The recognition that people in the general population hear voices is at the foundation of Romme and Escher's work. They are leaders in setting an understanding of voices in a mental health context within this wider framework, with the important consequences of understanding that hearing voices is not by itself a problem or a symptom of mental illness. For Romme and Escher, voices are only a problem when the person hearing them has difficulty coping with them. Their research has found that ordinary people who hear voices accept them and find them predominantly positive in impact, whereas psychiatric patients who hear voices are more likely to find them distressing and to feel powerless in relation to them.
This ‘practitioner's handbook’ is about helping those who find their voices difficult and distressing. In some respects it takes a radical approach: it is not concerned with psychiatric diagnosis, it is decidedly lukewarm about the benefits of medication, it emphasises self-help and social empowerment and it treats seriously the contributions of alternative therapies. But the heart of the book draws heavily on the more mainstream approaches to voices developed in the past decade within social psychiatry and clinical psychology. The social psychiatric perspective (Romme and Escher's own approach) proposes that difficulties coping with voices are best understood by examining the person's life history, in particular traumatic life events thought to be related to the onset, and the wider context of often overwhelming social difficulties, such as housing, work or relationship problems. However, the authors also draw very extensively on psychological, in particular cognitive—behavioural, approaches to helping people with distressing voices. Such approaches also set the voices in the context of a person's life circumstances and consider the role of triggering events, but emphasise the appraisals made of the voices — for example, as powerful and malevolent — as mediating between the voice experience and the way the person responds. Both approaches require a very detailed assessment of the voices themselves, their onset, the person's life history and circumstances. Both also see the content of the voices as important and meaningful, usually pointing to the person's concerns.
The handbook is divided into three parts. The first part is introductory, providing some of the background research on the authors' understanding of voices. The second part, on the assessment process, provides a full description of the authors' assessment interview, as well as an exceptionally detailed set of instructions on writing a report and deriving a formulation (called here a ‘construct’). This is certainly useful, but strangely prescriptive given the open-mindedness evident elsewhere in the book. For example, using case material, the reader is instructed on every element of writing a report, including the choice of first or surnames (always use first names) and what to include about a person's occupation (‘the fact that she followed a chiropody course…[is] not relevant’). Nevertheless, the interview and the method described for deriving hypotheses about the development and understanding of voices, coupled with case descriptions, evidently stem from extensive experience of working with voice hearers. Drawing on this will enrich my clinical practice.
The third part is on interventions. For me, this part was less convincing and strikingly different from the previous section. It lacks an essential feature of a handbook, in that it does not point the practitioner to a coherent set of methods with guidance on their use. Rather, it surveys a range of approaches, generally quoting directly and at length from others' work. This covers cognitive—behavioural, and alternative therapies (with an intriguing more detailed description of reincarnation therapy), self-help and working within the voice hearers' own theories (mystical, transpersonal, metaphysical, reincarnation, parapsychological). Although passing reference is made to studies of some of the cognitive—behavioural approaches, the rest of this section relies for its evidence base on occasional case histories.
Overall, this is an intriguing and readable book, which opens up new ways of making sense of voices. It will be of interest to anyone working in the field. However, I would not recommend it to an inexperienced practitioner as a handbook.
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