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The recovery process with hearing

voices: accepting as well as exploring
their emotional background through a
supported process
a bcd
Marius Romme & Mervyn Morris
a
Intervoice, Birmingham City University, Birmingham, UK
b
Centre for Community Mental Health, Birmingham City
University, Birmingham, UK
c
Central Assertive Outreach Team, Birmingham and Solihull
Mental Health Foundation Trust, Birmingham, UK
d
Soteria Network, UK
Published online: 04 Oct 2013.

To cite this article: Marius Romme & Mervyn Morris (2013) The recovery process with hearing
voices: accepting as well as exploring their emotional background through a supported
process, Psychosis: Psychological, Social and Integrative Approaches, 5:3, 259-269, DOI:
10.1080/17522439.2013.830641

To link to this article: http://dx.doi.org/10.1080/17522439.2013.830641

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 Psychosis, 2013
Vol. 5, No. 3, 259–269, http://dx.doi.org/10.1080/17522439.2013.830641

The recovery process with hearing voices: accepting as well as

exploring their emotional background through a supported
process
Marius Rommea and Mervyn Morrisb,c,d*
a
Intervoice, Birmingham City University, Birmingham, UK; bCentre for Community Mental
Health, Birmingham City University, Birmingham, UK; cCentral Assertive Outreach Team,
Downloaded by [University of Toronto Libraries] at 12:53 26 January 2015

Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK; dSoteria
Network, UK
(Received 5 April 2013; accepted 28 July 2013)

This paper reports on the methodology, results and conclusions from a study of
50 voice-hearers’ stories of the experience of their recovery process. The original
text includes full first-hand accounts and this paper provides details of questions
put forward in order to analyse the information from these reports. It also
discusses how these questions were derived from earlier studies. The results are
presented as identifiable steps towards recovery. The conclusion accentuates
evidence that assuming voice-hearing is a psychotic symptom might not be
justified. The study identifies the opportunities that become available when
psychiatric services recognise voice hearing as an acceptable and understandable
variation of human experience.
Keywords: hearing voices; recovery; user-involved research; therapy guidelines

Living with voices: Fifty stories of recovery (Romme, Escher, Dillon, Corstens, &
Morris, 2009) was a landmark publication in the field of voice-hearing research and
is to date the largest published collection of recovery narratives of and by people
who hear voices. The purpose of this article is threefold: (i) to report on the research
underpinning this study and its methodology, (ii) to present its key findings and (iii)
to reflect upon the further questions this study raises with respect to the recovery
process.
Is it justified to call hearing voices (auditory hallucinations) a psychotic symp-
tom? Epidemiological research has clearly shown that between 4% and 8% of the
general population hears voices; the majority in the absence of a psychiatric diagno-
sis (Eaton, Romanoski, Anthony, & Nestadt, 1991; Johns & van Os, 2001; Tien,
1991). This paper – which reports on the recovery process of 50 voice-hearers,
focussing on their own experiences, in their own words – also makes this highly
questionable. Following a Jasperian tradition, psychiatry has taken the position that
“understandability” should not be used to differentiate a diagnosis, i.e. exploring the
“content” of voices is not required, thus reducing the experience to its “form”, a

*Email: mervyn.morris@bcu.ac.uk

© 2013 Taylor & Francis

 260 M. Romme and M. Morris

symptom of a psychiatric illness. However, this study “content” reveals that there
are clear relationships between the characteristics of the different voices and the
problems of the hearer, from which we conclude that voices are better understood
not as an illness, but in relation to the person’s problems in daily life.
Living with voices built on a series of earlier studies by Romme and Escher
(1989, 1993, 2000) and Corstens, Romme and Escher (2006) which identified nine
issues as being helpful to recovery. Working with a new sample (only 5 of the 50
voice-hearers had participated in the earlier studies), Living with voices examined
the relevance of these nine issues to the interviewees’ recovery. This study was not
driven by adherence to a particular methodology, but is consonant with a narrative
approach, and is more fully discussed by Gadsby (2011). This may be perceived as
problematic, but we were primarily focused on constructing a design that allowed us
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to explore particular questions while at the same time allowed people to tell their
own stories, personally and directly.
Before coming to the results of this study, we should first discuss how we identi-
fied these nine research questions. Early work by Romme and Escher (1989, 1993)
offered a radically different way to think about voice-hearing experiences. This chal-
lenged people not to approach voices primarily as a symptom of an illness, but to
understand them as a reaction to problems in the voice-hearer’s life about which the
voices try to communicate with the voice-hearer. From bringing 300 voice-hearers
together in a congress setting (Romme & Escher, 1989), and from intense case stud-
ies with 13 voice-hearers (Romme & Escher, 1993), “accepting” the voices emerged
as an essential precondition for understanding them. From this we derived the
research question: Do voice-hearers describe accepting their voices as important for
their recovery?
Building on this work, a comparison study of patient and non-patient voice-hear-
ers (Honig et al., 1998; Romme & Escher, 2000) made clear that these groups do
differ in the way they cope with their voices. A second research question emerged:
Do voice-hearers describe coping strategies they use to get more control over their
voices as part of their recovery?
In the same study, Romme and Escher (2000) also observed three phases of
development that their participants went through in their recovery process: (i) a
phase in which the voice-hearer is still overwhelmed by anxiety and feels powerless;
(ii) an “organisational” phase in which they become more the owner of their voices;
in this phase, Romme and Escher observed that voice-hearers become interested in
the phenomenon itself and in the hearing voices movement. This led to the research
question: Do voice-hearers speak about an interest in the voice-hearing phenome-
non or movement as part of their recovery?
In the third phase of coping with voices and problems, it is essential to renew
contacts with the outer world (Romme & Escher, 2000). People must make choices
– such as whether to stay “a victim” (Coleman, 1999), whether to take medication
or not and under what conditions, whether to take up a study or a job. This led to
the fourth research question: Do voice-hearers describe making choices as a step in
their recovery?
In all the studies of Romme and Escher (1989, 1993, 2000, 2006), voice-hearers
relate their voice-hearing experience to traumatic experiences they have endured.
Trauma is related both to the onset of their voices but also to overwhelming emo-
tions and memories about which the voices speak or which are triggered by the
voices. The interrelation between hearing voices and experienced trauma is now
 Psychosis 261

sufficiently described in the literature (Read, van Os, Morrison, & Ross, 2005; Va-
rese et al. 2012) and led to a fifth question: Do voice-hearers tell about the personal
aspects of their voices, as part of their recovery?
The experience of trauma can give rise to many problems. It can be difficult for
people to acknowledge that the trauma has really happened and to talk about these
experiences (Herman, 1992), and to develop another view on their shame and guilt
feelings (Warner, 2008). As Ron Coleman shows (1999), it can also be challenging
to take back power from the voices as it is the power that is given to the voices by
the hearer that makes him/her the victim of the voices. As power is never given back
but has to be taken back, we formulated as a research question: Do voice-hearers
describe taking back power as a step in their recovery?
While taking back power in itself appears to influence the relationship with the
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voices, there might also be more reasons to change the relationship by recognising
that there are instances when “recognizing voices could be right” (Romme & Escher,
1993). We therefore decided our seventh research question: Do voice-hearers
describe changing their relationship with their voices as important in their recovery?
A pilot study by Corstens, Romme and Escher (2006) examined what elements
were helpful to the recovery process of 12 voice-hearers. This study employed the
Maastricht Interview (Escher, Romme, & Hage, 2000) and Ron Coleman’s (1999)
personal report of his recovery process. Through it we learnt that a helpful begin-
ning of the recovery process is to meet somebody who is interested in the voice-
hearer as a person and not only in his/her symptoms. We therefore asked: Do recov-
ered voice-hearers describe meeting such a person during their recovery process?
This 2006 study also showed that giving hope was a very important stimulus to
work on one’s recovery, particularly when considering the stigmatisation of
voice-hearing, and negative experience arising from trauma, childhood adversity and
coercive forms of psychiatric care (Jarosinski, 2008; Knight, Wykes, & Hayward,
2003, p. 216, McCarthy-Jones, 2012, p.136; Tooth, Kalyanasundaram, Glover, &
Momenzadah, 2003). Our final research question derived from earlier studies
became: Did the recovered voice-hearer meet a person who gave hope and/or
showed a way out?
A new research question was also formulated from the stories where we
observed that some people began to recognise their own emotions in what the voices
told them. This led to: Do voice-hearers recognise their own emotions in what
voices express, or take over, from them?

Participants
Over the last 25 years networks of voice-hearers have formed in over 23 countries
worldwide, connecting us with voice-hearers from across many cultures who have
recovered from the distress of their voices. For this study we asked key people in
these networks to approach recovered voice-hearers they knew to ask whether they
would contribute to what became Living with voices (Romme et al., 2009). The key
figures went on to be the editing authors.
People participated in this study because they supported our intention to publish
their personal stories, and through this offer hope, giving greater attention to the
possibilities of recovery, and contribute to a process of positive change.
Within our largely European sample, we successfully found a diverse and
gender-balanced group of people who differed in age, diagnosis and type of care or
 262 M. Romme and M. Morris

treatment received. All but three of our participants described receiving psychiatric
care, often over extended periods: 32 had stays in psychiatric hospital, 3 in day care,
and 12 in community or psychotherapeutic treatment. Twenty-six of the voice-hear-
ers reported being given a diagnosis of schizophrenia, 4 a dissociative disorder, 5
depression, 3 borderline disorder, 2 a manic-depressive disorder (40 in total). Three
did not receive a diagnosis because of being still quite young, and seven people did
not clearly report this.

Instruments
All the voice-hearers we selected initially received a letter of invitation to partici-
pate, asking them to either write their recovery story or be interviewed by the person
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who sent them the letter. We explained our purpose was to collect 50 stories for pub-
lication, creating a qualitative evidence base for other voice-hearers to identify with
and for professionals to overcome their hesitation in trying out the “Accepting” and
“Making Sense of” voices approach. A “Guide for writing an anthology” was
included in the letter and consisted of three parts.
The first part was a shortened list of the Maastricht hearing voices interview
questions (Escher, Romme, & Hage, 2000), asking: who you are (name, age, gender,
etc.); some characteristics of the voice hearing experience, for example whether
voices were “me” or “not me”; the characteristics of up to five main voices; when
they started and what was happening at that time; the most important triggers pro-
voking them in the here and now; what impact they had when you were most hin-
dered; your explanation for them; coping strategies you use or have used and how
the voices reacted; how you relate to your voices and if then how this has changed?
The second part asked: how did you came into contact with the accepting voices
approach and what benefits has this for you? Who talked to you first about your
voices and showed interest, and what did you do with this information? We also
asked participants to tell about other people they had met and had a positive experi-
ence with; to describe them as briefly and clearly as possible. We also asked people
to reflect on whether they had experienced the benefits of the Accepting Voices
approach, as published by the English Hearing Voices Network (Downs, 2005) and,
if so, give some evidence of how.
The third part asked: how is your life now; how do you feel on average; do you
still hear voices and can you cope with them? We also asked participants to com-
ment on their everyday life now – their family life, jobs, homes, financial security,
etc. – and how dependent or independent they felt on others people around them.
We also wanted to know if people were engaged in the hearing voices movement.
Finally, we reinforced our commitment to diversity, reminding participants that:
“It is not necessary at all to keep the order of the parts as proposed in these guide-
lines. Feel free to tell your story in your way. The only thing we would like is that
you check afterwards if most items are covered in your story and eventually put the
missing ones in.”

Results
All the participants heard voices with the characteristics of an auditory hallucination,
especially being “not me”. The data analysis found a high proportion of positive
responses to the nine research questions, and less high on the tenth. These are
 Psychosis 263

reported here as steps made by the participants to realise their recovery; the number
of positive answers out of 50 is given with an example of each step to make them
more clearly understandable.

(1) Meeting someone who takes an interest in the voice hearer as a person
(31). Don tells his therapist in an evaluation of his support: I was spoken
to as a person, I became an identity. You were interested in a theatre play I
had written. Before that, I was treated as a patient; lived in no-man’s-land;
there was a cessation of my feelings.
(2) Giving hope, by showing a way out (36). Family members can play this
role, as with Antje: “I was at a point in my life where I said to myself this
cannot be life. My conclusion was to bring it to an end definitively. My
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mother was very worried, and then she saw Hannelore, the coordinator of
the German [hearing voices] network on TV. My mother got the address
and went there, participated in a group and after that told me about it. But
I really did not want to know. She left a flyer called ‘Accepting Voices’ on
the desk by my bed. I read it. I was very surprised that a psychiatrist was
writing in a different way about voices. At that time I also had a new doc-
tor, and she was different. She was the first who asked if anything had hap-
pened to me at the start of my hearing voices”.
(3) Meeting people who accept the voices as real; being accepted as a voice-
hearer by others, but also by oneself (45). Ron writes: Anne Walton, a fel-
low voice-hearer who at my first hearing voices group asked me if I heard
voices. When I replied that I did, she told me “that they were real”. It
doesn’t sound like much, but that one sentence has been a compass show-
ing me the direction I needed to travel, and underpinned my belief in the
recovery process.
(4) Using coping strategies to get more control over the voices (31). Stewart:
I was already able to talk back to my voices with my thoughts, but I learnt
to make a specific time of day, the evening, when I would focus, and simply
tell the voices “later” if they came at another time.
(5) Becoming actively interested in the hearing voices experience (34). Ami
tells: “I came across advertising on a billboard that somebody would give
a lecture about hearing voices, a lecture given by Liz Bodil [Karlsson, who
promoted accepting voices in Sweden]. This was the turning point. She
also sold books. That book ‘Accepting Voices’, I read in one night. I just
felt this is for me. This described my experience and also said there is a
reason for voices”.
(6) Recognising the voices as personal and becoming the owner of one’s
voices. Alongside accepting voices as real, this issue was most frequently
part of what people told (45). Flore puts this succinctly: I was never con-
fused. It was my abuser.

Gina wrote: When I went out, the voices sometimes said to me “She is going out
again” and that felt like criticism. It was none of their business because I had no
work so I could go out. But then I realized that I had the same thought myself. There
were more examples: When the voices said “See how awful she looks”; it happened
on days when I felt myself pretty awful. But they always made such exaggerated
statements. By exploring this I started to realize that in a certain way the voices
 264 M. Romme and M. Morris

expressed my own thoughts. It is rather strange, but they are your own thoughts
about an emotion.
The personal aspect of the voices refers also to the links voice-hearers make with
the adversities they have endured. In this study, 18 voice-hearers related their voices
to their sexual abuse; 11 related them to their emotional abuse; 6 to intense adoles-
cent problems; 4 to high levels of stress; 2 to being bullied; 2 to their physical abuse
and in 7 it was not clear what kind of adversities had been endured.

(7) Changing the power structure between you and your voices (31). Debra
writes: … perhaps they were not as infallible or as powerful as I initially
believed. I decided to test this out. I decided that I would set the demons
some tasks. I gave them the simple task to wash the dishes unaided. They
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were unable to achieve this, and so the seed of doubt as to their actual
power was sown.
(8) Making choices (38). Frank: I joined the self-help group and did a study
for the network. I didn’t think long about it because I knew I needed
friends, because I didn’t want to become isolated.
(9) Changing the relationship with your voices (38). Andreas writes: I realized
that the continuous chain of hatred in the relationship between me and my
voices needed a breakthrough. Only when I acknowledged that many
things the voices were telling me were true did I become able to forgive
them. Only when I asked the angry voices to forgive me did I become less
depressed.
(10) Recognizing one’s own emotions and accepting them (26). Eleanor:
Everyone has their private demons, and his [the voice’s] demonic aspects
were the unaccepted aspects of my self-image. The contempt and loathing
that he expresses is actually to do with me in that it reflects how I feel
about myself. He is like a very external form of my own insecurities, my
own self-doubt.

As reported here, the response to the questions we put forward to the participants
confirmed many of the observations from our earlier studies, as well as the one we
selected after reading through the studies. However, there are also some even more
challenging new results.

(11) Still hearing voices. A most challenging result was that most recovered
voice-hearers still heard voices, a finding corroborated by Harrow, Jobe
and Faull (2012). This clearly indicates that getting rid of voices is not nec-
essary in order for people to recover from their distress with their voices
and so should not be the ultimate goal. Recovery was mostly the result of
accepting the voices as real; meeting others and becoming interested in the
phenomenon; learning to know the personal aspects of their voices; recogn-
ising the problems they represent; making choices and letting other influ-
ences enter your life; becoming more powerful and understanding.
Altogether this changes people’s relationship with their voices, and also
often gives a better personal insight into emotions and coping with them. It
is quite understandable that getting rid of the voices is not the ultimate goal
because hearing voices is a human variation (Watkins, 1998), as evidenced
by the epidemiological research cited above. Human variations are not
 Psychosis 265

targets for elimination, but something people learn to live with, such as
homosexuality, left-handedness, dyslexia, etc. Voice-hearers who are
patients hear voices that are part of a reaction to severe problems. In the
recovery process it is not the coping with voices which is most important,
but coping with the problems that lie at their roots.
(12) Personal links between the voices and childhood adversities and problems
in life. Many studies accentuate a statistical relationship between childhood
adversities and developing a psychosis. One of the most important findings
of this study was that there are “personal links” between the characteristics
of the different voices and the kind of adversities, especially childhood
adversities, the person has experienced. These links can be used in support-
ing voice hearers to become active participants in their recovery process.
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For example, with sexual abuse, some voice-hearers recognised the identity of
one of their voices as that of their abuser, or that the age of one of the voices was
the same age they were when the abuse started or ended. We also found that the
voices warned the voice-hearer to be careful because of what had happened, or
scolded the voice-hearer if they did not defend themselves well enough in various
social situations. There are situations where the voice was angry with the voice-
hearer (for example, calling her a hooker because she was sexually aroused during
the sexual abuse), leading the voice-hearer to feel guilty about that emotion. With
physical abuse, we have found the same kind of links, such as the characteristics of
the voices being recognised as the people involved in the physical abuse. We
observe also that the voices set the voice-hearer up to be aggressive as a result of
the endured adversity. This is because physical abuse can give rise to an anger that
could not be expressed at the time the abuse took place.
With being bullied, the voices can be a group of voices reminding the voice-
hearer of their experience of a group of bullies, as if they live on for him/her. What
the voices say resembles what the bullies said at the time, such as “loser”, “she’s a
nutter” or “she’s disgusting”. There are other problems reported that relate to being
bullied, such as being afraid to get on a bus that is full of passengers, or not liking
to go into crowded places.
Emotional neglect. This sometimes resulted in not being able to express emo-
tions in situations where expressing emotions were forbidden when young. For
example, Frans’ mother became psychotic when he was four years old, and this
made him afraid of emotions in a family where expressing emotions was forbidden
in order to protect mum. As a result, later in his life he was not able to express
anger, and when it was not possible for him to avoid becoming angry, as in a con-
flict in his student accommodation. Frans started to hear two voices instead of
expressing his anger, one of these voices being very rationalistic, the other very
emotional. For Frans, aggression is the key in the slot of this childhood adversity.
That is how recent stresses provoke voices.
In experiences where emotional neglect consisted of heavy criticism during long
periods in the voice-hearer’s younger years, the person was not able to succeed.
Frank, who started to hear voices twice, on both occasions at the end of academic
studies, was prevented from doing his exams by his voices.
There are many more adversities that lead to hearing voices and can be
recognised by the links with the characteristics of the diverse voices heard. In the
 266 M. Romme and M. Morris

book Living with voices, we published unedited stories to make it possible to

observe these connections.

(13) The need for medication: 44 of 50 were prescribed and took neuroleptic
medication before they started their recovery; 30 people subsequently
stopped taking medication during their recovery because they found it did
not help them; 14 indicated that medication helped in part but never when
only medication was given; 12 of 44 sometimes took medication but
always in a low dose. Half of the participants took it as an old routine, with
only six explaining why they still took medication, and the reason was
always to maintain an easier balance with their emotions. As Frans says:
“With Risperdal I just work on the whole day. I am less excitable.” He
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works as an IT specialist in a big company and had studied physics. He

was diagnosed as schizophrenic.

Discussion
Recovery from the distress of voices is rightly called a process because we see there
are distinct “developmental” phases. For voice-hearers as well as for professionals it
is of great value to work in a structured way and to use instruments like a structured
interview or the work book of Coleman and Smith (2005), because it is then easier
to follow these developmental phases (Romme & Escher, 2000). These phases can
be observed in this study and the steps taken in the recovery process can be divided
according to these three phases.

Phase 1: The startling phase, when people are still overwhelmed by the strange
new experience of hearing one or more voices. The goal in this phase is to get more
control over the voices and to learn to talk about them, to accept them as real,
because that will reduce anxiety. To this phase belongs:

 meeting a person who is interested in the person of the voice-hearer;

 being given hope and shown a way out by someone;
 meeting someone who accepts the voices as real;
 exercising coping strategies to get more control and reduce anxiety

Phase 2: the organizational phase. Arriving at this phase, the voice-hearer has
grown more used to the experience. The goal at this time is to own the voice and in
this phase we include:

 supporting the voice-hearer to extend their interest in the voice-hearing experi-

ence, by reading or taking contact with other voice-hearers;
 analysing the personal aspects of their voices by making a profile, psychologi-
cal formulation or construct with the voice-hearer (identifying the links
between the characteristics of the voices and their problems in life and work-
ing through shame and guilt feelings about what has happened);
 stimulating the voice-hearer to take back power from their voices.

Phase 3: The stabilisation phase. When the voices are seen as belonging to the
hearer, meaning that what they say clearly relates to them. The main task for the
 Psychosis 267

voice-hearer and their supporters becomes solving the problems in daily life that are
linked to hearing voices, shifting the focus to relating to real life. In this phase
belongs:

 stimulating the voice-hearer to make choices in order to recover, by making

contacts in the world around and choose what they want in life;
 finding out how to change their relationship with their voices;
 exploring with the voice-hearer how possibly their voices could express their
own emotions.

Conclusion
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Professionals alongside other voice-hearers can play an essential role in the recovery
process of people who are held back by their voices. A necessary first step is to
accept voices as being real, after which it is then vitally important to support the
process of relating to the voices. By accepting there is meaning in the voices, people
can find a way to recognise what has happened to them, and also understanding their
social and emotional conflicts.
It is clearly not necessary to pathologise people’s voices as part of an illness, dis-
ease or brain disorder. Of course the brain is involved, with voices being part of its
functional interaction. We can accept that our explanation of voices is not a univer-
sal truth for all voice-hearing experiences, but we can at the very least reasonably
extrapolate from the voice-hearer accounts in our study that there are very many
more voice-hearers who are fundamentally misunderstood when using the lens of
mainstream psychiatry, and mistreated as a result.
The various diagnostic categories may tell something about differences between
people, but if first and foremost we accept the voices as part of the person, then
these diagnosis groups may simply reflect different ways a person copes with life
experience and emotions.
In cognitive formulations of voice-hearing, there is a helpful intention with prac-
tical tools that challenge the power and influence of the experience, but they do not
challenge the assumption that it is a symptom of an illness, an “auditory hallucina-
tion”. We believe we provide evidence that voice-hearing can be understood as an
integral part of the emotional and thinking life of a whole person, not as a fragment
of a wider disease process. Therefore, using the term “psychotic symptom” is clearly
misunderstanding voices.
Accepting voices as a human variation promotes the therapeutic relationship. In
tackling the root cause of distress from voices, developing psychodynamic tech-
niques could be effective because the voices could be formulated as a defence mech-
anism against overwhelming emotions. More pragmatically, EMDR (Eye Movement
Desensitisation and Reprocessing; Shapiro, 2001) may help with difficult memories.
We believe that there are a number of opportunities to develop ways of working
with voices, both through peer support (Dillon and Hornstein, this issue) and also
for the psychotherapeutic professions (Herman, 1992; Moskowitz & Corstens,
2007), where therapists recognise that for most voice-hearers the background is a
traumatic experience neither coped with nor worked through. Those therapists who
work with traumatised people could be of great help to people with distressing
voices. It is deeply troubling that many voice-hearers are kept within the psychiatric
system and not offered the correct therapeutic help they could benefit from. This
 268 M. Romme and M. Morris

situation discriminates against 4% of the world population, potentially 250 million

people. Happily only the smaller part are distressed by their voices, but this so easily
leads to a path away from recovery.

References
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Coleman, R., & Smith, M. (2005). Working with voices II: Victim to victor. Dundee: P&P
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