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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,
UK.
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:
10.1080/17522439.2013.816337
To link to this article: http://dx.doi.org/10.1080/17522439.2013.816337
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The origins of voices: links between life history and voice hearing
in a survey of 100 cases
Dirk Corstens
a
* and Eleanor Longden
b
a
Psychiatrist and psychotherapist, RIAGG Maastricht, Maastricht, The Netherlands;
b
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
voice-hearers
1
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: d.corstens@riagg-maastricht.nl
Psychosis, 2013
http://dx.doi.org/10.1080/17522439.2013.816337
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.
Methodology
Participants
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.
Procedure
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)
Gender
Female 57
Male 43
Ethnicity
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
voices.
(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
expectations.
(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
unclear.
(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
unclear.
Results
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
Age
Child voices (< 13 years) 19
Adolescent voices (1318 years) 10
Adult voices 94
Unknown 21
Gender
Female 66
Male 83
Without gender 30
Name
All voices named 46
No voices named 32
Mix of named and unnamed voices 22
Characteristics of
voices Utterances
Verbal 100
Non-verbal 17
Affect
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
Perspective
Voices speak in 2
nd
person 97
Voices speak in 3
rd
person 66
Voices speak in 1
st
person 42
Combination of 1
st
,2
nd
and 3
rd
33
Combination of 2
nd
and 3
rd
33
2
nd
person only 20
Combination of 1
st
and 2
nd
1
Personication
Voice of a family member 47
Voice of a known acquaintance 47
Ones own voice 28
Religious/spiritual framework 14
Paranormal framework 2
(Continued)
Psychosis 7
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Table 3. (Continued ).
Construct theme Areas of enquiry
% endorsed
(N= 100)
Content
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
Triggers
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
onset
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
(Continued)
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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
Non-abusive
acquaintance
32
Male friend or
acquaintance
25
Female friend or
acquaintance
20
Non-abusive family
member
30
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
perpetrator
12
Unidentiable 22
Social and emotional problems
represented by the voices Problems with self-esteem 93
Anger 60
Shame and guilt 60
Attachment and intimacy
difculties
45
Conict over sexual
identity
7
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%).
Discussion
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
names?
(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?
12 D. Corstens and E. Longden
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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).
Limitations
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.
Conclusions
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.
Acknowledgements
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.
Note
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).
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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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... 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. ...
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... 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). ...
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... 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. ...
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... 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. ...
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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.
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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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