by Joachim Schnackenberg and Paul Bomke.
The Hearing Voices Movement (HVM) has been a key player fighting for fundamental and paradigm societal and mental health provision change in the past 28 years. At its heart is the simple but crucial demand for a normal life, based on recovery and resilience principles and the knowledge that one can live well with voices and that voices can represent great resources of resilience and recovery if approached appropriately. This contrasts to the current experience of mental health services, where voice hearers often feel condemned to a life of supposed illness, a lack of hope, the crushing of dreams and the mal-treatment by people around them. Whilst as a movement it has continued to grow and is reaching ever more people, its central demands appear to largely have gone unheard in relation to public mainstream mental health service provision. In some countries recent policy changes have officially incorporated recovery thinking as a compulsory aim for mental health services, for example in the UK, the Netherlands, Australia, and New Zealand. However, as a member of the Hearing Voices Movement and a HVM approach trainer and mental health professional, the first author of this article, can testify to the lack of real and noticeable widespread change to incorporate this new mentality into discernible and noticeable practice change to date. Whilst exceptions do as always confirm the rule, it appears that for many services at best a token acknowledgement of the need to change appears to be taking place. For many other services and policy makers, engaging in a recovery orientated way appears to not even be on the horizon of current discourse (Bomke and Kendall-Taylor, 2014).
This raises the question of why. From a professional point of view, this appears to be largely a discussion around how to rightfully understand and define experiences and behaviour which have traditionally been associated with a supposedly chronic presentation of psychotic type disorders, such as schizophrenia. Many voice hearers who are part of the HVM have, however, not done us this favour and have recovered anyway (Coleman, 2011). The relative length of time for practice change to be implemented is of course not unusual when it comes to paradigm shifts taking place within any area of scientific enquiry (Kuhn, 1996). However, this should not serve as an excuse.
The challenges set before us by the Hearing Voices and Recovery Movement are to design services and facilitate societal change which will help voice hearers to heed the hope to “live your life and not the life of your voices.” (Ron Coleman, 2011, personal communication).
From a HVM point of view mental health services are instead frequently set up to both foster and make a chronically unwell life worse. Many voice hearers would add that they feel they managed to recover not because of mental health service provision, but despite it. The inherent power imbalance in the current set up between professionals and service users does inevitably lead to regular feelings of even greater powerlessness and a sense of abuse of this power in the lives of voice hearing service users. Many people give up any hope of recovery. It is of little surprise in this context that the public education drives of recent years and decades to supposedly demystify schizophrenia into a primarily biomedical phenomena, appear to have reinforced the public’s perception of dangerousness and fear of people with schizophrenia instead (Angermeyer and Matschinger, 2005; Link et al., 1999; Phelan et al., 1996).
In contrast to the relatively bleak current outlook of a life-long dependency on services, even if overall well resourced like in Germany for example (Bomke and Kendall-Taylor, 2014), there is a vast untapped potential to achieve significantly better mental health outcomes if the lessons of the HVM and other Recovery Movements were heeded.
We cannot force people to change or to achieve change. However, current systems place far too much emphasis on reactive professional expertise only and not on the preventative development and use of service users’ own resources and resilience. A typical example of the HVM approach might serve to illustrate this point here.
Case example 1
A voice hearer had been fearful of a particular voice whom he had experienced as only ever saying that he was complete rubbish, good enough for nothing, etc. He felt unable to cope and his life was dominated by professionals trying to support him in his distress.
Using the HVM approach, the voice hearer learned to engage with the voice and think about its meaning and eventually ask the voice why he was saying things like that. The seemingly surprising answer of the voice was: “The answer to your problems is in you.” Not only did this tremendously relief the voice hearer but it did also open up a completely new potential and the ability and belief that he needed to rely less on staff over time and properly begin on his recovery journey.
This is a fine example of mental health services traditionally often spending decades trying to just combat this or these kind of voices in people and not believing that voice hearers themselves have got anything significant to offer to help find a way out and forward. It is no surprise then that mental health outcomes continue to be low for people, as the political and mental health system’s way of dismissing voices and voice hearers potential is creating dependency on services.
Engaging with voices in a meaningful way is no small feat for voice hearers and the people around them and necessitates well resourced and helpful support. Dealing with the impact of often underlying very difficult and/or traumatic life experiences, would also need supportive mechanisms, which again could be provided by trauma-sensitive services.
The HVM has rightfully claimed leadership in addressing the need for a re-focussing of services. One of the training providers associated with the HVM is the efc Institute. The efc Institute has been collaborating with various organisations themselves focussed on wanting to promote a real recovery-focussed change in service provision. A fine recent example in this context is the collaboration with the Pfalzklinikum in South-West Germany (Bomke 2014), which started in 2013. Given the need for a real paradigm shift, the bravery to change one’s long held views is easier to undertake if staff know the organisational leadership on their side and when staff do not have to fear falling out of favour because of unconventional views. The collaboration with the Pfalzklinikum has thus far been a fine example in promoting and initiating the initial use of the HVM ethos. Newly trained staff would in turn act as agents of change and promote the new thinking with fellow staff and voice hearers as they were encouraged to do so by senior management staff. The organisation is also undertaking efforts to increasingly include experts-by-experience (i.e. voice hearers) as equal partners in the re-focussing of services. It has been heartening to see what is possible if people do feel able to engage in a recovery-focussed process, as evidenced in the following example from the Pfalzklinikum.
Case example 2
A voice hearer of about 20 years, who had allowed herself to engage in the HVM approach, did manage to achieve important changes in her life, thus improving her own mental health outcomes. Significantly, although having been a recipient of mental health services for about 22 years, she had never actually previously disclosed that she had been hearing voices all along, though suffering a lot with its distressing impact. She knew and feared that disclosure would lead to being labeled as mad, not believable, and also not being able recover and not managing to move on. It was only when she heard about the new HVM approach that she felt able to open up and thus discover her own ability to change.
Again, having engaged in the HVM approach, she did find in herself the ability to reclaim her life back and start to assert her needs, feeling less abused and badly treated by the people around her. She did this by understanding that her voices were on her side and not against her. In fact, the voices were telling her off whenever she was not speaking her mind and not believing in herself.
These case examples are in fact not an unusual experience for people who have engaged constructively with the HVM approach. Voices can always be used to further one’s own positive development. This does explicitly and particularly also include people with psychotic type disorders where this had previously not been considered possible and chronicity had been considered the norm for most. To anticipate and counter classic objections, this does explicitly apply to people who had been correctly diagnosed (disregarding the current validity debate on psychiatric diagnoses, and assuming they do have validity and reliability).
Public and professional debates should therefore be centred around facilitating a constructive public and private discourse around the provision of trauma-sensitive preventative and recovery-fostering services. This does explicitly also include addressing the power imbalanced relationships as addressed by current reactive policies of cost bearers. Innovation and fostering the promotion of inherent resilience in voice hearers which is aimed at prevention and proper resolution of underlying conflicts, rather than on administrating and maintaining people for life, is needed. It is the challenge of the HVM and other recovery movements, which make it no longer tenable to argue that a maintenance and reactive professionally- and cost bearer-led mental health provision is in fact acceptable.
Better mental health outcomes are possible to achieve. It may not even need more resources, but a different kind of focus on resources. Prevention is better than cure and we should of course never give up and always believe that recovery is possible for all people with psychotic type experiences.
Movements like these are well poised to be part of a broader understanding of a stronger prevention and of course resilience focus in mental health care provision. As mentioned before, in the palatine region of South-West Germany, the Pfalzklinikum tries to create such a way, by improving and linking organisational and expert knowledge around a socio-ecological approach of resilience. The Pfalzklinikum is based in the region, linked to all partners of mental health service provision in the region and led by the idea of a new way to improving resilience and recovery (Bomke, P., Kendall-Taylor, N. and Cawthorpe, D. 2014)
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1) Angermeyer M.C. and Matschinger H. (2005) Causal beliefs and attitudes to people with schizophrenia, Trend analysis based on data from two population surveys in Germany. British Journal of Psychiatry. 186, 331–334.
2) Bomke, P (2014) Pfalzklinikum – Service Provider for Mental Health, in: International Innovation: Health, August 2014 (Research Media, UK), pp. 38 – 39
3) Bomke, P., Kendall-Taylor, N. and Cawthorpe, D. (2014) Building a Road to Resilience. https://www.openaccessgovernment.org/building-road-resilience/ [Accessed 01 February 2015]
4) Bomke, P. and Kendall-Taylor, N. (2014) Framing change. Pan European Networks: Government – August 2014, Issue 11, pp. 178 – 179 http://www.pfalzklinikum.de/fileadmin/user_upload/Dokumente/2014-08-01_Framing_Change_PanEuropean_2014_issue_11.pdf [Accessed 31 January 2015]