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Making sense of voices

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Psychological, Social and Integrative Approaches
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Voice hearing in a biographical context: A model
for formulating the relationship between voices
and life history
Eleanor Longden , Dirk Corstens , Sandra Escher & Marius Romme
To cite this article: Eleanor Longden , Dirk Corstens , Sandra Escher & Marius Romme (2012)
Voice hearing in a biographical context: A model for formulating the relationship between voices
and life history, Psychosis, 4:3, 224-234, DOI: 10.1080/17522439.2011.596566
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Voice hearing in a biographical context: A model for formulating
the relationship between voices and life history
Eleanor Longden
, Dirk Corstens
*, Sandra Escher
and Marius Romme
Institute of Psychological Sciences, University of Leeds, Leeds, UK;
RIAGG Maastricht,
Maastricht, The Netherlands;
City University of Birmingham, Birmingham, UK
(Received 5 May 2011; nal version received 30 May 2011)
Growing evidence suggests a meaningful association between life experience,
particularly trauma and loss, and subsequent psychotic symptomatology. This
paper describes a method of psychological formulation to analyse the relation-
ship between the content and characteristics of voices (auditory hallucinations)
and experienced adversity in the life of the voice-hearer. This systematic process
of enquiry, termed a construct, is designed to explore two questions: (1) who or
what might the voices represent; and (2) what social and/or emotional problems
may be represented by the voices? The resulting information provides the basis
for an individualized psychotherapeutic treatment plan that examines the inu-
ence of interpersonal stress in creating vulnerability for emotional crises (i.e.
psychological predisposition) and the personally signicant events that cluster
before onset or relapse (i.e. the actual stressors which provoke voice onset or
continuance). A case example using this method is presented.
Keywords: trauma; hallucinations; hearing voices; psychotherapy; formulation
Psychological case formulation, an explanatory synthesis of the origin and nature of
presenting difculties, is a routine strategy within clinical psychology (Sturmey,
2009). It is increasingly regarded as good practice to apply this framework to
patients with psychosis due to its capacity for informing treatment and careplan
development, and potentially assisting individuals to devise more coherent, inte-
grated accounts of their experiences (Johnstone & Dallos, 2006; Jackson et al.,
2009). Formulation procedures may be particularly constructive for clients who do
not desire psychotherapy, in that simply establishing links between life events and
previously incomprehensible symptomscan provide a framework to integrate
traumatic, unassimilated experiences into existing representational structures
(Corstens, Escher & Romme, 2008; Fowler, 2000; Moskowitz & Corstens, 2007;
Moskowitz, Read, Farrelly, Rudegeair, & Williams, 2009; Romme & Escher, 2000,
2010; Suri, 2010). The importance of developing such explanatory frameworks has
also been addressed within the more general rubric of psychological adjustment fol-
lowing psychotic breakdown, and there is some evidence to suggest that individuals
who see mental health problems as originating from themselves, relevant to their
life context, and a source of potentially formative guidance about social and
*Corresponding author. Email:
Vol. 4, No. 3, October 2012, 224234
ISSN 1752-2439 print/ISSN 1752-2447 online
Ó2012 Taylor & Francis
emotional predicaments may have better long-term outcomes than those perceiving
psychosis as a globally damaging, causally independent disruption to their life (e.g.
McGlashan, 1987; Startup, Wilding & Startup, 2006; Tait, Birchwood & Trower,
2003, 2004). For example, Brett et al. (2007) examined differences in appraisals,
and contextual and response variables to anomalies associated with psychosis
between patients diagnosed with psychosis (n = 35), individuals meeting criteria for
an at-risk mental state(n = 21), and a non-clinical group experiencing Schneideri-
an-type symptoms of schizophrenia, including voices commenting or conversing
(n = 35). Amongst other results, the authors found that the non-patient, non-dis-
tressed population was more likely to use (psychological) frameworks to appraise
their experiences that were subjectively coherent and adaptive(p. 29), whereas
the other two samples were signicantly more likely to make causal attributions that
were beyond their individual control (in this case, biology). On face value, these
results do not permit rm conclusions to be drawn about causality, as the clinical
group might be reasonably expected to see themselves as ill. However, a more
detailed study by Stainsby, Sapochnik, Bledin, and Mason (2010), assessing illness
perceptions, symptom severity and social impairment amongst 50 adults diagnosed
with psychotic syndromes, found that a lower capacity to make sense(p. 41) of
symptoms (as assessed by the Illness Perceptions Questionnaire for Schizophrenia)
was associated with a poorer quality of life two years from baseline. The authors
concluded that interventions which promote recovery by helping clients to build a
more coherent sense of their difculties, via exploration of the personal life mean-
ings of ... psychotic experience, may be at least as important as interventions that
aim to reduce symptom levels(p. 41). Such ndings are congruent with emerging
(often user-led) denitions of recovery from psychosis that emphasize ownership,
personal meaning, hope and empowerment rather than passive concepts of mental
disease (e.g. Geekie, Lampshire, Randal & Read, 2011; Geekie & Read, 2009;
Romme, Escher, Dillon, Corstens, & Morris, 2009).
Formulating the voice hearing experience
Epidemiological research has demonstrated that voice hearing (VH) is not the sole
province of psychiatric patients, instead existing on a dimensional, experiential con-
tinuum within the general population (e.g. Johns et al., 2004; Van Os, Hanssen, Bijl
& Ravelli, 2000). Furthermore, prevalence rates across different subgroups appear
to be more inuenced by environmental and social factors than a categorical pres-
enceor absenceof psychopathology (Beavan, Read & Cartwright, 2011). This
paper does not presume to account for the origins of VH experiences per se, but
rather for a specic group of distressed voice-hearers, often presenting to psychiatric
services, and with a history of exposure to adverse events. Correspondingly, while
the robust associations between VH and adversity (particularly, although not exclu-
sively, childhood sexual abuse) is often mentioned in clinical literature (e.g. Gracie
et al., 2007; Lysaker, Buck & LaRocco, 2007; Read, Agar, Argyle & Aderhold,
2003; Read, van Os, Morrison & Ross, 2005; Romme, 2011; Romme & Escher,
2000, 2006, 2010; van Os & Tamminga, 2007) to our knowledge no method for
systematically elucidating the links between voice content and life experience is
currently practised in the eld of psychotic disorders. For example, whilst cognitive
approaches to case formulation (e.g. Chadwick & Birchwood, 1994; Morrison,
Nothard, Bowe & Wells, 2004; Trower, Birchwood & Meaden, 2010) advocate
Psychosis 225
exploring intellectual and emotional appraisal of ones voices, specic characteris-
tics, dialogical function, and associations between voice presentation and (changing)
psychosocial circumstances are generally not fully accounted for.
We will describe a clinical strategy for addressing the personal relationship
between distressing life events and certain characteristics of the voice(s) a person
hears. This process of systematic enquiry is based on two theoretical and clinical
Stress-vulnerability. Heightened emotional reactivity is considered central to
the constitutional diathesis of the stress-vulnerability model (Nuechterlein &
Dawson, 1984). However, the aetiology of stress-vulnerability should not be
seen as an inevitable biogenetic phenomenon, rather potentially acquired as a
result of early trauma and stress exposure (Lardinois, Lataster, Mengelers,
van Os, & Myin-Germeys, 2011; Read, Perry, Moskowitz, & Connolly, 2001;
Van Os, Kenis, & Rutten, 2011). Therefore VH onset may potentially be
understood by differentiating between: (1) the inuence of interpersonal trau-
mas in creating vulnerability for emotional crisis (i.e. psychological predispo-
sition); and (2) the personally signicant events that cluster before onset or
relapse (i.e. the actual stressors which provoke voice onset or continuance:
see Romme & Escher, 2010).
Phenomenology. In terms of distressed voice-hearers and/or those requiring
psychiatric assistance, research suggests that acute anxiety, or the reactiva-
tion of past stress, is: (1) associated with VH in a sizeable number of cases
(e.g. Read et al., 2005; Romme & Escher, 1989; Shevlin et al., 2010; Whit-
eld, Dube, Felitti, & Anda, 2005); (2) that distressing, negative interpreta-
tions of initial VH experiences may predict subsequent psychopathology
(e.g. Bak et al., 2005a; Chadwick & Birchwood, 1994; Morrison et al.,
2004); and (3) that such appraisals are most likely to be made by individu-
als with a history of trauma or stress exposure (e.g. Andrew, Gray, & Snow-
den, 2008; Bak et al., 2005b; Chisholm, Freeman & Cooke, 2006). Indeed,
available literature suggests that the conceptual and clinical ubiquity of VH
experiences in different psychotic and trauma-spectrum conditions means
that VH may be linked to adverse life experiences per se rather than to a
particular DSM diagnosis (e.g. Honig et al., 1998; Kingdon et al., 2010;
Moskowitz & Corstens, 2007; Moskowitz et al., 2009; Scott, Nurcombe,
Sheridan, & McFarland, 2007).
The Maastricht Approach of Romme and Escher (e.g. 1993, 2000) endorses psycho-
logical therapy and self-help methods to interpret and decipher the problems VH
may represent. In order to understand the possible biographical dynamics of VH,
Romme and Escher (2000) advocate devising a construct: a dynamic, psychosocial
formulation that explores possible interpretations of the original situation that
prompted voice emergence. From this perspective, VH is understood as a (distorted)
reection of conictual situations harbouring certain personal themes: a manifesta-
tion of a vital defensive manoeuvre whereby transforming emotional conict into
voices is psychologically advantageous. An important objective for working in this
way is not eradication or cure, but to discover ways to cope both with the voices
and emotions which evoked their presence. Indeed, understanding, accepting and
resolving relevant social-emotional dilemmas can be seen as a valuable therapeutic
226 E. Longden et al.
goal, in that attaining mastery over adverse experiences is an important part of
recovery not only from distressing voices (Romme, 2011; Romme & Escher, 2010)
but from mental health problems more generally (Young & Ensing, 1999). For
example, an analysis of 50 recovery stories by Romme et al. (2009) demonstrates
how, at least for some voice-hearers, establishing, validating and exploring links
between life events and distressing voices provides a promising avenue for support-
ing and promoting the recovery process. Similarly, research by Beaven (2011), Bea-
van and Read (2010) and Fenekou and Georgaca (2010) illustrates how many
voice-hearers experience personal meaning in voice content, and that this informa-
tion is of potential therapeutic benet.
Making a construct
Our approach follows the established principles to clinical formulation elaborated
by Johnstone and Dallos (2006), in that the process is: tentative; collaborative; ame-
nable to constant re-formulation; incorporates systemic, social and/or political fac-
tors; and respects and defers to client views on its truthfulness and expediency.
While formulation does not have to be correct, it does have to be useful (Butler,
Table 1. Exploratory themes used to devise a construct.
Exploratory theme
Identity of the
Enquire about the character of each voice that the person hears, such
as name, gender and age (if known and/or applicable). If the voices
are very numerous, ask the person to devise groups and describe
them collectively.
Characteristics and
Identify how each voice talks (e.g. shouting, whispering, screaming)
and if they are especially benevolent or malevolent. How do the
voices relate to one another? Is there a hierarchy between them?
What do they actually say: ask for specic and literal phrases. Can
the voice-hearer identify people from the past or present who
behaved or spoke in a similar fashion? If so, this may provide
indications of individuals who are represented by the voices and/or
were implicated in the adverse experience(s).
Triggers What situations and emotions provoke the voices and how do they
respond? Certain feelings can make the voices more active (e.g.
shame, guilt, anger, anxiety, sexual feelings). Alternatively they may
be elicited by the presence of specic people (e.g., family members),
or being in a particular context or environment (e.g., social
situations). Again, this may refer to the circumstances and themes
related to VH emergence.
History of the
What was happening in the persons life when each voice appeared
for the rst time? Did particular circumstances evoke overwhelming
emotions or conicts? How did the voice(s) develop afterwards in
terms of content and inuence?
Childhood history The voice-hearers unique biography carries vital communication
about the course and content of his/her distress. What occurred in
his/her life before he/she heard voices? Childhood experiences may
inuence personality development and determine resilience and
coping strategies in adulthood. What interpersonal vulnerabilities can
be inferred from early relationship development (e.g. attachment
organization and/or traumatic events)?
Psychosis 227
1998). Thus it is important that voice-hearers feel acknowledged during the process
and that their experiences are conceptualized in a coherent, personal account that
makes sense to them. In this respect, clinicians should remain mindful and reexive
about any pre-existing values or assumptions they may bring to the procedure
(Johnstone & Dallos, 2006).
In our experience, many individuals nd it liberating and validating to be
respectfully questioned about their voices. Although some are unable (or unwilling)
to acknowledge underlying difculties, we have found that a systematic exploration
of relevant information may reveal both the persons psychosocial vulnerabilities
and the contextual circumstances that originally provoked VH. In this respect, we
refer to the psychodynamically informed approach of Gareld (1995), who endorses
a similar emphasis on the role of emotion and analysis of circumstances in which
symptoms rst appeared: Unbearable affect reaches its peak in the precipitating
event ... a situation that carries a burden to the patient that cannot be coped with
by ... [their] usual methods ... [L]ike the news reporter, the clinician is interested
in who, what, why, where, when, and how(pp. 3133).
We advocate a methodical, collaborative approach towards this search for mean-
ing, because the presence of VH suggests that painful emotions may potentially
evoke sensations and memories relating to the original adverse experience(s).
Before commencing, it is therefore important to develop a relationship with the
client by demonstrating a broader, compassionate interest in their his/her life and
difculties. We often nd it benecial to provide positive examples of other voice-
hearers in order to motivate the person to talk about his/her voices (e.g. information
about voice-hearers who never entered the mental health system and/or learned to
cope with their experiences).
It generally takes around 90 minutes to conduct construct interviews. In order to
organize the required information, ve specic themes are examined. These ques-
tions, adapted from the Maastricht Hearing Voices Interview (MI: Romme &
Escher, 2000), are exploratory queries for structuring information gathering (see
Table 1). Developed on the basis of numerous interviews with voice-hearers
(Romme & Escher, 1989, 1993, 2000), these categories are based on the hypothesis
that VH characteristics are personally signicant to the voice-hearer, and as such
are related to aspects of their life history.
On concluding the interview, the therapist writes a report summarizing the
formulation and presents it to the voice-hearer, who is asked to read and com-
ment on it to clarify omissions or misunderstandings. We have often found
that the actual process of interviewing for a construct may have a therapeutic
side effect, in that participation can help overcome the emotional and/or cog-
nitive avoidance that is common in many voice-hearers. Furthermore, having a
written report of their lived experiences can act as an incentive for individuals
to begin discussing their stories more fully, identifying practical and social
issues hindering recovery, and exploring new coping strategies (both with the
voices themselves, as well as associated emotional and social dilemmas).
The resulting information is then used to explore two fundamental questions
about representation in order to formulate the construct:
(1) Who might the voices represent
Voices may often resemble the identity and/or characteristics of signicant individu-
als in the life of the voice-hearer, in either a literal or metaphorical way (e.g. as
228 E. Longden et al.
The Devil, or a female perpetrator represented as a male voice). Similarly, they
may symbolize aspects of the voice-hearer themselves and/or specic, intolerable
emotions that inuenced VH onset and continuance.
(2) What problems may the voices represent
This question explores circumstances at the root of the VH experience generally
problems, situations and events that were so overwhelming that they exceeded the
ability to cope. What kind of social-emotional dilemmas can be identied that deter-
mined the voice-hearers vulnerability at the moment the voices began?
In clinical terms, the answers to these questions are used to formulate a treat-
ment plan. Generally, this follows a stage model of healing and recovery (e.g. Her-
man, 1992; May, 2004; Romme & Escher, 1993) in terms of: establishing safety
(coping with the most challenging aspects of the voices); making sense of ones
experiences (using voices as clues to internal emotional conicts); and social recon-
nection (working through experiences that have been difcult to integrate and
accept). Although beyond the scope of this paper, we refer to Corstens et al. (2008)
and Romme and Escher (2000).
Case example
To prevent recognition, a pseudonym has been used and some biographical details
changed. The individual concerned has seen this account of her story and given per-
mission to have it reproduced.
Laura, a 21-year old woman living in supported accomodation, had a diagnosis of
paranoid schizophrenia. She was prescribed neuroleptic medication, which failed to
mitigate the voices and resulted in distressing adverse effects.
Identity of the voices. Laura heard 12 voices. The most dominant, Satan, was
male and aged around 22. The second voice, Aurora, was female and aged
around 30. Laura collectively described the remaining ten voices as The Chorus.
These voices were genderless and had no names or ages.
Characteristics and content. Satan was menacing and aggressive, instructing
Laura to kill herself, and to stab, bite, burn and chokeother people. It predicted
ominous events that Laura would be powerless to preventand referred to her by
degrading names like the bitch. In contrast, the voice of Aurora was benevolent
and supportive, and provided reassurance and advice (e.g. everything will be ne,
you will get through this). Aurora and Satan did not interact with one another.
Finally, The Chorus was belittling, threatening and offensive. They often concurred
with Satans predictions, although could also argue with him about the best way of
punishingLaura. Laura was unwilling to disclose the exact content of The Cho-
russpeech, as she felt so ashamed of their coarse, insulting comments.
Triggers. Laura heard Satan constantly, although he was particularly intrusive
when she was feeling angry or depressed. Aurora appeared whenever Laura felt
sad or hopeless. Finally, The Chorus was triggered when Laura was in social situ-
ations, as well as by feelings of guilt and shame, both about herself and on other
peoples behalf.
Psychosis 229
History of the voices. Laura rst heard Satan and Aurora aged eight. Aurora
was named after the heroine in the animated lm Sleeping Beauty to reect her
serenity and gentleness. She always sounded older and more mature than Laura.
Satans original name was Georgeand he always remained one year older than
Laura. The name related to Enid BlytonsFamous Five novels (a popular series of
English childrens books) wherein the character, George, although female, is bold,
assertive and tenacious. Laura could cope well with the voices and never disclosed
their presence. Two years ago, Laura was raped by a male acquaintance, upon
which she stopped hearing Aurora. Soon after, Laura renamed George Satanin
order to reect his increasingly malicious and threatening nature. The Chorus began
one year ago, after Laura was rejected by a group of girls with whom shed hoped
to seek friendship, and who had made cruel comments about her psychiatric history.
The content of The Chorus has been consistently negative.
Childhood history. Laura was a gifted child academically, and studied with older
children in order to sit her A-level examinations two years early. She was often
lonely as a child and had few friends, although recalled: I didnt need friends
because of the voices.She was close to her father, but had a difcult relationship
with her mother who could be intimidating and emotionally remote. Lauras
upbringing was inhibiting in that she was not encouraged or permitted to express
strong emotions, like anger, or to advocate for her needs.
Who might the voices represent? Lauras initial VH experience were voices as
childhood companions. The female voice, who was mature, nurturing and compas-
sionate, may have compensated somewhat for Lauras own maternal deprivation, in
that her mother was remote and emotionally withholding. The male voice was play-
ful and boisterous and a good playmate. The voices changed after a deeply trau-
matic incident of sexual victimization, which shattered several of Lauras
assumptions both about the world and herself. At this point the protective, reassur-
ing voice withdrew. The manifestation of Satan appeared partly inuenced by
Lauras attacker, and The Chorus appeared with a group of bullying, rejecting peers.
Furthermore, both Satan and The Chorus were associated with anger (the world is a
bad place), guilt (anger at yourself ) and shame (everybody sees how bad I am).
What problems may the voices represent? On one hand, Lauras relatively iso-
lated position as a child, and on the other her unresolved traumatic experience
(which created unbearable, overwhelming feelings). In addition, her sense of disem-
powerment within the family and being unpermitted as a child to express strong
emotions or ensure her own needs were met.
Comment. Lauras initial experiences were characteristic of children with rich
fantasy lives who may develop VH in response to physical solitude and/or an inabil-
ity to relate to the people around them (Escher & Romme, 2010). The negative
change in the voices emerged after a violent, anxiety-provoking situation where
Lauras basic sense of trust was destroyed, provoking intense fear. Both the external
sources of aggression and her own negative self-image were embodied in her voices.
After working to discover the emotional themes represented by her voices, Laura
began to move towards recovery in a positive, constructive and protable way. She
was initially supported to nd safety strategies for containing and managing the
voicesintrusions and reduce the anxiety associated with them. Laura also derived
great benet from attending a self-help group and meeting other voice-hearers, includ-
ing individuals who were coping successfully with their voices. Laura subsequently
engaged well with therapeutic work, focusing around issues of expressing needs,
230 E. Longden et al.
communicating anger, and addressing feelings of trauma and loss. By elucidating the
relationship between her voices and her life experiences, the fear and shame aroused
by the voices began to cease. Contrary to Lauras initial wishes, the voice of Aurora
did not reappear, although Laura eventually stated that, by developing a secure base
within herself, she no longer required Aurora to perform this role. The voice of Satan
became progressively less menacing, and The Chorus has begun to recede entirely.
Laura recognized that the voices had offered a protectivefunction in bringing her
attention to unresolved emotional conicts. Later she began to spontaneously refer to
Satan as Georgeagain. At the time of writing, Laura has started a relationship with
a supportive partner and has successfully applied to study mathematics at university.
She copes successfully on a much-reduced dose of medication, and has plans to with-
draw entirely from neuroleptics over the next three months.
This case study, sustained by an analysis of constructs for 80 voice-hearers
(Corstens, Longden, Romme, & Escher, in preparation), supports the position that it
is no longer sustainable to deem VH as part of a disease syndrome, rather than as a
personal response to painful unresolved emotions whose meaning or purpose can be
deciphered. The construct addresses social-emotional events, interpersonal conicts,
and psychosocial adversity within the voice-hearers life in a coherent and accessi-
ble manner. Furthermore, these personal developmental issues can be utilized to
guide recovery journeys, wherein both voices and associated emotional conicts are
suitably interpreted, acknowledged and integrated by the hearer. The VH experience
becomes a personal story, the reclaiming of which may be a fundamental part of
gaining control both over ones voices and ones life (Boevink, 2006; Dillon, 2010;
Longden, 2010; Romme et al., 2009). By incorporating cooperative, humanistic and
existential (i.e. meaning-making) elements into therapeutic protocols it is hoped that
individuals can be supported to listen to their voices without anguish, wherein the
personal signicance of VH can be explored more fully and (re)integrated into a
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... The Maastricht Interview is a structured questionnaire designed to assess the experience of voice hearing and related life events while allowing clinicians to develop a comprehensive formulation of the relationship between voices and a client's life story (Escher, 2012). The objectives of the interview are to (a) help clients understand the people, problems, and stressors the voices represent in the person's history and circumstances and (b) assist the voice hearer in coping and finding solutions to the problems related to AVH (Corstens et al., 2008;Romme & Escher, 2000). The questions were developed by voice hearers in partnership with professionals from the Netherlands and emphasize communicating about voices in a respectful, curious, and validating manner. ...
... The questions were developed by voice hearers in partnership with professionals from the Netherlands and emphasize communicating about voices in a respectful, curious, and validating manner. The individual's interpretations are accepted without labeling, and the voice hearer is considered an expert in their experience (Romme & Escher, 2000). ...
... The Maastricht approach recognizes that some voice hearers may not view themselves as having a mental illness and may not wish to stop hearing voices (Romme & Escher, 2000). Others continue to hear voices despite taking medications and are seeking adjunct therapies to cope with distress (Hoffmann, 2012). ...
Childhood trauma and stressful life events have been linked to the development of auditory verbal hallucinations (AVH). Those who experience distress related to AVH are known to seek support from mental health services where antipsychotic medications are a key pillar of care. Some service users have expressed dissatisfaction with the support options available and are seeking more trauma-informed therapeutic approaches. The Maastricht Interview offers an empowering and structured method for understanding AVH and interconnected life experiences. This paper reviews the therapeutic benefits and risks associated with the Maastricht Interview and proposes a clinical shift toward helping interested clients reduce distress through understanding the personal meanings behind voice hearing.
... Voice experiences, their association with psychological distress, how they are understood transdiagnostically and in the context of individuals' life experiences has begun to change over recent decades (e.g., Aleman & Laroi, 2008;Longden, Madill, & Waterman, 2012;Schnackenberg, Fleming, Walker, & Martin, 2018;Toh, Thomas, & Rossell, 2015;Waters & Fernyhough, 2017). Rather than being a meaningless phenomenon, voices are understood to be an important source of meaning-filled information regarding personal threats, vulnerability, and unresolved trauma (Romme & Escher, 2000;Steel et al., 2020). Furthermore, voices may serve a protective function insofar as it is psychologically advantageous to experience internal conflicts as voice-like (Corstens, Longden, & May, 2012). ...
... From a formulation perspective, speaking with the EDV can provide new understandings or 'constructs' regarding the content, meaning, and intentions of voices (Romme & Escher, 2000). ...
A proportion of individuals given an eating disorder diagnosis describe the experience of an eating disorder ‘voice’ (EDV). However, methods for working with this experience are currently lacking. Voice Dialogue (Stone & Stone, 1989) involves direct communication between a facilitator and parts of the self to increase awareness, understanding, and separation from inner voices. Adapted forms of this method have shown promise in working with voices in psychosis. This study aimed to explore the experience and acceptability of Voice Dialogue amongst individuals with anorexia nervosa who experience an EDV. Nine women participated in a semi‐structured interview following a single Voice Dialogue session. Interview transcripts were analysed using interpretative phenomenological analysis (IPA). Three overarching themes were identified: (i) “separating from the EDV”; (ii) “better understanding of the EDV”; and (iii) “hopeful, motivated, and afraid of recovery”. The majority of participants found Voice Dialogue acceptable and helpful for exploring their EDV. Whilst preliminary, the results suggest that Voice Dialogue has potential in terms of helping individuals establish a more constructive relationship with their EDV and motivating change. Further research is needed to build upon these findings. Implications for addressing the EDV using voice‐focused interventions are explored.
... The seminal work started in 1987 of Romme and Escher, in collaboration with well-known recovered and recovering voice hearers (such as Ron Coleman, Jacqui Dillon, Racchel Waddingham, Peter Bullimore, Patsy Hague, etc.), paved the way for many voice hearers and practitioners to understand voice hearing as less distressing through making sense of who/what the voices are and how they might relate to the voice hearer's life story, thus de-pathologizing and normalising the experience (Romme & Escher, 1989, 2013Romme et al., 2006Romme et al., , 2009. For many, this can be empowering and contribute towards the development of harmony in voice hearervoice relationships (Lafferty & Allison, 2021;Romme et al., 2009). ...
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Background Some people receiving mental healthcare experience distress related to voice hearing and the available support. Some practitioners lack knowledge and confidence in providing this support. Furthermore, coercion in mental healthcare can negatively affect voice hearer-practitioner relationships. Previous research investigating mental health distress, including voice hearing, has largely emphasised an individual-centric perspective. Less is known about voice hearers’ and practitioners’ relational experiences within mental healthcare contexts and how this might influence voice hearing. Methods This was a qualitative study that utilised a constructivist Grounded Theory methodology to explore the experiences of voice hearers (n = 15), through semi-structured interviews, and practitioners (n = 18) through focus group discussions (n = 3). Results A tripartite relationship theory situates experiences of voice hearing within a mental healthcare context, mediated through a tripartite voice hearer – voice – practitioner relationship. This consists of five themes: Level of agency; Interpersonal dynamic; Who’s making sense; Medication: helping or hindering; and Personal bully. Discussion This paper presents a novel theory, grounded in voice hearers’ and practitioners’ experiences. This expands on current knowledge about voice hearing by situating voice hearing experiences within relational and clinical contexts.
... The intervention was based on the "hearing voices" model developed by Romme and Escher (2000), combined with cognitive-behavioural therapy techniques (Thomas et al., 2014). Hearing voices in this model is not regarded as a symptom of mental illness but a distressing mental experience that has meaning and function for the hearer. ...
This paper describes a pattern regarding the relationship between feminine sexuality, religiousness and psychotic distress that was discerned in two independent multiple case studies in Greece. One study utilized grounded theory to develop a model of therapeutic change through recording the development of voice hearers’ understanding and coping with their voices during a therapeutic intervention. The other study applied biographical and thematic analysis to interviews with persons with psychosis and their families, in order to explore family narratives regarding life with a family member with psychosis. A common pattern was detected for all the female participants, whereby following a religious upbringing in childhood and pursuing independence from the family together with social and sexual exploration in early adulthood, the onset of psychosis marked a return to the family home and a religious frame of reference. The psychotic experiences seemed to resemble engrained experiences of shaming regarding sexual and gender norms. Moreover, they had the effect of re-signifying female identity and sexuality, bringing them into line with conservative religious principles. This pattern suggests that psychotic experiences may not only express culturally prescribed female gender norms but also may serve to regulate women’s sexuality in conservative religious cultural environments.
... Indeed, as a result of his empirical work, he concluded that struggling against the voices only causes them to become stronger. In his publications, such as Accepting Voices (Romme & Escher, 1993) and Making Sense of Voices (Romme & Escher, 2000), as well as others published in the journal Mind, Romme described an innovative approach involving the extraction of meaning from psychosis. This may be painful for some people due to the realization and facing of difficulties. ...
Introduction: Since the introduction of newer psychiatric treatment methods during the 20th century, debates about the effectiveness andappropriateness of such treatment have featured. Advocates among those who promote the sociological, biological, psychological and spiritual understandings of mental illness and its treatment have created tangible tensions with those supporting each position commonly indulging in fierce attacks on the others. Aims: The aim of this paper is to explore some of the principal treatment viewpoints that characterized the late 20th century (1990 onwards) and early 21st century (up till 2020). Ultimately, these debates guided contemporary practice towards a biopsychosocial-spiritual view of mental illness in a move towards holistic person-centered care, which nowadays is the advocated model in many health systems. Methods: The authors undertook a literature search in order to locate published debates on psychiatric treatment during the late 20th century (1990 onwards) and the early 21st century (up till 2020). Results: Debates emerging from 36 articles were identified and synthesized in a narrative review. Conclusions: Exploring the various debates that have characterized mental health care serves as a crucial reflective exercise on what needs to be considered when claiming that contemporary care is based on a holistic and person-centered approach. In this view, critical evaluation is needed so as to avoid repeating the coercive and inhumane mistakes of the past.
... Une des conséquences de cette approche est que les personnes qui entendent des voix disposent essentiellement des termes proposés par la psychiatrie -délires, hallucinations, symptômes, maladie, diagnostic -pour faire part de ce qu'elles vivent, ce qui peut avoir pour effet d'enfermer leur parole dans le discours médical (Grard, 2016). En présentant les voix comme un phénomène faisant partie de la diversité des expériences humaines, l'approche développée par les groupes d'EV s'inscrit contre une perspective capacitiste de l'être humain qui relègue l'entente des voix à la folie et nourrit les tabous et la stigmatisation envers les EV (Romme et Escher, 2000;Longden et al., 2012;Molinié, 2018). Au sein de ces groupes, les membres sont: «encouragés à prendre en main leurs expériences et à les définir par et pour eux-mêmes» (Molinié, 2018, p. 117). ...
Dans le milieu médical, l'approche qui a longtemps prédominé à l'égard des voix est de les faire taire par la médication et de ne pas aborder le sens qu'elles ont pour les personnes de peur d'alimenter l'entente des voix et la détresse des personnes. Une des conséquences de cette situation est que les personnes disposent essentiellement des termes proposés par la psychiatrie - délires, hallucinations, symptômes, maladie, diagnostic - pour parler de leurs voix, ce qui peut avoir pour effet d'enfermer la parole des personnes dans le discours médi-cal. Dans les groupes d'entendeurs de voix, les personnes reprennent la parole dans un es-pace sécuritaire entre pairs et développent leurs propres explications à propos de leurs voix. L'article décrit les retombées positives de ce processus qui permet l'ouverture à un plura-lisme explicatif psychologique et parapsychologique des voix. Nous soulignons néanmoins la persistance des explications médicales des voix au sein de ces groupes en raison de leur so-cialisation de long terme au langage psychiatrique et de l'autorité des discours médicaux. Mots clés: groupes d'entendeurs de voix; pluralisme explicatif; récit; santé mentale; multisi-gnification; injustices épistémiques.
... Sandra and Marius created the Maastricht Hearing Voices Interview that is now globally used as a tool to elucidate personal meaning and clarity on the voice hearing experience. Together they published several books of which Accepting Voices (Romme & Escher, 1993), Making Sense of Voices (Romme & Escher, 2000) and Living with Voices (Romme et al., 2009) are the most important; the titles represent the new paradigm they created. ...
... The HVG approach is part of the Maastricht approach developed in the Netherlands by employees of the Social Psychiatry Department of the University of Maastricht in cocreation with voice-hearers who are both service users and non-service users (11). The Maastricht approach focuses on the importance of accepting voices and making sense of the whole voice-hearing experience (12)(13)(14). The approach has inspired many voice-hearers worldwide and has given rise to an international social movement, "The Hearing Voices Movement, " which offers an alternative to the traditional biomedical and cognitive-behavioral framework of hearing voices. ...
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Purpose/Aims: This study aimed to gain insight into the value of Hearing Voices Groups (HVGs) in the Dutch context. Specifically, we aimed to learn more about the meaning of HVG participation, as well as the aspects that contribute to that meaning, from the perspective of participants' experiences. Method: The study used a qualitative design with in-depth interviews to explore the experiences of 30 members within seven HVGs in the Netherlands. Interviews were recorded, transcribed, and analyzed using interpretative analysis inspired by the Grounded Theory method. Findings: The individual-level analysis revealed four different group processes that appear to determine the value that HVGs have for their participants: (i) peer-to-peer validation, (ii) exchanging information and sharing self-accumulated knowledge, (iii) connection and social support, and (iv) engaging in mutual self-reflection. We found that specific characteristics of HVGs facilitate these group processes and lead to specific personal outcomes. Combining the interview data from people who joined the same HVG reveals that, although all four described group processes occur in all groups, each group's emphasis differs. Three related factors are described: (i) the composition of the group, (ii) the style of the facilitators, and (iii) the interaction between group processes and individual processes. Implications: Unique processes, for which there is little to no place within regular mental health care (MHC), occur within HVGs. MHC professionals should be more aware of the opportunities HVG can offer voice-hearers. Essential matters regarding the implementation of HVGs are discussed.
... The semistructured interview protocol was developed by T.M.L., R.P., and H.T. (Appendix 1). In choosing probes, we consulted the Maastricht interview protocol developed by Romme and Escher 22 and other established interviews about voice-hearing, such as the Leudar-Thomas Voices Pragmatics Assessment Interview (Appendix 1). 23 Questions were also informed by the clinical experience of the interviewers. ...
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In a side-by-side comparison, we found that the voices of patients who met the criteria for schizophrenia in Chennai, Tamil Nadu, India and in San Mateo, CA, United States were different. Both groups heard commands. In San Mateo, those commands were often violent, but in Chennai, commands often seemed more to do with everyday activities. Both groups heard voices that spoke about sexual activities. In Chennai, participants reported more voices that talked about sex, and they often experienced intense shame and guilt around these sexual voices. In San Mateo, sexual voices seemed to have less shaming content and were more often described with enjoyment. In San Mateo, voices were also more violent in general. We suggest that the content of voices may reflect local cultural ideas about voices and local cultural responses to specific features of the voice-hearing experience.
Spirituality and Psychiatry addresses the crucial but often overlooked relevance of spirituality to mental well-being and psychiatric care. This updated and expanded second edition explores the nature of spirituality, its relationship to religion, and the reasons for its importance in clinical practice. Contributors discuss the prevention and management of illness, and the maintenance of recovery. Different chapters focus on the subspecialties of psychiatry, including psychotherapy, child and adolescent psychiatry, intellectual disability, forensic psychiatry, substance misuse, and old age psychiatry. The book provides a critical review of the literature and a response to the questions posed by researchers, service users and clinicians, concerning the importance of spirituality in mental healthcare. With contributions from psychiatrists, psychologists, psychotherapists, nurses, mental healthcare chaplains and neuroscientists, and a patient perspective, this book is an invaluable clinical handbook for anyone interested in the place of spirituality in psychiatric practice.
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Aims: A trend has emerged in the last two decades which views hearing voices as a meaningful experience and attempts to facilitate both their exploration and the development of effective strategies of coping with them. This study explores the experience of hearing voices, aiming to highlight the complexity of the phenomenon and the meaning that the experience has for the person.Methods: Semi‐structured interviews were conducted with 15 individuals who currently hear voices and are being treated by the Thessaloniki Psychiatric Hospital. The interview material was analysed by the abbreviated version of grounded theory.Results: The two out of six main categories presented in this paper concern: (a) “the function of voices”, which includes what the voices say and how the hearer deals with them; and (b) “understanding hearing voices”, which includes the explanations given by voice hearers regarding the source and origin of voices as well as the relation of voices to reality and to their thoughts.Conclusions: The study highlights that hearing voices is a complex experience which voice hearers deal with in a variety of ways, and that voice hearers develop sophisticated frameworks for making sense of that experience.
Although rbe concept of recovery from severe psychiatric disability is being discussed and written about with increasing frequency, little consensus has been reached about the nature of this phenomenon. The purpose of the current study was to explore the meaning of the recovery process from the perspective of mental health consumers. Seven semi-structured qualitative interviews and two focus group discussions were carried out with a total of 18 people, and grounded theory analysis was used to identify common, underlying components of the recovery process. A model of the recovery process was developed, which included the higher order categories that recovery is a process of I) overcoming "stuckness," 2) discovering and fostering self-empowerment, 3) learning and self-redefinition 4) returning to basic functioning, and 5) improving quality of life. The relationship between the current model and the existing literature on the recovery process is discussed.
Case formulation is a key skill for mental health practitioners, and this book provides examples of ten case formulations representing the most common mental health problems in a variety of populations and contexts, offering commentary on contrasting formulations of the same case. Provides an overview of the general features of case formulation and how it can drive treatment. Features clinical cases from a variety of populations, focusing on a range of different problems. Covers all the major theoretical perspectives in clinical practice - behavioural, cognitive behavioural, psychodynamic, medical , and eclectic. Offers commentary on contrasting formulations of the same case for five different clinical problems.
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.
Hearing voices, self‐harm, eating “disorders” and dissociation, when viewed objectively, are frequently classified as symptoms of serious mental illnesses and disordered personalities that require treatment, eradication and cure. This convenient societal solution to the complex problem of endemic childhood abuse requires that victims of abuse endure further insult to injury and become the problem to be dealt with. By tracing the roots of so‐called “symptoms” back to their origins in traumatic childhood events and having the courage to bear witness to painful truths, a more accurate, humane and respectful picture emerges which reframes “symptoms” as essential survival techniques. The mark of a responsible society and responsive services is the willingness to share collective responsibility for these experiences, to honour them, support them and learn from them at all levels.
Despite an increasingly comprehensive research literature on hearing voices, few attempts have been made to define the phenomenon and fewer still have sought to do so based on voice‐hearers' subjective accounts. This paper uses a qualitative approach to develop a definition of hearing voices based on the essential characteristics of the experience. Fifty voice‐hearers from the general population participated in semi‐structured interviews exploring their voice experiences. Thematic analysis revealed five essential characteristics: the content of the voices is personally meaningful, the voices have a characterised identity, the person has a relationship with their voices, the experience has a significant impact on the voice‐hearer's life, and the experience has a compelling sense of reality. Implications for treatment interventions include the importance of acknowledging that voices are real, supporting the person to make meaning of who the voices are and what the voices say, and making connections between relationships with voices and relationships with significant others in the person's life.