EC Psychology and Psychiatry

Background: Hearing voices, formally known as auditory hallucinations, is a central symptom of psychotic disorders, but also seems to be encountered in persons without need of psychiatric care. In the last decades research has focused on the characteristics of the voice hearing experience, with emphasis on the relationship between voice hearers and their voices. The increased understanding of the function of the hearing voices experiences for the hearers has given rise to psychotherapeutic interventions for verbal hallucinations that aim to help the voice hearers better understand and cope with their voices, with promising results. This paper presents the change in the relationship between voice hearers and their voices that was achieved through a psychotherapeutic intervention based on the Romme and Escher model of voice hearing, coupled with cognitive-behavioural techniques.

Method: The intervention was conducted with 5 voice hearers, 3 men and 2 women, with diagnoses of psychotic disorders. It started when participants were hospitalized in an acute psychiatric unit and lasted over a year, totaling 25 - 30 sessions per intervention. It aimed to support voice hearers in making sense of their voices, through linking them with circumstances and events in their lives, and managing the voices, through developing more effective strategies for coping with them. Using grounded theory principles, the data was analysed through several analytical steps thematically, chronologically and comparatively, resulting in a model of therapeutic change.

Results: The final outcome of the study was a model of change in experiencing, understanding and managing voices, that depends on the phase of the hearing voices experience that the voice hearer was in the beginning of the intervention, in conjunction with the therapeutic strategies employed in the course of the intervention. In every case, the intervention seemed to help participants re-negotiate the relationship with their voices, cope better with them and, crucially, to move along to the next phase of the voice hearing experience.

Conclusion: The study verified the appropriateness of the Romme & Escher model for conceptualizing the voice hearing experience and guiding the direction of interventions aiming to bring about change in the relationship of voice hearers with their voices. It generally highlights the importance of relational understandings of verbal hallucinations and of tailoring interventions to the particular characteristics and stage of the voice hearing experience of each client.

Keywords: Psychotherapeutic Intervention; Hearing Voices; Psychosis; Grounded Theory; Romme and Escher Model

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5^th edition) (2013).
2. Benjamin LS. “Is Chronicity a Function of the Relationship between the Person and the Auditory Hallucination?” Schizophrenia Bulletin2 (1989): 291-310.
3. Bentall R. “Doctoring the Mind: Why Psychiatric Treatments Fail”. Penguin (2009).
4. Birtchnell J. “How Humans Relate: A New Interpersonal Theory”. Hove: Psychology Press (1996).
5. Birtchnell J. “Relating in Psychotherapy: The Application of a New Theory”. Hove: Brunner-Routledge (2002).
6. Birchwood M., et al. “The Power and Omnipotence of Voices: Subordination and Entrapment by Voices and Significant Others”. Psychological Medicine2 (2000): 337-344.
7. Birchwood M., et al. “Interpersonal and role-related schema influence the relationship with the dominant “voice” in schizophrenia: a comparison of three models”. Psychological Medicine 34 (2004): 1571-1580.
8. Bogen-Johnston L., et al. “It’s just a bit like a rollercoaster”: a longitudinal qualitative study exploring a model of the phases of voice hearing”. Psychosis: Psychological, Social and Integrative Approaches4 (2019): 308-318.
9. Chin JT., et al. “Relating” to voices: Exploring the relevance of this concept to individuals who hear voices”. Psychology and Psychotherapy: Theory, Research and Practice 82 (2009): 1-17.
10. Corstens D., et al. “Talking with voices: exploring what is expressed by the voices people hear”. Psychosis 4 (2012): 95-104.
11. Couto ML and kantorski P. “Voice hearers: A review about meaning and relationship with voices”. Psicologia USP 29 (2018): 3.
12. Craig TK., et al. “AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial”. Lancet Psychiatry 5 (2018): 31-40.
13. Deamer F and Hayward M. “Relating to the Speaker behind the Voice: What is changing?” Frontiers in Psychology11 (2018).
14. De Jager A., et al. “Investigating the Lived Experience of Recovery in People Who Hear Voices”. Qualitative Health Research10 (2016): 1409-1423.
15. Hayes SC., et al. “Acceptance and commitment therapy: Model, processes and outcomes”. Behaviour Research and Therapy 44 (2006): 1-25.
16. Hayward M. “Interpersonal Relating and Voice Hearing: To What Extent does Relating to the Voice reflect Social Relat¬ing?” Psychology and Psychotherapy: Theory, Research and Practice4 (2003): 369-383.
17. Hayward M., et al. “Relating therapy for people who hear voices: a case series”. Clinical Psychology and Psychotherapy 16 (2009): 216-227.
18. Hayward M and Fuller E. “Relating therapy for people who hear voices: Perspectives from clients, family members, referrers and therapists”. Clinical Psychology and Psychotherapy 17 (2010): 363-373.
19. Hayward M., et al. “Applying interpersonal theories to The understanding of and therapy for auditory hallucinations: a review of the literature and directions for further research”. Clinical Psychology Review 31 (2011): 1313-1323.
20. Hayward M., et al. “Relating therapy for voices (the R2V study): study protocol for a pilot randomized controlled trial”. Trials 15 (2014): 325.
21. Hayward M., et al. “Beyond beliefs: A qualitative study of individuals’s opinions about their changing relations with their voices”. Psychosis: Psychological, Social and Integrative Approaches2 (2014): 97-107.
22. Hayward M., et al. “Relating Therapy for distressing voices: Who, or what, is changing?” Psychosis, Psychological, Social and Integrative Approaches (2018).
23. Henwood K. “Grounded theory”. In M. Slade and S. Priebe (Editions.), Choosing methods in mental health research: Mental health research from theory to practice Hove: Routledge (2006): 68-84.
24. Jackson LJ., et al. “Developing positive relationships with voices: a preliminary Grounded Theory”. International Journal of Social Psychiatry5 (2011): 487-495.
25. Johns LC., et al. “Auditory verbal hallucinations in persons with and without a need for care”. Schizophrenia Bulletin 40 (2014): 255-264.
26. Kalhovde AM., et al. “Sometimes I walk and walk, hoping to get some peace.’’ Dealing with hearing voices and sounds nobody else hears”. International Journal of Qualitative Studies on Health and Well-being 26 (2014): 1-12.
27. Karlsson LB. “More real than reality’: A study of voice hearing”. International Journal of Social Welfare 17 (2008): 365-373.
28. Larøi F., et al. “Culture and Hallucinations: Overview and Future Directions”. Schizophrenia Bulletin 40 (2014).
29. Leff J., et al. “Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study”. British Journal of Psychiatry 202 (2013): 428-433.
30. Mawson A., et al. “Voice hearing within the context of hearers’social worlds: An interpretative phenomenological analysis”. Psychology and Psychotherapy: Theory, Research and Practice 84 (2010): 256-272.
31. Mayhew SL and Gilbert P. “Compassionate mind training with people who hear malevolent voices: a case series report”. Clinical Psychology and Psychotherapy 15 (2008): 113-138.
32. McCarthy-Jones S and Oestreich LK. “Australian Schizophrenia Research Bank”. Whitford T. J. Reduced integrity of the left arcuate fasciculus is specifically associated with auditory verbal hallucinations in schizophrenia”. Schizophrenia Research 162 (2015): 1-6.
33. Milligan D., et al. “Time changes everything? A qualitative investigation of the experience of auditory verbal hallucinations over time”. Psychosis: Psychological, Social and Integrative Approaches2 (2013): 107-118.
34. National Collaborating Centre for Mental Health. Psychosis and Schizophrenia in Adults: Treatment and Management”. Nice. Clinical Guidelines (2014): 178.
35. Pandarakalam JP. “Pharmacological and Non-Pharmacological Interventions for Persistent Auditory Hallucinations in Schizophrenia”. British Journal of medical Practitioners2 (2016).
36. Paulik G. “The role of social schema in the experience of auditory hallucinations: a systematic review and a proposal for the inclusion of social schema in a cognitive behavioural model of voice hearing”. Clinical Psychology and Psychotherapy 19 (2012): 459-472.
37. Romme M and Escher S. “Accepting Voices”. MIND Publications (1993).
38. Romme M and Escher S. “Making Sense of Voices”. MIND Publications (2000).
39. Sorrell E., et al. “Interpersonal processes and auditory hallucinations: A study of the association between relating to voices and distress in clinical and non-clinical hearers”. Behavioural and Cognitive Psychotherapy 38 (2010): 127-140.
40. Thomas N., et al. “Psychological therapies for auditory hallucinations (voices): Current status and key directions for future research”. Schizophrenia Bulletin4 (2014): S202-S212.
41. Trner DT., et al. “Psychological interventions for psychosis: A meta-analysis of comparative outcome studies”. American Journal of Psychiatry 171 (2014): 523-538.
42. Teed A and Charmaz K. “Grounded theory methods for mental health practitioners”. In D. Harper and A. R. Thompson (Editions.), Qualitative research methods in mental health and psychotherapy: A guide for students and practitioners Chichester: Wiley (2012): 131-146.
43. Van Der Gaag, M., et al. “Initial evaluation of the effects of competitive memory training (COMET) on depression in schizophrenia-spectrum patients with persistent auditory verbal hallucinations: a randomized controlled trial”. British Journal of Clinical Psychology 51 (2012): 158-171.
44. Van Der Gaag M., et al. “The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: A meta-analysis”. Schizophrenia Research1 (2014): 30-37.