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See editorial, pp. 394-395, this issue.
Julian Leff, c/o The Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG, UK. Email: [email protected]Declaration of interest
None.
The introduction of antipsychotic medication benefitted many patients and helped to initiate the wave of discharges from psychiatric hospitals. Unfortunately, one in four patients with schizophrenia fails to respond to antipsychotics 1 and continues to experience persistent auditory hallucinations, which have a major impact on their lives and can lead to suicide. 2 In an attempt to tackle this problem we developed a novel therapy to give patients control over their ‘voices’. The rationale derived from the observation that when people are asked about the worst aspect of hearing voices their invariable response is the helplessness. However, research has shown that patients who can initiate a dialogue with their voice feel much more in control. 3 Patients are often advised by professionals to ignore the voices and not to engage with them. However, the approach of Romme and colleagues 4 of encouraging patients to enter into a dialogue with their voices has proved to be therapeutic. Furthermore, the association between trauma of various types in early life and the later development of auditory hallucinations is evidence for an understandable psychological origin for voices, although the exact mechanism has yet to be established. 5,6 Some patients realise that their low self-esteem, induced by traumatic childhood experiences, is echoed by the voices that harass them. The development of persecutory auditory hallucinations can be formulated as an exteriorisation of a severely critical component of the psyche that cannot be tolerated. 7 If this is correct, then ignoring the voices negates the possibility of reassimilation of this rejected component of the patient's internal world. In 26 people who heard voices, Chadwick & Birchwood 8 studied their experiences and beliefs about the voices. All participants interviewed who heard voices giving them commands, held additional beliefs that if they disobeyed, they would be punished or even killed. These authors developed a therapy based on asking the patients to test their belief in the dire consequences of disobeying these commands, a strategy that met with some success. An alternative approach of facilitating a dialogue between the patient and their persecutor in which the patient...