Hearing Voices

The phenomenon of hearing voices is usually viewed as a symptom of mental illness to be suppressed with medication. The Hearing Voices movement, which began during the 1980s in Europe and is now gaining traction in North America, is taking a different therapeutic approach.

The multiple Oscar-winning picture Birdman earned praise for its highly choreographed visual technique, star Michael Keaton’s physical performance, and its multi-layered narrative. But to Natasha Merrick, who identifies as someone who hears voices, the movie offered a new way of looking at mental illness. While movies and books often portray psychosis as a sign of a character’s tragic descent, Birdman offers a more complex view. “Most people have very fixed ideas of mental illness,” she says. “It means the person is not thinking in the correct way, and they need to be fixed, stopped, and taken care of. But this movie is showing [Michael Keaton’s character, Riggan] in an expanded state where he’s able to experience magic and also find meaning and connection.”

Years earlier, Riggan starred as Birdman in a Hollywood blockbuster series. As he tries to mount his own adaptation of a Raymond Carver short story on Broadway, a series of backstage mishaps and personal dramas threaten to upend his show. He is taunted by the voice of Birdman, but he also levitates, moves objects with his mind, and flies. “He’s having magical thinking, but he knows the world doesn’t see him that way,” Merrick says. “People with psychosis have that dichotomy, and it’s very stressful. I think that’s what makes you crazy, is that split between your inner and your outer life. What he needs is to achieve balance, to be able to work within that state of mind.”

Through the lens of magical realism, the film doesn’t make a distinction between hallucination and reality, but focuses instead on the meaning of Riggan’s otherworldly experience. That’s essentially the philosophy of Hearing Voices, a grassroots movement started in the 1980s by Dutch psychiatrist Marius Romme. Prompted by a patient experiencing auditory hallucinations who argued that the content of her voices mattered, he began to explore the idea that hearing voices is more than a symptom of disease that should be treated with medication.

Today, the Hearing Voices network is an international organization with groups in many countries. Hearing Voices groups are facilitated by a voice hearer and usually a health professional, and while different groups vary in their methods, the basic idea is for people to learn to engage with their voices and gain power over them. Controversy has often followed the groups because they are perceived as being anti-medication (some are, and others call themselves “pro-choice”). Tanya Luhrmann, an anthropologist at Stanford University who has written widely on the movement, describes the origins like this: “What Romme noticed was that attributing meaning to voices had made a difference to someone who was hearing them. By the psychiatric standards of the time, this was shocking. In the new biological psychiatry, which had begun to dominate the profession in Europe and America in the 1970s, voices were symptoms of psychotic illness in the same way that a sore throat was a symptom of flu... In biomedical psychiatry, mental health professionals ask whether the patient hears voices, not what the voices say.”

For almost three years, Merrick led a Hearing Voices group in North Vancouver. Her own experience of mental illness began in her late teens, when she started feeling a hand on her shoulder. A few years later she began to hear voices. It started with one child’s voice, calling her name, and then quickly became a multitude. The voices would pretend to be her friend, telling her she was special, but they quickly drew her into a kind of paralysis. She was working as a janitor in Vancouver at the time, and she would find herself sitting in a room for hours listening to the voices. They constantly disrupted her sleep, and one night, feeling scared and fatigued, she saw a red vision of her soul leaving her body. She walked to St. Paul’s Hospital and checked herself in. Later she was diagnosed with schizophrenia.

Over the next 15 years, her life was largely controlled by the voices. She managed to complete a fine arts degree at Emily Carr University, but had several more stays in psychiatric wards. She tried several medications. One caused her to gain a significant amount of weight. Another made her chronically sleepy. None made the voices go away.

Into her mid-30s, she continued to be harassed by many voices and the feeling of hands on her shoulders or fingers in her ears. The voices would tell her stories about crimes they had committed as if they were trying to elicit sympathy from her. They would pick on her when she was broke and destroy experiences she enjoyed, such as listening to music. One day she left her home and went to stay with friends to escape them. On her return, she resolved that she wouldn’t let them control her anymore. Soon after, she was sitting on the couch and she saw a vision of her great uncle Jack Ferguson giving her a thumbs-up. Ferguson was a Royal Canadian Air Force pilot who was shot down in World War II, and the brother of her grandmother. Merrick recognized him from pictures she had seen. He started appearing to her regularly, and sometimes along with her grandmother. They would hold up signs with simple encouraging messages, and they were a calming presence in the midst of her terrible angst.

The voices would tell her stories about crimes they had committed as if they were trying to elicit sympathy from her. They would pick on her when she was broke and destroy experiences she enjoyed, such as listening to music.

Merrick continued to seek professional help, and during this period she was assigned to a community mental health team. For her, this was a new model of mental health delivery. It meant that instead of seeing just a psychiatrist, she would have a number of professionals including a social worker, a nurse and an occupational therapist helping her with other aspects of her life. She received help finding housing and was given a disability allowance. While she had always felt she should work, her case manager told her she should focus on her recovery. “That was the first time anybody had ever said that to me,” she recalled.

Encouraged by her mental health team, she decided to map a new course. She had already explored many ways of looking at her illness, reading all kinds of books and theories. She wondered if she had experienced trauma, which frequently figures in the histories of people with schizophrenia, but concluded that she hadn’t. She started researching her uncle Jack and found out fascinating details about his time in the war. She decided to ask her uncle Jack and her grandmother if they could help her. They said yes, they could.

VanishingVoices2Merrick began experiencing new voices, but these were different. They would have their own personas, and they would help her with various things. One coached her to face her fears, and another encouraged her to notice positive things. She had visited a Buddhist temple and learned to meditate, and over the next months she would spend dedicated time every day communicating with the voices she called her “spirit guides.” Slowly, she started to notice changes: her depression lifted within weeks, and the negative voices that had plagued her for years started to leave her. Eventually her team considered her recovery complete, and her file was closed.

Through her treatment with the North Shore Adult Community Mental Health Team, Merrick met Gillian Walker, an occupational therapist. Walker had recently worked in London, England, where she had become familiar with Hearing Voices. She liked the way people in the groups referred to themselves as “voice hearers” rather than “schizophrenics.” To her that was an important shift. “It’s the idea that these experiences don’t necessarily have to be entirely viewed as mental illness. Aspects of these conditions can have other interpretations. I find the current predominantly Western medical model to be quite narrow and I don’t know that it’s entirely helpful to be that narrow. So Hearing Voices was a refreshing additional approach.”

She and a colleague, Andrea Harowitz, both graduates of the UBC Occupational Therapy program, had been talking about several clients who had been repeatedly hospitalized. They felt that the therapies available weren’t sufficient. Walker suggested they start a Hearing Voices group. They felt that Merrick, who had completed peer support training, would be an ideal fit to work with the group. They asked her to be a co-facilitator along with Harowitz. This was the first Hearing Voices group in British Columbia.

While she wasn’t familiar with the Hearing Voices movement, Merrick felt that it aligned with her own way of thinking. She researched the method and began to work with the group. One of the strategies she encouraged was for her clients to use their “good voices” to help overcome the bad ones. “Lots of people experience good voices, but we don’t associate good voices with schizophrenia because we’ve pathologized the experience,” she says. “We think a voice is a symptom of illness and therefore it’s always bad.” She points to the experience of Riggan, who is troubled by the pestering voice of Birdman but who also says it speaks “the truth.” She likens that character to the Greek daemon, as described by Carl Jung and Joseph Campbell.

“The Greeks accepted the experience of hearing voices, but the daemons were not nice. They would whip you and shove you and make sure you did the right thing. They were like Birdman.”

About six months after the group began meeting, Harowitz and Merrick spoke at the 2012 conference of Psychosocial Rehabilitation Canada in Vancouver. This helped generate interest in Hearing Voices. Now, Vancouver General Hospital and Coast Mental Health have groups, and a community group also meets in Vancouver.

Walker also reached out to one of her former instructors at UBC, Michael Lee. She and Merrick visited his psycho-social rehabilitation classes several times to talk to students in the Master’s of Occupational Therapy program. He appreciated their visits because he feels that the Hearing Voices approach gives a necessary new dimension to the treatment of mental illness.

“For the longest time we looked at hearing voices as a medical problem and didn’t really look at how it impacted on the person’s daily life. We would say, ‘OK, you’re hearing voices, take medication,’” says Lee, pointing out that the role of the occupational therapist is to help a client resume their normal activities. While more therapists are starting Hearing Voices groups, there is not much evidence supporting its effectiveness. So in discussions with Walker, Lee agreed to be the principal investigator on a multi-phase small‑scale research project. Three pairs of students will be contributing towards this research project, which is part of the requirements of their master’s degrees. They will be investigating how participating in the Hearing Voices group impacts on different aspects of recovery.

“We believe it is very crucial to enable people hearing voices to have an opportunity to voice their perception, rather than what we’ve been doing for the longest time, which is having professionals, doctors or therapists, describing the problem. Now we encourage people with lived experience to come forward and tell us the meaning. So this is quite a bit of a cultural shift,” says Lee.

Hearing Voices is currently known as an “emerging practice,” not an “evidence-based practice,” and Walker acknowledges that the model is not for everyone and that more peer-reviewed research needs to be done. But she has seen the benefits that group members have gained. Much research has supported the therapeutic effects of meeting others with similar experiences, and people who hear voices have previously not had this benefit. She thinks that Hearing Voices resonated with others in the mental health community in Vancouver because they acknowledged the limitations of the therapies currently available.

“One of our clients right now is about 19, he was recently diagnosed, and he comes to the group and he says, ‘I’m okay with being diagnosed with the illness model, I’m okay taking meds and with the idea that there may be something wrong with my brain. But another part of me feels like I had a really spiritual experience, and I’m interested in talking about that.’ I think that means that he’s still holding on to who he is, and he’s not seeing the experience entirely as symptom. I think that’s an example of how Hearing Voices has helped someone look at their identity, and where does it fit in the diagnosis. Whereas in the past, I don’t know if that conversation would have been possible.”