Just accept it: The voices are real

August 9, 2012
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Instead of denying the "delusions" and "hallucinations" experienced by her patients, a clinical psychologist describes the transformative and healing power gained by accepting these voices as real.
Jessica Arenella, PhD
Clinical psychologist and psychotherapist Jessica Arenella, PhD, practices in New York City.

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.After all, you tell your patients to do all kinds of things and they ignore you too!

4. Voices may be positive and helpful.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. 

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Holly Molly!

The voices are real? The patient thinks they are real, so hey they are real...

WOW! Is that what you tell your schizophrenic patients that see dead people? Accept it, they are real!

Holly Molly!

I'd take your license for incompetence!

Holly Molly!

It's clear that Doriansward doesn't much like this, but the idea is that to the person who's hearing the voices, they are "real" in that they are heard, or are reportedly heard or perceived, by that individual.

Accepting another person's reality by allowing for the fact that they may indeed be perceiving something - even dead people - that other's can't see doesn't make them any more real. It's just a logical first step for a therapist to begin helping the other person work through it until they can either deal more successfully with it or see it for what it is--something that doesn't really exist.

Denial

I've never denied that the patient hears the voices! I've only stated that they are NOT real.

The voices are real

This is an impressive argument. I think a great deal of energy in psychiatry and psychology...actually, most of the helping professions...is invested in learning a set of concepts and vocabulary that fixes the way we interpret what people who come to us for help actually experience. Some of those professional interpretations are unhelpful. They dismiss the reality of the human experience they were designed to explain. But professionals become so invested in what they "know" that it is very difficult for us to accept that the basic approach to the problem may be off the mark or not informed by the best physical evidence.

Yes, the central auditory system responds to what we term hallucinations in a manner similar to the way it responds to externally generated sounds and signals. So, at the neurophysiological level, the voices are real.

Another issue is that traditional psychiatry - that developed in the latter half of the 20th Century - is frozen by a classificatory system that is not readily adaptable to the newest developments in neurophysiology. The DSM's - in all their iterations - rely on classifying observable and/or reported behaviors that can be verified empirically. This is a gross level of observation from a neurophysiological perspective. We are only beginning to understand the complex pathways in the CNS that support the behaviors we observe clinically.

Thank you for your thoughtful observations.

voices and reality

reality is perception. I hear and see things many ppl don't. till I ran into some one that heard the same things I heard ( we could repeat the voices back to each other ) I thought they were real b4 that but now I KNOW they'r real. they have an agenda I don't understand. there are three separate "department" of the same organization, or so I interpret it. anyway it's a question of what can we learn. they are more advanced then us but we can glean some truths from them and usually when they are driving us nuts it cause we are off the path god has for us. if u ppl are "treating" others by having them block out the voices my question is why ? they can't go around us only threw us. it's the next step in human evolution. we lost the tail lol the body is ok, it the mind that needs the most work now. we got groups of ppl hearing the same voices. it's REAL, not just real to the ppl hearing them and its being pushed on us. all the kids on meds for "ADHD" "ADD" ect. that's opening up their minds. till we accept that truth we'r stuck in a rut.

Liar

LIAR LIAR

Reality

Real voices are sound waves created by another physical entity which our eardrums interpret.

So these voices are NOT real.

Are they hearing them? YES, but they are a creation of their mind.

They should accept that they ARE having this experience, but that the voices are a creation of their imagination and therefore CAN be controlled.

To the person that mentioned Christians, I should point out that the Bible has many passages where God clearly kills women and children. So to say that somehow people that believe in God would be hearing a benign voice is flawed. Just look at all the killings from mothers that hear God tell them to kill their children and then went ahead and did it.

My sister now hears Jesus making jokes to her. I wonder what would happen if Jesus told her a bad joke?

Any advice on how to talk to her so that she gets help? or should I just let it be?

Thanks.

Excellent article

Thank you for publishing this well written article. Living in London, I first heard about HVN about 15 years ago, and have since met people who have been helped by their approach. It is one of many that question the traditional approaches and ask mental health treatment professionals and consumers to turn their assumptions upside down.

I like the way Dr Arenella clarifies that hearing voices is not always an indication of a disorder. And it also clarifies how HVN helps people to manage their experience.

voices are technology

I have succesfully gained full control over the voices. It took two years of suffering but ive won. I have the mental ability to push the voices out of my mind, my house and into a far distance so i barely hear them outside, and rarely inside. i used my imagination combined with remote viewing subtechniques and precision mental acuity. I have coached other voice hearers to try what i have, i have had momentary succes with 3/3 people ive talked to. which proves that over time and with a combination of techniques, it can work to make them so quiet people can rest at night and be on low doses of meds or even not at all. I think voices are both good and bad, and are manipulating our reality for some hidden purpose. I also believe a secret group of humans know how to induce voices to have the technology to cause people to suffer pain inducement, voices, and gangstalking. I plan to win.

Can you help me?!? Voices

I am hearing voices consistently throughout the day and night. IT IS NON-STOP. I know each of the voices as past friends or current relatives. They claim to be using technology to do this but will not tell me how and claim that they will act as if nothing is happening if I talk to them about it. They have given me signs to prove it is real and I need to find out what technology is responsible. This is URGENT! Please help if you can.

There is non-stop discussion and criticism of my every action. They have the ability to replay sounds exactly the same (recorded) and make them deafening loud. They can create a ringing in my ears that is pervasive and the affect overall is intrusive. When they are confident and mocking me they will say things about how they are doing it. One thing they refer to are sound amplifiers and that there are implants in my ears. This sounds crazy I know but it is happening to me and I don't know where to find answers. They will, at times, slip up or get mad enough that they let information slip that I do not and find later to be true or false. For example, a reference to a news article with the title exactly as it appears in a magazine I haven't read. A real example is that they have printed google maps on my printer in the middle of the night. There is not way this could occur without knowing my network password and the drivers necessary for my printer and which printer in the house to use.

They torture me through sound and claim to be conditioning me in better behavior. However, they also mock me and "assign points arbitrarily" for good and bad things that I do in their opinion. This leads to a certain level of torture through sound (sometimes deafening) depending on the groups moods and things of that sort. They claim to have 3 people on out of a group of 12 at a time and change their voices via a voice synthesizer and recordings that they replay in order to make it seem as though a larger number of people are "on" at a time. I do not know how this is happening

Please help! I'm begging.

Malika Burman, MD

Thankyou for your insights, 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. Where there is too much consensus, there is also a lot of malarchy, so I'll also say everyone is different, and all points of view are valid. It takes a skilled and compassionate clinician to know which point of view fits for whom.

Malika Burman, MD

A thoughtful and balanced comment, Dr. Burman. Thanks for sharing it.

My wife has d.i.d. and as I

My wife has d.i.d. and as I have helped her healed, it has taught me to listen to the voices in my head and it actually seems to help me deal with the stresses from dealing with her disorder when I address the concerns of "the voices."

I validate each and every girl (voice) in my wife's system and treat her as real (but incomplete) and my wife's recovery has been phenomenal and she rarely struggles with the things that are very typical of other d.i.d. people: suicide, need for antidepressants, self injury, etc.

Sam

I guess the context in which

I guess the context in which the word "real," (i.e. "the voices are real") is used may present to be ambiguous and therefore generating this controversy. Of cource, the experience of hearing voices is real and hearers need to accept the fact that it's real they hear voices. This may be a symptom of mental illness and they need to seek help. 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 halluciantions and/or delusions. Questions: 1. In reference to the example of someone who hears voices that she/he is a terrorist, what if another voice/thought commands him, 'kill them before they kill you?" 2. What is the rate of success, if any, had been statistically reported using this approach?
Tayo

Context

Your comment about the context of "real" is very important. An individual, along with a treatment professional or even a group of people, can accept that he/she is hearing voices. That's a first step in treatment, it seems.

But accepting that voices are speaking or being heard does not equate to an endorsement of what the voices are saying. One may listen to or hear something without acting upon it.

This is where the filter of the group comes in--as a means of helping the hearer to reflect on and to understand the content of the voice and how to deal with it.

Of course, the HVN approach seems to build on the idea that most voices and voice hearers are not malevolent--that was the first thing said at the HVN introductory meeting (not a group session) that I attended. So, your questions 1 and 2 are good ones to ask.

In addition to asking the author (who is not linked to HVN) to address this, I'll also reach out to the HVN folks.

Dennis

Careful

I had one of my client's 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 processs but accepting them as real can as I have seen be dangerous. Take a look 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 apears that you are saying they are "real" and with that comes power of what "they" are saying. Many of the command voices are of destructive content and as I have seen 1st hand believing them and acting on them can be destructive.

Steve T.

i disagree

there is ample proof that voices are coming not from the brain but from technology, read "the origin of the influencing machine" dating back 100 years psychiatry has recorded and kept silent this fact, that voice hearers get more than voices, but pain inducement. Why in the world would a body turn on itself? It wouldn't. what needs to be done is tell voice hearers how to defear psychic technology. energy follows a path. And it can be accessed from both directions. Thats how my voices are not able to be loud at all. In fact right now they only resonate from my left ear and i can barely make out what they say, because i faced my fears, i faced the horde of scenarios they placed in my reality. i saw the most amazing and terrible things. And im here to talk about it. Stop creating dellusions upon dellusions. help people face this head on with proper mental enhancements and usage.

Nurse with 15 years in HVN movement

I have 28 years experience as both working as a nurse, and last 15 years of being part of the HVN movement. Accepting that the voices are real is definitely fundamental to the healing process, as is understanding what the voices are about.

What we have found is that a high percentage of voice hearers are the victims of childhood trauma, which has left them full of guilt & shame, low self-esteem and self-confidence and little belief in themselves. Often, the voice they hear is that of their abuser, or themselves at the age of abuse.

When you look at all the inquiries into murder committed by "schizophrenics," many were also under the influence of drugs & drink and many of the murders involved people that they knew. Many of these people had been told just to ignore their voices which, by the way, is almost impossible. Or, they lied to mental health workers about their voices because the automatic response of the worker was to give them more medication.

What actually happens when you begin to talk about the voices is that 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?

In that conversation, the person can easily come to the conclusion that the voice is a voice of the devil. Now if the person is a Christian, one can argue that the voice of the devil is there to tempt you, which you can refuse. Conversation like this can lead the person to become more in control.

With out the conversation though, the person is alone in his or her battle and may succumb to their relentless voices. Interestingly, though, when voices say to kill themselves, most voice hearers spend their lives trying to resist them.

There is actually no evidence base for the so called dangers of engaging with a person in their psychosis. However there is plenty of evidence around that if we workers don't engage in dialogue, people remain trapped within their misery on lethal cocktails of psychotropic medication or self-medication with alcohol & illegal substances. These people are left to spend their lives with inadequate services, with little hope of full citizenship and the joys of life we all expect and need.

Well said, Karen

Karen,

I am no expert about the HVN movement, but your description and example offered some insight into how voice hearers might benefit from this type of dialogue--how it might help them go from a place of mistrust and fear into a greater sense of safety or control.

I'm glad you spoke up.

Dennis

Trying to be careful, hope this clarifies

Acknowledging that a person is really hearing a voice- albeit 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 voices speaks the truth and that the client should follow and 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".

(BTW, 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.)

Jessica Arenella

Most people think that voices

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 and promotes negotiation. We stress that the dialogue is a "tool for life" and that it can be used in a variety of situations.

Linda Gantt, PhD, ATR-BC
Executive Director
Intensive Trauma Therapy, Inc.
Morgantown, West Virginia

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.

Of course we should always strive to understand and accept people's experiences, and to treat them with compassion and respect. And it is probably more fruitful to work with people to change their relationship with their voices, than to argue with them.

Reality

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."
Jessica Arenella

Thank you

This is exactly the issue. Experiences of mental health distress are as real as the symptoms of any physical illness. As you rightly point out, acknowledging the reality of the voice experience is different than obeying a command that might be spoken.

Many people test their experience of reality every day, such as women going through menopause often ask, "Is it hot in here, or is it just me?" While this may be a slightly humourous example, it is in the same genre of being able to share an experience in safety and with acceptance.

I wonder if something like mindfulness has any beneficial effects for people who hear voices? I know there are programmes in mindfulness based stress reduction from Jon Kabat-Zinn, and another programme developed to help people suffering with depression, from Oxford University (working in conjuction with JKZ).

Blurring the distinction

You make an important point here about "reality."

Some reality can be objectively observed--like multiple people who agree that they're having a conversation with each other. Some other "reality"--like having dreams--cannot be validated (objectively) in the same way, but can be accepted as real, perhaps because we've all had dreams or because we love/trust/care for those who report the dreams to us--like when a loved one, young or older, has a nightmare.

Your last point is especially important, I think: That it is probably more fruitful to work with people to change their relationship with voices than to deny that the voices exist and question the person who claims them. Denying the reality of another is hardly the basis for a treatment relationship.

Dennis

Wonderful discussion

A person who hears voices should certainly be able to discuss that occurrence, but should be given a good physiologic description of why this might occur, as well as being offered an opportunity to cause this condition to cease. This is a physiological condition, and very real. If the person enjoys the voices and they cause no harm, then why not? But I suspect most people don't enjoy that condition any more than folks enjoy tinnitus.