Listening to the voice of reason

MADNESS is a creative way of dealing with pain, " argues Rufus May, a recovered schizophrenic who used to hear voices urging him to kill himself. He and Dutch psychiatrist Dirk Corstens told a conference of mental health workers in Dundee recently that they need to explore more creative ways of dealing with voice-hearing.

Mental health professionals travelled from as far as Italy to hear about the "voice dialoguing" technique, in which, at its most extreme, the mental health professional engages with the voices themselves, in the first of a series of seminars on recovery.

Hearing voices - for instance after a bereavement - is a surprisingly common experience. Corstens says: "My aunt, who had lost her husband, used to sit on the bed and talk to him every evening. She could hear him talking back and that was a very reassuring and happy experience for her."

It is thought 5-10-per cent of the population hear this kind of voice at some time. In some cultures voice hearing is even more common – many Aborigines report hearing the voices of their ancestors, for example.

But, for many mental health patients, their experience of voice hearing is of angry, unpleasant, even violent voices urging them to kill themselves or others.

Traditionally, psychiatrists have been trained not to engage with patients’ voices, instead viewing them as a symptom and an indication of how well drugs are working. It is this approach that the event set out to challenge.

For Sue Cowan, a professor of mental health studies at Abertay University who is organising the series with a training group called Working to Recovery, the message is liberating.

She herself has heard voices, when she was studying for exams and hadn’t slept for two nights. “I could hear these two voices coming from a corner of the room and quite bizarrely they were talking about the correct way to roast a joint of meat.”

Cowan explains: “In training you are discouraged from engaging with peoples’ delusions so mental health professionals often don’t feel they are allowed to discuss patients’ voices with them or to ask questions about them. But the voices are these people’s reality and for nurses to engage with them as human beings they need to be allowed to accept that.”

Ron Coleman, a voice hearer who with his wife, Karen Taylor, a psychiatric nurse, runs the training group Working to Recovery, was psychotic in his twenties and tormented by the voices of a Catholic priest who abused him as a boy and a partner who killed herself. He has now learned to accommodate and deal with the voices which he still hears but which have become more positive.

For him, orthodox psychiatric treatment – heavy medication and a refusal to engage with his voices – did more harm than good. “They never asked the right questions, they never asked who the voices represented. They never saw the relationship between that and my illness. At that time, in the 1980s, they just saw it as ‘bad genes’.”

For Cowan, acceptance and encouragement from professionals is an important part of recovery. “When I say recovery I don’t mean a cure, I mean being able to cope with the illness and to be able to live in and contribute to society.”

Corstens adds: “We are not trying to get rid of the voices but to make the patient’s relationship with them more equal.”

Corstens says he has found this technique effective with scores of patients although he concedes that as yet there is no randomised, controlled trial that shows it works. But he argues that conventional treatments are far from effective. “Currently, if a patient comes in to a psychiatrist’s office and tries to talk about their voices that may just be taken as a sign that the dosage of their anti-psychotic drug needs to be increased.

“But for many people, at least 30-per cent, antipsychotic drugs do not get rid of their voices and they cause lots of unpleasant side effects such as obesity and diabetes.” Patients quickly learn not to talk about what they are experiencing, he adds.

Corstens has worked with a range of sufferers over the years. Some have found in the course of a few sessions that they are able to identify what their voices represent and have become much more able to deal with them.

“The voices are symbolic, they are about story and metaphor. But they generally have a protective function, ” he claims.

One of his techniques is to ask the patient to allow the voice to speak directly to him through them.

“The voice may start off by saying that the person should kill themselves but after questioning it may turn out that they simply want the person to avoid more pain, if the voice is aggressive it may be out of a desire that the person should defend himself from abuse.”

Voices, Corstens believes, are generally linked to trauma, abuse and neglect in childhood. “We can work on making the patient stronger and on strategies the patient has developed themselves for dealing with the voice. For instance, they may limit the amount of time they spend each day listening to the voice and, after that, ignore it.”

Some mental health professionals in the audience at the Dundee event expressed concern over the potential risks of encouraging patients to channel hostile voices and others said mental health patients often had no desire to discuss their voices.

Rufus May, a psychologist who works with self-help groups in Bradford, said the answer to these concerns could be group work. “Sometimes people have suppressed their voices for so long and they have never been allowed to talk about them. They may be very fearful of the voices. But we find after being in the group and hearing other people talk about their voices that they usually begin to want to do that.”

At the University of Edinburgh, Dr Stephen Lawrie is unconvinced. He concedes that anti-psychotic medicine is not a perfect cure and that outcomes from schizophrenia are better in the developing than in the developed world. “But the fact that most people will have to stay on the medication for the rest of their life doesn’t prove it doesn’t work. You wouldn’t say that about heart medication, ” he says. For him, antipsychotic drugs remain an effective way of getting rid of a distressing symptom. “Most patients who come to see us want us to help them and to get rid of these voices. The drugs do that.”

He says the only talking cure which seemed to have an evidence base was cognitive behaviour therapy. “If a patient wants to take a psychological approach we can request that although psychological services tend to be snowed under with people suffering from

depression.” He says: “If a nurse came to me and said she wanted to try some voice dialoguing with a particular patient I would not necessarily be opposed if the patient seemed to me strong enough for something that

The Herald
May 1st 2007