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A data synthesis is presented from 100 clinical cases, 80% with a diagnosis of schizophrenia or other psychotic disorder, in which Romme and Escher’s “con- struct” method was used to formulate voice-hearing content and characteristics in relation to life events. Across the sample, most participants heard between two and five voices and the average duration of voice hearing was 18 years. At least one adverse childhood experience was reported by 89% of the sample, including family conflict, neglect, physical/sexual/emotional maltreatment, and bullying. In addition, a broad range of acute, precipitating stressors were associ- ated with the onset of voice hearing itself in both childhood and adulthood. In 94% of cases, it was possible to clearly formulate the underlying emotional con- flicts embodied by the voices (e.g., low self-worth, anger, shame and guilt). Representations for voice identity (e.g., disowned aspects of self, a family mem- ber, a past abuser) were formulated in 78% of cases. It is proposed that many individuals hear voices that make psychological sense in the context of life events, and that this information can be clinically applied in ways that serve personal recovery.
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The origins of voices: links between life
history and voice hearing in a survey of
100 cases
Dirk Corstensa & Eleanor Longdenb
a Psychiatrist and psychotherapist, RIAGG Maastricht, Maastricht,
The Netherlands.
b Institute of Psychological Sciences, University of Leeds, Leeds,
Published online: 09 Sep 2013.
To cite this article: Psychosis (2013): The origins of voices: links between life history and voice
hearing in a survey of 100 cases, Psychosis: Psychological, Social and Integrative Approaches, DOI:
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The origins of voices: links between life history and voice hearing
in a survey of 100 cases
Dirk Corstens
* and Eleanor Longden
Psychiatrist and psychotherapist, RIAGG Maastricht, Maastricht, The Netherlands;
Institute of Psychological Sciences, University of Leeds, Leeds, UK
(Received 29 January 2013; accepted 7 June 2013)
A data synthesis is presented from 100 clinical cases, 80% with a diagnosis of
schizophrenia or other psychotic disorder, in which Romme and Escherscon-
structmethod was used to formulate voice-hearing content and characteristics
in relation to life events. Across the sample, most participants heard between
two and ve voices and the average duration of voice hearing was 18 years. At
least one adverse childhood experience was reported by 89% of the sample,
including family conict, neglect, physical/sexual/emotional maltreatment, and
bullying. In addition, a broad range of acute, precipitating stressors were associ-
ated with the onset of voice hearing itself in both childhood and adulthood. In
94% of cases, it was possible to clearly formulate the underlying emotional con-
icts embodied by the voices (e.g., low self-worth, anger, shame and guilt).
Representations for voice identity (e.g., disowned aspects of self, a family mem-
ber, a past abuser) were formulated in 78% of cases. It is proposed that many
individuals hear voices that make psychological sense in the context of life
events, and that this information can be clinically applied in ways that serve
personal recovery.
Keywords: auditory hallucinations; psychosis; trauma; formulation; causal
explanations; diagnosis; hearing voices
Hearing voices which others cannot hear has traditionally been deemed a perceptual
psychopathology, closely associated with schizophrenia, and often accorded limited
signicance beyond determining diagnostic and prognostic status. More recently
however, understandings of this experience have been rened to incorporate the
psychosocial, emotional, and interpersonal circumstances. In particu-
lar, emerging associations between voices and traumatic events particularly, though
not exclusively, childhood abuse (e.g., Bentall, Wickham, Shevlin, & Varese, 2012;
Longden, Madill, & Waterman, 2012a; Read, van Os, Morrison, & Ross, 2005;
Shevlin et al., 2011), have energised an enhanced appreciation of voices as mean-
ingful representations of psychological distress and social adversity. Furthermore,
evidence suggests that in addition to voice presence, associations exist between inci-
dences of trauma and loss and the phenomenology of voice hearing itself. For
example, voice utterances may directly embody traumatic events (e.g., Hardy et al.,
2005) and specic adversities, such as childhood sexual abuse, may inuence
*Corresponding author. Email:
Psychosis, 2013
Ó2013 Taylor & Francis
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specic types of voices, such as those that are imperious and commanding
(McCarthy-Jones, 2011). In some circumstances, interactions with ones voices can
reect a more general, pervasive manner of social relating, including patterns of
entrapment, powerlessness, and subordination (e.g., Birchwood et al., 2004); in
effect, embodying the social world of the voice-hearer (Mawson, Berry, Murray, &
Hayward, 2011). Furthermore, voice content appears to be a better predictor of dis-
tress and psychiatric need than more traditional diagnostic variables like Schneideri-
an structure (e.g., Beavan & Read, 2010). In this respect, traumatic intrusions and
appraisals may inuence and protract voice maintenance (e.g., Andrew, Gray, &
Snowden, 2008), and for many individuals, explicating links between life events
and distressing voices provides a valuable framework for advancing recovery
(Romme, Escher, Dillon, Corstens, & Morris, 2009).
In this regard, Romme and Escher (2000) have advanced a method of psycho-
logical formulation, known as the construct,which provides a systematic way to
place voice phenomenology within a biographical context. In doing so it follows
the original tenets of the stress-vulnerability model (Zubin & Spring, 1977) by
emphasising the formative inuence of environmental factors: in effect, differentiat-
ing between the acute stressors that directly precipitate voice-hearing onset, and
developmental events that create vulnerability for emotional crisis. In order to relate
these factors to voice hearing, the construct utilises specic areas of enquiry (voice
identity, characteristics and content, triggers, history of voice hearing, personal his-
tory of the voice-hearer) to explore two fundamental questions about representation:
(1) who or what might the voices represent; and (2) what social and/or emotional
problems may be embodied by the voices. The method overlaps with best-practice
principles of psychological formulation (Johnstone & Dallos, 2013) in that it sum-
marises core areas of difculty, respects and refers to client views on accuracy and
expediency, integrates systemic, social and/or political factors, is amenable to con-
stant revision and re-formulation, and uses an available evidence-base to link theory
with practice (e.g., the demonstrated link between voice hearing and psychological
stress). The meaningof experience is not imposed on the voice-hearer, but co-
constructed in a process of collaboration and exploration, then subsequently
employed to guide an individualised intervention plan that applies information
about voice manifestation and emergence to promote recovery (Corstens, Escher, &
Romme, 2008; Longden, Corstens, Escher, & Romme, 2012b; Romme & Escher,
2000). This is consistent with the premise that construing meaning and narrative
from distressing symptoms, including those in the context of psychosis, can help
elucidate unresolved emotional conicts and, in turn, promote hope, understanding,
empowerment, reectivity, and psychological adjustment (e.g., British Psychological
Society Division of Clinical Psychology, 2011; Johnstone & Dallos, 2013; Stainsby,
Sapochnik, Bledin, & Mason, 2010).
The purpose of the current study was to retrospectively analyse constructs from
100 voice-hearers in order to identify common and recurrent themes. Although
several investigators have examined voice content and/or characteristics in relation
to life events (e.g., Andrew et al., 2008; Daalman et al., 2012; Hardy et al., 2005;
Read, Agar, Argyle, & Aderhold, 2003; Reiff, Castille, Muenzenmaier, & Link,
2011) to our knowledge none have done so in the context of detailed clinical
assessment, or provided an extensive, theoretically informed phenomenological sur-
vey whilst retaining a semi-structured interview protocol. In addition, the current
study will address several issues concerning the construct method: (1) whether it is
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possible to retrieve enough information to formulate voice representations (includ-
ing with recipients of long-term psychiatric treatment and/or those with diagnoses
of so-called schizophrenia-spectrum disorders); and (2) what psychosocial problems
may contribute to voice emergence and maintenance.
At the time of making their constructs, all participants experienced voices to the
extent of causing signicant emotional distress and/or impairing social or occupa-
tional functioning. Participants were self-selecting, to the extent that they requested
to develop constructs through clinical contact with the authors. All were in receipt
of statutory psychiatric care and had heard voices within at least one week prior to
the constructs being made. Participants were recruited from various countries during
the course of the authorsclinical work, including parts of Western Europe
(Denmark, the Netherlands, the UK, Sweden), Australia, and Cameroon.
The mean age of the sample was 35.94 years (SD = 11.72; range 1562) with a
female to male ratio of 57:43. The majority of participants (80%) had a diagnosis
of schizophrenia or other psychotic disorder, and an extensive duration of voice
hearing (M=18.21 years; SD = 13.77). The most common experience was to hear
between two and ve voices, although a small proportion (7%) reported clusters of
more than 20 voices. The main demographic and clinical characteristics of the sam-
ple are reported in Tables 1 and 2.
The 100 constructs were gathered by the authors either singly or in collaboration
(93%) between 2002 and 2012, with an additional seven obtained via two col-
leagues trained in the construct method. A majority (63%) were devised during
teaching sessions facilitated by the authors, in which participants volunteered to talk
Table 1. Main demographic characteristics of the sample.
% endorsed
(N= 100)
Female 57
Male 43
White 90
South Asian 6
Afro-Caribbean 4
Employment status
Unemployed 76
In paid employment 15
Student 9
Marital status
Single 68
Married or co-habiting 16
Divorced 16
Mean SD
Age 35.94 (11.72)
Psychosis 3
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about their experiences in front of a mixed group of other voice-hearers and/or
mental health professionals. The remainder were obtained during individual clinical
contacts. The initial aim in formulating the constructs was as a clinical tool rather
than to generate research data. However, permission was sought from individuals to
use their information for educational and research purposes, with the understanding
that it would only be presented in a numerical or otherwise anonymised form.
In group situations, voice-hearers were reassured that the primary purpose of the
exercise was to demonstrate ways of discussing and exploring voice-hearing experi-
ences. The formulation aspect was de-emphasised so that participants did not feel
pressured to give the right responsefor the benet of the audience. Information
was elicited by questioning around each of the ve main construct themes (e.g.,
identity, characteristics, etc.) and recording summarised responses on ipchart paper
so that participants could see what was written and correct it if necessary. The two
questions about representation were considered in collaboration with the participant,
with the author(s) proposing suggestions and prompts in the respectful and explor-
atory way stipulated by Romme and Escher (2000). Primacy was always given to
voice-hearer interpretations, regardless of whether this was a framework endorsed
by the author(s). If constructs were devised in a group situation, the author(s) met
with the voice-hearer in private for 30 minutes afterwards to discuss the construct
and ascertain its accuracy and usefulness.
The notes derived during this process were subsequently used to create full-
length constructs, which were presented in the format described by Corstens et al.
(2008) and Longden et al. (2012b). All participants (and, if requested, a nominated
mental health worker and/or family member) then received written copies to provide
further opportunities for reection, correction, and feedback. In this respect, all
constructs in the present study had been read, veried, and validated by the voice-
hearer concerned. The criteria for selecting constructs for the current analysis was
based on the 100 most recently completed for which voice-hearer consent had been
obtained. In addition, constructs were only included if the voice-hearer agreed with
the way in which their experiences had been formulated.
Table 2. Main clinical characteristics of the sample.
% endorsed (N= 100)
Psychiatric diagnosis
Schizophrenia 68
Other psychotic disorder 12
Borderline personality disorder 8
Affective disorder 5
Diagnosis not disclosed 7
Number of voices
One 18
Two ve 52
Sixten 21
1120 2
>20 7
Mean SD
Years of mental health service use 9.48 (12.04)
Duration of voice hearing in years 18.21 (13.77)
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Coding framework
As no established method exists for assessing links between life events and voice
phenomenology, the coding frame was devised in reference to clinical expertise,
existing theoretical and empirical literature, and the pilot work of Romme and
Escher (2000) when originally delineating the construct (see below).
The study data was derived from coding the contents of completed, participant-
approved constructs. The latter all began with (1) brief demographic descriptions,
then (2) proceeded to outline the ve main variables of enquiry (voice identity,
characteristics and content, triggers, history of voice hearing, personal history of the
voice-hearer). The nal section 3) formulated questions about representation (who
or what might the voices represent; and what social and/or emotional problems may
be represented by the voices: see Corstens et al., 2008; Longden et al., 2012;
Romme & Escher, 2000). To obtain the necessary frequency data, one author ini-
tially coded all constructs according to the criteria described below. To conrm
agreement and consistency in this coding system, a subset of 30 constructs were
then selected at random and rated on the same criteria by both the second author
and an independent rater from the Bradford and Airedale Early Intervention in Psy-
chosis Service. One area of enquiry, voice identity (i.e., numbers of voices, their
name, gender and/or age) was not coded in that the information was provided
unambiguously by the voice-hearers and was not open to interpretation. The
remaining variables were coded for each voice according to the following criteria:
(1) Voice content and characteristics. This query refers to how voices express
themselves and how they relate to the voice-hearer and/or each other. Voice
characteristics were categorised using the following criteria: verbal or non-verbal
utterances; perceived malevolent or benevolent intent; emotional impact; spatial
location (internal or external); rst-, second-, or third-person articulation; and
identication: for example, as a known acquaintance, a family member, religious/
spiritual frameworks (e.g., God,”“the Devil), paranormal frameworks (e.g.,
ghosts), or a voice that is recognised as belonging to oneself, including oneself at a
different age. Content was coded in the following way: commanding; criticising;
threatening; making premonitions; interacting with one another; making direct
references to trauma (e.g., talking about abuse); speaking in a foreign language;
providing advice or encouragement.
(2) Triggers. When making a construct, appreciating what aggravates or elicits
the voices can be relevant for understanding their emotional dynamics, as well as
the underlying problems associated with them. Information was assessed according
to whether voices were provoked by the following criteria: specic individuals
(e.g., family members, acquaintances); specic circumstances (e.g., social situations,
a particular room in ones home), and/or particular emotions (e.g., guilt, shame,
anger). Data were coded as not identiableif there were no obvious triggers for
(3) History of the voices. This variable refers to proximal life circumstances that
precipitated voice onset (i.e., events that occurred within six months prior to voices
rst manifesting). The age of rst onset was asked for, and whether new voices had
subsequently appeared. Codes were derived from the framework developed by
Romme and Escher (2000) around interpersonal stressors that may inuence voice
emergence and incorporated: childhood maltreatment (sexual, physical, emotional,
neglect); serious physical illness (life-threatening and/or necessitating signicant
Psychosis 5
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educational or social disruption); peer bullying; family conict (e.g., chronic domes-
tic arguments, rejection of the voice-hearer by other family members); sexual or
physical assault post-age 16; bereavement; sudden, unexpected death of signicant
individuals; relationship breakdown; experiencing excessive criticism and/or high
expectations; leaving home for the rst time; problems at school; and witnessing
violence. Because of the numerous experiences reported, an othercategory was
utilised which incorporated less common stressors associated with voice onset (e.g.,
workplace stress, giving birth, spousal illness, visiting a psychic, being adopted,
starting psychotherapy, moving home).
(4) Childhood history. This question addressed distal, formative experiences and
stressful exposures in the voice-hearers life prior to voice onset. Codes included:
sexual, physical, and emotional maltreatment; neglect; serious physical illness; fam-
ily conict; peer bullying or rejection; experiencing excessive criticism and/or high
(5) Who or what do voices represent? When formulating voices, it is often ben-
ecial to identity who or what they resemble (and thus what psychosocial dilem-
mas, and consequent interventions, are indicated by these representations).
Personications can be metaphorical; for example, a voice deemed The Devil
may be formulated as representing an abusive perpetrator or, more specically, as
the persons feelings in relation to the abuse, or the part of the voice-hearer that has
identiedwith the perpetrator (Dillon, 2011; Longden et al., 2012a; Romme
et al., 2009). Voice representation was coded as: an abusive family member, a non-
abusive family member, a known abuser, a non-abusive acquaintance, or aspects of
the self. Data was coded as not identiableif the answer to this question was
(6) What problems do voices represent? This question informs the second half
of the construct and explores circumstances at the core of voice hearing experi-
ences; generally a legacy from overwhelming events, emotions, and circumstances
that disempowered the person and which have not been properly integrated
(Romme & Escher, 2000). As such it provides a snapshotof the prevailing areas
of difculty in the persons life. The codes applied were problems and conicts
relating to: shame and guilt, sexual identity, self-esteem, anger, and attachment and
intimacy. Data were coded as not identiableif the answer to this question was
Information about the voices and associated life events
The full results of this part of the analysis are reported in Table 3.
Identity of the voices. The most prevalent reported experience was to hear voices
that could be clearly personied in terms of age, gender, and name. Adult, male
voices were the most common, although a proportion also reported child (19%),
adolescent (10%), or female voices (66%). Most voices had either elected names
for themselves or been named by the voice-hearer, with only 32% of individuals
reporting nameless voices.
Characteristics and content. All participants experienced verbal articulations
from their voices, with 17% also reporting non-verbal sounds, such as crying or
laughing. The most prevalent experience was hearing solely negative and malicious
voices (59%), which either criticised (98%), commanded (73%), or threatened
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Table 3. Response characteristics for sections of the construct.
Construct theme Areas of enquiry
% endorsed
(N= 100)
Identity of voices
Child voices (< 13 years) 19
Adolescent voices (1318 years) 10
Adult voices 94
Unknown 21
Female 66
Male 83
Without gender 30
All voices named 46
No voices named 32
Mix of named and unnamed voices 22
Characteristics of
voices Utterances
Verbal 100
Non-verbal 17
Malevolent voices only 59
Benevolent voices only 4
Both 37
Negative emotional impact only 79
Positive emotional impact only 1
Both 20
Voice location
External (outside head) 74
Internal (inside head) 14
Both internal and external 12
Voices speak in 2
person 97
Voices speak in 3
person 66
Voices speak in 1
person 42
Combination of 1
and 3
Combination of 2
and 3
person only 20
Combination of 1
and 2
Voice of a family member 47
Voice of a known acquaintance 47
Ones own voice 28
Religious/spiritual framework 14
Paranormal framework 2
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Table 3. (Continued ).
Construct theme Areas of enquiry
% endorsed
(N= 100)
Voices criticise the hearer 98
Voices command the hearer 73
Voices criticise others 66
Voices criticise the hearer and others 65
Voices make threats 64
Voices interact with one another 63
Voices give advice/encouragement 35
Voices refer to traumatic events 17
Voices make premonitions 5
Voice speak in foreign language 5
Specic emotions 76
Specic circumstances 50
Specic individuals 15
No obvious trigger 19
History of voices
Age of rst onset
Under 10 years 35
1120 years 24
2130 years 24
3140 years 10
>41 years 5
Unclear 2
New voices appearing at later ages
Yes 65
No 35
Life events associated with initial voice
Family conict 47
Emotional abuse 36
Severe personal criticism 35
Sexual abuse 23
Physical abuse 22
Bullying 19
Bereavement 18
Witnessing violence 17
Problems at school 17
Sudden, unexpected death 16
Relationship breakdown 11
Leaving home 11
Physical assault 9
Physical illness 7
Rape 7
Other 35
No identiable event 7
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(64%) the hearer. Only four people reported voices that were solely afrming and
supportive, although 37% heard a combination of positive and negative voices. The
majority of voices were experienced externally (through the ears), and spoke mostly
in the second and third person, or a combination of the two. Participants were also
more likely to report hearing the voice of a family member or known acquaintance
(both 47%) than hearing their own voice (28%). More unusual experiences included
voices that made premonitions, that spoke in a foreign language, or were identied
with paranormal or religious/spiritual frameworks.
Triggers. Many individuals could identify precise circumstances or emotions that
elicited or exacerbated voice presence. The list of personal triggers nominated by
the sample is too extensive to reproduce here, although the two most common
themes were emotions, such as guilt, shame, insecurity, sadness, anxiety, and sexual
feelings (76%), and discrete circumstances, such as social situations, meeting family
members, and being isolated (50%). In this sample, only 19 individuals couldnt
nominate any clear, consistent prompts for the voices.
History of the voices. Almost 60% of the sample reported voices beginning
before the age of 20 (35% before the age of ten), although it was also common for
new voices to appear at a later age, sometimes many years after initial onset. Only
7% were unable to identify clearly dened precipitating circumstances at the time
of voice emergence. The remainder reported a broad range of stressful, interpersonal
events directly preceding voice onset; the most common being family conict,
emotional abuse, severe personal criticism, and sexual abuse.
Life events before voices onset. The majority of the sample (87%) had experi-
enced chronic social and interpersonal adversities before their voices started. The
most frequently reported were family conict and four types of childhood abuse
(emotional, physical, sexual, and neglect) often in combination. When examining
both traumatic precipitating events and antedating events, it is apparent that 89% of
the total sample had endured severe stressors at some point over their life-course.
The 100 constructs
The full results of this part of the analysis are reported in Table 4.
Who or what do the voices represent. The substantial majority of the sample
(78%) heard voices whose identity could be formulated in terms of lived
Table 3. (Continued ).
Construct theme Areas of enquiry
% endorsed
(N= 100)
Childhood history
Emotional abuse 72
Family conict 65
Neglect 45
Physical abuse 41
Sexual abuse 30
Bullying 30
Domestic violence 23
High expectations 18
Serious physical illness 9
No identied stressors 13
Psychosis 9
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experience. It was common for voices to be recognised as representations of aspects
of self, including the voice-hearer at a particular age, or disowned aspects of the
personality. These associations were often closely interlinked with precipitating
events; for example, hearing the voice of ones seven-year old self in adulthood,
Table 4. Voice hearing representations.
% endorsed
(N= 100)
Who or what do the voices represent
Aspects of self 48
Abusive family member 45
Father 31
Mother 23
Brother 6
Grandmother 5
Uncle 4
Grandfather 2
Male friend or
Female friend or
Non-abusive family
Father 10
Mother 5
Grandmother 3
Brother 3
Sister 2
Grandfather 1
Uncle 1
Other female relative 1
Other male relative 1
Other perpetrator 23
Spouse 2
Other male perpetrator 23
Other female
Unidentiable 22
Social and emotional problems
represented by the voices Problems with self-esteem 93
Anger 60
Shame and guilt 60
Attachment and intimacy
Conict over sexual
No identiable problems 6
Other 57
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when one was abused aged seven. However, many voices were personied as sig-
nicant others, most frequently abusive (45%) or non-abusive (30%) family mem-
bers who in some way had played an important part in the voice-hearerslives.
Common representations included abusive parents, a male friend or acquaintance,
or a male perpetrator who had victimised the voice-hearer in some way. In this
respect, the greater frequency of male representations corresponded to the higher
number of male voices.
What problems do the voices represent. The voices heard by the majority of the
sample (94%) could be formulated as specic representations of social-emotional
conicts, most often resulting from interpersonal stress. Almost all the sample
reported a pervasive lack of self-worth. Other underlying problems embodied by
the voices included the expression of anger (60%), shame and guilt (60%), and
difculties with intimacy and attachment (45%).
The current study is consistent with previous research demonstrating associations
between voice hearing and traumatic life events (e.g., Read et al., 2005; Shevlin
et al., 2011; Varese et al., 2012), and the likelihood of individuals in psychiatric ser-
vices to report a high volume of negative, persecutory voices (e.g., Andrew et al.,
2008; Beavan & Read, 2010; Honig et al., 1998). Furthermore, it represents a
fusion of these perspectives by demonstrating that, in the majority of cases, associa-
tions between voices and precipitating life events can be established using princi-
ples of psychological formulation.
In terms of the study aims, we found that it is possible to retrieve enough infor-
mation to answer questions considering voice representations with individuals who
are actively hearing voices, in receipt of long-term psychiatric treatment and/or have
a diagnosis of schizophrenia. Voice emergence was additionally related to a range
of social and emotional vulnerabilities, the most common being problems with self-
esteem, anger, shame and guilt; which in turn were linked with previous adverse
experiences. In this respect, participants were mostly able to provide sufcient
information to formulate a relationship between their life history and their voices.
This was still the case when voice content did not contain literal reections of trau-
matic events, a nding that is consistent with Romme and Eschers (2000) experien-
tial, making senseapproach to voice hearing, which locates the experience as
emotionally signicant and psychologically interpretable.
Clinical implications
All individuals in the sample reported experiencing voices for at least two years
(63% for 10 years or more), and in this respect are representative of patients who
have been subjected to voices for long periods and for whom traditional treatment
has little impact. Our work with the construct method demonstrates that many
voice-hearers can identify clear, precipitating events for the emergence of their
voices and, with support, are able to create a personal story about the relationship
between their voices and these experiences. For many, these were lived narratives
that had previously been obscured behind the label of schizophrenia, the patient
role, and the pessimistic implications of a disease-model of voice hearing.
Conversely, the construct aims to re-establish associations between voices and the
Psychosis 11
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events which precipitated their presence (expressed in terms of the two representa-
tional questions: who or whatand what problemsdo the voices represent?). On
the basis of this study, we suggest that psychiatric assessment of voice hearing
could reveal a dynamic socio-emotional understanding if specic questions were
incorporated into traditional assessment repertoires (see Table 5).
Many distressed voice-hearers have neither a specic awareness of who the
voices are,nor a coherent, integrated emotional-cognitive model of why their
voices appeared. Therefore the representations presented within the construct create
a meaning and understanding for the voice-hearer in terms of an individualised,
explanatory model for their experiences. By relating voices to overwhelming emo-
tions, events and problems, voice-hearers may acquire a fresh, personal knowledge
in which painful feelings and beliefs can be addressed and reconciled with authentic
problems from their past (and often in their present). Although voices are often
experienced as real,and are associated with genuine people and emotions (which
one can learn to cope with) they arenot the real persons, but represent an internal
emotional world. In this way, the construct has the capacity to create both distance
(insight, new understanding) and proximity (the relevant emotions can become the
focus of future recovery interventions). By deconstructing symptoms into com-
plaints (Bentall, 2006) that emerged in a specic psychosocial context, strategies for
relating to voices can therefore be derived from the level of individual experience
rather than putative syndrome. In this respect, information on directing the themes
of the construct towards treatment and recovery planning can be found in Romme
and Escher (2000), Romme et al. (2009), and Corstens et al. (2008).
Finally, the high incidence of trauma in the sample supports the contention that
psychiatric staff should receive support and training to facilitate routine enquiries
about exposure to abuse and adversity (e.g., NHS Confederation, 2008). This is
particularly relevant given the signicant under-detection of posttraumatic stress in
Table 5. Suggested assessment questions, and supplementary prompts, for a socio-
emotional understanding of voice hearing.
(1) What identity do your voices have?
Are they male or female? How old are they? Have they always been that age or have
they grown older?
(2) Do your voices have names?
Did they name themselves or did you name them? Do you know why they have those
(3) What do your voices say to you?
Do they interact with each other too? Are some voices more dominant, either with you
or amongst themselves?
(4) Do your voices remind you of people you know, or have known?
Is their tone familiar? Is their content familiar? Has anyone else ever said those
things to you?
(5) Are your voices negative towards you, or other people?
(6) Do you hear comforting or supportive voices?
(7) What triggers your voices, or make them worse?
Do the voices respond to particular people/places/emotions? Are there specic people/
places/emotions that make them less intense?
(8) What was happening in your life when the voices started?
Have they changed since then?
(9) What was your early life like?
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patients diagnosed with psychosis (Lommen & Restifo, 2009), and that such
patients are less likely to receive an appropriate clinical response even when abuse
is disclosed (Agar & Read, 2002). As such, accurate assessment is imperative for
providing recourse to suitable interventions, and devising treatment plans that
encompass relevant cognitive, affective, and psychosocial factors. This may include,
for example, ways in which posttraumatic beliefs impact on voice hearing
attributions, strategies for coping with dissociation, and narrative techniques to aid
memory contextualisation and integrate traumatic material (e.g., Corstens, Longden,
& May, 2012; Ogden, Minton, & Pain, 2006; Ross & Halpern, 2009).
These constructs were created in a systematic, standardised manner with voice-hear-
ers who were broadly representative of a chronic psychiatric population in terms of
clinical and demographic characteristics. Nevertheless this was a naturalistic, obser-
vational study derived from retrospective clinical data and situated within a broader
therapeutic process. Performing a similar enquiry in a more controlled way would
necessarily strengthen the reliability of the ndings.
A main limitation of this study was the self-selecting nature of the sample, and
the fact that these individuals were motivated to engage in making sense of their
voices may limit the generalisability of the results. An important avenue for future
research is to therefore replicate the process with a random sample of voice-hearers
in order to clarify indications and contra-indications. In this respect, although we
have received extremely positive anecdotal evidence from both voice-hearers and
their family members and/or workers, it would be preferable to derive formal out-
come data in order to elucidate the approachs long-term outcomes in terms of treat-
ment and recovery planning. Furthermore, the descriptive nature of the current
research does not permit a more detailed, theoretically driven exploration of how
voice representations can arise.
A further limitation is that the study did not permit sufcient exploration of the
experiences of participants whose voices could not be formulated in psychosocial
terms. For example: whether these links existed but the construct process failed to
identify them; or whether voice-hearers were unwilling to disclose particular events
(possibly due to lack of report with the researchers), or were not aware of them
(i.e., as part of a posttraumatic, dissociative response: Moskowitz, Read, Farrelly,
Rudegeair, & Williams, 2009). Some people are also disinclined to work within the
connes of a narrative model, and cannot conceive themselves within the frame-
work of a story (Woods, 2011). Another possibility is that these voices were unre-
lated to social/emotional conicts; which in turn raises the question of whether they
were aetiologically different to those of the other participants.
In this respect, all information in the study was reliant on participant disclosure
of adverse life events, which it was not possible to independently verify (although
retrospective accounts of trauma amongst groups with complex mental health
problems have repeatedly proven sufciently valid and reliable to justify the use
of self-report measures: e.g., Fisher et al., 2011; Goodman et al., 1999; Meyer,
Muenzenmaier, Cancienne, & Struening, 1996). In regards the training groups, we
found that the atmosphere of acceptance, mutuality, and solidarity usually
motivated people to tell their personal stories and share experiences. Generally
voice-hearers who didn't want to disclose traumatic content would not volunteer in
Psychosis 13
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such a group, or would ask to meet with the trainers and create a construct
privately. Nevertheless, it is likely that some voice-hearers didn't feel sufciently
safe to share painful stories, meaning that if this procedure inuenced the results
of this study, it would probably be an underestimation of associations between
trauma and voices.
Our work with the 100 voice-hearers demonstrates that it is both possible and pro-
ductive to engage in an exploration of traumas and vulnerabilities with individuals
who are often strongly identied with a patient role (i.e., schizophrenia). These
were people who had generally not responded well to traditional psychiatric treat-
ments and were seeking help in nding a more personal explanation for their dis-
tress. These data show that a signicant proportion of so-called chronic psychotic
patients are responsive to an approach that acknowledges and relates to their social-
emotional problems and, by extension, that it is possible to make sense and give
meaning to voices; to relate them to overwhelming life experiences; and to under-
stand voices as representations of the events and problems that underlie their emer-
gence. By deconstructing diagnostic classications and shifting clinical emphasis
towards psychosocial difculties, we wish to formulate interventions which both
provide opportunities to address past adversities in voice-hearerslives, and which
promote more constructive, healing strategies to deal with the interpersonal and
social dilemmas that they are confronted with. In this respect, it is also important to
emphasise that such work utilises existing skills already employed by many profes-
sionals as part of good clinical practice and, as such, can be developed as the start
of a road away from therapeutical nihilism towards personal recovery-oriented
goals, wherein emotional vulnerabilities and posttraumatic responses can be
addressed in a restorative way.
We wish to acknowledge all the voice-hearers and professionals who have worked with us,
without whom it would have been impossible to devise the constructs. We would also like
to thank Birgitte Bjerregaard Nielsen, Yolanda van den Broek, Christine Brown, Ron
Coleman, Jacqui Dillon, Trevor Eyles, Inge Helle Jul, Matthew Morris, Mervyn Morris,
Pernille Norgard Kolk, Melissa Lee, Karen Taylor and Rozemarijn van der Vinne who made
it possible to conduct the workshops that enabled us to work with the voice-hearers.
1. We are using the phrase voice hearing,because it makes no assumptions about the
pathological nature of a subjective experience (Thomas & Longden, in preparation).
Although auditoryor verbal hallucinationsis a preferred term in psychiatric litera-
ture, this is not an expression that patients use to describe their experiences, and has
likewise been deemed reductive and depreciatory by authors and service-user organisa-
tions (see Dillon & May, 2002; Intervoice, 2010; McCarthy-Jones, 2012).
Agar, K., & Read, J. (2002). What happens when people disclose sexual or physical abuse
to staff at a community mental health centre? International Journal of Mental Health
Nursing, 11,7079.
14 D. Corstens and E. Longden
Downloaded by [Angela Woods] at 14:39 11 September 2013
Andrew, E., Gray, N., & Snowden, R. (2008). The relationship between trauma and beliefs
about hearing voices: A study of psychiatric and non-psychiatric voice hearers. Psycho-
logical Medicine, 38, 14091417.
Beavan, V., & Read, J. (2010). Hearing voices and listening to what they say: The impor-
tance of voice content in understanding and working with distressing voices. Journal of
Nervous and Mental Disease, 198, 201205.
Bentall, R. (2006). Madness explained: Why we must reject the Kraeplinian paradigm and
replace it with a complaint-orientatedapproach to understanding mental illness. Medi-
cal Hypothesis, 66, 220233.
Bentall, R.P., Wickham, S., Shevlin, M., & Varese, F. (2012). Do specic early-life adversi-
ties lead to specic symptoms of psychosis? A study from the 2007 The Adult Psychiat-
ric Morbidity Survey. Schizophrenia Bulletin. Advanced online publication. doi:10.1093/
Birchwood, M., Gilbert, P., Gilbert, J., Trower, P., Meaden, A., Hay, J., & Miles, J.N.
(2004). Interpersonal and role-related schema inuence the relationship with the domi-
nant voicein schizophrenia: A comparison of three models. Psychological Medicine,
34, 15711580.
British Psychological Society Division of Clinical Psychology. (2011). Good practice guide-
lines on the use of psychological formulation. Leicester: The Author.
Corstens, D., Escher, S., & Romme, M. (2008). Accepting and working with voices: The Maas-
tricht approach. In A. Moskowitz, I. Schafer, & M.J. Dorahy (Eds.), Psychosis, trauma and
dissociation: Emerging perspectives on severe psychopathology (pp. 319331). Oxford:
Corstens, D., Longden, E., & May, R. (2012). Talking with voices: Exploring what is
expressed by the voices people hear. PsychosisPsychological, Social and Integrative
Approaches, 4,95104.
Daalman, K., Diederen, K.M.J., Derks, E.M., van Lutterveld, R., Kahn, R.S., & Sommer,
I.E.C. (2012). Childhood trauma and auditory verbal hallucinations. Psychological
Medicine. Advance online publication. doi:10.1017/S0033291712000761
Dillon, J. (2011). The personal is the political. In M. Rapley, J. Moncrieff, & J. Dillon
(Eds.), De-Medicalizing misery: Psychiatry, psychology and the human condition
(pp. 141157). Eastbourne, UK: Palgrave Macmillan.
Dillon, J., & May, R. (2002). Reclaiming experience. Clinical Psychology, 17,2527.
Fisher, H.L., Craig, T.K., Fearon, P., Morgan, K., Dazzan, P., Lappin, J., & Morgan,
C. (2011). Reliability and comparability of psychosis patientsretrospective reports
of childhood abuse. Schizophrenia Bulletin, 546553.
Goodman, L., Thompson, K., Weinfurt, K., Corl, S., Acker, P., Mueser, K.T., & Rosenberg,
S.D. (1999). Reliability of violent victimization and PTSD among men and women with
serious mental illness. Journal of Traumatic Stress, 12, 587599.
Hardy, A., Fowler, D., Freeman, D., Smith, B., Steel, C., Evans, J., & Dunn, G. (2005).
Trauma and hallucinatory experience in psychosis. The Journal of Nervous and Mental
Disease, 193, 501507.
Intervoice. (2010, November 30). About Intervoice: The international network for train-
ing, education and research into hearing voices. Retrieved from November 30, 2010
Johnstone, L., & Dallos, R. (2013). Formulation in psychology and psychotherapy: Making
sense of peoples problems (2nd ed.). London: Brunner-Routledge.
Lommen, M.J.J., & Restifo, K. (2009). Trauma and posttraumatic stress disorder (PTSD) in
patients with schizophrenia or schizoaffective disorder. Community Mental Health Jour-
nal, 45, 485496.
Longden, E., Madill, A., & Waterman, M.G. (2012a). Dissociation, trauma, and the role of
lived experience: Toward a new conceptualization of voice hearing. Psychological Bulle-
tin, 138,2876.
Longden, E., Corstens, D., Escher, S., & Romme, M. (2012b). Voice hearing in biographical
context: A model for formulating the relationship between voices and life history.
Psychosis: Psychological, Social and Integrative Approaches, 4, 224234.
Psychosis 15
Downloaded by [Angela Woods] at 14:39 11 September 2013
Mawson, A., Berry, K., Murray, C., & Hayward, M. (2011). Voice hearing within the con-
text of the voice hearerssocial worlds: An interpretative phenomenological analysis.
Psychology and Psychotherapy: Theory, Research and Practice, 84, 256272.
McCarthy-Jones, S. (2011). Voices from the storm: A critical review of quantitative studies
of auditory verbal hallucinations and childhood sexual abuse. Clinical Psychology
Review, 31, 983992.
McCarthy-Jones, S. (2012). Hearing voices: The histories, causes and meanings of auditory
verbal hallucinations. Cambridge: Cambridge University Press.
Meyer, I., Muenzenmaier, K., Cancienne, J., & Struening, E. (1996). Reliability and validity
of a measure of sexual and physical abuse histories among women with serious mental
illness. Child Abuse and Neglect, 20, 213219.
Moskowitz, A., Read, J., Farrelly, S., Rudegeair, T., & Williams, O. (2009). Are psychotic
symptoms traumatic in origin and dissociative in kind? In P.F. Dell & J.A. ONeill
(Eds.), Dissociation and the dissociative disorders: DSM-V and beyond (pp. 521533).
New York, NY: Routledge.
Confederation, N.H.S. (2008). Brieng 162: Implementing national policy on violence and
abuse. London: National Health Service.
Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensori-motor approach
to psychotherapy. London: W.W. Norton.
Read, J., Agar, K., Argyle, N., & Aderhold, V. (2003). Sexual and physical abuse during
childhood and adulthood as predictors of hallucinations, delusions and thought disorder.
Psychology and Psychotherapy: Theory, Research Practice, 76(1), 123.
Read, J., van Os, J., Morrison, A., & Ross, C. (2005). Childhood trauma, psychosis and
schizophrenia: A literature review with theoretical and clinical implications. Acta Psychi-
atrica Scandinavica, 112, 330350.
Reiff, M., Castille, D.M., Muenzenmaier, K., & Link, B. (2011). Childhood abuse and the
content of adult psychotic symptoms. Psychological Trauma: Theory, Research, Practice,
and Policy. Advance online publication. doi:10.1037/a0024203.
Romme, M., & Escher, S. (2000). Making sense of voices. London: Mind.
Romme, M., Escher, S., Dillon, J., Corstens, D., & Morris, M. (Eds.). (2009). Living with
voices: Fifty stories of recovery. Ross-on-Wye: PCCS.
Ross, C.R., & Halpern, N. (2009). Trauma model therapy: A treatment approach for trauma
dissociation and complex comorbidity. Richardson, TX: Manitou Communications.
Shevlin, M., Murphy, J., Read, J., Mallett, J., Adamson, G., & Houston, J.E. (2011).
Childhood adversity and hallucinations: A community-based study using the National
Comorbidity Survey Replication. Social Psychiatry and Psychiatric Epidemiology, 46,
Stainsby, M., Sapochnik, M., Bledin, K., & Mason, O.J. (2010). Are attitudes and beliefs
about symptoms more important than symptom severity in recovery from psychosis?
Psychosis: Psychological Social and Integrative Approaches, 2,4149.
Thomas, P. & Longden, E. (2013). Madness, childhood adversity and narrative psychiatry:
caring and the moral imagination. Medical humanities. Advance online publication.
Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., Bentall,
R. (2012). Childhood trauma increases the risk of psychosis: A meta-analysis of
patient-control, prospective- and cross sectional cohort studies. Schizophrenia Bulletin,
38, 661671.
Woods, A. (2011). The limits of narrative: Provocations for the medical humanities. Medical
humanities, 37,7378.
Zubin, J., & Spring, B. (1977). Vulnerability: A new view of schizophrenia. Journal of
Abnormal Psychology, 86, 103126.
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... Phenomenological links between traumatic events and hallucinations have been studied several times (Corstens & Longden, 2013;Hamner, 1997;Hardy et al., 2005;Jessop, Scott, & Nurcombe, 2008;Mueser & Butler, 1987;Peach et al., 2020;Raune, Bebbington, Dunn, & Kuipers, 2006;Read & Argyle, 1999;Scott, Nurcombe, Sheridan, & McFarland, 2007). In the two most methodologically robust studies (Hardy et al., 2005;Peach et al., 2020), the authors developed coding frames to systematically investigate links between the phenomenology of trauma and hallucinations. ...
... These higher rates are likely attributable to the fact that multiple traumatic events and hallucinations were coded for links in the latter study. Corstens and Longden (2013) identified phenomenological links by asking voice-hearers to report on the identity of their voices and of their trauma perpetrators. They found that 45% of participants attributed the identity of their voice to an abusive family member and 23% to other perpetrators. ...
... Links between interpersonal trauma and voices were commonly observed by both participants and researchers, even when links were independently coded from separate ratings of trauma and voice phenomenology. The sample was larger than included in previous coding frame studies, and trauma-voice links were assessed more comprehensively than in prior research (Corstens & Longden, 2013;Hamner, 1997;Hardy et al., 2005;Jessop et al., 2008;Mueser & Butler, 1987;Peach et al., 2020;Raune et al., 2006;Read & Argyle, 1999;Scott et al., 2007). Namely, the descriptions of trauma and voices provided to researchers were formulated a priori and included at least identity, content, appraisals, and emotional and physiological-behavioural responses. ...
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Background Post-traumatic mechanisms are theorised to contribute to voice-hearing in people with psychosis and a history of trauma. Phenomenological links between trauma and voices support this hypothesis, as they suggest post-traumatic processes contribute to the content of, and relationships with, voices. However, research has included small samples and lacked theory-based comprehensive assessments. Method In people with distressing voices ( n = 73) who experienced trauma prior to voice-hearing, trauma–voice links were assessed both independently and dependently (descriptions were presented and rated separately and together, respectively) by both participants and researchers. A structured coding frame assessed four types of independent links (i.e. victimisation type, physiological-behavioural, emotional, and cognitive response themes including negative self-beliefs) and three types of dependent links: relational (similar interaction with/response to, voice and trauma); content (voice and trauma content are exactly the same); and identity (voice identity is the same as perpetrator). Results Independent links were prevalent in participants (51–58%) and low to moderately present in researcher ratings (8–41%) for significant themes. Identification of negative self-beliefs in trauma was associated with a significantly higher likelihood of negative self-beliefs in voices [participants odds ratio (OR) 9.8; researchers OR 4.9]. Participants and researchers also reported many dependent links (80%, 66%, respectively), most frequently relational links (75%, 64%), followed by content (60%, 25%) and identity links (51%, 22%). Conclusion Trauma appears to be a strong shaping force for voice content and its psychological impact. The most common trauma–voice links involved the experience of cognitive-affective psychological threat, embodied in relational experiences. Trauma-induced mechanisms may be important intervention targets.
... A recent systematic review also found that negative cognitions about the self, the world and others (as seen in internal and external shame experiences) were a well evidenced mediator between childhood trauma and voice hearing (Williams et al., 2018). Also in line with the notion of a link between shame and voice hearing, the content of voices often reflects themes of shame (Corstens and Longden, 2013) and appears to be shaped by past interpersonal trauma (Hardy et al., 2005). ...
... In support of this, there is evidence that intrusive trauma memories are associated with voice hearing experiences and proneness to voices (Brand et al., 2020a;Bortolon and Raffard, 2019;Gracie et al., 2007;Peach et al., 2019). Given the prominent themes of shame in voice hearing content (Corstens and Longden, 2013), and evidence of the involvement of shame-related emotions and cognitions, we propose that the characteristics of shame memories may also be a relevant mechanism in voice hearing. ...
Background Voice hearing occurs across a number of psychiatric diagnoses and appears to be present on a continuum within the general population. Previous research has highlighted the potential role of past experiences of shame in proneness to voice hearing in the general population. Aims This study aimed to extend this past research and compare people with distressing voices, people with voices but no distress, and a non-voice hearing control group, on various dimensions of shame and shame memory characteristics. Method In a cross-sectional, online study 39 distressed voice hearers, 31 non-distressed voice hearers and 50 non-voice hearers undertook a shame memory priming task in which they were prompted to recall a memory of a shaming experience from their past. They then completed questionnaires assessing the characteristics of the recalled shame event and the psychological sequalae of this event (i.e. intrusions, hyperarousal, avoidance, the centrality of shame memories, external shame, and self-criticism). Results The majority of recalled shame memories involved experiences such as interpersonal criticism or experiences of being devalued. Univariate analyses found no significant differences between the three groups with regard to the shame events that were recalled, but the distressed voice hearer group reported significantly more hyperarousal, intrusions, self-criticism, and external shame in relation to their experience. Conclusions The findings suggest that voice hearers recall similar types of shame experiences to non-voice hearers, but that problematic psychological sequelae of these shame experiences (in the form of intrusive memories, hyperarousal, external shame, and self-criticism) may specifically contribute to distressing voice hearing.
... Traditionally, fine-grain phenomenological studies of agents in psychosis have used qualitative analysis of open-ended interview transcripts (e.g., Beavan, 2011;Corstens & Longden, 2013) or approaches from phenomenological philosophy (e.g., Humpston & Broome, 2015;Larøi, Haan, Jones, & Raballo, 2010). Both are important but, by design, rely on systematic but subjective analyses that may mean the findings are not reproducible to the same degree as quantitative analyses. ...
... The male third person singular pronoun 'he' was more frequent in both vocal social agents and nonvocal social agents than the female equivalent 'she'. This finding is line with the results of previous voice hearing studies, which found that although participants report hearing male, female, and children's voices, the identity of voices was frequently described as male (Corstens & Longden, 2013;McCarthy-Jones et al., 2014). ...
Full-text available
Objectives: Psychosis has a strong social component and often involves the experience of being affected by 'illusory social agents'. However, this experience remains under-characterized, particularly for social agents in delusions and non-vocal hallucinations. One useful approach is a form of computational linguistics called corpus linguistics that studies texts to identify patterns of meaning encoded in both the semantics and linguistic structure of the text. Methods: Twenty people living with psychosis were recruited from community and inpatient services. They participated in open-ended interviews on their experiences of social agents in psychosis and completed a measure of psychotic symptoms. Corpus linguistics analysis was used to identify key phenomenological features of vocal and non-vocal social agents in psychosis. Results: Social agents i) are represented with varying levels of richness in participants' experiences, ii) are attributed with different kinds of identities including physical characteristics and names, iii) are perceived to have internal states and motivations that are different from those of the participants, and iv) interact with participants in various ways including through communicative speech acts, affecting participants' bodies, and moving through space. These representations were equally rich for agents associated with hallucinated voices and those associated with non-vocal hallucinations and delusions. Conclusions: We show that the experience of illusory social agents is a rich and complex social experience reflecting many aspects of genuine social interaction and is not solely present in auditory hallucinations, but also in delusions and non-vocal hallucinations. Practitioner points: The experience of being affected by illusory social agents in psychosis extends beyond hallucinated voices. They are a rich and complex social experience reflecting many aspects of genuine social interaction. These are also likely to be a source of significant distress and disability.
... A recent study found that people whose trauma experiences were characterized by significant childhood sexual, physical and emotional abuse reported higher amounts of negative voice content (as compared to those with emotion-focused, or no trauma; Begemann et al., 2021). Important parallels between the type of traumatic events that people have experienced and the specific content of their voices have also been noted (Corstens & Longden, 2013;Hardy et al., 2005). Experiences of childhood trauma have a number of psychological impacts, which may play a role in negative voice content. ...
Full-text available
Objective: People who experience distressing voices frequently report negative (e.g. abusive or threatening) voice content and this is a key driver of distress. There has also been recognition that positive (e.g. reassuring, or guiding) voice content contributes to better outcomes. Despite this, voice content has been neglected as a standalone outcome in evaluations of psychological therapies for distressing voices. We aimed to examine whether a modular cognitive-behavioural therapy (CBT) intervention for voices led to changes in negative and positive voice content. Design/methods: In a naturalistic, uncontrolled pre- and post- service evaluation study, 32 clients at an outpatient psychology service for distressing voices received eight sessions of CBT for distressing voices and completed self-report measures of negative and positive voice content at pre-, mid- and post- therapy. Results: There was no significant change in positive voice content. There was no significant change in negative voice content from pre- to post-therapy; however, there was a significant change in negative voice content between mid and post-treatment in which the cognitive therapy component was delivered. The CBT treatment was also associated with significant changes in routinely reported outcomes of voice-related distress and voice severity. Conclusions: The cognitive component of CBT for distressing voices may be associated with changes in negative, but not positive, voice content. There may be benefit to enhancing these effects by developing treatments targeting specific processes involved in negative and positive voice content and further exploring efficacy in well-powered, controlled trials with more comprehensive measures of voice content.
... En nuestra opinión, la literatura que hemos revisado reafirma la necesidad que ya apuntaban Read et al. (2005) de incluir sistemáticamente las experiencias traumáticas en la infancia en la evaluación de las personas que presentan síntomas psicóticos. Asimismo, el estudio del papel de la historia de experiencias traumáticas en la infancia nos parece que resalta que los síntomas psicóticos deben ser valorados como fenómenos enraizados en la biografía de las personas; es decir, como comportamientos que tienen un sentido y una función idiosincráticos (p.ej., Colina, 2001;Geekie y Read, 2012;Corstens y Longden, 2013;Romme y Escher, 2012). En esta línea, Longden et al. (2012) ya habían planteado, si bien centrándose en las alucinaciones auditivas, la necesidad de un cambio en la conceptualización de los síntomas psicóticos, debido a su falta de especificidad diagnóstica al estar en un continuo con el funcionamiento normal y la disociación. ...
Full-text available
En los últimos veinte años, el interés por el estudio de las variables contextuales en el desarrollo de la psicopatología ha desembocado en la aparición de múltiplesinvestigaciones. Algunas de ellas se han centrado en el estudio del desarrollo de lapsicosis, encontrando una relación con la exposición durante la infancia aacontecimientos traumáticos. El presente trabajo trata de recoger la evolución deestas investigaciones en los últimos diez años, así como establecer si ciertos tipos de traumas determinan la aparición de síntomas psicóticos específicos. Examinamos también la existencia de diferentes variables mediadoras y moduladoras de esta relación. Posteriormente, se discuten las implicaciones clínicas derivadas de dichos hallazgos en la literatura revisada.
Despite the clinical and theoretical importance of the negative content in auditory verbal hallucinations (AVHs), little research has been conducted on the topic. A handful of studies suggest that trauma or adverse life events contribute to negative content. The findings are somewhat inconsistent, however, possibly due to methodological limitations. Moreover, only trauma occurring in childhood has been investigated so far. In the present study, we studied the effect of abuse, experienced in either child- or adulthood, and clinical status on negative content of AVHs in four groups of participants that were assessed as part of a large, previously published online survey: Individuals with a psychotic disorder and AVHs (total n = 33), who had experienced abuse (n = 21) or not (n = 12) as well as a group of healthy individuals with AVHs (total n = 53), who had experienced abuse (n = 31) or not (n = 22). We hypothesized that having experienced abuse was associated with a higher degree of negative content. The clinical group collectively reported significantly higher degrees of negative AVHs content compared to the healthy group, but there was no effect of abuse on the degree of negative AVHs content. The presence of AVHs was more common amongst individuals who reported a history of abuse compared to individuals with no history of abuse, both in clinical and healthy participants with AVHs. This implies that at group level, being subjected to traumatic events increases an individual's vulnerability to experiencing AVHs. However, it does not necessarily account for negative content in AVHs.
Background The study explored the extent to which a sample of clinical psychologists in Early Intervention Psychosis (EIP) services routinely investigated trauma with clients. Method A novel vignette-semi-structured telephone interview approach was used. To avoid limiting conceptualisations of these phenomena, for example, by solely considering trauma as a contributory or aetiological factor in psychosis, the study was designed to allow wider exploration of relationships and other key factors. Results The majority of the sample reported routine investigation of severe adversity, abuse, or trauma (AAT) with clients, assuming broad definitions. Assessment procedures were collaborative and client-led. An appropriate context was deemed necessary before trauma was explored, including engagement and a psychologically safe environment. The overall findings highlighted explicit investigation of, broadly defined, trauma-related issues within heterogeneous approaches to working with psychosis. Discussion While trauma was one key factor, links with psychosis were complex in practice. Participants appeared to operate within a more complex understanding of psychosis than researchers may sometimes be willing to promote.
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Social work aims to promote human wellbeing through “social change, problem solving in human relationships and the empowerment and liberation of people” (AASW, 2010, p. 7). To achieve these aims, it is important to consider the various power dynamics within society. Much of the current research in the mental health field is examining the link between power imbalances and psychological distress (Johnstone et al., 2018; Morley, 2003). Understanding power, however, is fraught with complexities, and understanding power within a social work and social justice context is further complicated. The intersectionality of mental health, biomedical discourse, power dynamics and issues arising from transitioning from care (whilst acknowledging the young person’s experiences in care and prior to care) is similarly complex, and confusion around the social workers’ role understandably reflects this. This paper argues that if we acknowledge and work with the positive power that exists, we can challenge current discourses that utilise negative power, and together we can create better outcomes for care leavers.
Silvano Arieti is known for his comprehensive psychodynamic and biological theory of schizophrenia and mental illness. His writings continue to inform modern psychiatric theory and psychotherapeutic approaches to schizophrenia.
Many mental phenomena involve thinking about people who do not exist. Imagined characters appear in planning, dreams, fantasizing, imaginary companions, bereavement hallucinations, auditory verbal hallucinations, and as characters created in fictional narratives by authors. Sometimes these imagined persons are felt to be completely under our control, as when one fantasizes about having a great time at a party. Other times, characters feel as though they are outside of our conscious control. Dream characters, for example, are experienced by dreamers as autonomous entities, and often do things that frighten and surprise dreamers. Some imagined persons, such as characters in fiction, start off under conscious control of the author, but over time, can appear to gain an illusion of independent agency. I propose an explanation for different autonomy attributions: characters are by default non-autonomous, unless their personalities are well-practiced. Characters become autonomous because modeling their thinking has become automatized, like many other well-practiced activities.
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Hearing Voices: The Histories, Causes and Meanings of Auditory Verbal Hallucinations By Simon McCarthy-Jones Cambridge University Press. 2012. £65.00 (hb), 472pp. ISBN: 9781107007222 Hearing voices or having auditory verbal hallucinations and delusions is emblematic of psychosis. There is a sense
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The dominance of technological paradigms within psychiatry creates moral and ethical tensions over how to engage with the interpersonal narratives of those experiencing mental distress. This paper argues that such paradigms are poorly suited for fostering principled responses to human suffering, and proposes an alternative approach that considers a view of relationships based in feminist theories about the nature of caring. Four primary characteristics are presented which distinguish caring from technological paradigms: (1) a concern with the particular nature of contexts, (2) embodied practice, (3) the dialogical basis of caring and (4) the existential basis of caring. From this we explore the role of the moral imagination and our ability, through narrative, to acknowledge, engage with and bear witness to the injustices that shape the lives of those who suffer. This, we argue, is at the heart of caring. Clinical implications are discussed, including an exposition of the importance of narrative in recovery from trauma and distress. Narrative Psychiatry, The Sanctuary Model of care, and Soteria, are outlined as examples of this type of practice.
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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, 198930. Stone , H. and Stone , S. 1989 . Embracing our selves: The voice dialogue training manual , New York , NY : Nataraj Publishing . View all references: 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.
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High rates of childhood abuse (CA) have been reported among people with severe mental illness, but the content of psychotic symptoms is not generally considered pertinent to diagnosis and treatment. This study explores associations between CA and the content of adult psychotic symptoms. A sample of 30 respondents was selected from a larger study of individuals interviewed using standardized and open-ended questions to assess history of CA, and to elicit content of hallucinations and delusions (HD). Interviews included detailed descriptions of psychotic symptoms and CA experiences, which were coded using qualitative techniques. Based on a review of the research, we constructed a measure comprising nine categories of symptom content found to occur among individuals reporting CA (Threat, Somatic/Tactile, Olfactory, or Kinetic sensations, Real person involved, Fear, Malevolence, Sexuality, and Memories). This “trauma-relevant content score” was used to compare abused and nonabused groups, and was found to be higher among abused than nonabused respondents. Additionally, we examined parallels between interpersonal relationships described in HD and those experienced in the context of childhood trauma, using a multiple case study approach, and drawing on the Core Conflictual Relationship Theme (CCRT) method of analysis. Congruent patterns of interaction were identified in trauma and symptom descriptions of abused respondents. Implications for research and clinical practice include identifying symptom characteristics relevant to CA history, and developing a strategy to assess correspondence between individuals' trauma and symptom reports. Identification of trauma-relevant characteristics in symptom content can provide clinicians with an effective means of recognizing trauma-related illness. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The recognition that the personal cannot, ever, be other than politically developed from the women’s liberation movement of the 1960s (Hanish, 1970). It was an acknowledgment that the experiences, feelings and possibilities of our personal lives are not just a private matter of personal preferences and choices but are limited, moulded, defined and delimited by the broader political and social context. They feel personal, and their details are personal, but their broad texture and character, and especially the limits within which these evolve, are largely systemic. This concept is very relevant to contemporary mental health but, before looking at the political, I need to start with the personal. I would like to go back, right to the very beginning.
The meanings and causes of hearing voices that others cannot hear (auditory verbal hallucinations, in psychiatric parlance) have been debated for thousands of years. Voice-hearing has been both revered and condemned, 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 just people with unusual experiences, and have been beatified, esteemed or accepted, as well as drugged, burnt or gassed. This book travels from voice-hearing in the ancient world through to contemporary experience, examining how power, politics, gender, medicine and religion have shaped the meaning of hearing voices. Who hears voices today, what these voices are like and their potential impact are comprehensively examined. Cutting edge neuroscience is integrated with current psychological theories to consider what may cause voices and the future of research in voice-hearing is explored.
Essay review of Reclaiming Reality, by Roy Bhaskar, London: Verso, 1989, 218 pages, pb £10.95.
Objective. Both beliefs about mental health experiences (“illness perceptions”) and psychological adjustment (“recovery style”) have been found to predict outcome in psychosis. This study tested the hypothesis that recovery style mediates the relationship of such beliefs with outcome.Methods. Fifty people experiencing psychosis were assessed on measures of illness perceptions, recovery style, symptom severity, engagement, impairment, and quality of life at two time points two years apart.Results. Recovery style did not appear to mediate the relationship between beliefs about mental health problems and outcome. However, expectations of more negative consequences and lower ability to make sense of symptoms were associated with poorer quality of life.Conclusions. Interventions that support recovery by reducing expectations of negative impact of psychosis and helping clients to build a more coherent sense of their difficulties, via exploration of the personal life meanings of a person’s “illness” or psychotic experience, may be at least as important as interventions that aim to reduce symptom levels.