Psychological Approaches to Understanding and Treating Auditory Hallucinations

From theory to therapy

Mark Hayward, Clara Strauss, Simon McCarthy-Jones, Mark Hayward, Clara Strauss, Simon McCarthy-Jones

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9780415640114
• eBook ISBN: 9781317622260
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

This book draws on clinical research findings from the last three decades to offer a review of current psychological theories and therapeutic approaches to understanding and treating auditory hallucinations, addressing key methodological issues that need to be considered in evaluating interventions.

Mark Hayward, Clara Strauss and Simon McCarthy-Jones present a historical narrative on lessons learnt, the evolution of evidence bases, and an agenda for the future. The text also provides a critique of varying therapeutic techniques, enabling practice and treatment decisions to be grounded in a balanced view of differing approaches. Chapters cover topics including:

• behavioural and coping approaches
• cognitive models of voice hearing
• the role of self-esteem and identity
• acceptance-based and mindfulness approaches
• interpersonal theory.

Psychological Approaches to Understanding and Treating Auditory Hallucinations brings together and evaluates diffuse literature in an accessible and objective manner, making it a valuable resource for clinical researchers and postgraduate students. It will also be of significant interest to academic and clinical psychologists working within the field of psychotic experiences.

Chapter 1
What have we learnt about the phenomenology of voice-hearing?

Simon McCarthy-Jones

It seems logical that understanding ‘hearing voices’ should begin with listening to voices. Whilst some have turned a deaf ear to what the voices people hear are actually like, considering it irrelevant or even potentially harmful to even ask about, many have listened. This chapter will examine what this accumulated listening tells us, and thereby give an overview of what is formally termed the phenomenology of the voice-hearing experience. This is of importance because in order to be able to develop meaningful and accurate models of the causes of voice-hearing, and to aid the development of psychological interventions for those distressed by their voices, we need to know about the phenomenology of voice-hearing.

Phenomenology literally means ‘the science of appearances’, and can be seen to exist in two forms. First, there is what has been called ‘small p’ phenomenology, which is an approach to assessing experiences based in self-report and introspection, traditionally relied on by psychologists (McCarthy-Jones et al., 2013). There is then ‘big P’ Phenomenology, a more formal approach deriving from the work of Husserl (1960). The first step of this approach is to suspend taken-for granted assumptions or judgements about the cause, normality, or reality of what is experienced (Broome et al., 2012). This formal suspension (or epoché, as Husserl, 1960, termed it) opens the door to the inner structure of experience. The second step is eidetic reduction. This involves using imaginative variation to intuit the essence of a phenomenon, i.e., using one’s imagination to alter various aspects of the phenomenon in order to discern the invariant features that define it as the sort of entity that it is. For example, when one sees an apple, one can imagine that it might be a different colour, texture, size, or weight, or have a different flavour, without it becoming something other than an apple. None of these features are part of its essence. A similar process can be applied to experiences such as voice-hearing, allowing the phenomenologist to get a clearer picture of the phenomenon’s prototypical features, which can then be used to generate more nuanced descriptions of the overall experience (McCarthy-Jones et al., 2013). These descriptions are further specified by subjecting them to scrutiny within a community of voice-hearers (‘experts by experience’) and researchers (typically ‘experts by training’).

Consistent with this proposal, Garcia-Montes et al. (2012, p. 274) have argued that research should ‘give’ people diagnosed with psychosis a ‘turn to speak’, i.e., that research should take a (‘big P’) phenomenological approach, involving in-depth questioning of people about their subjective experiences, with questions that suspend or ‘bracket’ presuppositions about the phenomena under investigation, including its normality or abnormality, and its causes (Stanghellini and Lysaker, 2007). Yet, there are a number of problems with such a statement that are important to note and which highlight some problems in phenomenological research. First, the contention that people who hear voices should be ‘given’ a turn to speak may be disputed on the basis that people who hear voices should not need to wait around to be ‘given’ permission to speak by an authority; they can themselves ‘raise their voices’ (James, 2001). Second, this proposal implicitly suggests that the turn of the person hearing voices comes after the researchers have spoken and asked questions. An argument can clearly be made that the person hearing voices should be the first to speak in many senses, not the second. Methodologically, Garcia-Montes et al. focus on the first step of the big P phenomenological process described above, which appears relatively unproblematic. However, the second step of eidetic reduction is likely to prove more problematic. This is because, as has been noted elsewhere (McCarthy-Jones, Thomas et al., 2014), it may be queried whether the archetypal experience of literally hearing a voice is actually part of a class of broader experiences with fuzzy boundaries. A continuum can be conceptualised running from clear, externally-located voices, through internally-located voices with pronounced sensory qualities, internally-located voices which are experienced as more idea-like than perception-like, ‘soundless’ voices, and into delusions of communication. Indeed, why voice-hearing has been to some degree reified and plucked out of the pond of altered experiences undergone by those termed as having ‘psychosis’ remains to be clarified (McCarthy-Jones, Thomas, et al., 2014).

These larger problems notwithstanding, this chapter will review what is known about the phenomenology of voice-hearing. Due to the majority of research having focused on this experience in people diagnosed with a form of psychotic disorder, and also, to a lesser extent, in people without a need for care, it is voice-hearing in these two populations that I will focus on. Naturally, as such people have typically been drawn from WEIRD (Western, Educated, Industrialised, Rich, and Democratic; Henrich, Heine and Norenzayan, 2010) twentieth and twenty-first century societies, the generalisability of these findings are questionable. Although studies have already examined voice-hearing in diverse cultures including the Inuit (Murphy, 1976), the Yoruba people of Nigeria (Murphy, 1976), rural Malay communities in West Malaysia (Chen, 1970) and tribes living in the mountains of Borneo (Schmidt, 1968), more cross-cultural work is needed (Woods et al., 2014).

Furthermore, as the volume of ‘small p’ phenomenological work significantly outweighs the ‘big P’ phenomenological work (although the latter is currently being undertaken by projects such as the Hearing the Voice project based at Durham University in the UK, and the Lived Experience Research Network, based out of Chicago), I will necessarily focus on the former. I will then conclude by considering the implications of this work for contemporary psychological therapies.

The phenomenology of voices in patient populations

Descriptive accounts

Early psychiatrists such as Bleuler and Kraepelin wrote vivid, lyrical accounts of the phenomenology of the voices their patients reported. Kraepelin (1919, pp. 8–9) described multiple aspects of the voice-hearing experience, including its varying frequency, location, perceptual nature and content:

Often the voices torment the patient the whole day long, and at night also he hears ‘telephone gossip’, or perhaps he only hears them now and then, not infrequently in the form of single detached remarks.

The brain talks [or the body] Many patients hear the voices in the whole body; the spirits scream in the belly, in the feet, and possibly also wander about; a patient heard them speaking in his purse.

At other times they do not appear to the patients as sense perceptions at all; they are ‘voices of conscience’, ‘voices which do not speak with words’, ‘voices of dead people’, ‘false voices’, ‘abortive voices’. There is an ‘inner feeling in the soul’, an ‘inward voice in the thoughts’; ‘it is thought inwardly in me’; it ‘sounded as if thought’; ‘it was between hearing and foreboding’

What the voices say is, as a rule, unpleasant and disturbing… The patient is everywhere made a fool of and teased, mocked, grossly abused, and threatened… Some one calls out: ‘Rascal, vagrant, miserable scoundrel’, ‘incendiary, parricide’, ‘good-for-nothing’, ‘blackguard’, ‘anarchist, rogue, thieving murderer’, ‘filthy fellow, filthy blockhead, filthy beast’… ‘town whore’, ‘convict’, ‘criminal’.

Yet in addition to these negative voices, Kraepelin (1919, p.10) also noted that there were frequently

‘Good voices’, ‘good wishes’… God makes known to the patient that he will proclaim him, send him into the world as his son. ‘Here he is’, cries a voice from heaven. He hears that he is a king’s son, an officer’s son, that he is very musical.

Bleuler (1950, pp. 98–9) also described many other aspects of the experience, including their dialogic nature, their often torturous behaviour, and their ability to talk simultaneously:

The voice of his daughter tells a patient: ‘He is going to be burned alive’; while his mother’s voice says, ‘He will not be burned’.

At other times the same voice will amuse itself by driving the patient to utter despair in that they approve of his intentions, or order him to make a certain purchase and then berate him for doing so. The voices command him to go bathing and then jeer at him for obeying.

Often several voices talk at once so that the patient cannot follow them.

Such accounts offer a vivid, albeit second-hand account of the experience. First-hand descriptive accounts of voice-hearing are available both throughout history (McCarthy-Jones, 2012) and also from people who hear voices today (e.g., Romme et al., 2009). A particular benefit of such accounts is that they are not limited to phenomenological properties of the voices themselves, but allow a wider view of the phenomenology of the experience that often highlights how voices are embedded in the life of the person (which will be discussed further below), including how they are perceived to relate to life events. For example, in the first person accounts presented in the book Living with Voices: 50 Stories of Recovery (Romme et al., 2009), the content and identity of voices are often reported as being related to traumatic events in the voice-hearer’s past, which is consistent with research into the relation between voice-hearing and trauma (Read and Argyle, 1999; Read et al., 2003; Read et al., 2005; Bentall et al., 2012). Similarly, based on an examination of the phenomenology of historical experiences of voice-hearing, I have argued that many voices appear to have their roots in preceding events involving shame and guilt. However, in terms of the properties of the voices themselves, until the advent of large scale quantitative studies it was hard to determine what aspects of the experience were common or rare, and whether certain properties tended to co-occur with each other.

Formal quantitative research

The first, large-scale formal quantitative study (i.e. N≥100) of the phenomenology of hearing voices in a patient population was performed by Nayani and David (1996) and remains a seminal study in the field. The only subsequent larger study was a recent systematic examination of the phenomenology of voice-hearing by my colleagues from Melbourne and myself, which asked 199 patients, predominantly with schizophrenia spectrum diagnoses, about their voices (McCarthy-Jones, Trauer et al., 2014). In addition to these studies, there have also been a range of smaller studies in patient populations (e.g., Garrett and Silva, 2003; Hoffman et al., 2008; Leudar et al., 1997; Moritz and Larøi, 2008).

Based on these phenomenological accounts, Dr Phillip Resnick and I proposed that a typical voice-hearing experience could be discerned (McCarthy-Jones and Resnick, 2014). We argued that these findings suggested that the typical voice-hearer will hear more than one voice. The voices will be different from the voice-hearer’s own voice, and will sound much like hearing other people speak. The voice-hearer will usually be able to name the identity of at least some of the voices (e.g., identifying some of them as real, known people, or attribute the voice to a supernatural entity such as God or the Devil). The voices will typically be heard several times a day or most of the time, with the length of each instance being highly variable (lasting from just seconds to continuing for over an hour). The voices will attempt to influence the voice-hearer’s activity by issuing commands to perform specific actions, and may also judge the voice-hearer, typically negatively, through critical or abusive comments directed at him/her. In addition to these negative voices, positive voices will very often be reported, which are kind, loving and supportive. Voices will tend to be very repetitive in what they say. The voice-hearer will have some control over his/her voices (either their content and/or their activity), and some will be able to ask questions of the voices and get answers back. Individual voices will also typically be accompanied by background mumbling voices. In addition to this, voice-hearers will generally be able to clearly recall the first time they heard the voice (Romme and Escher, 1993), and will report other forms of hallucinations as well, such as music, clicks and bangs, visual hallucinations and/or tactile hallucinations (Nayani and David, 1996). Furthermore, they will have developed a range of strategies to cope with their voices (Farhall et al., 2007), will report that their voices become more frequent when they are alone, and that contextual factors (e.g., their mood) impact the frequency of their voices (Nayani and David, 1996).

These typical properties of voices, formally termed auditory verbal hallucinations (AVHs), are summarised in the first...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of figures
• List of tables
• List of contributors
• Acknowledgements
• Introduction
• 1 What have we learnt about the phenomenology of voice-hearing?
• 2 What have we learnt from behavioural and coping interventions for voices?
• 3 What have we learnt about cognitive appraisals of voices?
• 4 What have we learnt about cognitive appraisals of the self?
• 5 What have we learnt about the ability of cognitive behavioural therapy to help with voice-hearing?
• 6 What have we learnt about how to capture and measure the outcomes of psychological therapies for voices?
• 7 What have we learnt about relational approaches?
• 8 What have we learnt about mindfulness-based interventions and Acceptance and Commitment Therapy for distressing voices?
• 9 Psychological approaches to distressing voices: Where are we now and where are we going?
• Index