So, as part of using Linux I'd like to cut down on the amount of times I have to go messing with windows VM's for things. I can get the speech SDK installed and the voices I want in a 64 bit wine prefix and install elten, but when I run it the program just sits there and does nothing. I have the visual C redistributables from 2015 to 2022 installed in the prefix as well. Any other dependencies I could be missing?

switch to the desktop then move to the Elten's window again, it should speak. Remember, you should press shift+f1 few times, to switch to sapi5, and probably you cannot do it when elten is launched for the first time. Accept licenses, close elten, and rerun it.
I prefer to use 32 bit wineprefix at all, unfortunatly without possibility to play audio posts, but on 32bit elten will not crash, when you'll try to visit some mixed threads.

I couldn't even get the setup to run on 32 bit. I downloaded it from elten-net.eu, tried to run it using a 32 bit prefix and the window was up for a second then it exited. Is there a 32 bit setup separate from the main installer?

Hmm, i don't have any problems with running setup downloaded from elten-net.eu on 32 bit prefix. I discovered more problems on 64 bit prefixes, so i decided to switch to 32 bit.FIrst install all required dependencies, such as vcredist, wininet, urlmon and so on, then try again.

Are these things I can install with winetricks? Would make things a lot easier.

Yep, you can. Vcrun 2010 to 2015 should be enough.

and wininet and urlmon.

And sapi or speechdsk5.1, each of these should work.

So assuming I have a wineprefix variable exported, winetricks wininet vcrun2010 urlmon would install everything I need?

I've already install speechsdk.

vcrun 2010 to 2015, urlmon, wininet, speechsdk dbghelp and setup should work. If not, run the setup from a console and give me output.

OK, so elten is running, but it won't give me the licenses. I can use shift f1 to switch to sapi, but after that it just sits there, no tick sound, nothing. Closing and reopening does nothing either.

And when you pressing shift+f1 sapi speaks something?

Yes, it says using a selected sapi synthesizer.

So try to accept license before pressing shift+f1.

I launch it, alt tab away to another window and back, and it just hangs there. I have been waiting for a solid 30 seconds.

After 4 seconds when elten's window appear press super+d or another shortcud you've defined to minimize all windows and show desktop, then get back and you should be able to press tab to accept licenses.

OK, so I pressed ctrl alt D which visually I could see got rid of all windows, did this after about 4 seconds of elten opening, then I alt tabbed back to it and it still wouldn't work, again waited about 30 seconds.

If it helps, I'm using gnome on xorg as my display session.

If you have windows copy the content of the elten's directory from %appdata% to your elten's directory if it exists in drive_c\users\yourusername\ApplicationData\elten, as i remember correct path.