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  • Clinical Psychology and PsychotherapyClin. Psychol. Psychother. 17, 363–373 (2010)Published online 29 December 2009 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.672Relating Therapy for People whoHear Voices: Perspectives fromClients, Family Members, Referrersand Therapists Mark Hayward* and Ella Fuller Psychology, University of Surrey, UK Sussex Partnership NHS Foundation Trust, UK Current psychological models of voice hearing emphasise the per- sonal meaning that individuals attribute to the voice hearing experi- ence. Recent developments in theory and research have highlighted the importance of the relationship between the hearer and the voice. This study aims to contribute to this area of research, by exploring the experience and usefulness of a new form of ‘Relating Therapy’ that aims to modify distressing relationships with voices. Semi-structured interviews were conducted with ten participants and explored the experience and usefulness of a pilot of Relating Therapy: three therapists, three voice hearers, two relatives and two referrers. Interviews were transcribed and analysed using Interpreta- tive Phenomenological Analysis. Three themes that emerged from the analysis are presented for discussion: engaging with the therapeutic model; developing a new relating style; and how change is described and defined by participants. This study is consistent with the growing body of theory and research that highlights the interpersonal nature of the voice hearing experi- ence. It also offers tentative support for a therapeutic framework that aims to modify distressing relationships with voices as a means of bringing about positive change. Clinical implications and areas for future research are outlined. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message: • Conceptualising the voice hearing experience within a relational framework may be normalising, hopeful and helpful for some clients. • Similarities exist between social relationships and the relationship with the voice. • Therapy that aims to modify distressing relationships with voices may be of benefit for some voice hearers. Keywords: Voice Hearing, Therapy, Perspectives, Relating, Interpreta- tive Phenomenological Analysis* Correspondence to: Mark Hayward, Psychology Department, University of Surrey, Guildford, Surrey GU2 7XH.E-mail: m.hayward@surrey.ac.ukCopyright © 2009 John Wiley & Sons, Ltd.
  • 364 M. Hayward and E. FullerINTRODUCTION experience of hearing voices (Birchwood & Chad- wick, 1997; Nayani & David, 1996). An interpersonalAttempts to understand the psychological factors theory capable of considering issues of power andthat may mediate the emotional impact of voice proximity has been developed by Birtchnell (1996,hearing have focused primarily upon cognitive 2002) who describes relating along the intersect-variables: beliefs about the voice’s power and ing axes of power and proximity, represented atintent (Chadwick & Birchwood, 1994; Birchwood their two poles by ‘upper–lower’ and ‘distant–& Chadwick, 1997), and beliefs about the self in close’, respectively. Birtchnell’s Relating Theory dis-terms of esteem and efficacy (Chadwick, 2006; tinguishes between positive and negative relating;Close & Garety, 1998). A recent conceptual devel- the difference between these descriptions being aopment has led to the consideration of the voice as matter of relating competence and versatility.a representation of an interpersonal ‘other’. Ben- The application of Relating Theory to the experi-jamin (1989) was first to offer empirical findings ence of hearing voices has suggested that hearerssuggesting that hearers had ‘integrated, personally perceive their voices to relate to them negatively incoherent relationships with their voice’ (p. 308). a dominant (upper) and intrusive (close) manner,Subsequently, the phenomenological literature both associated with distress. In response, thehighlighted that voices are frequently aligned with hearer may seek to attain distance (also associatedsignificant individuals in the hearer’s social world with distress) or accept the need to relate depend-(Leuder, Thomas, McNally & Glinski, 1997; Nayani ently (a mixture of closeness and lowerness—& David, 1996) and are engaged with in conver- associated with lessening distress) (Hayward,sation (Garrett & Silva, 2003). This sense of rela- 2003; Hayward, Denney, Vaughan, & Fowler 2008;tionship with voices was qualitatively explored by Vaughan & Fowler, 2004).Chin, Hayward, and Drinnan (2009) who reported The understandings of voice hearing derivedthe acceptance of relational frameworks and an from Birtchnell’s Relating Theory lead to the devel-evolving sense of ‘we-ness’ by the majority of their opment of ‘Relating Therapy’ (Hayward, Overton,participants. Dorey, & Denney, 2009). Relating Therapy pro- The influence of relating variables upon hearers’ gresses through three broad and overlappingresponses to their voices has been clarified through stages: (1) socialization to Relating Theory and itsthe application of Social Rank Theory (Gilbert & implications for the interrelating between hearerAllan, 1998). Concerned primarily with issues of and voice, (2) exploration of themes within thepower, Social Rank Theory has suggested that relational history of the hearer (with regard tothe powerlessness of hearers relative to distressing social and voice relationships) and (3) explorationvoices is mirrored within the hearer’s social rela- and development of assertive approaches (e.g.,tionships (Birchwood, Meaden, Trower, Gilbert, & Dryden & Constantinou, 2004) to relating (to thePlaistow, 2000). Furthermore, this powerlessness voice and socially); and use of the ‘empty chair’seems to be rooted within interpersonal schema, and ‘experiential role plays’ (Chadwick, 2006) toboth reflecting and shaping pervasive patterns of explore the motives of the voice and practice relat-relating across an individual’s lifespan (Birchwood ing in an assertive manner (see Hayward et al.,et al., 2004). The mirroring of social and voice 2009 for further details of the therapy protocol).relationships creates therapeutic opportunities to Relating Therapy was piloted on an individualaffect change in one domain with an expectation of basis with five clients who heard distressing voiceschange in the other. Indeed, Birchwood, Meaden, (Hayward et al., 2009). The experience of distress-Trower, & Gilbert (2002) have demonstrated how ing voices and related ‘psychotic’ experiences caninterventions focussed upon social relationships significantly impact upon many people who are incan impact on distressing relationships with voices, contact with the client, e.g., family members (Add-and Byrne, Birchwood, Trower, and Meaden (2006) ington, Coldham, Jones, To, & Addington, 2003)focused on changes in the relationship with the and therapists (Lloret, Hayward, & Brown, 2009).voice that enabled changes in social relating. Additionally, the experience of hearing voices is However, if relationships with voices are influ- embedded in a relational context, and may beenced by interpersonal experience, they are likely to influenced by relationships and social interactionbe imbued with all the complexity and idiosyncrasy with family, friends and mental health workers.of social relationships. In addition to power, this will Consequently, this study aimed to qualitativelyinclude issues of proximity and intimacy, themes explore and capture the experiences and views ofthat have been reported as prevalent within the Relating Therapy across multiple perspectives byCopyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 17, 363–373 (2010) DOI: 10.1002/cpp
  • Relating Therapy for People who Hear Voices 365interviewing clients, members of their families, the tate answering the research question), and is alsotherapists and referrers. This approach is consistent flexible enough to enable the researcher to respondwith an important systemic notion that situates to the content of each individual’s interview, e.g.,the therapy process within a system of relation- by following-up interesting avenues that emergeships that may both influence and be influenced (Smith, 1995).by the intervention. Systemic approaches also The interview schedule aimed to explore theadvocate that exploring multiple key perspectives research question: What are the views of peoplegenerates a more complete overview of the topic who hear voices, therapists, referrers and relativesunder investigation, enhancing understanding and about the experience and usefulness of a thera-enabling the results to be cross-checked to explore peutic approach that uses a relational framework?credibility (Dallos & Vetere, 2005). Three broad areas were covered: (1) general/ scene-setting, (2) experience and views of Relat- ing Therapy and the relational approach and (3)METHOD perceived change. The interviews were conductedParticipants by the second author, audiotaped and transcribed verbatim.Participants in the current study were either:• clients who had participated in Relating Analysis Therapy as part of Hayward et al.’s (2009) Interpretative Phenomenological Analysis was therapy pilot (N = 3); selected as its aims and the epistemological back-• therapists who had offered Relating Therapy as ground are consistent with this study. The analy- part of the therapy pilot (N = 3); sis of the transcripts followed guidelines outlined• referrers of clients to the therapy pilot, who had by Jonathon Smith (e.g., Smith, Jarman, & Osborn, regular contact with the client (N = 2) or 1999). The first transcript was read a number of• relatives of clients within the therapy pilot, who times and notes were made in the left hand margin had regular contact with the client (N = 2). about anything that was perceived as important Demographic information about the participants or significant. The right hand margin was thenis presented in Table 1. used to note emerging theme titles that ‘capture the essential quality’ of what was found in the text (Smith et al., 1999, p. 221). These included someDevelopment of the Interview Schedule broader summaries of the text and more abstractSemi-structured interviewing was selected as this interpretations. Tentative connections betweenprovides the opportunity for some degree of struc- themes were then made, looking for clusters ofture to guide the researcher’s questioning (to facili- topics or concepts. These clusters were then allo-Table 1. Demographic characteristics of participants Gender Age Ethnicity Duration of voice hearing Treatment for voice hearingTherapist T1 Female 40–49 White British T2 Male 40–49 White British T3 Female 40–49 White BritishClient C4 Male 20–29 White British Less than 5 years Antipsychotic medication C5 Female 20–29 White British More than 10 years Antipsychotic medication C6 Female 40–49 White British More than 10 years Antipsychotic medicationRelative F7 Female 50–59 White British F8 Male Over 60 White BritishReferrer R9 Male 50–59 Chinese R10 Male 50–59 White BritishCopyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 17, 363–373 (2010) DOI: 10.1002/cpp
  • 366 M. Hayward and E. Fuller Table 2. List of superordinate themes and subthemes Superordinate theme Subtheme 1. Engaging with the • An intuitive model of voice hearing relational framework • Assessment of relating styles • Openness and honesty 2. Therapists’ approach • Therapeutic relationship • Non-judgemental about psychotic experiences 3. Developing a new • Developing understanding relating style • Drawing on positive relating styles • Assertiveness training • Bringing the dialogue into the room 4. Challenges to change • Perceived risks within therapy • Entrenched relating styles 5. Impact of change • Voice-hearer relationship • Acceptance of voices • Mental health and perceptions of self • Independence-seeking • Social relationships • Hopefulness and the possibility of changecated superordinate theme titles, resulting in a list Evaluation and Validityof preliminary superordinate themes for that par- Independent audit was used to explore the coher-ticipant. Throughout this process, it was important ence of the analysis and the grounding of inter-to check that these themes connected to the tran- pretations in the data (Dallos & Vetere, 2005). Thisscript to ensure that interpretations were grounded included a qualitative research group analysingin the text. extracts from two transcripts and also allocating The remaining transcripts were analysed in randomly selected quotations (from all 10 partici-the same manner. Throughout this process, the pants) to superordinate themes and subthemes. Apreliminary superordinate theme titles from the transcript with left and right margin commentsfirst transcript were held in mind, while there was also read by a psychologist with extensiveremained an openness to new and different ideas methodological experience who cross-checkedand issues. New emergent theme titles were then the comments with the transcript’s list of prelimi-tested against earlier transcripts, and the superor- nary superordinate themes. In relation to both thedinate theme lists (for each transcript) were modi- qualitative research group and the psychologist,fied as appropriate in the ongoing analysis. This where differences or elaboration arose, these wereprocess resulted in lists of preliminary superordi- discussed and agreement was reached about thenate themes for each of the 10 participants. allocation or interpretation of a particular quota- The lists of themes from all 10 transcripts were tion or comment.amalgamated and redefined into a master list1 ofsuperordinate themes and subthemes, again check-ing that the themes were represented in the tran-scripts (Smith et al., 1999). During this process, RESULTSsome themes were dropped, based on relevance The results section will provide a narrative accountto the research question, the richness of the pas- of the experience and usefulness of Relating Therapy,sages supporting the theme, and the frequency of from multiple perspectives (Smith & Osborn, 2003).the theme within and across transcripts (Smith & Themes and subthemes developed from the inter-Osborn, 2003). view transcripts are presented in Table 2. Three superordinate themes are partially reported. These themes and subthemes have been selected1 The language used to describe the themes (‘master list’ of for presentation because they reflect the process‘superordinate’ themes and ‘subthemes’) is consistent with of this novel form of therapy, rather than moreconventions outlined by Smith and colleagues (1999). contextual factors that may apply more generi-Copyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 17, 363–373 (2010) DOI: 10.1002/cpp
  • Relating Therapy for People who Hear Voices 367cally to therapy with people who hear voices, e.g., talked about the importance of developing a ‘lon-therapeutic relationship. The majority of reported gitudinal formulation’ with clients (T1) to guide thethemes and subthemes were evident within the intervention around their voice-hearing experience:data elicited from each of the four perspectives. ‘look beneath the surface and get a sense of . . . what thisSubthemes that represent a more restricted range experience connects to, relationally . . . and get a senseof perspectives are identified below. of the underlying issues that need to be addressed’ (T2). For example, with one client the underlying issuesTheme 1: Engaging with the Relational Model were around shame (T2). The therapy was described as helping clients toAn Intuitive Model of Voice Hearing ‘see a connection between that which they experience Encouraging clients to gain a sense of being in a and that which is going on in their lives’ (R9). T3relationship with the voice was described as ‘intu- referred to a ‘powerful week’ where the genogramitively . . . appealing’ (R9), because it offered a con- was used to consider the links between a pastceptualization of the experience in ‘a ballpark where abusive relationship and the current voice rela-the hearer has a real sense of knowing the terrain’ (T2). tionship. C6 agreed that this connection ‘becameThis was linked to the universal nature of expe- clearer through the therapy’ and described the impactriencing relationships (e.g., T3). Voices were gen- on her relationship with the voice: ‘I’m much lesserally described as having a personified identity, afraid than I was before. I have more understanding ofknowledge, intent (e.g., malevolence), and a history what’s occurring and having that gives me more powerof interactions and dialogue with the client. against him [the voice]’. F8 described this as discuss- The intuitive nature of the relational framework ing things that were ‘deep down’.was reflected in the ease with which participants Some participants valued the exploration of pat-could compare experiences with the voice to those terns of interaction, as a means of developing newwithin social relationships. The concept of disem- understandings about relationships. For example,powerment within both social relationships and C5 developed a new interpretation that hearingthe relationship with the voice was common in the Devil (her predominant voice) was a test ofparticipants’ accounts (e.g., R10): C4 expressed that faith rather than a punishment, by consideringteachers used to ‘talk about me, and make decisions’ ‘why would he do this, what would he be achieving bywithout involving him. He compared this with doing this?’ The process of exploring clients’ inter-the voices; ‘it’s the same sort of thing. They’ve had a pretations of relationships was also described asmeeting without me, and come to decisions without me’. facilitating changes in their views of themselves.The process of comparing relationships facilitated C6 explained that ‘she [the therapist] was workingclients in making sense of their voice-hearing expe- with me on accepting the fact that I hear voices, and thatriences: ‘being able to see that kind of link as opposed it didn’t mean that you were mad or bad’. These newto . . . I don’t understand this but it’s happening, I think understandings were seen as facilitating clients inhas been very illuminating for her’ (R9). making small changes in their relating styles (T1). Therapists also described the model as normaliz-ing and empowering for clients. There was a ‘sense Drawing on Positive Relating Stylesof relief’ (T1) as clients were encouraged to under- This subtheme was evident primarily within thestand their experiences within the ‘ordinary domain’ perspectives of the therapists. Therapists high-of relationships rather than as ‘mad stuff’ (T2). The lighted that one way of gaining ideas for introduc-emphasis on reciprocity in relationships allowed ing difference in the relationship with the voice wasclients to gain ‘a sense of . . . playing an active role by drawing on clients’ own experiences of positivein that relationship’ (T2), and recognize that they relating within ‘more functional’ relationships (T1).have ‘a choice about . . . how [to] respond’ (T1). In Therapists would aim to ‘shine a spotlight on timesthis way, clients realized that ‘like any relationship, when maybe she’s not been the passive recipient of an[the relationship with the voice] has the potential to experience, but she’s . . . taken more active roles in thosechange’ (T2). relationships’ (T2). Therapists might ask how the client would respond to criticism or threat withinTheme 3: Developing a New Relating Style these relationships and explore the possibility ofDeveloping Understanding using these ideas within the relationship with the Developing understanding about underlying voice (T1).issues and connections between experiences was Birtchnell’s octagon (a diagrammatic representa-consistently valued by participants. Therapists tion of relating styles; Birtchnell, 1994) was usedCopyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 17, 363–373 (2010) DOI: 10.1002/cpp
  • 368 M. Hayward and E. Fullerto record both positive and negative relating, so whisper. If you’ve got something to say, you say it outwas important in stimulating discussion about past loud or I won’t pay any attention to you at all’. She alsoexperiences of positive relating (T3). The genogram talked about counteracting the voice with logic.was also used to explore when and how clients For example; ‘If he’s saying you’re stupid, I’ll say I’mhad achieved more positive relating within other not stupid because I do group work, I do lecture work’relationships (T3). Both these diagrams facilitated (C6). C4 described ‘trying to reason with it’ but feltthe process of identifying ideas for change, and the ‘it doesn’t work’.possible impact of change, in the relationship with Therapists likened this process to cognitivethe voice (T3). behavioural therapy, in which clients challenge the validity of their own negative thoughts (T2).Assertiveness Training For example, T3 explained ‘when we were doing the The purpose of assertiveness training was ‘to evidential review of the voice content and its accuracy,think about the process of learning to relate differently’ that felt very CBT’. Yet therapists were clear that theto the voice (T2). Clients were encouraged to be approach was always ‘underpinned by this interper-‘less unquestioningly subservient’ to the voice, and sonal theory’ (T1).in the context of Birtchnell’s Relating Theory, to‘take a more upper position’ (T1). Therapists also Bringing the Dialogue with the Voicehighlighted that assertiveness training gave clients into the Roommore choice about possible responses to the voice This subtheme was evident primarily within the(T3). This is consistent with an important aspect of transcripts of the therapists and clients who talkedRelating Theory that advocates increasing versatil- about the process of bringing the dialogue with theity in relating styles (T1). voice into the therapy room. Often this took the Therapists and clients described the process of form of role play with the therapist saying some-learning to relate more assertively to the voice. thing that the voice might say (T3), and askingThis involved identifying different relating styles, the client to respond (T1). One therapist used ane.g., ‘relating passively, aggressively and assertively’ ‘empty chair’ to invite the voice into the room(T2). C5 and C6 valued using an ‘assertive[ness] more explicitly (C4, C5): ‘I essentially would, withbook’ (C5) that explained these relating styles (T3). his permission, clear a space on the settee and inviteClients were encouraged to explore the possible the voice into the room and ask him to converse as ifimpact of each relating style on themselves and the the voice was there, and tell me how he believed that therelationship with the voice (T1). It was also impor- voice might respond’ (T2).tant to consider why it might be difficult for clients Bringing the dialogue into the room allowedto be assertive in particular situations (T3). clients and therapists to gain further understanding Once clients were familiar with the concepts, of clients’ relating styles and unhelpful ‘reciprocal‘then we tried to figure out assertive answers to the roles’ within relationships (T2). C4 emphasized thatvoices’ (C5). Frequently this involved challenging the aim for him was also to ‘get the voice to under-the voice in terms of ‘the validity and accuracy of stand me a bit more’. This process enabled clients towhat he’s saying’ (T2) and whether the voice was experiment with ‘speaking in different ways’ to thebeing ‘reasonable or unreasonable’ (R10). Assertive voice (T1). T2 explained that the purpose was toresponses were written down to facilitate clients’ demonstrate ‘if [the client] or [voice] threw in some-recall of this new relating style, e.g., on cue cards thing different, how that could lead to all sorts of differ-(T3) or keyrings: ent conversations spiralling off of it. So it was creating the opportunity to have a different kind of conversation’.C5 We looked at ways of trying to remember how to be This often involved ‘practice and rehearsal’ of more assertive and how to respond to the Devil [voice] assertive responses (T3). in a better way. T1 suggested that this process can make the dia-I And what were those ways? logue ‘more real’ and ‘more personified’. T2 suggested that this was initially experienced as uncomfort-C5 . . . We made little notes on keyrings, it says ‘soul- able by C4, as it ‘brought the experience much closer’, mates will never be kept apart’, ‘show me some but after repeated practice, he ‘began to welcome proof’, ‘show me someone who agrees with you’, ‘I the opportunity’. C5 did not expect the ‘empty know God’s real because He speaks to me’. (C5) chair’ to work because ‘the voices . . . come from theC6 expressed assertive responses to the whisper- air . . . from all around, they’re not going to come anding voices that she hears: ‘you’re extremely rude to want to sit in one chair’. The ‘empty chair’ seemedCopyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 17, 363–373 (2010) DOI: 10.1002/cpp
  • Relating Therapy for People who Hear Voices 369to be stressful for C5 as she talked about it trigger- therapy was novel in its goal to facilitate clients ining a migraine. living with voices (F8), rather than an approach that ultimately seeks to eradicate voices. Partici- pants highlighted the role of power and controlTheme 5: Impact of Change (R10) in enabling clients to learn to live with theVoice-Hearer Relationship voice (T3): ‘with the therapy I’ve come to the conclu- Participants described a shift in clients’ relating sion that I might not be able to get rid of him. But Istyles from attempted distancing to more assertive can control him, and I don’t have to be depressed byengagement: ‘I’ve been trying to run away from the him’ (C6).voice all the time and I’ve learned to stand firm and This change through therapy seemed consistentfight back’ (C6). C5 also referred to a more ‘assertive’ with the goals and views of participants. C5 com-style, and less attempts to ‘escape’ the voice. This mented ‘there is definitely something good about accept-assertive relating style was commonly described ing the voices’, ‘I don’t want to get rid of them, I don’tas involving more engagement with the voice in feel like they should ever really die or anything’. F7terms of challenging rather than passively accept- noted the importance of relatives ‘coming to terms’ing its content (T3). For C5, this improved com- with voices too: ‘I’ve come to the conclusion that it’smunication with the voice and ‘we’re not complete not just going to be a miracle cure now . . . think he’senemies anymore’ (C5). C6 explained that the voice got to live with it’.‘runs out of steam’ when she responds assertively,then she can disregard him. Mental Health and Perceptions of Self Initially, clients were positioned as powerless Most participants identified changes in mentalvictims in relation to critical, powerful voices (e.g., health as important outcomes from therapy.R10). Many participants associated assertive relat- Clients were described as ‘no longer as distressed oring with an increase in clients’ power, e.g., feeling depressed’ (R9), ‘happier’ (C5) and showing a new‘slightly more in control, slightly more power, as if the ‘brightness’ in mood (F8). C6 reported that sincerelationship is becoming a slightly more balanced one’ therapy, she had experienced her longest period(T2). This was linked to a parallel decrease in the of time ‘without illness’ (C6). C4’s mother identifiedperception of the voices’ power. Voices became that ‘he’s definitely less paranoid’ (F7), which was‘more nuisance than . . . powerful’ (R10), and ‘less evident through him going out more. C4 said thereimportant’ to the clients through therapy (T1). C6 had not been any changes in the way he feels.summed up this parallel, reciprocal process of a Many participants talked about changes in clients’shift in power within the relationship; ‘the more views of themselves. C6’s therapist explained thatpower I get, the less he has’. For one client, this shift ‘her confidence seems to have grown’ as C6 feels betterin power was evident in the client feeling less about herself and her abilities (T3). Improved self-compelled to comply with the voice’s commands esteem reinforced changes in the relationship with(R9). the voice, as clients came to believe ‘I have a right C4 did not express any changes in his relation- to set a boundary’ (R10) or ‘I don’t deserve that’ship with the voice; ‘the voices are still very much (T1). Changes in the relationship with the voicethe same. So it hasn’t really touched upon it’. He served to strengthen self-esteem: ‘that gives mecontinued to describe the voice as a ‘bully’ with more confidence, more self-esteem, because I think Imalevolent intent, great knowledge and power. don’t have to be . . . under the control of the DevilWhen asked about his expectations about therapy, [voice] anymore. I can just try and be myself’ (C5).C4 said: ‘I thought I would get told about the whole Self-respect was described as evident in clients’conspiracy behind me. And then they would work with improved self-image (C6) and care about theirme on the real issues, you know’. He described this appearance (F8).as ‘the only therapy that I could see that would work’. Participants also referred to improved self-effi-This was linked to the content of his voices: ‘my cacy, e.g., the extent to which clients believedvoices always tell me that . . . one day you’re going to they could cope with problems. Through therapy,know about it’. clients developed ‘tools to deal with the voice’ (R10) that enabled them to feel ‘more able to deal withAcceptance of Voices the voices when they’re bad’ (C5). T2 described an Participants across all perspectives referred to increase in C4 feeling ‘he can change things, he canthe importance of clients coming to accept their control things’, although this was not supported byvoices. This was linked to a common idea that the C4’s account.Copyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 17, 363–373 (2010) DOI: 10.1002/cpp
  • 370 M. Hayward and E. FullerSocial Relationships future. Whereas now I can see that with practice . . . I This subtheme emerged in participants’ descrip- can get . . . [the voice] under control’ (C6).tions of how the therapy had affected clients’ social Therapists described the therapy as ‘intrinsicallyrelating and subsequently relationships with family, optimistic’ about the possibility of change (T1).friends and partners. T2 described how facilitating Yet they recognized that, in the context of long-assertive relating to the voice had a ‘ripple effect’ on standing negative relationships with voices, clientssocial relationships by clients applying the ‘guiding might struggle to believe that things could be dif-principles of our conversations’ to their life experi- ferent (T1). In this way, strengthening the belief inences. Some participants referred to clients taking the possibility of change was seen as a significantmore interest in social relationships, e.g., F7 talked outcome from therapy: ‘if we, over a space of a fewabout her son increasing engagement with friends short weeks, can work to a point where maybe changeand family. can be um conceived of . . . maybe that’s actually some- Many participants described clients becoming thing quite significant’ (T2).more assertive in their relating to others, and theimpact of this on their positioning within socialrelationships. A significant change for both C5 and DISCUSSIONC6 was being able to say no within relationships: The aim of this study was to explore multiple per- spectives on the experience, process and useful- ‘it gives me the power to say no without feeling ness of a pilot of Relating Therapy for people who guilty . . . I can choose what I want to do more, hear voices. The results suggest that the therapy rather than . . . let him control me, and just be can be understood as a process of engaging with submissive’. (C5) the relational model, developing understanding, introducing different relating possibilities and ulti-Participants highlighted the importance of being mately bringing about change. Most participantsable to say no and set boundaries in relationships experienced and understood Relating Therapy as(R10), while ‘feeling ok’ and ‘without losing the person’ a helpful and positive process.(T3). C5 similarly described a shift with her partnerto more ‘equal terms’. For F8, the shift in socialrelationships was about a return to C6’s former Spread of Perspectives Across Themesself: he affectionately described the re-emergenceof the ‘bossy-boots’ and was ‘happy with the fact that The spread of themes across perspectives iswe’re getting my daughter back’. noteworthy given the decision to take a pan- Consistent with assertive relating, clients were perspective approach to analysis. The views of thedescribed as being more open and able to ask for therapists were evident across all of the reportedhelp from their family: ‘I’ve learned to be, with the subthemes, suggesting that they were engagedtherapy, to be more honest and ask for help when I need with the relational framework, its therapeutic useit, rather than wait until its too late and I’m ill’ (C6). F8 and the resulting changes. The views of clientstalked about C6 being more open about her voices were similarly evident across subthemes, withand paranoid worries. The impact of openness was the exception of drawing on positive relating styles.that her family could ‘try and point out what the This exception may relate to the differing tempo-solution is’ or help her challenge her worries and ral emphasis placed upon social relating by thera-‘allay her fears’. pists and clients: therapists working subtly with positive experiences of past social relationshipsHopefulness and the Possibility of Change in a theory and formulation driven manner; and A further area of change identified by partici- clients focusing upon relationships (with voicespants concerned clients’ views about the future. and socially) primarily within a forward-lookingC6 felt that therapy had allowed her to ‘face the recovery orientation.future’ more positively by helping her to ‘face up’ The most notable differences across perspec-to her traumatic past. C5 referred to the therapy tives concerned the referrers and relatives, whosegiving her a ‘more positive outlook on life’ by helping views were less consistently represented withinher use assertive responses to challenge the voice’s the superordinate theme that focused upon thepessimism. Some participants associated hopeful- therapeutic process (developing a new relating style).ness with increased independence seeking (T3) This raises questions about the extent to whichand self-efficacy (R10): ‘before I thought I had no referrers should be in dialogue with therapistsCopyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 17, 363–373 (2010) DOI: 10.1002/cpp
  • Relating Therapy for People who Hear Voices 371about psychological interventions; and the extent with this proposition, as therapy was describedto which therapy should be situated in a broader as enabling clients to consider new understand-process of family work. Referrers and relatives may ings and interpretations of the voices’ negativenot feel sufficiently informed about specific inter- relating.ventions (which may or may not be appropriatedepending on individual contexts), yet they may How is Change Defined?have important views about clients’ experiences,care and management that could impact upon the The participants within this study describedtherapeutic process. perceived outcomes as meaningfully linked and interconnected, rather than discrete ‘categories’. Consistent with the focus of therapy and its theo-The Interpersonal Nature of Voice Hearing retical underpinnings, the improved relationship with the voice was described as contributing toThe results of this study are consistent with many of the positive outcomes, e.g., facilitating aliterature that highlights the interpersonal nature more efficacious view of the self (Close & Garety,of the voice-hearing experience (Benjamin, 1989; 1998) and less negative relating within social rela-Birchwood et al., 2000, 2004; Chin et al., 2009). tionships (Birchwood et al., 2002; Hayward, 2003).Participants’ accounts suggest that the idea of a The outcomes related to acceptance and hope arerelationship with the voice is a meaningful, under- consistent with the recent emphasis on recoverystandable and intuitive concept, and was reflected oriented approaches that view enhancement ofin the way that participants talked about voices as quality of life as possible despite continuing ‘psy-personified entities, with knowledge, intent and a chotic’ experiences (e.g., Hayward & Slade, 2008).history of interaction and dialogue that commonly It was interesting to note that C4 was the onlypositioned the voice as powerful and intrusive, participant who did not identify positive changesand the hearer as powerless and seeking distance. from therapy. As the results suggest, C4 expected Furthermore, the ease with which participants or hoped that therapy would validate the realityidentified similarities between social relationships of his beliefs about a conspiracy against him, andand the relationship with the voice corroborated help him deal with the subsequent situation. Histhe findings of Birchwood et al. (2000, 2004) and therapist (T2) talked about being non-challengingHayward (2003). of beliefs, but was clear that he understood the task of therapy as facilitating C4 in relating differently to the voice. Consequently, the absence of reportedRelating Therapy change may be attributed to the lack of a sharedAccounts about the process of change seem con- goal between client and therapist (McGowan, Lav-gruent with literature suggesting that increased ender, & Garety, 2005).dialogical engagement with the voice can con-tribute to positive outcomes (e.g., Chadwick, 2006; LimitationsDavies, Thomas, & Leudar, 1999; Leudar, Thomas,McNally, & Glinski, 1997). This process of learning The sampling and data collection process mayto relate differently promoted assertive engage- have created potential biases that limit the utility ofment with the voice, rather than passive acceptance the results. The sample were selected on the basisand subservience, or resistance through shouting, that they were involved in the Relating Therapyavoiding and attempting to escape (Chadwick & pilot and therefore were relevant to answering theBirchwood, 1994). research questions about experiences and views Within Birtchnell’s model, Relating Therapy can of this therapy (Smith & Osborn, 2003). Yet thebe understood as encouraging clients to relate less sample was very broad in that participants variednegatively from a position of dependence (within greatly in perspective, age and other contextualthe power domain), involving less distancing and factors. This seems appropriate in an exploratorymore involvement and engagement with the voice study that seeks to develop understanding about(within the proximity domain). As well as modi- a novel form of therapy and generate further areasfying relating styles, Birtchnell also proposed that for exploration (Dallos & Vetere, 2005). However,therapy should help clients tolerate others’ negative this issue, combined with the small number ofrelating styles. Participants’ accounts within the participants, does reduce the extent to which thesubtheme developing understanding were consistent results can be generalized beyond this sample.Copyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 17, 363–373 (2010) DOI: 10.1002/cpp
  • 372 M. Hayward and E. FullerFuture Research (Ed.), A casebook of cognitive therapy for psychosis (pp. 108–131). Hove: Brunner-Routledge.This study suggests that conceptualizing the voice- Birchwood, M., Meaden, A., Trower, P., Gilbert, P., &hearing experience as a relationship may be nor- Plaistow, J. (2000). The power and omnipotence ofmalizing, hopeful and helpful for some clients. voices: Subordination and entrapment by voices andFuture studies should attempt to clarify the factors significant others. Psychological Medicine, 30, 337–344. Birtchnell, J. (1996). How humans relate: A new interpersonalthat may contribute to making this framework theory. Hove: Psychology Press.more or less helpful for different voice hearers. For Birtchnell, J. (1994). The interpersonal octagon: An alter-example, this may take the form of comparing how native to the Interpersonal cycle. Human Relations, 47,meaningful and useful this framework is deemed 511–529.to be by voice hearers with different characteris- Birtchnell, J. (2002). Relating in psychotherapy: The applica-tics (such as different backgrounds, explanatory tion of a new theory. Hove: Brunner Routledge.frameworks and voice characteristics). In addi- Byrne, S., Birchwood, M., Trower, P.E., & Meaden, A. (2006). A casebook of cognitive behaviour therapy gottion, multiple forms of data collection and mea- command hallucinations: A social rank theory approach.sures of change would offer more information and Hove: Routledge.understanding about this new form of therapy and Chadwick, P. (2006). Person-based cognitive therapy for dis-boost the validity of the findings. This might take tressing psychosis. Chichester: Wiley.the form of interviews and questionnaires before Chadwick, P.D.J., & Birchwood, M.J. (1994). Challeng-therapy commences (about expectations, hopes ing the omnipotence of voices: A cognitive approach to auditory hallucinations. British Journal of Psychiatry,and fears), at different stages of therapy (possi- 164, 190–201.bly utilizing observation of videotaped sessions) Chin, J., Hayward, M., & Drinnan, A. (2009). ‘Relating’and after therapy is completed (to explore overall to voices: Exploring the relevance of this concept toviews and outcomes). Such research may helpfully people who hear voices. Psychology and Psychotherapy:differentiate between the views and experiences Theory, Research and Practice, 82, 1–17.of clients and therapists, enabling the distinctive- Close, H., & Garety, P. (1998). Cognitive assessment of voices: Further developments in understanding theness and/or overlap of different perspectives to be emotional impact of voices. British Journal of Clinicalfurther clarified. Psychology, 37, 173–188. Dallos, R., & Vetere, A. (2005). Researching psychotherapy and counselling. Berkshire: Open University Press. Davies, P., Thomas, P., & Leudar, I. (1999). DialogicalACKNOWLEDGEMENTS engagement with voices: A single case study. BritishThanks are due to all the individuals who partici- Journal of Medical Psychology, 72, 179–187.pated within the study, and to Arlene Vetere for Dryden, W., & Constantinou, D. (2004). Assertiveness: Step by step. London: Sheldon Press.her advice and guidance. Garrett, M., & Silva, R. (2003). Auditory hallucinations, source monitoring, and the belief that ‘voices’ are real. Schizophrenia Bulletin, 29, 445–457. Gilbert, P., & Allan, S. (1998). The role of defeat andREFERENCES entrapment (arrested flight) in depression: An explo-Addington, J., Coldham, E.L., Jones, B., To, K., & Add- ration of an evolutionary view. Psychological Medicine, ington, D. (2003). The first episode of psychosis: the 28, 595–598. experiences of relatives. Acta Psychiatrica Scandinavica, Hayward, M. (2003). 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