Rufus May

Rufus May and Eleanor Longden

“We must become confident in our own abilities to change our lives; we must give up being reliant on others to do everything for us. We need to start doing these things for ourselves. We must have the confidence to give up being ill so that we can start being recovered.”
Coleman (2004: p.15)

The self-help movement offers a challenge to traditional approaches of professional help-giving, emphasising the expertise that lies within the individual. Self-help strategies are creative, continuously evolving and less amenable to the traditional types of evidence base as conventional approaches to the experience of living with voices . However self-help techniques are very compatible alongside professional help-giving approaches, as are self-help groups. Why are self-help movements required? The traditional psychiatric paradigm has emphasised medical remedies, which require a fairly passive response from the recipient. Hospital treatment, which many voice-hearers have been given to reduce their distress, has traditionally encouraged the patient to passively adapt to the routines of the hospital ward and pharmacological treatment. A self-help ethos offers a shift of emphasis from the passive to the active. It says we can change our attitudes and experiences by making choices and taking action.

This chapter will outline the emancipatory philosophy of the hearing voices movement before outlining the group and individual approaches to self-help that have emerged over the last 20 years. We will look at the three stages of voice hearing and likely self help strategies that will complement these stages.

“The Freedom to Hear Voices”: The Hearing Voices Movement

Since its launch in the late 1980’s, inspired by the innovative work of Romme and Escher (1989a, 1990, 1993, 2000), the hearing voices movement has proposed that self-help initiatives and the ‘expertise of experience’ should be given equal status to academic and professional wisdoms. While not denying that voice-hearing is often distressing and demoralising, the hearing voices movement disputes such psychological turmoil is indicative of organic pathology. Rather than a meaningless mental illness requiring eradication and ‘cure’ at the hands of a pharmaceutical arsenal, voice-hearing is deemed significant, decipherable and intimately entwined to a hearer’s life story. As an alternative to the traditional attempt to silence or cure the person of voices, understanding, accepting and integrating their emotional meaning is suggested as the recovery response. Voices are characterised as messengers which communicate important information about genuine problems and emotional traumas in the person’s life. Therefore it simply does not make sense to shoot the messenger; conversely, helping the person to listen to the voices without anguish is a more authentic long-term solution than extinguishing them and ‘ignoring’ the message. To recover from distress, the person must learn to cope both with their voices and the original problems at the heart of the experience. Moreover, the ethos of the hearing voices movement is to accept a diverse range of explanations for voice-hearing and support the person to find empowering ways to use these understandings- if an individual claims to be communing with God, and finds the experience valuable, no efforts are made to divest them of it, but discover what it means to them.

The philosophy of ‘accepting voices’ (e.g. Romme and Escher, 1989a, 1990, 1993, 2000) was developed in close collaboration with voice-hearers. It proposed that a) voice-hearing is a normal human experience which is widely prevalent in the general population b) has a personal meaning in relation with life history whose meaning or purpose can be deciphered and, c) is best considered a dissociative experience and not a psychotic symptom. The fact that many voice-hearers have suffered from trauma is a neglected aspect of the voice-hearing experience and psychosis in general (e.g. Read and Ross, 2003; Read, van Os, Morrison and Ross, 2005; Moskowitz and Corstens, 2007). Thus in addition to emphasising understanding the purpose/meaning of the voices, a specific treatment model for working directly with a person’s voices – emphasising their dissociative nature – has been developed by adapting the Voice Dialogue method (Stone and Stone, 1989) for working with voice-hearing (e.g. Corstens, May and Longden, in press; Moskowitz and Corstens, 2007). In contrast, Western clinical psychiatry sees voices as symptoms of an illness, a meaningless pathological phenomenon (Leudar and Thomas, 2000; Smith, 2007). As such, its only goal is eliminating the voices; it has little to offer voice-hearers who seek help beyond medication. However, from Romme and Escher’s perspective, rejecting the meaning of the voices is the same as rejecting the person.

Paul Baker, a British community development worker who was present when Romme and Escher publicly delivered their findings for the first time, later recorded: “Fundamental to this approach…has been its emphasis on partnership between voice-hearers themselves and professionals…this was a refreshing change from most of the approaches I had come across before which rarely – if ever, gave such importance to the views of those who had actually experienced the mental health difficulties under consideration” (Baker, 1989:11). Mark Greenwood, a colleague of Baker’s, was affected by his enthusiasm and organised a trip to visit Romme at his home in Maastricht. He was equally impressed: “We could see why Paul was getting so excited…we immediately grasped the significance of it” (quoted in James, 2001: 47-48). Romme (2000), has since likened the ‘emancipation’ of voice-hearer’s to the civil right movements of the 1960s, in which medicine wields a yoke of cultural, social and psychological oppression. From Romme’s perspective, psychiatry must change its attitudes toward voice-hearing in the same way it changed its attitudes towards homosexuality – learning to respect and support the experience rather than ‘cure’ it. The hearing voices movement affirms this protesting stance, and the approach has become progressively more powerful and influential, dispersing across Europe, Australia, Japan and elsewhere in the form of research, forums, conferences, publications and self-help groups. These activities evoked, induced and ultimately became embedded in what is now referred to as ‘the hearing voices movement’, a philosophical and social trend in which networks of voice-hearers organised outside the psychiatric system seek and elaborate ways to support one another, empower themselves and work towards recovery in their own ways. The foundation of such networks have created possibilities for acknowledging and supporting voice-hearers and, crucially, spread the forgotten revelation that people can learn to live with their voices. Accepting and making sense of voices has thus become a new paradigm, constructively creating new ways of recovery. From a political perspective, the hearing voices movement has also become an alternative to traditional psychiatry, where those who were traumatized by oppressive approaches could find acknowledgement and personal attention. Thus the hearing voices movement has challenged the political power of  psychiatry;  However, in contrast to the anti-psychiatry movement, voice-hearers themselves in partnership with others have gained  the right to be heard and a social movement has developed in which “experts-by-experience” have been able to challenge the psychiatric system.

Hearing Voices Groups

Hearing voices groups are forums in which individuals who share the experience of voice-hearing can gather together to gain support, exchange coping strategies, share feelings and reduce feelings of stigma, isolation and distress (see Romme and Escher, 1989b, 2000; Downs, 2005; Dillon, 2006). Sometimes the group may include relatives, friends and allies of people who hear voices, and empathic professionals may request permission to attend meetings in order to increase their own aptitude for assisting and supporting their clients. Often members will utilise the group for different purposes and in different ways. For this reason, it is generally not helpful to evaluate groups in terms of measurable outcomes, such as how many attend, as this will inevitably fluctuate as people’s needs, requirements and personal circumstances change (Downs, 2005). Generally most members will find considerable comfort and reassurance simply in the group’s existence, even if they use it intermittently. Groups vary in their emphasis on mutual support, exploring emotional issues and education and campaigning work and can often complement individual psychotherapeutic support  by providing people with the confidence to work more deeply on the emotions and narratives underlying their voice-hearing experiences.

Self-help groups aim to provide appropriate support and resources for voice-hearers to understand and cope with their experiences, share ways of coping, reduce distress and gain control; “a safe-haven where people feel accepted and comfortable” (Downs, 2005: 5). Because voice-hearing, by definition, is a lonely experience providing a space where feelings can be discussed freely and without censure often proves hugely empowering. Silence can be a handicap and Escher (1993) has interviewed many voice-hearers in order to elucidate the advantages of speaking about one’s voices to a compassionate audience. Her findings can be summarised as the following:

1. Engaging with the experience can help identify patterns, such as linking negative or difficult feelings to a critical voice.
2. Discussion can stimulate acceptance of the voice-hearing experience and help cultivate a healthy identity as someone who hears voices.
3. By recognising and exploring possible meanings, individuals may begin negotiating and improving their relationship with their voices.
4. It can be affirming and validating for individuals to recognise their own situation in the experiences of others.
5. Whereas avoidance can evoke feelings of powerless and anxiety, talking can reduce isolation and fear.

While mental health professionals can assist in organising this kind of self-help, it needs to be a genuinely shared and collaborative process with voice-hearers themselves. In contrast to clinical perspectives, in which self-help is often organised in terms of diagnostic categories (schizophrenia, manic depression) the English Hearing Voices Network advocates groups which are simply organised on the basis of shared experience (voice-hearing) regardless of psychiatric status. While professionals may be involved in an advisory capacity, or to provide resources and infrastructure in partnership with voice-hearers, the group is led by shared decisions of all its members. Group members seek solutions within their own frame of reference or understanding without pressure to conform to medical or even psychological explanations. This means that there is an ethos within groups that different understandings of voice-hearing are acceptable and that there is no one right way to understand the experience. There is an emphasis on voice-hearers taking responsibility for running self-help initiatives wherever possible. For example, the English Hearing Voices Network (which comprises of over 180 groups) now has a board of trustees entirely comprised of voice-hearing individuals, whereas previously there were a greater proportion of academic and clinical professionals involved in its leadership. Within groups, members are encouraged to be active participants and are seen as having unique understanding and expertise about their own experiences. This can often be developed within a dialogical context, where different understandings of voice-hearing are valued and exchanged. This atmosphere of mutual support and collective involvement enables former recipients of care to get involved in providing empowering and safe spaces for other voice-hearers. Safety is ensured by agreeing ground rules around confidentiality, mutual respect, equal opportunities, respect for different understandings and limiting access to non-voice hearers who just want to attend to ‘observe’. Groups become places where people’s courage to face their fears is generated. As Reeves (1997) describes, this courage enables people to commence on a journey of self-discovery.

In the weekly running of such groups, the democratic principle is for members to share decision-making in terms of how the group is run and what initiatives it adopts. In the UK over the last 20 years, hearing voices groups have primarily been a place for support and a forum for sharing self-help strategies. Yet as crucial as this function is, there has also been an equal emphasis on information dissemination, in which conferences, training courses, newsletters and self-help literature are widely distributed to create productive partnerships with professionals, relatives and other societal groups. Furthermore, this kind of outreach work has helped promote tolerance, awareness and positive explanations for voice hearing as well as spread the ethos of the hearing voices movement to a wider audience.

Within groups many helpful processes occur. Launch events and publicity actions, done in conjunction with local and national media, informs a broader population about the resources available.  A diverse range of coping strategies are regularly discussed and exchanged and groups can often generate their own literature about this and distribute it to interested parties in the wider community.  In relation to aggressive and bullying voices, voice-hearers are encouraged to learn how to resist destructive commands and realise they have a choice over their actions. Grounding, expressive and calming exercises are often explored within groups to enhance people’s coping abilities – not only to deal with the voice-hearing experience itself in a meaningful way, but also the challenging thoughts and feelings which often accompany it. Guest speakers from different spiritual, social and professional perspectives can broaden the awareness of group members.  People have the opportunity to learn to see their voice hearing as symbolic and meaningful. Within groups there is an educational opportunity to learn about different ways of understanding voice-hearing, including emotional, political, philosophical, cultural and spiritual understandings. Groups are also a space to find out about current research findings relating to voice-hearing. In addition, groups are a place where people support each other to deal with the prejudice and misunderstanding voice hearers often experience in community and psychiatric settings. Within groups people tell their stories about who they are and what they have been through, thus developing a stronger sense of autonomy, identity and self-determination. A space is also created where people can hear reassuring and empowering stories about how others have transformed their relationships with their voice-hearing experiences and their emotions.

In our experience of facilitating and attending self-help groups, this pooling of collective resources and abilities is an immensely positive, affirmative and empowering phenomenon. For this reason, we have included the following three stories to both illustrate the power of collective discussion and debate and to serve as inspiration and motivation for people to expect more from themselves and their lives:

Example One: “David”
David, a 45 year-old man who had been diagnosed with schizophrenia and received treatment for 20 years, came to the hearing voices group for the first time. That week there was a discussion about bullying, and how domineering voices often relate to bullying relationships people have experienced in the past. The next week, David spoke of the profound effect this had on him – no one had ever suggested possible links between his voices and his life experience before. He explained he had experienced sexual abuse as a child and how it made a lot of sense that his voices were linked to these experiences. He then described some of his voice’s communications. As well as criticising him, it urged him to seek revenge on authority. It spoke about the class system and said that when the time was right, he would be able to wreak revenge on people in power. Within the group we discussed the importance of interpreting menacing voices in a symbolical rather than literal way as well as the concept of ‘soft revenge’ (i.e. restoring justice in society without re-enacting violence on others). Realising that his voices related to disempowering experiences in his childhood (and his own need to address this injustice) gave David more confidence to resist direct commands from his voices and plan ways to get more involved in raising awareness about the damaging effects of childhood sexual abuse.  David also brought other examples of the content of his voices to the group. For example, if they said “you are useless” we discussed whether this was an indication David wanted himself desired to be more active. This lead to him thinking about ways to get more involved in voluntary work.

In such a situation it seems that the group can become an empowering place for people to think about the content of their voices and how this might relate to their own feelings, needs, desires and aspirations. The fact that this process is witnessed by others in a group setting can add to the power of the realisations people have and resolutions they make to act in new ways.

Example Two: “Catherine”
Catherine was a young mother and a survivor of torture who was seeking asylum and a regular member of her local hearing voices group. When she first came to the group she was extremely socially isolated. For six months she heard the voice and saw the image of a fellow prisoner (who had died when they were both incarcerated) standing by her bedroom window. In the group she described the guilt she felt about his death. Despite being reassured in the past that the perpetrators, not her, were responsible for her friend’s death, these feelings of remorse had never left her. Because she found the image extremely frightening, Catherine slept in her lounge and could not go into the bedroom. The group suggested she write a letter to her friend and explain her feelings and sadness about his death. She did this, however the image remained. In connection with the group, Catherine took part in a series of drama sessions that used improvisation and drama-games to explore power relationships and voice-hearing. Catherine also began attending a college after being told by another group member about a free crèche service at the college to access this. One day, shortly after a self-help group where we had concentrated on the value of facing your fears, Catherine decided to confront the image. Holding the hand of her young son, she walked up to it and touched it. Afterwards the image vanished – and has never reappeared.

The power of social connectedness of both attending the self-help group and later the college and drama group allowed Catherine to build up her confidence in being able to face her fears and find new ways to understand her trauma experiences which her voice-hearing and visions represented.

Example Three: “Nigel”
Nigel, a 29-year old man came to the group for the first time whilst an in-patient. Because the group had a guest speaker that week, I [Rufus] was aware we had not focussed on coping strategies as much as we normally do when a new member arrives, so I offered to spend some time with Nigel afterwards exploring his experiences. Nigel heard two voices. One, which he had heard for five years, sounded like a 50-year old man, was critical and often ordered him to self-harm. When asked if there was anyone in his life who had intimidated him in the way the voice did, Nigel identified a geography teacher who used to hit the desks with a ruler in a threatening way.  Nigel reflected that maybe this was a significant experience of a formidable authoritarian figure in his life and the voice therefore reflected many of the characteristics of this character. This voice had started shortly after Nigel had a major operation in which he thought he was going to die.  I explained that sometimes we may subconsciously invite figures in our minds to come and help us at difficult times. Nigel related to this to a memory of when he was very ill in hospital, thinking the Doctors were trying to kill him. In his dream-like state, he had requested ‘the devil’ to help him survive. Nigel had read Faust (who sells his soul to the devil in return for youth and power) when he was younger and considered that he might have used this story as a blueprint to recruit a powerful fighting spirit for help. I explained that he could change the ‘contract’ with this figure in order to reclaim his fighting energy and learn to stand up for himself.

We explored this possibility with me encouraging him to have  a conversation with his voice. Nigel had never conversed with it before, but with my support, asked the voice why he had appeared. The voice said: “To help you survive”.  Nigel then asked it why it told him to cut himself, to which it replied “To show people how strong you are”.  I then asked Nigel to ask the voice if it wanted him to stand up for himself and express his needs more: “Yes”, the voice said, “That is what I have been trying to tell him for years.” Nigel then asked the voice “So you ask me to self harm when you are frustrated that I have not stood up for myself?” The voice agreed this was the case.  We then did some assertiveness exercises and shadow-boxing to enact Nigel defending himself. The voice commented to Nigel that it particularly liked the boxing. I suggested he write a letter to the voice, acknowledging how it had helped him have a fighting spirit when physically ill but now the arrangement/contract needed to change as he wished to reclaim his fighting spirit and learn to stick up for his needs – and to invite the voice to support him in this endeavour. We discussed how he could learn to interpret his voice not as a bully but as someone who is trying to teach him to assert himself more and defend his boundaries more.

The second voice was female and aged about 25. She was less negative than the first voice and only spoke about Nigel rather than to him. Nigel said that he also felt aged 25, despite chronologically being 29. We reflected that the shock of the operation had prevented him from developing emotionally. I asked Nigel if anybody fitted the description of the voice. Nigel explained that he had a female friend who had died in a car-crash about the time of his operation, which made him feel guilty that she had died while he had survived. I explained how survivor guilt is very common in such situations and suggested he write a letter to his 25-year old self, explaining that he was entitled to live and that the best way to honour his friend’s life was to live his own to the full. I also suggested he take up a self-defence practice and read Non-Violent Communication literature to help him learn to express his feelings assertively. The final suggestion was for Nigel to regularly come to the hearing voices group in order to meet other people who had changed their relationship with their voices.

This example shows how individual (psychotherapeutic) work complements self-help group work. We have found that the sense of acceptance (or normalisation) one gets from attending a group gives people the courage to face and set boundaries with their voice-hearing experiences and find new ways to integrate the emotions the voices represent into their lives.  Nigel was soon discharged from hospital and became a regular member of the group as he rebuilt his confidence and began to plan ways to return to employment.

White (1996) has chronicled his experiences of self-help group facilitation under the title ‘Power to Our Journeys’, in which members describe how the sense of acknowledgement, justice, solidarity and ‘lightness of being’ the group provided helped rekindle their love of life. Similarly, Ron Coleman, whose own triumph from the anguish of voice-hearing is well documented (e.g. James, 2001; Laurance, 2003; Coleman, 2004) uses a travel analogy to describe the journey back to reclaiming one’s life. Although painful and arduous, the voyage is considerably eased by a good map of the terrain – and this is something self-help groups can provide. In the quest to change from “victim to victor” (Coleman and Smith, 2006) practical healing from distress goes hand-in-hand with learning to understand one’s self and experiences – personal input being the most powerful tool for change.

Coping Strategies

Voices can threaten, disturb, command and capture voice-hearers in a demoralising cycle of dependence, isolation and destructive activities. Furthermore, their influence tends to increase when the person pacifies them and sets no boundaries (Chadwick and Birchwood, 1994). Fortunately, there are many strategies voice-hearers can use to challenge the voices, impose their own limits and thus regain some control. As noted by Watkins (1998) a crucial source of distress and discontent for many voice-hearers relates to the fear of losing control. Given the peculiarly invasive quality that voices possess, this is an understandable imperative; being constantly invaded and imposed upon brings its own breed of helplessness. Thus a repertoire of methods for decreasing distress and regaining control is a key principle in any voice-hearer’s self-help strategy (e.g. Carter, MacKinnon and Copolov, 1996; Coleman, Smith and Good, 2003; Perron and Munson, 2006).

The following table illustrates a range of coping techniques that have been generated and discussed by members of the Hearing Voices in Bradford self-help group over the past few years. A certain amount of trial-and-error learning is germane to successful coping, as each individual must learn what suits them best and is most appropriate for their particular needs and circumstances. Furthermore, as voice-hearing is an experience which occurs within the context of a person’s whole life, a holistic, flexible approach to coping is the most apposite and useful. Thus the following categories are a good example of the considerable creativity and resourcefulness individuals can draw from in order to mitigate and ease their distress.

Table 1. Helpful and unhelpful strategies for coping with distressing voices.
Distraction Techniques 

• Watch films – comedy or inspirational.
• Read comedy novels or joke books.
• Listen to music.
• Tidy the house.
• Shopping.
• Phone a friend.
• Gardening.
• Exercise e.g. playing sport, walking the dog, running, dancing, swimming.
• Wear ear-plugs.
• Reading aloud.
• Puzzles/crosswords/sudouko.
• Arts and crafts.
• Watch TV.
• Cooking.
• Humming or singing.
• Playing board games/cards/computer.

Relaxation Strategies 

• Give yourself permission to relax.
• Recognise and acknowledge fears, then consciously let go of them.
• Prayer.
• Meditation.
• Massage/acupuncture/yoga.
• Focus on your breathing/breathe deeply.
• Listen to guided relaxation CDs.
• Listen to soothing music.
• Relax each muscle individually.
Self-Care and Comfort • Keep a list of achievements and strengths or a list of positive things other people have said about you.
• Positive self-talk and self-forgiveness.
• Look at comforting items e.g. e-mails, love letters, birthday cards, photos.
• Take a warm, scented bath.
• Wear comfortable clothes.
• Get help with practical problems e.g. housing, finances.
• Remember that situations/feelings frequently change -“This too shall pass”.
• Record positive statements onto a CD.
• Eat a healthy diet.
• Do something nice for ‘me’ each day.
• Keep in frequent contact with support network, even if feeling okay.
• Buy/pick fresh flowers.
• Change the sheets on your bed.
• Get a pet, or help care for someone else’s.
• Hold a safe, comforting object.
• Holidays.
• Humour.
• Plan the day to ensure there aren’t long periods of time with nothing to do.
• Sleeping.
• Create a personalised crisis plan when you are feeling well.
• Having good support around you.

Making Sense of the Experience 

• Keep a record of what the voices are saying.
• Talk about the voices to someone you trust.
• Join a self-help group, or set one up.
• Identify the voices – number, gender, age etc.
• Identifying triggers e.g. situations, emotions, other people…
• ‘Voice dialoguing’ – let someone you trust speak directly to the voices.
• Talk to the voices, find out how they feel.
• Write poetry/prose regarding feelings.
• Paint/draw emotions.
• Accepting that the voices themselves are not the problem, they are the result of a deeper, underlying problem. Your task is to find out more.
stressful life events and the voice hearing experience.

Challenging the Voices

• Refuse to obey commands, or delay obeying them.
• Ask the voices to justify their comments.
• ‘Time sharing’ – schedule a time for them, and refuse to listen until that time.
• Mentally visualize a barrier between yourself and the voices.
• Set boundaries – refuse to speak with negative voices unless they are respectful.
• Making deals e.g. “be quiet now and I’ll listen later”.
• Selective listening – only listening to the positive/least negative voices.
• Using positive voices as allies.
• Talk back to them (use a mobile phone if in public).
• Examine the validity of what they say e.g. Have they said the same things before? Do their predictions always come true? Is it possible to ignore them with no obvious consequences?

Things Which May Not Help 

• Being over-medicated and medication side-effects.
• Prejudice and stigma.
• Being labelled with a psychiatric diagnosis.
• Being told not to talk about voices because they’re “not real”.
• Professionals rejecting your explanation for your voices.
• Insomnia.
• Other people having low expectations for you.
• Being lonely and isolated.
• Not having information..
• Feeling negative.

Mindfulness

Mindfulness is increasingly being used for psychological approaches to voice-hearing and other experiences that can be seen as ‘psychotic’ (e.g. Chadwick, Taylor and Abba, 2005; Abba, Chadwick and Stevenson, 2008). Its roots are in Buddhist psychology, which has been developed over the last 3,000 years. We often use mindfulness at the beginning or end of self-help groups and the concept is becoming a progressively popular therapeutic approach; Acceptance and Commitment Therapy (e.g. Fletcher and Hayes, 2005) and Dialectical Behavioural Therapy (e.g. Robins, 2002) are two techniques for working with voice-hearers which place mindfulness at the heart of the method.

The aim of mindfulness is to develop an accepting approach to thoughts and feelings and through understanding these experiences develop more detachment and choice about how they influence us. Mindfulness aims to anchor the mind in ‘the here and now’ and promote a warm and compassionate approach to difficult events and experiences.  The writings of Jon Kabat-Zinn (e.g. 2001, 2005) and Thich Nhat Hanh (e.g. 2002, 2005) have been instructive self-help texts for many people using hearing voices groups. The following are mindfulness exercises that individuals within the hearing voices self-help movement report finding of benefit:

Mindful breathing
There are many mindful breathing exercises. Counting the breath involves counting each in-breath and out-breath:  “Breathing in one, breathing out one, breathing in two, breathing out two” and so on up to five (or ten). If the person becomes distracted and loses count they return to one again.  This is continued for a set time, say ten minutes.

Sitting calmly, focussing on the breath is another possible approach. Every time the person notices they have become distracted, they acknowledge the thought or feeling and come back to their breathing. If someone finds they are too easily distracted, visualising breathing in ‘healing white light’ and breathing out ‘black smoke of negativity’ is another exercise that can be used.

Alternate nostril breathing
Alternate nostril breathing involves the following exercise: hold one nostril closed and breathe in, then close the other nostril and breathe out, breathe back in the same nostril, close that nostril and breathe out the other. Repeat for ten minutes.

Mindful Walking
As we walk along the street, we can focus on each step whether we are breathing in or out, so we might be saying ‘in, in, in, out, out, out’ and so on. This technique can again reduce the number of thoughts flowing through our mind as we focus our concentration on our breathing. If indoors, we can do a slower meditation where we walk, very slowly, moving one foot forward in time with each in-breath or out-breath. If the person is practicing mindful walking on their own, they can invite someone they trust and respect to accompany them in their mind.  For example as someone is  walking and he/she breathes in they can say, for example “Ben, Ben, Ben,” inviting their friend’s presence to be with them; and as they breathe out say in their mind  “I am here, I am here, I am here” which also says that the person is there for their friend too (adapted from Nhat Hanh, 2002). A fourth type of mindful walking involves just walking slowly and focussing on each step and the environment as it is perceived through the senses.  This can be very calming and grounding if we do it in a park or other more natural setting.

Adopting a non-judgemental approach to challenging thoughts seems also very applicable to voice-hearing. Thich Nhat Hanh (2002) recommends smiling towards challenging thought structures, which he describes as habit energies, saying “Hello habit energy, I know you are there but you cannot make me do anything I don’t want to do. I acknowledge you are there but I am free form your influence.” We can use this same non-judgemental but assertive attitude towards voices.  From this position of tolerance we can go on to understand what emotions and relationship issues the voices might be representing.  This is similar to the attitudinal change recommended by Romme and Escher (2000): “Changing the relation to the voices is to become respectful to them, not fighting against them but talking to them slowly and with warmth, which has as a consequence that they also change their approach. It can also be testing out their power and finding that they are not almighty at all.”
 

Phases of Healing and Recovery

Trauma and recovery research and hearing-voices literature suggests there are three phases of healing: safety; making sense of one’s experiences and social reconnection (e.g. Romme and Escher, 1993; Herman, 1992; May 2004). This is not a linear process. For example, a deep sense of understanding one’s experiences may only come once someone feels grounded in a set of social relationships where they are valued and supported. The phases of recovery are more likely to be a circular, dynamic and iterative procedure that people need to revisit as they move forwards and become more confident in relations to their voice-hearing experiences and wider social relationships.

Phase One: Safety

Central to this preliminary stage is learning to cope with the intense anxiety that often accompanies the onset of voice-hearing. In recognition of this, Romme and Escher (1993) have deemed the beginning of voice-hearing as the ‘startling stage’, in lieu of its shocking and disorientating character. Even if voices are positive, the awareness that seemingly separate consciousnesses are imposing on our thoughts and feelings can be a deeply frightening, unsettling experience (e.g. Steele, 2002; Coleman, 2004). Furthermore, voice-hearing’s taboo status in western society means it is often treated with mistrust and fear. The dread that others will not understand or accept us may fuel the voice-hearer’s sense of shame, stigma and isolation.

Thus the key task in this stage is to normalise the experience, accept that one is hearing voices and then develop ways to regain a sense of control and calmness in order to deal with their intrusions. It is very important for the voice-hearer to find trusting relationships to talk with about the voices (Romme and Escher, 1991) and self-help groups can be good safe space to meet others who will listen non-judgmentally and share similar experiences reducing a person’s sense of isolation and alienation (Downs, 2005). Meaningful social activities can also be very grounding and if established or resumed can create significant levels of safety. Indeed, making social changes which reduce isolation or agitation, but increase one’s sense of social participation, can be significantly helpful at this stage. Self-help materials, normalisation literature and recovery stories can promote hope, optimism and acceptance. Very useful, accessible resources of this type are readily available on Internet websites such as Intervoice (intervoiceonline.org) and The (English) Hearing Voices Network (hearing-voices.org). Medication is one means of reducing the fear and anxiety associated with voice-hearing, although within the self-help movement many individuals make informed choices to seek other ways of reducing anxiety and coping with their distress (e.g. Longden, 2003; Hall, 2007; Harrow and Jobe, 2007). Where medication is used it is also recommended people learn other, more active strategies to induce relaxation or productively process and channel anxiety into action. Thus voice hearers learn to own their voices and take responsibility for their actions (Coleman and Smith, 2006). Distraction strategies can provide some initial relief, although their long-term benefit is not substantial and more active strategies are likely to be required to deal with voices more comprehensively. There are a broad range of relaxation exercises people can learn to use, including breathing exercises, self-massage techniques, yoga and more general physical exercises. For example Smith (2008) describes how Spinning (an indoor form of high-intensity cycling) provided her with ways to cope with a difficult, critical voice. Walking in natural surroundings may be very effective as a way to reduce anxiety and mindfulness techniques, as described previously, have been found to be of great benefit. Positive affirmations may also be helpful (e.g. Hay, 2004) as well as literature from the Emotional Freedom Technique (e.g. Lynch and Lynch, 2007).

Because preparation in advance of the voices beginning can be beneficial, anticipatory work such as identifying likely triggers (e.g. demanding social situations) and preparing ways to respond to the voices or implement coping strategies can be extremely helpful. Such preparatory work allows a greater sense of confidence in dealing with voices when they commence, or become particularly challenging.

For many people, a crucial component of coping with voices is learning ways to express anger and other emotions. Where voices encourage or command aggressive behaviour, finding a non-violent way to express agitation can be very helpful (e.g. hitting a punch bag; drumming; writing angry letters that you don’t have to send; doing intense physical exercises or recruiting support from others to assertively address some experience of injustice.) A voice-hearer who corresponds with one of the authors has learned that the symbolic action of screwing anger up into a ball and then blowing it away, or smiling at people she does not like helps her deal with her anger. Romme and Escher (2000) advocate listening carefully to what the voice says, wait a few moments write down what it said. This is followed by thinking of and writing down ten different ways of expressing anger, which can then be implemented by the person. Another soothing technique that can be prepared for times of distress is for the person to mentally generate a compassionate figure, which they imagine is sending them warm feelings and attitudes such as understanding, sympathy, love and reassurance. The figure can be real and known to the person or spiritual/imaginary (for example individuals can devise their compassionate figure as an animal such as a lion, or an angel, or wise guide etc). If desired, an object can be carried to symbolise this figure. Approaches of this nature have been used by Buddhists for hundreds of years, and can provide the person with an alternative set of values to customary, destructive thoughts about the self. Recently psychologists such as Gilbert and Procter (2006) have clearly outlined the technique to combat feelings of shame and self-loathing which difficult voices are often related to. Such visualisation techniques can also be used to create positive voices, or individuals can visualise the self-help group in times of distress or carry a picture of the group.

An important step is for the person to begin to set aside time to listen to the voices, rather than trying to avoid every confrontation with them. To this end, ‘time-sharing’ is an invaluable strategy whereby voice-hearers arrange to have a specific time to listen to the voice and insist the voices wait until this scheduled time before listening to them (possibly writing down what they say). Such time-limited listening should be coupled with neglecting the voices at other times of the day. This can be combined with asking the voices for information or writing down what they say in order to understand them better and challenge the avoidance most people adopt when they are afraid of experiences.  As well as helping acquire more distance and sense of choice, this strategy may be a progressive move towards dialoguing with the voice, a technique generally used in the ‘making sense’ stage.  In contrast, for ‘commentary-style’ voices, which resist conversation, Romme and Escher (2005) suggest making ‘simple replies’ in that individuals merely state whether or not they agree with the voices in a calm and assertive manner.

Phase Two: Making sense of one’s experiences

Once initial anxiety has been reduced, individuals may use the skills learned in the first stage to begin exploring the meaning of their voices more fully. Central to the ‘making sense’ process is paying detailed attention to the possible significance of the voices to the voice-hearer with regard to both past and present, understanding the underlying emotions the voices represent and finding ways to manage these experiences. Essentially, this is about the person learning to use their voices as clues to inner conflict that need to be understood and channelled in new ways.

There are particular self-help techniques that are likely to aid this exploration. For example, keeping a record about circumstances under which the voices are heard, what they have to say and the nature of any triggers can assist in identifying patterns and making meaning. Such ‘Voice Diaries’ are excellent self-help tools, not only for chronicling what the voices are saying, but as a space to reflect on one’s own thoughts and feelings about it. Engaging in psychological therapy can help a person learn to interpret their voices more symbolically. Developing an ongoing personal narrative about the relationship between one’s voices and one’s life history, and communicating this to others, can be constructive and affirming. Similarly, a recent literature has begun to advocate the importance of exploring and privileging the relationships voice-hearer’s have with their voices (e.g. Hayward and May, 2007; Chin, Hayward and Drinnan, 2008; Hayward, Denney, Vaughan and Fowler, 2008; Corstens, May and Longden, in press). Exploring the power and intimacy of these dynamics can help an individual gain a different perspective on what the voices are trying to communicate, as well as stimulate feelings of autonomy and control. At this point it is very important for individuals to have opportunities to develop a full, healthy identity as someone who hears voices. Thus the support and encouragement of groups can be very useful at this stage.

Certain emotions may be severely repressed in voice hearers so setting time aside to tune into one’s emotion as desires and needs is likely to be of benefit. Likewise, learning emotional communication skills and trying them out in social relationships (e.g. Rosenberg 2003) can help people learn to express and tolerate difficult, overwhelming feelings. In parallel to coping with the voices themselves, attention should be paid to the traumatic, underlying – and  often unresolved  – issues that originally evoked their presence. This should be carried out using psychotherapeutic interventions, which are very compatible with self-help initiatives . Therefore it is good if self-help groups establish links with psychological therapists who can facilitate such emotional work on both group and individual levels.

Spiritual frameworks are consistently found to be helpful explanatory models for many voice-hearers (Romme and Escher, 1993).  As a consequence, self-help groups and initiatives are flexible in incorporating and valuing these perspectives (e.g. May 2007) and linking people to spiritual communities and also giving spiritual communities educational support around self help approaches to hearing voices.

Phase Three: Socially Reconnecting

Recovery is about dealing with life and its difficulties. Voices challenge this process, but can also be adapted towards solving and understanding one’s emotional obstacles and social dilemmas. Thus, through accepting the voices, talking about them and finding positive ways to communicate with them, voice-hearers can learn to have pride in their experiences, give their voices a personal and positive meaning, cope with them effectively and create a life which the voices become part of – not the life that the voices dictate to them.

However, the shock of hearing voices – and the often catastrophic social reaction to the experience – means many people need to work hard and have good support before they are able to reconnect with valued activities and roles in society.  This ‘social inclusion’ and citizenship stage is as important and as challenging as any other given the prejudice and discrimination that exists currently towards voice hearing experience.  Therefore initiatives that support this social recovery stage need more support and attention from social institutions. For instance, vocational activity may follow on from a process of emotional healing, or it may be a necessary progression which allows the person to feel safe enough to commence such healing and ‘making sense’ processes. As described, many individuals link their voice-hearing to abuse and other experiences of injustice (see, e.g. Andrew, Gray and Snowden, 2008; Hammersley, Read, Woodall and Dillon, 2007; Pearson, Smalley, Ainsworth, Cook, Boyle and Flury, 2007). In this social recovery stage, survivors often choose a ‘survivor mission’ that seeks to address these experiences in some restorative way and help prevent future psychological violence (Herman 1992). Finding ways to contribute to the lives of others is also psychologically strengthening; finding roles that are valued by the self and others allows the nurture of self-confidence, which may have been severely damaged by periods of isolation and/or institutionalisation.  Some voice-hearers may decide to contribute to the Hearing Voices Movement by getting involved in community education initiatives; others can become role models by pursuing careers elsewhere whilst being open about their voice-hearing.  Social reconnection is also about educating the wider communities about the meaningfulness and acceptability of voice hearing.  Therefore in order to heal the denial and prejudice in wider society many voice hearers have lead and participated in media projects that offer respectful and informative accounts of the voice hearing experience (e.g. Gunesena, 2004; Jethwa, 2008; Regan, 2008; May, 2007).

Conclusion

The Hearing Voices Movement offers an emancipatory set of ideals where an individual can learn to see their voice hearing as an acceptable and meaningful experience. By embracing the experience through support from others and self-help approaches, voice hearing is reframed as both as an experience that one can live with and one that can inform us about our social lives and ways we can live together more peacefully. The ‘Maastricht Approach’, initiated by Romme and Escher, sees voices as a meaningful, interpretable experience originating within an individual’s personal history and against a backdrop of overwhelming emotions in traumatic, threatening conditions. By working within this frame of reference, the purpose and meaning of the voices can be deciphered and communication with them promoted. Such a framework sits comfortably alongside spiritual frameworks which many voice-hearers find helpful. Within the emancipatory approach self-help techniques and personal narratives are seen as equal to academic and professional knowledge bases.  Increasingly training events and resources are starting to reflect this power shift by increasing the involvement of people who hear voices more in their production. Thus a new, more collaborative approach to therapy and ways of working to recovery is emerging. Within this equation, recovery and empowerment are the main objectives and self-help the guiding force. Integral to this is the promotion of social support through affirmative stories, positive information and encouraging attitudinal change. Self-help movements can offer safe spaces for voice-hearers to discover the power of mutual encouragement and creative ideas in order to reclaim control over both their voices and their lives. For professionals, we believe it is our duty to facilitate such environments and opportunities through individual, societal and political support.

References

Abba, N., Chadwick, P. and Stevenson, C. (2008). Responding mindfully to distressing psychosis: A grounded theory analysis. Psychotherapy Research, 18(1), 77-87.

Andrew, E. M., Gray, N. S. and Snowden, R. J. (2008). The relationship between trauma and beliefs about hearing voices: A study of psychiatric and non-psychiatric voice hearers. Psychological Medicine, 38, 1409–1417.

Baker, P. (1989). Hearing Voices. Manchester: the Hearing Voices Network.

Carter, D. and MacKinnon, A. and Copolov, D. (1996). Patients’ strategies for coping with auditory hallucinations. Journal of Nervous and Mental Disease, 184(3), 159-164.

Chadwick, P. and Birchwood, M. (1994). The omnipotence of voices: A cognitive approach to auditory hallucinations. The British Journal of Psychiatry, 164, 190-201.

Chadwick, P., Taylor, K. N. and Abba, N. (2005). Mindfulness groups for people with psychosis. Behavioural and Cognitive Psychotherapy, 33, 351-359.

Chin, J. T., Hayward, M. and Drinnan, A. (2008). ‘Relating’ to voices: Exploring the relevance of this concept to people who hear voices. Psychology and Psychotherapy: Theory, Research and Practice (in press)

Coleman, R. (2004). Recovery: An Alien Concept (2nd Edition). Fife: P&P Press Ltd.

Coleman, R. and Smith, M. (2006). Working With Voices: Victim to Victor (2nd Edition). Fife: P&P Press Ltd.

Coleman, R., Smith, M. and Good, J. (2003). Psychiatric First Aid in Psychosis: A Handbook for Nurses, Carers and People Distressed by Psychotic Experience (2nd Edition). Fife: P&P Press Ltd.

Corstens, D., May, R. and Longden, E. (in press). Talking With Voices. Fife: P&P Press Ltd.

Dillon, J. (2006). Collective voices. Open Mind, 142, 16 – 18.

Downs, J. (2005). Starting and Supporting Hearing Voices Groups. Manchester: The Hearing Voices Network.

Escher, S. (1993). Talking about voices. In M. Romme and S. Escher (Eds.), Accepting Voices (pp. 50 – 59). London: Mind Publications.

Fletcher, L. and Hayes, S. C. (2005). Relational frame theory, acceptance and commitment therapy, and a functional analytic definition of mindfulness. Journal of Rational-Emotive and Cognitive-Behavior Therapy, 23(4), 315 – 336.

Gilbert, P. and Procter, S. (2006). Compassionate mind training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy, 13, 353 – 379.

Gunasena, M.(director).(2004). Evolving Minds. Undercurrents Films.

Hall, W. (2007). Harm-Reduction Guide to Coming Off Psychiatric Drugs. A publication by the Icarus Project and The Freedom Center. Available online at: http://theicarusproject.net/alternative-treatments/harm-reduction-guide-to-coming-off-psychiatric-drugs

Hammersley, P., Read, J., Woodall, S. and Dillon. J. (2007). Childhood trauma and psychosis: The genie is out of the bottle.The Journal of Psychological Trauma,6 (2/3), 7 – 20.

Harrow, M. and Jobe, T. H. (2007). Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: A 15-year multifollow-up study. Journal of Nervous and Mental Disorders, 195(5), 406-14.

Hay, L. (2004). I Can Do It: How to Use Affirmations to Change Your Life. London: Hay House Inc.

Hayward, M., Denney, J., Vaughan, S. and Fowler, D. (2008). The voice and you: Development and psychometric evaluation of a measure of relationships with voices. Clinical Psychology and
Psychotherapy, 15, 45 – 52.

Hayward, M. and May, R. (2007). Daring to talk back. Mental Health Practice, 10(9), 12-15.

Herman, J. L. (1992). Trauma and Recovery: The Aftermath of Violence From Domestic Abuse to Political Terror. New York: Basic Books.

James, A. (2001). Raising our Voices: An Account of the Hearing Voices Movement. Gloucester: Handsell Publishing.

Jethwa, J. (director). (2008). Demon Shoes. Scottish Hearing Voices Network.

Kabat-Zinn, J. (2005). Coming to Our Senses: Healing Ourselves and the World Through Mindfulness. London: Piatkus Books.

Kabat Zinn, J. (2001). Full Catastrophe Living: How to cope with pain and illness using mindfulness meditation. London: Piatcus.

Laurance, J. (2003). Life Stories: Ron Coleman. In Pure Madness: How Fear Drives The Mental Health System (pp. 134 – 138). London: Routledge.

Leudar, I. and Thomas, P. (2000). Voices of Reason, Voices of Insanity: Studies of Verbal Hallucinations. London: Routledge.

Longden, E. (2003). Psychosis: Recovery and Discovery, Asylum: The Magazine for Democratic Psychiatry, 14(1), 27 – 28.

Lynch, V. and Lynch, P. (2007). Emotional Healing in Minutes: Simple Acupressure Techniques for Your Emotions (2nd Edition). London: Thorsons.

May R. (2004). Making sense of psychotic experiences and working towards recovery. In  Gleeson, J. and McGorry, P. (Eds.), Psychological Interventions in Early Psychosis (pp. 245-260), London: Wiley.

May, R. (2007). Reclaiming mad experience: Establishing unusual belief groups and Evolving Minds public meetings. In  Stastny, P. and Lehmann, P. (Eds), Alternatives Beyond Psychiatry (pp. 117 – 128). Shrewsbury (UK): Lehmann Publications.

May R. (2007). Mental Health Special Issue of The Independent on Sunday’s The Sunday Review
18 March 2007. Independent News and Media LTD.

Moskowitz, A. and Corstens, D. (2007). Auditory hallucinations: Psychotic symptom or dissociative experience? Journal of Psychological Trauma, 6, 35 – 63.

Nhat Hanh, T. (2002). Be Free Wherever You Are. London: Parallax Press.

Nhat Hanh, T. (2006). Present Moment Wonderful Moment: Mindfulness Verses for Daily Living. London: Parallax Press.

Pearson, D., Smalley, M., Ainsworth, C., Cook, M., Boyle, J. and Flury, S. (2008). Auditory hallucinations in adolescent and adult students: Implications for continuums and adult pathology following child abuse. Journal of Nervous and Mental Disease, 196(8), 634-638.

Perron, B. and Munson, M. (2006). Coping with voices: A group approach for managing auditory hallucinations. American Journal of Psychiatric Rehabilitation, 9(3), 241 – 258.

Read, J. and Ross, C. A. (2003). Psychological trauma and psychosis: Another reason why people diagnosed schizophrenic must be offered psychological therapies. Journal of the American Academy of Psychoanalytic and Dynamic Psychiatry, 31, 247 – 268.

Read, J., van Os, J., Morrison, A. P. and Ross, C. A. (2005). Childhood trauma, psychosis and schizophrenia: A literature review with theoretical and clinical implications. Acta Psychiatrica, 112 (5), 330.

Reeves, A. (1997). Recovery: A Holistic Approach. Gloucester: Handsell Publishing.

Regan, L. (director). (2008). The Doctor Who Hears Voices. Kudos Films.

Robins, C. J. (2002). Zen principles and mindfulness practice in dialectical behavior therapy. Cognitive and Behavioural Practice, 9(1), 50 – 57.

Romme, M. (2000). Redefining Hearing Voices. Based on a speech given at the launch of The Hearing Voices Network, Manchester, England, Summer 2000. Available online at: http://www.psychminded.co.uk/critical/marius.htm

Romme, M. and Escher, S. (1989a). Hearing voices. Schizophrenia Bulletin, 15 (2), 209-216.

Romme, M. and Escher, S. (1989b). Effects of mutual contacts from people with auditory hallucinations. Perspectief, 3, 37-43.

Romme, M. and Escher, S. (1990). Heard but not seen. Open Mind, (49), 16-18.

Romme, M. and Escher, S. (1993). Accepting Voices. London: Mind Publications.

Romme, M. and Escher, S. (2000). Making Sense of Voices. London: MIND Publications.

Rosenberg, M. (2003) Non-Violent Communication: A Language of life. London: Puddle Dancer Press.

Smith, D. B. (2007). Muses, Madmen and Prophets: Rethinking the History, Science and Meaning of Auditory Hallucination. New York: The Penguin Press.

Smith, J. (2008). Spinning. Openmind, 150, 10-11.

Steele, K. (2002). The Day the Voices Stopped: A Schizophrenic’s Journey from Madness to Hope. New York: Basic Books.

Stone, H. and Stone, S. (1989). Embracing Our Selves: The Voice Dialogue Training Manual. Nataraj Publishing: New York.

Watkins, J. (1998). Hearing Voices: A Common Human Experience. Melbourne, Australia: Hill of Content Publishing Ltd.

White, M. (1996). Power to our journeys. American Family Therapy Acadamy Newsletter, Summer, 11 – 16.