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Discussion Paper on Maastricht Approach to voice Hearing

Discussion Paper

Auditory verbal hallucinations (AVHs) are experienced by an individual, in fully conscious state, without external stimuli. Around 5 - 28 of general non-clinical population, aged between 18-65 years, experiences AVH (de Leede-Smith and Barkus, 2013).It may have biological causes such as schizophrenia, bipolar disorder, depression, personality disorders, posttraumatic stress disorder (PTSD) and dissociative identity disorder (Steel et al., 2019).The purpose of the discussion paper is to compare and contrast Maastricht approach and biomedical approach for amelioration of auditory hallucinations. The scope of the discussion pertains to clinical AVH. It comprises elaboration of Maastricht and biomedical approaches to voice hearing, comparison of both the approaches, and implications of Maastricht approach in future mental health practice. Finally, the discussion is summarized. Any future work that may be warranted is also highlighted.

Traditional Biomedical approach to voice hearing

Traditionally, voice hearing has been addressed using biomedical model. This model specifies that voice hearing is a result of underlying illnesses, such as schizophrenia, and can be managed by use of antipsychotic medication. The model doesnt give any relevance to the content of voices being heard.
A major danger associated with this approach is potential side effects of long-term prophylactic use of drugs. The side effects may include changes in brain volume and risk of developing metabolic disorders. This leads to medicine discontinuation by the voice hearers, thus, making biomedical intervention inefficient. In addition, it has been observed that recovery in many cases of schizophrenia has been devoid of drug use. Furthermore, effectiveness of neuroleptic drugs is reduced in case of posttraumatic stress disorder (PTSD). This weakens curative role of medical intervention approach in voice hearing (de Leede-Smith and Barkus, 2013).
Maastricht Approach (MsV) to voice hearing

In 1987, Marius Romme and Sandra Escher gave the Maastricht Approach to ameliorate voice hearing. It is also referred to as Making Sense of Voices. The core philosophy of MsV approach is to normalize the experience of voice hearing than labeling it as psychotic (Kneisl and Trigoboff, 2004).

The core philosophy of Maastricht Approach is that

In this approach, auditory verbal hallucinations (AVHs) are not viewed as dysfunction of brain, but as psychology of thought.
It is stated that AVHs occur as a result of some unresolved trauma in life.
Many voice hearers do not have display symptoms of mental illness.

The content of the voices being heard is relevant and gives prominence to its intention and meaning. These help individuals who are distressed by their voices to manage the voices. Voice Dialoguing Technique in which the hearer dialogues with the voice was developed so that the voice hearer feels less threatened and takes a less submissive stance against the voice being heard. Hearing Voices Interview Tool has also been developed to help hearer define meaning of voices and reduce the emotional connection with them (Scott, McArthur and Tufanaru, 2018).
Coping of voice hearer can be developed by confronting the negative experiences of the past that caused the voices.
The MsV approach is theoretical with limited clinical evidence to show that it benefitted the voice hearers. Thus, the approach warrants more evaluation (Steel et al., 2019).

Contrast between Biomedical and MsV approaches

In Australia, European, and Western countries, the government policies are based on the premise that distress of voice hearing is dealt by pharmacological intervention. A limitation of this approach is that diagnosis is based on internationally adopted Diagnostic and Statistical Manual that undergoes revision. Therefore, though the symptoms remain same, the diagnosis of the illness and treatment varies with the updated Manual (Scott, McArthur and Tufanaru, 2018).

A major contrast between biomedical and MsV approaches is the importance of voice hearer. Biomedical model doesnt provide hearer with voluntary adoption of medical treatment, while MsV approach provides hearer with informed consent to every care intervention (de Leede-Smith and Barkus, 2013). Thus, inherently the biomedical approach is inept in catering to the psychological and emotional vulnerability of mental health patients. Treatment of AVH by drugs finds basis in brain dysfunctionality. However, MsV approach states that AVH is a dissociative experience than psychotic symptom. It is a reaction to unresolved life stressors.

High side effects of drug use for AVHs have caused the voice hearer to discontinue treatment. Biomedical approach to voice hearing ignores the content of the voices being heard. In contrast, MsV approach encourages and helps voice hearer to understand meaning and intention of the voices, and engage with them. Schizophrenic patients who understand their voices feel better than those patients who do not adopt this practice (Payne, Allen, and Lavender, 2017).

Implications of Future Practice

The core philosophy of Maastricht approach is hearer-led management of the auditory verbal hallucinations. This has major implications on future of mental health practice. It is significant to remove the social stigma associated with schizophrenia by transforming sense of identity of schizophrenic patients. The approach created tools for the voice hearers to engage with voices in a manner that voice hearing changed from their weakness to their strength. Hearing Voice Framework lays emphasis on peer support (Styron, Utter and Davidson, 2017). In future, clinicians, along with biomedical management of schizophrenia, can adopt Maastricht approach led patient care. To achieve best therapeutic outcome for voice hearers, it will be suitable to train clinicians in Hearing Voice Framework.

Maastricht approach of voice hearing is a psychotherapy that offers a new perspective for helping voice hearers who may not have found the support needed within mainstream psychiatric services. Its core philosophy of depathologising schizophrenia has given patients a positive social identity. The control of treatment is in hands of the patient and not the service provider. This empowers the voice hearer and may lead to better prognosis. The strength of the approach lies in peer group support and tools for better management of voice hearing. Empirical evidence is important to support any therapeutic approach. Presently, the approach is mostly anecdotal, thus, it is important for social psychiatrists to scientifically test its impact on voice hearing (Steel et al., 2019).


de Leede-Smith, S., amp Barkus, E. (2013). A comprehensive review of auditory verbal hallucinations lifetime prevalence, correlates and mechanisms in healthy and clinical individuals.Frontiers in human neuroscience,7, 367. Retrieved from https//doi.org/10.3389/fnhum.2013.00367Kneisl, C. R., amp Trigoboff, E. (2004).Contemporary psychiatric-mental health nursing. New Jersey Prentice Hall.
Payne, T., Allen, J., amp Lavender, T. (2017). Hearing Voices Network groups experiences of eight voice hearers and the connection to group processes and recovery.Psychosis,9(3), 205-215.
Scott, W., McArthur, A., amp Tufanaru, C. (2018). Effectiveness of psychotherapies that engage with the voices of Voice Hearers a systematic review protocol.JBI database of systematic reviews and implementation reports,16(6), 1373-1380.
Steel, C., Schnackenberg, J., Perry, H., Longden, E., Greenfield, E., amp Corstens, D. (2019). Making Sense of Voices a case series.Psychosis, 1-13.
Styron, T., Utter, L., amp Davidson, L. (2017). The hearing voices network initial lessons and future directions for mental health professionals and Systems of Care.Psychiatric Quarterly,88(4), 769-785.

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