I found the following research studies to be very interesting. One could interpret the findings to fit with a neuropsychoanalytic perspective: profound stress/anxiety (e.g., interpersonal/social) results in atrophy of certain neural regions (e.g., frontotemporal) and that the 'voices' themselves are not in an isomorphic relation to the neuropathology, rather they are attempts to override a feeling of personal and neural annihilation. There is also the crucial relation between voice and voice-hearer (as cogently described by CBT theorist/clinician Max Birchwood and others). One of my patients was told by a former therapist to strike back sadistically at his persecutory voices (e.g., "crack their skulls with a pipe" etc.). One of my concerns with this approach is that if the person partly identifies with her/his voices, might that not be unconsciously or even consciously, experienced as countertransference hatred, wishes to destroy the patient, or the very least reflective of the impotence and despair shared by both members of the therapeutic dyad (i.e., a failure of containment)? It also ignores the possibility that the 'voices' are serving functions for the patient such as providing evidence that he or she exists, is being kept in someone's mind (rather than dropped from mind and the concomitant sense of worthlessness), even if it is the mind of a persecutor. Persecutory relationships can provide a needed boundary when one is plagued with a terrifying sense of boundarylessness, i.e., something to fight against, an edge, a limit to one's terrifying fusion with the surround resulting in a sense of personal annihilation.

I have formulated this in papers I gave in Stavanger in 2000 and in Madrid in 2006.

Hubl and Dierks (2004), demonstrated with fMRI research with persons with auditory hallucinations, that the voices have a sense of being real, partly as a function of activation of the primary auditory cortex (Heschl's gyrus). They were interested in examining temporal activation patterns while persons were actively hallucinating. Hubl and Dierks, in brief, discovered the following temporal neural activation pattern: hippocampus, Broca’s area (speech activation), amygdala, PAC (primary auditory cortex-Heschl’s gyrus), and lastly, the primary motor cortex. Their temporal activation research, I believe, fits well with a neuropsychoanalytic model which places emphasis on emotional memories, traumatic experiences, and affective experience in general. In my previous papers, I hypothesized:

"My interpretations of the above data, are that the patient is co-opting 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, 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 and 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/internal 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."

I found the following volumes on 'voices' to be particularly helpful:

Spence , S.A. & David, A.S. (Eds) (2004). Voices in the Brain: The Cognitive Neuropsychiatry of Auditory Verbal Hallucinations. NY: Psychology Press.

Escher, S. (2005). Making Sense of Psychotic Experiences. Authors doctoral dissertation.

Blackman, L. (2001). Hearing Voices: Embodiment and Experience. NY: Free Association Books.

Brian Koehler PhD
Postdoctoral Faculty
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net