Student Nurses Discuss Hearing Voices and Self-compassion

Thank you to some students and a tutor of a UK-based class of nursing students for the following, which is a report of a small-group discussion. Some of those students were embarking on the final of four years of study (in order to become dual qualified nurses) and others the final of three years (to become solely a mental health nurse). The former are studying at Master’s level. The literature review we discussed is: 

Full article: Compassion-informed approaches for coping with hearing voices: literature review and narrative synthesis (tandfonline.com)

Leach, H., Kelly, J., & Parry, S. (2023). Compassion-informed approaches for coping with hearing voices: literature review and narrative synthesis. Psychosis, 1–11. https://doi.org/10.1080/17522439.2023.2253883

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We found that the discussion led us to talk not just about this review and its findings, but about ourselves, our life-experiences more generally, and self-compassion in particular. We also found that our discussion prompted more fundamental questions about mental health services and the UK’s Mental Health Acts than are perhaps apparent in the paper. In short, this apparently discrete area of mental health seemed to require us to revisit many other ways of thinking and aspects of nursing.

Although Leach et al.’s review is of an established body of literature, this discussion (and an accompanying taught session) is the first time the group have heard about the idea of working with voices in a non-biomedical way at university. However, some members of the group did have experiences of some of these ideas before. Firstly, for one student, a particular community mental health nurse placement mentor asked a wide range of questions about a service-user’s experience of voice-hearing to find out a lot of detail about the content and feeling of the voices. This was during an early placement within the the student’s course and the student has since noticed that it is in marked contrast to a more usual level of detail (which might be limited to phrases like “responding ++” written in the notes). This mentor suggested that “exploring the voices” in order to find solutions, was possible. They implied that a distressing voice might need a certain technique to help, but other voices could be approached differently. This mentor also had a view that distressing voices could be the result of trauma and perhaps the voice might be the voice of an abuser. 

Another student in the group had experienced a whole team with a rather non-medical approach to hearing voices, perhaps one that had some close parallels to Perry et al.’s paper. Within that team it was commonly accepted that it was important to find out what voices were saying. Psychiatric drugs were not seen as a treatment for hearing voices, but rather something to help with difficult emotions. Longer-term alleviation from the difficulties a person might have with voices would come from a non-judgmental attitude and understanding them in the context of trauma. It was noticed that the presence of staff with those attitudes seemed to have a beneficial, calming effect on both voice-hearer and voices, but that the occasional presence of staff with a stronger sense of voices as illness seemed less positive.

A third student had experience of a mental health peer support group. This was not specifically about voice-hearing but had it had left him with a sense that some voices were damaging but not all voices were bad. Finally, a fourth student had experienced inner conflict about the treatment given for someone who heard voices. Their recollection was that the treatment (Electro Convulsive Therapy) was prescribed with the aim of targeting the voices. However, in talking and observing the person, it was not at all clear that the voices were distressing for them. This made the student wonder if the treatment was proportionate. 

We found it interesting that there was such a diversity of experience about voice-hearing in the student group, with very different cultures experienced in different parts of the mental health service, perhaps even the result of the understanding of just one mentor. However, the students also said they thought that these were less common experiences and that the presence of voices was more generally a precursor to a conversation about risk, rather than a viewed as a therapeutic opportunity in mental health services.

The next part of our discussion surrounded the idea of self-compassion. A key finding of the paper is that: 

Over time, building a mutually compassionate relationship with one’s voices can help empower the voice hearer by resolving, rather than increasing, inner conflicts, and may increase opportunities to experience the presence of agreeable voices (p1). 

Leaving aside the culturally unusual claim made here that a person can build a relationship with a voice in which both parties are changed, we were very aware that, as a tutor and as students, it was simply not common for us to be talking about mindfulness and self-compassion together (one student felt that words such as “self-efficacy” and “concordance” were much more prevalent). We had a conversation about whether we, as people, were self-compassionate or not. We found the following sentence from the paper to be helpful for our understanding: 

They found levels of self-compassion, rather than self-esteem ratings, strongly predicted negative voices and voice-distress. The two are distinct, as self-compassion is based in recognition of universal humanity, while self-esteem is conditionally based on favourable social comparisons and social rank (Neff, 2003), highlighting the important influence of one’s self-perception in and of their social milieu (p5).

Two students felt that they had learned to be self-compassionate during and after significant challenges in their personal lives; for one it was a divorce, and for the other, the experience of having a child with complex health needs. Both felt that coming to terms with the expectations they and others may have felt of their lives was something that had driven this self-compassionate turn. Forgiveness was also important in these experiences – towards oneself and to others. Another student felt that their level of self-compassion was more variable, and one student felt that they were not self-compassionate. Perry et al.’s work is not about the importance of self-compassion for nurses, yet as a group we felt challenged to ask whether our lack of familiarity with self-compassion was odd, given that we are seeking to help others and given that the findings of this Perry et al.’s review suggests that it might be a core part of why some people might learn to live well with voices and some might become very distressed and stuck.

This open conversation about our self-compassion led us to think about mental health services, too, in three ways. Firstly, about diagnoses; then to think about the professional landscape on mental health nursing; finally about the UK’s Mental Health Acts.

It was striking in the paper that diagnosing was viewed as something about which to cautious. In the following statement it was ambiguous as to whether diagnoses are really mostly an identifier of a particular kind of self-and-voice relationship, or whether diagnosis has a potential negative effect on voice-hearing:

Participants without a diagnosis welcomed their voices and perceived them as nurturing. By contrast, participants with a diagnosis described being spoken to, or at, by the voices, with little or no reciprocal dialogue. 

We had come across this feature when listening to a TED talk by the voice-hearer and now academic psychologist, Eleanor Longden. When voices are described as part of an illness, they become something to fight against and the efficacy of drugs is measured against whether the voices are removed. Voice-hearing is very obviously seen as a symptom that can extend detention and coercion in mental health services, and for this reason alone a person might wish to be able to report an “all-clear”. It seemed that a diagnosis might decrease possibilities for self-compassion and reduce the sense of the person as someone whose universal humanity is visible to themselves and others. One student saw it as being “a confirmation of being wrong” and another as “kicking you when you are down”. In so doing, a diagnosis itself could make voice-hearing more difficult and delay better mental health. Yet we did wonder if a diagnosis always has to be this way – for some, the appeal of a diagnosis seemed to be its potential to link a person to a common human experience, too: “I’m not alone”. It might have been the presence in the group of several students who are studying to be dual qualified (adult and mental health, child and mental health) that led to a point in the discussion about whether there are similarities between this sense that fighting against voices is counterproductive and those who find the phrase battle with cancer to be really unhelpful, too, and that for both the idea of “living with” may be more positive and health-promoting (this is not to say that voices are like cancer in other ways).

As soon-to-be mental health professionals, the idea of personal self-compassion felt at odds with the expert image and defensible practice that our profession seems to demand. We noted that there is not much evidence of self-compassion in the targets and heavy accountability that seem most prevalent in our mental health nursing culture. As one student put it, “we are taught very early on that one fuck-up can cost us our PIN”. Perhaps the very idea of “the professional” is at odds with the idea of universality.

The UK’s Mental Health Acts seem to demand diagnosis and “treatment”. We asked ourselves a question: if the Mental Health Acts were abolished, how many psychiatrists would still have a job in a month’s time?! This led to the realisation that psychiatry and the Mental Health Acts have an almost completely symbiotic relationship. The Acts use medical language and require diagnosis and treatment, in which voices become symptoms that very often need to be fought against, not accepted with self-compassion. Perhaps even some psychiatrists might be uncomfortable with the reductionism of diagnostic language, but feel pushed towards it. The idea of universal humanity seems to disappear in the logic of the Mental Health Acts, which seem to have the idea of exception and abnormal as given. Psychiatrists must use the Acts in order to see their patients (we guessed 90% of appointments would not take place without them!). Each needs the other to survive. Along the way, something about this dynamic dramatically hinders the spread of the ideas found in this paper. After all, despite the recent publication date, these ideas that could not exactly be called new: a Google search reminded us that Romme and Escher’s book, Accepting Voices, was published in 1994!

This led to a further part of our discussion. Would abolishing the Mental Health Acts result in a net positive gain for society or for people who receive mental health services? The power to act coercively and to remove a person’s autonomy seems an extremely difficult, distasteful and even anti-nursing element of our role… yet simultaneously an essential option that at times becomes the most caring action. Somehow that troubling but probably necessary power has become enmeshed with a medical ideology and language, one that may causes all kinds of problems for individual health and for society too. It was beyond our conversation to imagine how the power of the Acts could be preserved without this feature.

Parry et al.’s paper about self-compassion as part of the recovery of better mental health for voice-hearers therefore led us into a set of existential questions, perhaps at the very heart of our complex identity as mental health nurses. It prompted us to ask questions about our own mental health and the role of self-compassion. It prompted to ask whether it is right that so little time is given to this kind of theme during our education – mindfulness, self-compassion and ways of thinking about our universal humanity. It prompted us to see that mental health services – or at least their medical heartland – seem deeply flawed even while they may be necessary. Yet it should not be forgotten that our conversation began with three examples of practice that felt different, perhaps changed for the better: an enlightened CPN, a team that saw voices as part of trauma in need of compassion and resolution, and a peer support group in which voices were not necessarily bad.
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And finally: the report author of this piece was asked at the moment of publication if he would like the AI assistant to review it and offer suggestions. This is what it said:

The content provides a comprehensive and insightful exploration of the discussion on compassion-informed approaches for coping with hearing voices. It effectively integrates personal experiences and research findings, fostering a deep understanding of the topic.

To improve the content, consider adding more specific examples and practical strategies related to implementing compassion-informed approaches in mental health nursing. Additionally, discussing potential challenges in incorporating these approaches into existing mental health services would further enrich the content.

…. and his response: Well, that isn’t that right on the money? Not enough “more specific examples and practical strategies related to implementing compassion-informed approaches in mental health nursing”. Out of the mouths of babes and the AI cloud….. and yes, how true: what challenges we face to incorporate these approaches, but it certainly would “further enrich our content” no end.