How to Talk to Someone Who Is Hearing Voices

Jessie (name disguised) lost eye contact with me and, cracking a smile, spoke to the invisible third party in the room. "I heard you," he replied to thin air, giving a dismissive wave of his hand. "She thought you’d like her joke, but it's kinda dirty," he chuckled to me.

Having cut my clinical teeth in a jail clinic, I was immediately exposed to a spectrum of hallucinatory presentations. From severely mentally-ill people to substance withdrawal to stress reactions, this was a realm demanding my attention. I had to quickly learn what did and didn’t work when interacting with people who heard voices because auditory hallucinations were the most prevalent and persistent kind (Ohayon, 2010; Waters et al., 2010). Over the years, I came to marvel at how I had gotten used to having a presence in the room I couldn't see.

Source: Liza Summer/Pixabay

More Common Than You think

Hallucinations are internally-generated sensory experiences. There is no external input contributing to the things a person is hearing, seeing, etc.

As such, while it may be a bizarre concept to the uninitiated, it's not an uncommon presentation in psychiatric and medical settings.

Though most regularly associated with schizophrenia, hearing voices, or auditory hallucination, is present in a variety of psychological disorders and organic medical conditions. Each year in the U.S. alone, 100,000 people aged 15-25 experience first-episode psychosis of a schizophrenia nature (Ziedonis & Small, 2017), never mind due to other complications.

Thakur and Gupta (2022) noted that 28 percent of people had experienced auditory hallucinations to one degree or another. This ranges from psychopathology like schizophrenia to hearing your name called or a phone ringing while falling asleep, known as a hypnogogic hallucination. Therefore, chances are, even if you don't specialize in schizophrenia-spectrum illnesses, you'll eventually encounter someone displaying or reporting hallucinatory activity.

Are you prepared?

While helping professionals are educated about hallucinations as symptoms, the prospect of encountering someone hearing voices remains uncomfortable for many. Other than basic inquiries on duration and content, usually presented as a checklist, many students and supervisees have confessed to feeling stuck when encountering voice-hearers. They also become perplexed as to why their well-intentioned efforts to learn about the voices engender frustration in the person seeking help.

As elaborated in 3 Things, Therapists Shouldn't Say, therapists' well-meaning offerings sometimes have unintended, negative outcomes. What follows are three more items, this time specific to interacting with voice-hearers, that, if possible, should be avoided.

1.) Are the voices real?

This may seem like an innocuous “reality check” statement to help assess the level of impairment. Some patients are stable enough to realize they're slipping; others may be convinced of a real presence. It's especially important in crisis settings when considering the level of care required. This question has a propensity for backfiring, though, as it can be perceived by the patient as, "I'm [evaluator] not so sure about that." In other words, it may come across as calling them a liar or crazy.

People who report hearing voices often do it with angst. I’ve been told more than once, “It’s been happening for a while. It's embarrassing telling someone you hear voices; they’ll think you’re nuts or dangerous.” It's a sensitive arena, and we can't afford to risk the helping alliance by asking such a potentially-offensive question.

I learned this the hard way. Early on, while interviewing an inmate that complained of hearing voices in solitary confinement, I asked if he believed they were real. He shot back, "What's that mean?" I reasoned, "Well, there's nobody in the cell with you, but you said it’s like someone talking in your ear." He finished, "It doesn't matter if I'm alone or not. I don't know where it comes from. Yes, it's real. I'm listening to a voice from somewhere!"

2.) What are they saying?

When giving trainings, I ask attendees what is important to know about the nature of the voices. Invariably, someone says, “Are they commands to hurt themselves or someone else?” Upon further discussion, this is a seemingly reactive inquiry. It’s well-intended, not only for patient well-being but to cover the evaluator legally.

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Though such commands are a concern, if a clinician’s initial reaction to someone saying they hear voices is immediately interrogative, i.e., “are they telling you to kill yourself?” it can seem they are covering their butt and don’t care about the person’s experience/want to help them. Asking for content right away may also seem invasive, as it may be embarrassing or shameful, and they need time to develop trust before sharing details.

Remember, too, that if voice-hearers are paranoid, the hallucinatory content tends to follow suit. Sometimes, when sitting with someone clearly responding to voices, I'd begin to guide them back by offering, “You got distracted there for a minute, are you OK?” Not infrequently, this was met with a derivative of, “They’re saying not to talk to you.” In acute situations, actively-hallucinating patients have become more tormented, crying and shaking their heads, spontaneously offering, “I can’t talk about it anymore. They said to shut up; it’s louder when I talk.”

Not seeming so prying can help quell the paranoia and get more engagement. As you'll read below, there are other ways to try to get at the desired information.

Source: GerdAltmann/Pixabay

3.) Did you take your medications?

First, consider the condescending quality of this inquiry. Second, if this is one of the first questions presented, it’s akin to cross-examination, implying, if the person said no, “Guilty! If you take your medications, you wouldn’t be having this problem." It's almost certain to make this person defensive, especially if their psychosis has a persecutory theme.

It can carry an accusatory tone, but it also ignores the complex struggle of the voice-hearer’s experience; it's as if the hallucinations are simply a neurochemical phenomenon. While it is clear that neuroleptics can be very helpful, like depression, anxiety, and bipolar illnesses, it’s more complicated than that. Even if they're helpful, there are psychosocial contributions, side effects to contend with, medications that may not be affordable, or paranoia about being poisoned or controlled can halt medication compliance.

Alternatives to the Above

The material sought in all three of the above questions is important and shouldn’t be ignored. Given the pitfalls of those lines of inquiry, though, we need alternative routes to the same material.

Instead of the above kind of questioning, it can be more effective to get the same material by adopting an experience-based line of inquiry. Rather than just getting answers about the voices by asking pointed questions, a more conversational approach can be more conducive to understanding the person's experience of hearing voices. This undoubtedly makes for a richer experience, especially if it’s someone you're doing therapy with. To illustrate, the following example supposes a more productive interview with the aforementioned inmate:

Clinician: "I heard you’ve been having a hard time and wanted me to check in with you. What’s going on?"

Inmate: "Oh man! Stress! I’ve been in solitary for three weeks and I can’t take it anymore! Locked in an 8 x 10 cell for 23 hours without contact except for meal delivery. My head is messing with me. There’s people talking but it’s not from the vents and there’s no one else in my cell!"

Clinician: "No wonder you’re stressed if that’s what going on. Fill me in on hearing these people that aren’t there."

Inmate: "It’s one, sometimes two people it sounds like; in my ear, just like a phone call!"

Clinician: And we know there’s no phones cells.

Inmate: "Exactly."

Clinician: "I know that’s a nerve-wracking experience, hearing these things from thin air, that’s one thing. But I'm curious, how has what they’re talking about been affecting you?"

Inmate: "It’s nonsense, confusing. Sinister laughter, comments like ‘What do you think!?’ or 'Through that wall.' It can just sound like a crowded room, too, and I can't hear things clearly."

Clinician: "Anything else, like comments to do things?"

Inmate: "No, just those random things."

Clinician: "Clearly this isn't getting easier for you- being in solitary, now hearing those things. I know you’ve never been to solitary before, but have you experienced the voices before?"

Inmate: "No, that’s what so scary about this."

Readers can see that, through this more conversational approach, we were able to learn about his perception of the voices-he was still rooted in reality (i.e., “my head is messing with me!”), and learn about the contents without the risky questions.

As for medications, to be responsible clinicians, we must, of course, ask. However, being curious rather than pedantic is likely going to get a better response. "Did you take your medication?" will yield a "yes/no," "why/why not?" interrogative exchange.

Instead, if it's known someone has prescriptions, asking, "If I recall, you were taking some medications to help with the voices. What's the verdict on those lately?" This helps open a dialogue about their experience with the medications. Second, if they are not taking them as prescribed, it is less threatening than "Are you taking the medications?" as they may perceive a "no" answer could imply a pending finger-wagging reply.

Readers interested in learning in-depth about interacting with people who hear voices in a more existential manner, rather than in a basic, scientific way, are encouraged to read Harry Stack Sullivan's Schizophrenia as a Human Process (1962).

Disclaimer: The material provided in this post is for informational purposes only and not intended to diagnose, treat, or prevent any illness in readers. The information should not replace personalized care from an individual's provider or formal supervision if you’re a practitioner or student.