The following article has been kindly written and contributed by Dr Mark Franks, Clinical Psychologist, Private Practice

Hearing Voices Groups are an effective way of helping people understand and manage the experience of hearing distressing voices.

Here, the author draws upon his experience of facilitating Hearing Voices Groups in both community and inpatient settings, highlighting ideas for clinicians who are interested in these groups.

Group Structure

• Hearing Voices Groups run for between 60 to 90 minutes, although groups on inpatient settings tend to be shorter. It is advisable to avoid breaks since this can interrupt the momentum of the group. Groups are usually offered on a weekly basis.
• The size of the group can be anything from four to eight. Any fewer and this limits the scope for group discussion. More than this, and people may be too anxious to contribute. However, there needs to be flexibility with this since attendance at groups can vary.
• Enlisting the help of someone with a lived experience of hearing voices as a group co-facilitator can help people feel more understood and validated.
• Encouraging regular attendance at groups is important due to the motivational difficulties and social anxiety that people with psychosis often experience. Asking family, carers and other professionals to provide support and encouragement can be helpful.
• Consideration should be given to establishing Hearing Voices Groups for specific populations such as gender, stage of illness or cultural background. For example, the author established Hearing Voices Groups specifically for Pacific Island peoples in Auckland, New Zealand.

Group Content

Hearing Voices Groups should be conducted in an environment of understanding, respect and support. Making this explicit at the beginning of each group is essential. Since people are often anxious about attending, a brief mindfulness exercise can be used to commence the group, such as mindful breathing or a body scan.

Hearing Voices Groups facilitated by the author usually consist of two parts. Firstly, a group discussion about the voices that people hear, followed by a discussion about understanding and managing voices. To begin, people are asked to rate their voices in the past few days on a zero to ten scale, ten being the most distressing that their voices have ever been. This is a useful icebreaker and gently encourages people to begin talking about their voices. Group facilitators then use questions to generate further discussion, for example:

• "How many voices do you hear"
• "Are the voices male or female, young or old, familiar or unfamiliar"
• "What do the voices say to you"
• "What triggers the voices or makes them worse"
• “What is the impact of the voices upon you and your life”
• "Why do you think you hear voices"

This shared exploration is extremely normalising and can be the most therapeutic aspect of the group. Group facilitators should make clear that people's voices may temporarily worsen from talking about them, since the voices do not like being exposed.

Helping people to understand the causes of voices can also help them to manage the shame and stigma that often accompanies psychosis. For example, the author presents psychosis and hearing voices as "an extreme form of stress and anxiety to the point that people lose their grip on reality" as well as moving away from solely biological explanations towards ones that incorporate childhood and life experiences.

For managing distressing voices, a discussion about coping strategies that people currently use, noted on a whiteboard, can be useful. Group facilitators then introduce strategies such as relaxation, distraction, self-care, mindfulness and problem solving. The emphasis here is on managing stress, stress being one of the main factors that exacerbates distressing voices. Discussing values and goals can also be empowering, encouraging people to overcome avoidance and gradually push out their comfort zone to pursue these. This helps people to challenge beliefs about the omnipotence of their voices, a key maintenance factor in hearing voices.

To reinforce the content of the group, handouts are provided such as voice diaries, along with a list of self-help resources including:

• The self-help book Overcoming Distressing Voices (Hayward, Strauss & Kingdon, 2018).
• Phone Apps such as Smiling Mind and Headspace.
• YouTube clips such as The Voices in my Head by Eleanor Longden, or In My Mind - Living with Psychosis by Attitude. Time permitting, these can also be shown in the group.

For anybody interested in this area, the book Treating Psychosis (Wright, Turkington, Kelly, Davies, Jacobs & Hopton, 2014) is an excellent resource, complemented by the website www.treatingpsychosis.com