From: Haddock, G. & Slade, P.D. (Eds.) Cognitive-Behavioural interventions with Psychotic disorders, London: Routledge, ps. 137-150


Chapter 8


Marius Romme and Sandra Escher




In this chapter we intend to show that people hear voices in the normal population even when there is no evidence of psychiatric disease (Tien, 1991; Baton et al., 1991) and that the reported presence of verbal hallucinations is not always related to psychopathology (Barret and Etheridge, 1992).


Despite this, hearing voices does occur in specific psychiatric diseases at a much higher percentage than in the normal population. For example, schizophrenia, 53 per cent (Landmark et al., 1990), major affective disorders, 28 per cent (Goodwin and Jamison, 1990) and the normal population, 2.3 per cent (Tien, 1991 ). Although these two kinds of information appear to be contradictory , there are two possible connections. First, it may be that there is a connection between specific characteristics of hearing voices and the existence of psychiatric illness, or second there may be a connection between hearing voices and problems in the person 's life history .In the latter case, it is possible that psychiatric patients may have experienced more problems which they have found difficult to cope with than the average person.


In our own research, we have not found a connection between the characteristics of hearing voices and specific psychiatric illnesses. This led us to question whether hearing voices has a functional role in aiding coping with problems in daily life. In more dramatic terms: is it a survival strategy instead of a symptom of a particular illness? If this is the case, then there should be a connection between hearing voices, life history and living circumstances. To investigate this question further we conducted an experiment where we brought together a large number of people who heard voices. Within this group of voice hearers we compared people who could cope well with their voices with those who felt they could not cope.


The results of this investigation will be presented in this chapter, followed by some short case examples. These examples will demonstrate how the connection between hearing voices, life history and living circumstances manifests itself and how this connection may be handled in learning to cope with hearing voices. These examples may also demonstrate that as long as the phenomenon of hearing voices is viewed as a symptom of a disease, and treatment is focused on this disease, problems in daily life and circumstances as expressed by the voices, will not be solved.




At the end of the last century, Sidgewick (1894) showed that the phenomenon of hearing voices appeared in 2 per cent of the normal population. Recently, Tien (1991) replicated this research, with the help of the National Institute of Mental Health Epidemiological (NIMH) catchment area programme using the structured Diagnostic Interview Schedule for auditory hallucinations (D.I.S.; Robins et al., 1981). He found that there was a prevalence rate of 2.3 per cent, in a survey compiled from 15,000 members of the general population. Only one third of these hallucinators reported distress or impairment of functioning (level 5 D.I.S.), meeting the D.I.S. criteria for a psychiatric diagnosis. Eaton et al. (1991) selected a sample of 810 individuals from the same NIMH programme. They found a prevalence rate of auditory hallucinations of 4 per cent elicited by psychiatrists using the same D.I.S. Only a small minority of these people (16 per cent) met the D.I.S. criteria for a psychiatric diagnosis.


In the 19808, Posey and Losch (1983) and Bentall and Slade (1985) developed a questionnaire assessing different aspects of experiencing auditory hallucinations. In both studies the authors found a number of normal students who claimed to have had hallucinatory experiences. More recently, Barret and Etheridge (1992) replicated Posey and Losch's (1983) study using their auditory hallucination questionnaire, and found the same frequencies as those reported by Posey and Losch on all listed items. Subsequently, they conducted a second study where they compared hallucinators and non-hallucinators on tendencies towards psychopathology. They used the Minnesota Multiphasic Personality Inventory (M.M.P .1. ) for the ten standard clinical scales (Graham, 1987). They found as many people in the hallucinating group as in the non-hallucinating group with a scale score above seventy which Graham suggests indicates pathology. This result indicates that hearing voices cannot reasonably be explained only as the result of psychopathology .




If hearing voices in itself is not the result of psychopathology, then we may expect that it would not be linked to a specific disease and would appear in a wide variety of psychiatric disorders and that the quality of the voices would not be related to specific diagnoses. In order to research this particular point, the authors made an inventory of a group of patients undergoing treatment at a community health centre in Maastricht, Holland. All patients were asked by their case manager (this being in most cases a Community Psychiatric nurse) to complete a questionnaire that included both open and closed questions that probed for experiences of hallucinations.


The total sample consisted of 288 patients of which 165 (57 per cent) were female. The mean age of the participants was 45 years (plus or minus 13 years), with a median age of 43 years. About one third of the population was diagnosed as having an affective disorder, one fifth with schizophrenia and the third largest diagnostic group was a personality disorder (see Table 8.1).


Twenty-eight percent (n = 81) of the population reported hearing voices over a prolonged period of time. The percentage found for the two major diagnostic groups, 53 per cent in schizophrenia and 28 per cent in affective disorders, were similar to those found by others (Landmark et al., 1990; Goodwin and Jamison, 1990).


In this study, we also compared the quality of perceived hallucinations as related to these two major diagnostic groups. As Table 8.2 indicates, there were no significant differences found between those diagnosed with schizophrenia and those with an affective disorder as far as the quality of voices was concerned.


We concluded that hearing voices is present in people with very different kinds of diagnoses and that qualitative characteristics of hallucinations are not specific to a particular psychiatric diagnosis.




When hearing voices in itself is not the result of psychopathology, nor is it specific in characteristics to any specific psychiatric illness, it is of interest to analyse the differences between people who can cope well with their voices and those who cannot.


In an earlier study the authors brought together a group of people who heard voices (Romme and Escher, 1989). We conducted this study because in our clinical approach we felt quite powerless in our attempts to assist people with auditory hallucinations and we did not feel able to help a number of sufferers sufficiently (a notion already reported as a result of previous research by Falloon and Talbot, 1981). Even when medication helps in diminishing anxiety or chaos, one must then continue to prescribe prophylactic medication, otherwise the voices, together with their accompanying hindrances, will in most cases reoccur. Many of our patients did not know how to cope well with their voices. As a result of these observations we looked round for a television talkshow which would be willing to help us explore the phenomenon more fully. A patient with auditory hallucinations recounted her story on this talkshow and requested that people experiencing hearing voices and who were coping well with them, telephone after the programme, as we were looking for individuals who would be able to help the patient cope better. The result was unexpected as more than 500 people hearing voices responded to our request. We followed this up by sending out a questionnaire in order to obtain more information concerning the characteristics of their voices, their medical history and most important for us, their ability to cope and the methods they used. As a result of this questionnaire we learned that there were quite a number of people who could cope well with their voices, but to our astonishment, we also received questionnaires from people hearing voices, who had never been a psychiatric patient. We were especially interested in exploring the coping methods used by these people. We decided to organise a conference so that people hearing voices could meet and exchange their experiences. This conference was held in Utrecht in 1987, and resulted in the formation of an organisation for people who heard voices. This organisation now has more than 1000 members. By meeting a large number of these people we have had the opportunity to interview both a number of good copers and bad copers about their voice experiences and coping methods. We would like to begin with a report on some of the data accumulated from the questionnaire comparing good and bad copers, and patients and non-patients (Romme et al., 1992).


The questionnaire comprised thirty open-ended questions and was distributed amongst 450 people suffering from chronic auditory hallucinations or hearing voices. Of the 254 replies received, 186 were able to be used for analysis. It was doubtful as to whether thirteen of these respondents were actually experiencing true hallucinations therefore these were excluded. Of the remaining 173 respondents, fifty-eight reported an ability to cope with their voices.


Differences between good and bad copers existed in what we call the power structure between the voices and the person who hears them, as well as in the coping strategies that were used. Table 8.3 compares the power structure between those who said that they were able to cope well with the voices (group A) and the group who said they were not able to cope with the voices (group B).


Table 8.3 shows that those who could cope with their voices (Group A) experienced themselves as significantly stronger than the voices (72 per cent) while those who could not cope experienced the voices as being stronger. The most important differences between the two groups were:

Those who could not cope (B) often experienced voices which were stronger than self.

Those who could not cope (B) often experienced voices in a negative sense.

Those who could cope (A) experienced less imperative voices.

We also found differences between the good (A) and the bad (B) copers, in the kind of coping strategies that were used. These are illustrated in Table 8.4. Those people who did not cope well with their voices (group B) used different coping strategies to those who could cope with their voices.


We also found differences in social circumstances between patients and non-patients which are shown in Table 8.5. The main differences were:

I. Non-patients were more likely to be married than patients.

2. Non-patients experienced or perceived more support than patients.

3. Non-patients were more likely to discuss their voices with people other than patients.


The most relevant differences between copers and non-copers may be interpreted as relating to feeling 'stronger' not only with respect to the voices, but also with respect to their environment, i.e. feeling less threatened and more supported in the environment.




Receiving support and having the opportunity to talk about voices with other people appear to be associated with them being accepted by others. As a result of the conference in 1987 for people who hear voices, it became clear that all of the people who heard voices experienced problems with the societal taboo factor associated with them. It is difficult to talk about voices with others without being looked at in a strange way, so therefore empowering people who hear voices will have to take place on an individual and societal level.


Our approach addresses both levels. As a way of stimulating societal changes, we organise annual conferences, information meetings in psychiatric hospitals and conduct interviews with patients and non-patients on television and in popular magazines. In the following case studies we have outlined our approaches on an individual level.




We have developed an interview schedule that has allowed us to explore the dynamics of the relationship between the voices and the life history of patients who hear voices. We are currently investigating this relationship more systematically in a study that includes three groups of people hearing voices: those who have a diagnosis of schizophrenia, those who have a diagnosis of dissociative disorder and those who have never received a psychiatric diagnosis, but who hear voices. The results of this comparison are not yet available. In this chapter we will provide a description of some cases to illustrate the dynamics that exist between hearing voices and , the life history of the person experiencing them. The following examples illustrate different categories of life influences which we have found to be related to the onset of voices.

1. Intolerable or unsatisfying living situations

2. Recent traumas

3. Aspirations or ideals

4. Childhood trauma

5. Emotional intolerance and control

When discussing these examples, the following areas are of special interest in understanding the dynamics of the interaction between voices and the life history of

* the person hearing them:

* the identity of the voices

* the characteristics of their communication with the person, e.g. the way of talking, the age of voices and what they say

* what triggers the appearance or disappearance of the voices

* what important change in the individual's life was related to the onset of hearing voices

* the characteristics of a person 's upbringing and childhood including any special experiences that occurred in that period.


Intolerable or unsatisfying living circumstances


A 16-year-old young woman heard a voice that said unpleasant things to her. It was a male voice who called himself Erichem. In the background she also heard other voices who wanted to help her, but these voices were not very powerful. In addition, she heard voices of relatives that had passed away. She saw them and could communicate with them. They included her grandmother, her grandfather and her uncle. Sometimes she had prophecies and sometimes she saw coloured auras around people.


The young woman had a problem only with the unpleasant voice, which angered her. This voice first appeared when she was 14 and having problems with her father. Her father was very concerned with her performance and wanted to control her life. The voice of Erichem treated her in the same manner as her father. Whenever she was tense the voice appeared, but when she was relaxed or, for example, working at school, the voice would disappear. The voice of Erichem spoke directly to her and also spoke about her. The voices of the family members who had passed away spoke directly to her and gave her advice or offered solutions to existing problems.


The following interpretations were made relating to her voices and life history. The identity of the voice did not mean anything to her. She could not imagine a person around it or link the voice to anyone in particular. The voice was completely identified through the characteristics of its behaviour. This was more or less the same relationship that she had towards her father. The relationship was dominated by his behaviour and did not have the characteristics of a personal relationship like the one she shared with her mother. Erichem's dialogue made her angry. This was also the case with her father, but expressing anger towards him was not possible.


The following provided the starting point for treatment, beginning with the confirmation of the good relationship with her mother, together with increasing her coping strategies towards the anger of Erichem. The mother sometimes advised her on how to cope with Erichem 's behaviour, which she achieved, because the mother could cope more easily with the aggression of the father than the daughter. In the next step, it was important to establish, with the help of the mother, a more personal relationship with the father rather than a relationship based on the experiences of her upbringing.


This meant that the father also had to become more personally involved with both women. Additional steps were taken to ensure that the daughter would no longer act as an intermediary in the poor relationship between the mother and father. Direct psychodynamic interpretations did not make a lot of sense in this therapeutic approach. Looking for better ways of dealing with daily living problems was more effective and made more sense. This may be particularly important for young people in their development into adulthood.


Recent trauma


Hearing voices following the death of a loved one is not uncommon (Frantz, 1984). One usually hears the voice of that specific person. This can happen for a short period of time or, in some cases, it can linger on. This is mostly dependent upon the problems encountered during the mourning process. It is less commonly known that voices can appear following other kinds of trauma, e.g. divorce or loss of a job. The following is an example:


Monique was a 30-year-old woman who was fired from her job and felt that she had been treated in an unpleasant way. Losing her job left her with a strong feeling of helplessness. She was so ashamed about what had happened to her that this made it difficult for her to talk about it. After some time she began to notice that when she sat in a cafe, for example, she would hear people seated at the table behind her talking about her and discussing what had happened to her.


She heard people say things about her in the exact voice of the person in the cafe. She found this so threatening, that after a brief period she would leave the situation. Her reaction went further than thinking people were talking about her: she clearly heard what they said about her. The identity of the people around her did not change, only the things that they were saying and how they related to her problem.


We made the following interpretation. The identities of the voices were those of people around her. This fitted in with the trauma of losing her job. She had lost her job because people from another firm had been gossiping about her. What the voices said also fitted in with the trauma because they were talking about what had happened to her. The trauma of losing her job was the change in her life which triggered the voices.


The following intervention and strategies were utilised. A direct explanation of the relationship between the voices and the loss of her job did not help and was not accepted by Monique initially. Information was provided regarding the nature of her experiences. While participating in a self-help group she discovered that she was not the only one to have had such experiences. This opened up her interest in her voices and helped to diminish the shame she was experiencing. The main issue in therapy was then to help Monique to get up the nerve to look for a new job. The voices almost completely disappeared when she started to apply for, and finally found, a new job.


Aspirations and ideals


In this category we placed those people who hear voices which are easily related to certain aspirations or ideals. Examples of this are when people use their voices to guide them when they have a difficult decision to make, and also when people strive for ideals that are not possible to achieve, e.g. denying their sexuality. Here we provide an example of somebody whose voices confront him with difficulties in attaining certain desired goals.


This man was married and 27 years old when he came to our rehabilitation department. He had started to hear voices in his head and also sometimes through his ears. The voices were men and women talking to each other. He did not recognise the voices as those of people he knew. His own thoughts were repressed by the voices so that when they were there he could not think. He wanted to get rid of the voices because they mostly consisted of critical comments. The voices mainly occurred in stressful situations. Those situations were specially related to his training for an administrative education. The voices in those situations worsened his own negative thoughts about himself. He had doubts about his possibilities to follow this education and the voices confirmed these doubts in an exaggerated way. The voices were absent when he was alone or with his wife. This was confirmed by a research method called experience sampling (de Vries et al., 1990).


The changes in his life situation when he first heard voices were not clear. We made the following interpretation. The voices did not belong to anyone special, they had no clear identity and they destroyed his own thinking. Thus, we made the interpretation that the voices confronted him with his own doubts about his education. The voices may have been right. The voices may have been more realistic than his own ideal to proceed and finish his training successfully.


In therapy this is a difficult dilemma, because it has consequences for the person's professional life and labour possibilities. The therapist dealt with this by stimulating him to formulate his own opinion about the things the voices were telling him. It took some time before the therapist, in discussion with the man, reached the conclusion that his training was too difficult. He improved, i.e. the voices reduced in frequency, after he stopped his training course. At the same time he was offered an unpaid job as a concierge at a school, which he came to like very much. He had to give up his original aspiration, but by doing so the quality of his life was augmented.


Childhood trauma in combination with emotional control


The best known trauma after which hearing voices occurs is the experience of incest. The research of Ensink (1992), showed that 27 per cent of incest victims researched heard voices later in their lives. It was striking that this phenomenon was most likely to occur when the trauma took place before the age of 7. As there are other kinds of childhood traumas associated with hearing voices, we have chosen here to provide an example of development of voices following trauma not specifically related to incest.


A young woman began to hear voices after her fourteenth birthday. When she reached age 23, the voices began to worsen and her behaviour towards the voices began to change. From that time, she began to hear voices that read her mind. This occurred two times a week, sometimes lasted for up to eight hours and took place on Wednesdays and Sundays. While in this state, she was unable to do anything. In the beginning the voices were female. Prior to the moment that the voices began to worsen, she had experienced some problems at a female student club. During her introduction for membership she had been confronted with sexual subjects that disturbed her. Afterwards, she was afraid that she had acted in a ridiculous manner and this resulted in her not returning to the student club. Her sensitivity towards issues of sexuality originated from her earlier life. Her mother had been a psychiatric patient and always expressed herself in a very rude and negative way about sexuality. Thus, as a child the young woman decided never to become sexually involved. Up until the time we saw her she had managed to avoid sexual relationships completely.


We made the following interpretation. The young woman could not say that the voices had any identity. We interpreted the voices as being her own mind telling herself what she was thinking. The onset of voices was connected to her confrontation with sexuality. The first episode of hearing voices occurred when she was around 14, which was also the beginning of her menstruation cycle. The second occurrence, when it began to worsen, was after she was confronted with the sexuality problem at the student club.


For this reason we decided to confront her about her decision not to deal with sexuality as we concluded that the voices were confronting her with this problem anyway. We also made this decision because she was slipping more and more into a patient role. The day after the confrontation she had sex for the first time with a boy she hardly knew. She became psychotic. We supported her, but also continued to confront her. We were able to do this because we had informed all therapists involved. After a few months she decided to change her attitude. Today she is married and she has developed into a much more independent person. She is once again in charge of herself, although every now and then she hears the voices but has developed a much more independent attitude towards them.




What we have shown with these examples is that the voices know the person with whom they are communicating extremely well; they usually say things that are especially relevant for the person hearing them and usually are related to their problems. The voices usually refer to an unsolved problem in daily life, and/or emotions related to a trauma that has not yet been resolved, or problems that are connected to earlier traumas or unrealised ideals that, in some cases, are impossible to realise.


In treatment, it is not relevant to reject the voices but to stimulate the curiosity of the person hearing the voices about their content. As long as the person hearing the voices reacts only in an emotional way, it will be difficult to stimulate curiosity. This is a difficult process to accomplish. One possibility is the focusing technique, as described by Bentall et al. (1994) which is described in more detail in Chapter 3. Besides focusing on characteristics of the voices, the kind of ,relationship that exists between the person and the voices and the possibilities of changing these relationships, it is also important to work on the problems that the person hearing voices is confronted with in their daily life.


Our experience with people hearing voices is that if the total attention in therapy is focused on treating the psychiatric illness, problems in daily life as expressed by the voices will not be solved. The final objective is not only to influence the methods used in coping with the voices but to change the manner in which he or she copes with their problems.



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