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The experience of hearing voices: Daring to talk back

The experience of hearing voices: Daring to talk back. Dr Mark Hayward Sussex Partnership NHS Foundation Trust & University of Sussex. April 2011. Presentation Overview. A variety of voices Mediation of responses to voices Relationships with voices Applying a new theory of relating

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The experience of hearing voices: Daring to talk back

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  1. The experience of hearing voices: Daring to talk back Dr Mark Hayward Sussex Partnership NHS Foundation Trust & University of Sussex April 2011

  2. Presentation Overview • A variety of voices • Mediation of responses to voices • Relationships with voices • Applying a new theory of relating • Daring to talk back • Brief consultation

  3. The hearer’s view • ‘the Devil’ • ‘the man next door’ • ‘Miranda’ • ‘the people I hear’ • ‘the people in the garden’ • ‘murder voices’

  4. Spirits Commanding Prophets Guiding Family/Friends Powerful Madness ? ? Special/Gifted Scared Hopeless Comforted Guilty Watched Inferior Looked after Hearing and Feeling

  5. Hearing Feelings Mediation of Responses to Voices • Beliefs about the voice’s power, identity and intent (Birchwood & Chadwick)

  6. Cognitive model of voices (Chadwick & Birchwood, 1994) Activating event = voice speaking ‘Be careful’ Beliefsabout voices = power, intent and identity It is the Devil, he is watching and waiting to get me Consequences= distress and attempts to escape Terror; avoids going to the shops

  7. Hearing Feelings Mediation of Responses to Voices • Beliefs about the voice’s power, identity and intent (Birchwood & Chadwick) • Beliefs about the self (Close & Garety)

  8. Beliefs about the self (Close & Garety, 1998) Voice content (NATS) Helplessness Negative beliefs (Worthless, useless, helpless) (as hearer loses struggle for control)

  9. Hearing Feelings Mediation of Responses to Voices • Beliefs about the voice’s power, identity and intent (Birchwood & Chadwick) • Beliefs about the self (Close & Garety) • Social Empowerment of the hearer (Romme & Escher)

  10. Social Empowerment(Romme & Escher, 1993, 2000) • 33 % of 450 people ‘coped’ with their voices • voices considered positive and friendly • more likely to be married • perceived themselves to be well supported by others • more likely to talk to others

  11. Hearing Feelings Mediation of Responses to Voices • Beliefs about the voice’s power, identity and intent (Birchwood & Chadwick) • Beliefs about the self (Close & Garety) • Social Empowerment of the hearer (Romme & Escher) • Childhood trauma (Escher)

  12. Childhood trauma(Escher, 2002) • 80 children followed over 3 years • Voices persisting in only 40% • Traumatised by early events and recent triggers • Grief • Problems in home • Problems at school • Circumstances beyond control

  13. Hearing Feelings Mediation of Responses to Voices • Beliefs about the voice’s power, identity and intent (Birchwood & Chadwick) • Beliefs about the self (Close & Garety) • Social Empowerment of the hearer (Romme & Escher) • Childhood trauma (Escher)

  14. Relational Backdrop • “Integrated, personally coherent relationships with their voice” (Benjamin, 1989) • “Individuals experience their voices not as their own thoughts, but attribute them to others. Consequently, it is possible to view an individuals relationship with a voice as interpersonal, and indeed the relationship shows many of the dynamics common to ordinary relationships” (Chadwick et al, 1996)

  15. Mirroring of Relationships (Birchwood et al, 2000, 2004) Rank Power Appraisals driven by interpersonal schema Social Voice Social Voice

  16. But surely,……………… ‘if relating to voices is influenced by relationships in the real world, it is likely to be imbued with all the complexity and idiosyncrasy of social relationships. This will include issues of power and proximity…’ (Hayward, 2003, P. 371)

  17. Relating Theory Birtchnell (1996, 2002) UPPERNESS (relating from a position of relative strength) DOMINATING CLOSENESS (becoming involved) DISTANCE (remainingseparate) WITHDRAWAL CLINGING LOWERNESS (relating from a position of relative weakness) HELPLESS

  18. Applied to Voice Hearing (Hayward 2003; Hayward et al, 2008; Vaughan & Fowler 2004; Sorrell et al, 2010) VOICE ‘DOMINANCE’ Distress Malevolence Resistance HEARER ‘WITHDRAWAL’ Resistance Negative content ‘incognito’ voices Distress VOICE ‘INTRUSIVENESS’ Distress Malevolence HEARER ‘DEPENDANCE’ Benevolence Engagement Less negative content

  19. Is “relating to a voice” meaningful to hearers? (Chin, Hayward & Drinnan, 2009) • YES • Evidence of “relating” in their interaction “Erm we still have this ‘go away I’m not listening’, ‘yes you are, you’re going to listen to me’ kind of relationship” “when I talk to [the voice of] my mum she asks me how my day’s going and I tell her what I’ve done and what I’m doing” • Personification facilitated understanding and predictability • NO “[…] I’ve said to them many times that er ‘there’s you or me but no we’” • Because relationships (in the social sense) should be supportive and involve mutual interest

  20. ClinicalImplications Two possible ways to work therapeutically to modify the relationship with the voice: • At the level of social relating, e.g. assertiveness training (Birchwood et al, 2002) • At the level of voice relating, e.g. Personification of and engagement with voices (Chin et al, 2009)

  21. Voice and You (VAY) (Hayward et al, 2008) VOICE DOMINANCE (7 items, e.g. my voice wants things done his/her way) VOICE INTRUSIVENESS (5 items, e.g. my voice does not let me have time to myself) HEARER DISTANCE (7 items, e.g. I try to hide my feelings from my voice) HEARER DEPENDENCE (9 items, e.g. my voice helps me make up my mind )

  22. Can relationships with voices change? (Hayward et al, 2009) • Explore parallels with social relating • Enhance awareness of reciprocal nature of relationship • Explore ways of relating to the voice differently

  23. Case series • N=5 • Voices for 12 Months, irrespective of diagnosis • Baseline x 2 • 12-24 sessions • Post therapy, 1 & 3 month follow-up • PSYRATS & VAY

  24. Mary • Heard voice of The Devil • Responsible and lacking faith • Consistent with relational history • Following an ‘attack’ – she stood firm

  25. Joseph • Voices of famous people – ‘greatness’ • Voices of ‘team’ lead by a bully from the past • Team relating perceived as unidirectional • Consistent with relational history • Breakthrough = Understanding

  26. Hearer views on therapy(Hayward & Fuller, 2010) • ‘To hear someone talk about them as if they were real, instead of … just telling me that I need more medication or… ‘don’t listen to them, they’re not real’. • ‘I’ve been trying to run away from the voice all the time and I’ve learned to stand firm and fight back’

  27. Hearer views on therapy (cont.) • ‘we’re not complete enemies anymore’ • that gives me more confidence, more self-esteem, because I think I don’t have to be… under the control of the [voice] anymore. I can just try and be myself’ • ‘it gives me the power to say no without feeling guilty… I can choose what I want to do more, rather than… let him control me, and just be submissive’

  28. Where next – another world?

  29. Relating Therapy in Second Life? • Socialisation to SL • Familiarisation with private space in SL • Creation of avatar to represent hearer • Creation of avatar to represent dominant voice • Text dialogue between hearer and voice avatars – modified to become more assertive • Continual adaptation of avatars’ appearance to reflect changing relationship

  30. Your thoughts From a worker’s perspective, what would it be like to work with voices in Second Life? Discuss in small groups for 10 minutes Scribe allocated to each group Feedback one headline

  31. Issues from consultation with hearers • Socialisation to include guide to on-line safety within SL • Need for a second consent – post socialisation • What about non-human voices, e.g. Spirits? • How utilise SL data to reflect outcome

  32. Next steps • Further consultation • Development of study design • RfPB application in September • Recruitment to small case series in October

  33. Key references • Benjamin, L.S. (1989). Is Chronicity a Function of the Relationship Between the Person and the Auditory Hallucination? Schizophrenia Bulletin 15, 291-310. • Birchwood, M., Gilbert, P., Gilbert, J., Trower, P., Meaden, A., Hay, J., et al. (2004). Interpersonal and role related schema influence the relationship with the dominant ‘voice’ in schizophrenia: a comparison of three models. Psychological Medicine, 34, 1571-1580. • Hayward, M. (2003). Interpersonal relating and voice hearing: To what extent does relating to the voice reflect social relating? Psychology and Psychotherapy: Theory, Research and Practice. 76, 369-383. • Hayward, M., Denney, J., Vaughan, S., and Fowler, D. (2008). The Voice and You (VAY) A person’s assessment of the relationship they have with their predominant voice. Clinical Psychology & Psychotherapy, 15, 45-52. • Hayward, M. Overton, J., Dorey, T. & Denney, J. (2009). Relating Therapy for people who hear voices: A case series. Clinical Psychology & Psychotherapy, 16, 216-227

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