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Listening to the Voices People Hear: Auditory Hallucinations Beyond a Diagnostic Framework

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Abstract

While voice hearing (auditory verbal hallucinations) is closely allied with psychosis/schizophrenia, it is well-established that the experience is reported by individuals with nonpsychotic diagnoses, as well as those with no history of psychiatric contact. The phenomenological similarities in voice hearing within these different populations, as well as increased recognition of associations between adversity exposure and voice presence/content, have helped strengthened the contention that voice hearing may be more reliably associated with psychosocial variables per se rather than specific clinical diagnoses. Evidence is examined for understanding voice hearing as a psychological response to environmental stressors, and the implications of this for clinical practice. Consideration is also given to the impact of the International Hearing Voices Movement, an influential survivor-led initiative that promotes person-centered, nondiagnostic approaches to the voice-hearing experience.

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... It is important to note that recent phenomenological research has raised questions about the discreteness, coherence, and validity of "auditory hallucinations" as classically defined (e.g., Jones & Luhrmann, 2015;Rosen et al., 2016). Moreover, the definition of voice hearing is broader than the classical definition of auditory hallucinations (both verbal and nonverbal) in the clinical literature, encompassing the perception of diverse types of anomalous sounds that may or may not be experienced as distressing (Hearing Voices Network, 2018b;Jones & Shattell, 2013Longden, 2017;Wilkinson, & Anderson-Day, 2016;Woods, Jones, Alderson-Day, Callard, & Fernyhough, 2015;Woods, Romme, McCarthy-Jones, Escher, & Dillon, 2013). Put simply, a person who hears voices, or a voice hearer, experiences sounds (e.g., human speech), messages, and/or other meanings that others do not. ...
... At other times, the person might believe the voice to originate from a spiritual entity or otherworldly force, a technological device, or another human who is unseen at the time of utterance. Although the many determinants and meanings of heard voices are beyond the scope of this article, it is important to note that heard voices are not (even within conventional definitions) necessarily or always a signifier or so-called "symptom" of "psychopathology," as is commonly assumed (see Woods, 2015), but rather-as extensive epidemiological work (see van Os, Linscott, Myin-Germeys, Delespaul, & Krabbendam, 2009) and the efforts of grassroots movements such as the Hearing Voices Network have demonstrated (e.g., Hearing Voices Network, 2018a; Jones, Marino, & Hansen, 2016;Jones & Shattell, 2013; see also Watkins, 2000)-a diverse, heterogeneous group of experiences that are more often than not meaningfully related to the person's life history and contexts (e.g., Longden, 2017;Wilkinson & Anderson-Day;Wilkinson & Bell, 2016;Woods, 2015), can (as aforementioned) be pleasant or friendly as well as distressing (Woods et al., 2013;Woods et al., 2015), are frequently transient or intermittent, and quite often occur in nonclinical populations-in other words, in persons who do not seek clinical care and do not meet criteria for a psychiatric diagnosis (van Os et al., 2009). Voice hearing is increasingly investigated and conceptualized outside of conventional biomedical arenas (e.g., Watkins, 2000;Waugh, 2015)-especially in international and interdisciplinary scholarshipand is currently the focus, for example, of large multidisciplinary study in the United Kingdom (see Hearing the Voice, 2019). ...
... In consideration of our focus on hearing voices, we might turn to a small but growing body of literature suggesting that social marginalization may have itself been a long-subjugated truth of experiences commonly known as "psychotic." This literature, collectively known as the "social defeat" literature (Selten, van der Ven, Rutten, & Cantor-Graae, 2013), indicates that the experience of exclusion from a dominant social group is the common psychological denominator underlying the various social risk factors for psychosis, including homelessness, forced migration, racial/ethnic segregation, multiple deprivation, and childhood trauma (see also Longden, 2017;Longden, Madill, & Waterman, 2012;Rosen, McCarthy-Jones, Jones, Chase, & Sharma, 2018;Kamens, in press, 2018). (Social defeat theory also suggests that these risk factors lead to alterations in the mesolimbic dopamine system, thus positing a wholly biopsychosocial model that acknowledges both neurological changes and psychosocial risk factors.) ...
... This risk can be seen clearly in clinical and social contexts and means that non-psychotic and non-schizophrenic hearers of voices are afraid of being judged as mad, crazy or disturbed (de Kalhovde et al. 2013;Faccio et al. 2013;Jager et al. 2016;Longden 2017). These individuals may live with these fears for years, avoiding speaking about their experiences to others whilst understanding that hearing voices does not negatively impact their lives in general (Ruddle et al. 2011;Beavan et al. 2011). ...
... An individual's system of beliefs may not only influence how he or she interprets voices but may also help one understand his or her relationship with these voices (Slade 1976;Murphy 1978;Bentall 2003;Shawyer et al. 2013). These voices may serve the function of a response or an attempted solution in the face of situations perceived as uncontrollable; voices may be considered a form of persecution or salvation (Salvini and Bottini 2011) and may give comfort (Freeman and Garety 2003;Hill and Linden 2013) or guide action against stress (Evensen et al. 2011;Longden 2017) or sentimental disappointments (Kumari et al. 2013) and as an accompaniment to daily life (Hayward et al. 2011). The hearer's relationship with the voices can serve to structure or organize his or her personal or social life, and the voices may accompany the hearer during much of his or her life and may direct his or her behaviour (Salvini 1998;Perona-Garcelan et al. 2015). ...
Article
The phenomenon of hearing voices is currently a much-discussed topic, both in the field of research and in the field of care services. The majority of people who report “hearing voices” do not subsequently receive services or receive a diagnosis of psychopathology. This topic raises questions for professionals in the health field about the lack of tools that can help illuminate the phenomenon. The purposes of this work are (a) to highlight the psychological studies that approach the phenomenon in a non-psychopathological way and (b) to determine which concepts could aid the comprehension of the phenomenon. The method consists of a systematic review of the literature that characterizes the phenomenon of hearing voices from a non-pathological perspective. The literature offers different theoretical approaches to interpret the phenomenon in a way that is not necessarily pathological and presents new tools for examining the phenomenon. For example, a few studies state that it is possible to coexist with voices, while others indicate that it is necessary to know how to manage voices. We highlighted and discussed several concepts that can support doctors, psychiatrists and practitioners in understanding “hearer” patients, particularly attention to the context of belonging, attention to language, and the role of the sense-making process.
... There is a well-documented difference of approach between psychological formulation and the psychiatric medical model (Bentall, 2004;Johnstone & Boyle, 2018;Longden, 2017), and perhaps this appears most evident within forensic settings. The complexity and requirement for risk management in these settings can result in heavy-handed approaches, a reliance on medication, and barriers to creative and empowering approaches to therapy. ...
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This reflective article describes my experience of attending Hearing Voices Group training and the subsequent establishment of such a group within a medium-secure forensic hospital. I discuss the philosophy of the movement and consider how this sits alongside other forms of clinical and theoretical information. I attempt to find balance between, what I consider to be flaws, and the many positive aspects that come with the approach.
... Devised in collaboration with voice hearers, the framework has become established within the international Hearing Voices Movement (Corstens, Longden, McCarthy-Jones, Waddingham, & Neil, 2014), although it has largely remained beyond academic investigation and outside of mainstream clinical services. Defining features of the approach are its emphasis on depathologising the voice hearing experience, its transdiagnostic scope, and the value it places on exploring the content, potential meaning and intentions of the voices (Corstens et al., 2014;Longden, 2017). ...
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The current evidence-base for the psychological treatment of distressing voices indicates the need for further clinical development. The Maastricht approach (also known as Making Sense of Voices) is popular within sections of the Hearing Voices Movement, but its clinical effectiveness has not been systematically evaluated. The aim of the approach is to develop a better understanding of the role of the voice, in part through opening a dialogue between the voice hearer and the voice. The current study was a (N = 15) case series adopting a concurrent multiple baseline design. The Maastricht approach was offered for up to 9-months. The main outcome, weekly voice-related distress ratings, was not statistically significant during intervention or follow-up, although the effect size was in the moderate range. The PSYRATS Hallucination scale was associated with a large effect size both at the end of treatment, and after a 3-month follow-up period, although again the effect did not reach statistical significance. The results suggest further evaluation of the approach is warranted. However, given the large variance in individual participant outcome, it may be that a better understanding of response profiles is required before conducting a definitive randomised controlled trial.
... L'entente des voix est un phénomène fortement stigmatisé socialement qui s'accompagne de préjugés selon lesquelles les voix sont «irréelles», des productions d'un cerveau dérangé et d'un esprit délirant de la part de personnes perçues comme imprévisibles, voire dangereuses (Read et al., 2013). Dans le milieu médical, l'approche qui a longtemps prédominé est de faire taire les voix par la médication et de ne pas aborder l'expérience des voix de peur de rendre cette expérience plus réelle et d'accentuer la détresse des personnes (Longden, 2017). 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). ...
Article
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.
... It turns out, for example, that hearing voice is prevalent in the general population, and that these experiences may not necessarily be indicative of a serious mental disorder (Maijer, Begemann, Palmen, Leucht, & Sommer, 2018). In the absence of harm, it is difficult to argue for the medicalization of such experiences, and there are now support groups for those with these experiences (Longden, 2017). That said, hearing voices may be a symptom of a range of mental disorders, other than psychotic disorders, and there is evidence from community surveys that such symptoms are associated with significant disability, which is unlikely to be simply a reflection of lack of social accommodation (Navarro-Mateu et al., 2017;Pierre, 2010). ...
Article
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The question of ‘what is a mental disorder?’ is central to the philosophy of psychiatry, and has crucial practical implications for psychiatric nosology. Rather than approaching the problem in terms of abstractions, we review a series of exemplars – real-world examples of problematic cases that emerged during work on and immediately after DSM-5, with the aim of developing practical guidelines for addressing future proposals. We consider cases where (1) there is harm but no clear dysfunction, (2) there is dysfunction but no clear harm, and (3) there is possible dysfunction and/or harm, but this is controversial for various reasons. We found no specific criteria to determine whether future proposals for new entities should be accepted or rejected; any such proposal will need to be assessed on its particular merits, using practical judgment. Nevertheless, several suggestions for the field emerged. First, while harm is useful for defining mental disorder, some proposed entities may require careful consideration of individual v. societal harm, as well as of societal accommodation. Second, while dysfunction is useful for defining mental disorder, the field would benefit from more sharply defined indicators of dysfunction. Third, it would be useful to incorporate evidence of diagnostic validity and clinical utility into the definition of mental disorder, and to further clarify the type and extent of data needed to support such judgments.
... Lived experience approaches position "voice hearing" as a meaningful human experience, which can be understood in the context of voice hearers' psychosocial, emotional and interpersonal circumstances (Beavan & Read, 2010;Corstens & Longden, 2013;Holt & Tickle, 2014;Longden, 2017;Longden, Corstens et al., 2012). Hearing voices can be highly distressing to individuals, and one popular theory among several is that of voices as expressions of dissociation following trauma (Longden, Madill et al., 2012;Longden & Read, 2016). ...
Article
Background Research indicates that clinical staff lack confidence in delivering clinical care for voice hearers. Understanding staff experience is therefore likely to benefit staff training. Objective To explore staff experience of delivering clinical care for voice hearers using qualitative methodology. Method A total of 18 multidisciplinary staff from five acute psychiatric wards participated in brief semi-structured interviews. Interviews were analysed using thematic analysis. Results Six themes were identified. Participants reported Challenges of Understanding Subjective Experience (N = 16) of hearing voices, Empathy for Distress (N = 14) caused by voices, Curiosity about Experience (N = 10) and wish to understand, Anxiety about Clinical Risk (N = 8), especially regarding command hallucinations, Lack of Clinical Confidence (N = 7) in how to respond, and Diversity of Voices (N = 6) experienced by voice hearers. Conclusion Staff have empathy for voice hearers’ distress but feel they lack subjective understanding of what it feels like to hear voices. Lack of understanding, perceived clinical risks, and diversity of voices may be associated with reported lack of clinical confidence. Staff training that promotes greater subjective understanding has the potential to improve therapeutic relationships, clinical confidence, and quality of care. Using simulation technologies and involving people with lived experience in staff training may be ways to improve subjective understanding.
... The phenomenological similarities between experiences associated with mental health diagnoses and those voluntarily promoted and accepted in religious contexts raised many clinical and methodological questions (Cook et al., 2020). It seems of primary importance to understand which subjective and intersubjective processes are operating in the phenomenon of hearing divine voices, to reduce the risk of stigmatization and offer adequate psychosocial support to those that might be negatively impacted by it, and that risk to develop a psychopathological condition due to the voicerelated distress (Longden, 2017). There seems to be a component of social acceptability that considerably affects the evaluation of the phenomenon (Luhrmann et al., 2015b), and robust evidence supports a continuum view of hearing voices rather than a diagnostic model (Baumeister et al., 2017). ...
Article
Background: We explored the role of criticism of self and of others, and metacognitive abilities in hearing voices that may refer to god or a divine presence, and qualitatively compared differences and similarities between persons who were diagnosed with psychosis and those who were not. Methods: We recruited two samples of persons who heard divine voices: six were diagnosed with brief psychotic disorder (sub-sample A) and six were not (sub-sample B). All participants were interviewed according to a mixed-method design that integrated content analysis and phenomenological procedures. Results: The narratives of sub-sample A showed higher levels of self-criticism and other-criticism and lower levels of narrative coherence than those of sub-sample B. The latter showed an intention of the voices characterized by compassion and connectedness. Conclusion: This qualitative study highlighted the importance of considering criticism and metacognition as central mechanisms in understanding the distress of persons hearing divine voices.
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Recent research has supported the mediating role of dissociation in the relationship between childhood trauma (CT) and voice hearing in clinical and nonclinical populations. However, this mediating role has not yet been explored with regard to seeing visions (visual hallucinations). This study aimed to explore the mediating effect of dissociation on the relationship between CT and seeing visions. In total, 425 voluntary participants recruited from the general population completed an online survey evaluating CT, dissociative experiences, and the experience of hearing voices and seeing things. The findings showed that defensive dissociation mediated the association between CT and the experience of seeing visions. A similar model in terms of pathways and the model's predictive accuracy was found for hearing voices. Therefore, seeing visions may partly reflect dissociated traumatic events intruding into consciousness. Trauma-based interventions for seeing visions may be beneficial in improving distress associated with these experiences.
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Mental health consumers who hear voices frequently experience distress and express a desire to discuss their voice‐hearing experience. Nurses do not regularly demonstrate a willingness to engage in such discussions. With the introduction of educational strategies that develop empathy and an understanding of voice‐hearing experiences, it is anticipated that early career nurses will be able to translate such understanding into their professional nursing practice. To explore early career nurses’ understanding of providing care to mental health consumers who hear voices, a qualitative exploratory descriptive study was conducted in which nine early career Registered Nurses were interviewed regarding their experiences of caring for people who hear voices. Thematic analysis was employed to analyse the data and generate themes. Participants reported difficulty in developing relationships with consumers who hear voices, due to a workplace culture that was focussed on risk and lacking professional support. Nurses need specific education to develop the skills necessary to respond to consumers who hear voices and engage in dialogue that assists consumers to relate to the voices in a meaningful way. However, for this to succeed in practice, changes need to be supported by addressing the cultural barriers, such as risk‐focussed environments, that prevent nurses implementing best practice.
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Objectives: Making sense of voice-hearing-exploring the purpose, cause, and relationship with voices-is seen as therapeutically valuable for adults, but there is a paucity of research with adolescents. Family intervention is recommended for young people, yet little is known about families' perspectives on, or role in, a child's voice-hearing. This study therefore aimed to explore how both young people and parents had made sense of voice-hearing in the family context. Method: Semi-structured interviews were conducted with seven young people who hear voices (six females, one male, age M = 17 years) and six parents of young people who hear voices (five females, one male). Data were analysed using interpretative phenomenological analysis. Results: The young people struggled to reconcile their voice-hearing experiences within themselves, wanted control, 'normality', and not to let their mental health hold them back. Parents saw the voices as separate to their child, who they were protective of, and came to an acceptance and hope for the future amidst continued uncertainty. Pragmatism, and shame, ran through parents' and young people's accounts. Tensions between them, such as autonomy versus involvement, were also apparent. Conclusions: Few participants had made sense of their experiences in any concrete form, yet hope, control, and getting on with their lives were not conditional on having done so. Young people valued the family as a safe, non-enquiring space to be 'normal' and not to talk about their experiences. While all had been challenged by their experiences, an energy and strength ran through their accounts.
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Auditory verbal hallucinations (AVH: 'hearing voices') are found in both schizophrenia and post-traumatic stress disorder (PTSD). In this paper we first demonstrate that AVH in these two diagnoses share a qualitatively similar phenomenology. We then show that the presence of AVH in schizophrenia is often associated with earlier exposure to traumatic/emotionally overwhelming events, as it is by definition in PTSD. We next argue that the content of AVH relates to earlier traumatic events in a similar way in both PTSD and schizophrenia, most commonly having direct or indirect thematic links to emotionally overwhelming events, rather than being direct re-experiencing. We then propose, following cognitive models of PTSD, that the reconstructive nature of memory may be able to account for the nature of these associations between trauma and AVH content, as may threat-hypervigilance and the individual's personal goals. We conclude that a notable subset of people diagnosed with schizophrenia with AVH are having phenomenologically and aetiologically identical experiences to PTSD patients who hear voices. As such we propose that the iron curtain between AVH in PTSD (often termed 'dissociative AVH') and AVH in schizophrenia (so-called 'psychotic AVH') needs to be torn down, as these are often the same experience. One implication of this is that these trauma-related AVH require a common trans-diagnostic treatment strategy. Whilst antipsychotics are already increasingly being used to treat AVH in PTSD, we argue for the centrality of trauma-based interventions for trauma-based AVH in both PTSD and in people diagnosed with schizophrenia.
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Hearing voices peer support groups offer a powerful alternative to mainstream psychiatric approaches for understanding and coping with states typically diagnosed as “hallucination.” In this jointly authored first-person account, we distill what we have learned from 10 years of facilitating and training others to facilitate these groups and what enables them to work most effectively in the long term. Having witnessed the transformative power of these groups for people long considered unreachable as well as for those who receive some benefit from standard psychiatric treatment, we describe effects that cannot easily be quantified or studied within traditional research paradigms. We explain the structure and function of hearing voices peer support groups and the importance of training facilitators to acquire the skills necessary to ensure that groups operate safely, democratically, and in keeping with the theories and principles of the Hearing Voices Network. The greater use of first-person experience as evidence in deciding what works or does not work for people in extreme distress is advocated; randomized designs or statistically significant findings cannot constitute the only bases for clinical evaluations (Elisabeth Svanholmer, in Romme et al. 2009, p. 151).
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Auditory verbal hallucinations (AVH) are complex experiences that occur in the context of various clinical disorders. AVH also occur in individuals from the general population who have no identifiable psychiatric or neurological diagnoses. This article reviews research on AVH in nonclinical individuals and provides a cross-disciplinary view of the clinical relevance of these experiences in defining the risk of mental illness and need for care. Prevalence rates of AVH vary according to measurement tool and indicate a continuum of experience in the general population. Cross-sectional comparisons of individuals with AVH with and without need for care reveal similarities in phenomenology and some underlying mechanisms but also highlight key differences in emotional valence of AVH, appraisals, and behavioral response. Longitudinal studies suggest that AVH are an antecedent of clinical disorders when combined with negative emotional states, specific cognitive difficulties and poor coping, plus family history of psychosis, and environmental exposures such as childhood adversity. However, their predictive value for specific psychiatric disorders is not entirely clear. The theoretical and clinical implications of the reviewed findings are discussed, together with directions for future research.
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The international Hearing Voices Movement (HVM) is a prominent mental health service-user/survivor movement that promotes the needs and perspectives of experts by experience in the phenomenon of hearing voices (auditory verbal hallucinations). The main tenet of the HVM is the notion that hearing voices is a meaningful human experience, and in this article, we discuss the historical growth and influence of the HVM before considering the implications of its values for research and practice in relation to voice hearing. Among other recommendations, we suggest that the involvement of voice-hearers in research and a greater use of narrative and qualitative approaches are essential. Challenges for implementing user-led research are identified, and avenues for future developments are discussed
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There is robust evidence that childhood adversity is associated with an increased risk of psychosis. There is, however, little research on intervening factors that might increase or decrease risk following childhood adversity. To investigate main effects of, and synergy between, childhood abuse and life events and cannabis use on odds of psychotic experiences. Data on psychotic experiences and childhood abuse, life events and cannabis use were collected from 1680 individuals as part of the South East London Community Health Study (SELCoH), a population-based household survey. There was strong evidence that childhood abuse and number of life events combined synergistically to increase odds of psychotic experiences beyond the effects of each individually. There was similar, but weaker, evidence for cannabis use (past year). Our findings are consistent with the hypothesis that childhood abuse creates an enduring vulnerability to psychosis that is realised in the event of exposure to further stressors and risk factors.
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Background: Different psychological models of trauma-induced psychosis have been postulated, often based on the observation of "specific" associations between particular types of childhood trauma (CT) and particular psychotic symptoms or the co-occurrence of delusions and hallucinations. However, the actual specificity of these associations remains to be tested. Methods: In 2 population-based studies with comparable methodology (Netherlands Mental Health Survey and Incidence Study-1 [NEMESIS-1] and NEMESIS-2, N = 13 722), trained interviewers assessed CT, psychotic symptoms, and other psychopathology. Specificity of associations was assessed with mixed-effects regression models with multiple outcomes, a statistical method suitable to examine specificity of associations in case of multiple correlated outcomes. Results: Associations with CT were strong and significant across the entire range of psychotic symptoms, without evidence for specificity in the relationship between particular trauma variables and particular psychotic experiences (PEs). Abuse and neglect were both associated with PEs (OR abuse: 2.12, P < .001; OR neglect: 1.96, P < .001), with no large or significant difference in effect size. Intention-to-harm experiences showed stronger associations with psychosis than CT without intent (χ(2) = 58.62, P < .001). Most trauma variables increased the likelihood of co-occurrence of delusions and hallucinations rather than either symptom in isolation. Discussion: Intention to harm is the key component linking childhood traumatic experiences to psychosis, most likely characterized by co-occurrence of hallucinations and delusions, indicating buildup of psychotic intensification, rather than specific psychotic symptoms in isolation. No evidence was found to support psychological theories regarding specific associations between particular types of CT and particular psychotic symptoms.
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This article presents a report on the 2nd meeting of the International Consortium on Hallucination Research, held on September 12th and 13th 2013 at Durham University, UK. Twelve working groups involving specialists in each area presented their findings and sought to summarize the available knowledge, inconsistencies in the field, and ways to progress. The 12 working groups reported on the following domains of investigation: cortical organisation of hallucinations, nonclinical hallucinations, interdisciplinary approaches to phenomenology, culture and hallucinations, subtypes of auditory verbal hallucinations, a Psychotic Symptoms Rating Scale multisite study, visual hallucinations in the psychosis spectrum, hallucinations in children and adolescents, Research Domain Criteria behavioral constructs and hallucinations, new methods of assessment, psychological therapies, and the Hearing Voices Movement approach to understanding and working with voices. This report presents a summary of this meeting and outlines 10 hot spots for hallucination research, which include the in-depth examination of (1) the social determinants of hallucinations, (2) translation of basic neuroscience into targeted therapies, (3) different modalities of hallucination, (4) domain convergence in cross-diagnostic studies, (5) improved methods for assessing hallucinations in nonclinical samples, (6) using humanities and social science methodologies to recontextualize hallucinatory experiences, (7) developmental approaches to better understand hallucinations, (8) changing the memory or meaning of past trauma to help recovery, (9) hallucinations in the context of sleep and sleep disorders, and (10) subtypes of hallucinations in a therapeutic context.
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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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Although the hearing voices movement (HVM) has yet to take root in the US to the extent it has in the UK (and parts of Australia and Europe), recent publications and events, including a keynote presentation by UK hearing voices trainer Ron Coleman at the 2012 Annual NAMI convention and a TED 2013 talk in Los Angeles by British voice hearer and psychologist Eleanor Longden, suggest that the tide is starting to turn (Arenella, 2012; Grantham, 2012; Thomas, 2012). At its core, the HVM emphasizes a few basic, but important, points: that antipsychotic pharmacotherapy and various forms of psychotherapy that aim to suppress psychotic experiences are often-for too many people-ineffective or insufficient; that voices and other extreme experiences and beliefs carry important messages that need to be explored rather than silenced, and that voices themselves are often less of the problem than the difficulties individuals have in coping and negotiating with them (Corstens, Escher, & Romme, 2008; Longden, Corstens, Escher, & Romme, 2012; Place, Foxcroft, & Shaw, 2011).
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Background: For 25 years, the international Hearing Voices Movement and the U.K. Hearing Voices Network have campaigned to improve the lives of people who hear voices. In doing so, they have introduced a new term into the mental health lexicon: "the voice-hearer." Aims: This article offers a "thick description" of the figure of "the voice-hearer." Method: A selection of prominent texts (life narratives, research papers, videos and blogs), the majority produced by people active in the Hearing Voices or consumer/survivor/ex-patient movements, were analysed from an interdisciplinary medical humanities perspective. Results: "The voice-hearer" (i) asserts voice-hearing as a meaningful experience, (ii) challenges psychiatric authority and (iii) builds identity through sharing life narrative. While technically accurate, the definition of "the voice-hearer" as simply "a person who has experienced voice-hearing or auditory verbal hallucinations" fails to acknowledge that this is a complex, politically resonant and value-laden identity. Conclusions: The figure of "the voice-hearer" comes into being through a specific set of narrative practices as an "expert by experience" who challenges the authority and diagnostic categories of mainstream psychiatry, especially the category of "schizophrenia."
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Although people who hear voices may dialogue with them, they are regularly caught in destructive communication patterns that disturb social functioning. This article presents an approach called Talking With Voices, derived from the theory and practice of Voice Dialogue (Stone & Stone, 198930. Stone , H. and Stone , S. 1989 . Embracing our selves: The voice dialogue training manual , New York , NY : Nataraj Publishing . View all references: Embracing our selves: The voice dialogue training manual, New York: Nataraj Publishing), whereby a facilitator directly engages with the voice(s) in order to heighten awareness and understanding of voice characteristics. The method provides insight into the underlying reasons for voice emergence and origins, and can ultimately inspire a more productive relationship between hearer and voice(s). We discuss the rationale for the approach and provide guidance in applying it. Case examples are also presented.
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High rates of childhood abuse (CA) have been reported among people with severe mental illness, but the content of psychotic symptoms is not generally considered pertinent to diagnosis and treatment. This study explores associations between CA and the content of adult psychotic symptoms. A sample of 30 respondents was selected from a larger study of individuals interviewed using standardized and open-ended questions to assess history of CA, and to elicit content of hallucinations and delusions (HD). Interviews included detailed descriptions of psychotic symptoms and CA experiences, which were coded using qualitative techniques. Based on a review of the research, we constructed a measure comprising nine categories of symptom content found to occur among individuals reporting CA (Threat, Somatic/Tactile, Olfactory, or Kinetic sensations, Real person involved, Fear, Malevolence, Sexuality, and Memories). This “trauma-relevant content score” was used to compare abused and nonabused groups, and was found to be higher among abused than nonabused respondents. Additionally, we examined parallels between interpersonal relationships described in HD and those experienced in the context of childhood trauma, using a multiple case study approach, and drawing on the Core Conflictual Relationship Theme (CCRT) method of analysis. Congruent patterns of interaction were identified in trauma and symptom descriptions of abused respondents. Implications for research and clinical practice include identifying symptom characteristics relevant to CA history, and developing a strategy to assess correspondence between individuals' trauma and symptom reports. Identification of trauma-relevant characteristics in symptom content can provide clinicians with an effective means of recognizing trauma-related illness. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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While auditory hallucinations are considered a core psychotic symptom, central to the diagnosis of schizophrenia, it has long been recognized that persons who are not psychotic may also hear voices. There is an entrenched clinical belief that distinctions can be made between these groups, typically on the basis of the perceived location or the ‘third-person’ perspective of the voices. While it is generally believed that such characteristics of voices have significant clinical implications, and are important in the differential diagnosis between dissociative and psychotic disorders, there is no research evidence in support of this. Voices heard by persons diagnosed schizophrenic appear to be indistinguishable, on the basis of their experienced characteristics, from voices heard by persons with dissociative disorders or with no mental disorder at all. On this and other bases outlined below, we argue that hearing voices should be considered a dissociative experience, which under some conditions may have pathological consequences. In other words, we believe that, while voices may occur in the context of a psychotic disorder, they should not be considered a psychotic symptom.
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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.
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Although people who hear voices may dialogue with them, they are regularly caught in destructive communication patterns that disturb social functioning. This article presents an approach called Talking With Voices, derived from the theory and practice of Voice Dialogue (Stone & Stone, 1989: Embracing our selves: The voice dialogue training manual, New York: Nataraj Publishing), whereby a facilitator directly engages with the voice(s) in order to heighten awareness and understanding of voice characteristics. The method provides insight into the underlying reasons for voice emergence and origins, and can ultimately inspire a more productive relationship between hearer and voice(s). We discuss the rationale for the approach and provide guidance in applying it. Case examples are also presented.
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The history of the Maastricht approach and of the hearing voices movementRelevant research findingsAssessment: The Maastricht hearing voices interviewFormulation: Making the construct/breaking the codeCase vignette: MaureenMaking a treatment planTalking with the voicesRecoverySummaryReferences
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Dissociation: Mesmerism, multiple personalities and hysteriaPsychosis: Insanity, dementia praecox and schizophreniaDissociation, psychosis and schizophrenia: The merging of constructsConclusion References
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BACKGROUND: Childhood adversity is a putative risk factor for schizophrenia, although evidence supporting this suggestion is inconsistent and controversial. The aim of this review was to pool and quality assess the current evidence pertaining to childhood adversity in people with schizophrenia compared to other psychiatric disorders and to non-psychiatric controls.Method Included were case-control, cohort and cross-sectional studies. Medline, EMBASE and PsycINFO databases were searched. Study reporting was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist and pooled evidence quality was assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: Twenty-five studies met inclusion criteria. Moderate to high quality evidence suggests increased rates of childhood adversity in schizophrenia compared to controls [odds ratio (OR) 3.60, p<0.00001]. Increased childhood adversity was also reported in schizophrenia compared to anxiety disorders (OR 2.54, p=0.007), although the effect was not significant in the subgroup analysis of five studies assessing only sexual abuse. No differences in rates of childhood adversity were found between schizophrenia and affective psychosis, depression and personality disorders whereas decreased rates of childhood adversity were found in schizophrenia relative to dissociative disorders and post-traumatic stress disorder (OR 0.03, p<0.0001). CONCLUSIONS: This is the first meta-analysis to report a medium to large effect of childhood adversity in people with schizophrenia and to assess specificity for schizophrenia. Further research is required that incorporates longitudinal design and other potentially causal variables to assess additive and/or interactive effects.
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Background: Hallucinations have consistently been associated with traumatic experiences during childhood. This association appears strongest between physical and sexual abuse and auditory verbal hallucinations (AVH). It remains unclear whether traumatic experiences mainly colour the content of AVH or whether childhood trauma triggers the vulnerability to experience hallucinations in general. In order to investigate the association between hallucinations, childhood trauma and the emotional content of hallucinations, experienced trauma and phenomenology of AVH were investigated in non-psychotic individuals and in patients with a psychotic disorder who hear voices. Method: A total of 127 non-psychotic individuals with frequent AVH, 124 healthy controls and 100 psychotic patients with AVH were assessed for childhood trauma. Prevalence of childhood trauma was compared between groups and the relation between characteristics of voices, especially emotional valence of content, and childhood trauma was investigated. Results: Both non-psychotic individuals with AVH and patients with a psychotic disorder and AVH experienced more sexual and emotional abuse compared with the healthy controls. No difference in the prevalence of traumatic experiences could be observed between the two groups experiencing AVH. In addition, no type of childhood trauma could distinguish between positive or negative emotional valence of the voices and associated distress. No correlations were found between sexual abuse and emotional abuse and other AVH characteristics. Conclusions: These results suggest that sexual and emotional trauma during childhood render a person more vulnerable to experience AVH in general, which can be either positive voices without associated distress or negative voices as part of a psychotic disorder.
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The recognition that the personal cannot, ever, be other than politically developed from the women’s liberation movement of the 1960s (Hanish, 1970). It was an acknowledgment that the experiences, feelings and possibilities of our personal lives are not just a private matter of personal preferences and choices but are limited, moulded, defined and delimited by the broader political and social context. They feel personal, and their details are personal, but their broad texture and character, and especially the limits within which these evolve, are largely systemic. This concept is very relevant to contemporary mental health but, before looking at the political, I need to start with the personal. I would like to go back, right to the very beginning.
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The meanings and causes of hearing voices that others cannot hear (auditory verbal hallucinations, in psychiatric parlance) have been debated for thousands of years. Voice-hearing has been both revered and condemned, understood as a symptom of disease as well as a source of otherworldly communication. Those hearing voices have been viewed as mystics, potential psychiatric patients or simply just people with unusual experiences, and have been beatified, esteemed or accepted, as well as drugged, burnt or gassed. This book travels from voice-hearing in the ancient world through to contemporary experience, examining how power, politics, gender, medicine and religion have shaped the meaning of hearing voices. Who hears voices today, what these voices are like and their potential impact are comprehensively examined. Cutting edge neuroscience is integrated with current psychological theories to consider what may cause voices and the future of research in voice-hearing is explored.
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Background: We seek to estimate lifetime prevalence and demographic correlates of nonaffective psychosis in the US population assessed by a computer-analyzed structured interview and a senior clinician. Methods: In the National Comorbidity Survey, a probability subsample of 5877 respondents were administered a screen for psychotic symptoms. Based on the response to this screening, detailed follow-up interviews were conducted by mental health professionals (n=454). The initial screen and clinical reinterview were reviewed by a senior clinician. Results are presented for narrowly (schizophrenia or schizophreniform disorder) and broadly (all nonaffective psychoses) defined psychotic illness. Results: One or more psychosis screening questions were endorsed by 28.4% of individuals. By computer algorithm, lifetime prevalences of narrowly and broadly defined psychotic illness were 1.3% and 2.2%, respectively. Of those assigned a narrow diagnosis by the computer, the senior clinician assigned narrow and broad diagnoses to 10% and 37%, respectively. By clinician diagnosis, lifetime prevalence rates of narrowly and broadly defined psychosis were 0.2% and 0.7%, respectively. A clinician diagnosis of nonaffective psychosis was significantly associated with low income; unemployment; a marital status of single, divorced, or separated; and urban residence. Clinician confirmation of a computer diagnosis was predicted by hospitalization, neuroleptic treatment, duration of illness, enduring impairment, and thought disorder. Conclusions: Lifetime prevalence estimates of psychosis in community samples are strongly influenced by methods of assessment and diagnosis. Although results using computer algorithms were similar in the National Comorbidity Survey and Epidemiologic Catchment Area studies, diagnoses so obtained agreed poorly with clinical diagnoses. Accurate assessment of psychotic illness in epidemiologic samples may require collection of extensive contextual information for clinician review.
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Jaynes' elaborate theory of the evolution of human consciousness speculates that unconscious language use by the right hemisphere produced frequent auditory hallucinations in primitive people [1]. Jaynes offers some explanation as to why hearing voices would now be less common. It is parsimonious, however, to predict that hearing voices is still common, although usually unreported, in the modern normal population. Some clinical literature gives support to this prediction. This study tested the prediction by means of surveying 375 college students with a two-part questionnaire. The first section presented fourteen different examples of auditory hallucinations and asked whether the subject had experienced such occurrences. The second section asked for information concerning the characteristics of any hallucinated voices and for information about the subject that might relate to cerebral laterality. The results support the prediction that hearing voices is common within the normal population. Overall, 71 percent of the sample reported some experience with brief, auditory hallucinations of the voice type in wakeful situations. Hypnagogic and hypnopompic hallucinations were also reported. The most frequent incidents were hearing a voice call one's name aloud when alone (36%) and hearing one's thoughts as if spoken aloud (39%). Interviews and MMPI results obtained from twenty selected subjects suggested that these reports of hearing voices were not related to pathology. Further findings of a significant relationship between high rates of auditory hallucinations and the extent to which subjects reported skills in music, art, and poetry were interpreted as weak support for Jaynes' speculation that right hemisphere activity may account for auditory hallucinations. Overall, the results are seen as supportive of several of Jaynes' theoretical points.
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Two studies are reported that describe the phenomena of verbal hallucinations in the general population and test two explanations of those reports. Subjects were 198 male and 387 female college students who completed a verbal hallucination questionnaire plus one or more additional questionnaires. We found that a large minority reported hallucinations and that nearly half reported having them at least once a month. The present data indicated that these reports were not related to four measures of social conformity. Neither were they related to measures of overt, or incipient, symptoms of psychopathology. We have concluded that the majority of these reports are generally veridical accounts of conscious experience in normal individuals.
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There is a substantial body of research indicating an association between childhood adversity and later psychosis. Cross-sectional, correlational studies have given way to large-scale, case-controlled studies which indicate a dose-response association indicative of a causal relationship. Several psychological and biological models have been proposed which offer credible accounts of the processes by which trauma may increase the risk of psychosis, including cognitive, psychodynamic, dissociation and attachment perspectives. Clinically it is imperative routinely to enquire about traumatic experiences, to respond appropriately and to offer psychosocial treatments to those who report traumatic life events in the context of psychotic experiences.
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Fifty-three women outpatients participated in short-term therapy groups for incest survivors. This treatment modality proved to be a powerful stimulus for recovery of previously repressed traumatic memories. A relationship was observed between the age of onset, duration, and degree of violence of the abuse and the extent to which memory of the abuse had been repressed. Three out of four patients were able to validate their memories by obtaining corroborating evidence from other sources. The therapeutic function of recovering and validating traumatic memories is explored.
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Background: Cognitive models have postulated that auditory hallucinations arise from the misattribution of internally generated cognitive events to external sources. Several experimental paradigms have been developed to assess this externalizing bias in clinical and non-clinical hallucination-prone samples, including source-monitoring, verbal self-monitoring and auditory signal detection tasks. This meta-analysis aims to synthesize the wealth of empirical findings from these experimental studies. Method: A database search was carried out for reports between January 1985 and March 2012. Additional studies were retrieved by contacting authors and screening references of eligible reports. Studies were considered eligible if they compared either (i) hallucinating and non-hallucinating patients with comparable diagnoses, or (ii) non-clinical hallucination-prone and non-prone participants using source-monitoring, verbal self-monitoring or signal detection tasks, or used correlational analyses to estimate comparable effects. Results: The analysis included 15 clinical (240 hallucinating patients and 249 non-hallucinating patients) and nine non-clinical studies (171 hallucination-prone and 177 non-prone participants; 57 participants in a correlation study). Moderate-to-large summary effects were observed in both the clinical and analogue samples. Robust and significant effects were observed in source-monitoring and signal detection studies, but not in self-monitoring studies, possibly due to the small numbers of eligible studies in this subgroup. The use of emotionally valenced stimuli led to effects of similar magnitude to the use of neutral stimuli. Conclusions: The findings suggest that externalizing biases are important cognitive underpinnings of hallucinatory experiences. Clinical interventions targeting these biases should be explored as possible treatments for clients with distressing voices.
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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.
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I now come from the very firm belief that people can and do recover, that people are not defined by illness or diagnosis. I also believe that we need to look at people as a whole. Two years ago, however, I was firmly convinced that I was defined by my illness and limited by my diagnosis. I was told I could not live the life that I wanted and that I would need medication forever. I was never told I could recover. My journey was not an easy one and there were many occasions when I wanted to give up. Throughout my journey I discovered the importance of understanding my human experience thus far and how past events and experiences have shaped me into the person I am today. The story of recovery is still not a common enough story, but the possibilities of recovery are endless! Recovery is much more than becoming stable; it’s about bettering who you are and finding meaning. Recovery was made possible for me by people having hope that I could find myself again; people seeing past the so-called illness and seeing something in me, something worthwhile. My story is common. It is not extraordinary in any way.
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Discusses disturbances of perception found in adult female incest survivors and considers specific implications for therapy. Incest refers to repeated sexual contact between a child and an adult who has violated a position of trust, authority, or caretaking. Hallucinations frequently observed in female incest survivors are intrusive recollections taking the form of sensory phenomena and usually involve shadowy figures, often moving rapidly in the peripheral vision. Psychosensorial auditory hallucinations are common, and psychic auditory hallucinations are sometimes quite elaborate. Such perceptual disturbances, with certain thought disturbances, have been reliable evidence of an incest history. Avoidance and denial must be overcome in therapy. Reconstruction, linking interpretation, and derivative playbacks are useful therapeutic techniques for the adult female incest survivor. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Investigated symptoms of incest survivors by interviewing female community mental health outpatients at intake and during treatment. Mental status examination (MSE) procedures were used in relatively unstructured interviews. A minimum of 40 16–50 yr old incest survivors were identified. An MSE profile found to be exclusively associated with a history of childhood incest was developed. Thought content disturbances included recurring nightmares, intrusive obsessions, dissociation, and persistent phobias. Perceptual disturbances included recurring illusions and auditory, visual, and tactile hallucinations. The interviewing technique used for syndrome detection is described. It is suggested that a symptom is significant if it occurs 2 or more times a month or has occurred that often in the past; any combination of 7 symptoms or more is said to be predictive of incest. Discussion includes the nature, variations, and frequency of occurrence of individual symptoms. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Ed Marius Romme, Sandra Escher MIND Publications, £13.99, pp 258 ISBN 1-874690-13-8Auditory hallucinations are among the most distressing symptoms of schizophrenia, and much therapeutic effort in dealing with schizophrenia is aimed at extinguishing, or at least alleviating, the impact of the voices that people hear. Indeed, removal of auditory hallucinations is often taken as a sign of the success of treatment even if the underlying disorder remains.Modern psychological approaches to treating schizophrenia emphasise two points. The first is the strong evidence that prolonged exposure of the patient to active psychosis is in itself damaging. Thus, there is a good reason for reducing the length of exposure to symptoms, especially auditory hallucinations. Clearly, the most efficacious and widely used method is to treat the patient with neuroleptics, but some patients have …
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Cognitive and cognitive behavioural therapies for psychosis involve talking to patients about their symptoms and life predicament, and attempting to make sense of such problems in terms of a cognitive formulation of psychosis. The aim is to engage in collaborative discussions which lead to the fostering of less distressing and more constructive ways of understanding psychosis, and behaviour likely to promote recovery. Recent randomised controlled treatment trials provide strong evidence that such therapies can have a significant impact on the symptoms and problems presented by people with psychosis. This paper outlines the formulation and treatment approach of cognitive behavioural therapy for psychosis, provides a brief review of the findings of recent controlled treatment trials, and addresses issues relating to how cognitive behavioural therapies might be integrated within mainstream mental health services.
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Treatment non-adherence is a common problem in mental health services but little is known about non-adherence to psychological therapy for psychosis. The main aim of the present study was to investigate the role of patients' recovery style and the therapeutic alliance in provoking or forestalling patient drop-out from cognitive behaviour therapy (CBT) for psychosis. Ratings were made by two independent observers on 29 recordings of sessions from a controlled trial of CBT for psychosis. Sessions of 10 patients who dropped out of treatment prematurely were matched with sessions of 10 patients who stayed in. Another nine sessions were selected at random from the middle and late stages of treatment so that the sample was representative of all sessions in the trial. Patients who dropped out of treatment, compared with those who stayed in, were less engaged in treatment, showed less agreement with their therapists, and had a sealing-over recovery style before they dropped out but did not differ in their therapeutic bonds. The results suggest that the premature termination of the drop-outs was not provoked by the therapists but was due to the patients' lack of curiosity about their psychotic episodes and minimization of the impact of their illness.
Article
A large proportion of children across the globe suffer abuse or neglect. 1 , 2 Therefore, studies that shed light on the health consequences of adverse childhood experiences and examine the potential for resilience are of great importance. The meta-analysis by Varese et al. 3 in this volume is a welcome addition to these studies.