With One Voice

Guidelines for hearing voices groups in clinical settings

By Keith Coupland, Vicky Macdougall and Eric Davis


These guidelines have developed from the experience of practitioners and service users who have contributed to seven years of group work for psychosis in Gloucestershire, UK.


Voice hearing is often seen as a prime symptom of psychosis (American Psychiatric Association, 1994). However there are a significant proportion of the voice hearing populations that have never been psychiatric patients (Honig et al., 1998). Hearing voices (auditory hallucinations) is considered a first-rank symptom of the specific psychosis of schizophrenia (Schneider, 1959). There are three main psychiatric categories of patients that hear voices; schizophrenia (around 50 percent); affective psychosis (around 25 percent) and dissociative disorders (around 80 percent) (Honig et al., 1998).

However, many people who hear voices find them helpful or benevolent (Romme & Escher, 1993). In a large study of 15,000 people it was found that there was a prevalence of 2.3 percent who had heard voices frequently and this contrasts with the one percent prevalence of schizophrenia (Tien, 1991). In a study by Honig and others (1998), of the differences between non-patient and patients hearing voices, it was not in form but content. In other words the non-patients heard voices both inside and outside their head as did the patients but either the content was positive or the hearer had a positive view of the voice and felt in control of it. By contrast, the patient group was more frightened of the voices and the voices were more critical (malevolent) and they felt less control over them (Honig et al, 1998). The experience of hearing critical voices is often very anxiety provoking and leads to high levels of depression and suicidality (Harkavy-Friedman et al., 2003). Conventional approaches in psychiatry to the problem of voice hearing have been to ignore the meaning of the experience for the voice hearer and concentrate on removing the symptoms (audio hallucinations) by the use of physical means such as medication (Romme & Escher, 1989). Although anti-psychotic medication is very helpful to most sufferers of psychosis (Fleischhaker, 2002), there is a significant proportion (30 per cent) that still experience the 'symptoms' such as hearing voices despite very high doses of injected anti-psychotic (Curson, Barnes, Bamber, & Weral, 1985). The social psychiatrist Marius Romme, believes that anti-psychotic medication prevents the emotional processing and, therefore, healing, of the meaning of the voices (Romme & Escher, 2000).

Traditional practice in behavioural psychology concentrated on either distracting the patient or ignoring references by the patient to the voice hearing experience, in the hope that the patient would concentrate on 'real' experiences, which would then be positively reinforced (the assumption being that the voice hearing was a delusional belief). The effect of this approach may well have been to discourage the discussion about the voice hearing experience but without eradicating it (P.D.J. Chadwick, Birchwood, & Trower, 1996). However brain imaging has since confirmed that voice hearers do experience a sound as if there were a real person talking to them (Shergill, Brammer, Williams, Murray, & McGuire, 2000). Within the last ten years there has been considerable interest in the phenomenology, processes and coping mechanisms of people suffering from psychosis, using a broadly Cognitive Behavioural Therapy (CBT) approach (Drury, Birchwood, & Cochrane, 2000; Haddock, Morrison, Hopkins, Lewis, & Tarrier, 1998; Kuipers et al., 1998; Morrison, 2002; Norman & Townsend, 1999). Some practitioners advocate that CBT is the most appropriate, evidence based approach (Tarrier, Haddock, Barrowclough, & Wykes, 2002). Other practitioners, including psychiatrists, psychologists and nurses have developed a broader-based alliance of therapeutic approaches to psychosis within the spectrum of approaches from psychodynamic to cognitive behavioural (Martindale & International Society for the Psychological Treatments of the Schizophrenias and other Psychoses., 2000). Radical changes have also been taking place amongst psychiatrists (Kingdon & Turkington, 1998; Perris & McGorry, 1998), who are now paying closer attention to the meaning and content of the voices (Romme & Escher, 1989).

Although group work has been reported to be a therapeutic medium by voice hearers themselves (Baker, 1995) there has been little formal use of such groups by professionals treating psychosis. The reason for this may be that group work has been steeped in psychodynamic principles, which suggested that people with psychosis were unable to benefit from participation in analytic groups where the group leader remained silent and anxiety built up in group members (Yalom, 1983). This perception is now changing and given the right conditions of a clear structure, clear boundaries, here and now focus on specific issues and an attempt to reduce anxiety at an early stage of the group work, then group work with psychotic patients can be successful in reducing symptoms as well as providing peer support (Addington & el-Guebaly, 1998; Albiston, Francey, & Harrigan, 1998; Andres, Pfammetter, Garst, Teschner, & Brenner, 2000; Buccheri, Trygstad, Kanas, Waldron, & Dowling, 1996; P. Chadwick, Sambrooke, Rasch, & Davies, 2000; Free, 1999; Gledhill, Lobban, & Sellwood, 1998; Halperin, Nathan, Drummond, & Castle, 2000; Hyde, 2001; Kanas, 1988, 1991, 1996, 1999; Levine, Borak, & Granek, 1998; O'Neil & Stockwell, 1991; Schermer & Pines, 1999; Smith, 1999; Vassallo, 1998; White & S., 2000; Wykes, Parr, & Landau, 1999; Yalom, 1983)

Philosophy and theoretical underpinning

Despite theoretical differences between psychodynamic approaches and CBT approaches there is now a great deal of positive overlap to the benefit of those suffering psychosis (Schermer and Pines, 1999). Of late there has been renewed interest in using attachment theory as an approach to healing the early trauma of many sufferers (Allen, 2001) as well as new developments in such fields as drama therapy (Casson, 2004). Some psychiatrists are interested in moving from a strictly biological model of voice hearing and schizophrenia to an individual psychological approach (Leuder & Thomas, 2000). Others are interested in combining models into the bio-psycho-social approach with psychiatrists trained and working with talking therapies as well as medication (Gabbard & Kay, 2001). There are useful ideas in the self help approach of the Hearing Voices Network (Downs, 2001) but self help hearing voices groups have not been viable in Gloucestershire.

An adapted form of the stress vulnerability models has been incorporated as an explanatory framework for the voice hearing (Nuechterlein & Dawson, 1984; Zubin & Spring, 1977) that reduces the suggestion of weakness (vulnerability0 and emphasises the on going ability to cope, learn and evolve competency as well as be affected by illness (Davidson & Strauss, 1992).

Overall the groups in Gloucestershire have adopted the Integrative Approach to groupwork for psychosis (Kanas, 1996). This approach emphasises reduction in isolation by increasing social interaction, learning to overcome the distress of symptoms (especially by sharing coping strategies) and being user led as to the content of sessions, so long as that is within the clear framework already negotiated. The facilitators are practitioners who use a directive approach to reduce anxiety. The group is seen as a coming together of individuals in a shared endeavour to help each other (a work group) rather than the group process bringing about change (analytic group).

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