Just accept it: the voices are real: accepting the reality of voice-hearers can open the door to change and recovery, says psychologist.
Author: Arenella, Jessica
Pub Date: 11/01/2012
Publication: Name: Behavioral Healthcare Publisher: Vendome Group LLC Audience: Academic; Trade Format: Magazine/Journal Subject: Health; Health care industry; Psychology and mental health Copyright: COPYRIGHT 2012 Vendome Group LLC ISSN: 1931-7093
Issue: Date: Nov-Dec, 2012 Source Volume: 32 Source Issue: 6
Accession Number: 313161183
Full Text: Command hallucinations are one of the most dreaded and misunderstood phenomena in psychiatry. Overcoming this apprehension is one of the greatest barriers to working effectively with people who hear voices, whether they are diagnosed with psychotic, mood, or dissociative disorders. So, consider these four facts as an anxiolytic of sorts:

1. Voice-hearing is not necessarily a sign of psychiatric illness. (1) Many people in the general population report hearing voices. However, if they aren't in need of psychiatric help and don't mention such experiences in daily conversation (or at cocktail parties), then no one is the wiser.

2. Hearing voices is not in itself a significant risk factor for violence. (2) Under most conditions, even command hallucinations do not predict violence. Generalized hostility and substance abuse are stronger predictors . (3)

3. People frequently hear voices telling them what to do and do not follow them. (4) After all, you tell your patients to do all kinds of things and they ignore you too!

4. Voices may be positive and helpful. (5) Sometimes, voices may be experienced in a very positive way--as a form of instinct, intuition, or guidance. For example, on the morning of September 11, 2001, a woman reported hearing a voice that said, "Get off this train now." She decided to exit the subway one station before her usual one near the World Trade Center. Don't you wish sometimes that you had a spirit guide to keep you from harm?

These are among the things I learned from a two day workshop sponsored by the NYC Department of Health and Mental Hygiene, Office of Consumer Affairs, about facilitating Hearing Voices Groups. Daniel Hazen from Hearing Voices Network (HVN) USA and Ron Coleman from INTERVOICE (International Network for Training, Education and Research into Hearing Voices) spoke about the history of the Hearing Voices movement around the world over the past 25 years, sparked by psychiatrist Marius Romme's experience with voice hearer Patsy Hage and subsequent research by Professor Romme and Sandra Escher. HVN groups are self-help groups, ideally run by voice-hearers, but also sometimes facilitated by family members or co-facilitated by professionals.

A raftal departure from orthodoxy

There are two central tenets of the Hearing Voices Network approach:

1. The voices are real.

2. You can change your relationship with your voices.

Yes, the voices are real. This is a radical departure from what we usually tell our patients: "You are hallucinating (i.e., the voice is NOT real) and once you understand this you will take your medication and the voices will go away." Then, we have to keep repeating this until the patient has "insight" and the patient tells you the voices are gone. This is an uphill battle and we've all seen patients on cocktails of psychotropics who still hear voices.

But, what if we try understanding the opposite idea, that the voices are real? What if we acknowledge that the person who reports hearing voices is in fact hearing a voice, or two, or two dozen? After all, the portions of the auditory cortex that light up when you talk to your patients, light up just the same when she or he is "hallucinating." (6) What if we consider that the voices are received and processed like other voices? How might we approach a patient who was being emotionally abused by a non-supportive family, an abusive partner, or bullied by peers and strangers?

Once you acknowledge the experience of voice-hearing as real, then the door opens for a constructive conversation about how to make sense of the experience, how to respond to it and then, how to alter the experience. In HVN groups, as in 12-Step programs, peers who have been through the intensity and stigma of the experience are considered an invaluable resource for recovery, because they have first-hand experience of the realness of the voices.

If professionals want to help voice hearers, then they must make a commitment to accepting the voices as real. If the professional remains afraid of the voice-hearer's experience and tries to smother it as an irksome symptom, the door to recovery is slammed shut. The professional or other peers often need to help or support the voice hearer in accepting and listening to the voices, particularly when the messages are of a disturbing nature.

Once voice-hearers, peers and professionals have acknowledged the reality of the hearer's experience, change is possible. Change begins when, often with the help and support of a HVN group, a hearer acknowledges the existence of his or her voice(s)and takes steps to alter his or her relationship with the voice(s):

* Hearers may come to realize when voices are most likely to occur, or that they are unwittingly encouraging the voices by their own actions, for example:

* feeling lonely and avoiding socialization, so as to create a void in life that voices come in to fill.

* recognizing that a chattering voice might well be an engaging distraction or outlet from other problems (i.e. unemployment, relationships, etc.).

* Hearers may learn strategies to be more empathic but also more assertive with the voices:

* thinking of voices as though they are family members--some pleasant, critical, provocative, distant, chattering or argumentative--can help a hearer to make sense of them.

* understanding the nature of a voice or voices can help hearers set limits, particularly with abusive voices, such as asking the voice to speak more respectfully or constructively.

Time for a new approach?

The United Stares seems poised and at its most receptive to these new perspectives on voice hearing. In January 2012, when I attended the HVN training, I expected to be one of the few mental health professionals, assuming that voice hearers and peer advocates would be in the majority. I was surprised that most of the attendees were from various mental health and social service agencies and that the professionals and paraprofessionals outnumbered the consumers.

Since that time in NYC, HVN groups have been established within clubhouses and Personality Recovrey Oriented Services (PROS) programs. There are also a few independent groups, including one that two voice-hearers and I co-facilitate.

I was asked to help organize a free two-hour lecture with Ron Coleman (a recovered backward psychiatric patient and voice-hearer), and his wife who is a colleague at their consultant agency, Working to Recovery UK, in April. Much to my surprise, this meeting, held at a local library, brought a standing-room crowd of more than 60 people. There were psychiatrists, neuropsychiatrists, researchers, psychologists, mental health professionals, professional students, and voice hearers.


The response of this audience was over-whelming and mostly positive. A few psychiatrists were offended, deriding the encouragement of voice-hearers to talk amongst each other as "dangerous." This seemed absurd to me, much like telling alcoholics at an AA meeting that they cannot speak about their past excessive drinking for fear that it might trigger future episodes. (Clearly, this is not how self-help groups function.)

In June, I helped organize a full-day training by Ron Coleman and Karen Taylor, this time with a modest fee. This event brought in nearly 80 registrants. What I found most impressive was the number of agencies that paid for their employees to attend. There were psychologists from a state psychiatric inpatient facility, as well as a variety of other professionals and paraprofessionals from clubhouse and day treatment programs, case management agencies, residential treatment facilities, and city hospitals. Indeed, more than half of the registrants were sponsored by their employers.

The groundswell of curiosity and participation that I have witnessed in my limited participation with HVN suggests to me that mental health leaders, professionals, and front-line staff are coming to believe that "treatment as usual" for voice-hearers:

* Is insufficient in itself and often imply not potent enough to help many in this population,

* Costs too much in money and staff yet still yields sub-optimal treatment outcomes,

* Costs too much in terms of the physical health of our patients, primarily due to the multiple chronic medical issues linked to antipsychotics, as well as their lack of social interaction,

* Places a heavy financial burden on systems of care, due not only to inconsistent behavioral outcomes but also costly chronic medical problems.

For these reasons, I believe that many in the field--and certainly many consumers--believe that the time has come to consider alternative treatment approaches like those offered by HVN.

I am concerned that our many resource-intensive programs--ACT teams, case management, supportive housing, mandated inpatient and outpatient treatment, mobile crisis units, and more--will not achieve their full potential to help psychiatric patients recover until mental health professionals and paraprofessionals learn the tools needed to listen to and work with voice-hearers more effectively.


"This voice kept telling me that I was the real terrorist and I would be assassinated."


"The voice told me that I had to get off of the train immediately or else I might die."

RELATED ARTICLE: Hearing voices: Readers sound off

Following the August 9, 2012 release of this story on our website, www.behavioral.net/voicesarereal, we heard from readers who not only criticized and questioned, but also praised this therapeutic approach. Below are excerpts from the many comments the article received, sorted by date and subject, along with replies from the author and other professionals.

Blurring the distinction between reality and, unreality


I have trouble understanding what it means to say that we should "accept that the voices are real". Certainly the experience is real, but surely there is an important distinction between experiences that are triggered by external stimuli and those that are not. I may "see" things when I dream, but I would never claim that my dreams are as "real" as the outside world.

(Jessica Arenelta, PhD--08/2012012)

To say that the voices are real is to grant legitimacy to the person's subjective experience. I hope this example clarifies what I mean: When a patient goes to a doctor for knee pain, the doctor acknowledges that experience as real and makes inquiries about the type of pain, when it started, what makes it feel worse/better, etc. The doctor doesn't say, "The pain doesn't exist" or "I've examined your knee and I don't see any evidence of pain." Even if the doctor takes an MRI of the knee and there is no structural damage, the doctor would work with the patient to find another explanation for the pain before saying, "The pain isn't real and the sooner you accept this the quicker you will get better."



I had one of my clients come in and show me this article. I have 20 years of mental health experience and work daily with this population and am disturbed at your conclusions and lack of insight.

Accepting the voices is part of the healing process but accepting them as real can, as I have seen, be dangerous. Take a took at our recent violent acts nationally from those who suffer from this illness. Again be careful what you are saying and how you come across as it appears that you are saying they are "real." With that comes power of what "they" are saying. Many of the command voices are destructive and, as I have seen firsthand, believing them and acting on them can be destructive.

(Jessica Arenella, PhD--08/16/2012)

Acknowledging that a person is really hearing a voice-albeit a disembodied voice-is light years away from believing that the voice is speaking the truth and that one should engage in destructive behavior based on what this voice says. Believing in the client's experience is not the same as believing that the voice speaks the truth and that the client should follow the destructive commands. I am fully aware that there are people who succumb to destructive voices and commit great acts of violence; people who hear these types of voices are at risk of behaving violently. It sounds like these are many of the clients you work with.

Fortunately, this is not representative of voice hearers generally (e.g. some do not hear commands or violent content, some feel disgusted and alarmed at destructive voices and have no inclination to listen to them). Stigmatizing people who hear voices - by identifying them with horrific mass murderers-contributes to feelings of shame, isolation and resentment that only worsen the situation. Just today a person in the Hearing Voices Group said that she didn't tell anyone about the abusive voice she had been hearing for 20 years because she didn't want people to be afraid of her and think she was one of those "mass murderers or schizophrenics."

I am curious about why your client wanted you to see this article, but I understand that due to privacy concerns this is probably not something you can respond to.



I think healthcare professionals need to be cautious to suggest to a client that the voices are "real" and should be "listening to the voices," particularly command hallucinations or delusions. [If one] hears voices that she/he is a terrorist, what if another voice/thought commands, 'kill them before they kill you?"

(Karen, psychiatric nurse--11/07/12)

... What actually happens when you begin to talk about the voices, the person gains more trust, they really open up about their experiences so that you can actually have a dialogue about their "command hallucinations." For example, if a person says that "God has told me to kill someone," you can have a conversation with them about the nature of God; that it is not God's nature to wish you to kill, but then, who could have that nature? ... If the person is a Christian, one can argue that the voice of the devil is there to tempt you, which you can refuse. Conversations like this can lead the person to become more in control ...

Where voices come from

(Linda Gantt, PhD, ATR-BC--08/1312012)

Most people think that voices come from schizophrenia. In our trauma clinic we have treated many clients who hear voices directly linked to their trauma histories. Medications are not necessary in these cases. We help people deal with their voices (even those command hallucinations that urge suicide) by using an "externalized dialogue." This method helps diminish the mystery of the voices ...

(Malika Burman, MD--09/07/12)

... as a psychiatrist in private practice who treats many individuals diagnosed as 'schizophrenic,' I agree with your approach and have watched many people gain control over their lives, take their power back; and become leaders and healers in their own right via the guidelines outlined here.

(Karen, psychiatric nurse11/07/2012)

... What we have found is that a high percentage of voice hearers are the victims of childhood trauma ... Often, the voice they hear is that of their abuser, or themselves at the age of abuse.


(1.) Romme M. & Escher, S. (1999). Making sense of voices: A guide for mental health professionals working with voice-hearers. London: Mind Publications

(2.) Monahan J., Steadman J., Silver E. Applebaum P.S., Robbins Pamela C., Mulvey E.P., Roth L.H., Grisso T. & Banks S. (2001). Rethinking risk assessment: The Macarthur study of mental disorder and violence. NY: Oxford University Press.

(3.) Monahan et al. (2001).

(4.) Monahan et al (2001).

(5.) Romme & Escher (1999).

(6.) Dierks T, Linden DE, Jandl M, Forrhisano E, Goebel R, Lanfermann H, Singer W. (1999). Activation of Heschl's gyrus during auditory hallucinations. Neuron. 1999 Mar;22(3):615-21.


Jessica Arenella, PhD, is a clinical psychologist and psychotherapist with a private practice in New York City.
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