Four years ago, a woman came to speak to my third year psychology class at the University of Auckland. Her story completely changed the way I thought about voice-hearing. Like most people, I associated “hearing things” with being very unwell psychologically; with madness. Yet here was an articulate, hilarious and confident woman – a mental health educator – who was very much in touch with reality.
The first voice she heard was a supportive, maternal voice which didn’t cause her any distress. Later, she heard a group of demonic-like voices who threatened to harm her or those she cared about. She was diagnosed with schizophrenia and institutionalised for many years.
Her turning point came when she asked her voices to show her some of their power by doing the dishes. When they didn’t, their hold over her started to loosen. Slowly, she learnt how to deal with her voices, built relationships with others and finally gained employment helping other voice-hearers. Hers is one of the stories of recovery recorded in Living with voices: 50 stories of recovery.
What struck me most about her story was how easy it was to draw an analogy between her voices and internal “self-talk”. Immediately, the experience of voice-hearing seemed less foreign and incomprehensible and more akin to what most people experience. This “inner-speech” theory is in fact the most well-known neuropsychological theory about what causes voices.
Apart from making voice-hearing seem less foreign, her story challenged several assumptions I held. First, it seemed that she was able to live a functional, productive and meaningful life while still hearing voices. Second, a diagnosis of schizophrenia is thought to carry with it a very poor prognosis, with little hope of recovery.
So, is her experience unique? It seems not. There is evidence of long-term recovery for around half of people distressed by their voices, enabling them to live meaningful lives and function to a degree considered normal by most people.
Indeed, it appears that hearing voices is not an abnormal human experience. General population studies show that 10% to 40% of the non-psychiatric population hear voices at some point in their lives. It is also not unusual for those who have lost a loved one to hear the voice of the deceased during the months following their death (although many initially deny this due to stigma surrounding voice-hearing). So it seems possible to be a “healthy” voice-hearer.
The other thing that really stood out from what she said was the profound mismatch between her needs and the help she got. She needed to talk about her experiences and figure out how to deal with her voices. At that time, however, talking to voice-hearers about their voices was discouraged as it was believed that this would worsen their symptoms. Instead, she was treated mainly with medication (in those days, large doses of it).
So, what treatments are available today? Medication remains the first-line treatment for distressed voice-hearers. Many find antipsychotic medications helpful, as they “dampen down” physical, mental and emotional responses.
But they can have serious side-effects. These include changes in metabolism that lead to weight gain and increased risk for stroke, heart disease and diabetes. They may also make some people feel “foggy” or “zombie-like”.
Medication is ineffective in eliminating voices in at least one-quarter of cases. This has lead to talking therapies gaining acceptance as a treatment for distressing voices. Instead of trying to get rid of voices, talking therapies aim to diminish the distress they can cause.
One way of doing this is through considering the evidence for and against beliefs about voices that make the hearer feel more upset. If your voice says threatening things and you believe it is powerful and intends to harm you, it makes sense to feel frightened. Testing out whether the voice has the power to do things (like doing the dishes) in a carefully planned way (for example, it wouldn’t be helpful to ask for a message through something ambiguous like a television program) can help the hearer feel more in control and less frightened.
Other strategies that can help in day-to-day management of voice-hearing include decreasing overall stress, listening to certain music, reading and focusing one’s attention on other sounds. Unfortunately, no one formula works for everyone: a lot of trial and error is usually required to find out what works.
The Maastricht approach – which is closely connected to the consumer movement, including the Hearing Voices Network – takes a more radical perspective. It defines voices as representing an emotional problem, either literally or metaphorically. This opens up interpretive possibilities, so even critical or threatening voices can be viewed as helpful.
One voice-hearer, for example, came to interpret a voice saying “I’ll kill you” as a warning not to make a particular decision in her life.
Another person who identifies that a critical voice appears or becomes louder when they are over-stressed or over-tired may come to respond by resting or giving excess work to a colleague. So the critical voice becomes protective. Putting voices into the context of the hearer’s life history helps the hearer to make sense of them and identify what positive role they could have.
Interestingly, voice-hearers’ style of relating to their voice is similar to how they relate to other people. Those who feel socially inferior to others, for instance, report feeling inferior to their voices. They are also more likely to comply with instructions to harm themselves, while the opposite is true of those who feel superior in both spheres.
We know that some people who are distressed by their voices learn ways to cope with their voices effectively and eventually recover. But how do they do it? That is the question we will be asking voice-hearers taking part in our research.
It’s hoped that giving voice to their experience, expertise and insider knowledge will help others struggling with their voices and help shape treatment approaches.