Voice hearing in a biographical context: A model for formulating the relationship between voices and life history
by Eleanor Longden, Dirk Corstens, Sandra Escher and Marius Romme

in: Psychosis: Psychological, Social and Integrative Approaches. 2012; 4(3): 224-234. (for references go to that paper)

Psychological case formulation, an explanatory synthesis of the origin and nature of presenting difficulties, is a routine strategy within clinical psychology. It is increasingly regarded as good practice to apply this framework to patients with psychosis due to its capacity for informing treatment and careplan development, and potentially assisting individuals to devise more coherent, integrated accounts of their experiences. Formulation procedures may be particularly constructive for clients who do not desire psychotherapy, in that simply establishing links between life events and previously incomprehensible “symptoms” can provide a framework to integrate traumatic, unassimilated experiences into existing representational structures. The importance of developing such explanatory frameworks has also been addressed within the more general rubric of psychological adjustment following psychotic breakdown, and there is some evidence to suggest that individuals who see mental health problems as originating from themselves, relevant to their
life context, and a source of potentially formative guidance about social and emotional predicaments may have better long-term outcomes than those perceiving psychosis as a globally damaging, causally independent disruption to their life . For example, Brett et al. (2007) examined differences in appraisals,
and contextual and response variables to “anomalies associated with psychosis” between patients diagnosed with psychosis (n = 35), individuals meeting criteria for an “at-risk mental state” (n = 21), and a non-clinical group experiencing Schneiderian- type symptoms of schizophrenia, including voices commenting or conversing (n = 35). Amongst other results, the authors found that the non-patient, non-distressed
population was more likely to use (psychological) frameworks to appraise their experiences that were subjectively “coherent and adaptive” (p. 29), whereas the other two samples were significantly more likely to make causal attributions that were beyond their individual control (in this case, “biology”). On face value, these results do not permit firm conclusions to be drawn about causality, as the clinical group might be reasonably expected to see themselves as “ill”. However, a more detailed study by Stainsby, Sapochnik, Bledin, and Mason (2010), assessing illness perceptions, symptom severity and social impairment amongst 50 adults diagnosed with psychotic syndromes, found that a lower capacity to “make sense” (p. 41) of symptoms (as assessed by the Illness Perceptions Questionnaire for Schizophrenia) was associated with a poorer quality of life two years from baseline. The authors concluded that interventions which promote recovery by “helping clients to build a more coherent sense of their difficulties, via exploration of the personal life meanings
of . . . psychotic experience, may be at least as important as interventions that aim to reduce symptom levels” (p. 41). Such findings are congruent with emerging (often user-led) definitions of recovery from psychosis that emphasize ownership, personal meaning, hope and empowerment rather than passive concepts of mental

Formulating the voice hearing experience
Epidemiological research has demonstrated that voice hearing (VH) is not the sole province of psychiatric patients, instead existing on a dimensional, experiential continuum within the general population . Furthermore, prevalence rates across different subgroups appear to be more influenced by environmental and social factors than a categorical “presence” or “absence” of psychopathology. This paper does not presume to account for the origins of VH experiences per se, but rather for a specific group of distressed voice-hearers, often presenting to psychiatric services, and with a history of exposure to adverse events. Correspondingly, while the robust associations between VH and adversity (particularly, although not exclusively, childhood sexual abuse) is often mentioned in clinical literature to our knowledge no method for
systematically elucidating the links between voice content and life experience is currently practised in the field of psychotic disorders. For example, whilst cognitive approaches to case formulation advocate exploring intellectual and emotional appraisal of one’s voices, specific characteristics, dialogical function, and associations between voice presentation and (changing) psychosocial circumstances are generally not fully accounted for. We will describe a clinical strategy for addressing the personal relationship between distressing life events and certain characteristics of the voice(s) a person hears. This process of systematic enquiry is based on two theoretical and clinical premises:

  • Stress-vulnerability. Heightened emotional reactivity is considered central to the constitutional diathesis of the stress-vulnerability model. However, the aetiology of stress-vulnerability should not be seen as an inevitable biogenetic phenomenon, rather potentially acquired as a result of early trauma and stress exposure . Therefore VH onset may potentially be understood by differentiating between: (1) the influence of interpersonal traumas in creating vulnerability for emotional crisis (i.e. psychological predisposition); and (2) the personally significant events that cluster before onset or relapse (i.e. the actual stressors which provoke voice onset or continuance: see Romme & Escher, 2010).
  •  Phenomenology. In terms of distressed voice-hearers and/or those requiring psychiatric assistance, research suggests that acute anxiety, or the reactivation of past stress, is: (1) associated with VH in a sizeable number of cases; (2) that distressing, negative interpretations of initial VH experiences may predict subsequent psychopathology; and (3) that such appraisals are most likely to be made by individuals with a history of trauma or stress exposure. Indeed, available literature suggests that the conceptual and clinical ubiquity of VH experiences in different psychotic and trauma-spectrum conditions means that VH may be linked to adverse life experiences per se rather than to a particular DSM diagnosis.

The Maastricht Approach of Romme and Escher (e.g. 1993, 2000) endorses psychological therapy and self-help methods to interpret and decipher the problems VH may represent. In order to understand the possible biographical dynamics of VH, Romme and Escher (2000) advocate devising a construct: a dynamic, psychosocial formulation that explores possible interpretations of the original situation that prompted voice emergence. From this perspective, VH is understood as a (distorted) reflection of conflictual situations harbouring certain personal themes: a manifestation of a vital defensive manoeuvre whereby transforming emotional conflict into voices is psychologically advantageous. An important objective for working in this
way is not eradication or “cure”, but to discover ways to cope both with the voices and emotions which evoked their presence. Indeed, understanding, accepting and resolving relevant social-emotional dilemmas can be seen as a valuable therapeutic goal, in that attaining mastery over adverse experiences is an important part of recovery not only from distressing voices (Romme, 2011; Romme & Escher, 2010)
but from mental health problems more generally (Young & Ensing, 1999). For example, an analysis of 50 recovery stories by Romme et al. (2009) demonstrates how, at least for some voice-hearers, establishing, validating and exploring links between life events and distressing voices provides a promising avenue for supporting and promoting the recovery process. Similarly, research by Beaven (2011), Beavan
and Read (2010) and Fenekou and Georgaca (2010) illustrates how many voice-hearers experience personal meaning in voice content, and that this information is of potential therapeutic benefit.
Making a construct
Our approach follows the established principles to clinical formulation elaborated by Johnstone and Dallos (2006), in that the process is: tentative; collaborative; amenable to constant re-formulation; incorporates systemic, social and/or political factors; and respects and defers to client views on its truthfulness and expediency. While formulation does not have to be correct, it does have to be useful (Butler,1998). Thus it is important that voice-hearers feel acknowledged during the process and that their experiences are conceptualized in a coherent, personal account that makes sense to them. In this respect, clinicians should remain mindful and reflexive about any pre-existing values or assumptions they may bring to the procedure.


Table 1. Exploratory themes used to devise a construct.

Identity of the voices
Enquire about the character of each voice that the person hears, such as name, gender and age (if known and/or applicable). If the voices are very numerous, ask the person to devise groups and describe
them collectively.
Characteristics and content
Identify how each voice talks (e.g. shouting, whispering, screaming) and if they are especially benevolent or malevolent. How do the voices relate to one another? Is there a hierarchy between them?
What do they actually say: ask for specific and literal phrases. Can the voice-hearer identify people from the past or present who behaved or spoke in a similar fashion? If so, this may provide indications of individuals who are represented by the voices and/or were implicated in the adverse experience(s).
Triggers                                                                                                                                                                            What situations and emotions provoke the voices and how do they respond? Certain feelings can make the voices more active (e.g. shame, guilt, anger, anxiety, sexual feelings). Alternatively they may be elicited by the presence of specific people (e.g., family members), or being in a particular context or environment (e.g., social
situations). Again, this may refer to the circumstances and themes related to VH emergence.
History of the voices
What was happening in the person’s life when each voice appeared for the first time? Did particular circumstances evoke overwhelming emotions or conflicts? How did the voice(s) develop afterwards in
terms of content and influence?
Childhood history                                                                                                                                                       The voice-hearer’s unique biography carries vital communication about the course and content of his/her distress. What occurred in his/her life before he/she heard voices? Childhood experiences may influence personality development and determine resilience and coping strategies in adulthood. What interpersonal vulnerabilities can be inferred from early relationship development (e.g. attachment organization and/or traumatic events)?


In our experience, many individuals find it liberating and validating to be respectfully questioned about their voices. Although some are unable (or unwilling) to acknowledge underlying difficulties, we have found that a systematic exploration of relevant information may reveal both the person’s psychosocial vulnerabilities
and the contextual circumstances that originally provoked VH. In this respect, we refer to the psychodynamically informed approach of Garfield (1995), who endorses a similar emphasis on the role of emotion and analysis of circumstances in which symptoms first appeared: “Unbearable affect reaches its peak in the precipitating event . . . a situation that carries a burden to the patient that cannot be coped with
by . . . [their] usual methods . . . [L]ike the news reporter, the clinician is interested in who, what, why, where, when, and how” (pp. 31–33). We advocate a methodical, collaborative approach towards this search for meaning, because the presence of VH suggests that painful emotions may potentially evoke sensations and memories relating to the original adverse experience(s).
Before commencing, it is therefore important to develop a relationship with the client by demonstrating a broader, compassionate interest in their his/her life and difficulties. We often find it beneficial to provide positive examples of other voicehearers in order to motivate the person to talk about his/her voices (e.g. information about voice-hearers who never entered the mental health system and/or learned to
cope with their experiences). It generally takes around 90 minutes to conduct construct interviews. In order to
organize the required information, five specific themes are examined. These questions, adapted from the Maastricht Hearing Voices Interview (MI: Romme & Escher, 2000), are exploratory queries for structuring information gathering (see Table 1). Developed on the basis of numerous interviews with voice-hearers
(Romme & Escher, 1989, 1993, 2000), these categories are based on the hypothesis that VH characteristics are personally significant to the voice-hearer, and as such are related to aspects of their life history.

On concluding the interview, the therapist writes a report summarizing the formulation and presents it to the voice-hearer, who is asked to read and comment on it to clarify omissions or misunderstandings. We have often found that the actual process of interviewing for a construct may have a “therapeutic side effect”, in that participation can help overcome the emotional and/or cognitive avoidance that is common in many voice-hearers. Furthermore, having a written report of their lived experiences can act as an incentive for individuals
to begin discussing their stories more fully, identifying practical and social issues hindering recovery, and exploring new coping strategies (both with the voices themselves, as well as associated emotional and social dilemmas). The resulting information is then used to explore two fundamental questions about representation in order to formulate the construct:
(1) Who might the voices represent
Voices may often resemble the identity and/or characteristics of significant individuals in the life of the voice-hearer, in either a literal or metaphorical way (e.g. as “The Devil”, or a female perpetrator represented as a male voice). Similarly, they may symbolize aspects of the voice-hearer themselves and/or specific, intolerable
emotions that influenced VH onset and continuance.
(2) What problems may the voices represent
This question explores circumstances at the root of the VH experience – generally problems, situations and events that were so overwhelming that they exceeded the ability to cope. What kind of social-emotional dilemmas can be identified that determined the voice-hearer’s vulnerability at the moment the voices began?
In clinical terms, the answers to these questions are used to formulate a treatment plan. Generally, this follows a stage model of healing and recovery in terms of: establishing safety (coping with the most challenging aspects of the voices); making sense of one’s experiences (using voices as clues to internal emotional conflicts); and social reconnection (working through experiences that have been difficult to integrate and accept). Although beyond the scope of this paper, we refer to Corstens et al. (2008)
and Romme and Escher (2000).

Case example
To prevent recognition, a pseudonym has been used and some biographical details changed. The individual concerned has seen this account of her story and given permission to have it reproduced.

Laura, a 21-year old woman living in supported accomodation, had a diagnosis of paranoid schizophrenia. She was prescribed neuroleptic medication, which failed to mitigate the voices and resulted in distressing adverse effects.
Identity of the voices. Laura heard 12 voices. The most dominant, “Satan”, was male and aged around 22. The second voice, “Aurora”, was female and aged around 30. Laura collectively described the remaining ten voices as “The Chorus”. These voices were genderless and had no names or ages.
Characteristics and content. Satan was menacing and aggressive, instructing Laura to kill herself, and to “stab, bite, burn and choke” other people. It predicted ominous events that Laura would be “powerless to prevent” and referred to her by degrading names like “the bitch”. In contrast, the voice of Aurora was benevolent and supportive, and provided reassurance and advice (e.g. “everything will be fine”, “you will get through this”). Aurora and Satan did not interact with one another. Finally, The Chorus was belittling, threatening and offensive. They often concurred with Satan’s predictions, although could also argue with him about the best way of “punishing” Laura. Laura was unwilling to disclose the exact content of The Chorus’
speech, as she felt so ashamed of their coarse, insulting comments.
Triggers. Laura heard Satan constantly, although he was particularly intrusive when she was feeling angry or depressed. Aurora appeared whenever Laura felt sad or hopeless. Finally, The Chorus was triggered when Laura was in social situations, as well as by feelings of guilt and shame, both about herself and on other
people’s behalf.                                                                                                                                                       History of the voices. Laura first heard Satan and Aurora aged eight. Aurora was named after the heroine in the animated film Sleeping Beauty to reflect her serenity and gentleness. She always sounded older and more mature than Laura. Satan’s original name was “George” and he always remained one year older than
Laura. The name related to Enid Blyton’s Famous Five novels (a popular series of English children’s books) wherein the character, George, although female, is bold, assertive and tenacious. Laura could cope well with the voices and never disclosed their presence. Two years ago, Laura was raped by a male acquaintance, upon which she stopped hearing Aurora. Soon after, Laura renamed George “Satan” in order to reflect his increasingly malicious and threatening nature. The Chorus began one year ago, after Laura was rejected by a group of girls with whom she’d hoped to seek friendship, and who had made cruel comments about her psychiatric history. The content of The Chorus has been consistently negative.
Childhood history. Laura was a gifted child academically, and studied with older children in order to sit her A-level examinations two years early. She was often lonely as a child and had few friends, although recalled: “I didn’t need friends because of the voices.” She was close to her father, but had a difficult relationship
with her mother who could be intimidating and emotionally remote. Laura’s upbringing was inhibiting in that she was not encouraged or permitted to express strong emotions, like anger, or to advocate for her needs.     Who might the voices represent? Laura’s initial VH experience were voices as childhood companions. The female voice, who was mature, nurturing and compassionate, may have compensated somewhat for Laura’s own maternal deprivation, in that her mother was remote and emotionally withholding. The male voice was playful and boisterous and a good “playmate”. The voices changed after a deeply traumatic incident of sexual victimization, which shattered several of Laura’s assumptions both about the world and herself. At this point the protective, reassuring voice withdrew. The manifestation of Satan appeared partly influenced by Laura’s attacker, and The Chorus appeared with a group of bullying, rejecting peers. Furthermore, both Satan and The Chorus were associated with anger (the world is a bad place), guilt (anger at yourself ) and shame (everybody sees how bad I am).
What problems may the voices represent? On one hand, Laura’s relatively isolated position as a child, and on the other her unresolved traumatic experience (which created unbearable, overwhelming feelings). In addition, her sense of disempowerment within the family and being unpermitted as a child to express strong
emotions or ensure her own needs were met.
Comment. Laura’s initial experiences were characteristic of children with rich fantasy lives who may develop VH in response to physical solitude and/or an inability to relate to the people around them (Escher & Romme, 2010). The negative change in the voices emerged after a violent, anxiety-provoking situation where
Laura’s basic sense of trust was destroyed, provoking intense fear. Both the external sources of aggression and her own negative self-image were embodied in her voices. After working to discover the emotional themes represented by her voices, Laura began to move towards recovery in a positive, constructive and profitable way. She was initially supported to find safety strategies for containing and managing the
voices’ intrusions and reduce the anxiety associated with them. Laura also derived great benefit from attending a self-help group and meeting other voice-hearers, including individuals who were coping successfully with their voices. Laura subsequently engaged well with therapeutic work, focusing around issues of expressing needs, communicating anger, and addressing feelings of trauma and loss. By elucidating the relationship between her voices and her life experiences, the fear and shame aroused by the voices began to cease. Contrary to Laura’s initial wishes, the voice of Aurora did not reappear, although Laura eventually stated that, by developing a secure base within herself, she no longer required Aurora to perform this role. The voice of Satan became progressively less menacing, and The Chorus has begun to recede entirely. Laura recognized that the voices had offered a “protective” function in bringing her attention to unresolved emotional conflicts. Later she began to spontaneously refer to Satan as “George” again. At the time of writing, Laura has started a relationship with a supportive partner and has successfully applied to study mathematics at university. She copes successfully on a much-reduced dose of medication, and has plans to withdraw entirely from neuroleptics over the next three months.

This case study, sustained by an analysis of constructs for 100 voice-hearers, supports the position that it
is no longer sustainable to deem VH as part of a disease syndrome, rather than as a personal response to painful unresolved emotions whose meaning or purpose can be deciphered. The construct addresses social-emotional events, interpersonal conflicts, and psychosocial adversity within the voice-hearer’s life in a coherent and accessible manner. Furthermore, these personal developmental issues can be utilized to guide recovery journeys, wherein both voices and associated emotional conflicts are suitably interpreted, acknowledged and integrated by the hearer. The VH experience becomes a personal story, the reclaiming of which may be a fundamental part of gaining control both over one’s voices and one’s life. By incorporating cooperative, humanistic and existential (i.e. meaning-making) elements into therapeutic protocols it is hoped that individuals can be supported to listen to their voices without anguish, wherein the personal significance of VH can be explored more fully and (re)integrated into a previously fractured sense of self.