Yalom’s therapeutic factors in hearing Voices Groups: a facilitator’s perspective

ABSTRACT

Over the past 35 years, peer-run Hearing Voices Groups (HVGs) have proliferated across the globe. More recently, research has begun to focus on the precise psychological mechanisms that make groups effective and enable individual psychological change. While important in their own right, theories of peer support are limited in their ability to explain the psychological mechanisms by which complex psychological transformation occurs. As such, it is necessary to look beyond peer support and borrow theories from the psychotherapeutic literature. Yalom and Leszcz’s (2005) seminal work, The Theory and Practice of Group Psychotherapy, may help shed some light on the psychological dynamics that bring about change in HVGs. Peer support and group psychotherapy differ widely in their histories, philosophical underpinnings, and approach to, and understanding of, mental distress. As such, theories of group psychotherapy cannot be broadly applied to HVGs without a nuanced understanding of the differences between HVGs and psychotherapy groups. In this paper, I use my lived experience as an HVG member and facilitator to highlight these differences, and explore where Yalom’s theory may be useful at understanding the change mechanisms at play in HVGs.

KEYWORDS:

• Hearing Voices Network
• peer support
• therapeutic factors

I recently found myself in a conversation with a group of clinical psychologists about the significant contributions of the Hearing Voices Network (HVN) in our understanding of, and responses to, voice hearing. As an HVN group facilitator, I find myself in these conversations frequently, and have always been interested in what mental health professionals find compelling or challenging about the groups. In this instance, the conversation turned to group dynamics and potential mechanisms of action. Specifically, the question was posed: can we apply group psychotherapy theories, specifically Yalom’s theory, to our understanding of Hearing Voices Groups (HVGs)? While HVGs and group psychotherapy are ideologically distinct, stem from unique histories and hold different perspectives on mental distress, it may nevertheless be instructive to look at HVGs through the lens of Yalom’s theory of therapeutic factors in order to understand their overlap, and importantly, their divergence. In this paper, I use my experience as a facilitator to look at if and how various aspects of Yalom’s theory can help us deepen our understanding of how change occurs in HVGs.

Introduction to Hearing Voices Groups

The establishment of peer-run HVGs is one of the primary initiatives of HVN, an international, survivor-led alliance between voices hearers, mental health professionals and the community that rejects the traditional psychiatric notion that voice hearing is inherently pathological and instead locates the experience as meaningful and worthy of curious exploration. HVGs are strongly aligned with the liberatory tradition of the consumer/survivor/ex-patient movement of the 1970s and as such, are explicitly rights-based in their orientation. Far from being traditional mental health support groups, HVGs take an emancipatory orientation which position voice hearers as the experts of their own experience, deconstruct traditional psychiatric norms about those who hear voices, and emphasise that people should be afforded the opportunity to explore their experiences without necessarily wanting to change them (Corstens et al., 2014; Dillon & Hornstein, 2013; Hornstein et al., 2021). Rather than being focused on outcomes, HVGs are focused on relationships. Core to the groups is the notion that transformation occurs through genuine, mutual connections with others (Corentin et al., 2023; Hornstein et al., 2020, 2021). HVGs prioritise non-hierarchical structure and a reciprocal exchange of information between participants, intentionally moving away from the “helper-receiver” binary that is commonplace in traditional mental health services (Hornstein et al., 2021). HVGs express no explicit goal beyond offering a social space for voice hearers to share their stories and have them non-judgementally witnessed and received by others (Corstens et al., 2014). These groups however are more than just a social hour for voice hearers: I’ve witnessed profound change in how individuals understand and relate to themselves, their voices, and other people. It is precisely how these changes come about as a result of being in a relationally-focused group that I find particularly interesting and where I think Yalom’s theory may help shed some light.

Brief introduction to Yalom’s theory

In their seminal work, The Theory and Practice of Group Psychotherapy, Yalom and Leszcz (2005) conceptualise mental distress as arising from dysfunctional relational dynamics. The goal of group psychotherapy, therefore, is to elucidate and provide corrective experiences for these dynamics, thereby enabling successful functioning outside of the group. Group cohesion is the foundation upon which successful groups are built, with group relationships being seen as the primary agent of therapeutic change. Yalom posits that within groups, individuals do not actually need to express their difficulties verbally, rather, they inadvertently enact their distress within the group and display dysfunctional patterns of relating to themselves and others through their interactions with the other group members. The therapist and other group members then provide feedback on these dynamics in order facilitate an iterative process of self-reflection and social, emotional and behavioural adaptation. As such, groups are focused on the “here-and-now,” meaning that the dynamics going on within the group take therapeutic precedence over incidents that have gone on outside the group or in an individual’s past.

In addition to these relational processes, Yalom further outlines 12 therapeutic factors for successful psychotherapy, several of which will be considered in more detail below: (1) universality; (2) altruism; (3) instillation of hope; (4) imparting information; (5) existential factors. The remainder of this paper will look at which of these factors may be at play in HVGs, and the particular ways in which they may manifest.

Why look at HVGs in light of Yalom’s theory?

Because peer support is wide reaching in scope and there is no single outcome that peer support groups hope to achieve, the theoretical literature on potential mechanisms of action is limited. As such, it may be helpful to look beyond peer support theories and pull from theories of group psychotherapy. Both HVGs and group psychotherapy are explicitly relational in nature. So, while the groups differ in terms of form, structure and intended outcomes, there may be common relational processes at play.

Applicability of specific therapeutic factors

Universality

Universality is defined as the realisation, often for the first time, that one is not alone in their distress and that others share similar thoughts, feelings and histories. Yalom understands universality as being crucial for the establishment of trust and cohesion within the group, but is not, in and of itself, essential for therapeutic change. As such, universality is seen as a means to an end, rather than an end itself. On the contrary, I would argue that universality is the factor most strongly at play in HVGs. Likely due to the unique stigma that accompanies voice hearing, many HVG members cite universality as the most important part of being in the group. In my experience, realising that other people have similar experiences facilitates the following process: an individual will come to the group deeply fearing that they are “crazy”. “Crazy” in this instance is akin to being alien and unintelligible. Meeting people with similar experiences leads them to conclude that they are not in fact “crazy”. The power of this realisation should not be underestimated, on one occasion I heard a woman remark that she “felt human” for the first time in her life after attending the HVG and realising she was not alone. What is particularly interesting about this is that people report this feeling of commonality even when they have experiences that are highly idiosyncratic and wholly unshared by other group members. Perhaps having the social label of being a voice hearer, carrying a diagnosis of schizophrenia, or holding a deep fear that you are “crazy” and therefore completely alone is what is catalysing this sense of similarity. Alternatively, it may be because HVGs emphasise resonance through emotions, by which I mean that even if someone does not share a particular experience, they will be able to connect with the emotions that underpin and accompany it.

There’s an element of this that I’ve always found a bit surprising. Voice hearers are coming to HVGs saying that it is the first time they’ve ever had the ability to speak to other people with the same experiences. This is despite the fact that almost everyone I’ve met in groups has spent many years in mental health services and often, a significant amount of time in psychiatric hospitals – presumably places where other voice hearers are present. It makes me wonder if there is something about HVGs, possibly their non-coercive, non-judgemental and non-hierarchical atmosphere, that make them a unique microcosm in which universality can develop.

Altruism

The role of altruism in HVGs is similar to that of psychotherapy. Yalom posits that altruism arises when individuals realise, again, often for the first time, that they can be of service to others. Many voice hearers come to the group feeling as though they are a burden to others. They have often been told for many years that they have no insight, little to contribute, and will always be the recipient of help. In HVGs, however, the binary between “helper” and “helped” is broken; everybody is assumed to have wisdom to share, and that wisdom seamlessly sits alongside personal struggles. Indeed, I’ve always felt that the most successful groups were the ones where somebody remarked “I couldn’t tell who the facilitators were during that group”. When people are allowed to be complex – to struggle and contribute – their sense of self shifts: away from a sense of being a burden toward being somebody with hard-earned wisdom that has the capacity to relieve suffering in others.

Instillation of hope

According to Yalom, the success of others within a group can serve as a source of inspiration. In group therapy, hope is an important catalyst for engagement, with Yalom noting the ameliorative effects of positive expectations and encouraging therapists to help clients believe that the group will help them get better. He also emphasises the utility of pointing out specific group member’s improvements as a means of inspiring others. While it is certainly the case in HVGs that seeing others live a full and fulfilling life alongside their voices can provide a roadmap for navigating through difficult experiences, there are noteworthy areas of divergence in how hope is utilised. The first is that central ethos of HVGs is that they honour hopelessness (Hart, 2017). Situations are not reframed in order to help people to see the positive or to convince them that things will get better. Perhaps surprisingly, in my experience it is often this bearing witness to hopelessness that ultimately enable an individual to move through the depth of their despair and start to consider the possibilities for their future. The second is that in HVGs, no explicit effort is made for individuals to have positive expectations of the group. Indeed, as previously mentioned, individuals do not have to have a desire or expectation to change in order to attend the group. Finally, while there is certainly space within HVGs to celebrate individuals’ growth, it would never be used explicitly as an example to others. Doing so would violate the group’s non-hierarchical ethos and would position some members as “more recovered” than others, which is antithetical to HVN’s conceptualisation of subjective wellbeing.

Interpersonal learning: role of self-disclosure

Self-disclosure serves a very particular function in both types of groups. Yalom informs his participants before joining the group that self-disclosure is mandatory in order for therapy to be effective. The timing of such disclosure is also crucial, as the group has to be cohesive enough to effectively respond to such a disclosure. While it is arguable that people who self-disclose get more out of HVGs than those who do not, self-disclosure is never mandatory and indeed, silently witnessing others is seen as valuable participation. For many in both types of groups, fear of rejection surrounds self-disclosure, thus necessitating group cohesiveness in order for disclosures to take place and be effective. The aftermath of self-disclosure differs across groups. In psychotherapy groups, the purpose of self-disclosure is to enable others to accept the individual’s experience and this acceptance helps correct and underlying emotional disturbance. For people in HVGs, many of whom have had their experiences dismissed, vilified, or met with loss of liberty or social standing, disclosure often feels very high stakes. Fortunately, in HVGs once someone does disclose, they are most often met with acceptance and learn that there is a whole group of people who share similar experiences. Furthermore, individuals who never self-disclose (I have seen people wait for many months before saying anything about their experiences, but I’ve personally never seen anyone who never discloses anything, though I imagine such people do exist) are likely still getting some benefit from the group, as the group is voluntary and presumably people would not return if nothing was being gained. While self-disclosure is never mandated in HVGs, the people who may hold more responsibility for demonstrating the benefits of self-disclosure are the facilitators. In other types of mental health groups, group leaders rarely disclose personal information; as such, in HVGs self-disclosure on the part of the facilitators is necessary to help solidify the non-hierarchical structure of the groups. When facilitators (or indeed other group members) self-disclose and are not met with negative consequences, it serves as a powerful example to more hesitant group members. Witnessing disclosure – and crucially, the lack of negative consequences that follow disclosure – is something I often hear cited as one of the most powerful factors of HVGs.

Existential factors

Existential factors encompass several issues relating to meaning-making, responsibility, and the capriciousness of existence. Yalom notes that in group psychotherapy, this factor was essentially considered an afterthought and is seen as less important therapeutically than anything that occurs relationally between members. Here again, there is a major point of difference between HVGs and psychotherapy groups. Existential factors are often front and centre in HVGs, with conversations about the meaning of anomalous experiences serving as a central component of the groups. More than that, HVGs focus on exploring and expanding what it means to be human. Questions such as “why do I hear voices?” “what does it mean to live a good life as a voice hearer?” and “why is voice hearing considered outside the realm of ‘normal’ human experiences?” are commonplace within groups. And due to HVN’s ethos of accepting all interpretative frameworks for voice hearing, conversations frequently delve deeply into the spiritual and/or philosophical. Issues such as justice and fairness are paramount, not just because many individuals within the group are grappling with the effects of interpersonal and/or systemic trauma and oppression, but because HVGs boast a socio-political ethic which emphasises issues of justice both within and beyond the group. As such, while existential factors are deprioritised within psychotherapy groups, they are often central within HVGs, and may serve as the only opportunity for people, people who often have been told that they have no insight into their experiences or into how the world works, to explore philosophical questions about meaning and human existence.

Applicability of relational processes

Group as social microcosm

Yalom argues that in group psychotherapy, the group will act as a social microcosm, meaning that over time, individuals will relate and respond to others within the group the same way they relate and respond to others outside the group (be it through monopolising tendencies, seeking out and then rejecting advice, persistent submissiveness to other group members). In this way, group participants are enacting their distress and maladaptive behaviours; they have no need to describe them because they will be on full display. While it is certainly conceivable that HVGs would act as social microcosms as well, unlike in therapy, the goal is not to explicitly bring these dysfunctional relational dynamics to light. In HVGs, there is an emphasis on allowing members to recount how relationships are for them outside the group and taking that at face value because, for many group members, their reality has been consistently questioned or diminished. As such, it is necessary in HVGs to trust that each individual is truly the expert of their own experience, even if other group members have a different interpretation or believe that somebody should behave in a different way. I question whether HVGs can truly be seen as a social microcosm for the outside world. In psychotherapy groups, presumably individuals will enact situations that cause others to respond to them in a similar way they are responded to by individuals outside the group; in HVGs, the hope is that group members will respond to each other in a way that is different from the outside world.

Working in the here-and-now

Yalom states that it is of primary importance for group psychotherapy to deal with the “here-and-now,” meaning the dynamics occurring at present within the group, as opposed to the content of what an individual is saying. The reasons for this are two-fold: 1) focusing on the content of what people are talking about inevitably leads to bias; and 2) focusing on the here-and-now privileges understanding the relational dynamics at play, which ultimately is what is necessary to resolve an individual’s underlying distress. Yalom argues that regardless of the content brought up by participants, at the end of the day, all things lead back to the group and that’s where the discussion needs to focus.

In order for a group to be oriented to the here-and-now, it has to be process-focused rather than content-focused. This is a marked difference to how HVGs function. Of course, there are crucial relational processes that enable group cohesion, self-disclosure, curiosity and the exploration of one’s own experiences, these relational processes are rarely talked about explicitly within the group. Rather content, particularly in terms of the content of voices and other anomalous/unshared experiences, is seen as paramount. The assumption within HVGs is that having the ability to articulate the particularities of one’s own experience will lead to deeper self-knowledge, which in turn, could enhance coping, change the nature of or the relationship to voices, and have a variety of impacts on life outside the group. Since HVGs are designed to disrupt the ways of thinking and interacting found within the psychiatric system and other systems of power, placing a strong emphasis on voice content is a necessity given that this avenue of exploration has been historically shut down in psychiatric spaces. Furthermore, because HVGs are explicitly trauma-informed and human rights-based in their orientation, talking about the interpersonal dynamics within the group at the expense of exploring personal and structural trauma would be gravely inappropriate.

There are, of course, areas of subtle overlap here as well. For example, if an HVG participant discloses past trauma, it would be entirely appropriate to comment on the fact that the individual felt safe enough within the group to self-disclose (and potentially this would help an individual understand that the relational dynamics within the group are different than those that were present during a traumatic event, though this is never the expressed purpose of the group). However, in a departure from Yalom’s theory, it would not be appropriate to then focus the group discussion on what specifically enabled the participant to disclose.

Conclusion

This paper has outlined, how, in my opinion as an HVG facilitator, elements of Yalom’s theory of group psychotherapy can be applied to enhance our understanding of HVGs. While there is considerable overlap between some of the therapeutic factors and processes at play in both types of groups, sufficient nuance in required to fully elucidate how HVGs differ from psychotherapy groups. As such, while the theories can help us to understand HVGs, the central catalyst of change in both groups – namely relationships with other group members – manifests considerably differently. Whereas the goal in group psychotherapy is to have corrective relational experiences, the goal in HVGs is to have healing relational experiences that provide validation, model curiosity into one’s psychological life, and position each individual as inherently valuable and able to contribute to the wellbeing of others.

Acknowledgements

I would like to thank Filippo Varese, Eleanor Longden, Sandra Bucci and Tony Morrison for their input on previous versions of this manuscript.

Disclosure statement

I have received financial compensation for training/facilitation for the Hearing Voices Network.