Students collectively annotate each reading — asking questions, responding to each other's questions, or sharing other perspectives or knowledge. Perusall's novel data analytics automatically grade these annotations to ensure that students complete the reading, and as an instructor, you get a classroom of fully prepared students every time. Perusall provides you with a simple "confusion report" that summarizes areas your students misunderstood, disagreed with each other about, or were most engaged with — along with examples of the best annotations, so you can call out specific questions or individuals in class.
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Perusall encourages students to continue the conversation about the text even after they log off; when other students answer their questions, Perusall sends them an email summary, with the ability to respond without leaving their email client or smartphone. There is no cost to use Perusall beyond the cost of purchasing the book. Note: Students must purchase through Perusall to access the book in Perusall. Structure is helpful. Conversely powerlessness is unhelpful. In my research Diane said her voices were a coping mechanism.
Some voices are triggered by developmental crises, like having to learn to cope with grief, or to make choices in life, or to forge a separate identity. Voices might be a problem, but not every problem is an illness. Escher et al. In children with whom the voices were psychiatrised and made part of an illness and not given proper attention, voices did not vanish, but became worse, the development of those children was delayed.
From what voice hearers have told me, I am able to offer the following Psychosis and hearing voices 2 17 description of different types of voice hearing experiences. This is useful because therapists need to know something of the nature of this experience to enable them to work with people who hear voices see Slade and Bentall, I illustrate the description with actual examples of what people have said to me during the research.
I suggest that voices fall into the following categories. For example: Diane: I know that I can hear my dad in my head. She liked to blame me of something or other, real or unreal. I hate it! Seeing her image before my eyes annoys me and shows me how powerless I am about these voices and hallucinations. Three women heard the voice of their abuser or rapist. Internal commentators Internal commentators can be experienced as critics, persecutors, controllers, sometimes commanding self-harm, suicide or violence to others.
For example, Pat heard a conversation in my head. Tina: I have asthma and they the voices told me to stop taking my steroids so I had an asthma attack. They put me in intensive care on a ventilator. Simon: One voice was a piss take, take the mickey. The other chap was trying to be helpful.
Jimmy: Some voices are friendly, some are aggressive. Friendly ones younger, the more antagonistic ones are older. For example: Diane: The voices are real today. I like listening to the good people they make me feel secure and wanted and that I have a purpose in life.
They say that they love me and that they care about me and I really like them being around, like for example last night.
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I could ask them all night if they was still there for security. Today I felt anxious about going out. So Sandra and Tara told them to fucking shut their mouths so I felt alright but Annie kept making me laugh so I felt like a nutter!! The voices were nice to me last night because they told me beautiful fantasies and they made me relaxed and comfortable. Feels intrusive but also sometimes helpful and also controlling. This was helpful when she could choose whether to follow the guidance, sometimes exercising choice was a struggle. I used to hear noises from my wee.
A noise: dur, dur, dur like a telephone ringing. Diane: I was hearing bad voices due to sleep deprivation, through traffic, the shower. TV, kettle, microwave, fridge freezer.
Gloria heard music before she heard voices. Tina: I thought they were demons. People have seen the way he is. John asked me something that no one has ever asked me: why do you think these voices are so angry? Some of the voices are characters, with names, histories and changing natures, others 20 Psychosis and hearing voices 2 just odd words or noises. Voices can thus be seen as roles, having function and meaning. With respect to the reported age, middleaged voices were more common. Oppression keeps people suppressed by lowering their selfesteem.
Those who do not cope experience voices which were stronger than self and negative Romme and Escher, To further elucidate the voice hearing experience I will now identify certain themes that recur. The voices reinforced his low self-esteem by reminding him of things of which he was ashamed. It has changed. See p. Diane: I feel either high for five minutes then low for three hours. They are my worst fears, hopes and even dreams. In particular many statements people made about their voices concerned the impact of high levels of negative emotion expressed in families.
This is in line with previous research Romme and Escher, ; Martindale et al. Furthermore, as if in a feedback loop, the voices apparently add to stress levels: Psychosis and hearing voices 2 21 Jimmy: Voices. It is important to note that stimulating activity alleviates voices, conversely lack of stimulus and isolation seem to exacerbate voices.
Voices and thought Bentall , cited in Romme and Escher, proposed a cognitive theory, namely that people who hear voices mistake inner thoughts for external stimuli: he and others have developed cognitive models and therapy Chadwick et al. For some in my research, there was a link between thoughts and voices. Tina said that after her second marriage to a man who was domineering, I stopped having my own thoughts and kept my thoughts to myself. There have been long periods tonight of feeling people are inside me and trying to put awful thoughts into my head.
They seem to pass through me, these people. For so long I battle mentally with one thought from one person. Achieve success, then another one comes along! Distraction may not help the already distracted person. For example, Dillon said his voices challenged him to concentrate and then distracted him.
Then in response to a question: Sorry, I missed that: I was trying to concentrate on two things at once: I heard a voice saying something and I missed what you said. What did the voice say? Also there may be people in libraries if I got to know them I might share some interest. Did the dramatherapy we did help people communicate more?
Voices and boundaries In order to have a coherent, separate sense of self, we must be able to separate from the other and establish clear boundaries. He heard voices when confronted with vulnerability or powerlessness and a lack of boundaries, as when his grandmother was ill and when he saw babies. Thomas presented a similar case of Peg, a woman who heard voices in the context of vulnerable children or elderly people who were ill Leudar and Thomas, In psychotic experience the boundary between self and other dissolves so the person may feel overwhelmed by the other.
Dillon said he was not sure of his Psychosis and hearing voices 2 23 boundaries: where he began and ended. Hallucinations are waking nightmares. The boundaries between phantasy and reality, waking and dreaming are blurred. Unconscious material erupts, spilling over the boundary of consciousness to overwhelm the vulnerable ego.
Voices seem to cross boundaries between people. Bosga and Watkins give accounts of people who consider voices to be the result of clairvoyance and extra sensory perception ESP. My study revealed similar views. There does appear to be some telepathic involvement. Dillon, Leah and Diane thought hearing voices was telepathic. Diane wondered if she was psychic: she thought this would explain the voices.
Without commenting on the possibility of clairvoyance, I noted that this idea could express her need for contact at a safe distance and a wish that people could know, without her stating, her needs. When, as a small child, she came home one day, with soiled underpants, after being anally raped, her mother did not guess what had happened: perhaps Diane had wished her parents could have read her thoughts, guessed her trauma, which was then unspeakable. The idea of such communication at a distance may have comforted them at that time.
I will further examine the issue of distance in Chapter 7. Voices and abuse Voices breach boundaries: abuse is also a breach of boundaries. The frequency with which voices are associated with the aftermath of abuse deserves special notice. I know two sisters, one of whom was sexually abused by her father, the other was not. The one who was abused hears voices, the other does not. Chu and Dill found that: 63 per cent of female inpatients had suffered child abuse and noted the common occurrence in these patients of psychotic symptoms, particularly auditory hallucinations.
Diane: I hear voices that say that my brother-in-law is going to come up to the house and rape and strangle me. I wish he would then I could knife him in the stomach for abusing me. I need therapy for the experience of abuse not so much for voices: though they are connected. Harry was physically abused by his father: his voices told him to physically harm himself and attack his son. Many participants in my study had experiences of being a victim or felt victimised by the voices: Theo was bullied as a child and attacked as a young man.
I feel victimised. The link with abuse throws light on one particular aspect of the voice hearing experience: secrecy and isolation increase the power of the voices: disclosure reduces their impact. It was my secret. I suppose I was frightened of making it worse, which it did, still does sometimes. I think before. Since people do know about Mr the impact is not as bad. Warner 39 has described the tactics of abusers who ensure children keep abuse secret. Of the twenty-one participants in the study, ten had mothers with mental health problems; one person had both parents mentally ill, two had a mentally ill grandparent and one a mentally ill uncle.
Gloria speaking about her voices : When we oppress ourselves the messages we draw on are often from the past and out of date: the here and now is what we must refer to for ourselves. Grief and loss in a previous generation can be transmitted down a generation. For example, Sheila said: Before I was born mother lost two daughters. Mum would never talk about it. From 3 years old Sheila had an imaginary, invisible friend. This friend would talk to her, keep her company: it was not a problem but a comforting experience.
It used to annoy me Mum: if I was naughty it was my friend: they told me to do it. Dillon was interested in history: in fascism, communism and revolution. His grandfather did not talk about the Holocaust. Dillon became ill while at university where he was studying history: he likened his breakdown to the iceaxe murder of Trotsky who was Jewish. Dillon believed the Germans were against him. See Slade and Bentall 3 for another example of voice hearing in a man whose mother and girlfriend were from Germany and Holocaust survivors; see also Bloom about the intergenerational transmission of the effects of the Holocaust.
In these two examples the theme of not being able to speak again occurs. I further explore this issue in Chapter 6. Slade and Bentall 24 argued that it was the inability of the person hallucinating to control, modify or stop their voices that is the single most important factor in contributing to fear and distress. Tina: When the voices are there I have no control.
Ben: spoke of voices, physical — shocking, I feel thrown about. I have panic attacks. I will further explore this issue in subsequent chapters. The onset of voices Escher et al. If family history and child abuse are important we could expect voice hearing to emerge in childhood. As did Sheila, some participants began to hear voices when they were children or adolescent. A relationship ended. He became obsessed with this girl and heard her voice.
It seems that the emergence of voices here has connections with the isolation of the young person. However, for others voices emerged in adulthood for example, following rape or a head injury and here isolation also appears to have a deleterious effect. Sensory deprivation can trigger voices Slade and Bentall, 30— Just as I might switch on the radio when alone, voice hearing may be a creative response to loneliness: the brain generating company!
I feel so lonely and unwanted. I was self-reliant from 13 mother was ill, father disengaged, Diane lonely at school. Her inner world was then populated by voices to offset the outer world of loneliness. During therapy this intrapsychic creativity resulted in the emergence of a new voice who said she was coming to take Diane away: in effect to rescue and love her.
Drama, Psychotherapy and Psychosis: Dramatherapy amd Psychodrama with People Who Hear Voices
Thomas also describes the emergence of a new, positive voice during therapy Leudar and Thomas, Diane described the voices as a substitute family. She complained of not receiving enough support from the psychiatric service: history was repeating itself. I went un-noticed much of the time. Such feelings of loneliness may be expressed by the voices: Anton: The voices are voices of loneliness and depression. Many had had experiences of abandonment and rejection, deprivation and neglect.
Marton, reported in Guardian, 3 January , p. Haggard, A number of people in my research were refugees or from refugee families. In Isolation and Personality, Haggard stated that normal subjects experiencing temporary isolation reported perceptual disturbances such as the spontaneous appearance of partial or full-blown visual, auditory, and somatic hallucinations or delusions, color anomalies and distortions of tactual experience, body image and the time sense. Affective disturbances, including spontaneous bursts of such affects as fear, anxiety, and anger, or reactions involving restlessness, boredom, agitation, and a sense of depersonalisation were frequently reported.
As for cognitive processes, some subjects reported a rapid disintegration of their ability to attend, concentrate, or think in a directed and sustained manner, to solve abstract problems or even to carry out such simple tasks as serial counting. Haggard, In these experiments the subjects knew they were being observed and could terminate the experiment whenever they wanted: they had some control. Their symptoms mostly dissipated within half an hour. However, some reported that certain reactions persisted a good deal longer, such as feelings of fatigue, dizziness, drowsiness, loss of motivation, feelings of being confused or disoriented; others reported continued preoccupation with various thoughts and feelings, such as fears and anxieties or suggestions which occurred during isolation.
What if the person had withdrawn into isolation and knew that no one was there, that they were, or believed themselves to be abandoned. Some children are left alone for hours and recently some have been found abandoned by callous or disturbed parents for days. One person in my research remembered going hopelessly to his room as a child and hallucinating a figure coming through his bedroom wall to offer comfort. Such a hallucination would be a creative response to loneliness and distress; it could also however mean a child might begin to rely on such self-generated sources of nurture when the outer world offered none.
Isolation Psychosis and hearing voices 2 29 might even be protective in an emotionally abusive environment: children might withdraw for self-preservation although they might also be sent to their room in preparation for sexual or physical abuse so that aloneness would be mixed with dread. Self-imposed isolation may be a way of coping: a withdrawal to prevent the person being overwhelmed: she or he may be attempting to protect themselves or others from hostility, abuse, judgement and criticism.
The isolation is thus a way of distancing oneself from the other see Chapter 7. Gloria: I thought I would harm my family in response to voices so I distanced myself. Diane: I felt great comfort in being isolated but. This disassociation from others can also signal a dissociation from feelings and aspects of self, resulting in an experience of blankness and a lack of ability to relate to others.
Cheryll: I cut myself off from normal people. If I got back to normality I would have normal feelings but now I cut off from feelings and people. Sadness was expressed not infrequently in association with being alone or lonely. Nayani and David, Martindale et al. In Ferenczi accepted that child sexual abuse was pathogenic.
As a defence the child sinks into a dream or trance state. The child may well become psychotic which is a defence not dissimilar to the original trance state, a protected but lonely hiding place. Masson, Tina reported: When the voices are there. I go into trance. Diane wrote in her journal: I keep spacing out for some unknown reason.
Professionals may also deny the reality of voices or be unable to hear what people say: Jenny: I never talked about it hearing voices. I tried one time. I got smacked back and told I was living in a fantasy land. Having attempted to speak of her reality and being rejected, Jenny withdrew.
Years later she did not tell her psychologist that she was hearing voices through over a year of therapy. Withdrawal from others and the world may be a withdrawal from hostile reality, turning instead to fantasy. Reality then comes to mean the other — outer, non-self, hostile — while fantasy is the realm of the inner self, a haven from disappointment.
Fantasy may make up for something lacking in outer reality: Dave reflecting on inner city poverty, mental illness and emotional deprivation : My early memories are of a surreal life amongst dereliction slum clearance and fantasy. I remember sending psychic message at the age of 16 to a girl I fancied whilst masturbating. Listening to voices, hallucinating, daydreaming may be a creative way of coping with social and psychological deprivation. In his journal Dillon stated that day after day he spent the rest of the day in solitary contemplation.
A non descript day of shadows and silence. Psychosis and hearing voices 2 31 Voices may also soothe, comfort and support and when they diminish due to therapy they may be missed: Diane: The voices are real today. They say that they love me and that they care about me and I really like them being around.
I could always rely on the good voices to help me get whatever I was doing or going somewhere. I have created a world inside my head where they voices can help me all the time so what every body else says is wrong. When one man was gang raped he was confused as to what was real due to the drugs that had been put in his drink. On not remembering Just as people can practise memory skills and therefore remember more, so I have come to believe people can practise not thinking, not feeling, not remembering.
Sometimes people may prefer not to feel, think or remember. I have memory problems. He makes me forget. The voice has blocked the past. Cheryll chose a button with holes in it to represent the holes in herself, left by gaps in her memory. She said that she liked this ability to blank out memories. Such forgetting may be defensive and can be exacerbated by the effects of medication and electroconvulsive therapy ECT.
Prolonged stress can also damage the hippocampus which plays a critical role in memory. The resultant memory loss may mean a loss of self and identity as our memory is one of the ways that we construct our sense of self. Memory problems affect relationships: 32 Psychosis and hearing voices 2 Pat said she had a problem with short-term memory. This affected her ability to recall things her husband said and caused frustration in their relationship.
As herself in the past she would deny it all. Many of the voice hearers have had experiences of evil, of being overwhelmed by destructive power that threatens their survival, both in having been abused and in experiencing voices that command them to do evil acts: Tina: I thought I was under spiritual attack. I tried to kill my mother when I was poorly. I thought that she was, that everybody, was against me. The voices tell me that as well.
They got me down, the doctors, as being paranoid psychosis. I see demons on their faces. I hallucinate: and their faces change and they look evil. And I thought she was trying to hurt me. I felt very very strong. I was going to throw her down the stairs. She shouted at me called her name.
I came to my sense and put her down. She was very frightened. Harry heard an evil voice he named as Satan, a destructive part of him he did not want to own. Jenny wanted her therapist to be an ally. This statement is in harmony with shamanic ideas of illness: the loss of soul. Shamanic healing involved travel, in altered states of consciousness, to different, spiritual levels of reality to rescue the lost soul of the patient from demons.
The shamanic model of illness served humankind for thousands of years. Each culture develops models to explain madness and I now turn to an examination of some of the current western models and offer my own in Chapter 3. Chapter 3 Psychosis and hearing voices 3 Models of madness Why do we need a model of madness? Such is the disturbing, overwhelming power of psychosis that therapists approaching work in this area can feel frightened and bewildered.
Shamans had a cosmology that gave them a sense of direction during their trance journeys in search of the lost soul of the patient Eliade, The model a therapist chooses must empower him or her to travel through the landscape of madness and accompany their clients on their healing journey.
The medical model The medical model is a sophisticated, continuously evolving system of diagnosis and treatment supported internationally by thousands of doctors, researchers and drug companies. Its effect in clinical practice has been to deny that there is meaning in psychotic experiences.
The model states that the content of voices what they say is meaningless: it is the form of the voices whether they are third person etc. Diagnosis Diagnosis is a process by which doctors attempt to orient themselves in the landscape of madness. In my view diagnosis is not the business of therapists who must accompany people, whatever the diagnosis, on their therapeutic journey. Diagnosis, moreover, is problematic. Despite 34 Psychosis and hearing voices 3 a century of diagnostic research during which entire generations of psychiatrists and patients have accepted there is an illness called schizophrenia, many have now come to the conclusion that schizophrenia does not exist as a discrete disease entity see Slade and Bentall, ; Bentall, ; Boyle, ; Parker et al.
Schizophrenia may now more accurately be described as a group of symptoms, i. The diagnosis can blind clinicians to the need for therapy of someone diagnosed as schizophrenic who is also a survivor of trauma. This is problematic as some people have been misdiagnosed as schizophrenic when they are survivors of abuse and their voice hearing experiences are post-traumatic symptoms. Psychosis can alternatively be seen as a spiritual emergency: when individuals are struggling with the meaning of their life experience and their very survival is at stake. Due to the social stigma of a diagnosis, a patient can experience discrimination, exclusion and oppression.
A diagnosis may also bring secondary gains including incapacity benefit in the United Kingdom and so keep people in the sick role recovery might result in poverty. Some people want a diagnosis as helping them get a handle on their experience , while others doubt their diagnosis. For example, we can compare Diane and Gloria. No one was willing to listen — people said this is in your best interest.
Eventually Gloria was proved right: she was in fact suffering from hypothyroidism and had indeed been misdiagnosed. It stops the voices altogether. At least mine voices are under control by the medication. The tablets numb them down a bit. Others doubted the value of their medication: Dave: Modecate has never stopped voices for me.
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One of the problems with medication is that it flattens your emotions; it induces a tranquillity of sorts but this is more like a numbness or hollow feeling. Sometimes wondered if depressions are due to medication. While often helpful, medication is not, by itself, the solution.
Even Tina, who found her medication beneficial, felt the need for further help: I think you need more than that. I think. A combination of medication and therapy may offer the best outcome combined with a holistic assessment of needs such as housing, diet, education, employment, hobbies, work, physical exercise, social, spiritual, cultural opportunities : the reliance on medication alone can result in people being dangerously over 36 Psychosis and hearing voices 3 medicated.
Since medication is not the whole answer, indeed it may become part of the problem as neuroleptics can cause irreversible brain damage Breggin, and numerous distressing side-effects, even sudden death Healy, ; Martensson, it seems logical further to explore the potential value of appropriately designed psychotherapy to this distressed group of people. The danger of a diagnosis of schizophrenia or other major mental illness is that once so labelled people are offered medication and some supportive activities but no psychological therapy.
Consequently people may be denied even the simple counselling they need to get their life back to normal after a period of psychosis. In practice many mental health workers have counselling training and do offer their clients such support but in a busy psychiatric service this is often not available in a regular way. Even when the psychotic experiences are the result of physical processes in the brain, the person may still need psychological support to cope with voices and other psychotic and life experiences.
These may also relate to traumatic experiences previously not recognised by psychiatrists searching for biological substrata. He had suffered several head injuries. The psychiatrists had not paid attention to the facts that he had been physically abused as a child and as a young adult; that he was chronically lonely; his mother had been depressed; his father was abusive. No psychological treatment had been offered as he had been assessed as not suitable for cognitive therapy.
Nevertheless within weeks of starting dramatherapy his persecutory voices were reduced. Everything is ultimately true or false if you want to believe it. The vulnerability may be due to genes, to neurodevelopmental problems in the womb, brain injury after birth or substance misuse. Creative activities and therapy can be part of such a package of care.
Engel proposed a biopsychosocial model. A dimensional model Rather than being the result of discrete diseases it is possible to view mental distress as occurring on a continuum; likewise hallucinations can be seen to be at one end of a continuum with vivid mental imagery at the other end Slade and Bentall 19, Voices may begin as thoughts, feelings, intuitions, fantasies or simply recollected echoes of what we have heard repeated like a tape loop. Hallucinations are experienced by people who have many different diagnoses, and none.
This model is entirely consistent with the method. It is not aware that there is a distinction between itself, a separateness from itself, and other beings and objects. From that moment on, the child must live in these two dimensions. The more impoverished, in every sense, is the experience in objective reality, the more the child will retreat into the subjective reality where once again it is all powerful, the only being in the world. When the breach between these two areas of experience becomes unbridgeable, this retreat into the first universe in which the child is unrestrained in its fantasy productions, madness may plant its seed.
Moreno and Moreno, 28—29 The causes are interpersonal and the treatment is therefore interpersonal. The prognosis is good if the person can develop positive relationships tele with the therapist and others auxiliaries and eventually expand their social network their social atom, see Chapter 9. The patient is given the right to explore his or her hallucinations and delusions through psychodrama: to act these out and be accepted as a creative human being. These different models then are beliefs which inform the way we behave towards people who have unusual experiences.
Dramatherapists need a model for their work and so I offer the following, which taken together with the theory of distance Chapter 7 and the theatre model of the self Chapter 9 can provide a theoretical framework and foundation for the safe practice of dramatherapy with people who hear voices and have psychotic experiences. Ordinary reality is a containing culture we share with others: it is social.
Their inner world of fantasy, delusion, fear is projected out onto external reality and they are lost in the confusion between these worlds. I create stories in my head. She said that these fantasies helped her cope: hearing voices. People dissociate from the unbearable in search of safety, nurture, power, survival when no other way of escape is possible Watkins, —, ; Mollon, 9—10, ; Bloom, What cannot be expressed directly is then expressed through the psychotic imagery just as in dreams. Spirituality may provide comfort, strength, meaning and a feeling of being special. Imagination may enable a powerless person to feel powerful.
For a time this alternative reality may be preferable to the social reality and help the person survive. Moreno provided an example of this psychotic creativity when a woman created a hallucinatory lover Moreno, a: This psychotic creativity is not wholly conscious nor in the control of the person: indeed unconscious processes may drive the creative process.
The person is then overwhelmed by a combination of intrapsychic and interpersonal forces: historical, environmental, emotional, spiritual, psychological, biochemical. They may experience voices and delusions that they are unable to comprehend or control, loss of self or parts of self and loss of a sense of social reality. Alternatively they may be empowered by psychotic strength, delusional conviction, grandiosity, manic energy that temporarily protects them from, or impels them towards, that other possible escape from intolerable reality — suicide.
An environmental model Listening to people who hear voices has enabled me to construct an environmental model of psychosis: it is a contribution to the development of the biopsychosocial model and is multidimensional, taking into account the complexity of life. The simplistic search for a single cause, whether genetic or biochemical is doomed to failure and we must understand that psychosis is multifactoral with many interpersonal and intrapsychic elements interacting. This view is supported by Romme and Escher: the hearing of voices is not solely. Romme and Escher, 16 The environment surrounding the genesis of psychosis is complex and many layered: for clarity I divide it into sections but it must be remembered that these sections continuously interrelate and that what may appear discrete sections are in fact processes that influence each other.
This model can be seen as a wave slowly developing with gathering momentum. The wave begins its journey long before conception. Attachment Theory. Autism and Aspergers. Brief Psychotherapy. Child and Adolescent Studies. Clinical Psychology. Cognitive-Behavioural Therapies. Culture and Psychoanalysis. Eating Disorders. Existential therapy. Expressive Arts Therapies.
Family, Couple and Systemic Therapy. Gestalt Therapy.
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