RFT: A behavioral conceptualization of voice hearing

I’ve been overloaded lately, hence the extended absence, but a part of my own self-care is to read great work.

I’ve just read a manuscript by McEnteggart, Barnes-Holmes, Dillon, Egger, and Oliver (2016) in Trauma & Dissociation that definitely fits the description. Let me just say, it’s a potential game-changer. Definitely worth a read. 

Enteggart et al. reconceptualize voice hearing behaviorally. This, again, is one of those publications that could be a game changer if it tests out empirically. ‘Hallucinations’ are one of those things that our field does not generally deal well with. Most clinicians refer out for medication and do some basic work to help the individual cope. We essentially medicate symptoms and cede to big pharma.

I will say that there has been some other really impressive work in this area by third-wave clinicians which should also be recognized. Bach & Hayes (2002) demonstrated acceptance-based strategies as effective in reducing rehospitalization for individuals with psychosis. Veiga-Martinez, Perez-Alvarez, & Garcia-Montes, 2008 did a case study on acceptance of auditory hallucinations. And, Vilardaga, Levin, and others have done relevant work on deictics, empathy, anhedonia. The work of this group also utilizes Ecological Momentary Assessment and Ecological Momentary Intervention (read making everything more feasible via mobile phone) that is methodologically elegant while addressing issues specifically relevant to this population.

Additionally, there is some relevant work in progress by several groups spread across the world on BPD. Michel Reyes and others are looking at the treatment order/treatment targets/process for BPD and there seems to be a convergence in what is happening in these areas.

Just as a refresher, deictics include I-YOU, HERE-THERE, and spatial relations that form the establish the core of our perception of the world. If you’re interested in this area, see also a whole host of fascinating work by Louise McHugh The Self and Perspective Taking.

I’ve also written some on self-other organization and derealization/depersonalization from an RFT perspective in my blog.

Enteggart, Barnes-Holmes, Dillon, Egger, and Oliver (2016) represents a complete behavioral conceptualization of voice hearing that I’ve seen by far. Their review of literature describes the behavioral conceptualization from traumatic learning history to voice hearing. They explicitly address how what can appear as pathological processes, can in fact, be normal processes responding to an abnormal environment.

Trauma and particular types of trauma are likely to create the experience of hearing voices as learning history is what establishes our sense of self. The way that we, others, the world react to us becomes part of how we construct our world, straight down to our perceptual experience (based on RFT). The “I” perspective is what learning history arrives through; however, as discussed in Enteggart et al. in many types of traumatic learning histories that perspective may be too heavily influenced by the perspective of another. Meaning, a frequent part of abuse is for someone to take control of another psychologically and/or physically, to impose different views onto the person of what is true/harmful/acceptable than the individual might arrive at on their own.

This may blur the ‘self,’ and based on RFT, blurring the ‘self’ may blur relations tied to the self (i.e., perception of sensory experience, perception of time, understanding of the other, the world, etc.) As you can imagine, this is some pretty hefty stuff.

What is key here is that if this conceptualization stands up to empirical testing, we need to change the way we treat voice hearing. Efforts that treat the symptom are most likely going to reinforce blurred self-other relations. Envision a clinician telling a client what the voices are and aren’t – that may lead to some change in symptoms, but it is also reinforcing, from an RFT perspective, an externally determined reality.

This is why it’s important for us to understand processes we treat. What seems perfectly logical and, in the short run, may even lead to symptom reduction can reinforce the very problem we seek to address. McEnteggart et al. discuss treating the experience of voices with work on self-other relations, an entirely different model.

What it also pulls, for me, is the value of RFT to innovation and integration. Because when we think in behavior-behavior relations and take a true functional-analytic perspective we understand that findings in one area may, and even should, apply in other areas. When we look at behavior and its function we can move past the limits of construct based statistics, measures, and talk to those in other areas – learning, innovating, and improving this world.

 

 

 

 

 

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