Living Mindfully with Voices

Rufus May works as a clinical psychologist in the NHS in Bradford England. His interest in recovery from psychosis and other difficulties is rooted in his own experiences of psychosis when he was 18 and subsequent recovery journey. His website can be seen here. 

Rufus May offered to share the following article on this blog a few month ago. He hopes his article 'Living Mindfully with Voices' will be of help to people who hear voices and their friends and supporters.  He also says that he also hopes it will be helpful to the voices which are part of many people's lives.

Introduction

Mindfulness is the ability to live life with as full awareness as possible of the present moment.This paper will consider how we can live more in the present moment and how we can ground ourselves in this awareness and deal wisely with powerful memories and voices from the past.  

Mindfulness is rooted in Buddhist meditation practice but over the last 40 years has been developed in the west as a tool for reducing stress and increasing well-being.  

Living mindfully is, essentially, about slowing down and noticing moments that we normally might ignore.  Instead of living in our minds; continually prioritising our plans and reflections on memories, we are encouraged to be more anchored in our awareness of the unfolding present moment.  From a mindfulness perspective we have a tendency to spend too much time getting caught in the trance of thinking, being preoccupied either with the future or going over past events.  These types of thinking can cause us to miss the present moment where everything takes place.  Mindfulness practices help increase our ability to return to the 'here and now' and to notice when we are getting distracted and lost in thoughts. 

Being more mindful we can experience less stress that comes from repetitive worrying. Also with mindfulness we can learn to look after strong emotions or worrying thoughts by stepping back to the bigger space of mindful awareness.  From this position we can relate to our thoughts and emotions with a gentle nurturing awareness. In this way we avoid either feeding them with anxious thinking or suppressing them.

Our relationships benefit from us being more present, more grounded in the moment of interaction.  If we are preoccupied with our thoughts and we only half listen to people, this reduces the quality of our responsiveness and therefore our relationships.  So being more mindful is also very beneficial to relationships.  It is also helpful in our relationship with our own thoughts and feelings.  

A mindful approach is accepting and non-aggressive.  We may be discerning, for example, about what we pay attention to but we do so in a respectful way.  If uninvited thoughts persist in arising in our minds we acknowledge them and pay them some attention rather than wrestle with them or merely try to block them out.  By practising mindfulness we can become more aware of how our attention is and how scattered we are. Then gradually, our concentration and awareness can become more open, flexible and less habitually driven.

Mindfulness approaches have been incorporated into various psychological therapy approaches. Examples include Gestalt therapy, Dialectical behaviour therapy, Acceptance based commitment therapy and Mindfulness based cognitive behavioural therapy.  In my work with hearing voices self-help groups over the last 12 years I have found that people who hear voices have found a variety of mindfulness techniques helpful.  This article aims to reflect on some of the implications of applying mindfulness to the relationship people have with their voices.

A psychological way of understanding voices is to see them as separated off parts of the person or their emotional experience.  Some voices seem to be replaying memories while others seem more sophisticated chunks of consciousness with their own emotions and motivations.  Like other parts of the personality, they are shaped by past events.  I see these beings as based in separated off parts of consciousness.  It appears to me that people who hear voices have an ability to connect with parts of the mind most people can only intuitively sense but not directly hear (except in their dreams).

Some voice hearers see their voices as spiritual.  There is a psychological approach that can embrace this possibility.  The psychologist Karl Jung proposed that the unconscious was linked to the collective unconscious.  Jung suggested that in certain dream states and other states of consciousness we can connect to a group consciousness, like a psychic internet.  Here we can meet archetypes and experience more fully our interconnectedness.  This offers us a view of the unconscious being possibly linked to a spiritual realm.  Many voices I have come across and the people that hear them are convinced that their voices are spiritual in nature.  I take an agnostic position on this, and therefore endeavour to respect different spiritual understandings.  My intention is not to explain all voices psychologically but to help people make peace with their voices so they can get on with their lives.  

In the west we can get obsessed with trying to explain the origin of phenomena.  However a relational approach to voice hearing does not require such explanatory knowledge.  In a relational approach it is not so important whether someone's voices are spiritual beings or psychological parts.  What is important, is how we live with and relate to these experiences.  I find if we are aggressive towards voices this seems to agitate them.  If we find ways to listen to them in a balanced way from a place of strength and grounded awareness they seem to become calmer and more helpful.  This gentle style of relating that is promoted by mindful approaches has had some success when applied to to pain management.

Living mindfully with pain

Jon Kabat Zinn (2001) has developed mindfulness exercises to help with stress and pain management.  Researchers have realised that our sense of pain is made more difficult by our resisting attitudes towards the pain.  So if we think: “I wish I did not have this pain” or “Why is this pain happening to me?” or “When will this wretched pain go away?” these resistant thoughts make the pain more painful.  Alternatively Jon Kabat Zinn has found if people find ways to mindfully be with the body including the painful parts of the body and not resist it, the sense of pain reduces.  One of the practices recommended is the body-scan where one progressively focusses on sensing different parts of the body.  Similarly, over the last 25 years, people have found in the hearing voices movement that if they find ways to accept their voices, the experience becomes more manageable (Romme and Escher 1991).

Mindful attitudes

Jon Kabat Zinn emphasises the importance of certain mindful attitudes.  These include:

●    Acceptance - accepting what is present rather than denying it or wishing it was not there. 

●    Non-judging - observing objects and events without evaluating them.

●    Patience - we stay with the present moment and don't rush towards the next exciting event, we focus on the unique unfolding of what is happening now.

●    Beginners mind - seeing things with an open mind and noticing their unique qualities.

●    Letting go - developing the ability to switch attention and let go of one object of concentration and focus on another 

●    Being with - as opposed to trying to fix or control things or achieve constantly

●    Non-striving - by accepting the present moment and its accompanying sensations we let go of constantly striving for better moments.  We focus on the journey rather than just the destination.

●    Non-attachment - this is about relating to things with kindness but not clinging onto them recognising that everything changes. 

These friendly attitudes are about honouring what is there and noticing the unique possibilities rather than trying to change things to fit with our ideals.  In adopting this attitude we discover that  when we accept something it changes. Western society encourages us to try to get rid of unwanted experiences. Mindfulness is about being accepting without giving in to experiences. Voice hearing is a socially judged experience so people often internalise this refusing to accept what they are experiencing. The mindful attitudes such as being open minded, patient and non-judging offer a useful alternative to the discriminatory approach that society can encourage towards voice- hearing.

Mindful supporting

I have found having a mindfulness practice where I meditate regularly and practice mindful attention exercises assists me to support people hearing voices.  I have a part of me that seeks to fix things and give advice when people are struggling emotionally. Whilst this is sometimes helpful I have also found the best thing to do is to be present and listen mindfully both to the person I am with and also to myself.  

When I feel stuck in the way I am relating to the person or people hearing voices I will pause. Then I will assume an upright but relaxed posture and listen to my feelings in my body, to my contact with the floor and chair I am sitting on. I will also tune into my sense of the space around me, the light in the room and the sounds that I can hear.  I may also become aware of my breathing, for two or three breaths.  When I can bring this awareness into consultations and group work it seems to create a bigger space to hold what is happening and to allow for new meanings to emerge.  

Edward Podvoll (2003) developed the Windhorse project in America based on mindful forms of support to young people with psychotic experiences. He called this way of being with people 'basic attendance'.  The Mindful attitudes mentioned earlier are central to this approach. He also felt that within the context of a being present with people as they are, there were times to 'lean in' on them.  'Leaning in' describes how in the context of a good relationship we may invite people to join in an activity or take on a new responsibility like cooking a meal or leading a walk.  So being mindful does not mean we passively accept people as they are without ever intervening with suggestions. It does mean that being comfortable with silences and being as present as possible with people is seen as a powerful element of compassionate and emancipatory forms of support.

Mindful living

Gradually through practising mindfulness we learn to be kind to ourselves.  Mindful living is finding ways to be more aware of the present moment.  We try to live more gently, more consciously, noticing the sensations in the here and now.  Right now, I am sitting on a train at Wakefield station.  I am noticing the coffee I am drinking and the texture of the paper cup against my lips.  I can also notice my posture and the slight aching sensation in the centre of my back. It’s 7.40 in the morning in October and the grey skies are now lit up by a pale morning light.  Factory smoke pumps out on the horizon.  If I focus on the sounds around me I hear the movement of the passenger behind me as he rearranges his belongings (I am guessing he is by the level of movement).  I can hear the train accelerating away from the station, the turning of a newspaper, the mutter of an Ipod and various sniffly noses.  I am used to doing this because most days I will spend time just observing sights, sounds and feelings coming into my senses.  

I use an exercise called “5, 4, 3, 2, 1” where I takes the time to notice 5 things I can see, 5 things I can hear and 5 things I can feel.  Having done that you proceed to notice progressively 4, 3, 2 and 1 things you can see hear and feel.  This is like a structured mindfulness meditation.  It wakes me up and gives me a greater sense of spaciousness between me and my thoughts.

  In mindfulness thoughts are likened to clouds and consciousness the blue sky, the idea being that we are more than our thoughts.  This is quite challenging to the western mind which really values the thinking mind.  In the East, the thinking mind is seen as a tool but one that is good to put down intermittently rather than allow it to rule all the time.  Voices can reflect our own anxious thinking so finding ways to reduce this by paying more attention to the present and less time worrying can be helpful.

Mindfulness and anger

 I discovered mindfulness 10 years ago when a friend gave me a book titled ‘Anger - Buddhist Wisdom for Cooling the Flames’ by Thich Nhat Hanh.  As well as my job as a psychologist, I had a demanding role speaking up about mental health practice and the need for changes and from time to time I would get overwhelmed with angry feelings.  I needed to find a different way to deal with anger rather than venting it with football terrace style language with my nearest and dearest.  Mindfulness gave me a space to listen to myself and how I was feeling in the 'here and now' and also ways to give me a break from thinking.  I developed an intention to do a sitting meditation every day and try to live more mindfully throughout the day.  

Mindfulness does not take an aggressive approach to unwanted thoughts or feelings, it does not try to get rid of them.  For example the mindfulness teacher Thich Nhat Hanh suggests greeting difficult feelings such as anger by saying: “Hello anger my old friend.”  After acknowledging the feeling we then engage in fifteen or twenty minutes mindfulness (perhaps going for a mindful walk) to look after the anger, then we try to understand the underlying causes and respond accordingly (Thich Nhat Hanh, 2001). 

Whilst we do acknowledge anger, we are encouraged not to react impulsively to it’s presence, so that we don’t do what it seemingly want us to do.  We might say “Hello anger I know you are there I am going to take care of you with mindfulness and then try to understand better the causes of your pain.”  So we dance between mindful concentration and friendly inner dialogue.

Mindful dialogues

Balancing grounding ourselves in awareness and friendly dialogue is very compatible with voice dialogue ideas that are being used by people who hear voices and their supporters .  A popular way to structure time with voices is to make regular time to listen to voices and dialogue with them (Romme and Escher, 2000).  I use a voice dialogue or 'talking with voices' approach where I talk directly to other peoples voices and they report back to me the voices responses (Corsten et al 2007).  Through such dialogues we aim to discover the protective function of hostile and aggressive voices and the experiences that are driving them.  When the emotions of aggressive voices are acknowledged and responded to, the voices calm down or withdraw.  I find the mindful attitudes of being very centred and aware and non-judgemental supports me when I am dialoguing with aggressive voices or parts of people.  

Some voices that are replaying abusive relationships may not respond to mindful dialoguing. It may be that the person and the voice are caught in a way of relating that can be shifted through role-play. I have found if the person can imagine the original person the voice is reflecting in an empty chair and confront them the abuser voice loses its power significantly. In the role-play, letting the abusive person know what they did was wrong that the person feels angry and how they will not l people or that person treat them like that again are useful things to say in the role-play. This is a technique commonly used in Gestalt and drama therapy.

Dealing with hungry ghosts  

This friendly firm but fair approach to our demons is not new.  Tibetan Buddhists have had a similar approach to hungry ghosts for hundreds of years.  Hungry ghosts are difficult spirits, arising from moments in our past that we have not been able to stay fully present with.  Examples of hungry ghosts are emotions like jealousy or self loathing.  Pema Chodron (2003) writes about a ritual where hungry ghosts are offered a cake and greeted warmly:  “Thank you for coming along to remind me that I was not present, please come back any-time you want to.”  There is a sense of honouring the unwanted guest and at the same time being assertive and making the effort to act non aggressively to both oneself and the disconcerting guest.   So being friendly to unwanted psychological or spiritual guest is an approach that has been used for hundreds of years.

Accepting voices

As I have mentioned, the Hearing Voices movement which has developed over the last 25 years has similarly promoted an accepting approach to voices.  Self help groups have found that a non-aggressive approach to voice hearing experiences is more practical and sustainable than trying to get rid of voices.  This accepting voices approach highlights the role of people learning to set boundaries with their voices but also dialogue with them.  There is a creative tension in the hearing voices movement and therapeutic approaches to voice-hearing.  There are competing desires in individuals and groups to take back control and ignore voices and the more friendly approach of setting boundaries but also engaging in regular dialogue if this seems likely to be beneficial.  I think mindfulness gives us valuable tools to help this latter approach, to facilitate people learn to live more harmoniously with voices. In mindfulness meditation when we are distracted by thoughts instead of trying to exclude them from our mind we invite them to join our awareness.  

Integrating challenging experiences

I was on a week long Soto Zen retreat where we were expected to meditate mindfully for half hour periods staring at a blank wall.  Each day there was a chance to ask the teacher questions.  A Chinese woman asked the teacher “How do you still your mind?  My thoughts are racing around all over the place.”

 The teacher replied “You can't still your mind but you can invite your mind towards stillness.” 

The Chinese women responded: “That sounds good but how do you do that?”

“You need to welcome your unwelcome thoughts” replied the teacher. 

I had a number of thoughts racing around my mind about my meditation neighbour Morris who was very fidgety and had terrible posture.  I had thought about ways to try and change my situation.  I wanted to meditate next to someone still and upright.  It was a silent retreat so I thought about writing a note to Morris about his posture but that seemed too interfering.  Then I thought about writing a note to the event organisers “please can you help Morris with his posture I am worried about it.”  Again I thought I might be seen as interfering, so I left it.  On the third day I was happy to hear that the teacher would be checking everybody's posture.  As I was meditating mid afternoon I heard “pad pad pad” and then I felt the gentle touch of the teachers hand applying gentle pressure to the middle of my back.  In the absence of words such human contact feels quite powerful and reassuring.  Then he moved on.  To my horror I glanced to my left and realised Morris was not there, he was outside the building having a cigarette.  

It was then I decided to put the teacher's advice into action, to welcome your unwelcome guests.  “Welcome Morris” I said in my mind every time Morris turned up and slouched about breathing heavily.  At first I welcomed him in my mind as if through gritted teeth but the more I did it the more my welcoming gradually warmed up.  I began to realise that Morris was reminding me of how distractable I was and I began to thank him for this reminder.  By the end of the week I was quite fond of Morris and strangely his posture had improved.  Welcoming my resistance had been difficult but when I stuck with it it lead to a decrease in my mental agitation.  I wondered how welcoming could be used in a similar way to change a relationship with aggressive voices.  The welcoming has to be genuine and so the first thing that needs to be done is the person needs to build up a sense of inner strength and confidence from which one feels able to welcome unwelcome guests.  If one feels impoverished its difficult to be generous.

At the same time as being friendly to difficult experiences there is also a sense of not giving into destructive thought patterns or impulses.  We acknowledge urges and notice them but do not become a slave to them.  So the accepting approach promoted by mindfulness is not a passive acceptance but an active one where one is able to step back from impulses and choose how best to act.  We do not go along with voice's demands but if they are persistent in their attempts to communicate we attempt to listen to understand the hidden energy they are flagging up.

Awareness can be painful

 Mindful practices can trigger buried memories.  For example the body scan in which we focus progressively on different parts of the body can trigger repressed memories held or associated with the part of the body we are focussing on.  I trust that people can be the best judge of how and when to use mindfulness practices and when to use other ways to manage stress.  Different exercises may feel safer to use at different times.  The person may want to take a break from the direct use of mindfulness practice and digest their life situation in other ways for a while.  It’s important to learn to be gentle with oneself and in one's own time find ways to be more aware and less ruled by habitual thinking and fears from the past.  I have found when there are a lot of distracting thoughts, doing something quite dynamic can be very helpful.  For example doing some shadow boxing, jogging, dancing or shaking out tension.  After doing some vigorous exercise it is often easier to do more gentle mindful exercises.

Mindful Activity

It can be helpful to spend time each day doing one thing mindfully.  Mindful activity means trying to focus our attention wholeheartedly on the thing we have chosen to do.  Firstly we decide what might be best to do.  Then we focus our fully on it.  Every time we get distracted we bring our attention back to what we are doing, we will probably need to do this hundreds of times.  If we keep getting distracted by something we give it some attention as it may be important. Or we can make a time to address the distracting issue (or experience) before returning to our mindful activity.  There are many activities that can be done mindfully such as washing up, dog-walking, cooking, cleaning, gardening and exercise.  I have found my mind gets a chance to calm down when it regularly is applied to mindful activity.

Coming back to our senses

Being mindful is about slowing down.  We allow ourselves to become grounded in our senses.  By being more tuned into the here and now we can become less addicted to drama.  We can step back from powerful feelings and think how to respond to them without letting them dominate our lives.  We can welcome unwelcome voices, thoughts and feelings without letting them overwhelm us because we are grounding ourselves in awareness of the present moment.  Right now, I am perched on a chair in my kitchen.  My back is upright but only became so when I started to tune into my senses.  If I have an aggressive thought I need to create a secure base with mindfulness from which to respond to it.  So I acknowledge the thought, then I immerse myself in a mindfulness activity for twenty minutes then I return to the thought; is it still there?  If it is I will dialogue with it non-judgmentally, ask it what it needs and see if I can find some common ground with it.  We can apply this approach to voices too.  It may help to do this with people you trust rather than on your own.  This is because if we feel supported we are less likely to become overwhelmed.  An aggressive voice is a message that part of me is hurting and I may need to channel my aggression in a helpful way.  Maybe write an angry poem, speak to someone understanding, try some shadow boxing or go for a run.

Dealing with strong feelings

In engaging in a mindfulness practice we notice what is coming up and return to the object of our concentration.  However if we have strong feelings coming up in the here and now it is important to find a way to give them acknowledgement and understand the context in which they arose.  I find it helpful to use Marshall Rosenberg's approach to non-violent or compassionate communication with myself (Rosenberg, 2003).  Rosenberg proposes that empathy to ourselves and others is the most important healing agent.  In reconciling with painful life events, he suggests we need to recognise the link between the facts of what happened, the uncomfortable feelings and the needs that were not met.  Rosenberg suggests we do not heal by just going over our past experiences.  Rather he suggests healing occurs when we are able to express how we are feeling in the present in relation to the past and think about what we needed but did not get.  For example: The facts were I was bullied in high school, I am feeling sad because I needed and did not get consideration, respect and emotional safety from the people around me.  Acknowledging feelings we now feel in relation to what we did not receive  in the past, allows us to release and transform trapped energy related to these relationship experiences.  

Mindfulness increases our abilities to notice our surroundings and perceptions but also to listen more deeply to ourselves and each other when strong emotions from the past arise.  I have found in my work together with people who hear voices that intrusive voices are pointing towards strong emotions that have not been listened to in a safe space.  Mindfulness practice can assist all of us to create these safe spaces to non-judgmentally help people speak their truth and reconcile with painful life events.

Experiences of using mindfulness

In the hearing voices group we regularly take time to do different mindfulness exercises.  People are encouraged to build up a daily repertoire of exercises that can help them reduce their stress and increase their ability to deal with strong emotions.  Many of these exercises are influenced by mindfulness (see for example the videos on my website www.rufusmay.com). Some people have found that mindfulness helped them stay calm and respond to their voices in a more thoughtful way.  Some people have found it useful to invite their voices to join in exercises, others have found it useful to dedicate an exercise to a particular voice or part of the person that seems in distress.  

Changing how as communities we relate to voices

At the moment as a society we do not accept voices.  Instead we try to remove them from conscious awareness or control them through the use of sedating drugs and distraction strategies.  A different approach is to support people who hear voices to become more present to their lives, if their voices are persistently seeking to be heard we need to find ways to listen to them from a place of grounded awareness.  As friends and supporters of people who hear challenging voices we also need to learn to live mindfully with voices and listen to their deeper meanings.  In this way of deep listening to people's voices we are likely to learn truths about hidden parts of our communities and become wiser and more aware because of it.  Therefore welcoming voices into our communities, whilst also setting boundaries with them is likely to lead to healthier ways to relate to ourselves and each other.  One modern example of this welcoming approach is on the internet where some people who hear voices have given their voices Facebook and Twitter accounts and are interacting with people and other voices across the world (an example of this can be seen on the Intervoice Facebook group).  

Conclusion

I have found mindfulness approaches have been supportive in helping people begin to accept voices in their lives and adopt an integrative approach towards them.  Society is afraid of hearing voices so has an aggressive approach towards them.  There is a history in Buddhist and mindfulness approaches of setting boundaries but at the same time being willing to listen mindfully and respond wisely to apparently intrusive experiences such as voices.  Mindfulness techniques, attitudes and ways of living seem to be a useful resource for approaching the voice hearing experience in a more inclusive way.  Acceptance is an established approach to the experience of hearing voices and the knowledge within mindfulness thinking and practices are increasingly being found helpful by people who hear voices and their supporters.

References

Chodron, P. (2003) Start Where You Are, Element, Harper Collins Press.

Corstens, D., May, R. and Longden, E. (2007). Talking with Voices: The VoiceDialoguing Manual (available from www.intervoiceonline.org) 

Hanh, T. N. (2001) Anger: Buddhist wisdom for cooling the flames, Rider publishing, Random House.

Kabat Zinn, J. (2001). Full Catastrophe Living: How to cope with pain and illness using mindfulness meditation. London: Piatcus.  

Podvoll, E. (2003)Recovering Sanity: A Compassionate Approach to Understanding and Treating Psychosis, Boston: Shambhala. 

Romme, M. & Escher, S. (1991) Accepting Voices, Mind publishing.

Romme, M. and Escher, S. (2000). Making Sense of Voices. London: Mind Publications.

Rosenberg, M. (2003) Non-Violent Communication: A Language of life. London: Puddle Dancer Press.Stone, H. and Stone, S. (1989). Embracing Our Selves: The Voice Dialogue Training Manual. Nataraj Publishing: New York



Note: You may also be interested in Manasa Ayurveda - a traditional Buddhist Ayurvedic approach to mental health and wellbeing, now being introduced in the West...