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Around 10% of the population hear voices that aren't there. Some people can live harmoniously with them, but for those whose voices are associated with a psychiatric illness, they can be frightening and menacingly real. We discuss the latest research on how auditory hallucinations occur in the brain, what it's like to live with v
oices in your head - and the healing power of the international Hearing Voices Network.
http://www.abc.net.au/rn/allinthemind/stories/2006/1689941.htm#
Transcript
Lynne Malcolm: Hello, I'm Lynne Malcolm. Welcome to All in the Mind, and this week, hearing voices when there's nobody there.
The voices in my head are speaking above the music
Like a fool of a DJ reciting this week's number 1.
Maybe someone else would enjoy this but I'm banging on the walls
Knocking at the doors, turn the volume down and leave the party. (Joe Twist)
A poem by Joe Twist about his struggle with the voices in his head. The sensation of hearing voices, or feeling a presence, when there's no one there is a fairly common human experience. People feel them as inner voices, spiritual guides, the voice of a departed loved-one or the voice of God.
It's thought that 10% of the population has had some form of this experience, sometimes it's spiritually uplifting and comforting but sometimes malevolent and terrifying. It's when the voices are associated with a psychiatric illness and they're frequent, intrusive and painfully real that they can severely disrupt people's lives.
This has been the case for Ron Coleman. On the phone from Scotland he told me about when he first started hearing voices.
Ron Coleman: I'd just broken my hip playing rugby and after I came out of hospital I went back to work and I was sitting in my office one day and I heard the voice behind me say, you've done it wrong. And I looked behind me and there was nobody there. From then on it got worse, and worse, and worse, I wasn't hearing one voice I was hearing two, then three. And eventually I was hearing six and that led me into hospital, the voices are so intense and they always pick on the bits of us that are our weaknesses. They leave us feeling as if we are worthless and hopeless and we become victims of that, really.
Lynne Malcolm: And they were all distinctly different voices were they?
Ron Coleman: Oh yeah, they were very different. I heard a voice say 'it was your fault, you led me into this sin, you deserve to burn in hell.' And that was the voice of a priest who was my abuser when I was a kid.
Lynne Malcolm: You were abused by a priest as a kid?
Ron Coleman: Yep, I heard his voice really clearly and he was probably the most distracting of my voices. I also heard the voice of my first partner who died and she would say things like, kill yourself, we can be a family again. And that became a real hard part of my life and eventually I just couldn't cope with it anymore and I broke down totally.
Lynne Malcolm: And she actually committed suicide, didn't she, your first partner?
Ron Coleman: Yep.
Lynne Malcolm: And do these voices sound like they're very separate to you; they're not coming from you somehow?
Ron Coleman: No, and I hear them externally, I don't hear them inside my head, I hear them outside. It's almost like I'm hearing you now I would hear it through my ears.
Lynne Malcolm: Ron Coleman, who now champions the International Hearing Voices Network which we'll hear more about later. Although Ron Coleman has experienced abuse and trauma in his life, and most of his voices are frightening and destructive, that's not always the case.
David Copolov: About a third of the people said that they would miss the voices if they disappeared, and a considerable number of those people said that the voices were helpful and guiding. But on the whole the voices that occur in the context of psychiatric illness are critical and cause the hearer to be distressed.
Lynne Malcolm: David Copolov is professor of psychiatry at Monash University and for twenty years worked at the Mental Health Research Institute in Melbourne. He and his colleagues did a large study into the cause and treatment of auditory hallucinations. And they were particularly keen to capture the subjective experience of those who hear voices, to get under their skin, as he put it.
David Copolov: An example might be someone who hears voices most of the day and they might have derogatory connotations about the person being a bad person and sexually misbehaving when they're not. The voices are intrusive, sometimes it can lead them to want to harm themselves and you can't talk the person out of it. So that the voices can be very, very distressing and can colour and flavour their lives such that they are unable to work, they're unable to engage in normal social relationships because of these derogatory malevolent voices causing the person considerable distress.
Lynne Malcolm: And how often would a negative auditory hallucination like that urge people to behave in ways that they wouldn't normally behave? For example, lead them to violence?
David Copolov: Well these are so-called command hallucinations and about 70% of people with schizophrenia have auditory hallucinations and about half of those have command hallucinations. And in a significant number those command hallucinations tell a person to do something – either dangerous to themselves or dangerous to others. And there've been many cases in the newspapers of, for example, mothers killing their children because the voices have told them to do so. In 2003 there was an example of Lucas Thomas, who climbed into the lion's enclosure in the Buenos Aires zoo because the voice of God had told him to taunt the lion. Fortunately no harm came from that but the voice was so compelling that he had to do what to everyone is an extremely dangerous thing.
The person who murdered the Swedish foreign minister Anna Lindt in 2004, Mijailo Mijailovic, said that he heard voices telling him that he had to kill the much-loved Swedish minister, and there was no vendetta but the voices had told him that that's what needed to happen.
Lynne Malcolm: Professor David Copolov. Thankfully not everyone who hears voices is driven to such behaviour but, living with these intruders, no matter how extreme, can severely disrupt people's lives.
Lyn Mahboub was 15 when she first heard voices – she was told she'd had a nervous breakdown and to go home and rest. In the following years she struggled with mental illness and was diagnosed with various conditions including depression, bi-polar disorder and psychosis. But a common symptom throughout was this sense of voices in her head.
Lyn Mahboub: What has happened on and off in my life is more of a hearing thought, so it's not an auditory experience for me, it's like hearing thought and it's very negative dialogue. I call it the interpreter that sort of interprets a lot of the interactions that I might have with people.
Lynne Malcolm: Why do you call the distressing side of these experiences the interpreter?
Lyn Mahboub: I guess each person that has these kinds of experiences over time finds meaning or their own understanding, and for me certainly the interpreter is a good description really of what it's doing because it appears to interpret various situations that I'm in, where I might be feeling paranoid or distressed and it gives me this account for what's happening.
Lynne Malcolm: Give me an example?
Lyn Mahboub: Well I might – my recent example was it'll say, you know, 'jump off a bridge, there's a good bridge, you're not worth it. This person is about to attack you', it's difficult to describe because at the time it's very distressing so I'm not totally taking full note of what's happening. People talk about command voices, for me they're not command voices they are just this negative dribble in the background and the fact that it exists is what is so distressing for me.
Lynne Malcolm: And does it feel like it's part of you or does it feel like it's coming from somewhere else?
Lyn Mahboub: I think that's the key, Lynne, is that very much, a lot of the time it feels like it's not part of me. And that's the negative aspects of what I hear and what I experience. Also I have a positive aspect to what I hear, it's what I call channelling and certainly that very much doesn't feel like me. I have information come through about things that I wouldn't ordinarily know.
Lynne Malcolm: Is the information usually correct?
Lyn Mahboub: A lot of the time it is very correct yes. When it comes to the distressing, disturbing, what I call the interpreter, that's kind of debatable and that's perhaps it's not a correct assessment of a particular situation.
Lynne Malcolm: So going back to that example you gave me about the voice telling you, or the thoughts telling you to jump off the bridge, in what context was that? Were you under particular stress?
Lyn Mahboub: Yes, yes, I was away in a different city of Australia, I was feeling particularly stressed by what I was doing at the time, it just got more and more and more in terms of severity. And I didn't feel in any way compelled to act on it, it's a bit like having somebody I guess in the room telling you awful things, you just think oh, go away, I don't really want to hear this right now. And the fact that it was happening in my head is what's distressing and it feels as though I'm starting to get unwell again, so of course there's an element of fear about it.
Lynne Malcolm: So have you ever taken medication?
Lyn Mahboub: Yes, I've taken anti-depressant medication and anti-psychotic medication and for the most part I've had a lot of reaction to the various medications. I have a sensitivity now to medication and I've got to be very careful – for example at one point in time I had HRT medication and that induced hallucinations or, you know, voice-hearing experiences in quite a severe way. Both internal and external, like most of my experience I would explain as internal, the experience of hearing things and getting information. But at different times when I was in hospital I would have the external experience. You know, mistake people for being in the room when they weren't in the room because I thought I was hearing them speak.
Lynne Malcolm: Whereas your internal experience, you know that they are thoughts in your head?
Lyn Mahboub: Well it feels to me as though the thoughts come into my head, that's the way I hear, I hear it with my inner ear if you like.
Lynne Malcolm: Lyn Mahboub, who is now a mental health advocate in Western Australia. You're with All in the Mind on ABC Radio National, Radio Australia and via podcast. I'm Lynne Malcolm: exploring the experience of hearing voices.
I woke up and they were in there
They didn't settle in, they moved in on me
I made room for them and offered them a cup of tea.
They raided the fridge, scattered bits of food on the floor
I sat in the corner, they rearranged the furniture around me
And crowded in on me
I tried to join them but they weren't having of it
They pushed me to the wall and stamped around loudly
So I turned on the radio, they smashed it and played with the pieces
I tried ignoring them but they wouldn't get out of my way
In the end, I gave up and went to bed
And when I woke up they were in there. (Joe Twist)
Lynne Malcolm: Psychiatrist David Copolov's study on auditory hallucinations drew from personal accounts and brain imaging data and he found that individuals' experience varies enormously. So where does this melee of characters and conversations in people's heads come from? What happens in the brain to determine the content of the hallucination? David Copolov.
David Copolov: We think of voices maybe as a distortion of auditory memories, we have memories of things that we've heard and things that have been said to us and it's our current conceptualisation that these voices are replayed, but in a very real sense of auditory memories and a distortion of these auditory memories feeding in to the regions of the brain that process hearing.
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Lynne Malcolm: So could you tell me a little bit more about what we know about what happens in the brain with auditory hallucinations?
David Copolov: Well a series of studies by our group and others has shown that during hallucinations there are regions of the brain that become active. And those regions commonly involve the regions of the brain, the temporal lobe under the temple that are associated with the processing of normal sounds. So it's as if the brain is being tricked, or the person is being tricked into believing that these voices are actually occurring because there's spontaneous activation of these hearing regions of the brain. There is also activation of regions of the brain, especially the hippocampu,s that are associated with the processing of memory, which is why we believe it's a combination of reactivation of memories with the false perception of external or internal voices.
Have you heard of phantom limb syndrome, where a person who might have had an amputation can feel their arm or leg even though the leg has been amputated? It's the part of the brain that is deprived of input from that region of the body, the brain responds to a lack of input by activity. So in hallucinations, auditory hallucinations, even though we've shown that there are subtle abnormalities of the hearing brain but not deafness as such, the evidence is that those base line abnormalities actually give rise to spontaneous eruptions within the dysfunctional hearing brain that then gives rise to this experience of hearing voices.
Lynne Malcolm: David Copolov. As we heard earlier, Ron Coleman was harangued by six voices after a cycle of sexual abuse as a boy and later the suicide of his first partner. Events which he says shaped his illness and his life. He spent six and a half years out of the next ten in and out of hospital. His treatments included electro-convulsive therapy and antipsychotic medication, but he emerged from hospital no better.
Ron Coleman: I ended up at the end of ten years I wasn't hearing six voices, I was hearing seven voices. So actually I came out of the system in a sense worse than I went in, in terms of the voice hearing experience. Beause the voices never changed, they were always there.
Lynne Malcolm: So what was the turning point, because you now manage them very differently? Tell me about what happened to turn you around.
Ron Coleman: I was in Manchester, I was in hospital and I heard a support worker who suggested that I went to this new group that was just forming in Britain called the Hearing Voices Network. Even at the very first meeting it made sense to me, a woman said to me, do you hear voices? And I said yes, and she said they're real. And as I thought about that it became clear that for years I'd been told they weren't real and I had to ignore them and therefore I was powerless, I couldn't do anything about it. And now somebody was saying to me, this experience is real so you have to do something about it, there's no point waiting for other people to do something for you. And then I started going more and more to the self-help group, to the Hearing Voices group.
Lynne Malcolm: Since then Ron Coleman's life has improved, because he's learned about alternative ways to manage his voices.
Ron Coleman: Yeah, I think it's about understanding why the voices are there. It's very easy to take a position that they're there because of some chemical imbalance and yet all those charts shows that about 70% of voice hearers can relate their voices directly to what happened in their lives.
Lynne Malcolm: You were getting similar messages though, weren't you, over and over again from these six or seven voices. Are you able to constantly learn by that?
Ron Coleman: It wasn't always the same thing. I've a voice that I call teacher, I have ongoing discussions with that voice about all sorts of things. And in a sense when I have major decisions to make now I would discuss it with my voices in exactly the same way you would discuss it as an internal dialogue in your own head.
Lynne Malcolm: So is there a sense that the voices can be helpful for you now?
Ron Coleman: Oh very much so, I mean through the group and through working on issues in my own life I was able to take control over the voices and experience and get on with my life. Married, got children, done all the things that I really wanted to do but was unable to do through that period of pain when the voices had control.
Lynne Malcolm: Ron Coleman has championed the Hearing Voices Network in the United Kingdom and plans to visit Australia later this month to help develop the network here. He's also written a number of books on hearing voices and you can check our website for details.
Even though medication and hospitalisation didn't help Ron Coleman much, most people seek treatment when the voices become difficult to manage. David Copolov.
David Copolov: Well by far the most important planks in treatment are the relationship with a therapist, talking about the voices, and medication. There is no doubt that the most effective treatment for psychotic symptoms including hallucinations is anti-psychotic medication. Although in about 25% of the people with hallucinations that are the result of a psychotic disorder, that medication isn't going to reduce the voices to a sufficient level. And in terms of psychological therapies, we've looked at cognitive behaviour therapy and what we call acceptance therapy to help people cope and to do two things: one, accept the reality of the hallucinations in the sense that they are occurring to the person, and two, trying to help them avoid unsuccessful coping strategies such as yelling and shouting back at the voices and helping them adopt other approaches that might allow them to cope with the voices more successfully.
Lynne Malcolm: The Mental Health Research Institute in Melbourne has established a free voices clinic for people who are distressed by their voices. They teach them coping strategies like these.
David Copolov: First of all trying to help a person understand other explanations for their voices. Sometimes, say, with command hallucinations, a person will feel that they really have to follow what the voice is telling them, otherwise immense harm will come to them. And so in the clinic there will be a testing of that theory and trying to encourage a person to not follow the voices and to find out that the consequences of not following what the voices say is not anywhere near as catastrophic – or is in fact not a problem at all. So in a sense, challenging the voices, keeping a diary in terms of the frequency of the voices and the things that cause the voices to get worse.
For example sleep deprivation, or using cannabis can actually make the voices worse, and being in a situation of stress, and if you can reduce the stress, or you can improve factors in a person's life or develop strategies for reducing those stresses and subsequently the voices.
Lynne Malcolm: David Copolov. The Hearing Voices Network was initiated by a Dutch psychiatrist, Marius Romme, in the early 90s, after one of his patients, Patsy Haig, impressed on him that the distressing voices she was plagued by were not a figment of her imagination – they were real. Together the doctor and patient went on a television chat show and were overwhelmed by audience response. After further research Marius Romme was convinced that validation of the voice hearer's experience and support from others can play a crucial role in people's recovery.
Lyn Mahboub has just returned from a Voice Hearers conference in the UK.
Lyn Mahboub: I mean I think that's one of the key things that people say is it was so refreshing for people to say yes, I experience it too. Your experience is real because traditionally the understanding was if someone was hearing voices or seeing things that it was a hallucination or a delusion, that it was not a real experience. But it's very real for the person who's having the experience. I know for myself when I'm feeling terror, my body responds with adrenalin, with sweaty palms, with everything, it's a very, very real experience. And I guess sharing this with other people you learn more new coping strategies of how to manage your voices and the experiences that you're having, so that you can reclaim life and get back on with things.
Lynne Malcolm: Can you tell me a little bit more about the coping strategies, besides sharing your experiences with others, that have the same experience, what are some of the coping strategies that you notice people use and what have you used to help you on the path to recovery?
Lyn Mahboub: Well some, just to list off a couple of things, a lot of the time people have negotiation with the voices. They might have structured time techniques, which is whereby you will listen to the voices at a particular time throughout the day and then you ask them to leave you alone at the rest of the time of the day so that you can go to work and do various other activities. Also voice dialogue is one of the things that people might do, whereby another voice hearer, or a worker, will sit and actually have a conversation with the person's voices. One voice hearer that I spoke to, she had been working with her voices quite successfully in some ways but then developed blackouts, and she went to the doctor and was diagnosed that she had something like atypical epilepsy.
So her partner engaged in dialogue with one of her voices. Through these kinds of conversations the voice was able to explain to her that there was a new voice who didn't understand the way in which to communicate. This other voice then taught the new voice how to do so in a way that was going to be productive for them all, and subsequent to that the blackouts stopped and she was able to get resolution. So by talking about the voices and getting a better understanding of exactly what's being said and why it's being said, the person is more able to manage the experience of hearing voices. Because a lot of the time living with the experience of hearing voices produces certain effects such as social withdrawal, anxiety and various other difficulty in having conversations and things like that. So through managing the voices, those kinds of effects which are often misunderstood as symptoms of an illness, you know, can be better worked with and navigated.
Everybody's different and I think that's the beauty of the groups, is that there's...for some people some coping mechanisms will be absolutely perfect. For other people that one might not work, but something else will, so the idea of sharing what works for them, and particularly for people that are living with voices in the community that haven't become patients, they've got a lot to offer, and that's why we encourage all voice-hearers to come forward and be involved in the networks.
Lynne Malcolm: I believe as part of the Hearing Voices Network, which is well and truly established in the UK but also I think growing here, one of the successful strategies some people who hear voices have used is to get others to have a dialogue with their voices, or even to get the voices to speak with each other. What do you think of this sort of approach and what might the mechanism be there?
David Copolov: Where we can get an explanation for voices and where we can normalise the experience, for example after bereavement there's been some important studies, a study of Sweden in the early 90s showed that about 30% of people in the year following the death of their husband or wife will either see or hear their loved one and that gives them some solace. So what the Voices Network is doing with information about the frequency with which people actually hear voices in the general community, is trying to normalise the experience. In fact that's also what we're trying to do with our studies on brain imaging of hallucinations. If a person knows that it's not just as your program says 'all in the mind', that there is in fact a biology, there's activation of the brain regions which make it clear to a person that they are hearing voices, even though there's no-one around.
Giving a biological explanation is in fact very reassuring. It is essentially a way of normalising that experience. And as we said before, a lot of people who hear voices don't have a psychiatric illness, some people hear voices in the context of being spiritualist, or of being an evangelical Christian. And there are, of course, many examples in history where people have heard voices, famous people have heard voices such as Joan of Arc and Socrates. In psychiatry there has been a tendency to have what I call a check-list approach to psychiatric symptoms, where you just register that a person has delusions, or hallucinations and once you've ticked the boxes you can then make a diagnosis.
Well, we're much more interested in the inner experience of what it is like to have voices and you have no idea how helpful people felt the process was to have a detailed understanding of their experience with hallucinations. So I think for example having the voices network established in Australia is a great idea.
Lynne Malcolm: Professor David Copolov of Monash University who's just received a major award from the Royal Australian and New Zealand College of Psychiatrists for his work on auditory hallucinations.
The voices in my head will speak
Like a classroom when the teacher leaves or pets left alone and hungry
But they're only there because they've got me to listen to them
The voices in my head will not be quiet
Not until I am. (Joe Twist)
Lynne Malcolm: I noticed a picture of you on the website when you were in Italy wearing a T-shirt, 'I hear voices and they don't like you'.
Ron Coleman: Yeah, I'm known for things like that. I also have a tattoo on my arm that says 'psychotic and proud'.
Lynne Malcolm: Oh really.
Ron Coleman: I guess that's just the way I am.
Lynne Malcolm: Ron Coleman, of the Hearing Voices Network in the United Kingdom. And you can contact the Australian Hearing Voices Network through the Richmond Fellowship in Western Australia.
The poetry in today's show is written by Joe Twist and read by John Jacobs.
For further information, links and references about this and past programs go to abc.net.au/rn and choose All in the Mind in the program list. And don't forget you can listen to or download the audio of our past four shows there too.
Thanks to producer Pauline Newman and sound engineer Jenny Parsonage. I'm Lynne Malcolm, and next week Natasha Mitchell will be back in the presenter's chair. So thanks for your company on All in the Mind this year, it's been a real pleasure. Bye for now.
Guests
David Copolov
Professor of Psychiatry Senior Advisor to the Vice Chancellor Monash University Winner of the Royal Australian and New Zealand College of Psychiatrists 2006 Organon Senior Research Award
Lyn Mahboub
Consumer Consultant (QBE) Director Hearing Voices Network Australia Richmond Fellowship WA
Ron Coleman
Mental Health Consultant "Working to Recovery" Fife, Scotland
Further Information
Hearing Voices Network Australia (Richmond Fellowship WA) info on workshops and contacts
Call for Papers, Poems, prose for an edited collection info from Lyn Mahboub @ RFWA
World Hearing Voices Day: 14th September. - Perth event
Hearing Voices Network
Mental Health Research Institute of Victoria
Ron Coleman Voices - website includes details of Ron Coleman's publications
and an online personal account from a voice hearer
Publications
Title: Accepting Voices
Author : Marius Romme & Sandra Escher
Publisher: Mind Publications 1993
Title: Hearing Voices - A Common Human Experience
Author : John Watkins
Publisher: Hill of Content Publishing Company 1998
Title: Command hallucinations and violence: Implications for detention and treatment
Author : Shawyer F, Mackinnon A, Farhall J, Trauer T, Copolov DL
Publisher: Psychiatry, Psychology and Law 10, 97-107, 2003
Title: Patients' strategies for coping with auditory hallucinations
Author : Carter DM, Mackinnon A, Copolov DL.
Publisher: Journal of Nervous and Mental Disorders. 184,159-64. 1996
Title: Auditory hallucinations: Insights and questions from neuroimaging
Author : Woodruff PW
Publisher: Cognit Neuropsychiatry: 9 (1-2): 73-91, 2004
Title: Central auditory processing in patients with auditory hallucinations
Author : McKay CM, Headlam DM, Copolov DL
Publisher: Am J Psychiatry. 157(5):759-66, 2000
Title: Cortical activation associated with the experience of auditory hallucinations and perception of human speech in schizophrenia: a PET correlation study
Author : Copolov DL, Seal ML, Maruff P, Ulusoy R, Wong MT, Tochon-Danguy HJ,Egan GF
Publisher: Psychiatry Research;122:139-52 2003
Title: The cognitive neuropsychiatry of auditory verbal hallucinations: an overview
Author : David AS
Publisher: Cognitive Neuropsychiatry.:107-23, 2004
Title: The auditory hallucination: a phenomenological survey
Author : Nayani TH and David AS
Publisher: Psychological Medicine 26, 177-89, 1996
Title: Cognitive Therapy for Auditory Hallucinations: A Theory-Based Approach
Author : Morrison AP, Renton JC
Publisher: Cognitive and Behavioral Practice 8, 147-160, 2001