I have been interested in the phenomena of auditory hallucinations since my early days as a psychologist at a New York City hospital in the mid 1970’s. I remember adolescent patients ‘losing’ their voices after being admitted to hospital, removing them from very unsafe environments outside the hospital (I realize hospitalizations can be very traumatic, especially in our present reductionistic and hurried climate). I do not think it was just the meds (Thorazine, Haldol, Prolixin being the main agents used at that time), that altered the symptoms. In fact, currently, I believe it was more likely that the person felt a kind of inner/outer sanctuary/protection from inner/outer danger situations which made the difference (and whatever contributed to this- e.g., reductions in mesolimbic hyperarousal, lowering of glucocorticoids, cortisol, etc.). To paraphrase Mark Twain: “You can’t depend on your ears when your imagination (self-reflective function impinged upon by unmetabolized traumatic memories, etc.?) is out of focus.”
Since that time, I have worked with countless individuals who reported hearing voices. I organized and was a therapist in a group for voice hearers at a state psychiatric hospital (outpatient satellite clinic) called the Resonance Group (at the time, I borrowed the term from a story I heard about a meeting between neuroscientist Paul MacLean and Papez, a neuroanatomist at Cornell University, in which in response to MacLean asking Papez what he thought was the neural basis of our sense of personal subjectivity, Papez did not give a list of neural structures, rather, he immediately replied, “Resonance,” a kind of parallel process demonstrating the very subject being discussed!). Most of the voices, but not always, were persecutory--creating further feelings of being unsafe, in danger of being taken over, colonized, controlled, unceasingly badgered, etc. I have studied this phenomenon from the perspectives of epidemiology, neuroscience (e.g., neuroimaging research), psychopharmacology, cognitive models, psychodynamic models, as well as phenomenological-subjective accounts. I reported on this research in my paper, “Hearing Voices: Speaking One’s Dissociated Mind” (presented at the ISPS congress in Stavanger, Norway in 2000).
In my updated paper, “Auditory Hallucinations: Speaking One’s Dissociated Mind,” I report on the research of Hubl and Dierks (2004), using fMRI with hallucinating individuals with a diagnosis of schizophrenia. Specifically, they were interested in studying the activation order of key neural regions mediating this symptom. This is an important aspect of research because temporal order of neural activation can potentially throw some much needed light on the dynamic nature of hallucinations. The dynamic nature of schizophrenic symptoms, from a neuroimaging perspective has been noted by Honey et al (2003), “Imaging brain structure and function in schizophrenia: new techniques encounter old problems” in Neuroimaging in Psychiatry edited by Fu et al (2003): “....interregional functional connectivity is, to a large extent, dependent upon synaptic changes that occur in response to experience--abnormalities in these changes are likely to produce abnormal connections” (p. 242). .
Hubl and Dierks (2004), in brief, discovered the following temporal neural activation pattern: hippocampus, Broca’s area (part of the mirroring system of the human brain), amygdala, PAC (primary auditory cortex-Heschl’s gyrus), and lastly, the primary motor cortex. These investigators concluded:
“We interpreted this sequence of pathological activation in the following way: memories come up [I would say emotional memories, possibly traumatic in origin-mediated by the hippocampus], nearly simultaneously the motor speech area [Broca’s area-replication of internalized emotional/interpersonal reaction patterns?] is activated. This seems to be related to an erroneous functional connection between subjective memories and language system. Broca’s area is a motor speech area and thus is relevant for the generation of inner speech, one mechanism considered to be important for the generation of auditory hallucinations. Somewhat later, the activation of the amygdala contributes to the emotional coloration of the auditory hallucinations [fear, rage, etc], and the activation of the PAC makes this mixture of memory, inner speech and emotional content heard [it is the activation of the PAC which results in the inner voice being perceived as an external ‘real’ voice].
My interpretations of the above data, are that the patient may be recruiting intact neural regions to help her/him cope with such issues of past trauma (physical, sexual, emotional abuse as well as emotional neglect), mortifying and humiliating experiences of powerlessness, helplessness, worthlessness, etc; social exclusion; threats of attachment disruption in terms of abandonment and rejection; separation terror (thus the voice which provides evidence and resonance that one is still alive, is being held in someone’s mind, even if in the mind of a persecutor-which is similar to Fairbairn’s comment that a bad object is better than no object, or reflects on the needed object as persecutory because it contains projected elements of the subject, and/or it is persecutory because it is needed, desired, depended upon and therefore beyond the omnipotent control of the subject, etc). The identity-maintaining aspects of voices, even if a negative identity, may be similar to Freud’s view of psychotic symptoms (e.g., hallucinations and delusions) as restitutional, i.e., a tie to the object world after the pathogenic withdrawal of emotional investment in the external world of relationships (thought to have originally occurred because of narcissistic injuries). From my clinical observations in long-term psychotherapeutic work with patients who hallucinate, I believe that the voices are the patient’s attempt to speak her/his dissociated mind and are also very much akin to what psychobiologically oriented attachment researchers have called the “separation cry.” The hope in the latter is that a safe attachment figure will locate the separated one, not a predator. The problem is, as pointed out by Gaetano Benedetti and many others, how to maintain oneself as a separate and autonomous individual at the same time as being in emotionally close relationships.
I have been very impressed by the work of Marius Romme & Sandra Escher (I had the good fortune of spending time with them recently in Madrid) as described in a series of articles and volumes. Of the latter, I recommend the following: Accepting Voices; and Making Sense of Voices: A Guide for Mental Health Professionals Working with Voice-Hearers. Both of these volumes are available through Mind Publications. Their informative and interesting website address is: http://www.mind.org.uk. Intervoice is a forum which encourages discussion about the meaning of the voice-hearing experience and considers the latest research and treatment (www.delphi.com/hearingvoices). Romme and Escher have been very instrumental in organizing voice hearer networks, self-help groups in various countries, including Holland and the UK.
Sandra Escher’s (2005) new volume is Making Sense of Psychotic Experiences. This is her doctoral dissertation and it contains epidemiological information: surveys report that 2-4% of the population experiences voices; historical reviews of the voice hearing phenomena, self-coping techniques, the relation between auditory hallucinations and life history/traumas, etc.
The CBT therapists/researchers in the UK have been making major contributions to the understanding and treatment of specific psychotic symptomatology, e.g., voices and paranoid delusions. There are numerous publications (Wiley publishes a grate deal of this research as well as Brunner-Routledge and Psychology Press) demonstrating the potential helpfulness of this group of approaches. Some of the many researchers who have made significant contributions to this body of knowledge include: Carlo Perris, Max Birchwood, Philippa Garety, Daniel Freeman, Elizabeth Kuipers, David Fowler, Anthony Morrison, Gillian Haddock, Peter Slade, David Kingdon, Douglas Turkington, Richard Bentall, John Gleeson, Patrick McGorry, and many others. John Reed and colleagues, Marius Romme and Sandra Escher, Colin Ross and many others have demonstrated the significant role of trauma (physical, emotional, sexual abuse, as well as emotional neglect) in the etiology of specific psychotic symptoms such as voices.
Psychoanalysts have made significant contributions to the understanding of such phenomena as hallucinations and delusions. I would include in this group such psychoanalysts as Freud, Federn, Arieti, Sullivan, Fromm-Reichmann, Searles, Ann-Louise Silver, Bion, Hanna Segal, Herbert Rosenfeld, Murray Jackson and Paul Williams, Bert Karon, Michael Robbins, Gaetano Benedetti and Maurizio Peciccia, Andrew Lotterman, David Garfield and Leston Havens, the Lacanians Francoise Davoine and Jean-Max Gaudilliére, Wilfried ver Eecke and Paul Moyaert, and myself.
For a good introduction to a multidimensional perspective on the phenomena of auditory hallucinations, I would highly recommend Voices in the Brain: The Cognitive Neuropsychiatry of Auditory Verbal Hallucinations edited by Sean Spence and Anthony David in 2004 and published by Psychology Press (www.psypress.co.uk) and Taylor & Francis Inc in New York. In this volume is an excellent array of articles covering phenomenological aspects and models of understanding, cognitive neuroscience models, neuroimaging research, psychological treatments, etc. The chapter on phenomenology (“Hearing voices: A phenomenological-hermeneutic approach”) by Philip Thomas, Patrick Bracken and Ivan Leudar is exceptional in demonstrating the value of this perspective.
In a recent discussion with David Silbersweig, co-director of the Functional Neuroimaging Laboratory, Cornell University, he asserted that his research on the neuroimaging of voices and paranoid delusions demonstrates a congruence between neuropsychiatric and psychodynamic models of psychotic symptomatology. We will be on a panel together at New York University (a two day conference on the integration of neuroscience and psychoanalysis) on March 31 and April 1 2005 discussing the implications of current neuroimaging research for psychoanalytic/psychodynamic models of psychosis. I highly recommend his research (his group has published numerous research articles on this subject). A good place to start would be “Mesolimbic activity associated with psychosis in schizophrenia: Symptom-specific PET studies,” published in The Annals of the New York Academy of Sciences 877: 562-574 (1999). For an excellent review of the research demonstrating the effects of psychotherapy on the CNS, I would recommend “The emerging dialogue between psychoanalysis and neuroscience: Neuroimaging perspectives” published in the Journal of the American Psychoanalytic Association, 51/3, pp. 773-801.
Recently, a young man consulted with me on his persistent persecutory voices (starting from age 5 years) despite various lengthy trials of antipsychotic agents. I asked him if the voices were ever supportive. To my amazement he said “Oh yes, but I really do not like these voices.” I explored this with him, and he informed me that when he experiences positive, tender, supportive voices, he feels that they are “taking me over,” i.e., he experiences a panicky loss of self. With hostile persecutory voices (the emotional need for enemies?), he can at least fight against them and this organizes and strengthens him, i.e., he feels less helpless. I wonder if this is one factor in accounting for the significant prevalence of persecutory as opposed to supportive voices. This fits with the continuum of capacity to experience intimacy and emotional closeness with other persons without feeling colonized, controlled, etc., eventuating in a terrifying sense of self-annihilation.
Currently my interests are in the phenomenology of voices, psychological treatments for the distress they cause as well as psychoanalytic understanding of these symptoms, neuroimaging research, and the possible relationship between mirror neurons and voices (in fMRI research, Broca’s area-an area not just used for the motor aspects of speech, but also for imitation learning, etc., is considered part of the mirroring system of the brain- is activated during voice hearing in fMRI research).
Brian Koehler PhD
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net
