Dirk Corstens Praktijk Psychiatrie - Hearing Voices Maastricht

From: Psychosis Vol 4 no 2 June 2012, 95-104

BRIEF REPORT
Talking with voices: Exploring what is expressed by the voices people hear
Dirk Corstens, Eleanor Longden and Rufus May

Although people who hear voices may dialogue with them, they are regularly caught in destructive communication patterns that disturb social functioning. This article presents an approach called Talking With Voices, derived from the theory and practice of Voice Dialogue (Stone & Stone, 1989: Embracing our selves: The voice dialogue training manual, New York: Nataraj Publishing), whereby a facilitator directly engages with the voice(s) in order to heighten awareness and understanding of voice characteristics. The method provides insight into the underlying reasons for voice emergence and origins, and can ultimately inspire a more productive relationship between hearer and voice(s). We discuss the rationale for the approach and provide guidance in applying it. Case examples are
also presented.
Keywords: auditory hallucinations; dissociation; trauma; therapy; psychosis

The fact that many people who hear voices have endured significant trauma is a much neglected aspect of the voice hearing (VH) experience (Read, van Os, Morrison, & Ross, 2005). Psychiatry frequently dismisses VH as a meaningless pathological phenomenon with no relevance to a person’s emotional or social circumstances, and
as such clinicians are generally encouraged not to engage with clients’ VH experiences (Romme, Escher, Dillon, Corstens, & Morris, 2009). In contrast, Romme and Escher (e.g. 1993, 2000) argue that VH onset is precipitated by individuals dissociating from emotional and experiential content, with voices emerging as (distorted) reflections of threatening, overwhelming events. Indeed, VH is understood as having a “protective” function: a manifestation of a vital defensive manoeuvre whereby transforming internal conflict into voices is psychologically advantageous. In lieu of this position, many people hearing disturbing voices have found that a turning point for recovery is changing the relationship through finding different ways of understanding and communicating with their voices (Romme et al., 2009).
Conceptualising VH within relational frameworks has recently become an area of psychological inquiry, with numerous authors exploring the reciprocal dynamics between hearer and voice (e.g. Beavan, 2011; Chin, Hayward, & Drinnan, 2008; Hayward, Overton, Dorey, & Denney, 2009; Pérez-Álvarez, García-Montes, Perona- Garcelán, & Vallina-Fernández, 2008). Because many people can identify relationship styles with their voices, preferred techniques in these studies are often role-playing scenarios that attempt to modify interactions between the individual and their voice(s). In our approach, which is derived from the Voice Dialogue method (Stone & Stone,
1989), we talk directly to voices in order to explore their motives, discover different ways of relating to them, and ultimately support the voice-hearer to develop a more constructive relationship. Working in this way can foster a more independent position from which an individual can reclaim control and choice. Some voices can even
become supportive (Moskowitz & Corstens, 2007).
The theory behind the technique
Voice Dialogue is derived from various theoretical traditions concerned with the psychology of Self, including Jungian, Gestalt and Transactional Analysis (in this context, voice does not actually refer to VH, but is a metaphorical allusion to aspects of one’s personality). Originally conceived for exploring different roles, conflicts, and tensions in social relationships, a key tenet of Voice Dialogue is that “normal” personality is essentially dissociative (i.e. we all have different personality components that exist simultaneously and of which we are not consciously aware). In contrast to the general assumption of a single, monolithic identity, the Stones suggest that everyone consists of numerous “selves” or “sub-personalities”, each with its own perception of the world, personal history, emotional reactions, and opinions on how we should live our lives. Dividing the personality into component parts in this way is not a novel concept. See, for example, the writings of Berne (1964), James (1891), Jung (1912/
2003), and Young (1994) for models using similar principles. Organised in opposites, so-called primary and disowned selves, these parts help us adapt to the demands of our daily interactions. Dominant selves want us to succeed in life by meeting the demands of social situation, yet in doing so they push away our more vulnerable parts. These (disowned) selves become repressed and unable to play a significant role, thereby restricting the repertoire of selves. Such adaptations are generally governed by rules that were prevalent during childhood, and initially the organisation of the selves is beneficial as we learn what behaviour is necessary and expected in daily life. However, as life circumstances change the selves often stay fixated in their original roles and prevent us from adaptation. Mostly we are unaware of this. For example, someone raised by strict, authoritarian parents may develop a primary self that strongly wants to appease people. The opposite, disowned self (which wants to challenge and ask questions, even if it means rejection) is pushed away by the more dominant “pleaser” self, which craves approval. A person with selves organised like this will frequently neglect their own needs in favour of satisfying other peoples’. Voice Dialogue facilitates exploration of the selves in order to heighten awareness
of the various sub-personalities one contains and establish greater control over the thoughts and actions relating to them. In the practice of Voice Dialogue the interviewer (who is not called a “therapist” but a “facilitator”) asks the client to concentrate on a self (e.g. the pleaser, the inner child, the controller) and go into the energy of this
particular self by standing/sitting in a different part of the room. This self is then questioned about its function in the person’s life. The facilitator does not engage in debate or persuasion or elaborate any pressure to change: they simply express their curiosity and desire to acknowledge the presence and individuality of this particular self, who in turn experiences this acknowledgement and displays feelings and emotions, like a “real” person. Finally, the facilitator asks if the self has any advice for the person, then thanks it and asks the person to return to their original seat and reflect on what has occurred. Mostly people express surprise and a sense of increased understanding about how this aspect of themselves conveys itself in daily life.
Talking with voices
In contrast, of course, voices are not felt as personality parts. On the contrary, they are experienced as autonomous (possibly malicious and controlling) entities that oppress and impose upon the hearer. Accordingly, getting rid of voices is a goal that preoccupies many people (voice-hearers and professionals alike). However in our experience, at least in the short-term, learning to cope with voices and accept their presence is a more realistic aim. Voices represent a part of the person that wants to be heard and acknowledged. Many voices are angry and malicious, but angry people want to vent their outrage and express why they are so incensed. In some respects, voices are like ordinary people. They have feelings, motives, shortcomings, and opinions. Furthermore,
they may not use rational strategies, but react out of frustration. Voice Dialogue therefore offers a good explanatory model of VH, as voices can be interpreted as selves that relate to overwhelming emotional difficulties in the hearer’s life (Corstens, Escher, & Romme, 2008).
Deeming VH a biological abnormality to be endured (rather than a significant experience to be explored) discourages engaging with voices on the grounds that they are meaningless symptoms of psychosis. Conversely, however, individuals who engage with their voices are generally less distressed and disabled than those who lack
the capacity or motivation to do so (Mawson, Cohen, & Berry, 2010; Romme et al., 2009; Shawyer et al., 2007; Veiga-Martinez, Perez-Alvarez, & Garcia-Montes, 2008). The fact that resistance towards voices is significantly associated with anxious and depressive symptomatology is consistent with claims that VH lies on a continuum
with intrusive cognitions whereby the act of suppressing and distancing against unacceptable thoughts paradoxically heightens the likelihood of occurrence (Chadwick, Lees, & Birchwood, 2000; Morrison & Baker, 2000). In contrast, acceptance and acknowledgment allows individuals to deflect attention and behavioural resources from avoiding and containing VH experiences towards the more important goal of living a fulfilling life (Valmaggia & Morris, 2010). Correspondingly, the dissociative literature generally accepts that direct engagement
with disparate, disowned aspects of the personality – including individuals with co-morbid “psychotic” experience – is crucial for therapeutic change and integration. Engaging and acknowledging voices has been advocated in the treatment of posttraumatic disorders (Brewin, 2003; Holmes, & Tinnin, 1995; Nurcombe, Scott & Jessop,
2008), and Ellason and Ross (1997) report significant reductions in Schneiderian-type voices in dissociative identity disorder patients two years after psychotherapy completion (see also Kluft, 1984). These approaches are partly guided by the rationale that VH’s biographical context provides a framework for both exploring psychosocial
dilemmas and integrating traumatic, unassimilated experiences into existing representational structures (Mollon, 2001). Given that VH is increasingly being conceptualised as dissociative (Moskowitz, Read, Farrelly, Rudegeair, & Williams, 2009), and that voices in patients designated psychotic cannot be reliably distinguished from those
diagnosed with dissociative disorders (Moskowitz & Corstens, 2007), a model for working with voices that emphasises their dissociative nature is a logical progression.
In a variant of Voice Dialogue, Talking With Voices, we have developed a procedure that approaches VH in patients designated psychotic in a style considered customary in the field of dissociative disorders. The approach does not focus on voices as a symptom of illness, nor does it concentrate on discovering what is “wrong” with the person. Instead, it offers a neutral yet robust approach that emphasises acceptance as a core value (Romme & Escher, 1993). An important principle is that we are not necessarily trying to change the voices, nor banish them from the person’s life: instead, we are trying to explore the relationship; help the voice-hearer reclaim control and ownership of their experiences; and understand the voices’ motives for appearing in a negative way. Indeed, both the voice and voice-hearer are generally unhappy in their mutual conflict, so improving understanding between both parties is an important aspect of the process. Further outcomes include discovering more positive ways of negotiating and relating to voices, altering power dynamics, enhancing coping, and heightening awareness and understanding of voice characteristics. Furthermore, voices often harbour information that can be beneficial for
understanding the difficulties voice-hearers experience in their interpersonal lives. Allowing others to “hear” the voices and witness the person’s experience more directly can also prove empowering and validating, as well as mitigating the sense of isolation voices often generate. Ideally, facilitators should have some formal expertise
in the Voice Dialogue method and/or have experienced it themselves. Furthermore, they must be capable of responding appropriately to the various experiences of violation and trauma that voice-hearers and/or voices may disclose (e.g. childhood abuse, sexual assault, attachment dysfunction).
Case example
“Jacob” is a 23-year-old man diagnosed with schizophrenia. He heard one extremely destructive voice that urged him to kill himself and commented incessantly on his thoughts and behaviour. Jacob was terrified of the voice and resented its presence. After several unsuccessful attempts to mitigate it using medication, he was referred to
one of the authors (DC) for therapy. Prior to speaking with the voice, several sessions were spent establishing a working relationship with Jacob, and gathering relevant information about his voice and its relation with his life circumstances. When the Talking With Voices method was described to Jacob, he was enthusiastic to try it. The voice also gave its permission, although it was initially hostile and expressed considerable animosity towards Jacob. It described its constant sense of outrage towards him, claiming that Jacob deserved to die because he was “weak” and servile. When asked if such prolonged anger was tiring, the voice agreed that it was: it wanted Jacob to be stronger, but all its comments only made him more anxious and fearful, which was deeply frustrating. The facilitator observed that the voice seemed to want Jacob to grow more resilient, which the voice agreed with, although when questioned further conceded that its methods for attempting this were not effective. The facilitator asked when Jacob became less anxious, to which the voice replied: “when he is supported”. The facilitator asked whether the voice knew how to support Jacob, and when it stated it did not, he described ways in which he had learned to support anxious people. The voice was intrigued, and agreed that it would like to become Jacob’s “Teacher”. In subsequent sessions the facilitator suggested ways the voice could improve its supportive qualities and over time it amended its previous haranguing, criticising attitude, evolving from a tormenter to an encouraging companion who helped Jacob express what he needed. Thereafter, treatment focus was shifted towards helping Jacob set attainable social and occupational goals.

Conducting a session

Before commencing, it is important to have some insight into the voice’s influence within the person’s life. A good tool for this purpose is the Maastricht Hearing Voices Interview (Romme & Escher, 2000), which examines associations between life history and VH through a systematic exploration of: voice characteristics; content; triggers; the history of VH; and significant events in the life of the voice hearer (Corstens et al., 2008). The resulting information provides the basis for a psychosocial, dynamic formulation of factors that provoked VH onset and/or continuance. Depending on available time, it can be administered either directly before speaking with voices or during a prior session.
Beginning the session
After describing the method’s rationale, the facilitator enquires how the person and the voices would feel about talking with her, taking care to explore why they find it a good idea or not. At all times she behaves as if talking to individual members of a continually present group, who must all give their consent. If the voices do not agree, then the facilitator explains the possible advantages, but she never coerces either voice-hearer or voices to partake in the interview. All three parties (facilitator, voice-hearer, voices) must concur and feel safe, and if this condition is not fulfilled then the session should not proceed. There are many other ways to achieve a better relationship with voices (see Larøi & Aleman, 2010), and these can be discussed as more suitable alternatives.
Talking with the voice
The facilitator asks the person to concentrate on the chosen voice and, when contact is established, to take another place in the room. This is usually based on where they feel the voice is coming from, although it is not the sole criteria and the chair can be placed anywhere, as long as it different to where the person was at the start of the session. Using chairs in this way is important for distinguishing to both voice-hearer and facilitator that what is speaking is a different part of the person. The voice is welcomed by the facilitator who tries to adopt a suitable attitude towards it. For example, a passive voice should be addressed in a gentle way, and a domineering
voice with respectful assertion. During questioning, the voice-hearer repeats the voice’s comments word-for-word. If the person prefers to remain dominant, the facilitator can speak indirectly to the voices, asking questions whose answers are formulated by the voice-hearer as an intermediary. This can be used as a warm-up exercise or the sole method, depending on the voice-hearer’s inclination, although if possible it is preferable to repeat the voice verbatim as it allows it to express itself more directly. Table 1 provides examples of questions to pose to the voice. Although it may seem strange to refer to the voice-hearer in the third person, we have found that directly addressing the voice stimulates it to remain present. In this model, the voice is performing a “job” for the voice-hearer. Throughout the process the facilitator engages with the voice in an open and respectful way, taking care to thank the voice for its explanations.
Ending the session
When the facilitator, voice-hearer, or voice wishes to close, the facilitator asks if the voice is happy to finish the dialogue, and maybe renew the conversation at another time. She says goodbye to the voice, and possibly makes a positive comment about it, then returns to the person who goes back to the chair they used at the start of the
session and reflects on what occurred. People often express surprise (particularly when the voice presents previously unknown information) and may express a new sense of objectivity towards the voice. The facilitator discusses how it felt to speak with the voice, and the voice-hearer provides their perspective on what it said.
Finally, an Awareness phase is initiated. The facilitator asks the person to stand beside her, and together they view the scene while the facilitator objectively summarises what she saw. Most people appreciate this, as it helps them to become (more) aware of what occurred during the interview. Before leaving, she encourages the person to continue making contact with the voices at home, and maybe consider some potentials for changing the relationship (e.g. negotiating; setting boundaries; using voices as clues to inner emotional conflicts; responding to voices in a constructive, tolerant way rather than with hostility, or avoidance). It can be helpful to keep a
diary of progress between sessions. Once this process is initiated, we frequently find that the voice-hearer and voices begin to develop things for themselves. Ideally, the voice-hearer should have the opportunity to talk with the voices directly using the chairs, as it permits them to rehearse speaking with the voices in a safe environment, and with confidence they may be able to do this independently. Sessions can also be summarised on paper afterwards by the voice-hearer and/or facilitator. Time for planning future sessions should be spent collaboratively so that the voice-hearer can determine what they want to achieve, and the facilitator can express any concerns she may have in advance.

Table 1. Potential questions.
1. Who are you? Do you have a name?
2. How old are you?
3. What do you look like?
4. How are you feeling at the moment?
5. Does (name of voice-hearer) know you?
6. When did you come into (name’s) life? What was your reason?
7. Did you have to do anything to look after (name)?
8. What do you want to achieve for (name)?
9. What’s your role in (name’s) life? Are you helping or causing problems?
10. What would happen to (name) if you weren’t there?
11. How does (name) feel about you?
12. What is it like being in (name’s) life?
13. Would you like to change anything in your relationship with (name)?
14. Do the other voices know about you? What do they think of you? Do they collaborate with
you?
15. Is there anything you want to advise/suggest to (name)?

Case example
“Nelson” is 47-year-old man with a history of severe childhood abuse. He served in the Army before mental health difficulties, precipitated by the murder of his wife, forced him to retire. He was diagnosed with paranoid schizophrenia, but had recently withdrawn from medication after finding it ineffective. He heard three voices: John
(aged 7); Judas (aged 47), and Mother (who resembled Nelson’s mother when he was 7 years old). Judas and Mother were the most domineering voices, whereas John represented the memories of Nelson’s abuse. Judas and John were constantly present but the Mother voice appeared intermittently, usually during periods of intense stress. Nelson attended a residential training workshop about VH run by two of the authors (DC and EL). As Nelson had never worked therapeutically with either facilitator, time was spent prior to the Talking With Voices session exploring the content and characteristics of his voices. Judas and John first appeared when Nelson was seven, when they instructed him to build a tent in his bedroom. Throughout his childhood, Judas and John provided companionship and comfort. The Mother voice appeared when Nelson had his first breakdown. This voice was cruel and destructive. In turn, John was debilitating due to the intense feelings of fear and despair he induced
in Nelson. Although Judas was perceived as having good intentions, Nelson found him frightening because of his austere, commanding nature. Nelson’s goal was to learn to understand his voices and to cope with them in a more constructive way. Both Nelson and the voices readily agreed to talk with us. Nelson was unsure which voice to speak with first, and we advised to start with a dominant one, then ask its permission to proceed to more disowned ones (if this is not done then the dominant voice, whose task is to protect the voice-hearer, may grow annoyed and aggressive towards the person and/or the vulnerable voices/parts). As Nelson was scared of the
Mother voice, we agreed to speak with Judas first. Because it is important that the voice-hearer takes responsibility for the process, Nelson was told to stay present during the dialogue and to intervene if necessary. Before proceeding, time was spent discussing ways to help both Nelson and the voices feel safe. We agreed that when Judas spoke, Nelson would need to stand and move about. We also reassured Nelson that we could deal with verbal aggression, as he was afraid Judas would offend us. Because Nelson was concerned the voice would take control of him during the session, we agreed to use a firm, military-like sentence (“You may now sit”) as a cue
for Judas to leave and Nelson to resume control. When we spoke with Judas, Nelson adopted a military stance and began pacing round the room. The voice of Judas was assertive, and spoke in short, precise sentences. He identified himself as an army officer and told us it was his responsibility to plan and organise Nelson’s life. Judas reported that Nelson could not travel, work, or socialise without him, and that he forced Nelson to go to nightclubs in order to meet women (one of Judas’ ambitions was for Nelson to overcome his fear of intimacy and find a partner). Judas described how he and John first appeared to help Nelson survive the abuse and bear his loneliness. However, Judas also told us that while he still knew John, they were no longer on friendly terms because “John didn’t grow up, whereas I became a man.” Judas stated that he didn’t know what fear was; he was always there and didn’t need rest or respite. He also explained his name: Judas was the protector of Christ, and Judas had a desire to help and support Nelson. Because Nelson’s family was very religious, Judas believed this was a name Nelson would relate to. His desire was to be accepted by Nelson. He was responsive to our suggestion to try to find more common ground with John. At the end of the conversation, we thanked Judas for
answering our questions and asked to speak with Nelson again. When Nelson sat down, the voice of John appeared. It was clear that John harboured significant pain, anxiety and grief. Because of the limited time available, we could not talk to John. However, we advised Nelson to discuss his feelings with John, and to try and promote contact between John and Judas. Nelson expressed his fear that he did not know how to connect with women, even though he wanted a relationship. We suggested that with Judas’ assistance, and when John felt safer, Nelson could try to meet a partner. Although some voice-hearers dissociate during a session, Nelson was aware of the conversation with Judas and showed no evidence of amnesia. For instance, he had been intrigued by Judas’ account of his name, as he had previously been unaware of its origins. On the basis of this work, Judas and Nelson’s relationship changed significantly, becoming more positive and supportive. Indeed, the next day Nelson told us that Judas had said “good morning” to him in a friendly manner for the first time in seven years. Nelson was advised to find ways to support the voice of John to mature and gain trust in Nelson, and to recruit the help of Judas in this by defending, reassuring and caring for John. In order to help Judas and John become allies again, Nelson intended to build a new tent (to mimic the one in which the three of them first met) to begin a process of integration and reconciliation. Email contact was sustained with Nelson after the course, in which it transpired that this strategy had been successful. Nelson subsequently began a paid position training junior psychiatrists in supporting and understanding VH.
 

Conclusions
Currently, the most dominant psychological model of VH comes from the cognitive tradition, which argues that VH arises from distorted information processing and misattribution of internal events. However, these perspectives seem inadequate given theway many voice-hearers conceptualise their experiences (Beavan, 2011) While persuasive at explaining how thoughts may be experienced as projected/intrusive, cognitive models provide a less compelling account of how externalised thoughts become audible, particularly as most voice-hearers make clear distinctions between voices and thoughts (Hoffman, Varanko, Gilmore, & Mishara, 2008). Dissociative processes, by contrast, appear indispensable for explaining one of the most vital aspects of VH: that of “other” dynamically engaging with “self”. It is not immediately apparent how individuals cultivate, negotiate, and modify relationships with externalised thoughts, yet a process of communication and interaction is how VH is consistently described
(Romme et al., 2009). Therapeutic models which recognise this not only resituate VH in the context of the hearer’s social relations, they emphasise the importance of integrating the experience within their own internal dialogue. Indeed, as May (quoted in James, 2009, p. 18) has observed “(w)hile some cognitive approaches might mindfully
step back from the voices, [Talking With Voices] can be seen as mindfully engaging with voices". This is particularly relevant given that much VH, including the most stressful, high-risk varieties, are often resistant to standard treatments that focus on eliminating the experience rather than understanding, interpreting, and integrating it
(Birchwood & Spencer, 2002). Furthermore, while more recent forms of CBT (e.g. Chadwick, 2006) are increasingly advocating relational ideas, they still do not address voices directly, rather beliefs and assumptions about them.
We have practiced the Talking With Voices approach with numerous voice-hearers over the last decade. These individuals experienced it as a safe way to enhance understanding of their voices through the provision of normalising frameworks and insight into the underlying reasons for voice emergence, ultimately acting as a catalyst for establishing more productive relationships between hearer and voice. Furthermore, the approach can improve social functioning for voice-hearers who are trapped in destructive communication patterns with their voices. Of course, not all voice-hearers are willing (or able) to directly dialogue with their voices, in which case other approaches are available. Furthermore, while one-session transformations can occur, prolonged and systematic exploration is often necessary to enact lasting change. Finally, the emotional material voices represent may sometimes be so threatening that voice-hearers dissociate when the facilitator communicates with the voice. In such instances, more prolonged therapy in the line of dissociative disorder protocols are needed. Future systematic research is being prepared to address indications, contra-indications andeffectiveness of the Talking  With Voices approach. Some considerations regarding this can be found at www.hearingvoicesmaastricht.eu.

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