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MIAMI UNIVERSITY The Graduate School Certificate for Approving the Dissertation We hereby approve the Dissertation of Emily K. Reese Candidate for the Degree: Doctor of Philosophy _________________________________ Chair Larry M. Leitner, Ph.D. _________________________________ Reader Ann Fuehrer, Ph.D. _________________________________ Reader Aaron Luebbe, Ph.D. _________________________________ Graduate School Representative Elise Radina, Ph.D. ABSTRACT VOICES, RELATIONSHIPS, AND MEANING MAKING by Emily K. Reese In this study, I explored the experiences of four women who hear voices and are not part of a clinical population. Each woman had a much different voice hearing experience from the other women in terms of duration, regularity, consistency, and sensory modality. I interviewed these women about the voices they have heard, their understanding of the voices, their interpersonal relationships, and their general mood and functioning. A robust meaning making system and healthy interpersonal relationships were associated with lower distress about the voices, and with lower distress in daily life in general. In addition, connection with a validational community, and to the integral universe (Leitner, 2010), also were associated with lower distress. I present several implications for clinical practice, elaboration of Experiential Personal Construct Psychotherapy theory, and future research. In particular, I challenge the notion that hearing voices is an automatic indicator of “mental illness.” Instead, I argue that relationships and meaning making are far better indicators of psychological health. VOICES, RELATIONSHIPS, AND MEANING MAKING A Dissertation Submitted to the Faculty of Miami University in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Psychology by Emily K. Reese Miami University Oxford, Ohio 2014 Dissertation Chair: Dr. Larry M. Leitner Table of Contents Introduction…………………………………………………………………………………………1 Terminology and Definitions ……………………………………….………………………1 Experiential Personal Construct Psychology ……………………….………………………3 General EPCP overview………….……………………………………………3 EPCP and trauma……..……….………………………………………………5 EPCP and relationships.………….……………………………………………7 Voices……………………… ……………………………………….………………………8 Hearing voices is a meaningful response to extreme distress……………....….9 Hearing voices is not necessarily tied to pathology ………..……………...…13 The Present Study.………… ……………………………………….…………………….15 Method……………………………………………………………………………………………16 Participants…….…………………………………………………………………………..16 Interviews……….…..……………………………………………………………………..17 My Approach to the Interviews...…...……………………………………………………..17 Data Analysis…….……………….………………………………………………………..18 Results………………………………………………………………………………….…………19 Alice……………...………………………………………………………………………...19 Alice’s voice hearing experience……………………………………………..19 Alice’s relationships…………………………………………………………..23 What we can learn from Alice………………………………………………..25 Barbara..……..…...………………………………………………………………………...25 Barbara’s voice hearing experience…………………………………………..26 Barbara’s relationships………………………………………………………..29 What we can learn from Barbara……………………………………………...32 Candace..….……...………………………………………………………………………...32 Candace’s voice hearing experience………………………………………….33 Candace’s relationships……………………………………………………….39 What we can learn from Candace……………………………………………..41 Diane..…….……...………………………………………………………………………...42 Diane’s voice hearing experience……………………………………………..43 Diane’s relationships…………………………………………………………..49 What we can learn from Diane………………………………………………...52 General Themes...…..……………………………………………………………………...53 Summary...……...…..……………………………………………………………………...55 Discussion…………………………………………………………………………………………57 Clinical Applications……..……………………………………………………………….57 Elaboration of EPCP Theory..…………………………………………………………….61 Limitations and Additional Future Research …………………………………………….65 Importance of Findings………..………………………………………………………….69 My Views……..……….……....………………………………………………………….70 References…………..…………………………………….………………………………………74 Appendix A—Phone Script ………………………………………………………………………78 Appendix B—Consent Form..…………………………….………………………………………80 Appendix C—Sample Interview Questions/Prompts …….………...………….…………………81 Appendix D—Participant Interviews ……………………..………………………………………82 ii Acknowledgments I would like to extend my heartfelt thanks to the following people: To Dawn Strongin, who taught me to wonder about the nature of “reality.” To my participants, who allowed me to bear witness to their stories. I am truly honored that you chose to share with me, and hope that I have done justice to your experiences. To all of the many friends who have supported me in so many ways throughout this process: Kat, Cat, Aki, Jeffrey, Julie, Pam, Linda, Karen, Dan, my family, and countless others. Finally, to Larry Leitner, who taught me to speak truth to power. If I can be half the psychologist that you are, I will count it a blessing. Again, my thanks to all of you. Words are woefully insufficient to express my gratitude. iii Voices, Relationships, and Meaning Making Many researchers have studied voice hearing, or “hallucinations.” However, the majority of researchers have focused on consumers of mental health services. Comparatively few researchers have explored the experiences of persons who hear voices and are not clients of the mental health system. Therefore, we know little about the ways voices play a role in the lives of people in a non-clinical population, despite the fact that, according to demographic data, voices are far more common than most people are aware. In this study, I have explored the experiences of four women in the general population who hear voices. I also have shown how we can better understand voices by considering them in the context of a person’s relationships and meaning making process. Before I explain the findings more thoroughly, I comment briefly on the terms and definitions used throughout the study. I then briefly describe relevant aspects of Experiential Personal Construct Psychology (EPCP), which is the theoretical lens I used to explore the experience of voices. EPCP can be a particularly useful theory to ground such an inquiry because it is open to nonjudgmental interpretations of various human experiences. Next, I describe two major conceptualizations of voice hearing that are relevant to the present study. Finally, I describe more concretely what I have investigated in this study. Terminology and Definitions It is challenging to make meaningful comparisons within the literature regarding voice hearing. This is due, in large part, to researchers’ use of misleading and/or judgmental terms, as well as their lack of clarity around definitions for various terms. For example, using a vague term such as “schizophrenia” provides the illusion of communicating meaningful information, when in reality, many clinicians disagree on who qualifies for this diagnosis. Without the ability to make comparisons between studies, we cannot draw conclusions with confidence. Therefore, to maximize clarity for the present study, I here discuss the terms I have used in this inquiry as well as the way I have defined them. Many authors conflate the terms “psychosis,” “schizophrenia,” “hallucinations,” and “hearing voices” such that they often are used interchangeably. Treating these terms as synonyms is unhelpful at best and highly misleading at worst. During the course of the present inquiry, I offered to share some literature with one of the participants that would provide perspectives on voice hearing different from the predominant psychiatric paradigm. The 1 participant eagerly expressed her interest in receiving this information, and I was excited to share this literature with her, recalling that I had quite a few articles to pass along to her which would not discuss voices in pathologizing terms. I experienced quite a shock when I actually went to look through the literature I had reviewed. The articles used such terms as “hallucination” (Barrett & Etheridge, 1992), “psychotic phenomena” (Jackson & Fulford, 1997), “psychotic experiences” (Johns & van Os, 2001; Jones, Guy, & Ormrod, 2003), “psychotic symptoms” (Jones et al., 2003), and more. These are articles which, I had thought when I first read them, presented the voice hearing experience in a relatively positive, non-judgmental light. It was not until I looked at them through the lens of anticipating how they might sound to a person actually having a voice hearing experience that I was able to experience how hurtful and pejorative these articles may sound. Therefore, I will use the term “hearing voices” throughout this paper, as it seems to be the least value-laden term of the set, and will use the other terms only when necessary to preserve specific wording from relevant literature or from my participants. I now must explain how I define “hearing voices” in order to provide context for my inquiry and findings. This is a challenging task considering the range of different experiences people have with voices. “Hallucination” is perhaps the most common term in the extant literature on hearing voices—although only about half of the authors in my review include any definition of hallucination in their writing on the subject. Among those who do, most offer a description similar to that in the Diagnostic and Statistical Manual of Mental Disorders (DSM- 5), describing hallucinations as “perception-like experiences that occur without an external stimulus” (American Psychiatric Association, 2013, p. 87). The DSM authors continue,

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