Making sense of the voices
Mental health professionals debate the various approaches to helping
voice-hearers
David Batty
Wednesday November 21, 2001
When Mike Smith trained as a mental health nurse in the early 1980s, he was
told to deny the existence of the voices that patients reported they heard.
His trainers argued it was potentially dangerous to give meaning to what psychiatry
regarded as auditory hallucinations. At the very least, staff risked hindering
their clients' recovery by encouraging such delusions.
But Mr Smith, now director of nursing at Northern Birmingham mental health NHS trust, found this approach increasingly frustrating. "Our clients' experiences were not real and they were not to be discussed," he recalls. "So I could be working with a someone for years and still have no idea what they were hearing. Yet according to the World Health Organisation only 33% of people with schizophrenia recover as a result of medication."
Then in 1993 the psychiatric nurse attended a conference organised by self-help group the Hearing Voices Network, where Dutch psychiatrist Professor Marius Romme and researcher Sandra Escher explained how helping patients to talk back to their voices could aid their recovery.
Romme and Escher found that 70% of the 700 adults they surveyed in Holland had started hearing voices after a traumatic life event. In long-term interviews, they found that encouraging people to describe their voices helped them to understand how the condition related to their life history. This made the experience much less frightening and easier to live with.
At the conference, Mr Smith met Ron Coleman, a voice-hearer who had recovered from the trauma of childhood sexual abuse as a result of this approach.
Working with a psychiatrist and the Hearing Voices Network, Mr Coleman had realised that his most frightening voice belonged to the priest who had sexually abused him when he was 11.
"The priest's voice played upon my Catholic guilt, making out that I was not the victim but had ruined a good man," he says. "Following Romme and Escher's approach, my carers helped me to replay what had really happened and recognise my innocence. I still hear the priest very occasionally but he has no power over me now."
In 1997, Smith and Coleman published a workbook for professionals and service users to provide a practical framework for Romme and Escher's research. Working with Voices asks voice hearers to identify their voices in terms of age, gender, how they are heard and when they occur. It won Mr Smith the Royal College of Nursing's nurse of the year award.
"The workbook includes a contract which requires the professional to recognise that their client's voices are genuine and that the they need to develop their own ways of coping with them," says the nursing director.
"Working with service users' beliefs enables you to uncover the root cause of their condition. Most do not regard their voices as delusions and want to make sense of them. Everyone who has used the workbook has been able to describe their voices in detail, although some have needed help. But this indicates a need for partnership."
Not everyone agrees with the approach. Dr Tonmy Sharma, a representative of the Royal College of Psychiatrists' anti-stigma campaign, says few patients can identify positive voices. "About 70% of patients with psychosis show improvements after nine months on medication," he says. "I have not seen evidence that talking to voices brings such widespread success."
Dr Phil Thomas, a consultant psychiatrist at Bradford community health NHS trust, believes there is a need for medication in cases where clients are frightened of their voices and want them to disappear. But he says psychiatry has been remiss in simply rejecting voices as unreal experiences.
"I have never found that getting patients to talk about their voices has distressed them," he says. "Using techniques such as cognitive behavioural therapy we can help people in distress to question and challenge their voices, so they don't automatically obey them."
Mr Smith does not propose that the Dutch model provides a miracle cure. "My research with about 70 clients has found that another 30% recover with this approach, but it is intended to complement traditional practices rather than replace them," he says. "Drugs clearly work for some people but we should offer different treatments to help those who do not respond to them."
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Useful sites
Maastricht University
(English version)
Psychminded: interview
with Marius Romme
Hearing Voices Network
Mind
YoungMinds
Royal College of
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