on analysing subjective accounts of hearing voices and person-centred therapy. kirshen ga

561 Pages·2017·7.78 MB·English

“NO-ONE’S EVER ASKED ME BEFORE”:
ON ANALYSING SUBJECTIVE ACCOUNTS OF
HEARING VOICES AND PERSON-CENTRED THERAPY.

KIRSHEN GAIL RUNDLE

A thesis submitted in partial fulfilment of the requirements of the
University of East London for the degree of Doctor of Philosophy

School of Psychology

May 2017
Abstract
There has been considerable debate about the value of psychological therapies for voice
hearers who suffer such distress that they seek psychiatric help. To date, however, the
utility of person-centred therapy for this client group has not been investigated.
A convenience sample of ten participants who heard voices and had decided to start
person-centred therapy was recruited from the researcher’s caseloads at a NHS mental
health trust, an independent low-secure psychiatric unit and a counselling agency. On
completion of their therapy, participants were interviewed about their experiences of
therapy and of hearing voices. Data were analysed using a thematic approach informed
by relational existential-phenomenological ideas. Brief consideration was also given to
qualitative and quantitative outcomes.
Three themes were identified that referred to how participants recollected their
experiences of voices before the therapy: i) An unwelcome intrusion; ii) “Feeling like a
freak”; iii) Poignant yearning for things to be different. A fourth theme referred to
participants’ accounts of their voices once that therapy had concluded: iv) Changing
experiences, different views - sometimes.
Four themes related to their subjective experiences of person-centred therapy: i) Being
treated like a person; ii) Being offered possibilities; iii) Forging a way through; iv) It’s
not always just about the voices.
In general, participants gave positive accounts of person-centred therapy suggesting it
could be a useful option for this client group. There was, however, some variation in
response. Findings demonstrated the importance of engaging with individual voice
i i
hearer perspectives on their unusual experiences, and on what might alleviate their
associated distress.
There was some evidence of reliable and clinically significant change which was
explored in relation to qualitative findings. Issues around the use of symptom related
measures to test effectiveness of therapy are discussed.
Some implications of this analysis for a person-centred understanding of the meaning of
voice hearing are offered, with a focus on the potential for growth.
Limitations of the study relating to the dual therapist-researcher relationship and to the
homogeneity and size of sample are discussed.

ii i
Chapter summary
Chapter Page
Part A: Introduction and context of the study ..................................... 5
1. How can we understand and explain voice hearing? .......................................... 7
2. How can distress occurring alongside voice hearing be alleviated?................. 39
3. Subjective accounts of hearing voices and of doing psychotherapy ................ 78
4. Issues concerning talking therapy ..................................................................... 88
5. Rationale for the study .................................................................................... 103
Part B: Methodology and method ..................................................... 110
6. Methodology ................................................................................................... 112
7. Operation of the study .................................................................................... 127
8. Decisions about how to evaluate the study ..................................................... 156
Part C: Findings ................................................................................. 175
9. Reflective account of my experience of working with this client group ........ 177
10. What is it like to hear voices? ......................................................................... 185
11. What was it like to have person-centred therapy? .......................................... 217
12. Consideration of psychotherapy outcomes ..................................................... 254
Part D: Discussion and conclusions .................................... 275
13. What do the findings mean? ........................................................................... 277
14. Evaluation of the study ................................................................................... 327
15. Implications and future directions .................................................................. 359
16. Summary, reflections and conclusions ........................................................... 372
References ........................................................................................... 375
Appendices .......................................................................................... 442
Glossary ............................................................................................... 534

iv
Table of contents

Abstract ....................................................................................................... ii
Chapter summary ...................................................................................... iv
Table of contents ......................................................................................... v
List of boxes, tables and figures .............................................................. xx
Abbreviations used in this thesis ............................................................ xxi
Acknowledgements ................................................................................. xxii
Dedication ................................................................................................ xxv
Background and overview of study........................................................... 2
Part A: Introduction and context of the study ......................................... 5
OVERVIEW OF PART A ..................................................................................................... 6
Chapter 1 ..................................................................................................... 7
1 HOW CAN WE UNDERSTAND AND EXPLAIN VOICE HEARING? ...................... 7
1.1 Understanding voice hearing as a symptom of mental illness or disorder ....... 7
1.2 Can voice hearing be explained in a non-medical way? ..................................... 8
1.3 How common is this experience? ........................................................................ 10
1.4 Historical and cultural differences ..................................................................... 11
1.5 Research into the causes of voice hearing .......................................................... 13
1.5.1 Biological causes?.................................................................................................. 14
1.5.2 Chemical causes? ................................................................................................... 15
1.5.3 Psychological causes? ............................................................................................ 15
1.5.4 Impact of adverse events........................................................................................ 18
v
1.5.5 Spiritual crisis/religiosity ....................................................................................... 22
1.5.6 Continuum of experience ....................................................................................... 23
1.5.7 Hearing Voices Movement: personal meaning, relevant help and living well ...... 24
1.6 Phenomenology of voice hearing ........................................................................ 26
1.7 The necessity of listening to voice hearers ......................................................... 28
1.7.1 Service user/survivor activism ............................................................................... 29
1.7.2 The importance of considering subjective accounts of hearing voices.................. 30
1.8 The language of deficit ........................................................................................ 32
1.9 The notion of recovery ......................................................................................... 35
2 HOW CAN DISTRESS OCCURRING ALONGSIDE VOICE HEARING BE
ALLEVIATED? .................................................................................................................. 39
2.1 Medication ............................................................................................................ 39
2.2 Soteria ................................................................................................................... 42
2.3 Self-help and help from family and peers .......................................................... 43
2.4 Talking therapy .................................................................................................... 44
2.4.1 Cognitive Behavioural Therapy ............................................................................. 45
2.4.2 ‘Third wave’ therapies ........................................................................................... 48
2.4.3 Family interventions .............................................................................................. 48
2.4.4 Open Dialogue ....................................................................................................... 49
2.4.5 Trauma focused therapy......................................................................................... 50
2.4.6 Approaches derived and developed from the work of Romme and Escher ........... 50
2.4.7 Other approaches ................................................................................................... 51
2.4.8 Person-centred therapy .......................................................................................... 52
2.5 Person-centred theory and therapy.................................................................... 52
2.5.1 Introduction to the person-centred approach ......................................................... 52
2.5.1.1 Person-centred theory of personality development and the origin of distress ...... 53
2.5.1.2 Theory of person-centred therapy.......................................................................... 53
2.5.1.3 Process conception of psychotherapy .................................................................... 57
v i
2.5.2 Wisconsin project .................................................................................................. 57
2.5.3 Learning from the Wisconsin study about person-centred work with clients who
have unusual experiences ............................................................................................................ 61
2.5.4 Some recent developments in person-centred theory of relevance to work with
people experiencing different realities......................................................................................... 66
2.5.4.1 Pre-therapy – working with “contact-impaired” clients ....................................... 66
2.5.4.2 Person-centred work with victims of trauma ......................................................... 67
2.5.4.3 Pluralistic perspective ........................................................................................... 69
2.5.4.4 Schmid – alienation and inauthenticity ................................................................. 70
2.5.4.5 Warner – the drive to continue processing ............................................................ 71
2.5.4.6 Summary of new developments .............................................................................. 73
2.5.5 Recent research into person-centred therapy ......................................................... 74
Chapter 3 ................................................................................................... 78
3 SUBJECTIVE ACCOUNTS OF HEARING VOICES AND OF DOING
PSYCHOTHERAPY ............................................................................................................ 78
3.1 Qualitative research on the experience of hearing voices ................................ 78
3.2 Qualitative research on client experiences of psychotherapy .......................... 82
4 ISSUES CONCERNING TALKING THERAPY ................................................... 88
4.1 Issues concerning process of therapy ................................................................. 88
4.1.1 Therapeutic alliance ............................................................................................... 88
4.1.2 Client as active self-healer ..................................................................................... 89
4.1.3 Evidence of harm ................................................................................................... 90
4.1.4 Part of the problem? ............................................................................................... 91
4.2 Issues concerning research into therapy ............................................................ 93
4.2.1 RCTs as the gold standard? ................................................................................... 93
4.2.1.1 Blinding? ................................................................................................................ 94
4.2.1.2 Objectivity of results .............................................................................................. 95
4.2.1.3 Standardising procedures ...................................................................................... 96
vi i
4.2.2 Meaning AND measurement ................................................................................. 97
4.2.3 Meaningful success criteria – following the lead set by experts-by-experience ... 98
5 RATIONALE FOR THE STUDY .................................................................... 103
5.1 Justification for more research into lived experiences of voice hearing and of
psychotherapy .......................................................................................................................... 103
5.2 The value of finding out how person-centred therapy is experienced by people
who hear voices ........................................................................................................................ 104
5.3 The research questions ...................................................................................... 105
5.3.1 What is it like to hear voices? .............................................................................. 105
5.3.2 What was it like to have person-centred therapy? ............................................... 106
SUMMARY OF PART A................................................................................................... 108
Part B: Methodology and method ......................................................... 110
OVERVIEW OF PART B.................................................................................................. 111
6 METHODOLOGY ........................................................................................ 112
6.1 Epistemological position and choice of method .............................................. 112
6.1.1 Starting point........................................................................................................ 112
6.1.2 Position within phenomenology .......................................................................... 114
6.1.3 Description versus interpretation of phenomena ................................................. 117
6.1.4 Approach to data analysis .................................................................................... 119
6.1.5 Decision to use clients as participants ................................................................. 122
6.1.6 Other methods considered ................................................................................... 124
6.1.6.1 Discourse analysis (DA)/Foucauldian Discourse Analysis (FDA) ..................... 124
6.1.6.2 Interpretative Phenomenological Analysis .......................................................... 125
6.1.6.3 Grounded theory .................................................................................................. 125
6.1.6.4 Narrative and life-story methods ......................................................................... 125
7 OPERATION OF THE STUDY ....................................................................... 127
7.1 Participants......................................................................................................... 127
7.1.1 Ethical approval ................................................................................................... 127
vi ii
7.1.2 Sample ................................................................................................................. 127
7.1.3 Demographic data (summarised in Table 7.1 below) .......................................... 128
7.1.4 Recruitment .......................................................................................................... 134
7.1.5 Informed consent ................................................................................................. 134
7.1.6 Medication ........................................................................................................... 135
7.1.7 Attrition rate and data for study ........................................................................... 135
7.1.8 Therapist contractual position .............................................................................. 136
7.2 Maintaining confidentiality ............................................................................... 137
7.3 Recording of therapy sessions ........................................................................... 138
7.4 Ensuring fidelity to therapy model................................................................... 138
7.4.1 My qualification and practice .............................................................................. 138
7.4.2 Independent assessors .......................................................................................... 139
7.5 Interview question areas ................................................................................... 140
7.6 Post-therapy interviews ..................................................................................... 141
7.6.1 Form and structure ............................................................................................... 141
7.6.2 Recording and transcription ................................................................................. 142
7.6.3 Option of reviewing draft transcriptions, analyses and finished analysis ............ 142
7.7 Method of data analysis and presentation of findings .................................... 143
7.7.1 Reading transcripts .............................................................................................. 145
7.7.2 Coding data for meaning...................................................................................... 145
7.7.3 Identifying themes ............................................................................................... 146
7.7.4 Coding data for each theme using fractions of lifeworld ..................................... 147
7.7.5 Iterative process between raw data and emerging themes ................................... 147
7.7.6 Writing up the themes .......................................................................................... 148
7.7.7 Independent auditing of themes and illustrative extracts ..................................... 148
7.7.7.1 Professional perspectives .................................................................................... 148
7.7.7.2 Participants’ perspectives.................................................................................... 150
7.8 Inclusion of outcome measures ......................................................................... 151
7.8.1 BAVQ-R (Appendix Gi) ...................................................................................... 152
ix
7.8.2 PSYRATS (Appendix Gii) .................................................................................. 153
8 DECISIONS ABOUT HOW TO EVALUATE THE STUDY ................................. 156
8.1 Overview ............................................................................................................. 156
8.2 Selection of evaluation criteria ......................................................................... 157
8.3 Evaluation criteria ............................................................................................. 160
8.3.1 Rigour .................................................................................................................. 160
8.3.2 Reflexivity ........................................................................................................... 161
8.3.2.1 Epistemological reflexivity .................................................................................. 161
8.3.2.2 Personal reflexivity .............................................................................................. 162
8.3.3 Resonance ............................................................................................................ 162
8.3.4 Relevance ............................................................................................................. 163
8.4 Potential limitations ........................................................................................... 163
8.5 Power and dual relationships............................................................................ 164
8.5.1 Dual relationship .................................................................................................. 164
8.5.2 Power differential ................................................................................................ 165
8.5.3 Power and mutuality ............................................................................................ 167
8.5.4 Power exploiting the participant .......................................................................... 167
8.5.5 Benefits of therapeutic research and therapist as researcher ............................... 170
SUMMARY OF PART B ................................................................................................... 174
Part C: Findings ..................................................................................... 175
OVERVIEW OF PART C ................................................................................................. 176
Chapter 9 ................................................................................................. 177
9 REFLECTIVE ACCOUNT OF MY EXPERIENCE OF WORKING WITH THIS
CLIENT GROUP .............................................................................................................. 177
9.1 Introduction ........................................................................................................ 177
9.2 Topics discussed in therapy .............................................................................. 177
9.3 The therapist’s experience of the process of therapy ..................................... 179
x