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
Examples of command hallucinations:
|“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.”|
|“It sounds like an emcee on a microphone, announcing my every move, before I even take it.”|
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 radical departure from orthodoxy
There are two central tenets of the Hearing Voice 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.