Two simple questions that have changed the way people hear inner voices
Once the province of prophets, "hearing voices" is still shorthand for madness. And yet in the past 30 years, a new understanding has been created by voice-hearers themselves, as part of the Hearing Voices Movement. This suggests that uncovering the roots of the voice can potentially help the hearer.
Voice-hearing has traditionally been understood as a symptom of psychiatric illness, being most closely associated with schizophrenia. It has been referred to as a "symptom of brain disease just like blindness" and is typically treated with medication, which can indeed help.
So what has led to a different approach to hearing voices? First, there has been the rediscovery that many people hear voices without distress or impairment, and we are now able to pinpoint what can make voice-hearing problematic. There is an 88% probability of correctly guessing whether a voice-hearer is a patient or not from simply knowing one thing: whether the voices are nasty. Studies, including some with "psychics", have also found that hearing voices frequently, and lacking control over them, is associated with it being a problem.
In addition, trauma has been found to be associated with hearing voices. In fact, suffering multiple childhood traumas is associated with later voice-hearing to approximately the same extent that smoking is with lung cancer. Not only does trauma increase the probability of voice-hearing, but the characteristics of the voices are often related to such events. However, the role of trauma in voice-hearing has historically been minimised, with hearers advised to chemically eliminate their voices, not to carefully explore them.
These insights have led to the creation of a new tool called the Maastricht Interview. This attempts to remedy the negativity of many voices by exploring their potential links to the past of the hearer.
It has its roots in psychiatrist Marius Romme's interactions with one of his voice-hearing patients, Patsy Hage, in the late 1980s. In conversation with Romme, he told me that he "discovered that as a psychiatrist I did not know anything about the experience of hearing voices, because my whole profession is trained not to go into the experience". When Patsy talked to other hearers about her voices, it was Romme, the highly trained medical professional, who was "the one who did not understand".
But working closely with his partner, Dr Sandra Escher, and many other voice-hearers, Romme co-developed the interview. Speaking of it today, Romme said:
We had never interviewed a voice hearer about their experience as that was forbidden in the profession. Still most psychiatrists don't know what to ask.
The purpose of the interview is to find the answers to two key questions: "Who do the voices represent?" and "What problems do the voices represent?" The voice-hearer and the interviewer then work together to "break the code" of the voices, uncovering the meaning of the voice in relation to the person's life history, which may not be readily apparent.
Dirk Corstens, a Dutch Psychiatrist, says he "almost always" uses the interview when a voice-hearer asks him for support. Hearers often remark to him that "no one has talked with me like that before". Corstens finds the interview helps acknowledge hearers' experiences, reduces feelings of isolation, and helps uncover how life events and related emotions may be driving the voices. In his experience, it has helped some hearers understand why the voices are speaking to them.
Likewise, Robin Timmers, who himself hears voices and is an expert by experience, says that it helps hearers move from "being in the experience" to "thinking about the experience".
Recovery does not necessarily mean the elimination of the voices. Instead, it can be living productively with them, as research psychologist Eleanor Longden has demonstrated.
Sometimes, though, the voices may vanish. Corstens relates the example of a 54-year-old woman, long in psychiatric services, who heard a single voice. In the interview, her personal history was highlighted and she discovered that the voice emerged when she was sexually abused by her employer. The voice appeared to be similar to his voice – it stopped talking when she realised this.
Voice-hearers as experts
At the start of training, many attendees, who include a range of mental health professionals, may feel, as one put it "useless … because I've not known how to help". After training, many feel they are better equipped to help the voice-hearers they work with. At a recent session, a psychiatrist reported that it "opened my eyes and understanding, gave me courage and inspiration and confidence about the ability to recover".
Yet there are limitations to this approach. As Romme notes, not everyone will be helped by the interview. People's anxiety about their voices may be too much or they may not feel able to revisit traumas. The evidence that the approach works is still limited to personal experiences and a small preliminary trial.
There is no one single reason why people hear voices, and no one single way to help. For some, the answer will still be medication; for others, it may be the meanings that the Maastricht Interview can help uncover. It may even be both. But for those who report benefiting from the interview, their lives have been changed forever.