Veenu Gupta is a Psychology PhD student at University of Liverpool, conducting research into the identities of lived experience researchers and providers. She has lived experience of psychosis herself and also uses these experiences in her work as a service user advisor to the National Clinical Audit into Psychosis and EXTEND Early Intervention in Psychosis study.
In this post, Veenu reviews Voices in Psychosis edited by Angela Woods, Ben Alderson-Day and Charles Fernyhough. You can follow her on Twitter @TheTealTigerUK.
Listening to the voices of voice hearers
The academic researcher is often curious about what it is like to hear voices and Voices in Psychosis aims to listen to, give voice to and understand this experience. The collection of essays is based on data from Hearing the Voice‘s longitudinal study of the voice-hearing experiences of forty people in Early Intervention in Psychosis services from the North East of England. It offers an interdisciplinary approach to understanding the same data through multiple perspectives and analyses, including accounts grounded in lived experience that embody the voices of psychosis.
The research team behind the study collaborated with those in many fields, including those with lived experience, psychologists, philosophers, historians, phenomenologists, and those in the field of humanities. For example, chapter 15 explores the nature of voice hearing and its qualities through phenomenology and chapter 11 explores the subject through comparison to medieval literature. The editors of the collection comment on the collaborative effort of the project, which sparked ideas for measuring this experience, to elucidate and investigate the phenomenon in novel and creative ways. The volume is also open access which helps share learning from this work to a large and varied audience, supporting voice hearers to be better understood.
Voices in Psychosis begins by setting the scene through providing an understanding of how voice hearing is understood in the mental health system, and its presence in many different types of mental illnesses such as schizophrenia, bipolar disorder, and borderline personality disorder. It describes the aetiology of voice hearing through different causes, for example, as linked to language hearing processes, biological influences, effects of trauma, cultural, and religious influences, amongst others. The plurality of the experience is detailed across the essays in the collection.
Who are the voices in the collection?
The forty participants whose experiences were explored in the Voices in Psychosis study have unique and individual experiences. It is acknowledged by the editors that they cannot be representative of all voice hearers in general. The majority of participants in the study were White British, as the region lacked diversity, but encompassed experiences from across the breadth of psychosis experiences including those with At Risk Mental State. However, a more diverse sample may have offered additional insight into the experience, that may not have been captured by this data specifically. Nevertheless, there is a richness to the data from these participants and the interdisciplinary expertise of the researchers which interplay with each other through the research process that enables the experience of voice hearing to be heard and meaningfully understood.
Engaging with voice hearers
Often those with psychosis and who hear voices are excluded by western society and their experiences stigmatised. Their experiences may be considered so far outside the realms of ordinary experience that engaging with experiences of psychosis might feel difficult for others to comprehend. I found it promising that the researchers made careful considered decisions on involvement of patients who were early on in their tenure in Early Intervention in Psychosis services, to ensure no harm was caused by the research process to them. The initial chapter on ‘interdisciplinary listening’ describes how interviewees may find it difficult to “open up” about their difficult emotionally charged experiences. The researchers developed thoughtful ways to enable these conversations whilst being mindful of the difficulty in talking about these experiences. It was interesting to see that navigating this experience was both difficult for the interviewee, but also for the interviewer in different ways. It acknowledges that the interviewer needed to navigate feelings of their own discomfort and also the discomfort of the interviewee, whilst trying to get meaningful data. The research interviewers avoided transactional interactions and instead were interested in building trust and fostering relationships so that lived experiences could be better discussed and shared. The volume suggests how the process of sharing voice hearing experiences may be a healing process in itself. Further chapters reflect on moving between the interviewer’s world and the world of the interviewee. The essays identify the power of similes, analogies and metaphors that voice hearers use to describe their experiences, and which have the power to bring the interviewer into the interviewee’s world.
Amplifying and bringing voices into the room
In reading the volume, I found it interesting to learn about the multiple methodologies used to work with people with psychosis, especially in clinical and research settings. Some examples that help the person hearing voices to explore their relationship with their voices include asking them to place their voice into “the empty chair” to give it an external body from which it can be observed and interacted with. Similar methods have been employed through AVATAR therapy, which helps give a physical character and embodiment to the voice through a virtual avatar. These types of therapeutic modalities can help change the relationships individuals have with their voices and give them more control over them and how they think of and relate to them. These modalities offer ways to bring the voices of the voice hearer into the room. This can support the researcher to observe, measure and interact with these experiences better, and enter the same version of reality as the person with psychosis.
Hearing from multiple lived experiences
The interdisciplinary process has value, but to what extent can we really understand a phenomenon if we have not experienced it ourselves? Voices in Psychosis also asks those with lived experiences to reflect on and understand their own experiences in relation to the people in the data. This idea of finding similarities and differences in experience has the consequence of validating others’ experiences and can lead to further insight through reflective contemplation on the experience of voice hearing. This process adds a multileveled perspective grounded in lived experience.
Initially I said I would review a few chapters, but the importance of the subject and the multiple perspectives offered made for a compelling read and I was intrigued to know more. As someone with psychosis herself, and who previously heard voices that were derogatory and persecutory I was interested in seeing whether others’ experiences mirrored my own. I identify with some of the manifestations and meanings ascribed to voice hearing detailed in the essays, such as how psychosis tells you, “I say the things you believe about yourself deep down.” This quote highlights how voice hearing is often a manifestation of our internal cognitions and how we think of ourselves or how we believe others think about us. Voice hearing is often a personalised attack based on these internal fears and vulnerabilities. This type of meaning attached to a voice hearing experience is termed an appraisal. Another example of appraisals explored include feeling like you are being punished for something. The type of appraisal we attribute to our voices has the potential to reduce or increase the distress we experience from hearing voices. Often the experience of psychosis is likened to “demonic” influences when being described through analogies and metaphors. This analogy is considered comparatively to medieval literature in the chapter on ‘Voices in Psychosis: A medieval perspective’ by Hilary Powell, which describes how psychosis is an experience of suffering. The author alludes to the idea that those who went through enormous suffering and endured this in religious stories were considered saints. She suggests that positively framed appraisals, like this one, may have some utility for those hearing voices in making sense of their own experiences in more helpful ways.
Conclusions
Voices in Psychosis emphasises its interdisciplinary approach to understanding voice hearing. It could be said that viewing this experience through multiple lenses might refract the experience through each perspective. However, I believe the interdisciplinary approach adds a richness to understanding the complexity of voice hearing. The collection of essays identifies how voice hearing might manifest in ways that reflect and mirror the cultural norms in society such as through popular ideologies or moralities that govern the world, historical and religious stories, trauma, and biological and psychological understandings that are entangled with the experience of voice hearing. This has the potential to be disentangled and understood through analysis and research methods. Voices in Psychosis is well worth reading if you want to enter the world of people with psychosis and understand what it is like to hear voices from multiple perspectives.
Voices in Psychosis is available to download and read freely by clicking the ‘Open Access’ button where the book is listed on the Oxford University Press website.