August 2016 I Indian Health Services Conference Hearing Voices Workshop: training and simulated experience “As a nation, it is up to all of us to know the signs of issues and lend a hand to those who are struggling,. . .

Shame and stigma too often leave people feeling like there is no place to turn. We need to make sure they know that asking for help is not a sign of weakness – it is a sign of strength.”

PRESIDENT OBAMA Objectives

§ Discuss what is voice hearing § Learning about the subjective experience of hearing voices and those that are distressing § Understand the day to day challenges that people with psychiatric disabilities experience § Changing practices to better address the needs of people who hear distressing voices § Describe support networks and coping strategies for voice hearers Has this ever happened to you?

You are in a crowd when you hear your name.

You turn, looking for the speaker.

No one meets your gaze.

It dawns on you that the voice you heard must have sprung from your own mind.

Studies have found that between 4% and 10% of people across the world hear voices It is estimated that between 5% and 28% of the general population hears voices that other people do not part I: hearing voices Hearing Voices

§ Voices can be critical, complimentary or neutral § It's difficult to explain what it is like to hear voices, particularly if you've never heard voices yourself § May give commands that are potentially harmful § Engage a person in conversations Mahatma Gandhi Saint Joan of Arc Saint Patrick Paul McCartney Anthony Hopkins Brian Wilson Carlos Santana Charles Dickens John Forbes Nash Sigmund Freud Socrates

ALL HEARD VOICES…

Hearing Voices

Don’t assume that means

Voices can be male, female, without gender, child, adult, human or non-human What are voices and who hears them? § Hearing voices is often thought of as a symptom of a serious mental illness § Research on the experiences of the general population shows that lots of people hear voices, and the majority of them are not mentally unwell § It is a common human experience Between 70% and 90% of people who hear voices do so following traumatic events Why do people hear voices?

• Voices as you fall asleep or wake up • Lack of sleep • Hunger • Physical illness • Drugs • Bereavement • Abuse or bullying • Other traumatic experiences • Spiritual experiences • Mental health problems: depression, anxiety, & stress Different Experiences

§ People can experience unkind and threatening voices § Voices can tell people to do dangerous or unacceptable things or try to control them § People may hear a kind supportive voice § Sometimes there may be more than one voice and they may talk or argue with each other § People may believe that they are hearing other people’s thoughts § The voices may be louder or more frequent if they are feeling stressed § They may hear or see things as they are falling asleep § They may experience the voices as being in their head, or they may feel that they are coming from outside and heard through their ears like other sounds However, there are clearly voice hearing experiences that can be very distressing and can disrupt our lives and ability to work, make friends, reach our personal goals… part II: mental health causes of mental illness are COMPLICATED

genetics environment physical strange or grandiose ideas Inability to cope with problems and daily activities Excessive anger, hostility, or violent behavior Marked personalities changes Marked changes in Excessive anxieties eating or sleeping warning signs for patterns mental illness

Thinking or talking about suicide prolonged depression and apathy or harming oneself abuse of alcohol or drugs biopsychosocial model: not one perspective is “correct” integrating perspectives most disorders are a result of biological, psychological, and social factors

not one single “cause” schizophrenia exact cause is unknown

3 factors believed important: • brain structure/ function

*increased dopamine levels • hereditary factors • environmental stressors

research

…showing abnormalities in the ventricles, prefrontal cortex, limbic region, and communication pathways of the brains of people who have schizophrenia. Neurotransmitters, including dopamine, and to a lesser extent serotonin and glutamine appear to be involved, although no causal relationships have been identified.

symptoms of schizophrenia • positive symptoms • • • disorganized thoughts • suspiciousness • Hostility

• negative symptoms • blunted/flat affect • social/emotional withdrawal • difficulty in abstract thinking • lack of ability to experience pleasure medications

§ common medications: § Haldol § Zyprexa § Risperdal § Thorazine

§ side effects include: blurred vision, tremors, stiffness, drowsiness, muscle spasms, uncontrolled muscle movements, lip smacking, jerking and twisting movements This foray into the uncanny is as close as most people come to experiencing auditory hallucinations or hearing voices, a condition that affects 70% of people diagnosed with schizophrenia and 15% of people diagnosed with mood disorders - such as mania or depression bipolar disorder

§ bipolar I disorder § characterized by one or more manic episodes, mixed episodes (rapid cycling), one or more major depressive episodes

§ bipolar II disorder § characterized by one or more major depressive episodes with at least one hypomanic episode mood disorders § causes § exact cause not known § related to neurotransmitters and genetic factors manic symptoms

§ elevated/expansive mood

§ grandiosity/delusions of grandeur

§ decreased need for sleep

§ pressured speech

§ flight of ideas

§ distractibility

§ irritability/intrusiveness

§ increased involvement in goal directed activity major depression

§ depressed mood

§ disturbance in appetite

§ weight loss/gain

§ sleep problems

§ decreased energy

§ feelings of worthlessness/guilt

§ difficulty concentrating

§ suicidal thoughts/attempts § loss of interest or pleasure in activities for at least 2 weeks mania and psychosis TOXICICTY impaired or unstable coordination weight gain/ Stroke or heart obesity problems involuntary movements or movement disorders blurred vision

warning signs for sensitivity to the sun side effects prescription drowsiness medications

CAN CAUSE CONVULSIONS, SEIZURES OR TREMORS sexual dysfunction Strong taste of metal diabetes cognitive decline or impairment psychotropic medications do not cure the illness, but can help treat the symptoms pills don’t give skills

but you can teach skills… part III: symptoms & experiences

Voices can be experienced in the head, in the ears, outside the head, in some other part of the body, or in the environment... Possible Voices

§ You did a bad job! § You are a bad person! § Overtime, you begin to have difficultly discerning between the statements § You stink! § You’re ugly! § You should hurt yourself! § You are the chosen one!

hallucinations

§ Auditory: Hearing things (e.g. sounds of footsteps or voices) § Olfactory: Smelling things § Gustatory: Having unusual tastes in the mouth § Tactile: Feeling sensations on the skin (e.g. something is crawling over them) § Somatic: These are feeling sensations deep within the body and can be very unpleasant § Visual: Seeing things that aren't really there (e.g. seeing people or shadows) Voices often reflect important aspects of the hearer’s emotional state – emotions that are often unexpressed by the hearer Recent Discoveries… 3 Factors § Reduced brain integration, social isolation, and high levels of emotionality § This view has become the focus of efforts to understand and help people with mental illness quiet their minds § Coping skills such as; listening to music, talking on an inactive mobile phone, combating negative voices with positive responses Cast Away WILSON part IV: hearing voices activity Patricia Deegan, PhD National Empowerment Center simulated experience Simulation Experience

§ Should have volume at a reasonable level § There is foul language on the recording. If this will be upsetting to you then please DO NOT listen § Do not drive or operate any machinery while listening to the content § Anyone who has experienced auditory hallucinations or has a history of hearing voices should NOT listen to this recording § If the voices become distressing or upsetting TURN OFF THE PLAYER! § This is not a marathon Simulation Experience

A few more important guidelines:

§ Do not communicate with each § Just be yourself. other about the content of the MP3 § Again if the content becomes Player during the simulation. disturbing you may turn it off § You can communicate with each and continue with the other about general topics, just not simulation with the player off what is on the player. or cease your participation. § It’s important to try and complete § At times, the audio will just the tasks not just sit back and be “white noise” just let it listen. continue and the voices will § You do not have to “role play” being come back. “crazy” during the simulation. SanDisk MP3 Players Volume control

Turn on and off press and hold center button Discussion

§ How did you best “deal” § Did you have any with the voices? physical response to the § Were you able to block experience? them out successfully if § Will this effect your you wanted to? approach in working § What was it like with those hearing compleng the mini voices? mental status exam? § What will you take away from this experience?

You get to take off your headsets… Voice hearers don’t have that option! part V: path to wellness is not about getting rid of voices but about:

§ The person understanding their voices in relation to their life experiences § The person changing their relationship with their voices so that the voices become harmless and/or helpful

People may hear one voice or many. Some people report hearing hundreds, although in almost all reported cases, one dominates above the others… what CAN you do to help? delusions and hallucinations

§ recognize and acknowledge that their delusions or hallucinations are real to them § don’t tell them there is no one there § don’t tell them you see or hear something that you don’t § ask what the voices are saying to get an idea of what the person is going through and messages they are hearing

§ realize that they may be overwhelmed

What can you do to help?

• undivided attention • summarize/paraphrase/restate • non-judgmental • silence • listen for real message • empathic listening • avoid becoming a precipitating factor • don’t take it take personally • be proactive

1. Don't isolate 2. Try some music 3. Keep a record 4. Some research suggests that if you put a rubber band around your wrist 5. Some people have found it particularly helpful to use "I statements” self-help intervention strategies § slow yourself down and take a deep breath ways to § eye contact § be clear, specific and firm de-escalate § display patience and empathy § remain calm & keep on discussion topic people § repetition is the key learning § consult with and/or refer to behavioral health services

Crisis Development Model Verbal or Physical

Crisis Development/ Staff Attitudes/ Behavioral Levels Approaches

defensive direcve

acng out person non-harmful control

tension reducon therapeuc rapport

CRISIS PREVENTION INSTITUTE reduce don’t call the person by stigma by their diagnosis leading by a person with mental illness example

be patient

have empathy treat with respect and dignity in case of an emergency

§ crisis line/crisis team § first responders § certified crisis intervention police officers

suicide hotline: 1-800-273-talk teen hotline: 1-800-248-teen Resources • Intervoice: The International community for hearing voices www.intervoiceonline.org

• New USA : Support groups for voice hearers and also trainings for leaders of support groups. www.hearingvoicesusa.org

• Hearing Voices Network, Manchester, UK (has links to other hearing voices networks and online groups): www.hearingvoices.org

• Voice-Hearers Support Group: http://groups.yahoo.com/group/voicehearers

• Hearing Voices Movement: http://en.wikipedia.org/wiki/Hearing_Voices_Movement

• Hearing Voices Info Booklet: http://hvna.net.au/upfile/HVNA_Info_Booklet.pdf

• National Alliance of Mentally Ill: http://NAMI.org

• Mental Health Foundation https://www.mentalhealth.org.uk/a-to-z/h/hearing- voices Homework

Be sure to take care of yourself or let someone else take care of you tonight! contact info [email protected]