At Black Country Partnership Foundation Trust, patients who hear voices are invited to join a Hearing Voices group co-facilitated by a mental health nurse, which has wide-ranging benefits
Traditionally, most people who hear voices are classified as having schizophrenia and treated with antipsychotic medication. However, in the past 25 years, that approach has been challenged by the Hearing Voices Movement, which promotes the acceptance of different explanations for voice hearing and regards it as a meaningful experience that can facilitate self-discovery and change. This article discusses the benefits of having a mental health nurse co-facilitate a Hearing Voices group in an acute mental health hospital setting, from the perspective of group members, the nurse and other staff on the ward.
Citation: Khan F, Allie S (2019) Benefits of nurse co-facilitation of a Hearing Voices group. Nursing Times [online]; 115: 2, 54-56.
Authors: Fauzia Khan is assistant psychologist; Samina Allie is chartered counselling psychologist; both at Black Country Partnership Foundation Trust.
- This article has been double-blind peer reviewed
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People who hear voices can be supported effectively in ways that differ radically from the traditional psychiatric approach. This article describes how a mental health nurse became involved in a Hearing Voices group (HVG) and how she was able to improve her own knowledge and skills, help patients on their journey to recovery, and help other nursing staff work more therapeutically with patients.
Hearing Voices Movement
In the past 25 years, the approach proposed by the Hearing Voices Movement (Romme and Escher, 1989) has led to what some researchers have called a paradigm shift. In traditional psychiatry, so-called auditory hallucinations are regarded as a symptom of psychosis, mainly schizophrenia (Bentall, 2003; Alpert, 1986).
However, 25-50% of people continue to hear voices despite taking antipsychotic medication (Newton et al, 2005) and 10-39% of the general population will hear voices at least once in their lifetime (Shergill et al, 1998; Tien, 1991); it has therefore become crucial to find alternative treatments. Psychological interventions using a symptom-based approach have been found to be particularly effective (Ruddle et al, 2011) and HVGs have become increasingly popular.
Inspired by the work of Marius Romme and Sandra Escher at Maastricht University in the Netherlands, the Hearing Voices Network:
- Helps develop HVGs;
- Promotes the acceptance of different explanations for voice hearing;
- Regards the hearing of voices as a meaningful experience that can facilitate self-discovery and change (Cortsens et al, 2014).
Romme and Escher’s approach has appealed to a wide array of professionals and voice hearers alike (Corstens et al, 2014; Cooke and Meddings, 1999). This is because it empowers voice hearers and creates a shared identity among them. Voice hearing is often stigmatised and stereotyped, so people may be afraid to talk about their experience, leading them to feel alone (Romme and Escher, 1989). HVGs allow them to talk about their experience without being judged. It validates, normalises and promotes the acceptance of hearing voices (Romme and Escher, 1989).
What the literature tells us
Research suggests that medical professionals often deter people who hear voices from exploring their experience and talking about it with others, which can compound their confusion and isolation (Dillon and Hornstein, 2013). Farhall et al (2007) postulated that engaging with other people about one’s voice hearing can be beneficial as a coping method.
In their qualitative study, Hayward et al (2014) found that talking about one’s voices with mental health professionals was a significant part of participants’ recovery journey. Some participants said professionals had not encouraged them to talk about their voices and they would have appreciated the chance to do so much earlier on in their journey.
Coffey and Hewitt (2008) intimated that interventions by community mental health nurses were restricted to medication reviews, access to a psychiatrist and counselling. They argued that talking about the meaning and content of voices was beneficial for voice hearers. It has been suggested that professionals may avoid talking with voice hearers about their experiences because they think this may reinforce the psychopathology (England, 2007). However, as outlined above, research has shown that people who hear voices would greatly benefit from engaging with mental health professionals about their experience.
Our Hearing Voices group
The Black Country Partnership Foundation Trust provides mental health, learning disability and community healthcare services in Dudley, Walsall, Sandwell and Wolverhampton. In 2007, an HVG was created by a chartered psychologist at Hallam Street Hospital in West Bromwich.
The group is open to hospital inpatients and those who have been referred to the home treatment team upon discharge. Patients access it via referrals from doctors, nursing staff or psychologists. Initially, the HVG was set up as a six-session closed group; over time, this was changed to an open drop-in group with sessions held weekly. The facilitators, a chartered psychologist and assistant psychologist adopt an eclectic approach, using:
- Cognitive behavioural interventions;
- Voice dialogue work;
- Creative work.
Fig 1 shows an example of the creative materials used to break the ice and get the group talking.
Since 2014, a mental health nurse has co-facilitated a number of sessions. One of the challenges with nursing staff having this role is that, due to shift work and the pressure of a busy acute ward, facilitation may sometimes be inconsistent.
We wanted to shift from a medical model to that of the Hearing Voices Network and support the nurse to take on board other perspectives. We also wanted to find out whether having a mental health nurse as co-facilitator had had any benefits. To that end, in September 2016, we elicited reflective accounts from the nurse and from one of the psychologists facilitating the group. Box 1 features the psychologist’s account, outlining her experience of the HVG and her views about having a mental health nurse as co-facilitator. Box 2 features the nurse’s account, outlining her views about the group, including the benefits of her presence for group members and the usefulness of the experience in terms of her own development.
Box 1. Hearing Voices Group: psychologist’s reflective account
“I have been facilitating the Hearing Voices group (HVG) for 11 years. In that time the group has evolved. It used to be a six-session closed group, which evolved to a drop-in format and invited a nurse as co-facilitator. This was invaluable, as she was able to engage patients on the ward we were struggling to recruit. Patients felt at ease with her style and this reinforced connections within the group.
“The group is becoming established and it appears that patients like its relaxed nature combined with a structure and boundaries that make them feel safe to share their experiences. We have opened the group to patients in the community under the home-treatment team to help them with the transition from the inpatient environment.
“During sessions, participants exchange ways of coping. Some comment on the voices troubling them and participants who do so receive good support from facilitators and peers. This creates close relationships between people who might not have had much contact with each other or might have been very isolated on the ward. Some participants talk about their experience to other voice hearers for the first time.
“The feedback we have received is that the group has been extremely supportive and that, for most patients, this is their first experience of sharing the intricacies of their voices with complete strangers. Our ethos was not to change their voices, but to develop their insight into, and understanding of, these voices, and introduce them to new ways of managing them.”
Box 2. Hearing Voices group: nurse’s reflective account
“I have co-facilitated the Hearing Voices group (HVG) on a number of occasions. While I was aware of the existence of such groups, I was unaware of how they worked and was keen to learn more, as the concept of hearing voices had not been explored in great depth during my training.
“I was worried about feeding voice hearers’ beliefs, and thought that by engaging in the content of their voices,
I would, in effect, reinforce their delusional beliefs and potentially make them worse. However, taking part in the group and working more closely with the psychology team made me realise that it helps voice hearers understand their experience and learn new ways of managing their voices. I have come to realise that the experience of hearing voices is real and that it is imperative to validate it.
“Being part of the group has allowed me to see things from a different perspective and not be restricted by the medical model. While that model has made a useful contribution to understanding and treating voices, it is not the only useful framework that exists. Co-facilitating the group has challenged my thinking. It has also allowed me to ‘join in’ with voice hearers and acknowledge their world view as important in helping them find ways to cope.
“I now recognise the importance of normalising the voice hearer’s experience. It is very validating for a patient to show them that you understand what they are going through. I now feel I can better engage with voice hearers and help them. I have learnt a repertoire of interventions and strategies to support them through their journey and have developed more empathy for this client group.
“I believe that involving mental health nurses in facilitating such groups is very important, as it allows us to work more closely with patients towards their recovery.”
Lack of knowledge
In her account, the nurse co-facilitator explains that, before her involvement with the HVG, her knowledge of voice hearing was limited and she was worried that, by discussing the content of their voices, she might be reinforcing voice hearers’ beliefs. Her limited knowledge led her to think that she did not have the appropriate skillset to support patients.
From the literature, it appears that this is a view held by many mental health professionals, including nurses. Place (2003), for example, argued that nurses were fearful of talking openly to people who hear voices, as they were concerned that they may open a “Pandora’s box”. A factor that may prevent nurses from engaging with voice hearers is their lack of awareness of effective strategies they can use (Place, 2003).
The nurse co-facilitator also explained that hearing voices was not covered in depth during her training. This could be one of the factors accounting for health professionals’ lack of knowledge and reluctance to work therapeutically with voice hearers. Place (2003) stated that student nurses were not routinely taught about coping strategies for hearing voices and that the focus of postgraduate training courses in psychosocial approaches lay elsewhere. They further argued that the literature was not accessible to nurses, as the methods proposed can be complex and, therefore, hard to understand without sufficient training (Place, 2003).
These findings stress the importance of putting more emphasis, in nurse education, on the skills and knowledge that are needed to work more closely with people who hear voices.
Both the facilitators found that having a nurse as co-facilitator allowed them to model skills that were effective in helping patients engage with their voices. The nurse helped recruit patients whom facilitators struggled to motivate, because she had already established a rapport with them on the ward.
Co-facilitation challenged the nurse’s belief that talking about the voices would “make things worse”. It allowed her to:
- Improve her understanding of the concept of hearing voices;
- Learn how to support patients using different coping strategies.
Observing at first hand the benefits patients derived from the coping strategies offered by the group increased her confidence in promoting the use of those strategies. She was, therefore, better able to help her colleagues on the ward to work more therapeutically with patients. Her involvement also helped other nursing staff understand what constitutes an appropriate referral to the group. As a result, we have seen a 50% increase in appropriate referrals from 192 to 288 since the nurse became a co-facilitator.
The presence of the mental health nurse as co-facilitator generated interesting discussions within the multidisciplinary team – particularly among doctors and other nursing staff – on the usefulness of exploring the voices that people hear and what they say. We also found that it spurred the interest of student nurses on placement at the hospital and increased their willingness to develop their skills and knowledge in this area.
Implications for practice
Nurses are a valuable resource in terms of co-facilitating HVGs on inpatient wards. In-house training on voice hearing would help nursing staff who work in mental health to gain a better understanding of the topic. For this to be successful on a wider scale, it is important to:
- Place greater emphasis on voice hearing during nurse education;
- Allow students to gain direct experience of how hearing voices is managed.
Developing nurses’ knowledge and skills will enhance their practice, while co-facilitating a HVG will help them gain greater self-efficacy. Future research could observe levels of self-efficacy in nurses who co-facilitate an HVG and ascertain the effect this has on their work performance.
- In traditional psychiatry, hearing voices is considered a symptom of psychosis
- The Hearing Voices Movement regards the phenomenon as a meaningful experience that can facilitate recovery
- Patients benefit from exploring their voices with peers and/or health professionals
- It is important to validate patients’ experiences and recognise their worldview
- Mental health nurses and student nurses need better training on, and exposure to, the management of hearing voices
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