|INTERVIEWING TIP OF THE MONTH
# 2 April 2000
Uncovering Auditory Hallucinations
TISA Description of the Problem: There is a common misconception that true auditory hallucinations are always heard as coming from outside the patient's head. This misconception may have originated with the work of the noted European phenomenologist Karl Jaspers, who, besides being remarkably brilliant, was almost always "on the mark" with his clinical observations. Jaspers made the distinction between true hallucinations (originating from outside the patient's head) from pseudohallucinations (originating from inside the patient's head). In this instance, the noted Jaspers missed the mark, for hallucinations, common to major psychotic processes such as schizophrenia and bipolar disorder, can be heard as originating both inside or outside of the patient's head, and are equally valid or "true" from a clinical standpoint.
Personally, I have talked with many patients with schizophrenia who describe their voices as "being in my head." In some instances these voices move out into space and truly seem more real at that point. In other cases, the voices always seem to be originating solely from outside or inside the patient's head. There are even reports of the voices moving inside patients' heads as their psychosis responds to antipsychotics. But the bottom line remains that auditory hallucinations can be experienced in both ways, and the DSM-IV accepts both types of voices as valid hallucinatory phenomena.
It is also interesting to explore what is meant by the word "real" because patients may tell the clinician that the voices are quite real but do not sound exactly like normal voices. It is not uncommon for psychotic patients to be able to identify their hallucinations as abnormal voices. Sometimes they may even possess names for them.
If a clinician is attempting to decide whether or not a patient is faking hallucinations, these points become important. A patient who is malingering may tend to describe the voices as sounding just like normal voices, which remains possible in psychosis but not typical. Malingerers, in my experience often are adamant that their voices are from outside their heads, because they mistakenly think that such a description is what the interviewer needs to hear in order to diagnose them as psychotic. Their adamancy on this point is what may give them away. Malingerers may also describe the voices as happening all of a sudden, unaware that most voices (and psychotic symptoms in general) usually have subtle prodromal phases in which the patient is often feeling sensations such as being uneasy and wary. During the prodrome of psychosis patients often are hypervigilant of their environment and often are experiencing agitation or having significant sleep disturbances.
Tip: To be adept at helping people to share their hallucinations, it is important to create a safe environment in which to discuss these most intimate of phenomena, which some patients are quite wary of sharing. It is the degree with which the clinician seems to be comfortable and knowledgeable about the experience of hallucinations that often determines the degree with which people feel safe sharing their hallucinations.
In the last analysis, there exists no better method of learning about hallucinations than the experience of asking questions about auditory hallucinations to numerous people, ranging form psychotic to non-psychotic. Only in this manner will the clinician develop a sound sense of the range of normal and abnormal responses.
Clinicians are sometimes at a loss as to how to raise the topic of hallucinations with a client, especially if they fear that the client may be "put-off" by the question. I have found the following technique to be of great utility in this regard. After the client has been describing some of their intense emotional turmoil, and after the best attempts have been made to engage the client, the following lead-in question is asked, "When you are feeling very distressed, do your thoughts ever get so intense or painful that they sound almost like a voice?"
The wording of this question allows the topic to be broached in a fairly nonaffrontive fashion, because the interviewer is tying the phenomena directly into the patient's pain. The clinician asks if the patient's thoughts sound like a voice, a phrasing that offers a backdoor to the reluctant patient who fears being viewed as crazy, for the hallucinating patient can say something like, "Well, I don't hear voices, but sometimes it's sort of like that." The clinician can then explore sensitively and will often uncover the actual extent of the hallucinatory process.
If in response to such questioning the client admits to voices the following questions can both convey to clients that the interviewer is genuinely interested in their experiences, as well as helping the clinician learn more about what true hallucinations feel like:
1. Tell me what the voices sound like to you?
2. What do they say to you?
3. Do they sometimes taunt you or say mean things to you?
4. Are they male or female voices?
5. Do you have names for them?
6. Do they seem to be inside your head or do they come from outside your head?
7. Are they loud or soft?
8. When you first heard the voices, what did you think they were?
9. What feelings do you have as you hear the voices?
10. Do you ever hear several voices talking to each other about you?
TISA Follow-up: In a typical initial interview, with a person experiencing psychosis, the interviewer may not have the time to ask all of these questions, but as time permits the clinician can pick and choose, constantly learning more about the phenomenology of hearing voices. Of course, an extremely important area to explore is whether or not the patient is hearing command hallucinations to harm either himself or others, but then the topic of command hallucinations will have to wait for a future Interviewing Tip of the Month.
Tip provided by:
The above interviewing tip is adapted from Psychiatric Interviewing: the Art of Understanding, 2nd Edition (1998) published by W.B. Saunders and written by Shawn Christopher Shea, Chapter 6 (pages 344-346)