The paper presents a clinical case study of a psychotherapeutic intervention, based on the model developed by Romme & Escher (2000), with an adult man in acute psychotic crisis who hears voices. The aim of this intervention was to decode the meaning of the voices and link the voices to the person’s history. At the same time, the person was trained in the use of cognitive and behavioural coping strategies, in order to manage the hearing voices experience and gain control over it. The specific case study was chosen because it highlights, amongst others, issues pertaining to disturbed communication and dynamics between family members, which createdouble-bind conditions and obstructthe development of an adult identity. The impediments in developing an adult identity pose obstacles to the achievement of the person’s autonomy and their detachment from their family of origin. In the paper we present the successive stages of the intervention, with emphasis on the changes achieved in each phase regarding making sense of and managing the client’s voices, and discuss its overall effectiveness for acquiring control over the hearing voices experience.
**Key Words: ** coping strategies, double bind, family dysfunction, hearing voices, psychosis, Romme & Escher model, voice dialogue
The experience of hearing voices is usually considered a symptom of psychosis, but it is also encountered in people without a diagnosis of psychosis or other mental health problems (Beavan, Read, & Cartright, 2011; Johns et al, 2014; Tien, 1991). This paper focuses on hearing voices in people with the diagnosis of psychosis. More specifically, we will present a case study of an intervention with a person who hears voices, which is based on the model developed by Romme and Escher (1993, 2000). The specific intervention is part of a PhD project, currently in completion,at the School of Psychology of the Aristotle University of Thessaloniki, Greece, with the title: “Application, recording and evaluation of a therapeutic intervention with people who hear voices”. The interventions, which are part of the research process, as well as their recording and analysis, are carried out by the first author under the supervision of the second. As part of the study, five 30-session interventions were conducted with people who hear voices, which were subsequently subjected to qualitative analysis in order to record and evaluate the process of the intervention regarding the achievement of understanding and management of the hearing voices experience.
Romme and Escher (2000), in their studies with adults and children who hear voices, found a connection between hearing voices and participants’ personal life history, as quite often the voices represented important relationships in the person’s life and unresolved issues from their present and past. Also, great emphasis was placed on the role that traumatic life events played in the subsequent hearing voices experience, in combination with other factors of vulnerability to psychosis. Romme & Escher (2000) created a semi-structured interview, known as the Maastricht Interview, in order to, firstly, explore the experience of hearing voice, and, secondly, create a case formulation with regard to the way the hearing voices experience is linked to the person’s life history. Finally, their model included coping strategies, aiming to help the person gain personal control over the hearing voices experience and change the balance of the relationship between the self and the voices.
Voice hearing and its relation to the person’s life story
In DSM-5 verbal hallucinations are defined as perceptual experiences in the absence of external stimulation, which are very vivid and clear, and are characterized by the same dynamic as other normal perceptual experiences. Verbal hallucinations are not subject to the voice hearer’s voluntary control (American Psychoanalytic Association, 2013).
The experience of hearing voices is connected to the person’s life history (Corstens & Longden, 2013; Longden, Corstens, Escher, & Romme, 2012; Romme & Escher, 2000). The voices often begin after a trauma or a social or emotional problem. Often, people are trapped in a combination of social difficulties, such as family problems and work insecurity, which make them feel powerless. Crises like these can drive people to inner disorganization, as they try to cope with very difficult emotions. The non-resolution of the problem might in some cases be part of a survival strategy. The voices are then incorporated in this strategy, and hearing voices functions as a defense mechanism. The voices are perceived as a threat that comes from the outside, and not from the inside, and in this way the voice hearer can blame the voices for the problems they face and the emotions they feel. The relationship between the voice hearer and the voices may function as a metaphor for the way the person interacts with the external word. Often voices represent a significant relationship in the present or the past and reflect the voice hearers’ problems.
Romme and Escher (2000) found that many situations can turn into problems for the people who hear voices and make them feel weak. For some people, voices are connected to a completely new and overwhelming problem. For others an old problem may re-appear and cause feelings of helplessness. These situations may concern problems of everyday life or problems of relationships with other people or the family, which seem insurmountable to the person. In these cases, the voices may represent the person who causes the problem and may constitute a metaphor for them. The experience of hearing voices can come about in situations of high pressure for achievement. In these cases, the voices act by reinforcing the insecurity or the negative thoughts about the self and its prospects for achievement. In other cases voices can emerge as a result of the person’s effort to cope with a particular emotion throughout their life, which, however hard they try to make disappear, is always there. The voices in this situation are a metaphor for the emotion which causes difficulty to the person.
In many cases, the voices are related either to a recent trauma or to past traumatic experiences. Often someone starts hearing voices while in bereavement (Ritcher, Luckstead, Otilingam, & Grajales, 2004; Watkins, 1998). In this situation the voice belongs to the dead person. The duration of the hearing voices experience depends on the course of mourning, and the presence of voices in most cases signifies that the person has yet to come to terms with the loss. When the person accepts the loss, the voices usually disappear. A less frequent occurrence seems to be that of voices in occasions of loss due to events other than death, such as job loss or divorce.
The voices also relate to traumas or problems of emotion tolerance in childhood. Ensink (1992) found that 27% of victims of incest during childhood started hearing voices in later life. Bentall (2004) comments that some children, for a variety of reasons, may have been deprived of experiences that contribute to the refinement of reality testing capacities. These children have poor reality testing abilities and are thus vulnerable to the emergence of hallucinations, when they experience disturbing thoughts and visions. The link between trauma and the emergence of hallucinations derives from the fact that trauma has this function, to cause an influx of disturbing thoughts and visions.
Nevertheless, the traumatic events are not confined only to childhood. Romme and Escher (1993) report links between voices and the experience of trauma in adulthood as well. Particularly traumatic events are situations which include psychological, physical and sexual abuse, perpetrated by husbands, fathers, brothers, sons and other relationships. Many men and women who hear voices report such experiences. Especially for women, abuse seems to be a very usual phenomenon. The connection between psychosis in general and hearing voices more specifically, during both childhood and adulthood, is well established in the literature (Longden, Madill, & Waterman, 2012; Read, van Os, Morrison, & Ross, 2005).
To conclude, Romme and Escher (2000) found, from case studies with voice hearers, that the voices the voice hearers knew very well. The content of the voices is highly correlated with the voice hearers and the voice hearers feel judged by the voices. The voices refer to unresolved problems of everyday life, problems linked to earlier trauma or to non realistic ambitions for the future.
We have addressed in this section the situations that usually precede the emergence of voices. There are, however, a variety of other environmental and biological factors that can interact with these situations and lead to the development of psychosis, one of the features of which is hearing voices, which include aspects of family functioning.
Family related vulnerability factors for psychosis
Regarding the vulnerability factors which can lead to the development of psychosis, emphasis has been placed on a combination of environmental and biological factors that can render a person vulnerable to the emergence of psychosis later in life. The environmental factors include stressful life events, traumatic experiences, childhood adversities, as well as family and social situations that trigger stress (Bentall, 2004; Morgan, McKenzie, & Fearon, 2008; Zubin & Spring, 1977). In this paper we will refer only to family relationships, which may be a stressful factor that contributes to the development of psychosis later in life. In the case study presented here the communication pattern within the family seems to have played a major role in the emergence of hearing voices and the subsequent development of psychosis.
Three different types of non-appropriate relationships between children and their families have been identified in families with a member diagnosed with psychosis. However, researchers, in an attempt to avoid stigmatisation of the family, claim that although these processes can influence the course of psychosis, they do not constitute etiological factors for the development of psychosis.
The first type of problem includes a disturbance in the emotional bond that usually forms between a child and its parent in the beginning of the child’s life. There is increasing evidence that when this type of bond, known as attachment (Bowlby, 1965), is insecure, then there is increased vulnerability to psychosis (Berry, Barrowclough, & Wearden, 2008; Gumley, Taylor, Schwannauer, & MacBeth, 2014; Ponizovsky, Vitenberg, Baumgarten-Katz, & Grinshpoon, 2013). Specifically, disorganized attachment has been linked to dissociative and psychotic experiences (Longden, Madill, & Waterman, 2012). Moreover, it has been argued that the link between childhood traumatic experiences and adversities – such as physical and sexual abuse, neglect and parental loss – and the emergence of psychosis in adulthood, which has been documented repeatedly (Skehan, Larkin, & Read, 2012; Varese et al., 2012), is mediated by disorganized relations with the primary caregivers and therefore by the establishment of a disorganized attachment pattern, which renders the person vulnerable to experiencing dissociative and psychotic phenomena when facing stressful situations (Read & Gumley, 2008).
The second type of disturbed family relationships is linked to the expression of emotions between the family members. The distinctive features of emotional expression that have been linked to psychosis are: 1) expression of hostility towards the person, which includes blame and rejection, 2) negative criticism regarding the person’s actions and feelings, 3) emotional over-involvement, which includes overprotection, self-sacrifice and intrusiveness (Vaughn & Leff, 1985). Several studies have shown that high expressed emotion in a family is associated with more relapses of the family member with a diagnosis of schizophrenia (Amaresha & Venkatasubramanian, 2012; Butzlaff & Hooley, 1998).
The third type of problematic relationship relates to disturbed communication in the family. Bateson and his colleagues (Bateson, 1972; Bateson, Jackson, Haley, & Weakland, 1956) developed a theory linking a double bind situation, a paradoxical mode of communication between family members, to the subsequent development of psychosis. More specifically, they defined as double bind the situation whereby in a vital relationship, such as that between child and parent, the person receives mutually excluding and contradictory messages. The receiver of the messages is subjected to long term exposure to them, from childhood, with no possibility to escape. In this situation, the receiver of the message is prevented from escaping, as they cannot either react or not react in a non-paradoxical way, because the message itself is paradoxical. This communicative situation is often combined with a moreorlessdirect prohibition for the receiver of the message to demonstrate awareness of the contradiction or of the real issues that are at stake. A person exposed for a long time to a double bind situation can follow three paths: 1) in an attempt to seek meaning, they may be driven to experiencing unusual phenomena (as in paranoid schizophrenia), 2) they may choose to literally follow all the commands and to abstain from forming any independent relationship (as in hebephrenic schizophrenia), or 3) they may choose to withdraw from engaging with other people as a form of perceptual defense (as in catatonic schizophrenia).
From the perspective of cognitive theory, continuing unclear, limited and contradictory parental communication may lead a child to experiencing cognitive confusion, thus increasing the possibility for the development of thought disorder later in life (Bentall, 2004). Other researchers have found strong associations between deviant communication within the family, negative affective style and the subsequent development of psychosis (de Sousa, Varese, Sellwood, Bentall, 2013; Doane, West, Goldstein, Rodnick, & Jones, 1981). Finally, even in cases of already developed psychosis, deviant parental communication has been associated with increased possibility of relapse (Velligan et al., 1996).
Another feature of families characterized by disturbed communication between their members is the disruption of family organization with regard to the roles of its members, which results in the young adult’s failure to be successfully detached from their family of origin and achieve autonomy. When a person towards the end of adolescence and the beginning of adulthood starts expressing strange behaviours, they fail to achieve autonomy from their parents. This failure contributes to the stabilization of the parent sub-system, as the parents often have difficulties in directly managing the problems in their own relationship and in functioning again as a dyad. In this way, the young adult becomes the weak member, in need of help and guidance by the parents. The parents tend to focus on their child’s problems, thus avoiding to deal with their own problems (Haley, 1997).
The Romme & Escher model
The model developed by Romme and Escher (2000) provides an integrated way of understanding and coping with the experience of hearing voices. The basic first step of this approach is the open admission by the person that they hear voices. Through the admission that they hear voices people can make choices regarding how they will react to them and gain personal control over their experience. This approach is inspired by the field of social psychiatry, which is founded on the deconstruction of mental illness to its various symptoms. According to this approach, the illness reflects the inability of the person to function in society. The illness behavior is considered a reaction to serious social problems and problems of relationships with other people, with which the person cannot cope.
The Romme & Escher approach (2000) proceeds with a deep exploration of the experience of hearing voices with the use of the Maastricht interview. Through the interview information is gathered about the nature of the experience, the voices’ characteristics, the history and development of the voices, the factors that trigger the voices, the voices’ content, the way the person understands the voices, the influence of the voices on the person’s everyday life, and the ways in which the person copes with the voices. The information gathered from the interview is subsequently used in order to develop a case formulation in collaboration with the voice hearer. The case formulation answers two questions: 1) which important relationship or person the voices represent, and 2) which problems the voices represent. At a later phase the person is trained in cognitive and behavioural coping strategies, which are generally grouped into focusing, distraction and stress reduction strategies, depending on the phase of the hearing voices experience that the person is going through at that time of the intervention (Haddock & Slade, 1996).
Another, distinct coping strategy for hearing voices is the voice dialogue (Corstens, Longden, & May, 2012). The aim of this strategy is to explore and change the balance of the relationship between the voice hearer and the voices, and not to change the voices. For the achievement of this aim, voice hearers need to understand the motives of their voices and to learn different ways of dialoguing with the voices. This approach borrows elements from Bakhtin’s theory of the dialogical self, according to which the self is a dynamic multiplicity of relatively autonomous ego-positions. In the dialogical model, the person consists of different selves or personalities. Each one of them perceives the world in their own way, on the basis of their personal history, their physical characteristics, their emotional and physical reactions and their views on life. The selves persist on what the person has learned in order to survive. The prevailing selves expel the more vulnerable parts and the selves that were previously functional in survival remain hidden, without playing an important role any more. The voices, from this point of view, represent the hidden selves, which where once functional for the person’s survival, but in the present phase persist in their past adaptive role, preventing the person from adapting to different future situations. In the technique of establishing dialogue with the voices, the facilitator helps the person to explore these different selves, by asking simple questions. For the achievement of this particular goal, the voice dialogue strategy borrows techniques from different approaches, such as Gestalt, psychodrama and analysis of the voices’ characteristics.
In general, Romme and Escher (2000) distinguish between three phases of the hearing voices experience: 1) the startling phase, when the person is overwhelmed by the strange, new experience of hearing voices, 2) the organization phase, during which the voice hearer gets accustomed to the voices and looks for ways to cope with them, and 3) the stabilization phase, when a better balance is achieved in the relationship between the voice hearer and the voices. Depending on the phase of the hearing voices experience, differentstrategies are applicable.
Clinical case study presentation
A 35 year old man, whom we will call Paul, visited the outpatient unit of Eginiteio Psychiatric Hospital of Athens, after extreme anxiety, triggered by the belief that he is being monitored, and hearing many voices. He receives a diagnosis of schizoaffective disorder. In the past he was seen by a psychologist for 3 years, and occasionally receives medication. Currently, he lives in a provincial town with his 70 year old father and his 67 year old mother. He has an older sister who lives and works in another city. For his first visit to the Psychiatric Hospital he comes accompanied by his sister. Paul works at his father’s business but wants to find another job, which causes intense conflicts with his father.
Paul describes his childhood as very difficult, as his father put pressure on him to work in his business, without providing appropriate support. Both parents also exerted physical violence upon him. Within the family there were many double messages regarding his adequacy or inadequacy to meet his parents’ demands and his father’s expectations. The relationship between his parents is described by Paul as distant. His father is presented as authoritarian and aggressive and his mother as weak. The mother, in situations of intense stress, has panic attacks and also takes psychotropic medication. The older sister left the family home at the age of 18 in order to study, with support from the parents.
Paul started hearing voices at the age of 16, and at the time the experience was not accompanied with distress. He describes hearing the voice of an older man in that period, who disoriented him from important decisions. At the same time Paul left school in order to work in his father’s business, after his father’s initiative and against his own will. During that period he works in his father’s business without payment, but wishes to follow another profession. The father severely challenges his ability to fulfill his expectations. The voices increase at the age of 19-21 and he starts to believe that he is being watched by other people, after using drugs. The drug use is described by Paul as a reaction against the pressure he felt from his parents. Paul mentions one attempt at attaining autonomy from his family of origin at the age of 28, through finding another job and an engagement, which resulted in separation 5 years later. During that time, the voices increase his senseofinadequacyto perform in his new job and create obstacles in his relationship with his partner. After the separation, he returns to his family of origin, followed by a period of isolation which lasts to the present time.
In the current phase Paul hears a dominant male voice aged 28, which continues to disorient him from his personal choices. This voice is triggered mainly when he is working at his father’s business. He also hears the voice of his self, as a weak positive voice, and other secondary voices, which also have the role of disorienting him from personal choices. He also holds a belief that some people control his thoughts and watch him. Regarding the phase of the hearing voices experience, in the beginning of the intervention Paul is in the organization phase. Paul was referred to me by the intake psychiatrist, after he had informed him of my study.
In our first session Paul is polite and his appearance is good, but he is very anxious and systematically avoids eye contact. He describes hearing many voices in his head, like a crowd noise. He also believes that some people want to harm him and control his thoughts through a microchip that they have installed in his brain. I find it difficult to follow his train of thought, as it is quite disorganized. I inform him about the purpose of our meetings and he agrees to participate in the hope that I will help him to cope with his voices.
The process of therapeutic intervention
The therapeutic intervention with Paul lasted for 27 sessions. The intervention can be divided into 4 phases.
During the first phase information was collected about the experience of psychosis as a whole and the stressful events that possibly played a role in its emergence and development, according to the Maastricht interview.
Paul describes the start of hearing voices:
_P: The voices began when I was 16, but I had accepted them as something that directed me. _ Subsequently, I understood that because of the voices I lost friends, situations I could have handled differently, not to close the door to girlfriends, it was my fault, I should not given the last strike.
T: Did you hear systematically the voices at 16?
P: It was occasionally, I remember an older voice … and most of the times, when I had to take a critical decision, for something to be done … to change my decision, this was not helpful at all.
The number of the voices increased at the age of 19-21, after using drugs. Then Paul started believing that other people wanted to harm him:
P: I was about 19-21 years old, it was the time I had started taking drugs, then I was also feeling that other people wanted to harm me.
At present, Paul describes his experience as follows:
P: I remember, because for some weeks before I took the medication, I was getting on edge, I was afraid of myself. Apart from the fact that I had suicidal tendencies, I was afraid I would take it out on someone, I was afraid for my parents, suddenly I lost confidence in myself, I had a very difficult time.
Paul holds a weakness/inferiority schema of beliefs about himself, which is related to the confusion of the child-adult role that prevails more generally in his life. The weakness/inferiority schema is encouraged by the voices he hears. The belief schema about others includes the perception of others as dismissive, critical and holding a negative view of him:
_P: Usually, I am a serious person, but often, when I go out, other people treat me somewhat _ mockingly. I am the kind of person who cannot stand this for myself and I feel ashamed. At some point they had put a camera in the house. I could have also done it to them, put a camera somewhere, but what would I gain by making fun of someone?
The belief schemas about the self and other people are associated with past stressful life events, which are mainly linked to the relationship with his parents.
T: How were things then with your family?
_P: They did not see me as their child, they saw me as a protector, as a person who helps with the shop. When I was not working, my mother would come and hit me with a _ broomstick to make me get up. At that time I went to a school but I gave it up, I was 21 then, it was a professional training school, I went for 1 year and then I left. I also went at the age of 16 to a technical school, but I did not finish it, I failed because of absences. My parents thought I was useless, but they kept pressing me to work in the shop.
The voices are interpreted as externally constructed, while the dominant voice is connected with Paul’s self:
P: They are something external, something constructed.
T: By whom?
P: By a person. Sometimes voices are heard as if they are constructed, I distinguish sometimes that this voice may be constructed.
The coping strategies for the experience as a whole that Paul has adopted are psychotherapy for 3 years in the past, which had a significant contribution to the separation of the self from the voices, and self-monitoring, voice dialogue, cannabis use and medication at the present time. My intervention centred mainly on the dialogue with the voices and the delimitation of the time of hearing voices. This intervention brought about significant results, because it contributed to a change in the balance of the relationship between the self and the voices, already from session 7, to a positive change in the characteristics of the voices and in Paul’s emotions regarding the voices and also to an increase in the sense of personal control over the voices.
P: I manage to control the voices to some extent with the coping strategy we talked about last time. When I try and think about something at the shop and the voices disturb me, I try the strategy, I tell them to talk later and the voices stop. I have reached a point where I can control the voices to some extent, more than at other times, the occasions have decreased, sometimes the voices used to totally disorganise me, this has now decreased a little bit and I am better, I can make important decisions more easily , if something is important I can process it better.
During the second phase of the therapeutic intervention, many and important changes take place, while the changes achieved in the previous phase are maintained and strengthened. Specifically, there is positive change with regard to the identity, characteristics and properties of the voices, Paul’s emotions regarding the voices and the relationship between self and voices. The most important change is in the balance of the relationship between self and voices. In this phase, greater differentiation of the self and thoughts from the voices is achieved, decisions are made more autonomously and the voices become mild and cooperative. In session 8, Paul describes his experience as follows:
P: Because I apply the coping strategy of postponement with the voices, I tell them to talk to me later, I leave some space to hear them. I do this, and their evilness has changed. The voices used to tell me “Why are you ignoring us?” … they are milder and agree when I ask them to talk to me later. At some point, I have a short dialogue, I tell them … “Tell me whatever you want, I will listen to you” … and for a short time I listen to them. The time I spent with my voices last night was 10 minutes.
And in session 10:
P: In the present phase I mainly hear the voice of my self, when I am thinking, I understand that I am thinking what I wanted to think, and I recognise that what I hear is not voices, it is something else, it is my thoughts.
At the level of interpretation of the hearing voices experience, information is added regarding Paul’s relationship with his parents and the voices are understood as related to Paul’s relationship with his father and to losses of beloved persons. The following exchange takes place in session 9:
T: We are very close to talking about some things regarding what I have understood about the voices you hear and what you have understood.
P: I have started thinking that the voices may be a reaction against my father, but I don’t know why this is happening. Also, when I started hearing many voices, I lost many of my own people.
Paul’s relationship to his parents is changing. Paul starts to negotiate and to make demands from a more equal position. He also formulates thoughts of autonomy from his parents:
T: How are things with your parents?
P: The situation has balanced out, to an extent, in relation to some things, I back down and I try to keep a balance.
T: This includes both your parents?
P: Each of them needs different training.
To the coping strategies Paul applies to the hearing voices experience, new ones are added, such as ignoring events that are not confirmed and negotiating coming off medication. My rolein this phase of treatment is to reinforce the continuing implementation of strategies already employed by Paul from the previous phase and the differentiation of the self from the family.
During the third phase of the therapeutic intervention many changes also take place. More specifically, there is continuation of positive changes at the level of the voices’ identity, characteristics and properties, the emotions they cause, as well as changes in the relationship between self and voices. The most significant change is the sense of personal control towards the voices and the change in the relationship between self and voices, which becomes more collaborative. Paul now wants to hear the voices. The changes occur in interaction and also arise as a result of changes and interventions in previous phases.
The voices cause mainly positive emotions and the sense of personal control increases. In session 14 Paul describes:
_T: _ _How _ _are _ _things _ _in relation to _ the voices ?
_P: _ I have one voice, at some point they were about to show up, then an idea came to my mind “Do not create voices to yourself” and the voices left. I somehow have control over this voice. It remains positive. There are sometimes some things , like commentaries, but I judge what they are.
And in session 17:
P: John comes at times when I seek company, he does not come the way I want to , but it is kind of like keeping me company.
At the level ofbeliefs about himself, Paul made connections between his relationship with his parents and the child-adult role confusion, which is the source of hisperception of personal inadequacy. Specifically, at a different point in session14 Paul comments about his parents:
P: I feel anger, I feel anger against both of them, they never listened to what I kept telling them, they did not trust me, if someone continually hears that they do not trust him, his self and his confidence get damaged. I wanted to do some things in my job, and I could not take responsibility, things that a child would do. I mainly feel anger. They always made me angry.
Paulnow interprets the voices as relating to life events that mainly concern the relationship with his parents.
T : Do you have any explanation about the voices?
_ P_ : I think they mainly come from drugs and from my family, my parents, they created something reactive in me. Drugs helped in this to a large extent. I helped, because I was reacting to everything, and all this got bound up together, and I got to this situation.
Paul’s relationship with his family changes in a positive manner, as does his relationship with other people. The coping strategies that Paul applies in this phase towards hearing voices are enriched, and he begins to participate in a hearing voices self-help group, while continuing to negotiate coming off medication. In this phase I mainly apply reality testing interventions in relation to the sense of threat from other people that Paul still feels.
The most important changes take place during the fourth phase of the therapeutic intervention. In terms of identity and characteristics of the voices, they are limited to one voice that approximates Paul’s characteristics and now he recognizes this voice as the voice of himself. With regard to the balance of the relationship between the self and the voices, the voice that is now approaching Paul’s features has mainly the role of strengthening his desires and is perceived as a part of himself. In session 18 Paul describes his experience as follows:
P: In this phase John has become a more serious voice, he is about my own age. T: How has this change occurred?
P: I cannot explain it, on the one hand I take the medication, on the other hand I have also helped myself. With the world outside I have a different relationship, somewhat different. Before, I felt it very intensely. I felt the gossip. I felt someone saying bad things about me, and apart from some things happening to me, some coincidences, I used to feel it inside of me. Now this has stopped and I feel more free. This has helped me to confront the voices, and with your help I found some ways to deal with the voices differently, the appointments I give them have had results.
At this phase Paul passes to the stabilization phase of the hearing voices experience. The feelings caused by hearing this particular voice are positive. This change is mainly due to the interpretation of the voices as a personal construction in the previous phase of the intervention. At the level of beliefs about the self, the inferiority/weakness schema is now limited to the domain of seeking work. At the level of beliefs about other people, the perception of other people as critical and rejecting declines, mainly due to the reality testing interventions in the previous phase.
The most significant change occurs at the level of interpretation of the hearing voices experience, as the two key questions regarding the problems and the important relationship represented by the voices are answered, according to the case formulation in Romme and Escher’s model. More specifically, the problem represented by the voices is Paul’s failure to build an integrated and independent adult identity and the important relationship represented by the voices is the relationship with his father:
T: If you look at the course of your life, what issue always came up and caused you difficulty?
P: Work, close to my father I did not feel confidence, rehabilitation.
T: What did the voices do in relation to the insecurity?
P: They disorient me, they make me angry.
T: Are they related to this insecurity?
P: Yes, may be.
T: Are they related to the difficulty to make decisions in your life?
T: Was there in your environment someone who was trying to disorient you to the point that made you angry in a similar way to what the voices did?
P: My father was trying to disorient me and guide me, and my mother too, in a bad way, “do this, do that”.
In terms of relationships with the family Paul manages to impose his personal limits, and in terms of relationships with other people he makes new friends.
In session 20 Paul proceeds on his own to reducing his medication, which results in an increase of the number and intensity of the voices and of the perception of exposure and threat. However, Paul does not lose his personal control over the voices.
Evaluation of the therapeutic intervention
Summing up, in the first three phases of the therapeutic intervention changes take place at the level of the characteristics of the voices and the balance of the relationship between the self and the voices. Furthermore, Paul is making connections between stressful life events and beliefs about himself and others, which contribute to the interpretation of hearing voices as associated with himself. In the fourth phase of the intervention, a case formulation based on the model of Romme and Escher is drawn up. The changes in the first three phases of the intervention contribute to changes in Paul’s relationship with his family and with other people and the self is empowered.
The primary objective of the therapeutic intervention is, at a first level, the development of personal control over the hearing voices experience. Paul is in the organization phase of the hearing voices experience, but has not yet developed successful coping strategies for the voices. This primary goal of the therapeutic intervention is consistent with Paul’s main demand, which is the management of the hearing voices experience. A second key objective of the therapeutic intervention is to make sense of the hearing voices experience.
Regarding the first objective of increasing personal control over the hearing voices experience, this is achieved mainly at the second phase of the therapeutic intervention and continues until the end of treatment. During the second phase of the intervention, the increased personal control contributes to a change in the characteristics of the voices, which then also brings about a change in Paul’s feelings towards them. In this way, Paul manages to separate himself more from the voices and his sense of personal control increases. In the third phase of the intervention, Paul’s personal control over voice hearing is maintained, and this continues through to the fourth phase. The continuing sense of personal control also contributes to a change in the characteristics of the voices and Paul’s emotions towards them, which leads to the eventual connection of the dominant voice to himself. The dominant voice in the fourth phase of the intervention reaches Paul’s age and characteristics.
With regard to the second objective of the therapeutic intervention, making sense of the experience, the process of meaning making already starts from the first phase of the intervention, when it transpires that the hearing voices experience acts primarily by supporting the inferiority/weakness schema that Paul holds in relation to himself. Paul projects to other people his perception of inferiority, which has been created primarily through stressful events that concern the relationship with his parents. The belief schemas about the self and other people affect Paul’s relationship with his family and other people. In the second phase of the intervention Paul takes a step further and interprets the voices as associated with his relationship with his family. The changes in the sense of personal control and in the meaning of the hearing voices experience lead Paul to renegotiate his relationship with his family. In the third phase of the intervention, Paul proceeds to making connections between stressful life events and the belief schemas about himself and other people. At the same time, Paul maintains the interpretation of the hearing voices experience as linked to the relationship with his family. In this phase, the relationship with the family is changing and Paul sets his personal limits. This change also contributes to a change in the relationships with other people. In the fourth phase of the intervention, the voices are limited and the main voice approximates Paul’s identity and characteristics. Paul recognizes that voice as linked with himself. In this fourth phase, Paul passes onto the stabilization phase of the hearing voices experience. Furthermore, the inferiority/weakness belief schemas are confined to the domain of work and the perception of others as rejecting and critical declines. In this final phase of the therapeutic intervention I proceed, in collaboration with Paul, to drafting a case formulation based on the Romme and Escher model, which highlights the important relationship and the problems represented in his life by the voices.
This therapeutic intervention is an alternative approach to managing the experience of hearing voices. Its main objective is to connect the hearing voices experience with important life events and relationships with significant others. The basic aim is to decode the meaning of the voices and connect them with sides of the self of the individual.
This clinical example highlights the existence of fundamental issues of identity confusion and self image, which to a large extent are attributable to familial communication patterns and relationships between family members. Amongst others, there are issues regarding double bind messages between family members and Paul’s failure to get detached from his family of origin, to achieve autonomy and to form an adult identity. At the same time, the study highlights Paul’s function within the family system, which effectively consists of him being the target of his father’s negative criticism and authoritarianism, which in other circumstances would be targeted towards the vulnerable mother.
This therapeutic intervention proved to be moderately effective in strengthening the adult side of the self and developing personal boundaries against the intrusiveness of the other family members. The main limitation of this intervention is that it is an individual therapeutic model, while in this clinical example a family-based therapeutic intervention, aimed at changing interaction patterns between family members, might have been more effective.
Amaresha, A. C., & Venkatasubramanian, G. (2012). Expressed emotion in schizophrenia: An overview. Indian Journal of Psychological Medicine, 34 , 12-20.
American Psychiatric Association (2013) _Diagnostic and statistical manual of mental disorders, _ 5th edition (DSM-5). Washington, D.C.: American Psychiatric Publishing.
Bateson, G. (1972). Steps to an ecology of mind: Collected essays in anthropology, psychiatry, evolution, and epistemology . Part III: Form and pathology in relationship . San Francisco: Chandler Publications.
Bateson, G., Jackson, D. D., Haley, J., & Weakland, J.(1956). Towards a theory of schizophrenia . _Behavioral Science, 1, _ 251-264.
Beavan, V., Read, J., & Cartright, C. (2011). The prevalence of voice-hearers in the general population: A literature review. Journal of Mental Health, 20 , 281-292.
Bentall, R. (2004). Madness explained: Psychosis and human nature . Harmondworth: Penguin.
Berry, K., Barrowclough, C., & Wearden, A. (2008). Attachment theory: A framework for understanding symptoms and interpersonal relationships in psychosis. Behaviour Research and Therapy, 46 , 1275-1282.
Bowlby, J. (1965). _Child care and the growth of love _ (2nd ed). Harmondsworth: Penguin.
Butzlaff, R. L., & Hooley, J. M. (1998). Expressed emotion and psychiatric relapse: A meta-analysis. Archives of General Psychiatry, 55 , 547-552.
Corstens, D., & Longden, E. (2013). The origins of voices: Links between life history and voice hearing in a survey of 100 cases. _Psychosis: Psychological, Social & Integrative Approaches, 5, _ 270-285 .
Corstens, D., Longden, E., & May, R. (2012). Talking with voices: Exploring what is expressed by the voices people hear. Psychosis: Psychological, Social & Integrative Approaches, 4 , 95-104.
de Sousa, P., Varese, F., Sellwood, W., Bentall, R. P. (2013). Parental communication and psychosis: A meta-analysis. _Schizophrenia Bulletin, 40, _ 756-768.
Doane, J. A.,West, K. L., Goldstein, M. J., Rodnick, E. H., & Jones, J. E. (1981). Parental communication deviance and affective style: Predictors of subsequent schizophrenia spectrum disorders in vulnerable adolescents. _Archives of General Psychiatry, 38, _ 679-685.
Ensink, B. (1992) Confusing realities: A study on child sexual abuse and psychiatric symptoms . Amsterdam: Free University Press.
Gumley, A., Taylor, H., Schwannauer, M., & MacBeth, A. (2014). A systematic review of attachment and psychosis: Measurement, construct validity and outcomes. Acta Psychiatrica Scandinavica, 129 , 257-274.
Haddock, G., & Slade, P. D. (Eds.), (1996). Cognitive-behavioural interventions with psychotic disorders . London: Routledge.
Haley, J. (1997). Leaving home: _The therapy of disturbed young people _ (2nd ed). New York: Brunner/Mazel Publishers.
Johns, L. C., Kompus, K., Connell, M., Humpston, C., Lincoln, T. M., & Longden, E. et al (2014). Auditory verbal hallucinations in persons with and without a need for care. Schizophrenia Bulletin, 40 , S255-S264.
Longden, E., Corstens, D., Escher, A., & Romme, M. (2012) Hearing voices in biographical context: A framework to give meaning to voice hearing experiences. _Psychosis: Psychological, Social & Integrative Approaches, _ 4, 224-234.
Longden, E., Madill, A., & Waterman, M. G. (2012). Dissociation, trauma, and the role of lived experience: Toward a new conceptualization of voice hearing. Psychological Bulletin, 138 , 28-76.
Morgan, C., McKenzie, K., & Fearon, P. (Eds.) (2008). Society and psychosis . Cambridge: Cambridge University Press.
Ponizovsky, A. M., Vitenberg, E., Baumgarten-Katz, I., & Grinshpoon, A. (2013). Attachment styles and affect regulation among outpatients with schizophrenia: Relationships to symptomatology and emotional distress. Psychology and Psychotherapy: Theory, Research and Practice , 86 , 164-182.
Read, J., van Os, J., Morrison, A., & Ross, C. A. (2005). Childhood trauma, psychosis and schizophrenia: A literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavica, 112 , 330-350.
Ritcher, J. B., Lucksted, A., Otilingam, P. G., & Grajales, M. (2004). Hearing voices: Explanations and implications. Psychiatric Rehabilitation Journal, 27 , 219-227.
Romme, M., & Escher, S. (1993). Accepting voices . London: MIND.
Romme, M., & Escher, S. (2000). Making sense of voices: A guide for mental health professionals working with voice-hearers . London: MIND.
Skehan, D., Larkin, W., & Read, J. (2012). Childhood adversity and psychosis: A literature review with clinical and societal implications. Psychoanalysis, Culture & Society, 17 , 373-391.
Tien, A. T.(1991). Distribution of hallucinations in the population . _Social Psychiatry and Psychiatric Epidemiology, 26, _ 287-292.
Varese, F., Smeets, F. & Drukker, M., Lieverse, R., Lataster, T., Viechbauer, W. et al (2012). Childhood trauma increases the risk of psychosis: A meta analysis of patient-control, prospective and cross sectional cohort studies. Schizophrenia Bulletin, 38 (4), 661–671.
Vaughn, C., & Leff, J. P. (1985). Expressed emotion in families: Its significance for mental illness . New York: Guilford Press.
Velligan, D. I., Miller, A. L., Eckert, S. L., Funderburg, L. G., True, J. E., Mahurin, R. K., Diamond, P., & Hazelton, B. C. (1996). The relationship between parental communication deviance and relapse in schizophrenic patients in the 1-year period after hospital discharge: A pilot study. _Journal of Nervous and Mental Disease, 184, _ 490-496 .
Watkins, J. (1998). Hearing voices - a common human experience . Melbourne: Hill of Content Publishing.
Zubin, J. & Spring, B. (1977).Vulnerability – a new view on schizophrenia _. Journal of Abnormal Psychology, 86, _ 103-126 .