Trauma can contribute to voice-hearing but is not necessary for it. This article uses ethnographic and other data to show multiple pathways to voice-hearing in both clinical and nonclinical populations, excluding known causes like drugs or epilepsy. Trauma sometimes plays a major role, sometimes a minor role, and sometimes no role at all. Distinct phenomenological patterns in voice-hearing may reflect different salience of trauma for those who hear voices.
In communities where hearing voices is common and expected, people are taught cultural models to identify and explain voice-like events. These communities share common features: they teach discernment to accurately identify the legitimate voice of a spirit or being, and they use two methods to enable experiencing spirits—trained attention to inner experience and repeated speech to the invisible other. The ability to hear spirits becomes more skilled with practice, and what is heard becomes clearer over time. Despite shared cultural ideas, individual variation in experience exists, some possibly reflecting psychotic process. Voice-like events may be shaped by cognitive expectation, trained practice, and an experiential pathway.