Some experts think the problem is how doctors and society treat people who hear things, not the voices themselves.
Roc Morin in The Atlantic, 5 November 2014
“The first time that I heard this voice, I was very much frightened,” the prisoner testified. “When I heard it for the third time, I recognized that it was the voice of an angel … The voice said to me: ‘Go into France!’ I could bear it no longer.”
Joan of Arc, who spoke these words before her execution in 1431, is just one of many notable voice-hearers cited in the literature of Intervoice, an advocacy organization for individuals living with auditory hallucinations.
Other examples include Sigmund Freud, Winston Churchill, Socrates, William Blake, and Mahatma Gandhi. According to Intervoice founder Dr. Marius Romme, the lives of these extraordinary figures demonstrate the frequently benign nature of recurring hallucinations.
In many cases, Romme’s research has suggested, the phenomenon can even prove beneficial. “The problem,” he writes, “is not hearing voices, but the inability to cope with the experience.” In 1987, after two decades of clinical work, the Dutch psychiatrist began promoting a drug-free therapy in which patients were encouraged to accept and analyze their voices.
“If you tell someone in Ethiopia that you don’t hear voices, they actually look at you funny.”
At that time, Romme’s method was the antithesis of mainstream psychiatry. A 1973 Science article, “On Being Sane in Insane Places,” describes an experiment that exposed prevailing attitudes towards hearing voices. In the experiment, eight “pseudo-patients” made appointments at 12 different U.S. hospitals. The pseudo-patients complained of hearing voices that repeated the words “empty,” “hollow,” and “thud.” All were diagnosed with schizophrenia and given anti-psychotic medication. The pseudo-patients were held for between seven and 52 days, even though they had immediately ceased their simulated symptoms upon admittance.
Today, with decades of additional research and drug development to draw from, Western medicine still offers little else to those experiencing auditory hallucinations. Research even suggests that common treatments might be exacerbating the condition. In regards to schizophrenia, the World Health Organization states that “a substantial body of evidence shows a more benign course and better outcome in developing countries [than in developed countries].” As a recent Stanford study indicates, voices in nations like India and Ghana, are significantly more likely to be friendly than voices in the United States.
After examining how schizophrenia-related symptoms are viewed in different cultures, Ethan Watters concludes in his book Crazy Like Us that the stigma of diagnosis and its isolating effects are to blame for the disparity. Developing countries tend to have explanations for the condition, such as spirit possession, that exculpate individuals and preserve their existing identities.
The beliefs also sustain family and community relationships with the afflicted.
These modalities are at the heart of Romme’s methods. I traveled to the medieval city of Tilburg in the Netherlands to experience what Romme calls the “hearing-voices approach.” Romme’s protégé of 32 years, Dr. Dirk Corstens, was giving a workshop on the practice to seven voice-hearers. I sat down with Corstens and patients Michel and Angie (who declined to provide their surnames), to learn more about living with voices.
Morin: What happened here today?
Corstens: We tried to motivate people to talk a little more about their voices. Most of them never talk about them. Often, the voices forbid you to talk about them. Professionals also often don’t know how to approach the subject. The first day is a difficult day. You have to build trust.
Morin: What did they talk about?
Corstens: They told their stories about how they cope with voices, and we started to demonstrate what we call the “construct.” In the construct, you find the relationship between what happens in people’s lives and their voices. We try to make sense of the voices.
Morin: Can you give an example of that?
“Now, when I hear voices, I know what triggered them. I ask, ‘What am I neglecting in my own emotions?'”
Corstens: Today, we worked with a 43-year-old woman named Marie. She hears eight voices. The voices don’t have names, but she can differentiate them. They talk to her and to each other throughout the day. First, we explored how many voices there are, how old they are, their gender, and whether they have a name or not.
Morin: How do you use that information?
Corstens: We analyze every voice and try to explore what the characteristics are. So, these three voices—numbers 1, 6, and 8—are very aggressive and negative. They shout at Marie, “You are nothing! You have to die! Swallow pills! You have to mutilate yourself!” And they are there all day and every day, especially at night when she tries to sleep. There’s this child of three who is always crying. There’s this 18-year-old boy who criticizes her. And then, not very often, there’s this man who tries to protect Marie from the 18-year-old boy. There’s also this eight-year-old female voice—she’s playful and always tries to cheer Marie up, but the voice becomes angry if Marie doesn’t cheer up – which she rarely does. The group of voices, which she calls “the trustees,” shouts words to interrupt her conversations.
Morin: What do the traits of the voices indicate?
Corstens: They help us understand what problems these voices represent. A lot of it has to do with Marie being rejected, having no self-confidence, and not being able to make decisions herself. We try to find out when these voices started. In her case, they started when she was 27 and had final exams at university. But, it was all related to the divorce of her parents when she was six, and witnessing violence at home—being bullied, etcetera. All these things come back in the voices.
Morin: You mean that she internalized some of the people in her life?
Corstens: Well, they don’t have names, but we try to find out who these voices represent. The stepfather resembles one of the booing guys, another is a sister, another is an imaginary friend.
Morin: So, it’s a form of relationship therapy as well?
Michel: It really is. [Dr. Corstens and I] started to work with each other five years ago, or more. I was around 20 years old. It took about two years of work to actually figure out what the relationships were, what the triggers for the voices were, and what feelings are coupled to these voices. Once you start to learn to express yourself and work out these problems on your own, the voices don’t have to act out their part. Now, when I hear voices, I know what triggered them. I ask, “What is happening with me? What am I neglecting in my own emotions?” Does that make sense?
Morin: Because you recognize the voices are a part of yourself?
Michel: Yes. I used to experience them as different entities—not part of me. Now, I actually believe they are just a part of me I have to deal with.
Morin: Can you describe these voices?
Michel: The earliest voice started out as a drill sergeant—very strict, very dominant. I was about six years old. Later on, he developed into a really aggressive shouting voice when I started abusing drugs and alcohol. It got to a point where I couldn’t function well. He was constantly shouting, “You have to hurt yourself! You have to hurt other people!”
Then there is a second voice that came later on. He is actually not bad—actually quite positive. He doesn’t have a name, because in his opinion, a name doesn’t matter. He showed me certain options—certain things I could do to change my situation. He made me realize that I needed to stop drinking and taking drugs.
There is also another voice who would just scream some word and be gone. I call him “El Gringo”: the stranger. I don’t know who or what he is, and I did not understand what it meant. Later on, I would realize that it was triggered by a certain situation.
Morin: Who do you associate the voices with?
Michel: The aggressive dominant voice reminds me of my free-fight instructor. I associate with his anger when people hurt my feelings or when I don’t set my boundaries. The supporting voice is more like a grandfather, and he helps me when I’m in dilemmas. The third one, I really don’t know. The only thing he does is to stimulate me to start thinking outside of the box. He’s someone who helps you explore and seek things out.
Morin: How do you respond when you hear these voices now?
Michel: I take some time out, go on a walk—just give time to the voice. Something is wrong, and I have to figure out what triggered them to pop up.
Morin: Once you realize the problem, how do you resolve it?
Michel: I resolved a lot of problems by learning how to communicate. Instead of punching someone in the face, you can also talk.
Corstens: Or, say that you’re angry.
Morin: How about you, Angie—what have your experiences been like?
Angie: I only started a year and a half ago, so I’m not done yet. Half the time, the voices are still there. I’ve started engaging with them though. I’ve started asking what they want and there has been improvement. I’m very hopeful that maybe one day I can reach a point similar to Michel.
Corstens: It’s a work in progress. Angie is a Ph.D. student in economics – a high achiever.
Morin: Can you describe your voices?
Angie: My voices have always had a fixed pattern —a fixed list of things they say and a fixed list of things I was forced to do for them.
Morin: And, their personalities?
Corstens: Maybe, pick two.
Angie: Which would you suggest?
Corstens: Maybe, “Sam” and “Denial.”
Angie: Sam is actually the one who was most dominant in the beginning. He was very aggressive, always calling me names, and [doing] what I perceived as pushing me down. I considered him a symbol of everything that’s evil in my head. But, when I started to talk about it more in therapy, and I started to communicate more about what he was saying—why, according to him, for example, I was stupid or worthless—it actually started to change. He started to calm down. My therapist once remarked that he’s not as evil as I think he is. At first, I thought that was just an insane remark, but that moment of doubt made me think. From that moment onward, he started changing. It turned out that he was actually the one who was keeping me going. He was the one who was picking me up from my falls, and ensuring that I kept going with my daily routines as much as possible.
Morin: And, the other one you mentioned, Denial?
Angie: Denial is a very negative and aggressive voice. When he’s most aggressive, it feels like he fills all the space around me. He really freaks me out. I’m realizing more and more now that he has aspects from people in my life who hurt me. Sometimes his voice resembles someone I knew. Sometimes the message of the words that he uses are similar to some of the people I have come across in my life.
Morin: When you engage with your voices—when you ask them what they want or why they’re saying these things—what do they say in response?
Angie: It depends on the voice. It depends on his mood and my mood. It depends on how strong I am at the moment. Sometimes they do engage in conversations. Sometimes they answer your questions and they ask questions back. Other times, they refuse to engage and just shut you down. It really depends. With Sam, for example, I reached a point where I can go into a conversation with him, and he even uncovers aspects of other voices that I hear.
Morin: I’m curious, have you ever been given a psychiatric diagnosis?
Angie: Well, I got my diagnosis from Dr. Corstens.
Corstens: What diagnosis did I give you?
Angie: You gave me “dissociative disorder not otherwise specified.” I didn’t get “schizophrenia,” thank god!
Morin: What would that have meant to you?
Angie: Any diagnosis of schizophrenia for me at that point would’ve been very devastating. What’s commonly known about schizophrenia is that you just have a bad brain. That’s a conviction I’ve been holding my whole life, so I was really fearful that I might get confirmation from a psychiatrist.
Morin: Michel, what was your diagnosis?
Michel: To be honest, I really do not know. At the beginning, I told them not to tell me, because I thought that it would destroy me. I thought that I would actually behave towards the diagnosis. Later on, I believed it was schizophrenia—but, then again, what does that mean? I don’t really care.
Corstens: Someone did an official interview with him, and the label was indeed schizophrenia, paranoid type, but I never communicated that to him. I don’t believe in that. I don’t use that.
Morin: Because you believe that the label is self-reinforcing?
Corstens: Yes, and also because it’s not a valid diagnosis in the sense that there’s so much overlap with so many other diagnoses. There’s no one specific symptom.
Morin: What’s your opinion about the way that mainstream psychiatry treats voice-hearers?
Corstens: They treat it as a pathology, and honestly that’s the main problem. Hearing voices is normal. It’s a common human variation. It’s like homosexuality, or dyslexia, or left-handedness. My grandfather was lefthanded and he was forced to write with his right hand. I think it’s similar.
Hearing voices can be very difficult if you can’t accept it. You can become mad from voices, but voices by themselves are not the madness.
Morin: What does a successful treatment look like?
Corstens: It’s a complex question, but I think it’s a success if he gets a job, if she gets a partner. If people can do the things they want in life, it’s a success. And, some people without changing their symptoms, can change their lives.
Morin: Can your treatment work for anyone?
Corstens: No, because there are people who come to me who have been in psychiatry for 20 years, and they are so damaged by the system that it’s much more difficult. For example, we had one guy today—he was so traumatized by his diagnosis, and how he was treated, that it prevented him from sharing his experiences.
Morin: Do you advocate medication in any case?
Corstens: Yes, but we need to be careful. Have you read the book Anatomy of an Epidemic?
Morin: About the pharmaceutical industry? Yes, I have.
Corstens: That really shocked me. I did some research, and more and more we’re discovering that medication is not all good. It can improve symptoms, but it can also worsen them. We don’t know who needs lifelong medication and who doesn’t. I think rather than saying people with psychosis must have medication, we should say, people with psychosis might need temporary medication. Some might need lifelong medication too, but we should be careful. It’s an open secret that people die from these medications. You don’t tell a patient suffering from psychosis that if he takes this medication for 10 years it will decrease his life expectancy by five years.
Morin: I’m sure you’re aware that the Western world has the worst outcomes for schizophrenia. Do you see similarities between your work and approaches in the developing world?
Corstens: If you tell someone in Ethiopia that you don’t hear voices, they actually look at you funny. It’s very common to hear voices there. Seventy percent of the people in Ethiopia hear their ancestors. The best-documented results are from the open-dialogue approach in Finland. With open dialogue, the whole social network is engaged every day by two therapists. They have a remission rate of, I think, 70 percent after five years. After five years, only 30 percent take medication and 80 percent have a job. Nobody has done that before. This is not about medication. This is about talking, and engaging, and taking very seriously the utterances of the person who suffers from psychosis.
Morin: That brings up a good question for you, Michel and Angie. What role do the people in your lives play in your therapy?
Angie: I have told five people. My mother at the beginning was trying to convince me that it’s all in my own head, and that the voices are not real. But now, she is really doing her best to understand. I think she made a huge improvement in that respect. My boyfriend is also doing his best. I know that he’s not really able to relate, but he’s not judging, so that’s good. Two other people I told were friends of mine. We shared a very religious upbringing, so for them, it was an indication that I was possessed—something Satanic. They thought we should pray to God to remove it. So, we don’t talk about this topic anymore. The fifth person is another friend of mine, who overheard a conversation. She thinks it’s super cool that I hear voices—so, it varies.
Morin: Angie, I want to ask both you and Michel—do you want your voices to go away?
Corstens: That’s very hypothetical. It’s like asking a homosexual, “Would you like to not be a homosexual?”
Michel: I would say, hell no.
Corstens: When I met Michel for the first time, he asked, “Can you help me to get rid of these voices?” He asked for medication. I said, “Let’s wait.” In the beginning, many voice-hearers want to get rid of the voices, but when they learn to understand and to deal with the voices, they change their minds. There are people who have gotten rid of the voices and really regret it.
Morin: What do they regret?
Corstens: That you’re not alone. That you get advice. That you are challenged. Those are things that can enrich your life.
Angie: In reference to that, I remember when Sam changed and became very positive and supportive—and then there was a point when he suddenly disappeared. I remember not hearing him for about a week or two weeks. I was in tears. I missed him.
Morin: When he returned, did he tell you where he had been?
Angie: He never really came back as much as he was before. But, I think he came back because I kept calling him. “Where are you? Where are you?” Then he would make an appearance.
Corstens: I also think that many voices contain intuition or unconscious information that is not very accessible to us. So, in that sense, if you have peace with your voices then it’s like dreams. Sometimes a dream tells you something about yourself or your future.
Angie: It’s a privilege, in a way, to have that. But, when you’re in the process itself, it can seem like endless misery. I think it’s important to have support from someone who’s constantly assuring you that your voices have a meaning – it’s not that you’re just damaged. It makes you feel that, at least you are worthy of your suffering.
ROC MORIN is a journalist based in New York and the curator of the World Dream Atlas.
View the full article here: www.theatlantic.com/health/archive/2014/11/learning-to-live-with-the-voices-in-your-head/382096/