Psychosis

Are "Hearing Voices Groups" a Help or Harm?

What works for one end of the psychosis spectrum might not work for the other

Posted Sep 29, 2017

 Public domain
Self-portrait with bandaged ear and pipe, Vincent van Gogh (1889)
Source: Public domain

The Audio Files Podcast recently reached out to Psych Unseen for an interview about Voice Hearing Networks. Have a listen to the finished piece "Hearing Voices Networks" by Samia Bouzid and the entire multi-part podcast "Hearing Voices." In the meantime, here are answers to some questions about Voice Hearing Networks and where they fit into psychiatric treatment.

What are Hearing Voices Groups?

Hearing Voices Groups (HVG) are self-help groups for individuals who “hear voices” and their advocates. They meet in-person and online to encourage voice-hearers to discuss their experiences as they understand them in a supportive, non-judgmental environment. These groups originally appeared in the Netherlands in the late 1980s, but quickly spread throughout Europe and gained a firm foothold in the UK before coming to the US in the past decade. 

Hearing Voices Groups are often organized regionally or nationally into Hearing Voices Networks (HVNs). Collectively, HVGs and HVNs are part of the larger Hearing Voices Movement.

For information, see www.hearing-voices.org/ and www.hearingvoicesusa.org/

Is there a conflict between the Hearing Voices Movement and psychiatry?

Personally, I would like to dispel the idea that HVNs and psychiatrists are necessarily in opposition. That’s certainly not always the case. When there is a conflict between HVNs and psychiatry, it’s usually because one side makes an overgeneralization about the other adopting a “one size fits all” view across the spectrum of voice-hearing experiences.

In actuality, the idea that psychosis is distributed along a continuum of severity that might include different types of experiences is generally well-accepted within both the Hearing Voices Movement as well as psychiatry. Organizationally, neither group believes that treatment of psychosis across this spectrum should take the form of a “one size fits all” approach. Instead, the optimal interventions on one end of the spectrum might not be the best interventions at the other end.1

That said, it does appear that HVGs and HVNs sometimes adopt a critical view of psychiatry, claiming that psychiatrists reflexively label voice-hearing as pathological and dismiss the “meaning” that voice-hearing might hold for a person. In taking on that view, part of the message sometimes heard in HVGs is that the “medical model” of psychosis isn’t the best way to approach voice-hearing (or that it's no more valid than any other model). Since the groups are inherently supportive of any interpretation of voice-hearing, participation can embolden members to reject medical or psychiatric treatment, and especially medications, altogether.

Because of this, I think that it’s fair to say that psychiatrists who know about HVGs (many do not) in turn regard them with a certain amount of skepticism. In my own experience, however, it’s often the families of voice-hearers who view HVGs most critically—families who are trying desperately to get their loved ones engaged in treatment to see a psychiatrist, to see a therapist, to get back on meds, or to get back into therapy.

Is the criticism of psychiatry by the Hearing Voices Movement valid?

While a critical view of psychiatry is surely not representative of every individual HVG, HVN affiliates were key contributors to the 2014 publication of a document called Understanding Psychosis and Schizophrenia: Why People Sometimes Hear Voices, Believe Things That Others Find Strange, or Appear Out of Touch With Reality …and What Can Help by the British Psychological Society. This controversial publication drew concern from psychiatrists because of its mischaracterization of the medical model of psychosis and its potentially dangerous stance validating the rejection of psychiatric treatment. See my previous blogpost entitled “Psychosis Sucks! Antipsychiatry and the Romanticization of Mental Illness” for a more thorough discussion, but I’ll revisit some key points here.

First and foremost, the claim that the medical model of psychosis over pathologizes voice-hearing is, in reality, a mischaracterization, as my colleague Ron Pies has recently explained.2 For example, there’s no such thing as “hallucination disorder” in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The presence of other co-occurring symptoms is required for the diagnosis of a mental disorder, such as delusions for schizophrenia or depressed mood and other “neurovegetative” features for major depression. Also, the symptoms in question must be associated with distress or functional impairment. It’s therefore entirely possible that some people who find HVGs useful might not be diagnosed as having a mental disorder at all were they to see a psychiatrist. 

That said, psychiatrists see people who are help-seeking (or much more rarely, those brought in for involuntary treatment), so we’re more likely to evaluate voice-hearers who want to be rid of their voices than those that want to explore the meaning in them. We're also more likely to see patients on the more severe side of the mental illness spectrum. Accordingly, it shouldn't be surprising that an antipsychotic medication might be offered to a voice-hearer seeking help from a psychiatrist. At the same time, I’ll go on record to say that antipsychotic medications are sometimes over-prescribed for voice-hearing. This occurs not so much because psychiatrists disregard the personal meaning of voice-hearing for an individual, but because psychiatrists sometimes use hallucinations as a kind of “waste-basket” diagnosis even when a voice-hearing experience might be better characterized as a depressive rumination, an obsession, or even a non-pathological inner-voice experience like a worry, a conscience, or a muse. In some cases when voice-hearing occurs without clear evidence of a mental disorder, antipsychotic treatment may not be necessary.3 The idea that a broader “differential diagnosis” should be applied to voice-hearing experiences is slowly gaining traction in psychiatry, but still has a long way to go and requires additional research to understand the heterogeneity of voice-hearing experiences (see my previous blogpost entitled “Is It Normal to Hear Voices?” along with references 4 and 5 below).

Why are psychiatrists concerned about Hearing Voices Groups?

For psychiatrists, the relatively new presence of HVGs is reminiscent of what we used to sometimes see with Alcohol Anonymous (AA), if less so now. Back in the day, many AA groups took a decidedly averse stance on psychiatric medications, discouraging members from taken them even when there was good reason to do so (although the inappropriate prescription of medications like Valium to treat alcoholism by physicians was also a problem). When HVNs endorse the message put forth in the British Psychological Association’s Understanding Psychosis publication, the situation becomes eerily similar. 

As a psychiatrist, I tend to view HVGs a lot like AA or a cancer support group. They represent a valid self-help approach that lies outside of, but is ideally complementary to, the practice of medicine. For some patients, and especially for those who aren’t patients at all (e.g. a patient in remission from cancer or a voice-hearer without a diagnosed mental disorder), the support they receive from such groups can be profoundly helpful. But for others with more clearly defined illness such as schizophrenia, support groups do not represent adequate treatment by themselves.

People suffering from psychotic disorders often have “anosognosia” or a lack of insight regarding their mental illness and auditory hallucinations are often accompanied by delusions. Therefore, a “voice” is not just an inner experience, but a command from God or the devil, a radio transmission from a government satellite, or the whispering of malevolent neighbors heard through the walls. For psychiatrists, getting such a patient to accept an antipsychotic medication, even when it has clearly proven effective previously, can be an uphill battle. If that patient were to attend an HVG that validated a delusional interpretation of voices over thinking of them as a symptom of mental illness and supported a decision to avoid medications, things could go downhill fast.

Many of us who are prescribed medications by our doctors would prefer to find an alternative solution to a lifestyle change — embracing a new diet, exercise regimen, or spiritual practice. While these are sometimes reasonable alternatives for those on the healthier end of an illness spectrum, those kinds of interventions are at best suboptimal and at worst harmful in isolation for patients with severe mental illness.


Dr. Joe Pierre and Psych Unseen can be followed on Facebook and Twitter.

References

1. Pierre JM. Mental illness and mental health: Is the glass half empty or half full? Canadian Journal of Psychiatry 2012; 57:651-658.

2. Pies R. Hearing voices and psychiatry’s (real) medical model.  Psychiatric Times, September 2017. Available at https://pro.psychcentral.com/hearing-voices-and-psychiatrys-real-medical-model/0020313.html

3. Pierre JM. Non-antipsychotic therapy for monosymptomatic auditory hallucinations. Biological Psychiatry 2010; 68:e33-34.

4. Pierre JM. Hallucinations in non-psychotic disorders: Towards a differential diagnosis of “hearing voices.” Harvard Review of Psychiatry 2010; 18:22-35.

5. Waters F, Blom JD, Jardri R, Hugdaul K, Somner IEC. Auditory hallucinations, not necessarily a hallmark of psychotic disorder. Psychological Medicine 2017.