In 2016, shortly after I entered a CACREP-accredited graduate program for clinical mental health counseling, I began hearing, outside of the class setting, about an international human rights movement centered around the “voice hearing” experience — what would be called auditory-verbal hallucinations in clinical mental health settings. The movement includes people with unusual perceptions that often get labeled as psychosis.
I slowly came to learn about the movement through an introductory workshop, a three-day group facilitator training, attendance in online and in-person groups for a year, and the reading of the literature on the topic. Most recently, I traveled to Montreal for the 11th World Hearing Voices Congress, where I was able to shake hands with and hear one of the movement founders, Dutch psychiatrist Marius Romme, speak.
With this article, I hope to familiarize counselors with the Hearing Voices Movement and related international networks of recovery groups. I believe the Hearing Voices Movement is in alignment with the values and ethical principles of the American Counseling Association.
History and current development of the movement
The Hearing Voices Movement started in the 1980s in Europe when a patient confronted Romme about the limitations of the psychiatric care being provided. Why, the patient asked, was it OK for Romme to believe in a God whom he could not see or hear but not OK for her, the patient, to believe in voices that she really did hear? To learn more about the voice-hearing experience and to try to help his patient, Romme had the woman’s story told on TV and asked for other voice hearers to contact him. Approximately 550 reached out.
Remarkably, many of the people who heard voices did not need clinical help. Writing in the Journal of Mental Health in 2011 after conducting a literature review, Vanessa Beavan, John Read and Claire Cartwright asserted that it was safe to say that 1 in 10 people in the general population will hear voices. Romme eventually compared psychiatric treatment to eliminate voice hearing to conversion therapy for sexual orientation.
How did he come to that conclusion? By accepting the reality of the voices rather than just checking them off as a symptom to be treated, Romme said, he could learn much more about their origin and meaning and identify ways to help his patients. He discovered that voices were often a reaction to problems in life, such as bullying or abuse, with which the person could not cope. In other words, there was a relationship between the voices and the person’s life story.
The Hearing Voices Networks (HVN) are the network of community groups that emerged from the Hearing Voices Movement. As of early March, the Hearing Voices Network USA had 119 groups listed on its national website. At the World Hearing Voices Congress that I attended, it was reported that Brazil has quickly grown over the past few years to have 35 groups, whereas the province of Quebec in Canada started with one group in 2007 and now also has 35 groups. The majority of groups are in Europe, where the Hearing Voices Movement started.
The groups developed when people with experiences of voice hearing got tired of not being listened to and of being labeled as having mental disorders. They were also frustrated by the coercive nature of the often ineffective treatments. Individuals with experiences that might be labeled as psychosis in clinical settings can meet in these groups and explore their experiences in spaces that are free of clinical judgment. If a clinician brings a person to attend a Hearing Voices group, the clinician will often be asked to wait outside or in another room while the voice hearer attends. Members of these networks believe in the freedom of voice hearers to interpret their experiences in any way they see fit. The key to this approach is for individuals to be listened to in a curious, nonjudgmental way as they describe their experiences.
People are discovering that when listened to in this way, profound healing can occur. Eleanor Longden’s TED Talk, titled “The voices in my head,” is a great introduction to this approach. Longden describes how changing her perspective on hearing voices — from a disorder to be treated to experiences with meaning if one could just open up their metaphorical wrapping — led to a huge developmental shift that allowed her to make peace with her experience.
I firmly believe the Hearing Voices Movement is in alignment with ACA values. ACA has a rich tradition of promoting social justice, honoring diversity, and supporting the worth, dignity, potential and uniqueness of people. In clinical practice, counselors work to promote the ethical principle of client autonomy, fostering the right of clients to control the direction of their treatment and lives. This aspiration is realized with all range of mental health concerns, but experiences that could be labeled psychosis are generally approached differently in the U.S. mental health system, potentially indicating a blind spot in the field of mental health.
In contrast to the ACA values I learned in my first semester of graduate school, I began to have a growing concern when learning about counselor roles that stood in opposition to those values. Specifically related to psychosis were the two roles of providing psychoeducation and monitoring adherence to medications. This involves instructing the client in the medical model, explaining that hearing voices and other unusual experiences are symptoms of a brain disease process, asserting that symptoms have no personal value or meaning to be explored, and teaching that treatment should consist of attempting to arrest that disease process. In taking that approach, psychoeducation essentially serves to impose a particular value or framework on the client’s experience of hearing voices.
The American Psychiatric Association established the medical model upon its founding in 1844, writing in its journal at the time that “we consider insanity a chronic disease of the brain …” That is the lens and approach that the organization has taken and buttressed with evidence. Of course, the medical model framework is useful for some people, and many useful treatments have been derived from it. However, there are other people who prefer alternative social or developmental models and lenses that are more in alignment with ACA values.
A 2017 United Nations Human Rights Council report concluded that one of the barriers to mental health and wellness was a lack of free and informed consent. Specifically, “In order for consent to be valid, it should be given voluntarily and on the basis of complete information on the nature, consequences, benefits and risks of the treatment, on any harm associated with it, and on the availability of alternatives.”
The availability and awareness of alternatives and complementary approaches may be a key piece that needs some work. It is important for counselors to identify innovative approaches in line with the ACA ethical principles of client autonomy and nonmaleficence, or avoiding actions that cause harm. I believe the Hearing Voices Movement is one such promising innovative approach, with evidence building in academic journals and books, including Living With Voices: 50 Stories of Recovery, by Romme and colleagues (2009).
A developmental model
In contrast to the medical model, counselors rely heavily on a developmental model of client concerns. The Hearing Voices Movement comes very much from a developmental perspective and fully acknowledges that voices are often a reaction to problems in life. Having learned that with 70% of adults the onset of voices was related to trauma or conflicts, Romme and colleagues studied 80 children who heard voices and published the results in 2004 in the International Journal of Social Welfare. They found that 75% of children had an onset of voices in relation to circumstances they felt powerless over.
Although the Hearing Voices Movement acknowledges a trauma connection to the onset of hearing voices for the majority of people, a blanket causal explanation for all voice hearing is not declared. All explanations are given space to be heard in the Hearing Voices Networks groups, including the medical model, psychological models such as voices being subpersonalities of the voice hearer, spiritual beliefs that the voices are spirits, and other possibilities.
As a side note to the developmental perspective of hearing voices, there is a new culture emerging of tulpamancers — people who intentionally work to develop voices they call “tulpas” to interact with as friends, based on an ancient Buddhist practice. A researcher at McGill University, Samuel Veissière, has done phenomenological research on tulpamancers, and Tanya Luhrmann of Stanford University is working on a neuroimaging study of these individuals.
The book Living With Voices outlines a three-phase developmental recovery framework identified from people who recovered from the distress of hearing voices:
1) Startled phase: Anxiety and a feeling of being overwhelmed dominate. Sigmund Freud wrote about his experience of being a voice hearer while living alone in a strange city in The Psychopathology of Everyday Life. His description of his experience was translated into English as the voice suddenly pronouncing his name.
2) Organization phase: Interest in the experience is developed, and the voice hearer looks for more information.
3) Stabilization phase: Person recovers their own potential and capacity to live the life they choose.
Although this may appear to be a linear process, in actuality the process may be repeated each time that a new voice makes itself know to the voice hearer.
To clarify, in the Hearing Voices Movement, to “recover” does not mean that symptoms have been eliminated but rather that the person has recovered from the distress of hearing voices. As was the case in the not-too-distant past when homosexuality was termed a mental disorder, the solution is not to force people to be different than they are but rather to change society to allow people to accept themselves as they experience life and love.
A role for the counselor
In the U.S. mental health system, clients who hear voices are most commonly acculturated into the perspective that their voices reflect a disease process with no inherent meaning. Frequently, once a mental health professional identifies voice hearing as a symptom, the voice hearer’s underlying traumas are systematically ignored and invalidated. The only history then asked about is family history of mental illness to confirm the diagnosis, even though the person’s trauma history could be addressed in counseling.
The Hearing Voices Movement allows many voice hearers to discover relationships between their voices and their life experiences. Some voices have the tone or use the language of a childhood bully or an abuser. Often, voices express difficult emotions that the voice hearers are not able to express themselves.
The Maastricht interview, named for the Netherlands university city in which it was created, was originally a research tool designed in collaboration with voice hearers to learn more about their experiences, but it was found to have clinical value in the beginning process for clients to explore their experiences. The Maastricht interview can be considered a voice-mapping process in which the interviewer asks the voice hearer questions about the voices. Through this process, voices are discovered to serve different purposes, such as representing unfelt emotion, protecting the voice hearer, or attempting to solve loneliness or social isolation.
Among the questions the Maastricht interview uses to accomplish this are:
- Have you noticed whether the voices are present when you feel certain emotions?
- Are you able to carry on a dialogue with the voices or communicate with them in any way?
- Does the manner or tone of the voices remind you of someone you know or used to know?
- Can you describe the circumstances when you first heard them (each voice)?
- Please describe your own interpretation of what causes your experience and what your theory is for why you have this experience.
The Maastricht interview can be found on Intervoice, the International Hearing Voices Network website.
The Maastricht interview features eight specific questions that explore potential trauma experienced in childhood at home, in school or in the neighborhood. In addition to the counselor facilitating the organization phase of recovery for the client, these questions provide validation of the client’s life experience and raise awareness of unprocessed trauma that may be worked through more effectively with counseling than in the Hearing Voices groups.
Similarities with internal family systems
In Richard Schwartz’s internal family systems (IFS) model, a person is conceived as being born with several distinct parts (like subpersonalities), each of which can pick up burdens or traumas in life, and a core self that is not affected by traumas. The parts interact within the person, much in the way that different members of a family interact as a system.
I asked Schwartz if the IFS model could work with people who hear voices. He told me that it could. The voices can be worked with as parts in the IFS model, and Schwartz has done work with people with schizophrenia diagnoses.
In the Hearing Voices Movement, voices are seen as being very interactive within the individual who hears them. Likewise, in the IFS model, voices can be looked at as parts that interact as a family system. Additionally, in the Hearing Voices Movement, the goal is not to eliminate the voices (although that sometimes happens). Similarly, in IFS, the goal is not to eliminate the person’s distinct parts but rather to help the person discover and release unprocessed trauma burdens so that the system can live in a harmonized way. Much like in the Hearing Voices Movement, in which voices are acknowledged as real, IFS is best carried out from the understanding that a person’s distinct parts are real and can act within the internal family system.
In one last similarity of note, at the World Hearing Voices Congress, Romme said that most voice hearers know the age of their voices. At his workshop, Schwartz had some participants check in with their parts and find out what their ages were.
Romme has drawn comparisons between using treatment to try to eliminate a person’s voice hearing with using treatment to try to change a person’s sexual preference. I was struck when I first read this comparison because I at the same time kept reading about ACA’s push to support bans on conversion therapy for sexual preference. Romme repeated this comparison at the World Hearing Voices Congress.
Initially, I kept thinking about the level of distress people must feel who hear voices that tell them to harm themselves or others. But I have since met, talked with and listened to so many people who hear voices — and who have really taken control of their lives by changing their relationship to those voices — that I am beginning to think that Romme is right. In my lifetime, homosexuality was included as a diagnosable mental disorder in the Diagnostic and Statistical Manual of Mental Disorders. It took a rights movement to change that. The Hearing Voices Movement — a human rights and social justice movement — is now well underway, with networks in 37 countries and counting.
Laren Corrin is a counseling graduate student at the University of Southern Maine. Laren is an advocate for alternative frameworks for psychosis and complementary approaches to wellness. Contact Laren at larencorrin.com.
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.