“Maybe it’s kind of normal to hear voices”: The role of spirituality in making sense of voice hearing

ABSTRACT First-person accounts of voice hearing are scarce. This research aims to explore the role of spirituality in the sense-making process of hearing voices. Five semistructured interviews explored experiences of spirituality and hearing voices. Qualitative data was analyzed using interpretive phenomenological analysis (IPA). Three superordinate themes were identified: need for connection, values about self and identity, and making sense. The findings suggest a relationship between spirituality and voice hearing, and relate to the need for belongingness and self-identity. Acknowledging the sense making process and engaging in conversations about spirituality are implicated when providing clinical interventions for distressing voice hearing. Future research could explore further the differences between voices associated with spiritual experiences and “psychosis.”


Introduction
"Voice hearing" refers to the experience of hearing voices that no one else can hear. Hearing voices does not necessarily constitute a symptom of mental illness (James, 2001). However, within the context of mental health services, voice hearing is often perceived as a symptom of a disorder, typically psychosis (APA, 2013). Voice hearing can be experienced on a continuum; from benevolent to malevolent, or soothing to distressing (Boyd & Gumley, 2007;Clarke, 2013). The way a person makes sense of their voices influences whether they are experienced as distressing (Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001). The sense-making process involves a search for meaning, defining, and rationalization, influenced by an individual's interactions, past experiences, values, beliefs and social construction (Weick, Sutcliffe, & Obstfeld, 2005).
Voice hearing can be understood from a range of perspectives, including biological, psychological, social and spiritual (Cooke, 2017). Although spirituality is recognized as an important part of some people's lives, providing solace and meaning, there is a paucity of research into the experience of spirituality as a way of making sense of voice hearing.

Spirituality and hearing voices
In defining spirituality there is much debate focused on the complexities and diversity involved (Moreira-Almeida & Koenig, 2006), though a recurring theme is its relation to the meaning of life (McCarthy-Jones, Woegeli, & Watkins, 2013). The following definition will be used throughout this article: "an inner experience of connection to something greater than oneself, a personal state of the sacred and meaningful" (Lukoff, 2007, p. 635) Spiritual discourse around voice hearing in Western cultures is an emerging concept. Clarke (2013) appealed for a movement towards acceptance and appreciation of the impact spirituality may pose on mental health. A spiritual understanding of voice hearing can enable coping strategies and social support (McCarthy-Jones et al., 2013); or reduce an individual's control and aid in the development of "dysfunctional beliefs" (McCarthy-Jones et al., 2013). Individuals hearing voices may seek out spiritual or religious sources in the first instance, with mental health services being their secondary option for help (Moss, Fleck, & Strakowski, 2006;Pargament & Lomax, 2013). Jones, Guy, and Ormrod (2003) suggested that many individuals view religion as a source of strength and resilience. This evidence therefore conveys the possibility that hearing voices can be both a positive and negative experience for some individuals, dependent on their socio-cultural context and belief systems, as well as being an important part of their self and identity.
Within a social constructionist framework, though it is understood that psychosis and spirituality are social constructions, it is important to understand the differences between them, to understand how they each affect people differently (Jackson & Fulford, 1997). McCarthy-Jones et al. (2013) discussed possible differentiations between the experiences, suggesting that spiritual commands are not viewed as obligatory as "psychotic" voices are often perceived. Spiritual voice-hearing is also described as being shorter and less frequent and though it is agreed that phenomenologically similar, spiritual voice hearing does not coexist with other unusual experiences like "delusional beliefs." Spirituality can have a significant impact on the experience of hearing voices. However, there has been no qualitative study of individuals' experience of making sense of voices from a spiritual perspective. A better understanding of the role of spirituality in the process of making sense of hearing voices could help to improve interventions, boosting spirituality as a resource as opposed to a problem. This study aimed to explore and understand the experience of voice hearing from a spiritual perspective.

Design
This was a qualitative, single incidence, semistructured, interview-based study. Participants that hear voices explored how they made sense of this experience and the role spirituality had in their sense making. Interpretative phenomenological analysis (IPA; Smith, Flowers, & Larkin, 2009) informed both the interview questions and the analysis of the interviewees' response. The theoretical foundations for IPA lie within the exploration of an individual's relatedness to, or involvement in, a particular process; namely, there is an inference that in adopting an IPA methodology the researcher commits themselves to exploring and describing the means by which individuals will take to make sense of their experiences (Smith & Osborn, 2008). As sense-making is the premise of the present research, adopting an IPA methodology allows for the researcher to understand the proposed participant's lived experience in more depth.

Participants
Five participants between 20 and 52 years old (median 24 years) were recruited from community mental health teams and an early intervention in psychosis service. Care coordinators provided an information sheet to service users who heard voices. Service users who were in crisis or lacking in capacity were not provided with an information sheet. The contact details of those who consented to participate in the study were then forwarded to the lead researcher. Three males and two females participated, and all were White British (see Table 1 for participant demographics). From a social constructionist perspective, understanding social and cultural contexts is important to ensure we do not make assumptions about beliefs and values (Burr, 2006). To ensure an appropriately homogenous study population, purposive sampling was employed for in-depth analysis.

NHS ethics was granted by Sheffield Research Ethics Committee
The lead researcher (SL) conducted interviews. A semistructured interview schedule asked participants about their experience of hearing voices, their understanding and the contextual influences on their understanding. The researcher also asked about participants' understanding of spirituality; its role in their life and contact with mental health services. Interviews took place during a four-month period. All were audiotaped and lasted between 22 and 64 minutes (M = 37 minutes). IPA protocols informed the interview transcription and data analysis (Smith et al., 2009). Close examination of individual transcripts involved making comments of a descriptive, linguistic, and conceptual nature, from which emergent themes were drawn. Commonalities and differences amongst emergent themes were noted on collation and comparison of the transcripts. Organization of emergent themes allowed for super-and subordinate themes to be determined, and re-examination of the original transcripts allowed for quotation data related to these themes to be drawn. Ongoing interaction with the dataset enabled the exploration of the structure and relationships of these themes, allowing for thematic organization that best represented the information gathered. Transcripts were reviewed by authors AG and CS, who conducted analyses on the data that was then compared with the lead researcher's to increase reliability of the findings. Regular supervision and the use of a reflective journal allowed for conversations that aimed to reduce the influence of the lead researchers' natural biases, values and position.
Researcher's position. As this study was grounded in an interpretative protocol for its implementation and analysis, the lead researcher's socio-cultural position and own conceptions will undoubtedly have shaped its process. As a researcher, there is an inherent flexibility to probe any interesting areas that may emerge, and this is required to fairly make sense of an individual's personal world. It is acknowledged, however, that the lead researcher's relationship with spirituality and religion allows her to be open to it being helpful and unhelpful in times of need. The lead researcher was raised as a Catholic, though experiences in later life led to some conflicts with her faith. As such, there may have been some preconceived beliefs and attitudes towards the role of spirituality, its significance to people and its role in sense making though this was minimized through the use of a reflective journal and discussion and review of data and themes within the research team.

Findings
The following themes were generated from participants' accounts in response to the research questions. A summary of the super-and subordinate themes can be found in Table 2. All participants recognized spirituality as being significant in their sense making of voice hearing.

Theme 1: Need for connection
Subtheme 1: Finding a place to belong? Isolation versus belonging A search for belonging to counteract isolation emerged from the data. This sense of belonging was sometimes provided by the voices but could also keep participants distanced from others. Some participants isolated themselves for protection, with Scott describing how he "closed in a bit into me shell." Whereas others described becoming more reliant on their voices. Alice felt "utterly dependent" on her voices, which left her feeling unable to interact with her peers whilst at school. David isolated himself from his church community but needed to keep convincing himself of this: "I still pray, but I'm not going to church. I'm not going to church." Voices could also support participants in their search for belonging. Jeremy felt an increased sense of belonging within his Church community, because of hearing God's voice. It was perceived as an experience that connected him to a group of similar others as he spoke about how every Christian he had met, who had spoken with God, had also heard God speak back. He initially described feeling isolated, and immersed himself in Bible study, though his relationship with spirituality has changed: I think when I first became a Christian, I isolated myself. I read the Bible all the time. I was practicing my faith and I didn't have that level of trust within human beings which I now have. It's honestly . . . I've never been as welcome as I have within a church.
Subtheme 2: Disclosure to get help Participants described a process that determined whether they sought external help. For some, disclosing their experiences was an important part of this process. Alice described how she delayed talking about her experience because it was "all I'd ever known." Others, such as Scott, held back on sharing their experience for fear that they were "going crazy"). David spent some time reflecting on how he hadn't felt as though he needed additional help as he had already sought the help of God: "He was giving me really good advice. He's telling me to, I don't, really good advice in day to day, you know." Some participants felt grateful for disclosing their experiences to services. Scott described that this helped him to make sense of his voices, "because to me, I was going mad." There was a shared concept that disclosure and seeking support was ultimately helpful to the process of understanding their experiences. Though there was often an initial struggle and internal debate, participants did not express any regret in their decisions.

Subtheme 3: Understanding of others (or lack of) or being understood
All participants talked about being understood as being important to them whether they had experienced this and or whether they felt misunderstood. Throughout the interviews, some participants placed importance on the understanding of the researcher; David asked "did you used to be a Christian yourself?" and Louise sought clarity for the researcher's understanding of the local area to contextualize her experience more effectively: "Are you from [location]?" "Do you know like the reputation of some of the schools and some of the areas?" Other participants, such as Alice, spoke about how she felt she "couldn't talk to [her] friends" because they had not encountered the same experiences as her. Whereas Jeremy felt that once he had explained his faith and his relationship with his voices, this had helped others to understand: "I told her [care-co] everything Jesus has done in my life from day one. She's never asked me not to talk about my faith." Knowing that other people understood or appreciated their experiences was important to all the participants. This related to their experiences of being misunderstood and the stigma associated with some mental health difficulties Theme 2: Values about self and identity

Subtheme 1: Conflicts with beliefs
Most participants spoke about how their experience of voice hearing and their values of good and bad or evil had conflicted with their spiritual or religious beliefs. Jeremy described how he "always knew there was something wrong with the world," whereas Scott talked about how certain treatments should not work because "that would be like medicating God away." In a different way, David spoke about literal conflicts with his voices and values: "God wants you to, he's too strict and stuff like that. Yeah. Um [pause] so yeah, I went through a few weeks of talking with Satan." He spoke about feeling scared of God, as what he was saying to him did not match with the writings in the Bible. Thus, he described talking with Satan who, in turn, built a greater wedge between David and his faith. For example, Satan was: "Um, saying that a good Christian wouldn't think these things and stuff like that." All participants who spoke about such conflicts did ultimately describe finding resolution and peace. David found this by continuing to practice his faith in prayer; Jeremy articulated how this process had changed his outlook: "I've got redemption. I've got peace. I've got joy. And I've got love. And that's what God is at the end of the day God is love." This process of questioning their religious and spiritual understanding appeared as a confusing and fearful time for participants. They began to question the origin of their voices as well as their faith, creating a struggle with their sense of self and the lens through which they viewed the world. Whereas some participants pondered different narratives for understanding the self, this sense of conflict might have determined that there was no good fit, and may supersede understanding.

Subtheme 2: Constructing new identities
Some participants discussed how their actions and experiences had created a conflict with their preferred construction of self. David described that he was not a "good Christian" and referred to this notion throughout his interview: It [stammers] it sort of, sort of [pause] it's like [pause] before like, before the psychosis like God was everything in my life, at the time. But now um it's sort of becoming less important which is, which is not a good thing I guess from a Christian perspective.
David's comment here demonstrates a process of self-reflection and shame shared by other participants; identity as a Christian challenged by emergence of voices. His difficulty talking about this: "[stammers] it sort of, sort of [pause] it's like [pause]" illustrates further the impact that his experience has had on his sense of self, and the importance in having a robust self-identity. Here, David goes on to talk about how conversing with God was encouraged within his denomination of Christianity and how he had "started um [pause] I started uh, trying to talk to God. I was getting replies." Therefore, whilst he had a clear idea and could make sense of his voices' origins, the way this is expressed suggests uncertainty as well as difficulty revisiting where this began.
Where participants struggled to express their experience of hearing voices this appeared to affect their sense making. There was a recurring theme, however, for participants wanting to articulate their experience yet concerns on how this might be perceived: "Am I unusual?" (Scott); "[Pause] it's bizarre. I know, [stutters]" (David).
Participants found it hard to talk about their experiences; whether this was driven by their sense-making or wanting to sound "normal" to the researcher.

Subtheme 2: External to self
Some participants made sense of their voices by externalizing their source. Jeremy does this by distinguishing the voices he hears: So I have to utterly distinguish between the old voices that I used to hear, which were a result of my mental illness. And the voices, the voice of God which I know I hear. Which comes from the Almighty.
Distinguishing the two allows Jeremy to remain connected to his faith and the voice of God, and disconnect himself from the other voices he heard, allowing him to retain a preferred identity. Scott remains in the making sense stage; being open to different ways of understanding his experience: I don't know whether it's um a spirit that I hear, whether it's physically my mind that's become fragmented, or whether it's um [pause] a spirit that I'm hearing, or a poltergeist or [pause] I don't I don't know what they genuinely are.
Though it is clear that Scott does not have as strong a sense-making appraisal of his voices as Jeremy, it is apparent that he is open to interpretation and is balancing this between externalizing "a spirit . . . a poltergeist" and something more medical "my mind that's become fragmented." Jeremy expressed a stronger affiliation to his faith than Scott so it is plausible that he is less likely to consider alternatives when he is making sense of the experience. Like Scott, Louise described a genetic understanding for her voices: "but I think there's definitely something there genetically. It runs in the family because her mum was diagnosed . . . paranoid psychosis." She finds a way to make sense of her experience, whilst acknowledging that there is a shared construct within her family. On the surface, this presents as less comforting than understanding her experiences from a spiritual or religious source, yet Louise spoke with sincerity and ease about her experience, reflecting that she has made peace with this appraisal. Despite the differences in sensemaking, the tendency for some participants to externalize their understanding of their voices' origin may reflect uneasiness at attempting to acknowledge otherwise.

Subtheme 3: Influence of others
Finally, some participants also referred to the influence that others had on their sense making process. For some, this came from the way their families talked about mental health in the home and experienced by others: The thing is when you've, when you've got a parent like that, who can just spontaneously go off on one . . . but since like I've grown up, we've like talked a lot more about mental health like a lot more maturely. (Louise) Louise can reflect here that her earlier experiences of mental health influenced her views, with conversations later in life shaping her ideas further. Alice described a similar experience. When asked, what influenced her understanding of her voices, she responded: "Well my mum, I guess that's the easiest part . . . I was like introduced to her voices from an early age." There is a shared experience here of being introduced to parental mental health, likely those to which the participant has a primary attachment to. Both participants reflect this influenced their own sense making, which could be a result of this experiential information being readily available to them. Thus, the experiences of their parents' understanding of their voices likely played a role in their own.
Whilst some participants focus on familial influence, others place importance on the influence of services. Whilst Alice describes how she used to make sense of her voices as her mum had made sense of hers: "I used to feel the same way, that these were spirits haunting me" she then describes how this changed: "I mean obviously since having therapy I don't really believe that anymore.
She identifies a shift in her sense-making once she comes under mental health services. Having earlier described, "the idea of them being spirits was comforting to me" it appears that this has been altered. This was not a commonality among participant accounts, however: "[Mental health service] have been quite good. They, they talk to you about stuff, well [care-co] does, [care-co] talks to me about my faith and stuff like that" (David).
Here David is recounting that he understands his voices from a spiritual source, and that his mental health worker has been a positive influence in maintaining this conversation and understanding.
As has been illustrated, making sense of experiences is not a linear process for participants. It involves navigating experience and forming coherent narratives that are influenced by others and external factors. The sensemaking process is an integral part of an individual's journey with their voices and therefore influences on this are important to acknowledge.

Discussion
The current study represents an initial exploration of how spirituality may influence the experience of making sense of voice hearing from a first-person account.
Participants' narratives demonstrated a conflict in how they constructed their sense of self. Identity can be understood as the beliefs, qualities and expressions that make up a person; their self-identity, group or social category. Participants' experiences brought forward new identities, which allowed a connection with religious, spiritual and moral beliefs. Dennett's (1991) proposition of a philosophical view of the self suggests that narratives construct a sense of identity, whereas White (2007) rejected the idea of a core and stable identity but instead talks about relational identity; whereby it is socially and relationally constructed. This implies that identity formation is fluid, not fixed and changes in the different contexts in which we belong. Narratives of identity are shaped by social interactions, significant others and self-informed reflections (Jones & Coffey, 2012). For example, when David refers to his sentiments "from a Christian perspective" this infers he has an identity: "I am a Christian" though his implication is that this is a stable identity.
When a preferred self is challenged, an individual must either reassemble their view of the self or work out how the phenomenological experience best fits. Identities of those experiencing distress often result in re-formulation within a context of mental illness (Goffman, 1968). An individual, therefore, evolves from not only experiencing emotional and psychological responses to an experience, but also stigma and other social consequences (Jones & Coffey, 2012). This understanding of the self and acknowledgement of the challenge it poses has implications for support for voice hearers. Jones and Coffey (2012) suggest that a move beyond identification as "mentally unwell" may be a further step in the process towards a coherent sense of self without conflict. This was seen here with Jeremy, who claimed to be able to differentiate the voice of God from the voices of mental illness. An effective utilization of services, therefore, could be to support individuals to make sense of their experiences in a way that fits their values and therefore integrate their experience into their repertoire of a preferred identity. This would provide an additional pathway to recovery than a limited recovery defined by symptom eradication only.
Participants also identified a struggle between initially needing to isolate themselves when they began to hear voices and a need for belonging and to be "normal." A shared perception here is of connectedness to others; be that to people or with their voices. This struggle among the participants is representative of Baumeister and Leary (1995) belongingness hypothesis. Baumeister and Leary (1995) suggested that the need to belong is a fundamental and powerful innate motivation in humans, where a failure to satisfy belongingness can lead to social isolation (Baumeister & Leary, 1995;Mellor, Stokes, Firth, Hayashi, & Cummins, 2008). It is possible that belonging encourages a feeling of social connectedness and can stave off loneliness. Research has outlined that an unmet need for belongingness can exert influence on subjective well-being (Mellor et al., 2008). Services should therefore concentrate on improving individuals' sense of belonging and connectedness, whether this is with their voices or at a societal level. Liaising with hearing voices groups (HVG; Dillon, & Longden, 2012) and the use of psychological interventions such as voice dialogue (Stone & Stone, 2011) and voice relatedness (Hayward, 2003) are positive steps towards this approach and are in line with the findings. Evidence has shown that individuals who hear voices value the opportunity to meet others with similar experiences to their own (Ruddle, Mason, & Wykes, 2011) and participants in the present study also referred to the value of shared experience.
Descriptions of how voices are understood replicate Kalhovde, Elstad, and Talseth (2014) findings, whereby the overall understanding from the accounts pertains to seeking a sense of belonging. Parallels can also be drawn with Holt and Tickle (2015) findings where three overarching descriptive categories were found from participant accounts; the view of self, search for meaning, and explanations for voices. Pertinent here are the shared findings that voices can endorse a negative view of the self. Furthermore, both studies explore the sensemaking process and factors that may emerge. Of all six available qualitative studies on the experience of voice hearing, including the present research, it is clear that individuals hearing voices seek to develop frameworks to make sense of the experience (Fenekou & Georgaca, 2010;Holt & Tickle, 2015;Jones et al., 2003;Kalhovde et al., 2014;Minchin, 2017). The present findings support sense-making as part of the recovery process (Van der Hart, Brown, & Van der Kolk, 1989) with the themes drawn from participant accounts aligning with Leamy, Bird, Le Boutillier, Williams, and Slade (2011) findings of mental health recovery processes; empowerment, connectedness, identity, meaning in life and hope and optimism about the future.
This study found each participant faced different struggles, barriers, and comforts, so despite the general themes drawing similarities across their stories, how they are distinguished is also pertinent. The study supports the case that in order to improve engagement it is important for professionals to understand the meanings that are ascribed to individual's voices, that cause distress, so as to promote wellbeing, within an acceptable appraisal of the experience (Care Services Improvement Partnership, Royal College of Psychiatrists and Social Care Institute for Excellence, 2007;Lakeman, 2001). For example, in the present study Alice stated "no religion" on the demographics form, however identified as spiritual throughout her interview: "I think erm [pause] the whole idea of spirituality is how I've tried to normalize it." Developing shared formulations might help with conversations about spiritual beliefs and fits with the current psychological literature and guidelines stipulating the need and benefits of person-centered formulations (BPS, 2011;Johnstone & Dallos, 2013).
Understanding individual ascriptions of meaning to their experiences can also be achieved by working within a narrative model (White, White, Wijaya, & Epston, 1990). Making use of this way of working aids the development of a sense of positive identity whilst integrating spiritual beliefs, as well as owing power to the individual regarding their own life and experiences. The findings of this study also support the use of social interventions, such as groups, that can in turn draw upon an individual's sense of belonging and work to improve this within their family or community. Furthermore, it is important for clinicians to be encouraged to consider an individuals' spiritual beliefs when offering interventions, particularly as voice hearing can often be present for individuals experiencing psychosis. Here the guidelines for practice include pharmacological interventions (NICE, 2014), though implementation of such treatment could challenge individual's beliefs around their voices, as in the present study with Scott: "that would be like medicating God away" which could result in difficulties in engagement and the relationship between service users and professionals.

Methodological limitations
The low number of participants and relatively short interviews limits the breadth and depth of this study's findings. Further research is needed to further explore the experience of making sense of voice hearing and spirituality. Conducting multiple interviews with each interviewee could help to acquire more depth. Malterud, Siersma, and Guassora (2015) suggested that information power can guide a sample size. The more information held by a sample that is in keeping with the study purpose, the less the number of participants is needed. Smith et al. (2009) also note that within an IPA protocol depth is more highly regarded than breadth. Though rich data is provided from a purposely homogenous sample, generalizability of the findings to a wider population was not intended. All the included participants were White British; therefore, experiences are likely to differ among individuals from other ethnic cultures (see Minchin, 2017).
The recruitment methods adopted for this study were open to bias. Whilst care coordinators were made aware of the inclusion and exclusion criteria, it became apparent that potential participants were being filtered and selected if they had expressed an interest in religion or spirituality previously, despite this not being a requirement. This study also worked on a "self-selection" basis, therefore opening itself to bias. For example, some participants began the interviews by talking about their religion or spirituality as this is how the study had been "sold" to them. Finally, it is acknowledged that the professional of training of the authors, all clinical psychologists, with have influenced and biased the findings of the analysis. The authors reading of associated clinical literature and professional experiences in mental health services will undoubtedly have shaped the lens through which the interviews were analyzed (Burr, 2006). This may therefore have meant that mental health discourses were more easily seen, as opposed to spiritual meanings.

Future research
The findings of this study highlight some key areas for future research. Jeremy described the importance of differentiating between the voice of god and voices he associated with mental illness. Understanding this process of differentiation may provide insights and advance future interventions. This study did not focus on the factors associated with the onset of voice hearing experiences. Considering the influence of triggers to voice hearing and subsequent spiritual sense making processes would further enhance our understanding of this area. Future research could build on this study to explore the role of spirituality and sense making about voice hearing on a grander scale, making use of a larger sample size and more diverse demographics. Finally, it may be valuable to explore the attitudes of clinicians towards psychological interventions for hearing voices that are relationally based and to reflect whether more focus on increasing a sense of belonging and integrating experiences into their identity is related to better outcomes or recovery.

Conclusions
The present research provides supportive evidence for the role of religion and spirituality as a model for sense making about voice hearing, a basis for development of self and identity and potentially as a positive coping resource for individuals. The findings echo those of Minchin (2017) that encourages clinicians to value the expertise that service users bring to a clinical setting (Bassat & Sickley, 2010). Remaining a curious-observer will develop understanding of how an individual may make sense of their voices within a spiritual context, or indeed any social, cultural, or political context. As far as the authors are aware, this study is the first to examine the role of spirituality within the sense-making process of the voice hearing experience, and therefore holds pertinent implications for mental health services.

Disclosure statement
No potential conflict of interest was reported by the authors.