enough. HVN is greatly concerned with the therapeutic stance that psychiatry takes toward voice-hearing. But it is perhaps even more concerned with the cultural meaning that is ascribed to the phenomenon and therefore to its members. The cognitive-behavioral therapist who encounters a voice-hearing patient will by definition be open to any interpretation of the experience that works, be it religious, paranormal, or biomedical. But among themselves, and by extension in the realm of public discourse, they will invariably speak of them as “hallucinations,” which, in tacit criticism of its power, HVN always places in quotation marks.

Can the word hallucination really be destructive? The suggestion contradicts much recent psychopathological theory that has found medicalization to be healthful. Psychoeducation, the process of getting patients to accept the pathology of their experiences, is the psychological intervention for psychosis that has the greatest empirical support. And yet, there have always been those even within psychiatry who have noted the harmful reach of pathological terminology. Eugen Bleuler, the early theorist of schizophrenia, recognized the paradox into which a discipline that seeks to name and treat pathologies of the mind can lead its intended subjects. Often, he wrote, people “will admit that they are afraid to reveal their experiences because they will be considered pathological, and they themselves ‘crazy.’”³⁵ In 1983, the American psychiatrist Ian Stevenson addressed the effects of “hallucination” directly in an article in the American Journal of Psychiatry. Outlining the word’s psychiatric etymology and its varied manifestations, he suggested finding a nonpathological alternative:

Most persons who have unusual sensory experiences tell few people, or no one, about them. They rarely know that many other people have had similar experiences and have also remained silent about them for fear of being considered abnormal or worse. They have heard that hallucinations are symptoms of insanity, and they have no way of knowing that such experiences are not necessarily indicators of mental illness, either present or to come.³⁶

The problem that Stevenson raises is not the stigma associated with mental illness. Nor is it the malevolence of psychiatry. It is, rather, the practical and often immeasurable effects of language: the soft tyranny of offering a single pathological term for an experience that, both historically and in the present, reaches into more varied and more exalted forms of human consciousness than is typically assumed.