Christoffer Haugaard on Collaborating with Clients Who Hear Voices

Christoffer Haugaard: Thank you, Lawrence!

CH: I think what I’ve learned is that, based on the phenomenology of what voices appear to be and how they behave when you interact with them, the mind doesn’t seem to be unified. There seems to be multiple agencies, multiple perspectives that at least can be present and seem to have their own existence and are in some way tied to a particular person.

You can interact with these agencies or entities or whatever you want to call it. And, from my experience in working with people who hear voices, they respond favorably. The voices respond favorably to being treated as some kind of person, to being respected as having a perspective and their own agency, their own opinions, rather than being dismissed or rejected or taken to be not real, or only a symptom or a representation of something. They tend to appreciate being treated as if they are people too.   

CH: That’s complicated. In a way it wasn’t a stretch for me because personally, I was already quite familiar with other ideas about reality of the mind, other ontologies. I’ve always been interested in indigenous societies, shamanism, animism, that sort of thing, where people experience entities or agencies outside themselves or related to the world and interact with them.

So, that way of thinking was actually quite familiar to me, but I didn’t connect it to my work as a therapist at all. I thought of psychopathology as being something distinct from that. Or at least I didn’t have any particular interest in connecting those two things. So, I regarded voices as being dissociated thinking patterns that were on repeat in peoples’ heads.

My change in view happened because we made a discovery about it by coincidence. I was working with one of my patients, named Max, whose story has been published. He considered that maybe his voices had good intentions to begin with, and I just took that idea at face value. I suggested that I try to address these voices and tell them that we had these ideas about them, that maybe they had good intentions, and tried to explain to them that Max needed them to behave in a different way so they could assist him in life.

Max thought that was a crazy idea because you can’t talk to a mental illness, but he was kind enough to not tell me that. He just said, “yeah, sure, go ahead.” So, I spoke to the voices, and they responded very favorably to that. They enjoyed being respected and acknowledged for their good intentions, and they actually changed their behavior.

From that point onwards, Max was able to appeal to them using my words in the form of a letter. In five minutes, he could quiet them down. They had terrorized him for years but responded to this immediately. That required me to change my thinking. This certainly didn’t seem to be some thinking that was dissociated and stuck in his head on repeat like a broken record.

This was something living that was responding with an opinion, and had feelings that were different from Max’s feelings. I brought that idea with me to other patients where we were stuck and we found that treating voices in this way, acknowledging them as having their own perspective, their own opinions, being persons of some kind was very effective. We then collaborated with more and more people where we were able to confirm this.

And of course, that required me to dissociate myself from normal psychological and psychiatric thinking. I was working in a psychiatric hospital where the general idea was (and still is) that voices are false. They are hallucinations, and people should not involve themselves with them. They should reject them and not listen to them, and they should be medicated to go away. I had to dare to step completely outside of that idea. I think maybe I was willing to do that because I was familiar with that way of perceiving the world already. I just never connected it to my work as a clinician before. I had a predisposition, you might say, to think that way.

So, it wasn’t a big leap for me personally, but it was something I had to dare to do in a psychiatric context, where that was not how you thought about things. I had to deal with the possibility that other clinicians would think that I was indulging people’s insanity or entertaining their delusions. But to think that that helped me to not be persuaded by such doubts or such ideas was the fact that it was just very effective.

There was just a very immediate response from these voices and nothing else had worked. I was sitting with patients who had been medicated, sometimes heavily, and who had tried many different kinds of psychotic medication for years and years; and tried psychotherapy for years and years, and it hadn’t worked. It hadn’t made any difference to these voices. And now these voices were responding in ways that were entirely novel to these patients.

They were immediately surprised that the voices were responding like this. It was useful. They could suddenly find ways to deal with these voices so that they stopped being a menace to them. Their need for hospitalization decreased, and some of them even stopped needing it. The voices ceased to be a threat to them, something they could live with. Even in some cases, they came to appreciate the input of these voices. They changed their behavior, became more reasonable, more kind, stopped going on and on about people killing themselves and stuff like that, and becoming more constructive when they were engaged in a dialog. And that was very persuasive for me and for my patients that this happened.

And when I saw that happen and the difference it made to my patients, it was it was a no-brainer really. I did have concerns about how honest I should be about what we were doing. Should I tell my patient’s psychiatrist what we were doing? But that became easier along the way because it was working.  

CH: Yeah, and I already had a rebellious mindset. That’s why I became interested in Narrative Therapy to begin with. I was dissatisfied with how these peoples’ experiences were pathologized and just rejected as being just wrong and not worth listening to, not worth understanding, and just something that should be medicated until it stops. I was dissatisfied with how these people were not engaged in a more equal dialog about meaning and what might be helpful for them.

I had already been creating a group therapy format and participating in psychoeducation, where you tell people about diagnosis and treatments and all that. I’d become dissatisfied with being a clinician telling these people what to think about their experiences and describing it as something that was wrong with them. In the group format I developed, I invited patients to participate and interviewed them about their experiences and then together, reflect on what might this mean.

It was important to not privilege a psychiatric understanding. I wanted these people to participate in understanding their own lives and their problems instead of having to listen to yet another psychologist tell them stuff out of a textbook. I’d already done that before making these discoveries about voices. So, yeah, I definitely had that kind of rebellious mindset about it.

CH: As far as I’m aware, none of my colleagues had tried it out. It’s sort of just became a thing I did. Sometimes they would bring along a patient and ask if I could “talk to this guy or can you talk to this woman and see if you can do your thing?” So, it was more a thing I did after having published some of these accounts, circulating this knowledge, and making it available to people who hear voices. I have been contacted by people who have tried it out and found it to be effective. Not a lot. I hope there are more people out there using it that I’m not yet aware of.   

CH: Mostly I’ve been dealing with this in a very pragmatic fashion and haven’t worried too much about that, really. Treating the voices as people was just very effective. Trying to work out what voices mean in terms of ontology or psychology has not been a concern. My patients didn’t care about that, and it wasn’t necessary to figure that out in order to do the work with them. To my mind, people are free to make sense of their voices in whatever way works for them, you know? Some people will think “this is probably a part of myself in some way,” even though that’s actually not how the voices appear.

They actually appear and behave like something of their own. But, you know, a patient who prefers to interpret that as being parts of themselves, of course, is free to do so, and it doesn’t seem to actually be important what people think of it. Voices respond to it, no matter what the host human might think of it. Right? But it doesn’t seem to depend on what the patient believes, and we don’t have to figure out what to believe about it. We have to pragmatically make the assumption that voices are people — they have their own perspective, their own desires and intentions, and we treat them that way. As soon as people have the experience that voices respond to this, they really stop caring about how crazy it might seem. It just doesn’t matter when it works. I, of course, have been interested in trying to get some idea of how we can make sense of that

I think the more traditional psychological idea that these voices must be “split-off” parts of the self presumes that the self is supposed to be unified and that this splitting is not how it’s supposed to be. Thinking that way doesn’t lend itself to acting very well.

You know, it becomes sort of pretending. The therapist is pretending that the voices are persons, but they really think they’re not. So, if we want to develop an idea about what voices are that actually supports literally treating them as persons, we might need a different idea about voices. It seems to me that psychology, and certainly psychiatry, is not a very good place to look for that, because these ideas are very tied to a Cartesian way of thinking about the mind and very tied to particular notions of what’s normal that are really based on industrial Western societies and the recent couple of centuries.

Basically, much of psychology doesn’t take other societies into account, or how Europeans thought just 300 years ago, which was in many ways radically different. This idea of a self-contained subjectivity is quite recent, and historically not very normal, actually. Psychology and psychiatry are very tied to such a notion of what a mind is supposed to look like. But when you start looking at the history of religions as well as anthropology and ethnography, very different ways of how the mind operates begin showing up. And the word that has become more popular and recently redefined in anthropology is animism, which seems to be a way of understanding the world and mind, which is pretty much universal.

All societies that that have been studied used to be animistic, which revolves around the erroneous attribution of mind to things that actually don’t have minds. It is the “so-called” primitive belief, for example, that trees are alive or that a stone is alive. That was the original notion. And it was used to demonstrate that religiosity is a primitive, irrational thing that should basically be rejected, and that the religions of civilized societies are just refined versions of this primitive animism. It’s folly that that was the idea back at the beginning of anthropology.

But animism has since been redefined as being an epistemology that takes the subject to be the starting point for knowledge of the world. To interact with the world socially is a way to know the world, which is different from the rationalist scientific idea of taking the object to be fundamental. In scientific, rational thinking, we want to divorce subject and object from each other, and from that comes the Cartesian mind-body dualism. And in turn, the notion that voices are simply split off parts of the mind.

And in this vein, we then want to remove subjectivity as much as possible from the object of study, because real knowledge is objective, independent of perspective, independent of context. It seems that many societies, indigenous societies, assert just the opposite, but about the world; to know something is to invest subjectivity in it, to interact with it, to be socially engaged with.

To know the forest then, the forest must become a person. It must become a subject. We must see through the eyes of the forest to know the forest. That’s where the spirit comes to be. A spirit, then, would be the subjectivity of a relationship with something in the world. And in that sense, it’s a way of knowing, instead of regarding the world as consisting of a bunch of particles in causal relationships with each other. The world can be understood to be a set of social relationships, and that the world is fundamentally social, not just between humans, but between humans and trees and animals and so on and so forth.

In this sense, animism, may be an ontology and an epistemology, a way of engaging the world that makes a different bet to rationalism and modernity. I think these notions of subjectivity, where the mind is not closed but porous, relational, and elastic, seems to be actually a very universal way of operating for our species.  

And in that light, hearing voices isn’t that difficult to understand. You can look at voices as a way of understanding your life when something in your life begins to speak to you. It’s a personification and investment of subjectivity in some aspect of your life that is problematic that you need to deal with. That’s why it begins to talk to you, so developing the right relationship with it is the road to healing. These voices mustn’t be rejected. They must be listened to because they’re trying to tell you something, and you must establish good relations with it instead of rejecting it or ignoring it or battling it. 

CH: I guess you could say that the process of modernization has been closing human beings off from the world. In making the distinction between subject object and presuming that humans are exceptional and separate from the natural world, from our bodies, from other beings—we are asserting that we’re somehow entirely different and that only we possess minds, and the rest of the world is sort of dead and has no inherent meaning. From a historical perspective, you can certainly make the argument that modernization has operated like that; a rejection of being in relationship with the world.

CH: The older understanding in anthropology is that a spirit is a non-empirical entity that people believe has causal powers. That would be the old understanding of animism. The new animism in anthropology says that a spirit is a personified relationship with some aspect of the world, a relationship with something other than another human. So, when humans enter into relationships with a particular tree that may be important to them, this tree is personified by being related to in a social way. There’s an investment of subjectivity. The relationship becomes a hub of subjectivity in itself. That is what a spirit is.

CH: Yeah, but mostly with the voices I’ve met. It’s not trees that they have problems with. It's usually some aspect of existence. It can be aspects of our culture, for example, certain social norms that act in a personified way, and very often it’s a kind of helper. It’s like a companion entity of some kind that is trying to help people deal with something in their lives.

Often they turn out to be quite right about what people need, but because people have been rejecting this voice and been afraid of it, the relationship has gone sour. Sometimes it turns into a war. Sadly, sometimes psychiatry contributes to creating this state of war because they encourage people to reject their voices and in telling them that this voice is a sign that there's something wrong with your brain. That’s a very scary thing to come to understand. This element of fear and rejection tends to lead to a conflict with the voice, and then the constructive aspects of what a voice may be trying to tell people is completely lost in this war. What I’ve often done is try to be on a diplomatic mission to create a peace and to try to understand what the voice wants. Often the voices are able to communicate when you interact with them in a respectful way. Very often, they want something. When the person comes to understand this and finds a way to satisfy the voice in an acceptable way for the person, the war ends.  

CH: There’s often trauma. The first appearance of voices is often in the context of a traumatic event, but not always since some of the people I’ve collaborated with have been able to hear voices for as long as they can remember. Just seems to be an ability, something that they’ve just always had.

CH: I have collaborated with one among other voices that was extremely angry about how the world was being treated by humans and wanted the person hearing the voice to try to annihilate humanity. I wasn't able to, to work with that person in a very consistent way. A certain reason I haven’t collaborated with this person was due to the circumstances in their life, and of course, wanting to annihilate all of humanity is not a desirable or constructive thing to do.

It was not sensible to agree with this voice about that but to appreciate the anger of this voice was certainly relevant. Of course, I would see that as the fury of this voice. You know, wanting extreme things. And we need to channel that into something that’s acceptable for a human being to actually do, and killing people wasn’t it.  

CH: There is my collaboration with Alice that has been published. She heard a multiplicity of voices operating in a unified way that she called “the others.” They were very aggressive and wanted her to harm herself and other people. They enjoyed gore, suffering, pain, and things like that and wanted her to do them.

Of course, she didn’t want to do anything of the kind. Then they would torture her in various ways when she would not comply with them, and try to convince her to kill herself. Once she started talking to the others, she discovered that they had all this aggressive energy that they wanted to express through her.

Alice resisted that, but because of this, they felt trapped. They could not exercise their own being in any way. They were just trapped inside her. That caused suffering for them. They were in pain from not being able to express themselves in the way that they wanted, and therefore they didn’t want to exist anymore. The voices were trying to get Alice to kill herself, hoping that that would also put an end to their painful existence.

We found out by coincidence that they enjoyed having smoking breaks. One day, we were talking about something that they didn’t appreciate, and it seemed like an attack was coming on from them. To avert that, I said, “sure, you get it your way. We’ll talk about something else for now. You just take a break for a smoke or something.” And that was just a joke. I was trying to lighten the mood and as it turned out, that averted the attack. Alice then told me they liked that. They liked being offered a smoking break, this was after having made this discovery with Max that I mentioned earlier. After that, I brought cigarettes for them and we put them out on my desk.

They really liked that. Otherwise, they would want her to kill herself. The voices didn’t like me talking to Alice and trying to help her get better because they wanted her to die, but now they had to admit that I offered the cigarettes. No one else in the world had ever offered them anything, but I did, so they couldn’t thoroughly hate me. We also gave them coffee. We could avert attacks like that, and begin to teach them to behave more kindly and in a friendly kind of relationship instead of an aggressive one based on power, which was all they knew. They started becoming familiar with being friendly and what that meant, so we tried to accommodate them.

They also wanted all this blood and gore and aggression. They liked that but of course, Alice didn’t. I suggested putting on gory movies for them. I didn’t want to look at it. Alice certainly didn’t. So, I put them on my computer and turned the monitor away from us, up where the voices were receiving their cigarettes and coffee.

I chose something comical, something funny like Peter Jackson’s old gory comedy movies he made before the Lord of the Rings. Later on, Alice decided to start practicing martial arts and they really liked that too. She was doing something that had something aggressive in it, but which was socially acceptable and acceptable to Alice. The voices calmed down more and more. And in the end they became quite friendly and liked me and wanted to be friends with me. They eventually stopped bothering Alice, and she stopped being afraid of them. So that was this kind of negotiation, you know? Can we give you something that you'll appreciate, but which is also acceptable for Alice?  

CH: I think externalizing conversations already has some similarity with working with voices where there’s a practice of personifying problems. It has this animistic element to it. The leap isn’t that big. And then there’s the element of Narrative Therapy that’s called co-research. David Epston calls it co-research when you’re in a situation where you don’t know what to do, or how to deal with a problem. You relinquish your professional identity as the one who’s supposed to know stuff and invite the patient to explore. You work from the premise of “let’s explore this together.”

Narrative Therapy has roots in anthropology and ethnography, so this idea of collaboratively exploring the world without knowing in advance is essential. That is certainly what we did because we were in a situation where the usual stuff wasn’t working and we had to recognize the fact that we didn’t know what to do. It was a matter of just going with it to see what we could find and try it out and see what works. What we found with voices was that they responded well to this, so we did this consistently with one patient after another. 

CH: Yes. When I spoke with Max’s voices that first time, he had a positive experience because the voices responded and calmed down immediately. Max then asked me to write down for him what I had said to the voices. That became a letter that he would then use whenever the voices got worked up about something in his life. He would simply read this letter to them, and they would stop attacking him. I have also used letter writing with some of my other patients when we were trying to figure things out, and as a way of documenting our discoveries. In those instances, I would write to them and some of them would also write to me to explain to me what they had discovered, or what the history of the voices was like.

I’ve been writing letters, not to my patient, but to the problem, a personified version of that problem. In one case, I wrote letters to the voices of a patient with PTSD who had reoccurring nightmares. In one of those nightmares, he saw a dead man who had committed suicide. The patient had been the first person on the scene.

In the nightmare, they had a conversation where the patient was extremely angry with the dead man for the impact the suicide had on his life. The dead man told him that the suicide was his decision to make and that it didn’t concern other people. That made the patient even more furious to hear. This conversation would happen every week in a nightmare. I decided to treat this as if it were a voice and appealed to the dead man in the nightmares as a person. This person was a personification of the trauma the patient was living.

I wrote a letter for the dead man from me said to the patient, “please read this letter right before going to bed.” As with Max, the patient thought this was a crazy idea which was not going to work. But since he had been having the nightmare for two years, he was willing to go along with the plan. He liked me enough to try. The nightmare with the dead man stopped as did the other trauma-related dreams. He later told me that when I suggested this plan, he didn’t think it was going to work. But it did.  

CH: I’ve had quite a few patients when I read these letters. I’ve been writing it while they were there, and just wanted to read it to them to make sure that I had all the facts right. And they would cry, because it just hit something apart from their own sense of themselves or their own minds. But something else, seemed to just appreciate it.

CH: Yes, but with the twist that what seems to accomplish this work is the assumption that the problem is a person with good intentions. So it’s important not trying to resist the problem or undermining the problem, but to actually listen to what is the problem. I’m trying to acknowledge the good intentions of the problem, and then explaining to the problem the way I’m going about its work of helping the person. I ask the problem to consider that the way it’s been behaving is having all of these negative effects. And then I just ask people to read this letter on my behalf to the problem every day. I say to the person that all they have to do is read the letter to the problem. And that’s been very effective.

CH: In what sense?

CH: No, no, no, I get what you’re saying. Yes, I do sometimes try to relate to the problem as a person when people are not hearing voices, and that that’s often very effective. I don’t usually explicitly introduce that or explain that. I allowed the person to wonder, like I might say, “I wonder if this depression might be trying to tell you something.”

I might also wonder aloud if “the depression has come at the time that it did in your life for some reason”. And then, based on what people have told me, I consider “well, maybe this depression has been looking at you and has been looking at how your life has been unfolding and how you’ve been dealing with your life. And perhaps this depression is aware of the things that are important to you, and therefore this depression is dissatisfied. It has been dissatisfied with what you have been doing, how you have been compromising with the things that are important to you, the things that matter to you, that you have been sacrificing yourself for the boss at work or whatever.” I might add, “maybe this depression has decided to make an intervention to stop you from living your life the wrong way.” The thing is with depression, at least in my experience, they tend to be like a sawn-off shotgun. When they fire, they fire all over the place.

I might continue, “Maybe this depression is, in fact, trying to dissuade you from living in a way that isn’t right for you, but in interfering with your life, it’s just hitting everything, putting you completely at a halt with lots of negative consequences. But maybe this depression wants something for you. And maybe we need to try to hear that message. Maybe you need to try to satisfy the depression with what it actually wants, its intention, not all the negative effects it’s also having, but it’s intention for you; what’s actually important to you, how you’re supposed to live. Maybe you’ve been compromising with something essential in the way that you’ve been living up to the point where this depression stepped in and interfered with your life.”

Often I worry that people think I’m crazy when I say these things, but I’m surprised that they don’t. They tend to be on board with that quite immediately, actually.  

CH: Yeah, I make that assumption or at least try out that idea very carefully that the voices have good intentions before assuming that the problem has only bad intentions. Problems tend to respond quite well to the assumption that they have good intentions.

CH: They may or may not have those feelings, but I would try to invite the patient to explore the voice’s intention with me and also directly with the voice. The voice may have different reasons for wanting that. To become a teacher here in Denmark, you have to learn how to how to teach, how to communicate in a way that’s conducive to learning. I have the impression that voices have not had this course. Sometimes they’re very angry at their host human because they think the person hasn’t been taking care of themself, such as “Back when you were raped, you should have killed that rapist. I’m so angry with you because you didn’t and because you didn’t, I think you’re useless. You should die.” When what you’re hearing is just, “you should kill yourself, you’re useless,” It's very difficult to see the good intention, but it is often possible to actually unravel it.

What the voice wants is for this person to stand up for themself, but that communication needs to be translated into something that’s acceptable for an actual human being to do. We don’t want to kill anyone, and that may be the voices way of expressing a desire for protecting the person, defending themself. In Alice’s case, the “others” would say, “kill him,” whenever they were angry with me because they thought I overstepped my bounds or talked about something they weren’t comfortable with. There, I would say something like, “I’m sorry that I have offended. Please take another sip of coffee or let me give you another cigarette, and I’ll be more careful to not offend you in the future. That certainly wasn't my intention.” And then they’d calm down.

Sometimes voices can have these very violent and graphic ways of expressing themselves, and that language may need translation. It shouldn't necessarily be taken at face value. It may be an expression of extreme frustration and desperation on the voices part. And that’s what we need to understand so that we can respond to it in the right way; saying something like,“We don’t want to kill anyone, but there’s someone you want to blame. There’s someone you’re angry at, and you want something else for this person you’re talking to. Okay, let’s see if we can solve that, because I certainly get that. I get being angry at that. Right? This I get desiring to defend yourself. But, you know, voices, this person wasn’t able to do that back then. She was a child. She was powerless against this person. We have to find other solutions here. And I invite you voices to participate in that because I appreciate your good intentions. I wish she was able to defend herself back then, but she couldn’t. I understand why you want the rapist, that I get that. But we can’t do that. We have to find another solution. But I want to collaborate with you to find that something that this person wants, something that they can do.” 

CH: That’s a very big issue. We talked about spirits and animism and all that, but my point is not to say that voice hearing and spirit encounters in various cultures are the same thing, and that people in other cultures are all hearing voices and or that people in our society who hear voices would be shamans in other societies. That’s not necessarily the case. The point is more that animism provides a different way of understanding subjectivity and a way of handling subjectivity that fits quite nicely with what works for voice hearers. So, I can be agnostic about how voice hearing relates to spirits. It’s more about the commonality in the subjectivity.

You know, we might learn something from the spiritual practices in other cultures without it necessarily meaning that what we call mental illness is the same as the experiences that shamans deal with. I think that would be a conflation and an oversimplification.

But there’s a common structure of subjectivity around voice hearing and the practices and understandings in other cultures. It’s a better fit if we don’t view what I do through the lense of traditional, Western theories and practices. These don’t lend themselves very well to doing what I have done with voice hearers, because it would be very difficult to go from a traditional psychological model to offering cigarettes to a disembodied voice.

From an animistic perspective; however, it makes a lot of sense. These are offerings. We’re making an offering of tobacco that’s found in many indigenous groups in the Americas. To make an offering is to appease spirits by making a gift. And when you receive a gift, you enter a moral community of mutual obligation. That’s the logic of sacrifice which is like an offering. Alice’s others responded to that.   

CH: There’s a lot of similarities. When we set out to do this core research, David Epston and I along with these patients decided to not engage with the literature of the Hearing Voices Movement to just start from scratch and make discoveries. But a lot of what we found is very similar to some of the discoveries of the Hearing Voices Movement. And of course, the Hearing Voices Movement doesn’t have one unified idea or one unified practice. They have this idea that people should be allowed to find their own way, but certainly some of the discoveries that they have made are very similar with voice dialog. So, we have arrived at practices that are like what they have arrived at. I find that very encouraging, that without trying to do the same thing, we have arrived at similar practices, working from scratch. And that expands that notion of subjectivity across continents, across borders—not just ideological borders, but geographic borders. 

CH: This has been a very interesting conversation. Thank you very much. I’ve enjoyed it.