Making sense of voices

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Psychosis
Psychological, Social and Integrative Approaches
ISSN: 1752-2439 (Print) 1752-2447 (Online) Journal homepage: http://www.tandfonline.com/loi/rpsy20
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
To link to this article: http://dx.doi.org/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
a
, Dirk Corstens
b
*, Sandra Escher
c
and Marius Romme
c
a
Institute of Psychological Sciences, University of Leeds, Leeds, UK;
b
RIAGG Maastricht,
Maastricht, The Netherlands;
c
City University of Birmingham, Birmingham, UK
(Received 5 May 2011; final 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 influ-
ence of interpersonal stress in creating vulnerability for emotional crises (i.e.
psychological predisposition) and the personally significant 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 difficulties, 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 “symptoms”can 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: d.corstens@riagg-maastricht.nl
Psychosis
Vol. 4, No. 3, October 2012, 224–234
ISSN 1752-2439 print/ISSN 1752-2447 online
Ó2012 Taylor & Francis
http://dx.doi.org/10.1080/17522439.2011.596566
http://www.tandfonline.com

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 significantly more likely to make causal attributions that
were beyond their individual control (in this case, “biology”). On face value, these
results do not permit firm 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 difficulties, 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 findings are congruent with emerging
(often user-led) definitions 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 influenced by environmental and social factors than a categorical “pres-
ence”or “absence”of psychopathology (Beavan, Read & Cartwright, 2011). This
paper does not presume to account for the origins of VH experiences per se, but
rather for a specific 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 field 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 one’s voices, specific 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
premises:
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 influence of interpersonal trau-
mas in creating vulnerability for emotional crisis (i.e. psychological predispo-
sition); and (2) the personally significant 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-
field, 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)
reflection of conflictual situations harbouring certain personal themes: a manifesta-
tion of a vital defensive manoeuvre whereby transforming emotional conflict 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 benefit.
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
voices
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
content
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 specific 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 specific 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
voices
What was happening in the person’s life when each voice appeared
for the first time? Did particular circumstances evoke overwhelming
emotions or conflicts? How did the voice(s) develop afterwards in
terms of content and influence?
Childhood history The voice-hearer’s 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
influence 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 reflexive
about any pre-existing values or assumptions they may bring to the procedure
(Johnstone & Dallos, 2006).
In our experience, many individuals find it liberating and validating to be
respectfully questioned about their voices. Although some are unable (or unwilling)
to acknowledge underlying difficulties, we have found that a systematic exploration
of relevant information may reveal both the person’s psychosocial vulnerabilities
and the contextual circumstances that originally provoked VH. In this respect, we
refer to the psychodynamically informed approach of Garfield (1995), who endorses
a similar emphasis on the role of emotion and analysis of circumstances in which
symptoms first 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. 31–33).
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
difficulties. We often find it beneficial 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, five specific 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 significant 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 significant 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 specific, intolerable
emotions that influenced 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 identified that deter-
mined the voice-hearer’s 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 one’s
experiences (using voices as clues to internal emotional conflicts); and social recon-
nection (working through experiences that have been difficult 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
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 choke”other people. It predicted
ominous events that Laura would be “powerless to prevent”and 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 fine”,
“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 Satan’s predictions, although could also argue with him about the best way of
“punishing”Laura. Laura was unwilling to disclose the exact content of The Cho-
rus’speech, 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
people’s behalf.
Psychosis 229

History of the voices. Laura first heard Satan and Aurora aged eight. Aurora
was named after the heroine in the animated film Sleeping Beauty to reflect her
serenity and gentleness. She always sounded older and more mature than Laura.
Satan’s original name was “George”and he always remained one year older than
Laura. The name related to Enid Blyton’sFamous Five novels (a popular series of
English children’s 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 “Satan”in
order to reflect his increasingly malicious and threatening nature. The Chorus began
one year ago, after Laura was rejected by a group of girls with whom she’d 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 didn’t need friends
because of the voices.”She was close to her father, but had a difficult relationship
with her mother who could be intimidating and emotionally remote. Laura’s
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? Laura’s initial VH experience were voices as
childhood companions. The female voice, who was mature, nurturing and compas-
sionate, may have compensated somewhat for Laura’s 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 Laura’s
assumptions both about the world and herself. At this point the protective, reassur-
ing voice withdrew. The manifestation of Satan appeared partly influenced by
Laura’s 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, Laura’s 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. Laura’s 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
Laura’s 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 profitable way. She
was initially supported to find safety strategies for containing and managing the
voices’intrusions and reduce the anxiety associated with them. Laura also derived
great benefit 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 Laura’s 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 “protective”function in bringing her
attention to unresolved emotional conflicts. Later she began to spontaneously refer to
Satan as “George”again. 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.
Conclusions
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 conflicts,
and psychosocial adversity within the voice-hearer’s 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 conflicts 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 one’s voices and one’s 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 significance of VH can be explored more fully and (re)integrated into a
previously fractured sense of self (Moskowitz & Corstens, 2007).
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