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Title Hearing voices: Explanations and implications

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Journal Psychiatric Rehabilitation Journal, 27(3)

ISSN 1095-158X

Authors Ritsher, Jennifer B Lucksted, A Otilingam, P G et al.

Publication Date 2004

Peer reviewed

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winter 2004—Volume 27 Number 3

Hearing Voices: Explanations and Implications M

Jennifer Boyd Ritsher, Alicia Lucksted, Poorni G. Otilingam & Monica Grajales

Jennifer Boyd Ritsher, PhD, was Integrating information on voice hearing from multiple disciplines and perspec- with the Center for Health Care tives, we review current explanatory models and their implications for intervention Evaluation, US Department of Veterans Affairs and Stanford strategies. Far from always signifying a mental illness, voice hearing may result University, and is now with the University of California San from other causes, including drug side effects, brain lesions, and culturally-sanc- Francisco. tioned phenomena. Accordingly, a wide range of assessment, intervention, and Alicia Lucksted, PhD, is with the University of Maryland at Baltimore. self-management strategies are available and appropriate. We conclude that by offering a diversity of treatment options, eliciting patients’ causal theories, and in- Poorni G. Otilingam, MPH, was with the Center for Health Care corporating these into an individualized treatment strategy, clinicians are likely to Evaluation, US Department of Veterans Affairs and Stanford help clients control the distressing aspects of the voices, minimize stigma and dis- University, and is now with the University of Southern California. crimination, and make meaning of the experience.

Monica Grajales was with the Center for Health Care Evaluation, US Department of Veterans Affairs and During the days when I was living Carl Jung, and Sigmund Freud (Liester, Stanford University, and is now with alone in a foreign city—I was a San Francisco State University. 1996). (Here we treat “voice hearing” young man at the time—I quite as synonymous with “verbal hallucina- often heard my name suddenly tion,” although this may be debatable This work was supported in part by grant MH13043 and by the Department called by an unmistakable and in some cases, such as regarding reli- of Veterans Affairs Health Services beloved voice…” gious experiences). Research and Development Service and Mental Health Strategic —Sigmund Freud (1901/1966) Epidemiologic research spanning Healthcare Group. Part of this work was conducted while the first author a century shows that auditory halluci- was a postdoctoral fellow at the nations are experienced by a large Psychiatric Epidemiology Training Program at Columbia University. The number of people in the general popu- It has long been known that individu- authors thank Patricia Deegan, lation as well. In both the 1890s and Sandra Escher, Keith Humphreys, als sometimes hear voices that no one the 1980s, the incidence of auditory , Julia Rupkalvis, else can hear. Examples in historical Sharon Schwartz, Debora Wright hallucinations was about 2% within records and traditions date back sever- Tingley, Jodie Trafton, as well as the 10-year age groups (Sidgewick and staff of the Community Transitions al millennia. Some of the best-known Center at the Palo Alto VA, and sever- Epidemiologic Catchment Area stud- historical figures who heard voices al anonymous voice hearers for help- ies, reanalyzed by Tien [1991]). About a ful comments on earlier drafts. include Socrates, Moses, Jesus, third (31%) of homeless adolescents Mohammed, and Joan of Arc (Romme Correspondence should be addressed and 27% of incest survivors report a to Dr. Ritsher at the University of & Escher, 1993). More contemporary California San Francisco, Department history of auditory hallucinations examples include Mohandas Gandhi, of , VA Medical Center, 4150 (Mundy, Robertson, Robertson & Clement Street (116A), San Francisco Martin Luther King, Jr., Adolf Hitler, CA 94121, or [email protected]. Greenblatt, 1990). Even higher rates

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Psychiatric Rehabilitation Journal Hearing Voices: Explanations and Implications of 37 to 71% have been found among gies, meaning exploration, and the Brain regions connecting to the tempo- college students (Barrett & Etheridge, option of no intervention. Integrating ral lobe have also been implicated. For 1992; Posey & Losch, 1983). Among information on voice hearing from mul- example, there are reports of acute- people with psychiatric diagnoses, tiple disciplines and perspectives, in onset auditory hallucinations involving auditory hallucinations occur among this paper we review current explanato- lesions in the left frontal lobe (Hall & 53% of people with schizophrenia, and ry models and their implications for in- Young, 1992), the caudate nucleus 28% of people with major affective dis- tervention strategies. (Fernandez Pardal, Micheli, Asconape orders (Haddock & Slade, 1996). Thus, & Paradiso, 1985), and the brain stem although the majority of people with (Baurier & Tuca, 1996). Voices May Indicate schizophrenia may hear voices, the a Non-Psychiatric Speech-related cognitive deficits. At a vast majority of voice hearers do not Medical Condition level of analysis more proximal to the have schizophrenia. experience of voice hearing, neuropsy- Voice hearing may indicate a non- The characteristics of the experience chologists and cognitive scientists psychiatric medical condition. A range vary greatly. Many people hear only have focused on speech processing of factors has been documented, from their own name, and only during a time and attentional deficits, many of which brain abnormalities to medication side of stress. Leudar and colleagues (1997) would be consistent with left temporal effects, with varying causal pathways, posit that voices are rarely as richly in- pathology. For example, hallucinators ease of assessment, treatment implica- dividuated as people are, and that may misperceive their own normal sub- tions, and supporting research. Note what they say is typically mundane, vocalizations, or inner speech, as ex- that since the base rate of voice hear- such as commenting on ongoing activi- ternal (Stein & Richardson, 1999). ing in the general population is rela- ties. However, many experience their Others have characterized the faulty tively high, some of the case studies in relationship with the voice as a relation- cognition as poor source monitoring the literature could be reporting asso- ship with another person (Benjamin, (Morrison & Haddock, 1997), impaired ciations between voice hearing and 1989). Although voices typically seem discrimination of local targets (Carter, other conditions that are purely coinci- just as real and just as loud as a real Mackinnon & Copolov, 1996), under- dental. We hope that the present re- external voice, they do not seem more constrained perception (Behrendt, view will spur further research and real than actual voices, and they are 1998), and poor metacognition (Baker encourage critical thinking about these not always perceived as external to the & Morrison, 1998). topics. head (Junginger & Frame, 1985). The Hearing loss. Turning to a very differ- basic qualities of the voices are the Left temporal lesions. Lesions or ent causal pathway that may also in- same among patients and non-patients seizures in the left temporal lobe of volve temporal functioning, hearing (Barrett & Caylor, 1998; Honig, et al., the brain, particularly in the superior loss has also been known to precipi- 1998). gyrus, can produce hallucinated voic- tate auditory hallucinations. This can es, typically in the right ear (Tanabe, Voice hearing is often considered to be be triggered by middle ear infection Sawada, Asai, Okuda & Shiraishini, one of the most pathognomonic symp- (Carroll & Milnes, 1998), otosclerosis 1986). Additionally, people with audi- toms encountered in mental health (Marneros & Beyenburg, 1997), perfo- tory hallucinations have been found to settings. Someone hearing a voice typi- rated eardrum (Aizenberg, Dorfman- have reduced metabolism in brain re- cally receives a diagnosis of schizo- Etrog, Zemishlany & Hermesh, 1991), gions associated with language and phrenia or another serious mental or other insults. Hallucinations con- speech processing (Cleghorn, Franco, illness and is treated with psychiatric nected to hearing loss are typically mu- Szechtman, Brown, et al., 1992), small- medications. Although a purely psychi- sical, but can also be verbal. One study er left superior temporal gyri (Barta, atric paradigm may be appropriate in a reported an instance that progressed Pearlson, Powers, Richards & Tune, given case, other causal possibilities from tinnitus to musical hallucinations 1990), and deficits in attentional tasks include drug side effects, brain to voices carrying on a running com- requiring the involvement of the left lesions, the unconscious, spiritual ex- mentary—ostensibly a pathognomonic temporal cortex (Carter, Robertson, periences, and other culturally sanc- symptom of schizophrenia—all of Nordahl, Chaderjian & Oshora-Celaya, tioned phenomena. Other intervention which immediately disappeared after 1996). possibilities include cognitive-behav- ear surgery (Marneros & Beyenburg, ioral therapy, self-management strate- 1997).

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Psychoactive substances. Furthermore, ing attributions by the individuals, text shape the experience. For exam- many commonly ingested substances others around them, and healthcare ple, the voices heard by Saudi Arabian can cause auditory hallucinations. In professionals. psychiatric patients tend to have reli- addition to intentional hallucinogens gious and superstitious content, (such as LSD [Miller & Gold, 1994]), whereas those of British patients tend Voices May Be Present causal agents include psychiatric med- to emphasize commentary on present in Healthy Individuals ications (benzodiazapines [Chinisci, actions and instructions or commands 1985], imipramine [Terao, 1995]), other It is important to note that healthy peo- (Kent & Wahass, 1996). In other cul- medications (pentoxifylline [Gilbert, ple sometimes hear voices when no tures, spiritual experiences such as 1993], propranolol [Fernandez, one is present. For example, Posey & vision quests and long meditations de- Crowther & Vieweg, 1998]), drugs of Losch (1983), found that more than a liberately use physical exertion and abuse (methamphetamine [Matsuoka, third of college students reported hav- deprivation as tools to open conscious- Yokoyama & Yamauchi, 1996], ecstacy ing clearly heard their name called ness so that messages from the creator [Miller & Gold, 1994], cocaine [Siegel, when no one was present, and 5% or spirits may be received in the form 1978]), and traditional medicinal plants reported having held conversations of a vision or voice (Liester, 1996). (datura [Goates & Escobar, 1992], khat with absent or deceased people. Culture also greatly mediates the cir- [Pantelis, Hindler & Taylor, 1989], mabi Approximately 10% reported having cumstances under which voices may be bark tea [Hassiotis & Taylor, 1992]). heard a comforting or advising voice. experienced, such as those described Some substances produce tinnitus Most people who report auditory hallu- below. first, suggesting a similar mechanism cinations in population-based studies Situational Stress to that involved in deafness-precipitat- do not report clinically significant dis- One of the most common normative ed auditory hallucinations. tress or impairment (Haddock & Slade, contexts for hearing voices is extreme 1996). Such statements may sound Other somatic conditions. Finally, stress such as bereavement, trauma, surprising because mental health pro- many other somatic conditions have and fatigue. In one survey 70% of voice fessions have an exposure bias that been identified as causes of auditory hearers reported that their voices leads many of us to use exclusively hallucinations. Most are clearly related began after an emotionally traumatic pathological models of voice hearing. to the more proximal brain and audito- or stressful event (Romme & Escher, Only those in distress typically come ry dysfunctions outlined above. For ex- 1989). to our attention in research or clinical ample, tuberous sclerosis, which work (Cohen & Cohen, 1984). Liester Bereavement. It is normative in some causes cerebral calcification, has been (1996) presents a helpful continuum cultures and communities, and not un- reported to cause hallucinated voices describing the level of pathology of the common in many others, to “hear” and carrying on a running commentary voice hearing experience, which ranges “see” those who are recently deceased (Okura, Kawabata, Egawa, et al., 1990). from hallucinations to illusions to (Grimby, 1998). Hearing the voice of a Additionally, tuberculosis can produce imagination to revelations. In other deceased loved one is also sometimes tumor-like lesions in the brain, as words, the level of pathology may be reported by individuals as they are some have speculated caused Joan independent of the level of intensity dying or having a near-death experi- of Arc’s voices (Ratnasuriya, 1986). of the experience. ence (Watkins, 1998). Auditory hallucinations have also been reported in conjunction with Published work about voice hearing Trauma. The concept of posttraumatic Parkinson’s disease (Inzelberg, Kiper- among people without illness labels fo- stress disorder (PTSD) has roots in psy- vasser & Korczyn, 1998), migraine cuses on several different explanatory chodynamic theory, which posits that headaches (McAbee & Feldman-Winter, frameworks, which we refer to below very difficult emotions and memories 1999), and thyroid conditions (Pearce & as cultural influences, situational may be isolated from usual conscious- Walbridge, 1991). stress, inner voice, and spiritual com- ness. Their intensity and meaning may munication. These are not mutually ex- then cause them to manifest in non-vo- In some instances, these various bio- clusive categories. litional representations, including voic- logical factors may cause auditory hal- es. Some of the clearest examples of lucinations in the absence of other Cultural influences. Regardless of the trauma-induced voice hearing may be symptoms, thereby opening the door explanatory framework used by the found among those who have experi- for a wide variety of causal and mean- hearer or observers, culture and con-

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Psychiatric Rehabilitation Journal Hearing Voices: Explanations and Implications enced military combat (Wilcox, Briones that we all have “spirit helpers” of Many people have found that hearing & Suess, 1991). some sort—and that hearing voices re- voices gives them helpful guidance, flects openness to their help (Romme & leading to beneficial behaviors, in- Fatigue. In the Posey and Losch study Escher, 1993). Others discuss these ex- creased self-esteem, or personal fulfill- (1983) of college students, some of the periences as chance encounters with ment (Heery, 1989). For example, it is most common voice-hearing situations spirits of recently deceased strangers not typically considered aberrant for a were those associated with fatigue, (Romme & Escher, 1993). child to report hearing the voice of an such as driving alone at night. Brugger “imaginary friend” and many such chil- et al. (1999) reported on the common Jung (1961) viewed voice hearing as dren therefore do not receive treatment occurrence of voice hearing among contact with deceased ancestors for this (Escher, Romme, Buiks, world-class mountain climbers during through the collective unconscious. Delespaul & van Os, 2002). high-altitude climbs. Sleep researchers Similarly, some voice hearers describe also posit that auditory hallucinations their experience as “channeling”—that It bears reiterating that biologically re- can be manifestations of REM sleep in- is, temporarily becoming the mouth- ductionist explanations may not mesh truding into the waking consciousness piece for another being (Roberts, with a voice hearer’s spiritual or cultur- (Douglass, Hays, Pazderka & Russell, 1989). Often such experiences are de- al understandings. For example, while 1991). scribed as surprising and sometimes some speculate that temporal lesions frightening at first, but then becoming caused Joan of Arc’s voices The power of suggestion. Voices can benign or transcendent over time, as (Ratnasuriya, 1986), she died believing also be induced or triggered by hypno- the person and the spirit/being estab- that she heard the voices of saints and sis (Watkins, 1998). There is even a lish a mutual relationship. God, and her persecutors remained report of folie a deux in which exposure convinced she was possessed by to someone with voices caused voice Following a similar line of thought, demons or lying about hearing voices hearing in a second party (Dantendor- some religious experiences may be cat- at all. fer, Maierhofer & Musalek, 1997). egorized as hearing voices—such as hearing the voice of a deity during Still, even quite divergent explanatory Inner Voice prayer or moments of need. In many frameworks are not necessarily mutual- One idea that cuts across many non- traditions, it is seen as a healthy spiri- ly exclusive. For example, a patient medical explanatory frameworks is that tual experience (Liester, 1996). In con- might be able to agree with a doctor voices may deliver personally relevant trast, some Buddhist traditions view that brain dysfunction causes the voic- messages. From a psychodynamic hearing the “voice of God” as a stage es and yet also believe this to be sim- viewpoint, this phenomenon repre- in spiritual development to be tran- ply the mechanism through which an sents repressed unaccepted wishes or scended (Watkins, 1998). evil spirit is able to communicate with poorly integrated parts of the self, and him. A patient may accept the label of there is evidence that hallucinated crit- Many religions also hold that in hear- “psychosis” because it facilitates ac- ical voices are often reduced after psy- ing voices one may be hearing a spirit cess to medication and/or therapeutic chotherapy (Cullberg, 1991). In this or a demon. In a positive light, voices interventions she finds useful, even if model, voices should therefore be ana- (such as of angels in Christianity) have the doctor’s explanation of the causes lyzed for their personal significance been credited with guiding individuals of psychosis does not fit her experi- and integrated into the hearer’s self to find religion, to spread the words of ence. Similarly, life stress might make rather than silenced (e.g., through a religious figure, and to lead people someone more receptive to the influ- medication) in order to reach the away from danger (Liester, 1996). ence of negative messages from hallu- healthiest outcomes (Heery, 1989). Conversely, hearing tormenting voices cinated voices, regardless of their Many models conceptualize voices as may be understood as a sign that one’s original cause. one’s mind or soul “trying to tell you self or soul is possessed by a devil or something,” providing an opportunity demon. This historically common for personal growth (Liester, 1996). framework is still in widespread use Many Types of Interventions today and tends to lead to congruent Are Available Spiritual Communication treatments such as exorcism or other Still others understand voice hearing Many intervention options are avail- forms of faith healing (Al-Krenawi & as communication with spirits or be- able to assist people who hear dis- Graham, 1997). ings other than one’s self. Some posit tressing voices. Whether or not the

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winter 2004—Volume 27 Number 3 voices are classified as being caused allow voices to lead them into harmful themselves personally, or even as a by a mental illness, voice hearing can behaviors (Haddock & Slade, 1996). first line treatment for distressing voic- frequently cause clinically significant es (Mosher, 1999). Assessment may be an intervention in depression, dangerous behavior, and itself as it encourages clients to reflect Cognitive-behavioral therapy. even suicidality (Soppitt & Birchwood, on their experiences, can help to es- Cognitive-behavioral therapy and tech- 1997). tablish the therapeutic alliance, and niques have been successfully used to Across intervention models, one robust implicitly shows that there are people reduce voice hearing and its distress- theme is that people who have active who have had similar experiences. ing effects (Dickerson, 2000). Most of coping skills to deal with their voices Moreover, going over a long check-list these models explicitly incorporate hu- fare better in terms of distress and of coping strategies that others have manistic, collaborative, and existential functioning (Romme & Escher, 1989). found useful may give clients and clini- (meaning-making) elements. Their Coping well may or may not include cians new ideas to consider, and un- techniques have found very positive re- taking medications. What is most im- derscores that they are far from having sults even with chronically ill people portant is that the voice hearer is able “tried everything” (Carter, Mackinnon whose symptoms were non-responsive to arrive at an understanding of the ex- & Copolov, 1996, also see Table 1). to medication. perience that fosters the development Medication. For most clinicians, med- Transcranial magnetic stimulation. of effective management skills and per- ication is the first treatment of choice A recent report of a double-blind sonal growth (Haddock & Slade, 1996). for auditory hallucinations. crossover trial of transcranial magnetic Assessment. A first step in intervention Pharmacologic intervention figures stimulation of the left temporoparietal is assessment. Empirically validated prominently in standards of care for cortex found very encouraging results, assessment tools have recently been schizophrenia and other diagnoses but in a pilot study of only three pa- developed for key nuances of the voice- associated with hearing voices (e.g., tients (Hoffman et al., 1999). Two re- hearing experience (reviewed in Drake, Lehman & Steinwachs, 1998). The most ported almost complete absence of Haddock, Hopkins & Lewis, 1998). successful medication trials report voices for at least two weeks after These may be used to inform treatment positive effects in some 60-70% of treatment, and the third reported a plans, to establish baseline function- participants (e.g., Kennedy, Jain & great reduction in voice activity, while ing, and to evaluate the outcomes of a Vinogradov, 2001). This is substantial, changes were much less dramatic in wide range of interventions (Haddock & but also means that up to a third do the placebo treatment. While in the be- Slade, 1996). For example, Chadwick not experience significant symptom re- ginning stages, this could represent a and Birchwood (1995) found that be- lief. Although clinicians and voice hear- promising new treatment. liefs about voices directly affect clients’ ers know that finding the right Active coping and self-management. affective and behavioral reactions. medication at the right dose often The first-person accounts of voice- brings eventual relief, side effects can During assessment, it is particularly hearers and cognitive-behavioral thera- be considerable and even a “good re- important to ascertain whether the py models both emphasize the impor- sponse” may not silence the voices voice hearer believes that the voices tance of taking an active stance in (Sayre, Ritter & Gournay, 2000). are in control, because this has been managing one’s own voice-hearing ex- shown to increase the risk of violent Adherence to prescribed medications periences (Romme & Escher, 1989; behavior, particularly when coupled varies for many reasons, including the Haddock & Slade, 1996). The empirical with a sense of threat and hallucina- stigma of needing ongoing medication, literature shows that the intensity of tion-related delusions (Link, Stueve & significant side effects (Worrel, hallucinatory experiences can be al- Phelan, 1998; Link, Monahan, Stueve & Marken, Bechman & Ruehter, 2000), tered via changes in behavior or envi- Cullen, 1999). The perceived power and and financial costs. While many people ronment (Delespaul, deVries & van Os, authority of the voices are especially who hear voices welcome medication, 2002). Psychiatric consumer/survivor consequential and therefore important others—advocates, seasoned clinicians and other voice-hearers’ groups have to assess (Birchwood & Chadwick, and researchers among them—con- gathered a wide range of personal- 1997). Voice hearers who can “set lim- clude that the benefits of psychotropic management tools, from behavioral its” with their voices are less dis- medications do not necessarily out- tactics to holistic health-promotion, tressed by them and less likely to weigh the risks and costs, and so they advocacy, and coping with stigma. For advocate drug-free interventions for example, the National Empowerment

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Psychiatric Rehabilitation Journal Hearing Voices: Explanations and Implications

Center offers several self-help books, some may not want or need mental vidual’s personal growth potential. videos, and a well-respected training health care at all. When someone re- Hearing voices can be a debilitating module for clinicians on hearing voices ports that the voices cause no distress and stigma inducing experience. Using (Deegan, 1996). Handsell Publishing or impairment, or that they do not want a multimodal, personalized, collabora- also has an expanding selection of to stop hearing the voices, clinicians tive treatment approach can minimize consumer-oriented publications about should not jump to the conclusion that stigma, maximize self-efficacy, and voice hearing. Internet self-help re- the person has poor insight or is mini- speed recovery. To facilitate such an sources are expanding at a rapid pace mizing real problems. approach, we close by offering the fol- (e.g., hearingvoicesnetwork.com, hear- lowing points to consider when con- ingvoices.org.uk, voicesforum.org.uk), ducting an evaluation of a person who Conclusion and Clinical and some mutual aid groups for voice hears voices, which we wrote based on Implications hearers are available, such as the conversations with voice hearers and Hearing Voices Network in Britain. Auditory hallucinations have many service providers during the course of causes that must be distinguished be- researching the present paper. The We have compiled a list of pragmatic cause they can lead to radically differ- acronym “VOICES” may be used as a strategies for coping with voices (Table ent treatment options and programs of mnemonic. 1) from these various sources. Many of research. At the same time, there are even the most widely effective strate- Verify that it is really an auditory hallu- many pragmatic strategies for coping gies may initially seem far-fetched, cination. (Is it your own thoughts? Is it with voices that people can use regard- such as putting an earplug in one ear your own voice?). less of their explanatory framework. (Deegan, 1995). Although each may Origin of the phenomenon. only work for a minority of people, Professionals have traditionally been (Bereavement? Brain pathology? most people will find relief with at least trained to avoid discussing the specific Drugs? Stress? An illness?). one of them (Carter et al., 1996). It is content or characteristics of voices with difficult to predict which will work for their clients (Haddock & Slade, 1996) Impact of the voices. (How do they af- any given individual, so it is important under the assumption that doing so fect you? Are they distressing? Are they to persevere with experimentation. will “encourage” them. This needs to telling you to hurt yourself or someone This need for experimentation high- be reconsidered, because, when con- else? Are they helpful? How much can lights the importance of education, as sidered in light of the individual’s his- you affect them?). most individuals spontaneously think tory and background, the specific Culture. (Meaning of voice hearing, of trying only a few strategies, and fail experience of voices may hold vital psychiatry, medication, etc., to pa- to generate more even if their initial clues as to how they developed and tient’s reference groups). strategies do not work (Carter et al., how best to cope with them. A detailed 1996). It is typically recommended that understanding of individuals’ voice- Educate the person. (Many things can voice hearers use a graded approach, hearing experience yields more accu- cause voices; many coping strategies first practicing the strategies while not rate judgments of the degree to which are available). hearing voices, then using them in situ- the voices affect their level of distress, Strategize with the person and relevant ations when voices typically occur, impairment, and risk of harm to self or others. (Which interventions will be im- then achieving maximum control over others. plemented, how outcomes will be eval- the voices by deliberately inducing When voices are troubling, it is impor- uated, when intervention plan will be voices and then using their favorite tant to help voice hearing individuals adjusted accordingly). techniques to stop them again. develop effective personalized coping Intervention is Not Always Appropriate strategies—emotional, cognitive, and Intervention options should include behavioral (such as learning not to re- the possibility of not intervening. spond aloud to the voices in public)— Although it is an understandable reflex that address distress and impaired to subdue symptoms, this is not al- functioning directly, rather than only ways appropriate. Some people value focusing on reducing symptoms. Such their voice-hearing experience and plans must incorporate the voice-hear- want help with other problems, and er’s preferences and consider the indi-

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Table 1—Strategies for Coping with Voices

Strategy Representative Strategy Representative Citation Citation No Intervention (If voices are not causing distress Continued or impairment) 1 Develop a loving attitude toward Clinical Interventions even the tormenting voices 1 Medications 2 Accept voices as part of one’s life/ Cognitive-behavioral therapy (CBT) 3 develop a relationship with the voices 1 Problem solving training 3 Discuss voice hearing experiences openly with others to reduce stress and stigma 1 Systematic desensitization 4 Adopt certain postures 1 Psychodynamic or existential psychotherapy 5 Devise rituals 1 Aversion therapy 1 Deliberately go to sleep 7 Transcranial magnetic stimulation 6 Change of environment / Get out of the house 1 Behaviors Specifically Targeting Voices Avoid “triggering” situations 1 Earplugs—try just in one ear first 7 General Approaches to Mental Health Stereo headphones or loud music 7 That Also Help in Coping With Voices Watch TV 7 Reality checking 7 Sing or play an instrument 7 Avoid being in isolation 4 Hum 7 Interpersonal contact 1 Yawn or gargle 1 Attend self-help and support groups 11 Vibrate the tongue 7 Mutually respectful relationship with therapist 4 Read silently or aloud 4 Pay close attention to mental state and Repeat short phrases subvocally keep stress levels to a minimum 11 (e.g., counting, mantra, positive self-statements) 7 Temporary social withdrawal in order to Keep track of date, time and frequency of voices 4 regain self-control 1 Write down what the voices are saying 8 Focus or concentrate on something 7 Learn about voices (e.g., reduce fear Hobbies/handicrafts/gardening/yard work 1 by learning they are common in general population) 1 Relaxation or meditation 7 Try to ignore or tune out voices 4 Pray for help 1 Do as the voices say 9 Vigorous physical exercise 7 Focus on pleasant and positive thoughts 1 Have sex 7 Replace bad voices with good voices 7 Play a game 7 Yell or talk back at voices 7 Play with animals 7 Challenge or reason with voices 7 Eat comfort foods 7 Act directly in contradiction to the voices 10 Adjust diet/take vitamin supplements 1 Feel bigger and stronger than the voices 4 Improve self-esteem 1 Set limits to the voices or structure the contact 5

1. Watkins, 1998 5. Romme & Escher, 1993 9. Frederick & Cotanch, 1995 2. Lehman & Steinwachs, 1998 6. Hoffman et al., 1999 10. Haddock & Slade, 1996 3. Haddock & Slade, 1996 7. Carter et al., 1996 11. Group for the Advancement of 4. Deegan, 1995 8. Liester, 1996 Psychiatry, 2000

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