https://orcid.org/0000-0001-8271-4282
ABSTRACT
Background
Some people receiving mental healthcare experience distress related to voice hearing and the available support. Some practitioners lack knowledge and confidence in providing this support. Furthermore, coercion in mental healthcare can negatively affect voice hearer-practitioner relationships. Previous research investigating mental health distress, including voice hearing, has largely emphasised an individual-centric perspective. Less is known about voice hearers’ and practitioners’ relational experiences within mental healthcare contexts and how this might influence voice hearing.
Methods
This was a qualitative study that utilised a constructivist Grounded Theory methodology to explore the experiences of voice hearers (n = 15), through semi-structured interviews, and practitioners (n = 18) through focus group discussions (n = 3).
Results
A tripartite relationship theory situates experiences of voice hearing within a mental healthcare context, mediated through a tripartite voice hearer – voice – practitioner relationship. This consists of five themes: Level of agency; Interpersonal dynamic; Who’s making sense; Medication: helping or hindering; and Personal bully.
Discussion
This paper presents a novel theory, grounded in voice hearers’ and practitioners’ experiences. This expands on current knowledge about voice hearing by situating voice hearing experiences within relational and clinical contexts.
Introduction
Whilst voices can be experienced as nonsensical and distressing, according to Woods (Citation2013) alternative narratives to a dominant illness narrative (e.g. schizophrenia), typical of psychiatry, can shape voice hearing to be deeply personal and meaningful. Some people can struggle to cope with their voices, typically experiencing difficult relationships with voices or feeling distressed by abusive content. This can lead to contact with mental health services, in which voices are commonly framed as a symptom of psychosis (Pierre, Citation2010) or schizophrenia (Larøi, Citation2012). Although voice hearing experiences do not necessitate treatment per se, this is typically the purpose of admission and concerns predominantly the use of “antipsychotic” medication and Cognitive Behavioural Therapy for psychosis (CBTp) to reduce or stop voice hearing. The effectiveness and long-term use of “antipsychotics” is contested, e.g. Harrow and Jobe (Citation2018) report that at least eight studies by eight different groups of researchers (Bland & Parker, Citation1978; Harrison et al., Citation2001; Harrow et al., Citation2017; Kotov et al., Citation2017; Moilanen et al., Citation2013; Morgan et al., Citation2017; Wils et al., Citation2017; Wunderink et al., Citation2013) found no benefits associated with longer-term use (seven to twenty years) of “antipsychotics”. Alternatively, CBTp has only a small effect overall (Garety et al., Citation2008; Jauhar et al., Citation2014; Pontillo et al., Citation2016) and is not as widely available as medication.
Mental healthcare can also involve coercion, which can exacerbate distress. Commonly defined as “the practice of persuading someone to do something by using force or threats” (English Oxford Dictionaries), coercion has long been recognised by the World Psychiatric Association as an increasing global concern in mental healthcare (Kallert et al., Citation2011). It has been found to impact negatively on patients, e.g. worsen mental health (Hotzy & Jaeger, Citation2016; Jaeger et al., Citation2013; Swartz et al., Citation2003), perceived as traumatic (Paksarian et al., Citation2014) or a form of punishment (Olofsson & Norberg, Citation2001) and a recent thematic synthesis found it can contribute to disempowering relationships with practitioners (Allison & Flemming, Citation2019). In addition to evidence identifying previous trauma as an aetiological factor for people starting to hear voices (e.g. Gibson et al., Citation2016; Read et al., Citation2005; van Dam et al., Citation2012; Varese et al., Citation2012), some patients also perceive conventional treatment as traumatic, including feeling bullied by practitioners (see Allison & Flemming, Citation2019).
The seminal work started in 1987 of Romme and Escher, in collaboration with well-known recovered and recovering voice hearers (such as Ron Coleman, Jacqui Dillon, Racchel Waddingham, Peter Bullimore, Patsy Hague, etc.), paved the way for many voice hearers and practitioners to understand voice hearing as less distressing through making sense of who/what the voices are and how they might relate to the voice hearer’s life story, thus de-pathologizing and normalising the experience (Romme & Escher, Citation1989, Citation2013; Romme et al., Citation2006, Citation2009). For many, this can be empowering and contribute towards the development of harmony in voice hearer – voice relationships (Lafferty & Allison, Citation2021; Romme et al., Citation2009). However, recent evidence suggests that mental health practitioners can lack knowledge and confidence regarding how to support people distressed by voice hearing (Bogen-Johnston et al., Citation2020; Kramarz et al., Citation2020; White et al., Citation2019).
The above context emphasises the importance of relationships in supporting people distressed by voice hearing. However, there is a lack of research investigating specifically how voice hearer-practitioner relationships within mental healthcare contexts might affect voice hearing experiences and related support. According to Johnstone and Boyle (Citation2018), evidence regarding emotional distress broadly is informed by a dominant biological narrative concerned with understanding distress at an individual level, with insufficient consideration of broader contexts in which distress is experienced. This study aimed to address this through developing a theoretical explanation of voice hearer-practitioner interactions to establish how these might influence voice hearing experiences.
Method
Design
A qualitative constructivist Grounded Theory methodology was utilised as a suitable approach to investigate underlying social processes and actions to develop theory (Birks & Mills, Citation2015; Charmaz, Citation2014) regarding voice hearing experiences. Data were collected and analysed in two stages. The first involved semi-structured interviews with voice hearers, which provided space for recollection and reflection regarding potentially sensitive experiences. To enhance theoretical development, the second stage involved focus group discussions (three in total) regarding practitioners’ experiences of supporting people distressed by voice hearing from the same or similar clinical teams that provided support to most voice hearer participants. Through interactions between practitioners, the focus groups aimed to develop an understanding of the team culture regarding voice hearing. It was also a practical method of collecting practitioners’ experiences collectively during a time-pressured period for clinical teams. All data were collected and analysed by the author.
Participants
Fifteen people who heard voices who met the inclusion criteria of experiences of voice hearing and mental healthcare, minimum age 18 years, and English speaking were recruited. Following this, eighteen mental health practitioners were recruited who met the inclusion criteria of experiences of providing support for voice hearing within a mental healthcare setting, minimum age 18 years, and English speaking. Participant demographics are outlined in (voice hearers) and (practitioners).
Table 1. Voice hearer characteristics.
Table 2. Focus group participant demographic information.
Procedure
Ethics approval was provided by the university’s Research Governance Committee and NHS Health Research Authority (IRAS ID 248530) for the first stage of the study, which took place between October 2018 and October 2019. Further approval was granted for the second stage, which took place in October 2019. All participants were recruited via key contacts (practitioners) within a local NHS Trust and were provided with an information leaflet and gave written consent to participate in interviews/focus groups, which lasted 60–90 minutes. An initial interview guide was developed in consultation with a regional Hearing Voices Group (available on request) and used as an aide-memoire to help the interviews remain on track with the study aims. Informed by the methodology, questions were also influenced by specific follow-up prompts in response to participants and to develop theory. Data were recorded, transcribed, and transferred into NVivo (version 11).
Researcher’s position
Completing this study as part of a PhD, the author is a mental health nurse lecturer and influenced by the Voice Dialogue approach (Lafferty & Allison, Citation2021; Stone & Stone, Citation1989), which shaped his observations and interpretations during the study. In congruence with Charmaz (Citation2014), the author remained reflexive throughout the research process to develop grounded theory.
Analysis
Key features of Grounded Theory were utilised, including concurrent data collection and analysis, coding, constant comparison during coding, memoing, theoretical sensitivity and theoretical sampling (Charmaz, Citation2014; Corbin & Strauss, Citation2015). Initial and focused coding led to the development of provisional theoretical coding (Charmaz, Citation2014) towards the end of the voice hearer interviews (stage one). Analysis of the practitioner focus groups (stage two) involved initial and focused coding (concurrent data collection and analysis was not possible due to time constraints). Completion of theory development involved synthesis of the findings from both stages. Complementary experiences (but from different perspectives) were identified from comparing the voice hearer and practitioner coding. This contributed to the construction of the final theoretical codes to produce a broader tripartite voice hearer – voice – practitioner relationship theory (see for the focused and theoretical coding stages).
Table 3. Completion of theoretical coding.
Results
Voice hearers and practitioners shared complementary experiences relating to voice hearing and approaches to support these (e.g. both experienced challenges regarding their lack of relative influence on voice hearing and the type of support provided, and both found it difficult to engage in discussion about voices), encapsulated by the development of a tripartite voice hearer – voice – practitioner relationship theory (see ). This proposes that voice hearing, although a personal experience, is influenced by intra-personal (voice hearer – voices) and inter-personal (voice hearer – practitioners) relationships and interactions. The theory comprises five themes (including sub-themes): Level of agency; Interpersonal dynamic; Who’s making sense; Medication: helping or hindering?; and Personal bully, situated within a broader structure of mental healthcare.
Figure 1. Tripartite relationship theory of voice hearing.
Level of agency
Relational power between voice hearers, voices and practitioners varied and influenced participants’ voice hearing experiences. For example, some voice hearer participants believed they had more control over voices than medication; by contrast, some practitioners believed they could influence medication decisions but not reduce the impact of voices on voice hearers.
Constrained by coercion
Identifying coercion could be difficult. For example, practitioners believed they offered choice to patients to accept oral or enforced medication, but patients believed this was a coercive threat. Voice hearers experienced both their voices and practitioners as coercive, as illustrated by Edith and Hillary.
[Voices] have always had a hold on me … the things that they’ve made me do … it was that kind of power that they would have
As I tried to leave, I said this isn’t for me, [staff] injected me with Acuphase
Similarly, practitioners could also feel coerced by their peers and, as Carrie (practitioner, 1st focus group) states, “horribly conflicted”. Rose (practitioner, 3rd focus group) reflected “coercion is a two-way street … we are coerced by our staff and peers … and we do coerce our patients”. Interestingly, Rose later reflected practitioners could also coerce voices, “I’ve spoken to the voice in a coercive manner and … a few times the patient has said the voice is listening to you and it doesn’t want you to be here and it doesn’t want you to talk to it”.
Varying ability to influence change
Generally, voice hearers and practitioners perceived they lacked agency: voice hearers regarding their voices and the support provided; practitioners regarding their perceived lack of expertise and professional constraints. Voice hearers generally struggled to cope with their voices and wanted them to go away or become less distressing. Similarly, practitioners struggled to help voice hearers cope with their voices and wanted more professional support to improve their expertise and understanding of voice hearing.
I cried last week because there’s absolutely nothing I can do for this lady apart from go and visit once a week. It doesn’t matter what I do it’s not going to improve her quality of life
Voice hearers also wanted practitioners to be cognisant and “critical” of conventional interventions. Alternatively, practitioners wanted people to talk about their voices and resist voice commands and benefitted from believing they could help voice hearers.
As you get more experienced at doing it [talking about voices] you get more confident over the years. It’s alright to ask questions about people’s voices. It’s alright to ask them about if they’ve got a name, how old are they?
Interpersonal dynamic
Voice hearers simultaneously interacted with practitioners and their voices (and concentrated on avoiding interacting). This could be chaotic and stressful for voice hearers and difficult for practitioners when they attempted to engage with voice hearing experiences. Intra-personal interactions also influenced inter-personal interactions, illustrated by Bella (voice hearer):
“And I would say that my own kind of anxious avoidant pattern of relating, is manifested in the way that I’ve learned to relate to the voices”.
Extent of collaboration
Although talking about voices could help reduce voice-related distress, it was generally difficult for voice hearers and practitioners. For example, Jack (practitioner, 2nd focus group) commented that practitioners “can’t deal with somebody else’s distress” and Diane (voice hearer) commented voice hearing “makes practitioners uncomfortable … because they can’t just give you a pill”.
This led to conflicting perceptions regarding each other’s intentions. Voice hearers feared practitioners pressuring them into disclosing information about their voices, which could provoke voices to react aggressively. By contrast, practitioners believed voice hearers concealed voice hearing because of mental illness. Where there was greater collaboration, voice-related distress was reduced. For example, Ian (voice hearer) found his engagement in psychological therapy helpful:
From the start of the therapy things just started to get a little bit better with me understanding the voices, how they’re associated, and how I control them now
Acknowledging or avoiding voices
Most voice hearers struggled to be with their voices and so tried to avoid them.
It was once mentioned that if I give [voices] some love and attention, caring changes the whole relationship with them, it might help. It’s just something I can’t do with them … I don’t know how to love them or give them that care and attention that they probably need
Whereas some voice hearers believed practitioners avoided talking to them about voices, most practitioners lacked confidence and struggled to know how to meaningfully engage with voice hearing. Debbie, practitioner, 1st focus group) questioned the value of talking about voices:
If you accept [voices] into your reality, are you colluding? I think there’s sometimes questions about are we benefiting that person by engaging in that?
Instead, practitioners generally focused on voice hearers’ emotions (i.e. anxiety) and behaviours (i.e. social withdrawal) and responded through medication and symptom management.
Rather than asking [the patient] and distressing him by what [voices] were saying … I would just say are they inside your head or outside. And then that would give me an aim to say, okay let’s distract that. Whereas if they were inside his head, I’d just leave them because he was quite happy with those voices
Who’s making sense?
A key element of improving voice hearing experiences was to understand why voices were present. This was informed by how voice hearing was understood and who/what influenced this. Although voice hearers and practitioners attempted to make sense of voice hearing, there was typically a lack of collaborative endeavour and professional explanations were usually privileged.
Dominant narratives
Participants’ making sense of voice hearing was inextricably linked with power, both within the tripartite relationship (i.e. voice presence and content; voice hearer’s and practitioner’s beliefs and actions) and the broader clinical context. However, rather than identify the influence of dominant and alternative narratives, voice hearing was conventionally understood as a symptom of mental illness requiring treatment. Penny (practitioner, 3rd focus group) commented:
I think it’s very dependent on the patient’s level of insight and how motivated they are in terms of acknowledging what’s going on and what they can do about it. I have patients on my caseload who have been in service 30, 40 years and they still don’t have the insight to be able to work on their shared symptoms and their voices because they don’t acknowledge that they’re as a result of mental health problems, of schizophrenia, of psychosis.
Collective search for meaning
Exploring voice content and beliefs about voices involved the engagement of voice hearers with their voice hearing experiences and, to varying extent, practitioners’ involvement. Ken (practitioner, 2nd focus group) reflected on the value of remaining open minded in relation to this:
I think you’ve got to give [voice hearers] enough space to work a lot of things out themselves as well, to come to their own conclusions.
Medication: helping or hindering?
All participants reported medication as the primary treatment to support distress, to the extent that the real option concerned how much should be prescribed. Jack (practitioner, 2nd focus group) reflected on this, “I don’t think the mental health services are good at [providing alternatives] … medication has always been top of the list of what we call the intervention”. Determining whether medication helped or hindered voice hearing experiences was key, including agreement between voice hearers and practitioners on how best to use it (or not use it) in a context of limited options.
Agreement on its purpose
Voice hearers and practitioners had complex relationships with medication. Although both generally perceived medication could be helpful, they also believed it could be harmful but lacked sufficient agency to stop using it. Jack (practitioner, 2nd focus group) reflected, “[medication] is the predominant thing [that] keeps people in mental health services”. Some practitioners and voice hearers relied on medication in response to distress, which helped to some extent, but insufficiently impacted on voice content, voice presence and caused unwanted side effects. Consequently, it was important to agree on the purpose of using medication.
Control over treatment decisions
Voice hearers’ belief that practitioners could enforce medication, and practitioners’ belief that changing medication could be beyond their influence, entangled medication with a perceived lack of agency within the tripartite relationship and often led to medication compliance. Edith (voice hearer) illustrated this also included voices:
Getting my tablets down is quite a struggle, because one of my voices doesn’t like me having the tablets.
Debbie (practitioner, 1st focus group) reflected that, even if a patient doesn’t want medication:
As a clinical team there’s been a decision made [to medicate] that in the best interests of that person at that time … [because] … they’re so unwell.
Lack of alternative
Within a context in which medication dominates, almost exclusively, as an intervention, voice hearers and practitioners typically lacked confidence regarding alternative options. Rose (practitioner, 3rd focus group) commented:
A lot of people have said to me they’re frightened to tackle [voices] because they think if they try and tackle them other than with anything apart from medication that it will make the voices worse and they’ll attack them more.
Personal bully
This name derived from Noel, who described one of his voices as his “own little personal bully”. All voice hearer participants described at least some of their voices as bullies. The above four themes both influence, and are influenced by, the Personal bully. This was uniquely experienced by voice hearers, which initially appeared before their first admission into mental healthcare but continued beyond this and impacted on the tripartite relationship. Voices were positively influenced by voice hearers’ increased level of agency, development of effective relationships, meaningful explanations, and greater influence regarding medication decisions. This contributed to a change in some voices to become more supportive, even protective, for voice hearers.
Discussion
Practitioners’ opportunities to develop expertise in delivering psychological interventions are limited (Gilburt, Citation2015). It is therefore unsurprising that many can struggle to feel sufficiently expertise to effectively support people struggling with voice-related distress and distance themselves from voice hearing experiences. The tripartite relationship theory identifies how both voice hearers and practitioners can participate in reducing this distress. This can be supported by increasing both of their levels of agency regarding voices and support; by improving the interpersonal dynamic between voice hearers, voices and practitioners, particularly regarding engagement with voice hearing experiences; by acknowledging how sense is made of voice hearing; and collaboratively making decisions about support and the role (if any) of medication. Collectively, these factors influence and are influenced by the voices. This challenges the conventional individual-centric emphasis in mental healthcare, which can isolate voice hearers (in terms of their experiences) and practitioners (in terms of their approaches to support). Based on a thorough database search of CINAHL, Embase, Medline, PsychINFO, and the British Library Thesis Database (in March 2021) by the author, this is the first Grounded Theory study conceptualising voice hearers’ concurrent intra- and inter-personal interactional experiences relating to voices and practitioners.
These results support previous Grounded Theory studies (Fenekou & Georgaca, Citation2010; Holt & Tickle, Citation2015; Jackson et al., Citation2011) regarding the importance of functioning, relating, active searches for meaning, and control related to voice hearing. Fenekou and Georgaca (Citation2010) found that voice function (voice content and voice hearer reaction) and voice hearer understanding of voices (source and origin) informed voice hearers’ meaning regarding voices. In addition to voice function and understanding, in this study, meaning was constructed within clinical and relational contexts and other important factors included the influence of dominant narratives within mental healthcare, and the quality of the relational dynamic between voice hearers and practitioners.
Fenekou and Georgaca and also Holt and Tickle (Citation2015) found that practitioners failed to ask voice hearers about their voice hearing experiences and relied on increasing amounts of medication to alleviate distress related to voice hearing. Holt and Tickle argued that practitioners struggled to balance professional knowledge with remaining open (and developing knowledge) regarding alternative frameworks and, consequently, privileged professional perspectives, which limited the range of explanatory frameworks for voice hearers. Similarly, in this study, practitioners mostly lacked knowledge and confidence to engage in meaningful conversations about voices.
Holt and Tickle (Citation2015) proposed that voice hearers constructed understanding and searched for meaning regarding voices through several personal frameworks, affected by their sense of agency, stigma and sense of hope(lessness). This study’s findings closely align with this in terms of the influence of agency and the impact of dominant narratives on stigma.
Jackson et al. (Citation2011) found that voice hearers developed positive relationships with voices by reducing fear (through greater understanding and closer relationships with voices), establishing control (developing healthier relationships with voices and integrating voices with life experiences), relational closeness (with voices and connecting with their community), and developing a personally meaningful narrative regarding voices. The tripartite relationship theory supports this but emphasises practitioners’ contributions to a complex intra-interpersonal dynamic regarding voice hearers’ relationships with voices and their overall voice hearing experience.
Limitations
Although the recruitment strategy was intentionally broad to avoid under-recruiting difficult to reach participant groups, a lack of diversity resulted in all participants identifying as White British and predominantly female. Potentially, power impacted on participants in the interviews and focus group discussions. Many voice hearing participants reported active voices during interview, typically in response to questions. Participants possibly either withheld or felt obliged to disclose information due to perceived power attributed to voices and/or the author. It is also possible that the author’s role as the researcher impacted on focus group discussions with practitioners, influencing how comfortable practitioners felt disclosing information about their practice.
Implications
Voice hearers and practitioners want to reduce voice-related distress but experience challenges in achieving this. Through the tripartite relationship theory, voice hearing experiences can be understood within a relational dynamic involving voice hearers, voices, and practitioners. Improving these experiences within clinical contexts takes place within active and changeable relationships. They can be improved through increasing a sense of agency, improving the interpersonal dynamic, identifying how voice hearing is understood, and agreeing on the type of support and the role, if any, of medication. In addition to voice hearers undergoing change to help their own recovery, practitioners must also change to increase their therapeutic value in supporting voice hearers. They must be reflexive regarding how they develop interpersonally effective relationships with voice hearers and offer genuine opportunities for collaboration and shared decision-making.
Conclusion
Experiences of voice hearing can be positively influenced by conceptualising voice hearing within a relational voice hearer-voice-practitioner context, and in which voice hearers’ and practitioners’ levels of agency and their collaboration with voice hearing experiences are increased to develop meaningful understandings of voices and reach shared decisions regarding support. The tripartite relationship theory values voice hearers’ personal experiences but, importantly, also recognises that power struggles, interpersonal challenges, meaning making, all within a medication-dominant treatment context, are challenges experienced within relationships involving voice hearers, their voices and practitioners.
Acknowledgements
The author would like to thank all the research participants for their contributions towards the study.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Additional information
Funding
References
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