My Research with People who Hear Voices

For four years (1996-2000) I worked with people who hear voices (auditory hallucinations) in individual and group therapy. I conducted doctoral research into what people who hear voices find helpful or not helpful in dramatherapy and psychodrama. From 1995-2002 I was registered for a PhD at the Centre for Human Communication, at the Manchester Metropolitan University. I have now been awarded the doctorate. A book based on my PhD: “Drama, Psychotherapy and Psychosis” with a foreword by Zerka Moreno and an afterword by Dr. Sue Jennings, has been published by Brunner-Routledge.
ISBN: 1-58391-804-3 hardback £ 50.00
ISBN 1-58391-805-1 paperback £ 17.99
Order from :
book.orders(at)tandf.co.uk
NOTE: ON THIS WEBSITE TO PROTECT E-MAIL ADDRESSES FROM SPAM I HAVE SUBSTITUTED THE “@” SIGN FOR (at).

There have been fourteen reviews published so far in British professional journals and one in the USA, one in Italy. Here is the newest comment on the book, received October 2013:

“In all my years exploring and teaching psychodrama, sociometry and other action methods, John Casson’s book, Drama, Psychotherapy and Psychosis is the single most provocative and inspiring of any I have encountered. I have rarely, if ever, been so moved by the level of creativity, rigor and commitment to this highly under-served, misunderstood, and often degraded population. It is a book full of exquisite detail and inventiveness. For those of you who have not been exposed to John’s work, Have You Got a Treasure and an inspirational, possibly life changing, experience in store.”

Barnett J. Weiss, M.A, L.C.S.W. Former Director of the Moreno Psychodrama Theater inNew York City.

Drama, Psychotherapy and Psychosis:
Dramatherapy and Psychodrama with People Who Hear Voices
by John Casson

reviewed by Rosalind Hewitt, psychosexual therapist,
UKCP Journal Issue 38, Summer 2008

John Casson has pulled off the rare feat of turning his PhD into an accessible, well-structured and fascinating book for the lay reader. Comparatively few therapists are equipped or inclined to work with people diagnosed with schizophrenia, those who experience psychosis, or who hear voices. While probably even fewer UK practitioners are trained in psychodrama or dramatherapy. However this fascinating volume deserves the widest readership.

Casson quotes Joseph Levy Moreno, the creator of modern psychodrama, that it is “the science which explores the truth by dramatic methods. It deals with interpersonal relations and private worlds.” As defined by Sue Jennings, a leading exponent, dramatherapy is “the specific application of theatre structures and drama processes with a declared intention that it is therapy.”

Inevitably there is an overlap between the two therapies, but in psychodrama practitioners are more likely to work directly with a person’s difficulties, as in the empty chair technique. Whereas dramatherapists use stories, metaphors and objects to provide people with a safe distance from material that could be too threatening to be addressed directly. In this sense it is probably more akin to art and play therapy. Both approaches, therefore, offer excellent opportunities for holistic, creative and reparative work.

Chapters 1 and 2 provide a historical and personal perspective to hearing voices and their possible function: to give voice to unspeakable, disempowering experiences, such as childhood abuse and how, nonetheless, people can, literally, dramatically regain control of their lives. These ideas are further explored in chapters 3 and 4, which includes a useful examination of the models of madness and healing through the dramatic repertoire. In Chapter 7 case studies illustrate how this might be achieved in a non-threateningly and empowering manner, with even the most vulnerable clients. Several other chapters comprise in-depth explorations of individual and group work which include illuminating pieces of dialogue between the author and his clients. The last two chapters explain what clients find helpful and the constituents of good practice.

Even if therapists aren’t encouraged, as Casson hopes, to utilise psychodrama and dramatherapy in their practice they will almost certainly find his book a valuable and inspiring resource.

Rosalind Hewitt
Psychosexual Therapist
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The following review is by Sybil Ah-mane
and was published in Mental Health Today

DRAMA, PSYCHOTHERAPY AND PSYCHOSIS
John Casson
Brunner-Routledge 2004

This brilliant book explores the use of drama and psychotherapy with people who are experiencing or have experienced psychosis.

Even without prior knowledge of the use of psychodrama in working with mental health service users, this book can be read comfortably from cover to cover. It starts with a thorough and detailed look at issues surrounding psychosis before going on to give valuable insights into different techniques of psychodrama and psychotherapy. It is engaging, thought provoking and, equally importantly, accessible. The paragraphs are short and the language straightforward; in fact, the whole package makes it a real page-turner. Casson writes in a style open to all and willingly gives away all his techniques and in doing so, de-mystifies not only drama and psychotherapy but also psychosis itself.

I would recommend this book to anyone working with people affected by psychosis – not just people with an interest in drama or psychotherapy. Fundamentally, it promotes an approach that is respectful to users, giving them choice, control and a sense of hope. It explains how to work in this style and illustrates the potential for growth when professionals form relationships with clients based on equality and negotiation, and allow them to have a say in their treatment. Casson also gives some handy hints on ways the worker can look after him/herself during this process. This book is concise, informative and a surprisingly enjoyable read.
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During the research I invented the Communicube: see

www.communicube.co.uk

It was called the Five Story Self Structure at first and is a way of mapping and working with the complex experience of hearing voices. It has been found to be helpful in enabling and empowering many clients of all kinds to expand their sense of self and make sense of conflicting parts of self and experiences. The prototypes have been taken into the Science Museum in London and structures are on display in a new exhibition called MIND MAPS until August 2014.

Dr. John Casson at the MIND MAPS Exhibition, the Science Museum, Kensington, London

(Photo by Anna Casson)

Mind Maps: Stories from Psychology, explores how mental health conditions have been diagnosed and treated over the past 250 years. Divided into four episodes between 1780 and 2014, this exhibition looks at key breakthroughs in scientists’ understanding of the mind and the tools and methods of treatment that have been developed. Bringing together psychology, other related sciences, medicine and human stories, the exhibition is illustrated through a rich array of historical and contemporary objects, artworks and archive images.

The exhibition is from December 10th 2013 until 12th August 2014 at:

The Science Museum, Exhibition Road, South Kensington, London, SW7 2DD.

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I have also written a five act play:

“Voices and Visions” based on the research telling the story of four voice hearers and their therapy. If you are interested in this please be in touch. For information about the play please go to the Home Page on this site, at the end of the page.
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Below is a short report of the reserach and my speech at a recent conference for Refugees and Asylum Seekers:

DRAMATHERAPY, PSYCHODRAMA
AND VOICES

Abstract: This article is a summary report on qualitative research carried out over six years, 1995-2001, with people who hear voices (auditory hallucinations) into what they found helpful or not helpful in dramatherapy and psychodrama.

Key words: dramatherapy, psychodrama, hearing voices, auditory hallucinations, psychosis, schizophrenia, trauma, empowerment.

Introduction:
21 people, who heard voices and were clients of the Mental Health Services of two adjacent N.H.S. Health Trusts, were offered individual or group dramatherapy and psychodrama. They were asked at the start, during and after their participation what they found helpful or not helpful. This research falls into the fifth category of evidence for particular interventions, under the Department of Health National Service Framework for Mental Health, namely: expert opinion, including the opinion of service users.

Definition of Dramatherapy:
Dramatic healing rituals have been conducted by shamans for millennia. Dramatherapy is defined as “the specific application of theatre structures and drama processes with a declared intention that it is therapy,” (Jennings, 1992, 229). Theatre therapy was initiated by Goethe from 1775: he influenced Reil (who in 1803 recommended theatre therapy in Germany); by Coulmier, at Charenton 1797 – 1811, France; by Browne 1843, at the Crichton Royal Institute, Dumfries, Scotland; and developed by Iljine in Russia 1908-17. Dramatherapy developed internationally from the 1940s.

Definition of Psychodrama:
Psychodrama was created by Moreno in the 1920s – 40s and is recognised internationally as a form of psychotherapy. Moreno defined psychodrama as “the science which explores the truth by dramatic methods. It deals with inter-personal relations and private worlds.” (Moreno, 1993, 53)

Dramatherapy and psychodrama, as creative action methods in psychotherapy, overlap. They facilitate the development of the person through encouraging spontaneity and creativity. Since their inception they have been used with people struggling with psychotic illnesses. However this is the first research to examine the efficacy of these methods specifically with people who hear voices.

Who are the people in the study?
Half of the 42 people referred, 21 people: 9 women (aged 24 – 44) and 12 men (aged 20 – 50), completed an assessment of six sessions and chose to enter the study, taking up offers of individual or group therapy. Six (4 women and 2 men) were offered 44 sessions of individual therapy. Another woman was offered 40 sessions of individual therapy. Three men who were waiting for a group were given 17 sessions of individual therapy.
There were three groups (20 weekly sessions of up to two hours duration) offered sequentially: a men’s group and two mixed gender groups. Two men chose to attend two groups (of these, one man dropped out of the second group) and one woman chose to join a group after her individual therapy had ended. The low drop out rate (one woman and three men) suggests the long and careful assessment had built up a sufficient therapeutic alliance to sustain the person through the therapy. The first group suffered one drop out, the second group two drop outs, the third none. One person left individual therapy (after 30 sessions). Three people (two men and one woman) had experience of both individual and group therapy. For this study I have not been able to gather the opinions of those who dropped out, except in one case: so the results of this study are based on the opinions of 18 people. One person (Ron Coleman) who was not part of the cohorts but had psychodrama experience was interviewed for his opinions.

Age: ranged from 20 – 50: six in their 20s; ten in their 30s; four in their 40s, one aged 50.

Ethnic Diversity: 
One African; one S.E. Asian; one Asian; one half Jewish; one descendant of 2nd World War Ukrainian immigrants; one half Spanish adopted at birth by British couple: all of these had experienced the impact of racism; three experienced the dislocation of being a refugees from violent political upheaval: they had survived terrorism and genocide.

Diagnoses: 
Schizophrenia: 7: five women, two men (2 survivors of rape, 3 of sexual abuse, 1 of physical abuse.)
Paranoid schizophrenia: 7: five men, two women (2 survivors of sexual abuse, 2 physical abuse.)
Depression: 3: two women, one man (1 survivor of rape, 2 of physical abuse, 1 of sexual abuse)
Paranoid psychosis: 2: men ( 1 survivor of physical abuse, 1 of bullying)
Drug induced psychosis: 2: one man, one woman (both survivors of physical abuse)
Organic psychotic illness: 1 man (survivor of physical abuse)
Personality disorder: 2 women ( both survivors of rape, 1 of sexual abuse)
“Neurotic with voices” (originally diagnosed schizophrenic when 21): 1 man (bullied)
Several had more than one diagnosis. Two people did not have any diagnosis of a mental illness: both were survivors of abuse.

Experiences of trauma:
Survivor of sexual abuse as a child: 7 (women)
Survivor of rape as an adult: 4 (two women, two men)
Survivor of physical abuse as a child: 7 (five men, two women)
Survivor of bullying as a child/young person: 3 (men)
There were many other traumas: the death of siblings, assaults, head injuries, near death experiences, witnessing murder, other losses and the traumas of mental illness. There were traumas in parents’ and grandparents’ lives.

What we did:
Not counting the assessment sessions this research study is based on 349 individual therapy sessions and 60 group sessions (given the number of people in the groups this amounts to approximately equal numbers of client sessions in individual and group therapy).
We used warm-ups in the group and individual work: passing an object around; talking about our world; name and word games. We practised breathing, walking, movement, mirroring exercises, Tai Chi, physical games; relaxation; back massage; gave hugs; created rituals; worked with props and objects. I encouraged talking, singing, shouting and the use of the whole range of people’s voices. We played musical instruments and percussion. We used visualisation, imagined landscapes, used photographs; made drawings/paintings; told stories with symbolic objects, buttons, stones, dolls house furniture, toy animals, babushka dolls, toy theatre. People wrote poems and songs. We used play texts and then improvised dramas. We used hats, gloves, cloth to create characters and told their stories; made masks; used puppets; enacted myths; practised assertiveness and social skills, rehearsing situations, practised saying “No”. We used cardboard boxes (which could be smashed up with a rolled up newspaper/foam baton), cushions which could be punched or thrown, soft toys and a life size figure that could be thrown or hit to express anger. We enacted dramas about voices.
We used psychodrama to re-enact dreams/nightmares and take control/change of these intra-psychic dramas. Psychodrama enabled people to review and rehearse scenes with family or professionals where the person wanted to assert themselves. We used role reversal to explore voices.
People also took the opportunity to talk about their lives, their voices, their experiences of trauma and their feelings about past, present and future.

The opinions of the participants:
(All names are pseudonyms: the opinions in italics are verbatim transcripts from interviews or journals.)
The majority (80%) who took part found the methods helpful. Therapy provided people with support that was empowering: enabling them to cope, strengthening them through increasing confidence, raising self esteem and reducing isolation, thus diminishing the impact or frequency of negative/persecutory voices.

What was helpful in therapist behaviour:
What the people in this research have found helpful above all in me, as a therapist, has been my capacity to listen, without judgement. Other qualities that they have appreciated are my ability to be dependable, respectful, trustworthy, supportive, positive, warm, safe, playful. Therapist skills they have appreciated have been my facilitation of group process, holding the boundaries of time and space, being both professional and yet relaxed/calm/informal, my ability to share my own experiences, be creative, to motivate, not pushing yet confronting in a supportive way. It was my ability to relate, to establish a warm, friendly relationship that formed the basis of all therapeutic work. In research into what persons with serious mental illness wanted in individual therapy, “Friendliness was the quality most desired in a therapist.” (Coursey et al., 1995, 283)

Opinions about dramatherapy and psychodrama:
Cheryll: It’s active, fun, motivating – when you?re down or have low self esteem it’s uplifting and brings you out of your shell.
Roger: Dramatherapy has helped me survive. If I wouldn’t have joined the dramatherapy group maybe I wouldn’t be here.
Dave: The great thing about these groups… is that you are free to be what you want: – An adult, a child, thoughtful, flippant, sad, happy, you have freedom gained from shared and directed trust to be anything… It’s so good to act silly; to have fun as a child, to really have a laugh in a way I haven’t played since a small child feeling intimidated, scared, guilty, responsible and alone… I’m not sure personally if your groups alleviate voices directly; but it’s positive to be in them and if voices are stress related then by alleviating this stress as happens in the group, then it’s very useful… One of the problems with medication is that it flattens your emotions; it induces a tranquillity of sorts but this is more like a numbness or hollow feeling. Consequently whilst using medication it’s difficult to realise your emotional potential and therefore means of expression; whether they be writing, painting or John Casson’s dramatherapy group are important to maintain your sense of self as a human being and to realise that emotions can be expressed in a positive way without having to suppress everything and resulting in even more emotional flattening and long term psychological illness. John’s group is an important means of developing well being for this reason and I believe should be offered long term to people with not only voices but also other mental illnesses. I am making progress in well being and as a human being and want this to continue and be there for me when/if I relapse and to get better & better. I’m actually feeling stronger and more confident by expressing my feelings and insecurities in this controlled/metamorphic group situation and feel safer to do so now than a month or when the group started. There is a lot to be said positively for group therapy (even though it can be publicly painful) which I didn’t realise at first when I was fixed with the idea only 1 to 1 sessions were helpful.
Gloria: Only when I started dramatherapy I was able to state how I felt… (Dramatherapy) helps you to do the healing itself, to be instrumental in helping yourself, empowering rather than just taking medication which makes me anxious because of the high dose.
Harry: It (dramatherapy) helped me a lot: gave me more self esteem, helped me collect my thoughts better… It’s done a lot for me. Confidence boost in waking up to reality. I feel happier in myself. I don’t feel depressed. If anything does get me down it’s for a very short time. I can get out of it and get on with what I?m doing. I don’t feel confused. Even when I get in a stress situation I can take the breathing exercises, calm down, go through it slowly. It?s helped me in so many ways. I?ve not heard any voices since.

The benefits of creative action methods:

1 social:
The emergence from isolation is therapeutic and leads to a reduction of voices. Social skills can be learned and practised. People can be encouraged to become more assertive, to voice feelings and opinions. These activities lead to an improvement in a person?s relationship with themselves and in their relationship with others.

2 relief from tension:
Since stress exacerbates voices the person can benefit from relieving tension through relaxation, being able to express self, feelings, frustrations/aggression. Being creative raises self esteem, and expands people?s role repertoires, freeing them from debilitating constraints. Laughter resulting from having fun relaxes people.

3 insight and integration:
Therapy can enable people to gain insight into the sources of voices in earlier experiences. Working through these enables the person to own their voices and previously split off feelings, and thus achieve some resolution/integration of the intra-psychic difficulties that were the origin of the voices. Creative activity facilitates the integration of unconscious material, strengthens the ego, and promotes personal development.

4 rehearsing a future:
Recovery must be a possible future (Coleman, 1999): the instillation of hope is in itself therapeutic (Yalom, 1985, 6). But hope cannot just be given to people: they must discover hope for the future through their own practical efforts and experiences. Dramatherapy offers the possibility of rehearsing situations and practising behaviours to achieve competence and confidence.

5 distance and empowerment:
Essential to safe and effective work are the therapeutic relationships (with the therapist and other group members) and the degree of distance the person needs at any one time so as not to be overwhelmed and further disempowered. Creative structures provide varying degrees of distance, a safe container for feelings/fantasy and develop the observer ego. The methods can empower through choices and decisions being made by the people who hear voices. Their creative expression of will and responsibility for what is co-created is empowering. In dramatherapy people can experience being in control and letting go of control.

6 prevention of suicide and self harm:
There is some evidence in this study that therapy reduces self harm and suicidal behaviour as a result of the opportunity to express feelings and receive support. Therapeutic relationships hold people back from the brink.

7 the effect of therapy on voice hearing:
Seven people said they heard fewer voices; six heard the same amount; three found their voices less disturbing/aggressive; one person said they were more aggressive.
Cheryll: Yes, become soft, not harsh, not making threats. Part of the year the voices disappeared altogether. I was relieved…
Theo: (The voices have) gone softer, not shouting, nice, kinder. The aggressive voice has gone. A mumbled voice – nonsense, easier to dismiss…
Dave: The same but not as disturbing as they were. I feel more confident.

What was unhelpful:

What was unhelpful in therapist behaviour:
Anton: Pushing things, making them rush.
The emotional aftermath of sessions that were not brought to sufficient closure was difficult for people to cope with.
Gloria: Opening up some of the old wounds. It seemed to unleash a lot of pain without having a cushion there for me to fall on. It later allowed me to systematically heal that wound… Some of the role play had an adverse effect rather than clarifying. Instead of coming out feeling I’d resolved something I came out feeling halfway through an issue – perhaps it was more deeply embedded: it took a number of sessions to dismiss, something had resurfaced… Some issues are still deeply embedded.
Jenny: I can’t put myself back together and everything feels floating and in bits and that stayed like that for a while so I felt on my guard… I don?t know how to handle it when I come home. He were good at getting it out but no good at telling how to put it back. Perhaps finish a bit sooner and talk about what we?d done, and leave a bit more time at the end to stick myself together, pick up the pieces.

Following this feedback I changed the way I was working, ensuring the last 10-15 minutes were a time for re-integration, de-roling, reflection, closure, preparing to leave the session.

Inter-personal difficulties, conflict and hostility in the group were felt to be unhelpful.
Simon: Felt a bit of difficulty with Jimmy at one stage but it didn?t last very long. We didn’t seem to hit it off too well. I don’t know if it was a communication problem or a different clash of personalities or what. He seemed to get annoyed about something. I’m not so sure that some of it was particularly helpful.
As Simon suggests given time such conflicts can be worked through but this depends on people attending the group consistently.

Some said that lack of attendance with the resultant lack of time, continuity, depth was unhelpful.
Dave: (Group 1) It’s not so good when people miss groups; it throws the bonding/empathy/shared experiences and trust off balance for the following week.
Tom: (Group 2) It was just a shame when people had times when they were off. I would have found it better if everyone could have been there at the same time…
Simon: (Group 3) People not attending and it being such a small group: it did cause a bit of a difficulty in maintaining the continuity…

These suggest some people may need support for group attendance: as I was working alone it may be that support workers or others could accompany people whose motivation is low, enabling them to attend.

The end of therapy can result in an increase in voices: even a two week holiday was found to be an unhelpful break in the continuity of support. Co-therapy would mean therapist holidays did not result in a break for the group.
Diane: (After therapy) The voices have got worse. (She felt more isolated.)

This suggests a need for people to receive some social support after therapy and have some control over the duration and ending: the therapy available in this research was of an arbitrary length.

Conclusion:
I was able to innovate methods and show that dramatising psychotic material and working creatively with people who hear voices does not result in any deterioration of mental health but enables people to move from isolated fantasy/delusion towards shared reality.

Cheryll: I come up here in a fantasy world – so we could express that fantasy and connect with reality.

Cheryll echoes Goethe’s 1775 play Lila about the healing, through dramatising her delusions, of a woman struggling with a psychotic grief reaction.

Count Altenstein: It is your belief, doctor, that we may gain some influence over her if we play up to our niece’s fantasies.
Dr. Verazio: In the end fantasy and reality will meet.
(Goethe, 1973, 21)

I have been able to create an environmental model of psychotic process, a theatre model of the self, a dramatherapy model for working with people who hear voices and guidelines for good practice. Dramatherapy and psychodrama can contribute to the recovery of people who hear voices and strengthen their ability to cope.

Acknowledgments:
Dr. Alistair Stewart, Consultant Psychiatrist, Oldham for his support.
N.W. Regional Health Authority Research and Development Reactive Funding Scheme for the Research grant.
The Centre for Human Communication, Manchester Metropolitan University, for financial and academic support.

References:
Coleman R. (1999) Recovery an Alien Concept, Gloucester, Handsell Publishing

Coursey R.D., Keller R.E., & Farrell E.W. (1995) Individual psychotherapy with persons with serious mental illness: the clients? perspective. Schizophrenia Bulletin, 21 (2), 283-301

Goethe J. W. von, translated by Danielsson O. (1973) Lila, a play with song and poetry in four acts. published privately by O. Danielsson.

Jennings S. (1992) chapter IV.3 The Nature and Scope of Dramatherapy in Shakespeare Comes To Broadmoor edited by Murray Cox, London, Jessica Kingsley Publishers

Moreno, J.L. (1993) Who Shall Survive? Student Edition, Roanoke, Virginia, USA: American Society of Group Psychotherapy and Psychodrama, Royal Publishing Co.

Yalom I. (1985) The Theory and Practice of Group Psychotherapy, New York, Basic Books, Inc., Publishers
John Casson, July 2001
Whilst I assert the copyright of my work I am happy that people share this information with others towards the empowerment for people who hear voices and the development of good practice by therapists.

Speech at The Refugee and Asylum Seekers? Conference, Manchester
22/11/01 hosted by the Manchester Black Health Forum

Introduction
I am a psychotherapist using creative action methods to help adults who have mental illnesses and emotional problems. I have conducted research with people who hear voices, (auditory hallucinations) who are struggling with psychotic experiences and who are survivors of abuse into what they found helpful or not helpful in dramatherapy and psychodrama. From 1996-2000 I saw 42 people, of whom just under half, 20 people: 9 women (aged 24 – 44) and 11 men (aged 20 – 50), completed an assessment of six sessions and chose to enter the study, taking up offers of individual or group therapy.

Ethnic Diversity: 
Of these 20 people there was one African; one S.E. Asian; one Asian; one half Jewish; one descendant of 2nd World War Ukrainian immigrants; one half Spanish adopted at birth by British couple: all of these had experienced the impact of racism; three experienced the dislocation of being a refugees from violent political upheaval: they had survived terrorism and genocide. Two other people had the experience of emigrating and returning to Britain. Therefore about a third of a small random sample of people who struggled with auditory hallucinations in two adjacent normal psychiatric services had experiences of moving between countries and this confirms a previously noticed vulnerability of refugees to mental distress.
All names in this presentation are invented to protect the confidentiality and privacy of the people.
The meaning and origin of psychotic illness in traumatic experiences:
Some of their psychotic experiences, hallucinations and delusions referred directly to their experiences.
Ben had physical – shocking experiences, felt thrown about as if someone else had control through modern technology, giving him powerful electric shocks… From head to toe, as if someone was drilling a hole in it… My head is as if it had a bullet hole in it… Part of it is a political thing (beyond my control). It?s done so much harm to my life, my family’s suffered. As a child Ben witnessed the murder (a gunshot to the head) of his father during a civil war. (Such an image might be misunderstood as delusional when in fact it is reality based.) He had had shocking experiences of torture, loss and famine. He identified the war as the source of his problems. Ben was very troubled and disabled by a delusion that a controlling technical, non-human, agency outside him was the source of his problems and he was powerless. He had experienced the extreme destructive power and control of the military during war.
Ben: It’s hard to solve problems, I’ve lost freedom, I have not much freedom, I’ve not much ability, I’ve lost this/that… I lack so much, short of things, financial, family, security. I’m so isolated. Ben’s experience as a refugee had grossly disempowered him.
Two people were immigrants from Europe:
Roger’s father had been captured in Russia by the Germans during World War II and given the choice of death or joining their forces. He’d begged for his life whilst hundreds were machine gunned. Later he had been violent to his wife and to Roger. Roger lived with his mother and both suffered the stress of racist abuse.
Dillon’s father’s family had escaped the Nazi Holocaust, others relatives had perished. His grandfather had hidden in a English Protestant family and lost his Jewish identity. His grandfather did not talk about the Holocaust. Dillon became ill whilst at University where he was studying history: he likened his breakdown to the ice axe murder of Trotsky (who was Jewish). Dillon believed the Germans were against him. (See Bloom, 1997, 63 re intergenerational transmission of the effects of the Holocaust.) Shutzenberger (1998) has traced the pathogenic transgenerational influences that transmit the effects of trauma down the family tree.
Two people were immigrants from Africa:
Leah’s father and mother were refugees from a regime that had sent them into exile, making them stateless; he was violent to Leah and her mother until they separated.
Gloria’s family had fled from an oppressive regime and state terrorism which had resulted in the murder of two members of the family. The loss of one’s country is a deep, soulful trauma. One of Gloria’s voices spoke the language of her ancestors, one of Ben’s voices spoke his original, native language. The inhibition of refugees to speak their own language is due to the dominance of the culture they have entered: there is pressure to assimilate and they may be isolated from others who speak their language. The voices may be the only ones who speak the old language, as Gloria and Ben experienced. Gloria felt empowered when I said she could speak in any language she wanted to: she occasionally spoke her ancestral tongue. I encouraged Ben to speak his native language.
Dillon was frightened of fascists with air rifles. I later discovered this was not a paranoid idea but a political reality in his area. The alienation, deprivation and violence are aspects of the social/economic reality of some areas in our society. Poverty is part of their oppression.
Ben: Since I left (my country) I haven’t done that much. I lack so much, short of things, financial, family, security. I’m so isolated.
Gloria: It’s depressing when you have needs and are on very (low income)… I have this feeling of being divorced from society at large; which results in feelings of abandonment.
Such exclusion has a depressant effect and leads to people feeling powerless and withdrawing from the world: they become stuck in the house, isolated, fearful to go out. Such poverty translates into emotional and social poverty, a lack of satisfying roles and relationships. This loss of social skills can develop into chronic loneliness:
Leah, after the diagnosis of her psychotic illness, couldn’t go out for four months. Such isolation leads to depression and may exacerbate the voices: indeed the voices may people the loneliness and comfort by their presence. Voice hearing may be a creative response to loneliness: the brain generating company!
The fact that hallucinations of various kinds may be elicited in many people under conditions of extreme social isolation raises the possibility that people with a psychotic disorder such as schizophrenia who have become largely cut off from the normal social world might experience hallucinatory voices as a result of their sensory isolation alone. (Watkins, 1998, 19)
Isolation might not just be in a room, but in a culture: Pronounced effects have been reported when individuals have been separated by one means or another from their usual social or physical environments, with resulting reports of ?culture shock?, the psychoses of language-isolated refugees. (Haggard, 1964, 443)
Ben who had lost father, mother, grandparents, relatives, his country, language and culture said, I feel I’ve lost myself.
In isolation a person can feel lost or that they have lost their identity, (Coleman, 1999, 55).
Not only may refugees be isolated and unable to speak their original language but be unable to speak of their experiences: the trauma of losing their home and the losses and pain, the traumas they experienced before leaving their country and after arriving here.
In Ben’s life and in the lives of Gloria’s and Roger’s fathers and Dillon’s grandfather there had been times when to speak out would have cost them their lives. Ben was unable to speak when his father was murdered: survival meant passive, silent acceptance and his traumatic experience became unspeakable, locked within his psychotic illness. Psychiatric and the wider culture may prohibit speech.
Dillon: Many people with these problems can?t speak publicly, they feel they will be attacked/joked about…
Roger also expressed this experience of not being listened to by psychiatrists. He wrote a poem of wanting to scream but no one hearing.
Preventative Mental Health Work.
It seems to me that it is essential to good mental health to have social support, friends, a sense of belonging and power: to be able to feel effective. It therefore seems essential that people who are refugees and asylum seekers have support, build networks of self help and do not become isolated in a hostile environment. People need to find the allies: to search out not only people from the home culture but new friends and groups. It is also essential that the traumas of exile, of the experiences that led to exile are not buried but are talked about, processed and healing supported. Refugees need to meet together in groups, receive counselling and therapeutic help but above all not keep silent about their experiences, for in such a case the traumas may be transmitted down the generations. Refugees have survived and can be proud of their achievement in escaping: they are witnesses and have important stories to tell. Sadly the psychiatric services may not be well equipped to listen to these stories. The medical model of care can mean that hallucinations are regarded as symptoms of a biological illness and treated with medication rather than being acknowledged as symbolic communication of distress that cannot otherwise be expressed or processed. We need to work together to ensure culturally sensitive services are available. We share responsibility to find safe and creative ways to work together for positive outcomes. Refugees and Asylum seekers have enriched this country for generations. Their stories must be told: this story telling be healing for them and enriching for us who listen. Pain shared is pain lessened and teaches us to appreciate our freedom and value each other.

References:
This paper is drawn from my PhD thesis Dramatherapy as a Psychotherapeutic Intervention with people who Hear Voices (Auditory Hallucinations) Manchester Metropolitan University.

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Watkins, J. (1998) Hearing Voices, A Common Human Experience, Melbourne, Australia, Hill of Content