The experience of hearing
voices: Daring to talk back
Dr Mark Hayward
Sussex Partnership NHS Foundation Trust &
University of Sussex
April 2011
Presentation Overview
 A variety of voices
 Mediation of responses to voices
 Relationships with voices
 Applying a new theory of relating
 Daring to talk back
 Brief consultation
The hearer’s view
 ‘the Devil’
 ‘the man next door’
 ‘Miranda’
 ‘the people I hear’
 ‘the people in the garden’
 ‘murder voices’
Hearing and Feeling
Spirits
Commanding
Prophets
Guiding
Family/Friends
Powerful
Madness
? ?
Special/Gifted
Hopeless
Watched
Scared
Comforted
Guilty
Inferior
Looked after
Mediation of Responses to Voices
Hearing
Beliefs about the voice’s power, identity and intent
(Birchwood & Chadwick)

Feelings
Cognitive model of voices
(Chadwick & Birchwood, 1994)
Activating event = voice speaking
‘Be careful’
Beliefs about voices = power, intent and identity
It is the Devil, he is watching and waiting to get me
Consequences = distress and attempts to escape
Terror; avoids going to the shops
Mediation of Responses to Voices
Hearing
Beliefs about the voice’s power, identity and intent
(Birchwood & Chadwick)


Beliefs about the self (Close & Garety)
Feelings
Beliefs about the self
(Close & Garety, 1998)
Voice content
(NATS)
Helplessness
(as hearer loses struggle for control)
Negative beliefs
(Worthless, useless,
helpless)
Mediation of Responses to Voices
Hearing
Beliefs about the voice’s power, identity and intent
(Birchwood & Chadwick)


Beliefs about the self (Close & Garety)

Social Empowerment of the hearer (Romme & Escher)
Feelings
Social Empowerment
(Romme & Escher, 1993, 2000)
 33 % of 450 people ‘coped’ with their
voices
 voices considered positive and friendly
 more likely to be married
 perceived themselves to be well supported
by others
 more likely to talk to others
Mediation of Responses to Voices
Hearing
Beliefs about the voice’s power, identity and intent
(Birchwood & Chadwick)


Beliefs about the self (Close & Garety)

Social Empowerment of the hearer (Romme & Escher)

Childhood trauma (Escher)
Feelings
Childhood trauma
(Escher, 2002)
 80 children followed over 3 years
 Voices persisting in only 40%
 Traumatised by early events and recent
triggers
•
•
•
•
Grief
Problems in home
Problems at school
Circumstances beyond control
Mediation of Responses to Voices
Hearing
Beliefs about the voice’s power, identity and intent
(Birchwood & Chadwick)


Beliefs about the self (Close & Garety)

Social Empowerment of the hearer (Romme & Escher)

Childhood trauma (Escher)
Feelings
Relational Backdrop
 “Integrated, personally coherent relationships
with their voice”
(Benjamin, 1989)
 “Individuals experience their voices not as their
own thoughts, but attribute them to others.
Consequently, it is possible to view an
individuals relationship with a voice as
interpersonal, and indeed the relationship shows
many of the dynamics common to ordinary
relationships”
(Chadwick et al, 1996)
Mirroring of Relationships
(Birchwood et al, 2000, 2004)
Rank
Power
Appraisals driven
by interpersonal
schema
Social
Voice
Social
Voice
But surely,………………
‘if relating to voices is influenced by
relationships in the real world, it is likely to be
imbued with all the complexity and idiosyncrasy
of social relationships. This will include issues
of power and proximity…’
(Hayward, 2003, P. 371)
Relating Theory
Birtchnell (1996, 2002)
UPPERNESS
(relating from a position of relative strength)
DOMINATING
DISTANCE
(remaining separate)
CLOSENESS
(becoming involved)
WITHDRAWAL
CLINGING
LOWERNESS
(relating from a position of relative weakness)
HELPLESS
Applied to Voice Hearing
(Hayward 2003; Hayward et al, 2008; Vaughan & Fowler 2004; Sorrell et al, 2010)
VOICE ‘DOMINANCE’
Distress
Malevolence
Resistance
HEARER
‘WITHDRAWAL’
Resistance
Negative content
‘incognito’ voices
Distress
VOICE
‘INTRUSIVENESS’
Distress
Malevolence
HEARER ‘DEPENDANCE’
Benevolence
Engagement
Less negative content
Is “relating to a voice” meaningful
to hearers? (Chin, Hayward & Drinnan, 2009)
 YES

Evidence of “relating” in their interaction
“Erm we still have this ‘go away I’m not listening’, ‘yes you are, you’re going to
listen to me’ kind of relationship”
“when I talk to [the voice of] my mum she asks me how my day’s going and I
tell her what I’ve done and what I’m doing”

Personification facilitated understanding and predictability
 NO
“[…] I’ve said to them many times that er ‘there’s you or me but no we’”
Clinical Implications
Two possible ways to work therapeutically
to modify the relationship with the voice:
At the level of social relating, e.g.
assertiveness training (Birchwood et al, 2002)

At the level of voice relating, e.g.
Personification of and engagement with
voices (Chin et al, 2009)

Voice and You (VAY)
(Hayward et al, 2008)
VOICE DOMINANCE
(7 items, e.g. my voice wants things done
his/her way)
VOICE INTRUSIVENESS
(5 items, e.g. my voice does
not let me have time to
myself)
HEARER DISTANCE
(7 items, e.g. I try to hide
my feelings from my voice)
HEARER DEPENDENCE
(9 items, e.g. my voice helps
me make up my mind )
Can relationships with voices
change? (Hayward et al, 2009)
 Explore parallels with social relating
 Enhance awareness of reciprocal nature of
relationship
 Explore ways of relating to the voice
differently
Case series
 N=5
 Voices for 12 Months, irrespective of
diagnosis
 Baseline x 2
 12-24 sessions
 Post therapy, 1 & 3 month follow-up
 PSYRATS & VAY
Mary
 Heard voice of The Devil
 Responsible and lacking faith
 Consistent with relational history

Following an ‘attack’ – she stood firm
Hearer Relating
Voice Relating
25
VAY scores
15
10
5
0
1
2
3
4
5
6
7
8
9
10
1
11
2
3
Assessment occasion
Voice Dominance
4
5
6
7
8
9
10
Assessment occasion
Hearer Distance
Voice Intrusiveness
Distress and Control
4.5
4
3.5
AHRS score
VAY scores
20
20
18
16
14
12
10
8
6
4
2
0
3
2.5
2
1.5
1
0.5
0
1
2
3
4
5
6
7
Assessment occasion
Distress
Control
8
9
10
Hearer Dependence
11
Joseph
 Voices of famous people – ‘greatness’
 Voices of ‘team’ lead by a bully from the past
 Team relating perceived as unidirectional
 Consistent with relational history
 Breakthrough = Understanding
Hearer Relating
25
20
20
VAY scores
25
15
10
15
10
5
5
0
0
1
2
3
4
5
6
7
8
9
Assessment occasion
Voice Dominance
10
11
1
12
2
3
4
5
Hearer Distance
Distress and Control
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
1
6
7
8
9
10
Assessment occasion
Voice Intrusiveness
AHRS scores
VAY scores
Voice Relating
2
3
4
5
6
7
8
9
Assessment occasion
distress
control
10
11
12
Hearer Dependence
11
12
Hearer views on therapy
(Hayward & Fuller, 2010)
 ‘To hear someone talk about them as if
they were real, instead of … just telling
me that I need more medication or… ‘don’t
listen to them, they’re not real’.
 ‘I’ve been trying to run away from the
voice all the time and I’ve learned to stand
firm and fight back’
Hearer views on therapy (cont.)
 ‘we’re not complete enemies anymore’
 that gives me more confidence, more self-
esteem, because I think I don’t have to be…
under the control of the [voice] anymore. I can
just try and be myself’
 ‘it gives me the power to say no without feeling
guilty… I can choose what I want to do more,
rather than… let him control me, and just be
submissive’
Where next – another world?
Relating Therapy in Second
Life?






Socialisation to SL
Familiarisation with private space in SL
Creation of avatar to represent hearer
Creation of avatar to represent dominant voice
Text dialogue between hearer and voice avatars
– modified to become more assertive
Continual adaptation of avatars’ appearance to
reflect changing relationship
Your thoughts
From a worker’s perspective, what would it
be like to work with voices in Second Life?
Discuss in small groups for 10 minutes
Scribe allocated to each group
Feedback one headline
Issues from consultation with
hearers
 Socialisation to include guide to on-line
safety within SL
 Need for a second consent – post
socialisation
 What about non-human voices, e.g.
Spirits?
 How utilise SL data to reflect outcome
Next steps
 Further consultation
 Development of study design
 RfPB application in September
 Recruitment to small case series in
October
Key references
 Benjamin, L.S. (1989). Is Chronicity a Function of the Relationship Between




the Person and the Auditory Hallucination? Schizophrenia Bulletin 15, 291310.
Birchwood, M., Gilbert, P., Gilbert, J., Trower, P., Meaden, A., Hay, J., 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.
Hayward, M. (2003). Interpersonal relating and voice hearing: To what
extent does relating to the voice reflect social relating? Psychology and
Psychotherapy: Theory, Research and Practice. 76, 369-383.
Hayward, M., Denney, J., Vaughan, S., and Fowler, D. (2008). The Voice and
You (VAY) A person’s assessment of the relationship they have with their
predominant voice. Clinical Psychology & Psychotherapy, 15, 45-52.
Hayward, M. Overton, J., Dorey, T. & Denney, J. (2009). Relating Therapy
for people who hear voices: A case series. Clinical Psychology &
Psychotherapy, 16, 216-227