Abstract
While voice hearing (auditory verbal hallucinations) is closely allied with psychosis/schizophrenia, it is well-established that the experience is reported by individuals with nonpsychotic diagnoses, as well as those with no history of psychiatric contact. The phenomenological similarities in voice hearing within these different populations, as well as increased recognition of associations between adversity exposure and voice presence/content, have helped strengthened the contention that voice hearing may be more reliably associated with psychosocial variables per se rather than specific clinical diagnoses. Evidence is examined for understanding voice hearing as a psychological response to environmental stressors, and the implications of this for clinical practice. Consideration is also given to the impact of the International Hearing Voices Movement, an influential survivor-led initiative that promotes person-centered, nondiagnostic approaches to the voice-hearing experience.
The subject of this article is a complex and fascinating human phenomenon: the experience of hearing voices with no external origin, and which no one else can hear. In different cultures, societies, and historical eras it has been described and conceptualized in various ways: as locutions, splinter psyches and, more generally in modern times, auditory hallucinations.
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It is an absorbing topic that encompasses the nuances of perception, consciousness, and sense of self, and has been documented and deconstructed for over 2,000 years: alternatively reviled, celebrated, consecrated, and forensically scrutinized within such diverse specialties as anthropology, cultural studies, philosophy, psychiatry, psychology, and theology. Unsurprisingly, given this broad theoretical scope, practical responses to it have been complex and diverse. As McCarthy-Jones (2012) expresses it, voice hearing has been
understood as a symptom of disease as well as a source of otherworldly communication. Those hearing voices have been viewed as mystics, potential psychiatric patients or simply . . . people with unusual experiences, and have been beatified, esteemed, as well as drugged, burnt or gassed.” (p. i)
Although accounts of voice hearing as a biochemical anomaly have existed since the time of ancient Greece, the predominant framework for centuries in the Western world was demonic possession or divine inspiration (Smith, 2007). However, within the past century, more secular, medical explanations have ascended. 2 Today, at least in Western cultures, voice hearing has ubiquitous connotations with mental illness and emotional chaos, popularized in the media as disturbing and dangerous (e.g., Leudar & Thomas, 2000; Owen, 2012) and closely allied with schizophrenia (Bentall, 2004). Nevertheless, growing evidence demonstrates that voice hearing (including that in the context of psychosis/schizophrenia) can be understood in psychological terms; together with the proposition that, in many cases, voice presence and content are strongly linked with adversity exposure. This article will explore these concepts in greater detail, including the impact of the International HVM in promoting psychosocial, nondiagnostic approaches to the voice-hearing experience.
Voice Hearing as Diagnostic Criteria
While voice hearing has been characterized as “a symptom of brain disease just like blindness or hemiplegia” (Stephane, Thuras, Nasrallah, & Georgopoulos, 2003, p. 186), the claim that voice utterances are psychologically meaningful (rather than arbitrary content induced by disease) has a substantial history in the disciplines of psychiatry, psychology, and philosophy (see McCarthy-Jones, 2012; Middleton, Dorahy, & Moskowitz, 2008). Furthermore, it has long been recognized that voice hearing is not only prevalent in a range of nonpsychotic mental health conditions but is also widely reported among those in good psychological health and no history of psychiatric service use. Exact estimates are highly variable, most generally as a function of the age group examined and how voice hearing is defined, although a review by Beavan, Read, and Cartwright (2011) calculated a median of 13.2% in the adult general population, with rates of up to 49.1% among young adults for hearing a voice speaking one’s thoughts aloud (Pearson et al., 2008; Posey & Losch, 1983). While more complex voice utterances, such as entire conversations, are endorsed less frequently than hearing single phrases (e.g., Barrett & Etheridge, 1992; Posey & Losch, 1983), given that the prevalence of functional psychosis ranges from 0.2% to 0.7% (Kendler, Gallagher, Abelson, & Kessler, 1996), it is apparent that many more people experience voice hearing than receive treatment for psychosis. Indeed, some prevalence studies report that only a minority of respondents (between one third and one fifth) had sought psychiatric assistance for their voices (see Longden, Madill, & Waterman, 2012).
Recent work additionally suggests that the types of voices traditionally considered indicative of schizophrenia (e.g., externally located, sensorially vivid, experienced involuntarily, accompanied by “low insight/reality testing”) may often be just as likely to be endorsed by individuals with nonpsychotic, trauma–spectrum diagnoses and even, in some instances, among nonpatients (see Longden et al., 2012; McCarthy-Jones & Longden, 2015; Moskowitz & Corstens, 2007). In turn, while voice hearers with psychiatric diagnoses report more persistent, affectively negative voices than voice hearers who are not in receipt of psychiatric care, a review by Johns et al. (2014) has identified that voice hearing shares numerous phenomenological similarities (e.g., volume, location, personification, number, underlying neurological activity) in both patient and nonpatient groups. Indeed, despite modern connotations with psychosis, neither Kraepelin nor Bleuler considered voice hearing a primary feature in their respective concepts of dementia praecox and schizophrenia. Correspondingly numerous conditions in the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association [APA], 2013) acknowledge voice hearing as a potential feature (including some diagnoses not classified as schizophrenia–spectrum disorders, such as the dissociative disorders, some affective disorders, posttraumatic stress, and borderline personality disorder), and which in turn tallies with Bleuler’s (1911/1960) contention that voice hearing was aligned with so many conditions it could be more properly deemed a result of “loosened associations” rather than a primary symptom of psychosis. Contemporary links between voice hearing and schizophrenia mainly date from Schneider’s (1959) “first-rank symptoms,” wherein the experience of hearing voices commenting and/or conversing, bizarre delusions, and believing one’s thoughts are audible delimit the major pathognomic symptoms. However, Schneider concurred with Kraepelin and Bleuler regarding the negligible diagnostic status of voice hearing, including it as a first-rank symptom mainly because it was easy for clinicians to screen and detect (Moskowitz & Heim, 2011). Indeed, Schneider exhibited similar caution for the other first-rank symptoms, advising against overzealous application on the grounds that they may not be “crucially important features” of the syndrome (see Bentall, 2004).
In this respect, it should be noted that despite the link being maintained in previous editions, the fifth edition of the DSM (APA, 2013) deemphasizes the significance of voice hearing in schizophrenia (see Table 1). One rationale for the decision was that the phenomenon of voices commenting/conversing lacks diagnostic specificity (Grohol, 2013), and there is substantial evidence that this experience, as well as other Schneiderian symptoms, are prevalent in individuals meeting diagnostic criteria for dissociative disorders, where they may occur more frequently than in psychosis samples. For example, Ross et al. (1990) compared 368 patients diagnosed with dissociative identity disorder (DID) to 1,739 subjects diagnosed with schizophrenia and found that the DID group reported significantly more Schneiderian symptoms (M = 4.9) during clinical interviews than the schizophrenia group (M = 1.3). In terms of voice hearing, 71% of the DID group heard voices commenting, and 74% heard voices arguing—substantively higher than the patients diagnosed with schizophrenia (see also Dorahy et al., 2009; Kluft, 1987; Laddis & Dell, 2012; Ross, Heber, Norton, & Anderson, 1989; Ross, Norton, & Wozney, 1989; van der Hart, Nijenhuis, & Steele, 2006).
The Gradual Deemphasis of Voice Hearing as a Diagnostic Criterion for Schizophrenia in the Diagnostic and Statistical Manual of Mental Disorders (DSM), 1980 to 2013.
Note. In addition, these features should be present for at least 6 months and be accompanied by significant distress and impairment for a diagnosis to be considered.
Italics added.
The widespread presence of voice hearing across various age ranges, cultures, and different patient and nonpatient samples—and the sometimes-striking phenomenological similarities between these groups—has done much to augment the possibility that voice hearing is more closely linked with emotional, cognitive, and psychosocial variables per se than particular diagnoses. Crucially, this also applies to voice hearing in the context of psychosis/schizophrenia—despite prevailing frameworks, which suggest that such voices should not be accounted for in terms of psychological mechanisms, and in which medication is recommended as a first-line treatment response (Sommer et al., 2012). In this regard, an important formative theme in the voice-hearing literature is the role of adversity in voice onset and maintenance; a factor which shows more consistent associations than those between voice hearing and specific diagnostic classifications.
Adversity and Voice Hearing
A primary issue in reconstructing voice hearing as a manifestation of distress, as opposed to a symptom of disease, is its demonstrated relationship with adversity exposure (particularly, but not exclusively, childhood abuse). This is becoming an issue of considerable research interest in psychiatry and clinical psychology, with the claim even being made that a causal link between trauma and psychosis (including experiences like voice hearing) has moved “from heresy to certainty” (Read, 2013, p. 249; see also Read & Bentall, 2012; Read, Dillon, & Lampshire, 2014). Numerous narrative reviews (e.g., Larkin & Read, 2012; Longden et al., 2012; Morrison, Frame, & Larkin, 2003; Read, 2013; Read, Bentall, & Fosse, 2009; Read, Fink, Rudegeair, Felitti, & Whitfield, 2008; Read, van Os, Morrison, & Ross, 2005; Skehan, Larkin, & Read, 2012) and two meta-analyses (Matheson, Shepherd, Pinchbeck, Laurens, & Carr, 2013; Varese et al., 2012) are available that summarize this considerable literature. However, a recurring finding, derived from a variety of assessment and sampling methodologies, different populations (including nonpatients and patients with nonpsychotic diagnoses), and an array of cross-sectional, case-control, epidemiological, and prospective research designs (e.g., Bentall, Wickham, Shevlin, & Varese, 2012; Shevlin, Houston, Dorahy, & Adamson, 2008; van Nierop et al., 2014) is that exposure to traumatic stressors is associated with voice hearing in a substantial number of instances. Indeed, the first literature review into psychosis and childhood maltreatment (Read et al., 2005) reported more significant associations with voice hearing (particularly Schneiderian-type voices and command hallucinations) than for any other symptom. In turn, associations between adversity and psychotic-like experiences (including voice hearing), have been shown to remain significant when controlling for a range of possible demographic and clinical confounders (e.g., Bentall et al., 2012; Janssen et al., 2004; Morgan et al., 2014; Shevlin, Dorahy, & Adamson, 2007; Shevlin et al., 2008; Schreier et al., 2009; Spauwen, Krabbendam, Lieb, Wittchen, & van Os, 2006; van Nierop et al., 2014), as well as demonstrating a dose–response relationship (for review, see Read, 2013; Read et al., 2009; Varese et al., 2012). It is also important to acknowledge that while the legitimacy of stated associations between trauma and mental health problems have been challenged on the basis that patients may not dependably disclose abuse (e.g., Susser & Widom, 2012), evidence attests that reports of maltreatment among these groups are both reliable and valid (e.g., Dill, Chu, Grob, & Eisen, 1991; Fisher et al., 2011; Goodman et al., 1999; Herman & Schatzow, 1987; Meyer, Muenzenmaier, Cancienne, & Struening, 1996), with one study reporting that false claims of sexual victimization were no different between patients diagnosed with schizophrenia and the general population (Darves-Bornoz, Lemperiere, Degiovanni, & Gaillard, 1995).
Numerous mechanisms have been proposed as possible mediators between adversity exposure and voice hearing, many of which have been applied to psychosis-like experiences more generally. These include trauma-induced structural/functional neurological changes (e.g., Read, Perry, Moskowitz, & Connolly, 2001), dissociation (e.g., Moskowitz, Read, Farrelly, Rudegeair, & Williams, 2009 ), quality of attachment relationships (e.g., Sitko, Bentall, Shevlin, & Sellwood, 2014), and dysfunctional cognitive processes like impaired source monitoring (e.g., Brookwell, Bentall, & Varese, 2013) and memory disturbances (e.g., McCarthy-Jones, 2012). Many of these models overlap in complex ways, and when considered individually can only offer a restricted explanation of how adversity and voice hearing might be linked. Furthermore, as noted by Read (2013), different theoretical frameworks often depict comparable processes in contrasting ways (e.g., a decontextualized memory of abuse manifesting as a voice utterance might alternatively be described as a psychodynamic defense, depersonalization, reexperiencing, a psychotic symptom, or faulty source monitoring). Nevertheless, a recurring premise in both experimental and theoretical academic work, as well as survivor testimony (e.g., Coleman, 2004; Comans, 2011; Dillon, 2011; Romme, Escher, Dillon, Corstens, & Morris, 2009), is that for many individuals, voice hearing can be understood as a meaningful defensive response to an emotionally devastating event.
In addition to the presence of voices, adverse life events may also directly influence voice content. This is not inevitably the case; for example, a study with 100 patients diagnosed with psychosis and 127 voice hearers without psychosis (Daalman et al., 2012) reported that while sexual and emotional abuse significantly predicted voice presence, no associations could be found between childhood trauma exposure (sexual abuse, emotional abuse and neglect, physical abuse and neglect) and voice characteristics. Among other conclusions, the authors suggest that
trauma may . . . trigger both negative and positive voices, either in the absence or in the presence of a psychotic disorder. This suggests that childhood trauma renders the brain vulnerable to experience [voice hearing] . . . rather than just providing the content of these voices. (p. 2480)
However, it should be noted that this study assessed characteristics like location, frequency, volume, and emotional valence as opposed to descriptive analysis of voice utterances. When the latter is attempted, thematic or semantic congruence between adversity exposure and voice manifestation is apparent in many cases among psychosis patients (e.g., Corstens & Longden, 2013; Hardy et al., 2005; Raune, Bebbington, Dunn, & Kuipers, 2006; Reiff, Castille, Muenzenmaier, & Link, 2012), patients at high risk for psychosis (e.g., Falukozi & Addington, 2012; Thompson et al., 2010), and samples of mixed-diagnosis psychiatric patients (Read, Agar, Argyle, & Aderhold, 2003; Romme et al., 2009), with childhood sexual abuse appearing particularly associated with both command hallucinations (Ellenson, 1985, 1986; Read et al., 2003) and Schneiderian-type voices (Hammersley et al., 2003, Read et al., 2003; Ross, Anderson, & Clark, 1994). In this respect, seeking intelligible links between distressing life events and the content of voices (as well as experiences like delusions) is a therapeutic aspect emphasized during psychological formulation, on the grounds that “[s]uch links often provide indications of long-standing unresolved difficulties and associated negative self-evaluations . . . which may be closely intertwined with processes maintaining delusional beliefs and voices and may underpin aspects of the emotional reaction” (Fowler, Garety, & Kuipers, 1998, p. 127; see also British Psychological Society: Division of Clinical Psychology [BPS: DCP], 2011, 2014; Johnstone & Dallos, 2013).
Toward Psychosocial Perspectives of Voice Hearing
Taken together, this synthesis of theoretical, clinical, and experimental knowledge has fuelled a burgeoning research enterprise that seeks to explore the phenomenon of voice hearing beyond the confines of “psychotic symptom” and consider it as a relevant construct in its own right. Correspondingly, the experience has begun to inhabit social and scientific arenas that are more integrated, comprehensive, and exploratory than those previously available. For example, in the United Kingdom, Durham University (2014) has established Hearing the Voice, a multidisciplinary project that combines phenomenological, hermeneutic, and neuroscientific approaches to voice hearing. Likewise, in the Netherlands, Utrecht University (Hersencentrum, 2013) has developed a research initiative devoted to studying voice hearing in isolation from other first-rank psychotic symptoms. The International Consortium for Hallucination Research (which expends particular resources around voice hearing) held its inaugural meeting at the British Institute of Psychiatry in 2011 and is now in its fifth year. Among other objectives identified as desirable for theoretical advancement during these assemblies are several that accord with more holistic, psychosocial imperatives for voice hearing, including contextualizing its personal significance, exploring variations in phenomenology, locating the contributions of social influences and affective processes, and pursuing alternative, nonpharmacological candidates for therapeutic intervention (Waters, Aleman, Fernyhough, & Allen, 2012; Waters, Woods, & Fernyhough, 2014). In turn, phenomenological researchers have begun to reflect on the clinical, cultural, and political identities encapsulated by the term “voice hearer” (Woods, 2013), wherein voices themselves can be approached as “real, meaning-laden ‘actors’ in the theater of the mind” (Jones & Shattell, 2013, p. 562). However, notwithstanding the value of these academic developments, the focus of this article now turns to a more societally based, grassroots organization: the International HVM. This is a coalition of voice hearers and personal and professional allies which has arguably contributed more than any other initiative toward celebrating the voice-hearing experience; challenging discrimination, stigma, and pessimism; and promoting ways of working that genuinely exceed the constraints of psychiatric diagnosis.
The Work of the Hearing Voices Movement
The origins of what is known today as the International HVM date back to 1980s with the work of social psychiatrist Marius Romme and researcher Sandra Escher who, in collaboration with both patient and nonpatient voice hearers, began a pioneering course of critiquing and challenging the dominance of disease models of voice hearing and reconstructing concepts of expertise, professional power, and recovery potential. It is this process of partnership and equity that perhaps particularly distinguishes the HVM from similar intellectual movements (e.g., the antipsychiatrists) in that it was not a top-down process driven by professional polemic. Rather, from its earliest origins, the HVM has been characterized by a fusion of Experts by Experience (mental health service users, their friends, and family members), and Experts by Profession (clinicians, academics). Indeed, as Coleman and Ellis (2008) noted when describing Romme’s work, the insights he gained from one particular voice hearer, Patsy Haghe, essentially required discarding the edicts of his medical background and deferring to the expertise of his own patient—simply because her reasoning that voices were subjectively real and meaningful made more sense to him than available scholarly or clinical theories. Coleman (2004) described the aftermath in the following terms:
Romme . . . in his own words is a traditional psychiatrist . . . [but] when he listened to Patsy . . . and explored what she was saying, it was then in my opinion he stopped being a traditional psychiatrist. When he asserted in public for the first time that hearing voices was a normal experience and that voice hearing was not to be feared, he stopped being a traditional psychiatrist. When he continued his work despite being ridiculed and criticised by his peers, he stopped being a traditional psychiatrist and in my opinion became a truly great psychiatrist. (p. 13)
Over time, a complementary literature developed in which Romme and Escher outlined their research implications in further detail, including the importance of respecting and deferring to voice hearers’ understandings of their experiences, exploring ways of changing relationships with one’s voices, the impact of peer support, and the concept that subjective reactions to voices were a greater area of clinical concern than voice presence per se (e.g., Romme & Escher, 1989, 1993, 2000; Romme, Honig, Noorthoorn, & Escher, 1992). The appeal of this holistic approach was evidenced by its enthusiastic adoption by individuals seeking an adjunct, or alternative, to traditional biomedical models, and the first national HVN was launched in the Netherlands in the early 1990s. Today, HVNs exist in 32 countries across Europe, North America, and Australasia (with emerging initiatives in Africa, Asia, and South America) in which individuals identifying with the HVM ethos gather together to destigmatize the experience and promote public/clinical perceptions of voice hearing as an expression of personally and culturally significant information. In this respect, the HVM can be seen as a collective term for coalitions of voice hearers, family members, mental health workers, academics, and activists, whose activities are supported and coordinated via Intervoice (www.intervoiceonline.org), the organizational body of the HVM. In addition to this administrative role, an important function of Intervoice is to disseminate hopeful messages, promote training and research, and offer practical support for distressed individuals trying to make sense of their experiences. Furthermore, it also locates itself as a reformative social movement with a distinct political focus. As recounted by Longden, Corstens, and Dillon (2013), the work of the HVM’s early protagonists happened in a very particular context, namely growing concern with the medicalization of mental distress; moral and political protest over ineffective, inhumane psychiatric treatments; a growing awareness that psychosis could be worked with using psychological approaches; and the emergence of a powerful and articulate psychiatric survivor movement in the 1980s and 1990s. Coupled with the communication opportunities made possible by the Internet and social media, a powerful collective identity began to emerge in which voice hearers and their allies could gather together for the first time to express their needs, hopes, and aspirations and work together to challenge an established system. Taken together, the success of the HVM can be seen as offering “an attractive alternative for voice hearers who have not been fully helped by traditional approaches, who are searching for greater understanding and acceptance of their experiences, or who feel that their stories have not been heard or acknowledged” (Corstens, Longden, McCarthy-Jones, Waddingham, & Thomas, 2014, p. S285).
Principles of the HVM
Although the HVM combines a diverse range of perspectives and practices (see Corstens et al., 2014; Longden et al., 2013), activities under its rubric generally incorporate the following key values and beliefs.
Normalizing Voices
An important premise of the HVM is that hearing voices, as well as other unusual sensory experiences, are not bizarre medical abnormalities but rather a natural part of human experience. The latent capacity of all individuals to hear voices in different circumstances is borne out by epidemiological work (see Beavan et al., 2011), and in this respect, the HVM attempts to “deshame” the experience by emphasizing its prevalence across different cultural and historical contexts. Thus, while the HVM acknowledges the distress voices can cause, it refutes that such distress can be reduced to merely a symptom of neuropsychiatric illness.
Respecting Diverse Explanations
Although much research and educational activity within the HVM promotes psychological models, it is not intransigent in expecting members to accept this framework. Conversely, individuals are encouraged to draw from their own personal wisdom and expertise to make sense of their experiences (e.g., psychosocial, medical, paranormal, spiritual, and/or cultural), and are supported to learn and grow from these frameworks in their own way.
Ownership
Consistent with the person-centered emphasis described above, the HVM advocates a person’s right to take possession of their own beliefs and experiences and define them for themselves. As embodied in Romme’s original vision of “emancipating” voice hearers from social prejudice and psychiatric coercion, there is strong resistance to imposing a particular explanatory discourse on a voice hearer who does not find it helpful. In turn, it is recognized that people may experiment with numerous explanations before finding one that feels coherent and personally meaningful, and this process of discovery and ownership is supported and encouraged by HVM advocates.
The Role of Peer Support
Solidarity, fellowship, and support between voice hearers are cited by the HVM as valuable aspects of recovery. As such, peer support and self-help groups are a central and long-standing component of its aim to offer supportive spaces for exploring and sharing one’s experiences, improve social connections, and develop a sense of hope, pride, and empowerment (Dillon & Hornstein, 2013; Dillon & Longden, 2011; Oakland & Berry, 2015; Romme et al., 2009).
Accepting and Making Sense of Voices
From the earliest days of the HVM, Romme and Escher’s (1989, 1993, 2000, 2009) work has emphasized the importance of accepting the voice-hearing experience as subjectively real and recognizing that, with support, it is something that individuals can live with peacefully and profitably. This in turn is closely linked with their second main premise: that voices are personally meaningful; can be understood and interpreted in the context of individual’s unique narrative; and in many cases are precipitated and maintained by life events (particularly those that are disempowering and emotionally overwhelming). Active appreciation and prizing of voices as emotionally significant goes beyond basic acceptance, and may seem alienating for someone tormented by extremely controlling, malicious voices. In this regard, however, Romme and Escher (2000) have proposed that the voices can be understood as both problem and solution: an assault on identity and sense of self, yet simultaneously an attempt to preserve it by drawing attention to unresolved pain and conflict.
In summary, the HVM rejects medical positions that view voice hearing as aberrant, pathological, or symptomatic of underlying disease. While it avoids “romanticizing” the experience by acknowledging the considerable distress and demoralization it can cause, it nevertheless perceives such distress as an intelligible response that can explored and understood through placing voice hearing in an interpersonal context, supporting people to develop more positive and empowered relationships with their voices, and finding ways to cope with both the voice themselves and the underlying emotions and conflicts they might embody. Thus, the emphasis is not placed on clinical cure and voice elimination, but on growth, healing, and emotional exploration (see Table 2).
Contrasting Perspectives to Voice Hearing.
Beyond Diagnosis: Making Sense of Voices
As stated by the mental health activist Kellie Comans during an address to the 2014 World Hearing Voices Congress,
I’ve come home, to my people and my tribe. It is an unexplainable feeling to be so accepted and embraced by so many people and to feel like finally I belong somewhere. Like I have a real place in the world.
This quote powerfully illustrates some of the HVM’s central features: fellowship, pride, empowerment, and a safe, nonjudgmental space in which to tell one’s story. Furthermore, this process of sensemaking, compassionate exploration, and camaraderie occurs using numerous social, systemic, political, and therapeutic strategies within the HVM, including, but not limited to: voice hearer–led training; websites and social media; research and publications; peer support; promoting citizenship and social inclusion; debates, demonstrations, and activism; conferences; and media work (initiatives that are all enacted in respectful alliance between Experts by Experience and Experts by Profession to break down conventional us-and-them divides between workers and psychiatric survivors [see Longden et al., 2013]). Taken together, this means that there is no single strategy that should be taken as wholly representative of the HVM; at its heart, the Movement is about solidarity, acceptance, and social justice rather than a particular therapeutic model. Nevertheless, various methods for working with voices have still been aligned with the HVM, most particularly, peer support and self-help (e.g., Dillon & Hornstein, 2013; May & Longden, 2010; Taylor, Coleman, & Baker, 2000) and the exploratory technique of “Talking With Voices” (see Corstens, Longden, & May, 2012; Corstens, May, & Longden, 2012). However, given the theme of this special issue on diagnostic alternatives, the strategy emphasized below is one that fits under the general rubric of “contextualizing” voices—that is, exploring how subjective experience might shape one’s relationships with and beliefs about the voices one hears, as well as how this information can be applied in clinical ways that promote personal recovery.
The Construct
One approach popularized within the HVM is “the construct” (also known as “voice profiling”), which is a detailed assessment model devised by Romme and Escher (2000) to systematically explore and decipher associations between voice(s) content and characteristics and emotionally significant events in the hearer’s life. Unlike diagnostic approaches, which generally tend to strip voice hearing of its context, the intention of a construct is to deconstruct voices from generic symptoms, and reconstruct them into personally meaningful events that emerged in specific circumstances (Romme & Escher, 2000). Consistent with the HVM ethos, as well as best-practice approaches to psychological formulation (Johnstone & Dallos, 2013), the “meaning” of the experience is not imposed on the voice hearer, nor is the “professional” perspective privileged as the most accurate. Rather, the “story” of the voices is coconstructed in a process of collaboration and exploration that always respects and defers to the voice hearer’s views on its truth and usefulness (Corstens, Escher, & Romme, 2008; Longden, Corstens, Escher, & Romme, 2012).
In order to devise a construct, five key areas of inquiry are examined for each voice that the person hears (although if voices are very numerous, it may often be helpful to identify them via different groups):
voice identity (e.g., name, gender, age)
characteristics and content (e.g., whether they are negative or positive, their exact utterances, how they relate to one another and to the voice hearer)
triggers (the emotions, circumstances, or individuals that provoke the voices, and how the voices respond to these)
history of voice hearing (what was happening in the person’s life when each voice appeared for the first time; whether the voices changed since then in terms of content or influence)
personal history (significant events in the person’s life before they started hearing voices; particularly, but not exclusively, childhood experiences)
This information is subsequently used to explore two central queries to formulate a construct: (1) who or what might the voices represent and (2) what social and/or emotional problems may be embodied by the voices. An abridged example of a construct is presented in Box 1.
An Example of the Construct Method (Names and Some Identifying Details Have Been Changed)
“Jasper” is 22 years old and is diagnosed with schizophrenia. He has been prescribed antipsychotic medication, which “take the edge off things,” but has not been offered psychological therapy. He lives with his mother, with whom he has a good relationship, and is currently single although is keen to find a partner. He is unable to work or study due to the impact of the voices.
Identity of the voices. Aragorn (male, aged around 30 years), John (male, 22 years), The Voice (male, elderly).
Characteristics of the voices. The voice of Aragorn is compassionate and kind (e.g., this too will pass; you will survive and prevail). He speaks softly with an English accent and does not interact with the other voices in any way. The Voice alternates between being supportive and aggressive. Sometimes he praises Jasper, other times he can threaten him and tell him he’s a wicked boy, leading others into sin. He has a Scottish accent, and fluctuates between speaking softly and shouting. Jasper finds this voice the most disturbing. John is spiteful and undermining and makes cruel predictions (e.g., You’ll never get a girlfriend, You’re an embarrassment, everyone hates you) and encourages Jasper to self-harm by banging his head against the wall. John has never acknowledged the presence of Aragorn, although he sometimes agrees with what The Voice is saying.
Triggers. Aragorn often comes at night when Jasper is unable to sleep, and also when Jasper feels anxious and overwhelmed. The Voice is constantly present and “watching” Jasper, although is most vocal when Jasper is with his family, when he feels angry, or when he experiences sexual feelings. John is also present most of the time, but is worse when Jasper is in social situations, or when he feels under pressure, such as a job interview.
History of the voices. The Voice appeared when Jasper was 16. This was the age when his maternal grandfather died, who had sexually abused Jasper. This voice was neutral at first, but has become progressively negative over time, particularly when Jasper felt conflicted over whether to tell his mother and grandmother about the abuse. John appeared when Jasper was admitted to psychiatric hospital for the first time, aged 18 years. This voice has been consistently negative, although unlike the other two voices, it has aged as Jasper as aged and now sounds older than when it first started. Aragorn was the last voice to appear, which was when during Jasper’s fourth admission to psychiatric hospital. This voice would talk to Jasper when he was lying in bed and has always been kind and supportive. Jasper named it after a wise, reassuring character in The Lord of the Rings trilogy which he was reading at the time. He feels this voice is a source of courage, guidance, and strength.
Life history. Jasper was seriously ill with meningitis aged 8 years. He spent a lot of time alone as his father was working hard to cope with a crisis at his workplace, and his mother was looking after his younger sister. There were complications with his treatment and he ended up missing a year of school. Jasper found it intimidating to return after such a long gap. Around this time Jasper’s father asked his mother for a divorce, claiming that he regretted marrying and having children so young and that he could not cope with the stress of caring for a seriously ill child. Jasper feels considerable grief and guilt at his father’s departure. His father is now remarried and lives abroad, and Jasper and his sister only see him a few times a year. Jasper’s grandfather began sexually abusing him when he was 11 years, and Jasper has never told his family about it. He feels ambivalent about his grandfather, who along with Jasper’s grandmother gave him positive attention and could be kind and supportive. Jasper often felt lonely and “unlovable” as a child after his father left, and so valued this input from his grandparents.
His grandfather died very suddenly from a stroke when Jasper was 16 years, leaving his mother, sister, and grandmother deeply bereaved. Jasper felt unable to tell the truth about his grandfather, and begun hearing The Voice soon afterward. He became increasingly distressed, and was ultimately admitted to psychiatric hospital. This meant he was unable to sit his exams and gain a university place. At this point, the John voice began.
Who or what do the voices represent? Aragorn first appeared when Jasper was alone and overwhelmed in hospital. This voice is very paternal, and partly compensates for Jasper’s lack of a caring father figure, although is also related to the aspects of Jasper that are trying to survive and help himself. The Voice represents Jasper’s abusive grandfather. It is the same age as the grandfather was when the abuse occurred and speaks with the same accent. The John voice is the same age as Jasper and represents painful aspects of himself, particularly his low self-esteem and sense of guilt and conflict.
What problems do the voices represent? Aragorn relates to Jasper’s lonely childhood and lack of paternal affection and attention. The Voice relates to Jasper’s unresolved feelings of shame, guilt, and anger over his abuse, as well as his ambivalent feelings toward his grandfather and the pressure of protecting his memory from the other members of the family. John is related to Jasper’s fears about the future and his intense self-criticism. Both the external sources of threat in Jasper’s life, as well as his self-doubt and low self-esteem, are reflected in the voices.
Prior to beginning such work, it is important that sufficient time is given to develop rapport and alliance between voice hearer and interviewer. Corstens et al. (2008) further recommend the use of positive examples of the method and/or accounts of recovery (e.g., Romme et al., 2009) to help the person feel more confident and motivated to discuss their experiences. Once completed, a written version of the construct is prepared so that the voice hearer can comment on it and clarify any omissions or misinterpretations. Psychosocial themes identified within the construct can then be utilized to guide a customized “recovery plan,” which follows classic phase-orientated models of healing (e.g., Herman, 1992) broadly defined as establishing safety, making sense of one’s experience, and social reconnection (Corstens et al., 2008; Longden et al., 2013; Romme, 2012). Given that the construct only focuses on voice hearing, a more holistic sense of the person’s life and problems (as well as their strengths and abilities) can also be derived by using the tool as a complement to more general formulation (BPS: DCP, 2011), including, for example, a version of the construct that was developed for making sense of paranoia (see Bullimore, 2012; Escher, 2012).
In addition to informing care planning, there is also evidence that deriving meaningful narratives for experiences like voice hearing may, in some cases, be beneficial in and of itself. For example, an analysis of illness perceptions, symptom severity, and social impairment among 50 adults with psychosis (Stainsby, Sapochnik, Bledin, & Mason, 2010) found that a lower capacity to make sense of symptoms was associated with poorer quality of life 2 years from baseline, leading the authors to suggest that therapeutic approaches that support recovery by “helping clients to build a more coherent sense of their difficulties, via exploration of the personal life meanings of . . . psychotic experience, may be at least as important as interventions that aim to reduce symptom levels” (p. 41). In turn, the role of explanatory frameworks has been examined under the broader concept of “psychological adjustment,” with evidence to suggest that perceiving psychotic experience as related to life context and a latent source of insight into psychosocial problems may be more conducive to long-term recovery prospects than viewing symptoms as globally damaging and causally independent from one’s life experiences (e.g., Startup, Wilding, & Startup, 2006; Tait, Birchwood, & Trower, 2003, 2004). Indeed, such findings are consistent with concepts of “personal recovery” from mental distress, which emphasize hope, ownership, personal meaning, and empowerment (e.g., Leamy, Bird, Le Boutillier, Williams, & Slade, 2011). Corstens et al. (2008), who have extensive clinical experience with the method, likewise observe that the interview process may be therapeutically useful in and of itself, in the sense that it can support and motivate the individual to begin engaging more reflectively with their experiences, explore new coping strategies, and identify emotional and interpersonal factors that may be hindering recovery.
To examine the applicability of the construct method, Corstens and Longden (2013) assessed its utility with 100 individuals, 80 of whom were diagnosed with schizophrenia–spectrum disorders. Mean voice-hearing duration was 18 years and at least one adverse childhood experience was reported by 89 individuals. Voice personification (i.e., Who or what do the voices represent?) was formulated in 78 cases, most commonly disowned aspects of self or an abusive family member. Psychosocial conflict (i.e., What problems do the voices represent?) was apparent in 94 cases, most frequently low self-worth, anger, and shame/guilt. While acknowledging the limitations of the study, including its uncontrolled observational design, the authors concluded that:
It is both possible and productive to engage in an exploration of traumas and vulnerabilities with individuals who are often strongly identified with a patient role (i.e., schizophrenia). These were people who had generally not responded well to traditional psychiatric treatments and were seeking help in finding a more personal explanation for their distress. These data show that a significant proportion of so-called chronic psychotic patients are responsive to an approach that acknowledges and relates to their . . . problems and, by extension, that it is possible to . . . give meaning to voices; [and to understand them as representations of] . . . overwhelming life experiences. . . . By deconstructing diagnostic classifications and shifting clinical emphasis towards psychosocial difficulties, we wish to formulate interventions which . . . provide opportunities to address past adversities in voice hearers’ lives, and which promote more constructive, healing strategies to deal with the interpersonal . . . dilemmas that they are confronted with. (p. 283)
Challenges for the HVM
While the broad dissemination of the HVM in the past 20 years testifies to its popularity, it remains necessary for the Movement to examine its own practice and philosophies with the same degree of inquiry as the models that it critiques. In this respect, it is important to distinguish between its various objectives. As discussed by Corstens et al. (2014), the HVM’s emphasis on solidarity, social justice, and peer support “need little more evidence than the fact people find them helpful and empowering, and choose to attend” (p. S289). However, a similarly casual approach cannot be applied to therapeutic procedures intended for clinical use. Historically, the HVM has promoted the value of personal narrative and testimony and rejected scientific/empirical research agendas as reductionist and invalidating. Yet if its policies are to exceed the ideological, it is necessary to subject them to robust evaluation. This includes, for example, the claim that voices are always explicable in terms of psychological conflict, or whether some cases are more appropriately understood using biomedical illness models; similarly whether the term “voice hearer” may be a less desirable alternative for some individuals than a diagnostic description. As Jeffs (2012) describes in the blog post “If This Is a Post-Schizophrenia World Then Who the Hell Am I?”
. . . [M]y narrative has been challenged by a rapidly changing and much more politically complex mental health world. I was attending conferences where the medical model was deconstructed brutally, consumers were rejecting the illness model and calling themselves voice-hearers . . . I was in a whirlpool of theory and paradigm shifts around this enigmatic experience that has been my life for 35 years. The idea of “mental illness” has an awful pessimistic determinism which for some people is an unacceptable burden. Perhaps by constructing my life around my schizophrenia I have accepted that burden too easily. But I am not just a voice-hearer.
In this respect, it is important to increase understandings of how patients themselves may perceive psychosocial substitutes to biomedical explanations, and in what instances these may feel unsettling, alienating, or otherwise inappropriate (e.g., the belief that the concept of mental illness absolves one of “blame” or “weakness,” not wishing to acknowledge the impact of abuse perpetrated by a family member, the belief that attributing psychological meaning to voices augments their power and influence, or feeling that psychosocial explanations trivialize what is perceived as a serious medical condition). In this respect, the central tenet of the HVM is a good guiding point for clinical practice: the necessity of informed choice; the legitimacy of different explanatory frameworks (including nonmedical and nonpsychological ones); and respecting, accepting, and deferring to an individual’s identification of their own experience.
Conclusions
In the earliest days of the HVM, its principles and philosophies were seen as polemical and, in some circles, deeply controversial. For example, an early review of Accepting Voices (Romme & Escher, 1993) in the British Medical Journal expressed that:
These analyses are, no doubt, genuine accounts of what voice hearers believe about the origin of their own voices. It is when the authors themselves are speaking that a chill is sent down the reader’s spine. . . . If, as it says, this book is intended to be used by people who are beginning to hear voices then I believe it to be not just ill advised but potentially dangerous. (Cochrane, 1994, p. 1649)
Today, the HVM approach is accepted and acknowledged to the extent that its ethos is forcing fundamental shifts in the ways in which voice hearing is conceptualized and understood. As stated by Woods (2013):
Twenty-five years after the Hearing Voices Movement first created the space for people to discuss voices, “the voice hearer” has become established as an identity people can adopt, inhabit, and mobilize in order to lay claim to a view of voice-hearing as meaningful in the context of people’s lives. The challenge, perhaps, for the next quarter century is for the mental health professions to fully recognize this claim and its potentially radical implications. (p. 268)
The concept that Woods describes—that of patients as Experts by Experience who are empowered to oppose the diagnostic and biomedical authority of mainstream mental health services—has been an important legacy of the HVM, in that individuals are supported to explore their experiences beyond the rubric of generic “symptom” and to construct them as emotionally, culturally, or spiritually intelligible events. In turn, many of the HVM’s main suppositions have gathered empirical corroboration in the past decade, including the association between voices and adversarial life events, the psychological relevance of voice content, experiential similarities in groups of nonpatient voice hearers and those with psychotic and nonpsychotic diagnoses, the value of relational therapeutic approaches, and the fact that responses to one’s voices (which may be dictated by previous stress exposure) can be a more reliable indicator of psychiatric need than voice presence per se.
While medical classifications are helpful for some voice hearers, they are not useful for all, and they may even actively hinder recovery if the diagnostic process takes precedence over identifying and working with underlying social and emotional conflicts (Romme et al., 2009). Providing patients with a choice of alternative perspectives and frameworks (e.g., as a response to life stress) is not only scientifically justified it can provide new avenues for integrated, holistic intervention that are consistent with growing emphases on recovery-orientated mental health practice, as well as the increased acknowledgement of psychosocial treatments and etiological approaches to psychosis (BPS: DCP, 2014). For the past two decades, the HVM has emphasized the importance of hope, choice, and empowerment for distressed voice hearers. As such, it signposts a compelling framework for incorporation into statutory services, in which professionals can apply existing therapeutic expertise to derive and implement recovery-oriented goals and address the impact of social and emotional adversities in healing and restorative ways.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.