With once voice contd ...
The facilitators take an active role in running the group. They provide a high degree of structure for the early part of the group process (research and experience has shown that this is very important in order to reduce anxiety that people feel when they experience the group process). There may be a strong element of psycho-education, such as discussing what is meant by an hallucination, or a diagnosis of schizophrenia. This helps remove the feeling of being under pressure to contribute and self disclose, however the group members soon gain confidence to contribute. The early sessions should seek to establish the ground rules for running the group; the members of the HVG at Milsom St. produced the following:
Ground rules for groupwork
• All participants should have respect for the rules of the building i.e. where smoking is permissible.
• There will be a break for tea, coffee, cigarettes after 45 minutes, followed by another 30 minutes of group work.
• Confidentiality: members and staff should not share information they hear in the group about members, with people outside of the group unless for risk management reasons or where permission is given for supervision or education.
• The group should start promptly each week at the agreed time.
• The group members expect each other to attend regularly.
• The focus of the group work is the origin, content, meaning, understanding and ways of coping with the voices. This process helps us to be aware of how to deal with the voices.
• We will not criticise each other's contribution but we realise that what works for one person may not work for others.
• We aim to be supportive of each other in the group.
• Sharing is an important part of the group work.
• We will all be involved and take part in the group.
• Humour is an important part of the group, but laugh with us not at us.
• Facilitators are available for an agreed period of time after the group.
The following few sessions should follow a format that gives an opportunity for each person to explore their voice hearing experience. This would normally begin by establishing when the voice started this week and looking at some of the possible stressors that may have occurred at the same time. This may be a very useful time to introduce the concept of stress vulnerability and how voice hearing commonly occurs during periods of very high stress, and is a more common experience than is realised. Having established what stresses made the voices start, the group could explore what the consequences were of hearing voices.
At this stage the group is not looking at the first episode of voice hearing but what is triggering the voices over the last week. The group can then explore what behaviour the group members' use when the voice hearing starts and explore what coping mechanisms they are using to combat the negative effects of the voices. The sharing of this information seems to be very important partly because many of the voice hearers do not realise they have coping mechanisms and partly because it is useful to share other peoples' coping mechanisms.
At this early stage the emphasis may well be on learning and the group can be supplied with several very useful pamphlets (Baker, 1995 and Downs, 2001) as well as on-line leaflets by David Kingdon and the Mental Health Foundation. As confidence grows in the group an exploration of the origin of the voices can be made. This part of the group process needs extreme sensitivity and facilitators need to be very careful about the pace at which this exploration is made as some members relive past trauma. Our groups have been very supportive and have helped this process to the great benefit of those concerned. During these early weeks it also may be useful to end the session with a relaxation exercise as a way of reducing anxiety although several members are keen to tell jokes and this seems to be as helpful! Fun and good humour seem to be as important as the depth of exploration of the voices. For some people this part of the group work is stressful and it seems that initially they are getting worse before they start to get better. As confidence grows people often start to make changes both in their ability to cope with the voices and in the general quality of their lives. The middle part of the group work is concerned with going over the antecedents, behaviours and consequences of voice hearing. More effective ways of coping with the voices are discovered and discussed within the group. Personal goal setting and plans for the future can be introduced at this stage. We have also set up separate self-harm groups to work with the common phenomena of self-harm in voice hearers, especially women.
As the group progresses, the beliefs about the voices can also be examined. This again requires great sensitivity as often very complex beliefs build up over years of experiencing voices because the person may not have been able to talk to anyone else about it. Some beliefs take a form that conventional psychiatry would call delusional. These beliefs may have very protective functions for the voice hearer and should only be challenged if the overall benefit is a reduction in distress for the voice hearer or the prevention of harm. Direct challenging of any of these beliefs is often counter-productive. However, a gentle discussion about a belief by other group members often brings about changes much more quickly than a challenge from one of the group facilitators. It is important for the facilitators to "suspend disbelief" as many voice hearers have truly remarkable stories to tell. So-called delusional material can be explored in time (Kingdon and Turkington, 1991).
Bringing in outside speakers to the group is very helpful. The speaker could be a member of another hearing voices group. Several speakers are available to do this work and responses are usually very good as they are speaking from their own direct experience of the benefit of group work on their own lives. Other speakers that have proved useful are the clinical pharmacist and clinical psychologist. Some of the group members of the Gloucestershire Hearing Voices network are available to talk to new groups about their experiences of the recovery process.
Each session of twelve weeks includes creative work such as affirmation cards, drawing, story telling and so on. This work is based on the ideas of self-esteem building and self-acceptance (Dryden, 1998) and some of these CBT processes are incorporated into the groupwork. The nature of the group work changes with time and there becomes less emphasis on clear CBT approaches such as drawing out the antecedents to a particular voice hearing episode and the consequent beliefs, behaviours and coping processes to a more narrative style that involves facilitators and group members co-operating in forming and reforming members' life stories and how they perceive their "scripts" or unchallenged assumptions of their limitations (Roberts, 2000; Roberts & Holmes, 1999; Vassallo, 1998). The last session of each twelve-week block is spent as a celebration with a meal in a pub!
We initially evaluated the group using a series of measures of social functioning (Birchwood, Smith, Cochrane, Wetton, & Copestake, 1990); psychopathology (Lancashire, 1994) and beliefs about the malevolence of the voices (P. Chadwick, Lees, & Birchwood, 2000; P.D.J. Chadwick & Birchwood, 1995). We found some evidence for a reduction in anxiety, depression and voice hearing (Davis, Coupland, Edgar, & Macdougall, 1997) and in the long term, three members stopped hearing voices and returned to full time work. A qualitative evaluation showed that members appreciated the ability to share their experiences; feel less isolated and more accepted (Coupland, Davis, & Macdougall, 2002). Among the facilitators there was also a high degree of satisfaction in working in a group format and seeing changes taking place in members in a mutually supportive atmosphere.
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