Coping with voices : an exploratory pilot study

Hearing voices is an experience common to many people in psychiatric care but meaningful help in coping with the experience is less common. This paper presents a model of coping behaviour specific to hearing voices. It proposes that coping with voices includes hallucinatory control, emotion and problem focused coping and is a function of context, the features of voices, and beliefs about voices. Results from a pilot study exploring coping with voices are presented. A questionnaire which combined previously tested scales including voice topography (Hustig & Häfner, 1990), beliefs about voices (Chadwick & Birchwood, 1995) and general coping behaviour (Carver, Weintraub, & Sheier, 1989) was administered to 10 consumers of a mental health service with a recent history of hearing voices. The instruments were found to be reliable and easy to complete. Results are discussed in relation to the theoretical framework and suggest that people engage in a wide range of purposeful coping behaviour in response to voices that do not fit comfortably into arbitrary coping categories. Consideration of 'coping with' rather than 'amelioration' of voices ought to be a key focus of nursing, and the model of coping presented may be useful in making sense of, and facilitating coping behaviour. Hearing voices is an unusual experience that can be emotionally stressful, and which few people are equipped to cope with through prior learning. Nurses and other health professionals who would wish to support people in coping with voices are constrained by a paucity of research to inform their practice. This pilot study (completed in 1999) began to explore how people who hear voices cope with the phenomenon. Hearing voices is a common experience of people in psychiatric care and is a particular feature of the psychotic disorders, which are the most prevalent class of medical diagnosis for those receiving in-patient care in New Zealand (Disley, 1997). In Australia, between 4 and 7 people for every 1000 adults resident in urban areas are in contact with mental health services during any given month because of symptoms of a psychotic disorder (Jablensky et al., 1999). In a sample of 980 people with psychotic illness in Australia, 96% had experienced symptoms such as delusions and hallucinations at some point, 61% were experiencing these currently, and for 43% there was no complete recovery between psychotic episodes (Jablensky et al., 1999). Whilst clearly, a phenomena of concern to psychiatry, hearing voices may also be reported by people who do not regard themselves as mentally ill and have no other psychiatric symptoms (Romme & Esher, 1989). Some estimates suggest up to 70 % of the population may experience auditory hallucinations at some time and voices, are estimated to be experienced regularly by around 4% of the population (Nelson, 1997, p.179). Coping with voices: an exploratory pilot study By Richard Lakeman © 2000 www.testandcalc. com/Richard 2 Despite recent advances in the pharmacological treatment of psychotic illness complete and sustained amelioration of voices in chronic mental illness is seldom possible (Westacott, 1995). Furthermore, it has been estimated that between 2480% of “severely and persistently mentally ill” people in the community do not take psychotropic medication as prescribed (Mulaik, 1992), with side effects often stated as the reason for non-compliance (Sederer & Centorrino, 1997). Health professionals are often challenged to assist people cope with and make sense of hearing voices despite pharmacological treatments. For some people assistance with coping will be adjunctive to pharmacotherapy, whilst for others coping enhancement ought to be the primary intervention. Although hearing voices may appear to be a dramatic and easily assessable manifestation of mental illness, Tollefson (1996) points out that cognitive impairment rather than florid psychotic or positive symptoms appear to be most strongly related to poor psychosocial outcomes in schizophrenia. Hearing voices appears to be an experience that many people can adapt to and learn to cope with. Romme et al. (1992) found that a third of people, who claimed to hear voices and responded to a Dutch television request to talk about their experience, coped without recourse to psychiatry. A growing consumer movement considers that an attitude of acceptance is central to living with voices (Baker, 1995; Romme, 1998; Romme & Esher, 1989; Romme et al., 1992). The voice hearing experience is conceptualised by the ‘Hearing Voices Network’ as “. part of a pattern of personal growth and as a facet of human experience. ” (Parker, Harper, Georgaca, McLaughlin, & Stowell-Smith, 1995, p.123). This is exemplified by Pembroke (1998, p.30), who states “My voices belong to me and can no more be removed or treated than a person’s sexual orientation. It is not the hearing of voices that is the problem, it is the inability to cope with them”. Whilst these claims may sit uneasily beside medical discourse which formulates voice hearing as a “residual or drug resistant symptom” (Parker et al., 1995, p.125), to be useful to the person, the nurse must consider what it means to cope with voices. This is congruent with the purpose of nursing which Travelbee (1979, p.7) described, “ . an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering and, if necessary, to find meaning in these experiences. ” Clearly coping with voices involves more than controlling the experience. Theoretical Framework The framework of stress and coping proposed by Lazarus and Folkman (1984) and further developed by Carver, Weintraub, and Sheier (1989), as well as Slade’s (1976) explanatory model of hallucinations provided the theoretical framework for this study. For the purposes of this study coping was as a purposeful activity, in response to the appraisal of some aspect of the voice hearing experience as stressful. Coping with voices: an exploratory pilot study By Richard Lakeman © 2000 www.testandcalc. com/Richard 3 Context Voice hearing occurs in social and cultural context. Whilst hearing voices has come to be associated with psychiatric illness in the west, illness is not a universally accepted explanation. Throughout history voice hearers have influenced the development of humanity, including people such as Socrates, Plato, Joan of Arc, Carl Jung, Winston Churchill and Adolf Hitler (Baker, 1995). Even Florence Nightingale, is reported to have been influenced by hearing voices (WoodhamSmith, 1952, p.14). The way the experience is constructed and explained, as well as the person’s position in society will influence whether or not the person who hears voices is accepted or considered deviant in some way. Cultural beliefs invariably influence coping and help seeking behaviour. A comparison of coping strategy use between Saudi Arabian and UK patients whom heard voices (Wahass & Kent, 1997) found that Saudi Arabian patients used strategies associated with their religion whereas UK patients were more likely to use distraction or physiologically based approaches. It has been suggested that cultural attitudes towards hallucinations affect the person’s emotional reaction, the degree of control over the experience, and that therapists should consider the functional significance and meaning of hallucinations as well as the social context and the stimuli associated with them (al-Issa, 1995). Stress and coping, occurs against a cultural and social background, which must be acknowledged. Indeed groups such as the HVN exhort cultural change so that hearing voices is accepted in society. Emotion and problem focused coping According to Lazarus and Folkman (1984) coping strategies may be categorised as emotion focused (orientated towards regulating distressful emotions), or problem focused (behaviour aimed at solving the problem that is causing the discomfort). Carver, et al. (1989) have argued that some types of coping behaviour such as venting of emotion or behavioural disengagement do not fit comfortably into either category and may have either positive or negative effects on emotional state and the stressor. Carver, et al. (1989) identified 13 factors, which they claim, are conceptually distinct ways of coping but which may be classified as problem, emotion focused or other ways of coping. Each of these factors may be assessed using the COPE questionnaire (See Table 1), which was a key instrument in this study. Strategies employed from one situation to another may reflect relatively stable dispositional tendencies, although strategy use is likely to vary from situation to situation (Carver et al., 1989, p.277). Emotion focused coping may be more effective in circumstances where a stressor is uncontrollable and problem orientated coping more effective in situations where a problem is amenable to solution. There is now a considerable body of evidence that voice hearers can exert at least some control over voices. Coping with voices: an exploratory pilot study By Richard Lakeman © 2000 www.testandcalc. com/Richard 4 Table 1: COPE Factors (Carver, et al.,1989) Problem focused coping: Emotion focused coping: Other factors: • Active coping • Planning • Suppression of competing activities • Restraint coping • Seeking social support for instrumental reasons • Seeking social support for emotional reasons • Positive reinforcement and growth • Acceptance • Denial • Turning to religion • Focus on and venting of emotions • Behavioural disengagement • Mental disengagement • Alcohol-drug disengagement *