Hearing Voices

Fiona Orr

Director of International Activity and Mental Health lecturer at the University of Technology Sydney Faculty of Health

How did you get into mental health nursing?

I was at university studying special education but when I saw an ad promoting mental health nursing training.

So I decided to undertake a three year hospital-based training program to become a mental health nurse. Later I went on to do general nursing.  I finished that course, but went back to mental health because I enjoyed the time we had to talk, sit and listen to patients and their families.

Nursing education was transitioning from hospitals to universities around 1990, so at that point in time I did a Bachelor in Health Science Nursing.

I then went on and did a Masters of Letters and Research in women’s studies, and my thesis looked at blaming mothers for schizophrenia. So that involved historiography and interviewing women parents who had adult children diagnosed with schizophrenia.

Simultaneously, I got into education in nursing. So UTS is the third university I’ve worked at, and I’ve been in the UTS Faculty of Health for eight years working as a Lecturer in Mental Health nursing.

What is it about mental health that piqued your interest?

I’m interested in people and people’s behaviour- why we think and act the way we do.

I like meeting people, listening to people and talking to people, so since starting that course, I’ve never looked back – I’ve always been glad I did mental health nursing.

I also grew up in an area of Sydney which had a reasonably large mental health hospital, and it intrigued me; I wanted to know, what happens to people in psychiatric hospitals – how do they get help, how do they recover or get better?

What practical experience do nurses gain in mental health care at UTS?

In every clinical nursing subject, students will go out on a clinical placement and experience working alongside mental health nurses in a range of health services – in hospitals and the community, in justice health settings and also in non-government organisations.

We prepare for those placements here at UTS through collaborations with consumers and being involved in a number of simulations and online learning experiences that actually involve working directly with consumers who inform the kind of materials we present in the module.

For example, our “Hearing Voices” module was actually developed by consumers who hear voices (see more on this later).

We also do things like live simulation in our third year elective. So, the students actually meet several consumers during the online learning modules, where they see me and another academics interacting with consumers, and this is designed to develop the students’ therapeutic communication skills.

And then they get to meet the consumers live.  The students work in pairs with the consumer and they really learn about the lived experience of mental illness, talking to people who have sought help and can really comment on the kind of services that they’ve experienced and how they could have been better.

The consumer then gives feedback to the students about how the interaction went, about the therapeutic approaches they may have used and how they could develop that somewhat.

The consumers also really encourage students to use ‘recovery-focused’ communications, and to not see someone as a ‘diagnosis’ or a ‘condition’, but rather as a person, who happens to have experienced mental illness at a particular point in their life.

That person still has a whole range of goals, desires, achievements, strengths – they are much more than just their illness.

We find when students do this live interaction, the feedback has been overwhelmingly positive. Some say it’s one of the highlights of their degree.

To meet people before you go out on placement – to prepare and get feedback directly from that person – it’s just something invaluable that you can’t get any other way.

When students are out on placement, health consumers may not feel confident or comfortable enough to give that direct feedback in the clinical setting. But in the simulation, it works really well.

The ‘Hearing Voices’ simulation

The idea of this simulation originated in the USA and was developed by an academic called Patricia Deegan, a clinical psychologist who also hears voices – who has ‘lived experience’.

She and another group of people recorded simulated voices, sounds and experiences that they have when they hear voices.

So, in collaboration with a now-retired colleague of mine Kevin Kellehear, we worked with two others, Arana Pearson, an international educator with lived experience as a voice-hearer himself and Douglas Holmes who works at St Vincent’s Mental Health Service and also have lived experience as a voice-hearer. Both Arana and Douglas were trained by Patricia Deegan.

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Photo (supplied): Arana Pearson, Douglas Holmes, Kevin Kellehear and Fiona Orr


Together we developed a simulation workshop that we thought would be useful to students, to give them some insight and some awareness about what it might be like to hear voices.

The simulation would encourage nurses to think about how an awareness of this lived experience may influence their practice.

So with some teaching grants we developed the ‘Hearing Voices’ workshop.

At the workshop, students listen to recordings on MP3 players for 45 minutes. Whilst they’re listening to the voices and sounds, they carry out a number of everyday activities, like getting a coffee or asking directions. So they get an idea of what it feels like and how it affects them.

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Then the students come back and we discuss the experience in a large group.

I think students get a really good insight into what it’s like and people react in different ways – physically, emotionally and behaviourally.

Then in processing that, we get students to reflect on how, in practice, they might interact with people who hear voices and want to talk to you about it.

What impact has this had?

Personally, it led me to do my PhD study on voice hearing and the use of this simulation with a cohort of over 500 final year students.  I was really looking at measuring students’ empathy and their self-efficacy – their confidence – to talk to people about voice hearing, because the literature suggests that a lot of health professionals aren’t so comfortable talking about that.

The results (the PhD will be finished this year!) show that students now know ‘how it feels’ to hear voices and this is related to the experiential nature of the simulation.

The students’ empathy increased but its highest level was approximately six months after the simulation. The students’ confidence also increased immediately after the simulation and was maintained six months later.

The importance of empathy in Mental Health Nursing

Empathy is absolutely essential. I don’t think you could be a mental health nurse or any health professional for that matter without being empathetic.

There is intellectual empathy: the cognitive processes that we might use to try and get in someone’s shoes and understand how someone else might think or feel, but it’s more than that too.

It’s about connecting with or identifying with the underlying emotion that the person is trying to convey to you, and finding ways within yourself to develop that capacity.

Nurses are the professional group that are with healthcare consumers for extended periods of time, so being able to interact and develop rapport is central to the role of the nurse, and empathy is essential in performing that role.

Without that rapport, that connection, you can’t expect someone to talk about personal experiences, such as voice hearing.

It’s about working with the person, developing the idea of a collaborative partnership – an equal partnership.

Whilst the healthcare professional has the clinical experience, the consumer has the lived experience and knows how a condition affects them.

Families and carers also play a really important role because they have experiences in providing care too.

It’s important to make sure you never forget that as a nurse, or nurse-to-be, you’re working with people

The whole reason you’ve come into a Nursing degree is to be with people, to assist, support and care.  And remember to keep that care, compassion and empathy at the heart of what you’re doing.

That can be challenging in health systems which can be difficult places to work in, where people are very unwell with complex problems, and resources are often limited.

Also, when you’re out on placement, observe the system and think about potential areas where you might want to work… and don’t forget mental health nursing!

We always need more mental health nurses.  And of course, people have mental health needs throughout the healthcare system and can become mentally unwell in any healthcare context.

Mental health needs are everywhere, so even if students don’t want to specialise in mental health, they will encounter it in their health careers.

What makes a good mental health nurse?

A sense of humour is a good start.

You also have to be real – health consumers appreciate getting to know us.

Of course there are professional boundaries, but to be a real person who has life experiences and stories, and can relate to another individual is important.

Good nurses look beyond the diagnosis or the illness and see the person.

They see the strengths in people, their positive attributes and are willing to work alongside consumers.

But believe in yourself that you can do it, and that you can make a difference – consumers and their families will tell you when you do that.


Find out more about the UTS Bachelor of Nursing 

Byline: Jack Schmidt

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