Α DIALOGUE WITH VOICES

Summary

Counter to the reductionist, biogenetic view of voices as a symptom devoid of meaning, the therapeutic approach introduced by Corstens, Longden, and May offers the possibility of establishing a more harmonious relationship with voices as well as an opportunity to investigate underlying problems related to them. A Voice Dialogue, linked as it is with the long tradition of interactive structure of experience and suggesting as it does the perception of voices as a more dissociative than a psychotic experience, resuscitates such concepts in treatment as meaning, interactivity, and communication from which people who hear voices have for several years now been excluded.

A Dialogue with Voices

As defined by auditory hallucinations in DSM-V, voices are described as perceptual experiences gained without the presence or involvement of an external stimulus. Τhe problem, however, is that perceiving hallucinations as an abnormal state of perception can be misleading, as this particular stance leaves no room for the subjective experiences of the individual. Moreover, it creates a confusion in investigating the phenomenon, since it restrains investigation to a mere search of deficits in the cognitive process; that, in turn, causes complications in clinical and therapeutic practice, because it preventsdealing with such experiences beyond the targeted effort to eliminate them (Pérez-Álvarez, M., García- montes, J., Perona-Garcelán, S., & Vallina-Fernández, O., 2008). In attunement with the spirit and philosophy of intervention, we shall hereafter use in the present paper the more friendly term voices or alternatively voices experience and shall refer to people who hear voices as voice hearers (VH).

Moreover, psychiatry is often known to dismiss voices and their importance for those that hear them, to the detriment of hearers and professionals alike. For both get trapped in a relentless hunt of voices, followed by a constant effort to make the voices disappear, a practice which corresponds to a constant denial of the latter. In this manner, however, as will be analyzed below, some possible therapeutic paths are thus also dismissed along with the voices.

An increasing amount of scholarly literature has shown lately that the denial of these voices may prove harmful to hearers. The psychiatric definition of DSM does not leave much room for them and pushes for the cancellation of the 'truth' of such experiences. It therefore discourages their investigation, stripping them of real purpose and disclaiming their functionality. Of course, none of the above means that there are not several people who are suffering. But voices also occur to non-ailing people who naturally never seek mental health services. It seems that these correspond to about 2/3 of the 2-6% of the people who hear voices in total. (Sidewick et al. 1894; Tien, AY 1991, Eaton, WW, Romanoski, A., Anthony, JC & Nestadt, GJ, 1991; Lawrence C., Jones, J. & Cooper, M., 2009; Beavan, V., Read, J., & Cartwright, C., 2011)

One of the crucial distinguishing features of non-suffering people seems to be a balanced, harmonious relationship they enjoy with their voices and the strategies they use (Andrew et al., 2008; Longden, E., Corstens, D., Escher, S., & Romme, M., 2012; Romme & Escher, 1993, 2000, 2010, Sorrell et al. 2010). In recent years it’s been increasingly recognized that hearing voices is a common human experience (Watkins, 2008) and that the VH have experienced traumatic events at a significant rate (Bebbington et al 2005; Janssen et al 2004; Shevlin, M., Murphy, J., Read, J., Mallett, J., Adamson, G. & Houston, JE, 2011; Spataro, J., Mullen, PE., Burgess, PM., Wells, DL. & Moss, SA. 2006; Whitfield, CL, Dube, SR, Felitti, VJ & Anda, RF, 2005), which are associated with the phenomenology of voices (Beavan, V., Read, J., & Cartwright, C., 2010; Romme & Escher, 1993, 2000, 2010). Moreover, a lot of research suggests that voices also function as a survival strategy for HO (Romme & Escher 2010, Longden et al. 2012). They often occur in the midst of overbearing events prompting cataclysmic feelings that the person concerned cannot manage or during events that summon memories of past traumatic circumstances. (Romme & Escher. 2010; Beavan, V., Read, J., & Cartwright, C., 2010)

Seeking a dialogical encounter with the voices

In our present era of technique glorification and the domination of "Technological Psychiatry and Psychology", the aforementioned facts pose significant challenges on the philosophical and therapeutic level. "Technological Psychiatry and Psychology" here refers to the entire array of institutional or non-institutional interpretations and interventions that offer explanations exclusively through deterministic scientific models - disturbed subjects, with priority given to explanations as opposed to meaning and where very often the context is deleted (Thomas & Bracken, 2004). It is thus held, for example, that neuroscience will finally explain spiritual life in the language of science. Correspondingly, (psychological) life is believed to be accounted for by analogy to computers, thereby rendering the mind’s function amenable to scientific study. Inevitably, "therapeutic" answers are also provided through technological interventions based on quantitative data, where the mind can be examined as a thing (as the Cartesian "Res").

It is our belief  that we need a new philosophical framework. Further developing their reasoning, Thomas & Bracken (2004) see the prospect of meaning arising in the core of the search for such a framework. The key here, they say, is the primacy of meaning for human beings. Scientific research is but a mere product of human experience and history. It encompasses a certain manner of world discovery that displays the values ​​of the way we see nature. In the footsteps of Merleau-Ponty (1962), phenomenology means to look at the world afresh. Hand in hand goes the desire to place science in the proper position relative to human affairs. Such a mentality spills over into mental health, e.g. in the need to include ways of understanding human subjects that focus on the importance of meaning.

At the core of the practice of interpersonal phenomenology, respectively, lies the focus on the development of a non-interventional, non-controlling but actively empathic relationship, which leaves aside anything exclusively therapeutic or regulating. Briefly speaking, it can be described as "being together". The goal is to develop, over time, a common experience on the full social sense carrying the frame of the subject - past and present. (Mosher, 1999)

On another level, Felicity Deamer and Sam Wilkinson (2015) have just recently developed the thesis that a large group of voices could be better understood from the linguistic perspective of Pragmatic theory as communication experiences instead of as sound hearing experiences. Not only does this new perspective give meaning to "soundless voices", it also approaches the experience of hearing voices by deaf people, in whose case representation is often the key. Upon hearing a phrase, the VH automatically enters a process of interpreting / decoding intentions, as words and intentions come from intelligent beings. Eventually, "the way something is said and sounds is determined by the speaker’s emotion". If a more technocratic classificatory tactic were followed, the voices, according to researchers, could be seen in most anguished cases as a form of  "hallucinated communication" rather than as "hallucinatory sound", which is consistent with the idea that people are not merely perceiving beings but are rather profoundly social and communicative ones.

Aristotle famously taught that the city is a natural entity and that man is by nature a political animal. In this spirit, one can assume that the voices reflect social and political relations up to the social level of VH. In their references to Birchwood, Meaden, Trower, Gilbert, & Plaistow (2000) and Birchwood et al. (2004), M. Pérez-Álvarez and his colleagues (2008) highlight a significant link between the way that VH experiences his/her relationships with others in everyday life, for example as weak, inferior or subordinate, and how s/he experiences voices (as weak or inferior, respectively). Personal issues aside, voices may reflect the social atmosphere of the time. Eras that were perceived as difficult and dangerous, such as the 80s, have given birth to more negative and hostile voices than the 30s (Mitchell, J., & Vierkant, AD 2001). Not with standing the cognitive origin of these surveys, it is important that they seek to move away from a reductionist, biogenetic model that looks for impairments in the perceptual system in favor of a more relational glance.

Writing from a more dialogical angle, Vygotsky and Wittgenstein justify the importance of understanding human behavior by reminding us that it is integrated in an infinitely complex network of social, cultural, historical and political contexts. In this context, the voices can be seen as emerging through relationships (which clearly have a neurobiological dimension that we are largely ignorant of), as a phenomenon that can be described not only as a crisis plaguing the individual’s flowing relationship with the world but also as an attempt to overcome the crisis. According to Romme and Escher (2000), voices are as much an attack on the individual’s personal identity as they constitute an effort to keep it intact. For Moskowitz & Corstens (2007), voices are more than a natural phenomenon, for by questioning the voices’ psychotic dimension, they discern a dissociative character in them. This position forges an alternative epistemological look that poses questions regarding the already pending classifying criteria for psychoses and further influences, as we shall see, our therapeutic interventions, such as the one broached in this Article.

Seeking a dialogical meeting with the self.

The idea of a dialogical structure of experience is not new in the history of psychology. Still, the theory has had little effect on the development of interventions intended for people experiencing voices, and there was almost no attempt at understanding the phenomenon via personal (narratives), cultural, spiritual, political and other contexts. In recent decades, thanks also to the input contributed by diverse disciplines, the new psychological view of the self has been challenging the individualistic view, which sees humans as mostly logical, unified and conscious beings that enjoy cognizance, are in possession of the experience, interpret and organize it and themselves as logical, completed and conscious entities. For example, Harlene Anderson (1997), systemic therapist and pioneer in family therapy, writes: "Our self is an ongoing autobiography, (...) a continuous modification of our narrative, a ‘becoming’ through language and the stories we tell as we try to understand the world and ourselves".  As Anderson (long known for the postmodern practices she developed in family therapy) further stipulates, the idea that a person exists autonomously is part of a modernist view of the mind as a closed, self-sufficient unit. Such a perspective is linked to a decades-long view of the brain as a closed black box with inputs and outputs that performs a specific function, which itself can be mapped with modern imaging methods.

In view of all the above, the self can be described as an ongoing, composite, and complex internal conversation exactly as perceived in society: with conflicts and negotiations, exchanges and debates, with voices dominant and recessive. The self looks as though it were possessed by a multitude of "inner positions" associating dialogically among themselves, functioning as a sort of  "society of mind" (Minsky M., 1985).

According to Hermans & Hermans-Konopka (2010), the self as an internal community of perspectives contains a set of internal and external (internalized) positions involved in an ongoing dialogue. When some of these positions fall silent or get to dominate others, the extended self becomes monological. When, by contrast, all these positions are acknowledged and "heard", the extended self becomes more dialogical and functional, allowing for a better development of the individual. Ultimately, we exist by placing ourselves in a context; and like actors, we select the text of our oral discourse through a vast repertoire of possible positions.

Meaning emerges, respectively, from the peculiarities of the interactive exchange of members at that time; not in everyone's mind but rather in the interpersonal space among them. The meaning of an expression is produced by the listener and speaker alike, since for words to have meaning, a response is required (Seikulla & Trimble, 2009)

Nevertheless, the depreciation of personal meaning, which began during the period Foucault refers to as "the years of the great confinement", continues today for people who are diagnosed as patients, and who through reductionist, a-theoretical classificatory categories are commonly labelled as suffering from a protracted neurodegenerative disease of the brain. The demise of meaning, however, renders a human being dead. Conversely, dialogue "as an act of love" (Seikulla) can be extremely helpful for the VH.

In such a perspective, dialogue is essential if the voices are to become autonomous, equal, and accepting one another within a dialectical conflict as a means of attaining a pluralist identity, as Mikhail Bakhtin indicated (1984, p 293): "The dialogical nature of consciousness, the dialogical nature of human life itself, the simple form of an authentic life’s oral expression is an uninterrupted dialogue. Life is by nature dialogical. To live means to participate in a dialogue: to raise questions, to observe carefully, to answer, to agree, etc. In this dialogue, persons are fully involved throughout the course of their lives: with their eyes, lips, hands, soul, spirit, with their whole body, their whole presence. As persons, we are surrounded by reason and this reason pervading the whole structure of human life, becoming thereby a global symposium".

Talking with the voices: the theoretical background

Hence, the question that arises every time is: "Who speaks"? Or, in the case of VH, which voice speaks? Every voice, literally or figuratively speaking, comes from somewhere. In the case of the VH, the voice is often perceived as coming from a specified or unspecified entity and includes any form of communication (even sign language). It corresponds to the conceptual horizon, to the intentions and worldview of the talking subject. The voices contain messages, knowledge and information addressed to someone who hears the message and can respond in some way.

It is this wealth of meanings, knowledge and information that Corstens, Escher, and Romme (2008) sought to explore by lending an ear to the voices heard by people and striking up a dialogue with them as normal persons. Other interesting attempts had been previously made, such as the model of Davies and Thomas (1999) that utilized the ideas of Vygotsky, proposing a model of viewing voices as a variety of internal dialogue, where language plays a central role.

The "Voice Dialogue" approach was based on the work of Hal and Sidra Stone (1989), although it did not mention VH. Their work is reminiscent of the "horizontal dialogue of the self" proposed by Seikulla & Trimble, where all our voices reflect relationships and experiences of our lives. For example, when someone speaks of the memory of his father, all the voices and experiences associated with his father are shared in the dialogue by all participants. At the Community level, a differentiated adaptation of this approach has been applied since the early 80s in Finland as part of the Open Dialogue, an approach that puts into practice the principles of the dialogical self in the treatment of psychosis. In that context, Seikulla and Trimble suggest a vision of the mind as a continuum of voices talking to each other. The voices are the speaking personality, the speaking consciousness.

On their part, Hal and Sidra Stone (1989) were based on the theory that each person has different individual personalities, which affect emotions and behavior. Each person has different "selves", the so-called "sub-personalities",  each of which perceives the world in its own way and has its own history, its own emotional reactions and opinions onhow we should live our lives. These selves help us cope with difficult situations. Individual personalities are very important for accepting ourselves, otherwise we would be waging an "internal war". For example, the "dominant selves" expect us to achieve in life and demand that we do anything required of us by social circumstances. We learn these modes of adjustment very early in our lives, and our selves cling to what they have learned in order to survive. Our dominant selves reject our most frail pieces, and these, the so-called "denied" or "disowned" selves, lie dormant, unable to play an important role. The dominant selves are in control; they are always present and, in a way, function as an impediment, precisely because they control (Corstens, D., Longden, E., & May, R., 2012a, 2012b, 2016). The above approach is not new and is found in the work of Berne (1964), James (1891), Jung (1912/2003), and Young (1994).

For the Stones, the selves are organized into dipoles. For example, if you have grown up with the rule that "children should be seen but not heard",  you may develop a sovereign self that wishes strongly to please others and do what is necessary to become likeable. The opposite kind of self (one who wants to ask questions and provoke people, even if this entails the risk of rejection) is repelled by the stronger and more "oriented to be liked self", who yearns for acceptance and avoids rejection. A person split into thusly organized selves does not dare ask questions for fear of rejection. S/he is deprived of the choice between asking for anything that s/he needs and ignoring his/her needs. S/he has adjusted to the prevailing rule of his/her life. Initially, such a set-up of the selves may have been beneficial to the individual in coping with everyday situations. But circumstances change in life, and these selves remain attached to the initial adaptive roles. Thus, later in life, in other situations, with other people and needs, this specific set up of the selves may prevent adjustment. To a large extent we are not aware of this, as we are instead disconnected from important parts of ourselves (Corstens et al. 2012a, 2012b, 2016).

According to Corstens et al. (2012a), the predominant psychological interventions concerning voices come from the cognitive-behavioral therapy tradition (CBT), which sees in voices a disturbed information processing and/or an incorrect interpretation of internal events. This approach, however, does not explain how the externalized thoughts are heard, all the more so when most VH make a clear distinction between voices and thoughts (Hoffman, Varanko, Gilmore, & Mishara, 2008). As Rufus May (James, 2009) indicates, "while some cognitive approaches may retract consciously in the face of voices, the Voices Dialogue becomes consciously involved with the voices".

This whole approach does not focus on voices as a sign of illness but as an experience rich in meaning, which, if properly deciphered, can yield important information. Its fundamental principle is that we do not necessarily try to change the voices, or to eradicate them from human life. This is important, in view of the persistence of both VH and the professionals to help people get rid of the voices, an obsession often resulting in an irrational use of medication. For, at least in the short term, learning to manage one’s voices and accept their presence is a more realistic goal. The voices represent a part of the person that wishes to be heard. Many voices are fierce, aggressive and malicious; yet even a furious man needs to express his anger and let off steam, while just as importantly, behind anger often hide other primeval emotions. Usually, anger is associated with repression: you can’t attain what you want and you cannot or are not allowed to express it. In a sense, the voices are like normal people. They have feelings, motives, defects, capacities, and opinions. They don’t use rational strategies but react when they are upset. In what follows, a number of indicative papers summarizes the work recommended by Corstens et al. (2012a, 2012b, 2017), followed by an illustrative example.

Talking with the voices: the practice

Essentially, what we are trying to do is investigate the relationship of voices to their hearers. The investigation of the voices’ motivation and the discovery of various correlation methods with them can help the VH change his/her relationship with them, as well as adopt a different perspective on the voices’ content; for if the VH manages to develop a more robust attitude, voices may change. Our goal is not to get rid of the voices, but to render their relationship with their hearers more equal, thus helping the latter to regain control.

From our experience we know that usually neither the voices nor the VH are satisfied by their mutual rivalry and that an increased mutual understanding of both parties is essential. Moreover, our goals may include finding more positive ways of dealing and correlating with the voices as well as modifying the dynamic power; also, a successful management of the voices and an increased awareness and understanding of their characteristics. Progressively, our objectives expand (Tab.1). Sometimes the voices carry information about the history of the person involved, bearing messages that carry a metaphorical significance for the VH; they are related to life events and so getting to their roots helps expose the real problems facing the person from which s/he is very often disconnected. Sometimes the mere fact that a "disavowed" voice finds an audience is in itself a beneficial, empowering and potentially emancipatory prospect. Experience in Dialogue with the Voice is certainly required on the part of the interviewer, as are skills associated with both understanding and managing difficult emotions that emerge. Similarly, experience is required in the appropriate response to a variety of traumatic experiences that often lie behind and are hidden from view (e.g. child assault, sexual assault, emotional neglect, etc.) (Corstens, D., Longden, E., & May, R., 2012a, 2012b, 2016).

Table 1.

Long-term objectives in Dialogue with the Voice

1. Investigation of the underlying motives of voices

2. Strengthening of distancing the individual from the experience of voices

3. Attainment of a healthier dialogue

4. Conflict resolution

5. Collection of information regarding the voices and the role they play in the life and history of the person who hears them

6. Recognition and assumption of the necessary actions

7. Activation of an internal change process

The session: opening and procedure

The opening of the session should best be preceded by an interview with the VH concerning the voices, followed by the submission of a hypothesis about what problems and which persons the voices may represent (Romme & Escher, 1993, 2000). The session begins by investigating whether the VH and the voices consider it a good idea to engage themselves in such a process. For this purpose, the facilitator of the process asks the VH whether s/he wishes to invite a voice to participate or to suggest one herself, in which case the voice is also addressed (via the VH). All three parties need to feel comfortable before a detailed description of the process is presented. Throughout the process the facilitator behaves as though s/he were facilitating a group session, aiming for all parties to gain a mutual understanding. During the dialogue, the VH repeats the words of the voice as s/he would had s/he had a headset on the ear.

It is better to start with a more familiar voice. The VH composes herself in order to connect with the voice and when this is achieved, s/he is asked to sit in another chair in the room, usually toward the direction of the voice but certainly in a different place from the one s/he was sitting at the beginning of the session. This change of seat is extremely important, as both hearer and facilitator need to distinguish the voice as an entity that is separate from the individual.

The facilitator begins by welcoming the voice, with a view to adopting a suitable attitude towards it ("an alignment with the energy of the voice"). A passive voice, for example, should best be addressed in a polite manner, while a dominant voice with confidence and respect. During the process, the facilitator engages herself with the respective voice in an open and dedicated manner, and as soon as the questions are answered s/he thanks the voice for the clarifications it provided.

Indicative set of questions shown in Table 2.

Table 2

Indicative questions in a dialogue with voice

1. Who are you? Do you have a name?

2. How old are you?

3. What do you look like?

4. How do you feel right now?

5. When did you come to his / her life (hearer’s name)?

6. Does s/he know you?

7. Why did you come to his/her life?

8. How was his/her life then? What happened to him/her?

9. Did you have to do something then to protect him/her (name)?

10. What do you want to achieve for him/her (name)?

11. Would you like to change something in his/her life (name)?

12. What would it be like for him/her if you did not exist?

13. How does s/he (his/her name) feel about you?

14. What is it like to take care of him/her?

15. Would you like to change something in your relationship with him/her (name)?

16. (If there are multiple voices) Do the other voices know about you? What do they think of you? Do they cooperate with you?

17. Is there anything you would like to advise the hearer (his/her name)?

Should any of the three parties involved (facilitator, voice, VH) wish to terminate the dialogue, the facilitator asks the voice if it wants to finish the conversation, and perhaps resume at another time. After the voice gives its permission, the facilitator says good-bye to the voice, perhaps with a compliment or positive comment about it. She then returns to the VH, who, in turn, returns to the chair s/he was sitting in at the beginning of the session.

The session: closing and awareness

The person is encouraged to reflect more on what happened. S/he usually expresses surprise at what took place and may have already adopted an alternative stance toward this voice. The facilitator asks how s/he felt during the interview she had had with the voice and the person gives his/her own perspective on what the voice said. At this point, not infrequently, one more voice may emerge. In such a case, the process can be repeated (depending on how the person feels and the time available until the end of the session).

Essentially, the process comes to completion with the "awareness" phase. The facilitator asks the person to stand beside her and they examine the scene together, while she summarizes what happened. It is important to note that the facilitator does not use this opportunity to determine what occurred. She simply describes what she saw. Finally, she encourages the person to remain in contact with the voice at home and maybe think of some ways of changing his/her relationship with it. Questions that can be addressed to voices in subsequent sessions can also be scheduled in advance. We often see that once dialogue begins, things start to evolve between the individual and the voices. That is why it is important to keep a diary of what is happening. Sessions can also be summarized in a written report by the person himself at the end of each session. Sometimes the person may wish to audio- or video- ape the session.

Personal attitudes and mentality

While facilitating the dialogue, one needs to see the VH as a person who learns from the meeting, who must maintain control and take personal responsibility. Of course we want to reduce the influence of the voices, but our aim is not to banish them. It is possible to get to a point where the voices normally withdraw, either because they have served their purpose or because the underlying problems / reasons for their presence have been eliminated. It is also important to maintain a non-judgmental, calm attitude, without confrontations and fear. The facilitator does not respond to the challenges of voices and does not enter into conflict with them. She keeps a steady composure and does not adopt a moralistic attitude. Creating a relationship requires cooperation and respect, not servitude. One maystand one’s groundwith dynamism but not with authoritarianism when conversing with them.

Who does the method help?

The technique is very constructive for those VHs that maintain some communication with their voices because some of them may be too scared to try it, and so are in need of others’ help, advice and support for the communication to kick off. Nevertheless, some people who hear voices cannot or do not wish to communicate with their voices. For them, the method is not suitable. Moreover, hearers need to feel safe before doing the exercise as well as be able to maintain control, something that is essential in the coordination process. Finally, time should be allowed for the collaborative design of appropriate questions to be asked of the voices. Here, it is important that one plans ahead what one seeks to achieve and expresses any concern one may have in advance. VHs can also be given the opportunity to speak directly with the voices using the chairs. This enables one to practice the conversation with the voices in a safe environment and by thus gaining self-confidence, one can continue on his/her own, independently.

The technique may, of course, become dangerous when the VH feels s/he cannot retain control during the procedure. When this happens, the procedure is interrupted and the reasons for this are discussed, as when there is poor understanding between the facilitator and the voice hearer or when the facilitator responds inappropriately to the voices, in terms of either tone or content. It is important that the facilitator does not take personally the hostility or critical attitude of the voices. The procedure may become dangerous if done without a summary, when the chair is not used properly and when the conversation with the voices becomes an end in itself; for, the process has a dynamic character and may end up a "game" rather than a means of achieving specific objectives (such as autonomy and an improvement of one’s relationship with the voices).

Case in point

Kostas grew up in an environment of distant family relations, with his father absent from his life and with problems related to gambling addiction. According to Kostas, he was unwanted by his father. He felt neglected, and sought the company of others despite being bullied, otherwise he suffered from sadness and loneliness. He has suffered from phobias when in the presence of others since childhood, as he could not bear their mocking comments and insults. At the age of 5, he began to lose his hair (a disorder known as psychogenic alopecia) and a year later he was raped by an older child. From that incident until the age of 12 he was further abused sexually. Several years passed before he mentioned it to his mother, who did not react, and the psychiatrist, who had given him medication. At the age of 8 Kostas suffered physical abuse by his uncle. At the age of 11-12, he had homosexual relations with another boy of the same age for which he feels embarrassed, and at 13 he started using psychotropic substances. At the same time "the eyes of others speak about him". He first heard positive voices at the age of 6, and the experience became increasingly dysphoric during adolescence. His case is indicative of how the voices become intertwined with substance use, both determining it and being determined by it.

Kostas experienced the voices as omnipotent. They had acataclysmic effect upon him, as if he were obliged to obey whatever they said, as if the voices expressed the absolute truth. Utilizing the technique of the "Voice Dialogue", one of the authors (LK) tried to investigate the motives of the Lord’s voice, one among dozens of Kostas’ voices and perhaps the most important one. The Lord has his own age and is growing up along with Kostas. Until Kostas began to converse with the Lord’s voice, it was his worst nightmare. Before the Voice Dialogue was attempted, Kostas’ voices had been investigated and with Costas’ participation some conjectures were made in regards to these voices and what they might represent. Here’s a part of the report on voices:

" The voice of the Lord, 45 years old, is male, hoarse, loud, domineering, dynamic. At first I beheld his image as a mask-wearing figure, with a raised collar, two meters tall, with straight hair, sitting with his hands folded and looking. I’ve known the Lord for a long time, since I was 8 to 10 years old and I hear him daily. I hear his voice as an external one that others cannot hear, and more likely he is not part of me. He is imposing, commanding and exerts a huge influence on me. He often gives orders: "Go right" or "Do this or that" or even "Kill your mother." Usually I do not obey him, although one time he asked me to throw my car on the toll bars and I did. Another time I nearly obeyed and put a knife in my belly, as the voice was telling me: "Do it!" Finally, I was restrained by my mother. He often tells me: "You are mine. No one will snatch you from me. Do not try to escape. You are mine. I will not leave you." All the voices, including the Lord’s, describe what I am thinking, make comments about what I do or the people I hang out with and intervene when I chat. Generally, I cannot sever myself from the voices. When I hear them, I concentrate on what they say. And when I do not hear them, I miss them. It's as if I am missing a piece: an item of Akis the kid. For example, I may be doing something and they criticize me, so I wonder why they are doing this and I ask myself who I am. This brings me fear. I cannot influence the voices. They will say what they have to say and stop. They make me feel weak as they are sending me bad thoughts. I’ve never had control over them. With the Lord I feel a sweetness but I also fear him. I'm afraid and yet I like it. He is very powerful. I want to uproot him. I hate him. Lately I’ve been wondering if there’s something wrong with myself, that perhaps my self might be creating all these as a result of a wound I have suffered. The voices could be a part of my personality that I have had since childhood after all that I’ve suffered ."

In the process, some of the questions listed on the Table were utilized. The Dialogue lasted around seven minutes and was interrupted when Kostas got tired: " I am glad I spoke with him. He distressed me when he said that he rejoices in my pain. But I was glad he told me he hurts when I hurt. I feel some kind of bond there. He whom I thought meant me harm hurts when I hurt. And it pleases me when I say so right now. Whereas I was a wreck, whereas I wanted to kill myself, I felt 1% better. Perhaps the Lord loves me but doesn’t know how to show it. He yells at me in a nasty way. My father was like that. (....) The Lord has been with me since I was born. He may be a sadist. He showed you great trust. He  loves  you  too . "

As is evident from all the above, many possible routes are now being opened. In the following months it became possible to establish that specific voice as a constant, often appearing as a "voiceless presence"; one recognized by Kostas as a voice that is growing together with him and may represent a part of him which entails affection, kindness, care, love and compassion, a part that wants the good of others and regrets it when Kostas feels sad, something that was realized along the way as a characteristic of his late father. Another aspect of the matter, relevant and accepted by Kostas, is that this voice may be a part of him that wants him to be decent and fair to himself. The Lord may represent the voice of pride and integrity, a piece that can combine power and aggressiveness but also gentleness and generosity, characteristics which also seem to have been possessed by his father. In discussing the Lord, Kostas remembered with pride one incident when he stopped along the way to help a woman carrying a sack of potatoes. Today, the Lord is for Kostas a voice of pride and dignity.

In our opinion, the transformation process of a person’s relationship with his/her voices is not significantly different from the respective process occurring at the inner and inter personal level of our relationships. Often the problems are disguised, initial difficulties are deformed, and people adopt survival strategies, occasionally paradoxical ones, such as drug use or other self-harming cases and so on. We are all familiar with Nietzsche’s saying that the need for metaphor is the need to find oneself somewhere else. In light of this, many life situations may prove so painful that one needs to find oneself elsewhere, something that is often not possible, in which case escape can assume various alternative forms. Anxiety, weakness, guilt etc. are metaphors of this power relationship during traumatic events and emotional abandonment periods: they are feelings very often covered through use or figuratively expressed through the voices. The process of giving meaning to the voices is an ongoing, open process that one can see not only on the level of person but in a wider social, cultural, and political level as well.

Bibliography

American Psychiatric Association. (2013).  Diagnostic and statistical manual of mental disorders, DSM-5  (5^th ed.). Washington: APA.

Anderson, H. (1997).  Conversation, language and possibilities: A postmodern approach to therapy . New York: Basic Books.

Andrew et al. (2008). The relationship between trauma and beliefs about hearing voices: A study of psychiatric and non-psychiatric voice hearers.  Psychological Medicine, 38 , 1409–1417.

Bakhtin, M. (1984). Problems of Dostoevsky's poetics. In C. Emerson (Ed. & Transl.),  Theory and history of literature, Vol. 8 . Minneapolis, MN: University of Minnesota Press. Available online at www.mohamedrabeea.com/books/book1_7956.pdf

Bebbington et al. (2004). Psychosis, victimisation and childhood disadvantage: Evidence from the second British National Survey of Psychiatric Morbidity.  British Journal of Psychiatry, 185 , 220-6.

Beavan, V., Read, J., & Cartwright, C. (2011). The prevalence of voice-hearers in the general population: A literature review.  Journal of Mental Health , 20 , 281-29.

Berne, E. (1964).  Games people play. The psychology of human relationships . New York, NY: Penguin.

Birchwood, M., Meaden, A., Trower, P., Gilbert, P., & Plaistow, J. (2000). The power and omnipotence of voices: Subordination and entrapment by voices and significant others.  Psychological Medicine, 30 , 337–344.

Birchwood et al. (2004). Interpersonal and role-related schema influence the relationship with the dominant "voice" in schizophrenia: A comparison of three models.  Psychological Medicine, 34 , 1571–1580.

Corstens, D., Escher, S., & Romme, M. (2008). Accepting and working with voices: The Maastricht Approach. In A. Moskowitz, I. Schafer & M. J. Dorahy (Eds.),  Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology  (pp. 319–331). Oxford: Wiley-Blackwell.

Corstens, D., Longden, E., & May, R. (2012a). Talking with voices: Exploring what is expressed by the voices people hear.  Psychosis, 4,  95-104.

Corstens, D., Longden, E., & May, R. (2012b). "Talking with voices". In M. Romme & S. Escher (Eds.),  Psychosis as a personal crisis: An experience-based approach,  (pp. 165-178). London: Routledge.

Corstens, D., Longden, E., & May, R. (2017, publication forthcoming). Γιατί να μιλήσει κανείς με τις προκλητικές φωνές;  Τετράδια Ψυχιατρικής .

Davies, P., Thomas, P., & Leudar, I. (1999). Dialogical engagement with voices: A single case study.  British Journal of Medical Psychology, 72 , 179–187.

Deamer F. & Wilkinson S. (2015). The speaker behind the voice: Therapeutic practice from the perspective of pragmatic theory.  _Frontiers in Psychology, 6, _ 817. Available at: http://journal.frontiersin.org/article/10.3389/fpsyg.2015.00817 /full

Eaton, W. W., Romanoski, A., Anthony, J. C. & Nestadt, G. J. (1991). Screening for psychosis in the general population with a self-report interview. Journal of Nervous and Mental Disease, 179, 689–693.

Hermans, H. & Hermans-Konopka, A. (2010).  Dialogical Self Theory: Positioning and counter-positioning in a globalizing society . New York: Cambridge University Press.

Hoffman, R., Varanko, M., Gilmore, J., & Mishara, A. l. (2008). Experiential features used by patients with schizophrenia to differentiate "voices" from ordinary verbal thought.  Psychological Medicine, 38 , 1167–1176.

James, W. (1891).  Principles of psychology . London: Macmillan.

Janssen et al. (2004). Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatrica Scandinavica, 109, 38-45.

Jung, C.G. (1912/2003).  Psychology of the unconscious . New York, NY: Dover Publications.

Lawrence, C., Jones, J. & Cooper, M. (2009). Hearing voices in a non-psychiatric population. Behavioural and Cognitive Psychotherapy. 38, 363–373.

Longden, E., Corstens, D., Escher, S., & Romme, M. (2012). Voice hearing in biographical context: A model for formulating the relationship between voices and life history. Psychosis: Psychological, Social and Integrative Approaches, 4(3), 224-234.

Merleau-Ponty, M. (1962). Phenomenology of Perception. (Trans. C. Smith), London: Routledge & Kegan Paul.

Mitchell, J., & Vierkant, A.D. (2001). Delusions and hallucinations as a reflection of the subcultural milieu among psychotic patients of the 1930s and 1980s.  Journal of Psychology, 123 , 169–274.

Μoskowitz, A. & Corstens, D. (2008). Auditory hallucinations: psychotic symptom or dissociative experience?   Journal of Psychological Trauma , 6 , 35–63.

Mosher et al. (1994).  Daseinanalysis: Das Manual zur Praxis in der Soteria . Bonn, Psychiatri Verlag.ž

Pérez-Álvarez, M., García-Montes, J., Perona-Garcelán, S., & Vallina-Fernández, O. (2008). Changing relationships with voices: New therapeutic perspectives for treating hallucinations.  Clinical Psychology and Psychotherapy, 15 , 75–85.

Minsky, M. (1985).  The Society of Mind . New York: Simon & Schuster.

Romme, M., & Escher, S. (1993).  Accepting voices . London: Mind Publications.

Romme, M., & Escher, S. (2000).  Making sense of voices . London: Mind Publications.

Romme, M. and Escher, S. (2006). Trauma and hearing voices. In A. Morisson and W. Larkin (Eds _), Trauma and psychosis: New directions for theory and therapy _ (pp.162-192). London: Routledge.

Romme, M. & Escher, S. (2010). Personal history and hearing voices. In F. Larøi & A. Aleman (eds.),  Hallucinations: A practical guide to treatment and management  (pp. 233-256). Oxford: Oxford University Press.

Seikkula J. & TrimbleD. (2009). Οι θεραπευτικές συζητήσεις ως κοινή εμπειρία: ο διάλογος ως πράξη αγάπης.  Μετάλογος , 15 , 60-73.

Shevlin, M., Murphy, J., Read, J., Mallett, J., Adamson, G. & Houston, J. E. (2011). Childhood adversity and hallucinations: A community-based study using the National Comorbidity Survey Replication. Social Psychiatry and Psychiatric Epidemiology, 46, 1203–1210.

Sidgewick et al. (1894). Report on the census of hallucinations. Proceedingsof the Society for Psychical Research, 26, 259-394.

Sorrell E, Hayward M, Meddings S. (2010) Interpersonal processes and hearing voices: a study of the association between relating to voices and distress in clinical and non-clinical hearers. S. Behav Cogn Psychother. 38, 127-40.

Spataro, J., Mullen, PE., Burgess, PM., Wells, DL. & Moss, SA. (1989). Impact of child sexual abuse on mental health: prospective study in males and females.  British Journal of Psychiatry, 184 , 416-21.

Stone, H., & Stone, S. (1989).  Embracing our selves: The voice dialogue training manual . New York, NY: Nataraj Publishing.

Thomas, P., Bracken, P., & Timimi, S. (2012). The limits of evidence based medicine in psychiatry.  Philosophy, Psychiatry, & Psychology, 19 , 295–308.

Thomas, P. & Bracken, P. (2004) Hearing Voices a phenomenological – hermeneutic approach.  Cognitive Neuropsychiatry , 9, 13-23.

Tien, A. Y. (1991). Distributions of hallucinations in the population. Social Psychiatry and Psychiatric Epidemiology, 26,287–292.

Young, J. (1994).  Cognitive therapy for personality disorders: A schema-focused approach . Sarasota, FL: Professional Resource.

Watkins, John (2008) [1998].  Hearing voices:  Α common human experience . Melbourne, Victoria: Michelle Anderson Publishing.

Whitfield, C. L., Dube, S. R., Felitti, V. J. & Anda, R. F. (2005). Adverse childhood experiences and hallucinations.  Child Abuse and Neglect .  29 , 797–810.